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Purpose Incomplete stent apposition after the treatment of brain aneurysm can increase the risk of thromboembolic complications and remains to be the major concern during the procedure. Utilizing the high resolution cone-beam CT (HR-CBCT) and metal artifact reduction software (MAR), the metal artifact produced by the coil mass is reduced and the visualization of the deployed stent is optimized. After combining with the 3D digital subtraction angiography (3D-DSA), the resulting image is used for the evaluation of the stent apposition in the artery. Initial clinical experience of this novel imaging method is reported. Methods A total of 24 aneurysm patients who underwent the stent assisted coil embolization was selected for this study. All patients were treated using either Neuroform® stent or Enterprise® stent system. Artis PURE® Platform (Siemens) was used in this study. Acquisition protocols are follows. A HR-CBCT acquisition was performed to obtain the image of stent and coil mass. The dataset was then reconstructed using MAR. A 3 D DSA acquisition was performed for the visualization of the vasculature. The two datasets were combined using a dedicated software. A 3D volume rendering (VR) image was created and the stent apposition of each treated patient was evaluated. Results All 24 patients underwent the image acquisition successfully. Relationship between the deployed stent and the wall of the parent artery was well visualized in every patient although partial image defect of the stent due to the metal artifact was observed in the relatively large aneurysms. The incomplete stent apposition was frequently seen near the carotid siphon, especially at the inner curve of the target vessel. Conclusion Combination of high resolution cone-beam CT and 3D DSA for the evaluation of intracranial stents provided sufficient visualization of the deployed stent and parent artery. This imaging method can be used for the evaluation of stent apposition during/after the treatment of brain aneurysms. Disclosures I. Yuki: 1; C; Siemens Grant. S. Hataoka: None. T. Ishibashi: 1; C; Siemens Grant. C. Dahmani: 5; C; Employee of Siemens Healthcare. A. Ikemura: None. Y. Kambayashi: None. I. Kan: None. Y. Abe: None. S. kaku: None. K. Nishimura: None. T. Kodama: None. Y. Sasaki: None. Y. Murayama: 1; C; Siemens Grant.

Superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis is a common procedure for the treatment of cerebral ischemia and is useful for cerebral aneurysms and tumors. The STA has to pass through the dura and the dura cannot be sutured tightly around the STA to prevent vessel narrowing, so subcutaneous cerebrospinal fluid (CSF) collection is common. This study analyzed the feasibility of using a synthetic dural sealant in the STA-MCA anastomosis to establish watertight closure. Twenty-four patients underwent STA-MCA anastomosis for cerebral ischemia or cerebral aneurysm. After creation of a standard STA-MCA anastomosis, the dura was reapproximated closely, leaving a small defect around the STA. Then, DuraSeal(TM) was sprayed over the dural defect, and a negative-pressure drain was positioned before closing the skin. Only two patients developed subcutaneous CSF collection, which was managed conservatively. The patency of the anastomosis was proven by magnetic resonance angiography in all cases, and no ischemic complication suggesting chemical spasm of the STA due to the sealant occurred. With DuraSeal(TM), watertight dural closure can be obtained easily and safely in bypass surgery.

Objective: To evaluate if the MRI image findings of carotid arterial plaques using Magnetization-Prepared Rapid Acquisition with Gradient Echo (MPRAGE) is associated with the risk of thromboembolic event during carotid artery stenting (CAS). Methods: A total of 109 carotid stenting was performed on 99 patients. Correlation between the Pre-operative MRI findings of carotid arterial plaque using MPRAGE and the procedure related thromboembolic event was assessed. Distal protection devices were used in all cases including a balloon protection device (Guardwire) and filter devices (AngioguardXP, Filterwire EZ). All lesions were classified into three types according to the intensities on MPRAGE: high intensity (group A), intermediate intensity (group B) and iso-intensity groups (group B). Procedure related morbidity within 30days of procedure was evaluated using Modified Rankin Scale (MRS). Results: Neurological ischemic events associated with the carotid stenting occurred in 11 out of 109 procedures (10.1%). Two (1.8%) cases showed persistent neurological deficit and six (5.5%) showed transient neurological events. Ocular ischemia occurred in 3 cases (2.8%). Thromboembolic events in group A (n=40), group B (n=36) and group C (n=30) were 7 (23.3%), 4 (11.1%) and 0 (0%), respectively. The incidence of thromboembolic events was significantly higher in the combined group A and B as compared to that in group C (P=0.006). Thromboembolic events of CAS with use of Guardwire, Angioguard and Filterwire were 12.1%, 14.3% and 0%, respectively. In CAS for high intensity plaque (n=66), incidence of thromboembolic event with use of Angioguard (4 of 15, 26.7%) was higher than that of Guardwire (7 of 38, 18.4%). In group A, none of the cases (n=20) treated with filter wire showed procedure related ischemic event. Conclusions: High intensity plaque on MPRAGE can be related to high rate of thromboembolic events during CAS.

We used percutaneous cardiopulmonary support (PCPS) to resuscitate a 54-year-old man who had stabbed himself in the left anterior chest with a chopstick. Chest computed tomography showed that the chopstick had penetrated the heart. As he was in shock due to the development of tamponade while waiting for emergency surgery, we immediately decided to initiate PCPS. After cardiopulmonary bypass was established through a median sternotomy replacing PCPS, the chopstick was removed and the stab wounds were closed by mattress sutures. The postoperative course was uneventful.

OBJECTIVE Fusiform aneurysm of the anterior cerebral artery is rare and difficult to treat because of perforators. We encountered a patient with subarachnoid hemorrhage due to rupture of a fusiform aneurysm of the anterior communicating artery complex, and treated this patient with cerebral revascularization. CASE PRESENTATION A 39-year-old man presented with sudden severe headache resulting from subarachnoid hemorrhage. Digital subtraction angiography showed dilatation from the distal A1 segment to the proximal A2 segment of the left anterior cerebral artery. Despite intensive conservative treatment, repetitive angiography showed aneurysmal growth from this dilated portion. INTERVENTION Proximal clipping and clip-on wrapping on the A2 segment was successfully performed with a A3-A3 bypass. He was discharged without neurological deficit. CONCLUSION Cerebral revascularization technique is necessary to achieved appropriate obliteration without ischemic complications.

Venous thromboembolic complications are frequently caused by nephrotic syndrome, while arterial thrombosis has rarely been reported. We report the successful treatment of a 53-year-old man who suffered from sudden severe pain of the left lower limb and facial edema. Abdominal computed tomography showed that the left common iliac artery was occluded from its origin. Although he had left peroneal nerve paralysis, thrombectomy and fasciotomy were performed for limb salvage. Renal biopsy revealed minimal change nephrotic syndrome after the operation. No recurrence has been observed. Nephrotic syndrome might be considered as a cause of acute arterial thrombosis.

A 38-year-old man was involved in a traffic accident and experienced a heavy blow to the abdomen. He had traumatic abdominal aortic dissection with right lower extremity ischemia. He underwent percutaneous balloon fenestration, which is safe and minimally invasive, for relief of right lower extremity ischemia. He has been working for 2 years without any signs of vascular compromise. Percutaneous balloon fenestration is one of the few treatments for traumatic abdominal aortic dissection. (J Vasc Surg 2000;32: 616-8)

症例は71歳の男性で, 左腰痛を主訴に来院した. CTにより, 最大径5cmの炎症性腹部大動脈瘤と左水腎症と診断され, 内科に入院した. 1カ月後のCTにより, 動脈瘤は7cmに拡大し, 後腹膜腔への破裂が判明したため, 緊急手術になった. 瘤の後壁に50×10mmの破裂孔と血腫が存在し, sealed rupture と考えられ, 直型人工血管で動脈瘤を置換した.

We report successful surgical treatment in a case of acute type A aortic dissection complicated with distal arch aneurysm. A 74-year-old man presenting with sudden posterior headache was found by enhanced computed tomography to have an ascending aortic dissection (type A) and a distal arch aneurysm of 69 mm in maximal minor axis diameter. We performed total arch replacement, employing a four-branched graft and elephant trunk anastomosis through a median sternotomy. Because the aneurysm was not effectively thrombo-excluded, we performed descending aorta replacement using the elephant trunk through the left fifth intercostal space on the 44th postoperative day. The postoperative course was uneventful.

Saphenous vein graft (SVG) aneurysms are an unusual but potentially fatal complication after coronary artery bypass grafting (CABG). We report a case of multiple SVG aneurysms 23 years following CABG. Although the patient was on dialysis and had a poor left ventricular function, the aneurysms were successfully excised, and the ascending aorta was uneventfully replaced to be possible for percutaneous coronary intervention in the near future.

The pitfall of percutaneous cardiopulmonary support (PCPS), which is thought to be useful for the detection of massive pulmonary emboli in patients, was investigated. A case of massive pulmonary embolism occurring 9 days after repair of the left Achilles tendon in a 31-year-old woman is described. Preoperatively, the thrombi in the right atrium and between the left popliteal vein and soleus muscle vein, as well as a massive pulmonary emboli, were detected. Despite using PCPS, it was difficult to maintain arterial pressure because of the outflow cannular occlusion caused by the floating thrombus in the right atrium, and so therefore the patient became hemodynamically unstable. After the removal of the thrombus and after a cardiopulmonary bypass was established, a pulmonary embolectomy was performed.

We grew single crystals of ullmannite NiSbS and PbBiSe with the cubic chiral structure and carried out electrical resistivity, specific heat, and de Haas–van Alphen (dHvA) experiments to clarify their Fermi surface properties. The Fermi surfaces were found to split into two, reflecting the non-centrosymmetric crystal structure. The splitting energies between the two nearly spherical electron Fermi surfaces named α and α′ were determined as 220 K in NiSbS and 1050 K in PdBiSe for H || [100] or [001]. This difference in splitting energies between the two compounds originates mainly from the fact that the spin–orbit interactions of Ni-3d, Sb-5p, and S-3p electrons in NiSbS are smaller in magnitude than those of Pd-4d, Bi-6p, and Se-4p electrons in PdBiSe, respectively.

Purpose Fastest decision making for cerebral stroke is absolutely imperative to raise the chance of patient good recovery. With the increasing demand for immediately diagnosis and treatment of stroke, the telemedicine has become one of the most important tools to access the fast and immediate communication, and support the efforts of stroke team. ‘JOIN’ has been developed to maximize the communication by rapidly accessing diagnostic images and clinical information, taking advantage of today most common communication format: social network/SMS. Methods ‘JOIN’ was created to maximize the sharing and communication of patient data and images between hospital systems and paramedical staff members in and out of the hospital, through the today’s most common device: smartphones. ‘JOIN’ can transfer information such as clinical data, CT, MR, Angiographic and intraoperative images, as well as having on-fly expert opinion and real-time discussion inside of same chat room, making ‘JOIN’ the single and ultimate hub for the professionals to access ‘what’s going on’ with the patient.. The system is specially maximized for the communication in emergencies. Results A new pilot run of ‘JOIN’ in our hospital showed adequate performance and proper information flow, resulting in proper diagnosis and management of all stroke patients. The ‘JOIN’ system was introduced to our institution in August 2014, for communication with our affiliated hospitals. Conclusions The ‘JOIN’ is an efficient tool of appropriate standard management in most time demanding treatments of stroke. It is our belief that adoption of this app with smartphone will allow us to help and save the lives of more patients with cerebral stroke. Disclosures H. Takao: 1; C; NTT DOCOMO, INC.. T. Ishibashi: None. I. Yuki: None. S. Kaku: None. I. Kan: None. K. Nishimura: None. R. Mori: None. M. Watanabe: None. Y. Kanbayashi: None. Y. Yeh: None. K. Irie: None. T. Sakano: None. H. Arita: 5; C; NTT DOCOMO INC. T. Oobatake: 5; C; NTT DOCOMO INC. Y. Murayama: 1; C; NTT DOCOMO, INC.

Purpose To evaluate the potential advantages and limitations of 4D-DSA image acquisition, the acquired images on the patients with arteriovenous malformations (AVMs) and aneurysms were reviewed and analyzed. Methods Brain arteriovenous malformation (AVM) and brain aneurysm patients who underwent 4D-DSA during the pre and post assessment for the endovascular / surgical treatment were included. The obtained source image information of the 4D-DSA was transferred to a dedicated workstation and reconstructed using a software, “Syngo Dyna4D © ”. The results were reviewed and interpretation of each image finding was evaluated. The radiation dose required for each examination was calculated, and compared with that required for conventional 5-second 3D-DSA acquisitions. Results 10 aneurysm patients and 4 AVM patients underwent 4D-DSA. One patient had both an intracranial aneurysm and an AVM. 6 aneurysm patients underwent 6-second acquisition protocol. 12-second acquisition was used for all AVM patients as well as 4 aneurysm patients. For aneurysm evaluation, with a temporal sampling of 28.7-volumes/sec and a region of interest (ROI) of 42 cm x× 42 cm, the quality of the image was not sufficient to evaluate contrast flow patterns in the aneurysm although the sizes of all aneurysms were less than 10 mm in the largest diameter. With 12-second acquisition, anatomical information of both arteries and veins were simultaneously obtained in one scan, which was useful for the pre-operative evaluation of surgical clipping. For AVMs, temporal change in the appearance of each feeding artery clearly differentiated the different feeding patterns of each artery to the nidus component. Detailed anatomical structures, e.g. a stenosis in the main drainer which was not detected in the 2D-DSA and difficult to see in the conventional 3D angiogram, were better depicted in the 4D-DSA images. Average surface dose of the radiation was 115 mGy in the 6-second acquisition, 225 mGy in the 12-second acquisition and 105 mGy in the conventional 3D angiogram. Conclusions 4D-DSA provides useful information for the treatment planning of AVM patients by depicting the temporal change in the 3D-DSA. Current temporal resolution was not sufficient for the evaluation of contrast flow patterns in the small aneurysms. The 12-second acquisition which covers the entire arterial phase to the venous phase required approximately double the radiation dose of the conventional 5-second 3D-DSA. However, the dose required for the 6-second acquisition, which mainly covers the arterial phase, was similar to the conventional 3D-DSA. Disclosures I. Yuki: 1; C; Siemens Grant. T. Ishibashi: None. A. Ikemura: 1; C; Siemens Grant. Y. Kambayashi: None. I. Kan: None. Y. Abe: None. C. Dahmani: 5; C; Siemens K. K.. S. Kaku: None. K. Nishimura: None. Y. Murayama: 1; C; Siemens Grant.

Hemodynamic forces, including cyclic strain (CS) and shear stress (SS), have been recognized as important modulators of vascular cell morphology and function. PTEN (also known as MMAC1/TEP1) is a lipid phosphatase that leads to a decrease in intracellular phosphatidylinositol 3,4,5 trisphosphate (PIP3) and therefore can modulate the stimulating effect of phosphatidylinositol 3-kinase (PI3K). In this study, we focused on the upstream regulators of the PI3K-Akt pathway by assessing Akt, PTEN, casein kinase 2 (CK2) (a kinase that catalyzes phosphorylation of PTEN), and PI3K activity in endothelial cells (EC) exposed to CS. The activity of phospho-PTEN (n = 4) and phospho-CK2 (n = 4) increased in a time-dependent fashion, reaching maximal activity by 10 min of CS stimulation. The peak of phospho-Akt activity (n = 4) occurred later, at 60 min. Akt activity was altered by transfection of EC with dominant negative PTEN plasmids. Furthermore, CS increased PIP3 immunoreactivity in a time-dependent manner, reaching maximal activity after 60 min of CS stimulation, and these effects were affected by transfection of EC with dominant negative PTEN plasmids. Inhibition of PTEN activity had no effect on CS-mediated cell proliferation but inhibited CS-mediated suppression of apoptosis. J. Cell. Biochem. 100: 515–526, 2007. © 2006 Wiley-Liss, Inc.

Fluid shear stress is thought to be important in maintaining the phenotype of endothelial cells (ECs) in vivo. The purpose of the study was to determine the effect of varying levels of laminar shear stress on EC elongation and alignment and the role of p38 mitogen-activated protein kinase (MAPK) on the morphologic change induced by shear stress. Cultured bovine aortic ECs were subjected to 1, 4, 7, 14, or 20 dyne/cm(2) laminar steady shear stress. On morphometric analysis of static ECs, the average orientation angle was 41 degrees , whereas after 24 h shear stress at 1, 4, 7, 14, and 20 dyne/cm(2) the angles were 34 degrees, 33 degrees, 16 degrees, 11 degrees, and 10 degrees, respectively. The shape index of static ECs was 0.76, whereas the indexes of ECs exposed to shear stress were 0.72, 0.72, 0.65, 0.50, and 0.47, respectively. The time and the magnitude of activation of p38 MAPK were dependent on the level of shear stress. The results indicate that a minimum shear stress of 7 to 14 dynes/cm(2) is necessary for cell alignment and elongation and this correlates with activity of p38 MAPK. ECs exposed to shear stress in the presence of the p38 MAPK inhibitor SB-203580 did not orient in any manner and the shape index was similar to the static cells.

A case of a 19-year-old man with ulcerative colitis (UC) developed multiple pulmonary nodular shadows with cavity formation, elevated perinuclear antinuclear cytoplasmic antibody (pANCA) and positive lymphocyte stimulation test by drug (DLST) for mesalazine suggesting mesalazine induced Wegener's granulomatosis (WG). Transbronchial biopsy specimens were consistent with WG and thoracoscopic biopsy specimens were consistent with bronchiolitis obliterans organizing pneumonitis (BOOP). We diagnosed WG with BOOP-like variant, which was induced by mesalazine. To our knowledge, this is the first report of a limited form of WG associated with orally administered mesalazine.

Purpose Stent assisted coil embolization recently became a common treatment strategy for the wide neck aneurysms. Normal digital subtraction angiography (DSA), however, does not allow visualization of the deployed stents. With a combination of novel Metal Artefact Removal software (MAR) and C-arm CT, the coil mass, stent, and contrast material can be differentiated. In this study, experimental aneurysms were treated with stent assisted coil embolization and image analysis was performed using the C-arm CT and MAR. I. V. injection of the contrast to obtain the images was also performed. Methods A total of 12 experimental aneurysms were created in 6 swine. The aneurysms were treated with coil embolization using stent assisted technique. High Resolution (HR) C-arm CT with intra-arterial injection of the contrast dye (20%) was performed immediately after the treatment and obtained images were processed with MAR. Intra venous contrast injection (non-diluted) from femoral vein was also performed in 3 swine. Visualization of the residual aneurysms as well as coil loops protruded into the stent lumen was evaluated. Two patients previously treated with stent assisted coil embolization underwent the same image acquisition protocol, and the obtained images were evaluated. Results Coil loops protruded into the stent lumen, which were not visible before the MAR due to the significant metal artefact, were well visualised after the MAR. Likewise, Contrast filling into the residual aneurism was observed after the MAR in every aneurysm. Intravenous injection of the contrast material reproduced similar image quality as compared to the intra arterial injections. The C-arm CT images of the two patients showed remarkable reduction of the metal artefacts after the MAR processing. Conclusions The combination of the C-arm CT and MAR enables the differentiation of the coil mass, stent and contrast material by markedly reducing the metal artefact produced by the coils. This novel image modality may contribute to the evaluation of aneurysms treated with stent assisted coil embolization. Disclosures I. Yuki: 1; C; Siemens Grant. Y. Kambayashi: 1; C; Siemens Grant. A. Ikemura: 1; C; Siemens Grant. I. Kan: 1; C; Siemens Grant. Y. Abe: None. A. Mohamed: 5; C; Siemens Japan KK. C. Dahmani: 5; C; Siemens Japan KK. T. Ishibashi: 1; C; Siemens Grant. I. Kajiwara: 1; C; Siemens Grant. K. Nishimura: 1; C; Siemens Grant. Y. Murayama: 1; C; Siemens Grant.

Background and Purpose Double catheter coil embolisation (DCC) technique has been used for the treatment of wide neck aneurysms. Unlike Stent assisted Coil Embolisation (SAC), DCC does not require long term post-treatment anti-platelet therapy. Whether or not DCC can reduce the procedure related complications in SAC is not clear. In this series, consecutive unruptured wide neck aneurysm patients were treated primarily with the DCC. SAC was only used as a rescue therapy when the coil mass in the aneurysm was considered to be unstable. Clinical as well as angiographical outcomes of those who treated with DCC were reviewed. Methods A total of 597 unruptured aneurysm patients were treated in our institution between 2006 and 2012. Of these, 144 patients with wide neck (neck size >4.0 or dome-neck ratio Results A total of 129 patients were treated with DCC only, and 5 patients were shifted to the SAC based on the intra-procedural findings. The average neck size and the average dome-neck ratio of the treated aneurysms were 6mm and 1.3 respectively. Every aneurysm treated with DCC was successfully embolised. Intra-operative hemorrhagic event occurred in 2 cases. There was no intra-operative thrombo-embolic event. During the average follow up period of 809 days, post operative symptomatic ischaemic events were seen in two cases (1.6%) and post operative hemorrhagic event (procedure unrelated) was seen in 1 case (0.8%). Permanent morbidity and mortality throughout was 2.4% and 0.8% respectively. Recanalisation that required re-treatment was seen in 14.7% but there was no procedure related complication during the re-treatment. Conclusion The angiographic outcomes of the aneurysms treated with DCC in this series were comparable to the historical controls of the wide neck aneurysms treated with other adjunctive techniques. To minimise procedure related ischaemic/haemorrhagic event associated with the SAC, DCC may be a potential candidate of alternative treatment. Disclosures I. Yuki: None. T. Ishibashi: None. H. Arakawa: None. K. Irie: None. H. Takao: None. I. Kajiwara: None. K. Misaki: None. K. Nishimura: None. A. Ikemura: None. T. Abe: None. Y. Murayama: None.

Purpose To improve the visualisation of residual neck in the aneurysms treated with coil embolisation utilising the time-resolved contrast enhanced magnetic resonance angiography (4D MRA). Materials and Methods A total of 11 patients who underwent coil embolisation of brain aneurysm underwent 1.5 Tesla 4D MRA one year after the procedure. Of these, 6 patients were treated with stent assisted technique. The image information obtained from the 4D MRA was re-processed utilising a 3D Neuroimaging software (TeraRecon, Inc.) and compared to the images obtained from the cerebral angiograms. Results Six patients showed major recanalisation and five patients showed minimal residual neck of the treated aneurysm in the cerebral angiogram. The 4D MRA images obtained from each patient was consistent with the images from the cerebral angiogram. The susceptibility artifact induced by the coils and stents was significantly reduced as compared to the images of contrast enhanced time of flight (CE-TOF) images. The re-processed 3D images of 4D MRA in the Neuroimaging software showed great reproducibility of angiographical findings obtained from the cerebral angiograms. Conclusion The combination of the 4D MRA and utilisation of the 3D Neuroimaging software showed great visualisation of residual aneurysm. This imaging method can be a good alternative for the post-procedure follow up angiograms in the patients who underwent coil embolisation. Disclosures A. Ikemura: None. I. Yuki: None. T. Ishibashi: None. H. Arakawa: None. K. Irie: None. H. Takao: None. I. Kajiwara: None. K. Nishimura: None. I. Kan: None. Y. Murayama: None.