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Our hospital, located on the mainland, serves as a hub center for nine hospitals on the remote islands of Nagasaki Prefecture, Japan. There are no stroke specialists on these islands. We can transfer emergency patients from these islands to our hospital at any time, using a teleradiology system and three types of helicopter transport. We examined the efficacy of the drip and ship (DS) method for treating patients with acute ischemic stroke (AIS) on these islands, in comparison with patients on the mainland. From 2010 to 2017, we reviewed 98 consecutive patients with AIS who received intravenous recombinant tissue plasminogen activator (IV rt-PA) in our hospital or were transported to our hospital after IV rt-PA. Patients were divided into the Islands group (received IV rt-PA on the islands, DS; 31 cases) and the Mainland group (67 cases). The median transport distance from the islands was 112 km. The rate of patients achieving favorable outcomes was 54.8% in the Islands group and 64.2% in the Mainland group, with no significant differences. Multivariate analysis revealed that patients living on isolated islands did not have increased risks of unfavorable outcomes. Endovascular therapy (EVT), as part of the drip, ship, and retrieve method, was performed in 22.6% of patients in the Islands group and EVT in 38.8% of those in the Mainland group. The DS method seems feasible and safe for patients living on isolated islands with the use of 24-h helicopter transportation and teleradiology., Neurologia medico-chirurgica, 59(12), pp.504-510; 2019

Background: Carotid endarterectomy (CEA) is a conventional surgical technique to prevent ischemic stroke and the effectiveness for advanced lesions is established in many large studies. The vagus nerve is one of the cranial nerves that we usually encounter during CEA manipulation, which is identified as located posterior to the vessels in a position posterolateral to the carotid artery and posteromedial to the internal jugular vein. Case Description: We experienced an extremely rare case of the vagus nerve passing anterior to the internal carotid artery during CEA. Conclusion: We should be careful not to accidentally cut off because the variation of the vagus nerve can be mistaken for an ansa cervicalis. A delicate and complete dissection to understand the variation of the vagus nerve is crucial to minimize the risk of cranial nerve injury during CEA.

Background: Mechanical thrombectomy (MT) is standard treatment for acute ischemic stroke (AIS) with large-vessel occlusion within 6 h of symptom onset to treatment initiation (OTP). Recent trials have extended the therapeutic time window for MT to within 24 h. However, MT treatment remains low in remote areas. Nagasaki Prefecture, Japan has many inhabited islands with no neurointerventionalists. Our hospital on the mainland is a regional hub for eight island hospitals. We evaluated clinical outcomes of MT for patients with AIS on these islands versus on the mainland. Methods: During 2014–2019, we reviewed consecutive patients with AIS who received MT at our hospital. Patients comprised the Islands group and Mainland group. Patient characteristics and clinical outcomes were compared between groups. Results: We included 91 patients (Islands group: 15 patients, Mainland group: 76 patients). Seven patients (46.7%) in the Islands group versus 43 (56.6%) in the Mainland group achieved favorable outcomes. Successful recanalization was obtained in 11 patients (73.3%) on the islands and 67 (88.2%) on the mainland. The median OTP time in the Islands was 365 min. In both the Islands and Mainland groups, the OTP time and successful recanalization were associated with functional outcome. The modified Rankin Scale (mRS) score at 90 days ≤2 was obtained in two patients and mRS = 3 in four patients among eight patients with OTP time >6 h. Conclusions: Few patients with AIS on remote islands have received MT. Although patients who underwent MT on the islands had longer OTP, the clinical outcomes were acceptable. OTP time on remote islands must be shortened, as this is related to functional outcome. In some cases with successful recanalization, a favorable outcome can still be obtained even after 6 h. Even if OTP exceeds 6 h, it is desirable to appropriately select patients and actively perform MT., PLOS ONE, 16(1), e0245082; 2021

Cervical carotid disease is typical atherosclerosis, which is responsible for ischemic stroke. The effectiveness of carotid endarterectomy (CEA) for advanced carotid stenosis has been established in many large studies, and CEA is the gold standard in surgical treatment. On the other hand, endovascular carotid artery stenting (CAS) has become increasingly popular recently. It is very important to avoid any complications to maintain the effectiveness of CEA. The retractor device is important for the exposure of carotid arteries and for the safe surgical manipulation. We have started to use lone star retractor system (LSRS) to deploy the surgical field. LSRS provides the usability to handle and a shallower surgical field without the disturbance of surgical manipulation. And it can facilitate exposure of the distal internal carotid artery because surgeon can retract freely in whole circumference by towing with moderate strength. LSRS may bring the smoother and easier surgical manipulations in CEA.

A persistent primitive olfactory artery (PPOA) is a rare anomaly of anterior cerebral artery (ACA), which generally arises from the internal carotid artery (ICA), runs along the olfactory tract, and makes a hairpin bend to supply the territory of the distal ACA. PPOA is also associated with cerebral aneurysms. An accessory MCA is a variant of the middle cerebral artery (MCA) that arises from either the proximal or distal portion of the A1 segment of the ACA, which runs parallel to the course of the MCA and supplies some of the MCA territory. We experienced a rare case of coexistence of PPOA with an unruptured aneurysm and accessory MCA. Three-dimensional computed tomographic angiography (3D-CTA) has an excellent picture of the spatial relationship of the surrounding bony and vascular structure.

Lhermitte-Duclos disease (LDD) is a neurological disease caused by a hamartomatous lesion in the cerebellum. Clinically, LDD is commonly associated with progressive space-occupying lesion effects in the posterior fossa, increasing intracranial pressure, occlusive hydrocephalus, and focal neurological deficits of adjacent structures. The authors report the case of a 10-year-old boy with LDD who had been suffering from vomiting attacks (VAs). These VAs had been brief in duration but extremely frequent, and they had been resistant to antiemetic drugs since the early postnatal period. Magnetic resonance imaging at 8 months of age revealed a right cerebellar lesion with very little space-occupying lesion effect, but the causal relationship with VAs was not evident at that point, because no clinical symptoms or signs other than vomiting were suggestive of increased intracranial pressure. The VAs were initially diagnosed as autonomic ataxia and had been treated with antiemetic drugs for approximately 10 years, but the patient’s symptoms were not improved at all in frequency or duration. He developed convulsive seizures at 9 years of age and was referred to the authors’ epilepsy center. The VAs were initially speculated to represent an aspect of seizures, but antiepileptic agents proved ineffective against this symptom despite remission of convulsive seizures. Video-electroencephalography monitoring did not show any evolving ictal patterns associated with the vomiting. Careful reevaluation of MRI studies revealed that the cerebellar lesion was fused with the cerebellum, middle and inferior cerebellar peduncles, and dorsolateral medulla oblongata with some distortion. FDG-PET identified hypermetabolism in the cerebellar lesion. After establishing the diagnosis of LDD, the authors performed subtotal resection of the lesion based on the likelihood of a causal relationship between the cerebellar lesion and the vomiting center of the medulla oblongata. Postoperatively and for 2 years, VAs have remained completely suppressed. The authors hypothesize that the pathophysiology of VAs in LDD includes a tumor-like space-occupying effect on the vomiting center of the medulla oblongata, and even partial resection of the lesion may prove effective.

BACKGROUND Germinoma is one of the most radiosensitive tumors. Although radiotherapy (RT) can lead to long term-survival, it has the possibility to cause adverse effects. One of the more serious side effects include radiation-induced tumors that can contribute to a life-long prognosis. Case presentation A 40-year-old man was diagnosed with left basal ganglia germinoma at the age of 11 years old. Postoperatively, he received whole-brain radiotherapy 40Gy, focal radiotherapy 9.26Gy, and craniospinal irradiation. After these treatments, he was free from tumor recurrence or a secondary tumor during the long-term follow up. However, after 29 years, he began experiencing aphasia. A Magnetic Resonance Imaging (MRI) showed a developing 4.5cm round mass in the left parietal lobe with marked surrounding edema. He underwent surgical resection of the tumor at the left partial lobe. Pathological examination showed the tumor to consist of unclear pleomorphism, and the diffuse proliferation of heterocyst. Therefore, the pathologic diagnoses concluded as glioblastoma (Ki-67 labeling index was 50%). Conclusion: The tumor developed in the previously irradiated field, and it was not present prior to the RT. He did not suffer from pathologies favoring the development of the tumor. The interval between the radiation exposure and the onset of the second tumor was approximately 29 years, and the histotype of the tumor differed from the original tumor. Considering these clinical features, we diagnosed the glioblastoma as a radiation-induced tumor. Radiation-induced malignant glioma occurs frequently in patients after the treatment for acute lymphoblastic leukemia. Therefore, the radiation-induced malignant glioma after the treatment for germinoma is rare. Regardless of age, histology, and RT dosages, the patient has the possibility to develop radiation-induced malignant glioma. In conclusion, it is necessary to have careful monitoring even after 20–30 years of RT.

Mild cerebrospinal fluid (CSF) hypovolemia is a well-known clinical entity, but critical CSF hypovolemia that can cause transtentorial herniation is an unusual and rare clinical entity that occurs after craniotomy. We investigated CSF hypovolemia after microsurgical aneurysmal clipping for subarachnoid hemorrhage (SAH). This study included 144 consecutive patients with SAH. Lumbar drainage (LD) was inserted after general anesthesia or postoperatively as a standard perioperative protocol. CSF hypovolemia diagnosis was based on three criteria. Eleven patients (7.6 %) were diagnosed with CSF hypovolemia according to diagnostic criteria in a postoperative range of 0–8 days. In all patients, signs or symptoms of CSF hypovolemia improved within 24 hours by clamping LD and using the Trendelenburg position. As a cause of acute clinical deterioration after aneurysmal clipping, CSF hypovolemia is likely under-recognized, and may actually be misdiagnosed as vasospasm or brain swelling. We should always take the etiology of CSF hypovolemia into consideration, and especially pay attention in patients with pneumocephalus and subdural fluid collection alongside brain sag on computed tomography. These patients are at higher risk developing of pressure gradients between their cranial and spinal compartments, and therefore, brain sagging after LD, than after ventricular drainage. We should be vigilant to strictly manage LD so as not to produce high pressure gradients.

A case of apoplectic lymphocytic hypophysitis complicated by polymyalgia rheumatica (PMA) is described. A 72-year-old man was admitted to our hospital due to severe headache. Two months prior to admission, the patients had exhibited recent-onset stiffness and myalgia of shoulder and pelvic girdle that was compatible with PMR. Magnetic resonance imaging revealed a mass lesion in the pituitary fossa with focal hemorrhage. Endocrinologic studies demonstrated hypopituitarism. The headache and myalgia were improving with corticosteroid treatment; however, a trans-sphenoidal surgery was performed due to visual field loss. A white-colored mass was resected, and histologic examination showed diffuse infiltration of lymphocytes and plasma cells consistent with lymphocytic hypophysitis. Post-operatively, the headache and visual field loss resolved completely. This is the first documented case of apoplectic lymphocytic hypophysitis complicating PMR, and a possible mechanism for this rare association was discussed.

OBJECTIVES: As endovascular treatment becomes more prevalent, aneurysm recurrence from neck remnants, recanalization, incomplete obliteration and bleeding remain major concerns. In the current analysis, we attempted to identify factors related to disease progression and clinical outcome in patients treated with coil embolization. METHODS: This study included 58 patients who underwent endovascular coil embolization for treatment of intracranial aneurysm. The result of embolization was evaluated with three-dimensional time-of-flight magnetic resonance angiography (TOF MRA) and classified as a complete occlusion, a residual neck (minor, central and marginal types), a residual dome (central and marginal types). Patients were followed up clinically and radiologically. Statistical analyses were performed to establish factors that influenced the occurrence of adverse events such as recurrence of aneurysm. RESULTS: Overall, the complete occlusion rate was 18.8%, the occurrence of a residual neck was 67.2%, and the residual dome rate was 14.1%. The mean clinical follow-up was 31.2 months. Recurrences were found in 18 aneurysms, and major recurrences were retreated with coiling or surgery. The post-treatment study revealed that the marginal-type aneurysm filling has a significant impact on outcome. Thus, perianeurysmal edema was correlated with recurrence of the aneurysm. CONCLUSIONS: Three-dimensional TOF MRA was a sensitive tool for visualizing residual filling of embolized aneurysm and is useful for long-term follow-up of patients., Neurological research, 31(7), pp.674-680; 2009

Percutaneous transluminal angioplasty with stenting (PTA/stenting) for intracranial atherosclerotic stenoses is usually performed without any protection devices. We report a unique case of atherothrombotic stenosis with the vulnerable plaque in the cavernous portion of the internal carotid artery (ICA), which was successfully treated by PTA/stenting under cerebral protection with the flow reversal system. A 68-year-old woman presented repetitive transient ischemic attacks in the right ICA territory. Cerebral angiography revealed 80% stenosis in the cavernous portion of the right ICA. High-resolution magnetic resonance imaging (HR-MRI) demonstrated lipid-rich plaques at this lesion. PTA/stenting was performed with a proximal protection device under flow reversal. A filter device captured much amount of atherothrombotic debris with lipid-rich macrophages and leukocytes, which was consistent with HR-MRI findings. Some selected cases of intracranial atherothrombotic ICA stenoses may need endovascular treatment with cerebral protection system. HR-MRI is useful to evaluate plaque characteristics even in the cavernous portion of the ICA., Clinical neurology and neurosurgery, 110(10), pp.1031-1034; 2008

We present a unique case of a cavernous sinus (CS) dural arteriovenous fistula (DAVF), which recurred at adjacent sinuses following repeated transvenous embolizations (TVEs). A 68-year-old woman presented with progressive left conjunctival chemosis and diplopia. Cerebral angiography revealed a left CS DAVF, which was completely obliterated by TVE via the left inferior petrosal sinus (IPS). Two years later, the DAVF recurred in the left IPS, and again in the left sigmoid sinus (SS) 3 years after the initial treatment in spite of a second TVE. Moreover, the left SS and the left internal jugular vein, which had been previously stenotic, had been occluded. The third TVE resulted in the complete obliteration of the SS DAVF. CS DAVFs may recur at adjacent sinuses even after complete obliteration by TVE. Careful follow-up is necessary to check for the recurrence of DAVFs, especially in cases with venous flow changes, such as sinus occlusion, following endovascular treatment., The original publication is available at www.springerlink.com, Radiation medicine, 26(7), pp.431-437; 2008

Endovascular occlusion has been accepted as a safe, minimally invasive, and reliable treatment for ruptured dissecting aneurysms. Occlusion of the entire affected area is ideally the most complete treatment for such lesions. However, it is difficult to occlude the entire dissected lesion when it involves side branches due to the short-term risk of side branch occlusion, emboli dislodgement, and the long-term risk of parent artery recanalization. We herein present an extremely rare case where recanalization occurred after endovascular occlusion of a ruptured dissecting aneurysm of the posterior cerebral artery, and discuss its clinical implications. There are three mechanisms of recanalization: coil compaction due to loose or short segment packing, secondary dissection and occlusion of the false lumen. In endovascular occlusion of dissecting aneurysms that involve side branches, it is important to consider the risk of both recanalization and ischemic complications. We should attempt to insert the microcatheter into the true lumen and maintain dense packing as long as possible, unless the coils occlude the side branches following the procedure. Careful follow-up is necessary in all patients that received endovascular treatment.

Macrophages and by-products are important in plaque destabilization in atherosclerosis. Ultra-small superparamagnetic particles of iron oxide (SPIO)-enhanced magnetic resonance (MR) imaging may be suitable for the detection of macrophages in atherosclerotic plaques. The present study investigated the potential of MR plaque imaging using SPIO in 10 patients scheduled for carotid endarterectomy before and 24-43 hours after administration of SPIO (fercarbotran, 0.016 ml/kg). Three-dimensional gradient recalled acquisition in the steady state (3D-GRASS) was used for detecting macrophages within plaques. Signal loss on the post-contrast 3D-GRASS images was found in 5 of 10 cases, and accumulation of SPIO particles in the vessel wall was confirmed in 4 of these 5 cases. Intracytoplasmic localization of SPIO particles within recruited macrophages was verified by double staining analysis. A correlation between MR plaque imaging using SPIO and localization of macrophages was demonstrated in 6 of 10 patients. This study indicates that MR plaque imaging using SPIO is a potential functional imaging tool to detect infiltration of macrophages in human atherosclerotic carotid plaque., Neurologia medico-chirurgica, 48(4), pp.157-162; 2008

Giant fusiform aneurysms at the basilar trunk tend to have a poor natural history, and the surgical management for these aneurysms remains controversial. For these aneurysms, basilar trunk occlusion may offer a potentially long-lasting cure. However, the strategy for these aneurysms is difficult when the collateral supply from the carotid circulation is poor. The authors herein present a successful case of a thrombosed giant fusiform aneurysm at the basilar trunk with a poor collateral supply using repeated balloon test occlusion (BTO) and a second bypass surgery.A 46-year-old female was admitted to our institute because of progressing double vision. A radiologic examination revealed a thrombosed giant fusiform aneurysm at the upper basilar trunk, and the collateral supply from carotid circulation was poor. We attempted to perform a second bypass surgery before the basilar trunk coil occlusion due to intolerance after the repeated BTO. After confirmation of her tolerance against the third BTO, the aneurysm was successfully trapped using the endovascular technique.Various kind of bypass surgery should be tried for endovascular trapping of giant fusiform basilar trunk aneurysms, and repeated BTO is necessary to confirm the tolerance after bypass surgery especially for the complex aneurysms without a sufficient collateral supply.

Background Early detection of vulnerable plaques at risk of causing thromboembolic events is very important, and many investigators report the usefulness of high-resolution MRI. The purpose of this study was to determine whether the detection of atherosclerotic carotid plaques can be enhanced after administration of contrast agents and, if so, to evaluate the potential for functional information. Methods We studied 9 patients (10 subjects) who underwent a high-resolution MRI examination using a gadolinium-based contrast agent before CEA. Pre- and postcontrast-enhanced T1-weighted images were reviewed, and their histopathologic characteristics evaluated in the corresponding tissue slices. Results Strong contrast enhancement patterns were found in 6 of 10 subjects. For 5 of 6 subjects, many microvessels with inflammatory cells or intraplaque hemorrhages were demonstrated in their corresponding tissue slices. Contrast enhancement patterns were noted to be focal, diffuse, and along the luminal surface or the vessel adventitial boundary. Moreover, some plaques were clearly demonstrated by using contrast agent, and others were clearly divided into fibrous and lipid regions. Conclusion Gadolinium-based contrast agent can penetrate human atherosclerotic carotid plaques. The extent or size of neovascularization and the endothelial permeability are likely related to the mechanism of enhancement, and contrast-enhanced MRI may be essential for the identification of plaque neovascularization which is an important factor of vulnerable plaques. In addition to morphologic information, with the functional information provided using various contrast agents, we may expect a more correct diagnosis of carotid plaques at risk of causing thromboembolic events.

Background Echography is a convenient and noninvasive method of characterizing carotid artery plaques. However, recent reports suggest that multisequential MR imaging may yield better data regarding the instability of asymptomatic carotid artery plaques. Therefore, the goal of the present study was to show the useful information for asymptomatic carotid artery plaque. Methods A total of 6 patients (5 men, 1 woman; age range, 62-76 years; mean age, 69.2 years) with carotid artery plaques, which were detected during medical check-up using carotid MR angiography and/or echography, underwent MR imaging. Two-dimensional TOF MR angiography, T1WI, and fat-suppressed, cardiac-gated, black-blood proton density image, and T2WI were obtained with a 1.5-T MR imager. All plaques underwent carotid endarterectomy and histological examination. Results The MR imaging demonstrated high signals in at least one modality in 4 of 7 plaques. In the remaining 3 patients, MR imaging detected partial-high signals, which corresponded to histologically confirmed partial lipid core or hemorrhagic components in the fibrous tissues The TOF MR imaging showed 2 cases of thin fibrous caps, and MR imaging also showed a large mural thrombus in 1 patient. Conclusions Magnetic resonance imaging was useful in characterizing factors associated with plaque instability in patients with asymptomatic carotid artery plaques and may help guide therapeutic strategies for asymptomatic carotid artery plaques.

Background: Acute lymphoblastic leukemia (ALL) is the most common childhood malignancy. Although it was considered to be a poor prognostic disease, modern treatment protocols (aggressive chemotherapy and prophylactic cranial irradiation) have resulted in dramatically improved survival rates. In a group of low-risk ALL patients, the 5-year survival rate is estimated to be 85%. However, ALL patients who undergo this treatment are at risk of developing secondary neoplasms related to treatment, which has become an increasingly recognized problem. Case Description: A 3-year-old boy with ALL was successfully treated with chemotherapy (vincristine, prednisolone, mercaptopurine and methotrexate) and prophylactic cranial irradiation (total 18 Gy). At the age of 23, he was admitted to our hospital for weakness in the right leg. Computed tomography and magnetic resonance imaging revealed a parasagittal tumor of the left frontoparietal lobe with perifocal edema. The tumor was completely removed surgically and pathohistologically diagnosed as atypical meningioma. Conclusion: Long-term survivors who received radiotherapy for ALL in childhood are at risk for late complications, including radiation-induced meningioma. Therefore, careful follow-up neurological examinations, for example magnetic resonance imaging, are indicated in these patients. In addition, late complications should be taken into account during the initial planning of prophylactic radiotheraphy dosage, which has implications for informed consent of the patient.

Purpose: To determine whether the signal changes on magnetic resonance imaging (MRI), including fluid attenuated inversion recovery (FLAIR), T2*-weighted gradient echo (GE) imaging, and diffusion-weighted imaging (DWI) in diffuse axonal injury (DAI) patients correlate with the clinical outcome. Material and Methods: We diagnosed patients with DAI based on the following criteria: 1) a loss of consciousness from the time of injury that persisted beyond 6 h; 2) no apparent hemorrhagic contusion on computed tomography (CT); 3) the presence of white matter injury on MRI. Twenty-one DAI patients were analyzed (19 M, 2 F, mean age 34 years) with MRI (FLAIR, T2*-weighted GE imaging, and DWI). Results: 325 abnormalities were detected by MRI within a week after injury. The T2*-weighted GE imaging was significantly more sensitive than FLAIR and DWI in diagnosing DAI. DWI detected only 32% of all lesions, but could depict additional shearing injuries not visible on either T2*-weighted GE imaging or FLAIR. The mean number of lesions in brainstem detected by DWI in the favorable group (good recovery/moderately disabled) was significantly smaller than in the unfavorable group (severely disabled/vegetative survival/death). This trend was not observed on the T2*-weighted GE imaging and FLAIR findings. Conclusion: DWI cannot detect all DAI-related lesions, but is a potentially useful imaging modality for both diagnosing and assessing patients with DAI.

Objectives We quantified the rCBF and regional vascular reserve (CVR) in adult patients with moyamoya disease before and after surgery using IMP I 123 SPECT. Methods The patient population included 5 adult patients with ages at presentation ranging between 23 and 42 years. One patient had stroke, whereas 4 patients had transient ischemic attacks. Results Before surgery, the mean resting rCBF and mean CVR in the frontal, parietal, and temporal lobes of the surgically treated hemisphere were 40.09, 39.50, and 36.9 mL/100 g per minute and 15.39%, 27.09%, and 28.92%, respectively. After surgery, the rCBF increased significantly ( P = .0002, .0005, and .0062), but in a CVR evaluation, only the frontal lobe increased significantly ( P = .0055). In the unaffected hemispheres, the mean resting rCBF significantly increased only in the frontal lobe ( P = 038) and no significant increase in the CVR was observed after surgery. In 2 patients who showed steal phenomenon induced by acetazolamide administration, CVR significantly increased not only in the frontal lobe but also in the parietal and temporal lobe after surgery, although the CVR in these areas significantly decreased both before and after surgery in comparison to the mean CVR in all patients. Conclusions The frontal lobe showed severe hemodynamic ischemia. The cerebral hemodynamics in patients with moyamoya disease improved after surgical intervention, especially in severely damaged patients. Split-dose 123 I-IMP SPECT was therefore found to be a useful diagnostic modality for quantifying the hemodynamics of moyamoya disease.

We describe an adult case of Moyamoya disease (MMD) with progression, and review the clinical and radiographic records obtained in previous published reports of adult-onset (over 20 years) MMD with progression. A 43-year-old Japanese woman presented with MMD with angiographically verified progression. The first angiogram depicted severe stenoses at the terminations of both internal carotid arteries. Four years later, she was readmitted to our hospital for surgical treatment because of recurrent TIA once or more per month. An angiogram demonstrated marked progressive appearance. We confirmed only 19 cases of MMD with progression including our present one. We could roughly divide these cases into two groups by angiographic appearance (unilateral or bilateral lesions at diagnosis). Ischemic stroke was the most common initial presentation, and there were only two cases with hemorrhagic stroke. The mean period until follow-up angiography was 35.3 months, and most cases (84.2%) progressed to advanced stage within five years. About half (42.9%) of the patients were asymptomatic when angiographic progression was confirmed. Adult-onset MMD with progression includes several different pathological patterns. We suggest that careful observation is needed for at least five years after initial presentation to assess progression of MMD even in adult-onset cases.

Objective We report our experience using high-resolution magnetic resonance imaging (MRI) to identify carotid plaques and also discuss these MRI findings while comparing them with carotid endarterectomy specimens. Methods Eighteen carotid plaques from 17 different patients were observed using plaque MRI. The patients included 14 men and 3 women, aged 53 to 75 years (mean, 68.6 yr). Eight patients experienced a stroke and four patients experienced transient ischemic attack. The remaining five patients did not experience any neurological symptoms. Two-dimensional time-of-flight (TOF) MR angiography; T1-weighted imaging; fat-suppressed, cardiac gated, black-blood proton density imaging; and T2-weighted imaging were obtained with a 1.5-T MRI. Results Symptomatic plaques showed either vast or partially dotted high signals for each contrast. The high signal intensity on time-of-flight and T2-weighted imaging predicted the instability of the plaques (100% sensitivity and specificity). In particular, time-of-flight imaging predicted intraplaque hemorrhaging with 100% sensitivity and 80% specificity. MRI revealed that three of four asymptomatic lesions were unstable plaques. Conclusion High-resolution MRI was able to detect various signal patterns related to the plaque components, and it was thus considered to be very useful for evaluating plaque instability. The application of plaque MRI therefore may positively affect the decision-making process when selecting optimal therapeutic strategies to treat with carotid plaques.

Orbital infarction syndrome is a rare disorder resulting from cclusion of the ophthalmic artery and its branches. Zimmerman t al. first reported six patients with proptosis, opthalmoplegia nd blindness immediately after intracranial aneurysm surgery as rbital infarction syndrome [1]. To present, only ten cases (3 litertures) of orbital infarction syndrome after intracranial aneurysm urgery have been reported [1–3]. However two of three literaures were described by ophthalmologists. Neurosurgeons should ay attention to this rare but devastating complication. In order to ssist the early diagnosis of this complication, we report upon two ases of orbital infarction syndrome after intracranial aneurysm urgery.

BACKGROUND Basilar artery occlusion usually has a very poor outcome and is associated with a high mortality rate. Local intra-arterial thrombolysis may improve the clinical outcome and reduce mortality in the treatment of acute basilar artery occlusion. We evaluated the possible variables affecting recanalization and clinical outcome in patients with basilar artery occlusions undergoing thrombolytic therapy. METHODS We analyzed retrospectively the clinical course and outcome of a series of 26 patients between 1998 and 2001. All patients who were examined within 24 hours after onset of symptoms underwent emergency cerebral angiography and subsequent intra-arterial thrombolysis. Three patients additionally received percutaneous transluminal angioplasty of underlying stenosis at the site of thrombosis. RESULTS Outcome was good in 9 patients (34.6%) and poor in 17 (65.4%). Recanalization could be achieved in 24 patients (92.3%) and was not affected by age, sex, site of occlusion, etiology, thrombolytic drugs, or time interval. Good outcome was associated with younger age, good initial clinical condition, and no evidence of brain stem infarction. There was no association between the interval (greater or less than 6 hours) from the onset of symptoms until the end of thrombolysis and survival. CONCLUSIONS We confirm that intra-arterial thrombolysis reduces mortality in basilar artery occlusion. Young patients (

✓ Three cases of giant fusiform aneurysms in the middle cerebral artery (MCA) presenting with hemorrhages of different origins are reported, and appropriate literature is reviewed to investigate the characteristics of these lesions. Two patients had suffered a subarachnoid hemorrhage and the other had an intramural hemorrhage (dissection). Pathologically, these aneurysms presented with hemorrhages of different origins; classic rupture type (Case 1), dissection type (Case 2), and atherosclerosis-related thrombosis type (Case 3). Based on surgical and pathological investigations in these three cases and a review of the reported literature, the authors propose that giant fusiform aneurysms in the MCA are characterized by weaknesses in the internal elastic lamina with intimal thickening. Therefore, these lesions have the potential to present with hemorrhage in each of the three types. This finding indicates that there is a strong relationship between the pathological features of giant fusiform aneurysms and their clinical course, and that it is necessary to determine appropriate therapy for giant fusiform aneurysms in the MCA by evaluating cerebral blood flow, even if the lesions are found incidentally.

Polyarteritis nodosa (PAN) is a rare, systemic necrotizing vasculitis of small and medium size arteries that leads to aneurysms in various organs. Aneurysms associated with PAN are common in visceral arteries, however, intracranial aneurysms are rare, especially in childhood. A pediatric patient with PAN developed serial hemorrhagic strokes from a ruptured superior cerebellar artery aneurysm (subarachnoid hemorrhage) and a de novo aneurysm of the frontoorbital artery (intracerebral hemorrhage) after 9 months. Patients with PAN who present with intracranial aneurysms are candidates for intervention even if the aneurysm is unruptured and still small, and close observation is needed to detect de novo aneurysms in patients with chronic history of PAN.

A 61-year-old man with a history of cerebellar infarction was transferred to our hospital for the treatment of vertebral artery (VA) stenosis. The VA dissection was treated with endovascular stent placement followed by coil embolization in which shrinkage of the dissecting aneurysm was confirmed by the three-dimensional driven equilibrium (3D DRIVE) sequence. Using 3D DRIVE, the outer contour of the aneurysm was well visualized, free from the influence of the metallic devices. 3D DRIVE may be useful in the follow-up assessment of the vertebrobasilar artery after stent-assisted coil embolization.

Dolichoectasia of the intracranial arteries is a rare condition, and the vertebrobasilar system and the internal carotid artery are the most commonly involved structures. We report a rare case of idiopathic dolichoectasia of the anterior cerebral artery in a 22-year-old female. The patient caused an automobile accident and was brought to our hospital in an ambulance. A computed tomography scan and magnetic resonance imaging revealed no fresh lesions, but showed a prominent serpentine structure with calcification and flow void in the region of the interhemispheric fissure, which was suspicious for arteriovenous malformation or arteriovenous fistula. Cerebral angiography demonstrated extensive dilatation of the anterior cerebral artery, but no evidence of arteriovenous malformation or arteriovenous fistula. Single photon emission computed tomography revealed hypoperfusion of the right frontal lobe at rest. Electroencephalography showed no epileptic discharge. The patient's course was uneventful, and she was discharged with no neurologic deficit. There are few reports of hemodynamic changes in cases of dolichoectasia. In the diagnosis of cerebral dolichoectasia, cerebral hemodynamics should be examined carefully in addition to evaluating vascular disease by angiography.

Background Stroke is a major cause of dysphagia, but little is known about when and how dysphagic patients should be fed and treated after an acute stroke. The purpose of this study is to establish the feasibility, risks and clinical outcomes of early intensive oral care and a new speech and language therapist/nurse led structured policy for oral feeding in patients with an acute intracerebral hemorrhage (ICH). Methods A total of 219 patients with spontaneous ICH who were admitted to our institution from 2004 to 2007 were retrospectively analyzed. An early intervention program for oral feeding, which consisted of intensive oral care and early behavioral interventions, was introduced from April 2005 and fully operational by January 2006. Outcomes were compared between an early intervention group of 129 patients recruited after January 2006 and a historical control group of 90 patients recruited between January 2004 and March 2005. A logistic regression technique was used to adjust for baseline differences between the groups. To analyze time to attain oral feeding, the Kaplan-Meier method and Cox proportional hazard model were used. Results The proportion of patients who could tolerate oral feeding was significantly higher in the early intervention group compared with the control group (112/129 (86.8%) vs. 61/90 (67.8%); odds ratio 3.13, 95% CI, 1.59-6.15; P < 0.001). After adjusting for baseline imbalances, the odds ratio was 4.42 (95% CI, 1.81-10.8; P = 0.001). The incidence of chest infection was lower in the early intervention group compared with the control group (27/129 (20.9%) vs. 32/90 (35.6%); odds ratio 0.48, 95% CI, 0.26-0.88; P = 0.016). A log-rank test found a significant difference in nutritional supplementation-free survival between the two groups (hazard ratio 1.94, 95% CI, 1.46-2.71; P < 0.001). Conclusions Our data suggest that the techniques can be used safely and possibly with enough benefit to justify a randomized controlled trial. Further investigation is needed to solve the eating problems that are associated with patients recovering from a severe stroke.

We herein report the first case of progressive perianeurysmal edema preceding the rupture of a small saccular aneurysm, without any intervention or intraluminal thrombosis. A 71-year-old woman was incidentally noted to have a cerebral aneurysm (5mm in diameter) at the lower basilar artery. Twelve months later, magnetic resonance (MR) imaging showed a T2-elongated area around a dome of the aneurysm buried in the brain stem, suggesting perianeurysmal edema formation. Interestingly, the edema progressed with the formation of a bleb, in addition to an increase in size of the aneurysm over the following 3-year period. The aneurysm eventually ruptured as a brain stem hemorrhage without any subarachnoid clots 3 days after the final check-up with MR imaging, by which a significant increase of edema formation with an increase in size of the aneurysm and a marked expansion of the bleb was observed. These findings raise the possibility that bleb formation and an enlargement of a small cerebral aneurysm might also be associated with perianeurysmal edema and a subsequent aneurysmal rupture. In addition to the pulsatile flow and/or compression from the expanded aneurysm, local inflammation in the aneurysm wall may play an important role in such edema formation., Clinical neurology and neurosurgery, 111(2), pp.216-219; 2009

Specific binding sites for atrial natriuretic peptide (ANP) in the choroid plexus of rats with induced or congenital hydrocephalus were examined using in vitro quantitative receptor autoradiographic methods. The number of 125I-ANP binding sites in the choroid plexus of rats with kaolin-induced hydrocephalus was significantly higher as compared to findings in the control rats, whereas no differences in the binding affinity were observed 3 days and 3 weeks after the intracisternal injection of kaolin. Conversely, rats with congenital hydrocephalus (LEW-HYR and HTX rats) had a small number of binding sites for 125I-ANP in the choroid plexus, as compared to findings in the control rats. These alterations may relate to the pathophysiology of hydrocephalus. The possibility that atrial natriuretic peptide may be involved in the regulation of cerebrospinal fluid production in the choroid plexus must be considered.

Arterial communication between cavernous segments of the carotid arteries associated with unilateral agenesis of the internal carotid artery (ICA) is extremely rare. We herein present a case of unilateral ICA agenesis with transcavernous anastomosis that presents with an anterior communicating artery (ACoA) aneurysm, and discuss its embryogeny and clinical implications. A 55-year-old woman with no significant medical history was admitted to our hospital for further examination of agenesis of the left ICA, which was detected in a routine medical examination. She was free of clinical symptoms and had no neurological deficits. Radiological evaluation revealed agenesis of the left ICA with transcavernous anastomosis. Moreover, an incidental multilobulated aneurysm was detected at the ACoA. She underwent microsurgical clipping for this aneurysm, and the post-operative course was uneventful. Investigation of collateral pathways helps our understanding of the segmental nature of carotid artery development. Recognition of this anomaly also has important implications in the surveillance and detection of associated cerebral aneurysms.

✓The authors report three cases of progressive vasogenic brain edema surrounding a cerebral aneurysm after endovascular coil embolization. In all three cases embolization was incomplete due to the aneurysms' large sizes and wide necks. Follow-up magnetic resonance imaging revealed de novo vasogenic brain edema surrounding the aneurysms 3 to 6 months after the initial treatment. The edema progressed in parallel with regrowth of the aneurysms. All three aneurysms were deep in the brain parenchyma and showed intramural enhancement, suggesting hemorrhage or inflammation. Each patient underwent a second embolization for the aneurysm regrowth, which resulted in improvement of the edema. Based on the findings in these cases and review of the literature, it is suggested that incomplete occlusion of larger aneurysms that are deep within the brain may lead to a disorganized intraluminal thrombosis, aneurysm pulsing, and intramural hemorrhage or inflammation, all of which are associated with brain edema following aneurysm recanalization and regrowth. It should be kept in mind that incomplete embolization of larger aneurysms may cause such malignant change and that this complication may occur after endovascular treatment.

Atherosclerosis is currently considered a chronic inflammatory disease, and evidence is accumulating for a role of the immune system in the progression of atherosclerosis. Dendritic cells are specialized antigen-presenting cells with the unique ability to initiate a primary immune response to certain antigens by the activation of naive T-lymphocytes. Although dendritic cells are well known to be important in the development of different diseases, studies of vascular dendritic cells in atherosclerosis are rare, and their role is not clearly understood. Therefore, we investigated the immunohistochemical expression of vascular dendritic cells in atherosclerotic plaques. Between April 2003 and December 2005, carotid endarterectomy was performed in 26 consecutive patients, and 27 carotid plaque specimens were analyzed. We investigated the immunohistochemical expression of vascular dendritic cells in human carotid plaques by measuring the signal intensity of fascin-positive cells using an image analyzer. In addition, these immunohistochemical results were related to clinical data. The highest signal intensity of dendritic cells was found in plaque shoulders, and the mean signal intensity of dendritic cells was significantly higher in complicated than in uncomplicated plaques (P = .0029). Moreover, the mean signal intensity of dendritic cells in plaques from symptomatic patients was significantly elevated compared with plaques from asymptomatic patients (P = .0004). Although atherosclerotic plaque instability is determined by multiple factors, the immune and inflammatory pathways play a particularly important role. Dendritic cells play a role in atherosclerosis, and the present study suggests that the expression of dendritic cells in human carotid arteries may be strongly associated with the occurrence of ischemic stroke.

OBJECTIVE: Endodermal cysts are commonly found in the anterior spinal cord. Reports of intracranial cases are uncommon. We report a case of endodermal cyst located on the left oculomotor nerve. CLINICAL PRESENTATION: A 16-year-old female experienced diplopia followed by headache. Neurological examinations revealed left oculomotor nerve palsy. Magnetic resonance imaging scans showed a well-defined multilocular cystic mass in the proximity of the left oculomotor nerve at its exit from the midbrain. INTERVENTION: This patient underwent biopsy and drainage of the cyst. At surgery, the cyst seemed to be intrinsic to the oculomotor nerve and could not be totally resected. Pathological examination confirmed the diagnosis of endodermal cyst. CONCLUSION: Intracranial endodermal cysts are rare, particularly when associated with the cranial nerves. To our knowledge, this is the second case of endodermal cyst located on the oculomotor nerve. A detailed discussion and review of these case reports are presented.

T2*-weighted gradient echo (GE) imaging is useful for detection of intracranial hemorrhage in the patients with diffusion axonal injury (DAI). However, the temporal changes in the DAI-related lesions on T2*-weighted GE images are not clear. We report two very rare cases with DAI in which lesions identified on T2*-weighted GE images resolved in less than ten days.

Background and Purpose High-resolution magnetic resonance (MR) image has been introduced to diagnose and follow-up moyamoya disease and visualized moyamoya vessels and internal carotid artery stenosis. This study was performed to assess the utility of MR angiography (MRA) for the evaluation of anastomotic channels through the external carotid artery (ECA) in moyamoya disease patients. Methods Twenty patients with moyamoya disease were reviewed. The cortical anastomosis and superficial temporal artery (STA), middle meningeal artery, and deep temporal artery by MRA were evaluated and were compared with those by digital subtraction angiography if obtained. Fifteen patients (24 hemispheres) underwent bypass surgery, including encephaloduroarteriosynangiosis in 14 hemispheres and STA–middle cerebral artery anastomosis with encephalomyosinangiosis in 10 hemispheres. Five patients did not undergo any surgery. Results MRA could show these vessels and the patency of anastomosis formed by the surgery and also showed naturally formed anastomosis and ECA tributaries in the patients who did not undergo any surgery. Conclusion MRA provides useful information for follow-up evaluation on the development of the ECA system in moyamoya disease.

A series of 10 cases of posterior cerebral artery (PCA) aneurysms were retrospectively reviewed. There were five men and five women aged 38 to 68 years (mean 57.5 years). Seven patients presented with subarachnoid hemorrhage. Two aneurysms were found incidentally during clinical examination for stroke. One aneurysm was associated with moyamoya disease. All aneurysms were saccular. The aneurysms arose from the P_1 segment in three patients, the P_1/P_2 junction in three patients, the P_2 segment in three patients, and the P_3 segment in one patient. Two patients died before operation and one patient refused surgery. Aneurysmal clipping was performed for seven patients. All aneurysms except the P_2 and the P_3 aneurysms were treated via the pterional approach. Four patients had excellent outcome, but one patient with a P_3 aneurysm developed homonymous hemianopsia due to thrombosis of the parent vessel and another patient with a P_2 aneurysm had moderate disability from the initial insult. Coil embolization has been indicated as the first choice of therapy, but PCA aneurysms are good candidates for direct clipping., Neurologia medico-chirurgica, 44(4), pp.164-169; 2004

Background The authors present a rare case of a ruptured aneurysm at the choroidal branch of the posterior inferior cerebellar artery (PICA). Case description A 77-year-old female was admitted to our institute because of sudden onset of severe headache and vomiting. Radiologic examination revealed intraventricular hemorrhage caused by rupture of the aneurysm at the choroidal branch of the PICA. The fusiform aneurysm was resected after ligation via a midline suboccipital approach. Conclusion The conclusions drawn from this experience and a review of the literature include the following: (1) the aneurysm at the branch of the PICA is frequently associated with anomalies of the vascular structure, particularly in hypoplasty of the contralateral PICA; (2) hemodynamic stress is speculated to be a causative factor of these lesions; (3) cases with hypoplasty of the contralateral PICA have the possibility of developing nonmycotic peripheral aneurysms at the branch of the PICA; (4) these aneurysms should be managed immediately because of the high risk of rebleeding.