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BACKGROUND Both filum terminale arteriovenous fistulas (FTAVFs) and filum terminale lipomas (FTLs) are rare. Because of this rarity, there is a paucity of data regarding concomitant FTAVF and FTL, and the optimal treatment remains to be defined. The authors describe a patient with coexisting FTAVF and FTL treated with single-stage surgery. OBSERVATIONS A man in his 70s was referred to the authors’ department because of a suspected spinal vascular malformation seen on magnetic resonance imaging that was performed to investigate lower limb weakness, intermittent claudication, and urinary incontinence. Previous imaging had shown a terminal lipoma with an internal flow void. Computed tomography angiography and digital subtraction angiography revealed an FTAVF, the feeder being a lateral sacral artery. The patient was treated surgically with curative intent. The FTL and tethered cord that had been identified by imaging were treated in the same procedure. Postoperative digital subtraction angiography showed absence of the abnormal vessels. The patient was discharged home on the 19th postoperative day. LESSONS When considering treatment, it is important to determine whether symptoms are attributable mainly to FTL, tethered cord, or FTAVF. One-stage treatment is useful because it eliminates both the FTAVF and the factors that led to its development.

Background Aneurysms at the origin of a duplicated middle cerebral artery (DMCA) are quite rare. Here, we report a patient with such an aneurysm successfully treated endovascularly using our novel “wrapped-candy” low-profile visualized intraluminal support (LVIS) technique. Case Description A 44-year-old woman underwent endovascular treatment for an unruptured wide-necked aneurysm at the origin of a DMCA that incorporated the origin of the DMCA into its neck. Stent-assisted coiling was performed using our newly developed “wrapped-candy” LVIS technique. To protect the origin of the DMCA and increase the stent metal density at the neck, an LVIS blue 3.5-mm × 22-mm stent was deployed by pushing the delivery wire aggressively to transform the visible wire components of the LVIS into a shape like “wrapped candy,” maximizing the strut compaction at the neck of the aneurysm. Subsequently, the aneurysm component was coiled using a jailed microcatheter. The final procedural angiography demonstrated almost complete aneurysm occlusion with DMCA preservation. Conclusions Stent-assisted coiling can be a feasible treatment for an unruptured, usually wide-necked, aneurysm at the origin of a DMCA. The wrapped-candy LVIS technique may be useful in more challenging morphologies such as wide-necked aneurysms that incorporate the branch origin into the aneurysm neck.

Extramammary Paget’s disease (EMPD) is a rare form of neoplasm. Metastasis of EMPD to locations other than lymph nodes and intra-epithelial regions is rare; there are a limited number of case reports of metastases to the liver, lung, bone, and brain. We present a rare case of EMPD that metastasized to the brain and was treated with surgical resection. A 66-year-old man presented with a small palpable mass in the scrotum. After 5 years of observation, he was diagnosed with EMPD that metastasized to the lymph nodes and lung. Tumor resection and postoperative chemotherapy were performed. Six months after the last chemotherapy treatment, he presented with a right temporal lobe tumor and underwent surgical resection. Histopathological analysis revealed brain metastasis of EMPD. Three months after surgery, magnetic resonance imaging (MRI) showed local tumor recurrence, and intensity modulated radiation therapy (IMRT) (45 Gy/15 Fr) was performed. Although the metastatic brain tumor was well controlled, the primary tumor progressed. He was provided best supportive care and died 5 months after brain tumor resection. In this report, we present a rare case of brain metastasis of EMPD, treated with surgical resection, and histopathologically confirmed to be metastatic EMPD.

Background: Stent infection after carotid artery stenting (CAS) can be a life-threatening postoperative complication, but there is a paucity of data due to its exceedingly low frequency. We report a case of stent infection with pseudoaneurysm formation after CAS that was treated through replacing the infected stent and pseudoaneurysm with a polytetrafluoroethylene (PTFE) synthetic vessel graft. Case Description: An 86-year-old man was treated for the right internal carotid artery with CAS in local hospital. One month after stenting, he suffered aspiration pneumonia and septicemia. Three months after stenting, swelling and tenderness of the right side of his neck appeared. His general condition deteriorated due to septicemia and he was unable to ingest anything by mouth as a result of decreasing levels of consciousness. He was transferred to our hospital. Computed tomography and digital subtraction angiography showed the presence of a pseudoaneurysm around the stent. The neck mass enlarged daily and surgical intervention was required to prevent closure of the airway. Stent and pseudoaneurysm resection and in situ reconstruction with a PTFE synthetic vessel graft were performed. The patient returned to his local hospital 36 days after surgery and had a modified Rankin Score of 5. Conclusion: Although the risk of reinfection is high due to the nature of artificial material, stent/pseudoaneurysm resection and in situ reconstruction with a PTFE synthetic vessel graft might be one of the best options for patients suffering stent infection after CAS. To the best of our knowledge, this is the first report of treatment using this material.

BACKGROUND AND PURPOSE: The appropriate period of follow-up examinations after endovascular embolization for cerebral aneurysms using time-of-flight MR angiography is not well-known. We retrospectively investigated long-term results after endovascular embolization for unruptured cerebral aneurysms and evaluated the periods from embolization to recanalization and retreatment. MATERIALS AND METHODS: Between April 2006 and March 2011, one hundred forty-eight unruptured aneurysms were treated with endovascular coil embolization. Among them, we investigated 116 unruptured aneurysms, which were followed up for >5 years. Time-of-flight MR angiography was performed at 1 day, 3–6 months, 1 year after the procedure, and every year thereafter. RESULTS: The mean follow-up period was 7.0 ± 1.4 years. Recanalization was observed in 19 (16.3%) aneurysms within 2 years. Among them, retreatment for recanalization was performed in 8 (6.8%) aneurysms. No recanalization was detected in any aneurysms that had been stable in the first 2 years after embolization. A larger maximum aneurysm size was significantly correlated with recanalization (P = .019). CONCLUSIONS: Aneurysms in which recanalization was not observed within 2 years after endovascular coil embolization were stable during a mean follow-up of 7 years. This result may be helpful in considering the appropriate span or frequency of follow-up imaging for embolized cerebral aneurysms.

BackgroundEmbolic stroke with large vessel occlusion (LVO) is a major adverse event during ventricular assist device (VAD) support. In this study we aimed to clarify the efficacy of, and problems associated with, endovascular treatment (EVT) of LVO in patients with VAD support.MethodsWe retrospectively reviewed EVT for LVO in patients with VAD support between 2006 and 2017 at our institute and evaluated baseline characteristics, treatment variables, outcomes, and complications.ResultsThe study cohort comprised 12 consecutive patients (age 35.4±20.4 years), with 15 LVO events involving 20 arterial occlusions, who had undergone EVT. The median Alberta Stroke Program Early CT score was 10 and good collaterals were observed in 10 of 17 occluded middle cerebral artery areas. No study patients had received intravenous thrombolysis therapy. EVT was performed on 18 of the 20 occluded arteries and mechanical thrombectomy on 13 vessels. The successful reperfusion (modified Thrombolysis in Cerebral Infarction grade ≥2 b) rate was 67% in all EVTs and 85% with mechanical thrombectomy. Histological analysis showed fibrin-rich thrombi in four of five samples. Seven of 12 patients (58%) maintained their neurological function (modified Rankin Scale score ≤2 or equal to pre-stroke score) at 90 days. Periprocedural complications comprised two symptomatic intracranial hemorrhages and the 90-day mortality rate was 13%. Seven of 10 cardiac transplant candidates (70%) returned to the waiting list and three of them received transplants.ConclusionsEndovascular therapy for acute LVO stroke is feasible even in patients with VAD support.

Background and Purpose: Recent studies have demonstrated that endovascular reperfusion therapy improves clinical outcomes at 90 days after ischemic stroke. However, the effects on long-term outcomes are not well known. We hypothesized that successful reperfusion might be associated with long-term improvement beyond 90 days after endovascular therapy. To assess the long-term effects beyond 90 days, we analyzed the association of successful reperfusion with a temporal change in modified Rankin Scale (mRS) score from 90 days to 1 year after endovascular therapy. Methods: We retrospectively analyzed a database of consecutive patients with acute ischemic stroke who received endovascular therapy between April 2006 and March 2016 at 4 centers. We compared the incidences of improvement and deterioration in patients with successful reperfusion (i.e., modified thrombolysis in cerebral infarction score of 2b or 3) with those in patients with unsuccessful reperfusion. We defined improvement and deterioration as decrease and increase on the mRS score by 1 point or more from 90 days to 1 year after endovascular therapy respectively. Results: A total of 268 patients were included in the current study. The rate of patients with improvement tended to be higher in patients with successful reperfusion than in patients with unsuccessful reperfusion (20% [34/167 patients] vs. 12% [12/101], p = 0.07). The rate of patients with deterioration was lower in patients with successful reperfusion than in patients with unsuccessful reperfusion (25% [42/167] vs. 42% [42/101], p < 0.01). After adjustment for confounders, successful reperfusion was associated with improvement (adjusted OR 2.65; 95% CI 1.23–5.73; p < 0.05) and deterioration (adjusted OR 0.33; 95% CI 0.18–0.62; p < 0.01), independent of the 90-day mRS score. Conclusions: Successful reperfusion has further beneficial legacy effects on long-term outcomes beyond 90 days after stroke.

Ruptured vertebral artery dissecting aneurysm (VADA) causes subarachnoid hemorrhage (SAH), and parent artery occlusion (PAO) with endovascular technique (EVT) has been the first-line treatment for ruptured VADA. In this study, we have extracted 530 ruptured VADA, treated through PAO with EVT, from a nationwide, retrospective, multi-center registration in Japan (JR-NET3), and analyzed factors associated with outcome at 30 days and procedure-related complications. Complete occlusion was achieved in 497 cases (93.8%) and favorable outcome was obtained in 303 cases (59.1%). Older age (≥60 years), male sex, use of general anesthesia, non-specialist as the responsible doctor, and time delay from onset to treatment (≥24 h) were negative factors for favorable outcome in multivariate analysis, although these factors were not associated with procedure-related complications. Compared with previous studies (JR-NET1 and 2), the number of endovascular treatments for patients with VADA and severe SAH increased in this decade; however, the percentage of patients with favorable outcome did not decrease. This might be due to not only the improvement of endovascular treatment itself, but also increased access to endovascular specialists or standardization of management.

Background: Evidence supports endovascular coiling for ruptured intracranial aneurysms (RIAs). However, in some cases, it is difficult to achieve complete occlusion by coiling, such as with wide-neck aneurysms. We report our experience with intentional staged RIA treatment using targeted endovascular coiling at the rupture point in the acute phase, followed by delayed stent-assisted coiling, flow diverter stenting, or surgical clipping. Methods: Consecutive patients with RIAs treated between April 2015 and June 2021 were retrospectively investigated. Clinical characteristics, treatment complications, and patient outcomes data were collected. Results: Among 108 RIAs treated in our hospital, 60 patients underwent initial coiling; 10 patients underwent staged treatment. The aneurysm locations were the anterior communicating artery (n = 5), internal carotid-posterior communicating artery (n = 3), internal carotid-paraclinoid (n = 1), and vertebral artery-posterior inferior cerebellar artery (n = 1). The mean ± standard deviation aneurysmal diameter was 9.6 ± 5.4 mm and the mean aspect ratio was 1.2 ± 0.7. As the second treatment to obliterate blood flow to the neck area, we performed five stent-assisted coiling, two flow-diverter stentings, and three surgical clippings. Only one minor perioperative complication occurred. The median duration between the first and second treatments was 18 days (range, 14– 42 days). Good clinical outcome (modified Rankin scale score 0–2) at 90 days was achieved in 5 (50%) cases. The median follow-up duration was 6.5 months (range, 3–35 months); no rerupture occurred. Conclusion: Intentional staged treatment with a short time interval for RIA was effective and feasible.

BackgroundDuring the COVID-19 pandemic, decreased volumes of stroke admissions and mechanical thrombectomy were reported. The study’s objective was to examine whether subarachnoid haemorrhage (SAH) hospitalisations and ruptured aneurysm coiling interventions demonstrated similar declines.MethodsWe conducted a cross-sectional, retrospective, observational study across 6 continents, 37 countries and 140 comprehensive stroke centres. Patients with the diagnosis of SAH, aneurysmal SAH, ruptured aneurysm coiling interventions and COVID-19 were identified by prospective aneurysm databases or by International Classification of Diseases, 10th Revision, codes. The 3-month cumulative volume, monthly volumes for SAH hospitalisations and ruptured aneurysm coiling procedures were compared for the period before (1 year and immediately before) and during the pandemic, defined as 1 March–31 May 2020. The prior 1-year control period (1 March–31 May 2019) was obtained to account for seasonal variation.FindingsThere was a significant decline in SAH hospitalisations, with 2044 admissions in the 3 months immediately before and 1585 admissions during the pandemic, representing a relative decline of 22.5% (95% CI −24.3% to −20.7%, pInterpretationThere was a relative decrease in the volume of SAH hospitalisations, aneurysmal SAH hospitalisations and ruptured aneurysm embolisations during the COVID-19 pandemic. These findings in SAH are consistent with a decrease in other emergencies, such as stroke and myocardial infarction.

To elucidate the pituitary function of Japanese patients after aneurysmal subarachnoid hemorrhage (aSAH) and implicative factors related to growth hormone deficiency (GHD) after aSAH. We evaluated basal pituitary hormone levels among 59 consecutive aSAH patients with a modified Rankin Scale (mRS) ⩽4 at 3months after aSAH onset. Patients with low insulin-like growth factor 1 (IGF-1) SD score (SDS) or who seemed to develop pituitary dysfunction underwent provocative endocrine testing during a period of 3-36months after SAH onset. The relationship between IGF-1 SDS and clinical factors of the patients such as severity of SAH, aneurysm location, and treatment modalities, were assessed. Six patients (10.2%) demonstrated their IGF-1 SDS less than -2. Multiple logistic regression analyses revealed that patients who underwent surgical clipping had a significantly lower IGF-1 SDS (

INTRODUCTION HIV infection is known to cause a variety of central nervous system complications, such as malignant lymphoma (ML), toxoplasma encephalopathy, cryptococcal encephalopathy, progressive multifocal leukoencephalopathy (PML), brain tuberculosis and HIV encephalopathy. In our hospital, we performed brain biopsy for HIV-positive patients with central nervous system lesions suspected malignant lymphoma, or cases difficult to diagnose with blood, cerebrospinal fluid, and imaging alone. In this study, we retrospectively examined HIV-positive patients who underwent brain biopsy at our hospital, and analyzed diagnosis and treatment of patients with ML. Methods HIV-positive patients who underwent brain biopsy in our hospital from January 2010 to April 2019 were examined in this study. We analyzed background factors, preoperative examination results, pathological diagnosis, treatment and prognosis. RESULTS There were 1,894 HIV-positive patients who were treated at our hospital during the period, of which 16 cases underwent a total of 18 brain biopsies. The final diagnosis was 7 ML (6 PCNSL, 1 brain metastasis), 3 toxoplasma encephalopathy, 1 PML, 1 brain tuberculosis, 1 immune reconstitution syndrome, 1 Penicillium marneffei infection, 1 hematoma and one case that could not be diagnosed. In patients with ML, preoperative sIL-2 receptor was higher and EBV positive cases in cerebrospinal fluid tended to be more common (p=0.051, p=0.086, respectively). Five of the six patients with PCNSL were treated at our hospital, four of which were treated with highly active antiretroviral treatment (HAART) and whole-brain irradiation and one with HAARA alone, resulting four with CR and one with SD. Four patients, except one who had sudden death of unknown cause, were still alive without recurrence (median observation period 44.5 months). CONCLUSION At the moment, it is difficult to diagnose ML without brain biopsy. HIV-positive status has been regarded as a poor prognosis factor in PCNSL patients, but the prognosis seems to have improved with HAART.

AIM We evaluated the association between 11C-methionine positron emission tomography (11C-methionine PET) findings, isocitrate dehydrogenase (IDH) gene mutation, and O6-methylguanine-DNA methyltransferase (MGMT) promoter methylation in patients with grade II and III gliomas. MATERIALS AND METHODS Data were collected from 40 patients with grade II and III gliomas who underwent both magnetic resonance imaging (MRI) and 11C-methionine positron emission tomography (PET) as part of their pre-surgical examination. We examined IDH mutation through DNA sequencing, and MGMT promoter methylation through quantitative methylation-specific polymerase chain reaction (PCR). RESULTS A threshold of MGMT promoter methylation of 1.0% was significantly associated with tumor/normal tissue (T/N) ratio. The T/N ratio in samples with MGMT promoter methylation ≥1.0% was higher than that in samples with MGMT promoter methylation CONCLUSION 11C-methionine PET parameters can predict MGMT promoter methylation but not IDH mutation status. 11C-methionine uptake may have limited potential to reflect DNA methylation processes in grade II and III gliomas.

The epidemiology of patients with traumatic brain injury (TBI) has changed dramatically over recent decades as a result of rapid advances in aging societies. We assessed the influence of age on outcomes of patients with TBI and sought to identify prognostic factors for in-hospital mortality of TBI among elderly patients.Using a nationwide database, we analyzed data from 5651 patients with TBI. Univariate analysis was conducted to compare patient demographics, neurologic status on admission, radiologic findings, systemic complication rates, length of hospital stay, in-hospital mortality, and home discharge rates between elderly and nonelderly groups. Multivariable analysis was conducted to determine prognostic factors for in-hospital mortality among elderly patients.Overall in-hospital mortality was significantly higher in elderly patients (12.8% vs. 19.3%; P0.001). In-hospital mortality of elderly patients with mild TBI increased significantly at7 days after admission, whereas that of elderly patients with moderate or severe TBI was significantly higher immediately after admission. Age (odds ratio [OR], 1.62; P = 0.024), male sex (OR, 1.30; P = 0.004), Japan Coma Scale score on admission (OR, 5.95, P0.001), and incidence of acute subdural hematoma (OR, 1.89; P0.001) were associated with in-hospital mortality in elderly patients with TBI.Elderly patients with TBI showed significantly higher in-hospital mortality. Delayed increases in in-hospital mortality were observed among elderly patients with mild TBI. Level of consciousness on admission was the strongest predictor of in-hospital mortality among elderly patients.

The effect of HydroSoft coils on the prevention of recanalization and thrombosis after embolization is unclear. We herein report the results of the single-armed prospective Japanese HydroSoft Registry.Aneurysms with a diameter of10 mm that were treated with a ≥50% length of HydroSoft coils were registered. We evaluated the safety and recanalization rate and analyzed the factors related to their recanalization and thrombosis 1 year later.In total, 122 aneurysms were registered. Their mean maximum diameter and neck length were 6.4 and 3.9 mm, respectively. The mean length of the HydroSoft coils was 84.3%. No intracranial hemorrhage occurred, but 2 patients developed minor ischemic strokes. Angiographic examination immediately after the procedure showed complete obliteration, neck remnant (NR), and body filling (BF) in 20 (16.4%), 32 (26.2%), and 67 (54.9%) cases, respectively. One-year follow-up angiography showed complete obliteration, NR, and BF in 68 (55.7%), 15 (12.3%), and 15 (12.3%) cases, respectively, and 5 aneurysms (4.1%) were recanalized (4 and 1 with BF and NR as their initial angiographic result, respectively). Another 11 aneurysms still showed BF, although their thrombosis was promoted. No significant factors related to recanalization were identified. A high volume embolization ratio and small neck were significantly associated with thrombosis 1 year after embolization with HydroSoft coils.The safety and prevention of recanalization 1 year after the treatment appeared acceptable. The high volume embolization ratio associated with HydroSoft coils could induce progression of thrombosis for aneurysms characterized by NR and BF during the follow-up period.

Cases Traumatic intracranial aneurysm following blunt head injury is uncommon but can be induced by extension of skull base fracture and causes unexpected hemorrhagic complications. We present two cases of traumatic intracranial aneurysm in the paraclinoid area that was revealed by delayed massive epistaxis. Lack of initial neurological deficits omitted screening for cerebrovascular injury. Outcome Internal trapping was carried out using endovascular techniques in both cases, with extracranial–intracranial bypass in one case. No recurrent bleeding occurred in either case. Conclusion To prevent unexpected delayed life-threatening hemorrhagic accidents, careful assessment of skull-base fracture is prerequisite, even in cases of mild facial injury.

Chemoradiotherapy for primary central nervous system lymphoma (PCNSL) is associated with a considerable risk of long-term neurotoxicity. The present study aimed to assess the health-related quality of life (HRQOL) of outpatients with PCNSL who have received radiotherapy and high-dose methotrexate (HDMTX) chemotherapy, and to determine the factors that cause a decline in HRQOL and interfere with home living. A total of 37 patients were surveyed 0.9–14.2 years after their initial diagnosis and treatment. Each patient completed a multi-part HRQOL questionnaire that was used to examine the associations of HRQOL scores with leukoencephalopathy, Karnofsky performance status (KPS) scores, age, history of recurrence and HDMTX-based chemoradiotherapy. The results demonstrated that the history of recurrence, number of cycles of MTX chemotherapy and age affected the development of leukoencephalopathy. Reductions in KPS score were associated with a history of recurrence (P=0.03), but not with leukoencephalopathy (P=0.8). KPS score, leukoencephalopathy and age were significantly associated with a decline in HRQOL score. A decline in the HRQOL associated with a reduction in KPS score was also observed by multivariate analyses. Deterioration of the HRQOL among outpatients with PCNSL post-chemoradiotherapy was significantly associated with older age (≥66 years) and decreased KPS score. Older patients with a history of recurrence had a higher risk for deteriorated QOL due to development of leukoencephalopathy. Therefore, it is recommended that clinicians monitor the KPS score among outpatients with PCNSL. QOL examination for older patients with a lower KPS score was found to be particularly important for identifying any obstacles for home living.

Low-grade glioma (LGG) is often encountered in relatively young individuals, including women of childbearing age. Notably, case series describing pregnant women with LGG have been reported in the literature. The present study reported a case of pilocytic astrocytoma (PA) requiring tumor resection during pregnancy. The patient had a history of γ-knife radiotherapy for a brainstem tumor 17 years previously. The histological diagnosis was unclear. The tumor had remained stable following radiosurgery for 17 years, including during her first pregnancy. However, rapid tumor growth around the fourth ventricle occurred at week 25 of her second pregnancy. Therefore, an urgent tumor resection was performed despite the pregnancy. Partial resection was performed since the tumor had infiltrated the brainstem. The histological diagnosis was PA. The residual tumor volume decreased gradually following the delivery. Immunostaining of the tumor for the expression of progesterone receptor revealed focal staining. It is possible that reproductive factors, including specific hormonal changes during pregnancy, affected the tumor growth. The present study described this rare case of PA, which exhibited rapid growth and required urgent surgery during pregnancy.

We herein present the case of a 49-year-old female patient presenting with nausea and headache. The patient's medical history included breast cancer with bone and lymph node metastasis. Computed tomography (CT) examination revealed a high-density lesion in the right subdural space, suggesting hematoma. During surgery planned for subdural hematoma drainage, an en plaque subdural yellowish-white tumor was identified, without hematoma. Histopathological examination revealed metastatic breast cancer. The patient was administered predonisolone and her neurological symptoms gradually recovered. However, 12 days after the first operation, the clinical course was complicated by vomiting and rapid loss of consciousness. Emergency CT revealed that the subdural tumor had enlarged and decompression was performed as life-saving surgery. However, the patient's condition progressively deteriorated and she finally succumbed to the disease 2 months after the second operation. The aim of this study was to present the case of a patient with a large en plaque subdural tumor mimicking subdural hematoma and causing rapid loss of consciousness and cerebral herniation.

Background and purpose We report the outcomes of carotid artery stenting for patients with angiographically visible occipital artery–vertebral artery anastomosis. Methods Among 47 consecutive patients who underwent carotid artery stenting from January 2007 to December 2010, seven patients for whom cerebral angiograms clearly showed occipital artery–vertebral artery anastomosis were selected. Four different protection methods were used: distal internal carotid artery protection; carotid flow reversal; seatbelt and airbag technique; and double protection method of protecting both the external and internal carotid artery. Results One patient with distal internal carotid artery protection showed a high-intensity lesion at the border of the upper thalamus, internal capsule and lateral ventricle wall after carotid artery stenting. The other patient with the double protection method did not show any high-intensity lesions on postoperative diffusion-weighted imaging in the vertebrobasilar territory. All seven patients with visible occipital artery–vertebral artery anastomosis showed ipsilateral vertebral artery severe stenosis or occlusion. Conclusion Large occipital artery–vertebral artery anastomosis may be a pathway for embolic materials during carotid artery stenting. External carotid artery protection is recommended for carotid artery stenting in such patients.

Gliomas are genetically and histopathologically heterogeneous. Intratumoral heterogeneity in the MGMT promoter methylation status is an important clinical biomarker of glioblastoma. A higher uptake of 11C-methionine in positron-emission tomography (PET) reportedly reflects increased MGMT promoter methylation; however, non-stereotactic comparison of MGMT methylation and 11C-methionine PET images may not be accurate. The present study examined the correlation between 11C-methionine uptake and MGMT promoter methylation in non-enhancing gliomas using stereotactic image-based histological analysis. Data were collected from 9 patients with newly diagnosed non-enhancing glioma who underwent magnetic resonance imaging and 11C-methionine PET during pre-surgical examination. Clinical data were also collected from 3 patients during repeat surgery. The correlation between 11C-methionine uptake and MGMT methylation or cell density was analyzed using histological specimens obtained by multiple stereotactic sampling and an exact local comparison of 11C-methionine PET images and histological specimens was made. A total of 31 stereotactic sample sites were identified. In newly diagnosed cases, the tumor to normal uptake (T/N) ratio revealed a significant positive correlation with MGMT methylation (R=0.54, P=0.009) and a marginal correlation with cell density (R=0.42, P=0.05). In recurrent cases, the T/N ratio demonstrated no correlation with MGMT methylation (R=0.01, P=0.97) or cell density (R=0.15, P=0.70). An increased uptake of 11C-methionine in PET may reflect increased MGMT promoter methylation according to stereotactic image-based histological analysis. 11C-methionine PET could therefore be a useful tool for detecting regional MGMT promoter methylation in non-enhancing primary glioma.

The introduction of systemic chemotherapy for advanced hepatocellular carcinoma in recent years has led to the prediction that cases of brain metastases from hepatocellular carcinoma will increase. However, because brain metastases from hepatocellular carcinoma are relatively rare, the characteristics of this pathology are poorly understood. We carried out a multicenter retrospective study to verify the characteristics of brain metastases from hepatocellular carcinoma in Japan. A total of 38 patients were enrolled and patient characteristics were poor general condition in many patients due to the progression of primary cancers. Stereotactic radiosurgery/stereotactic radiotherapy alone was the most common treatment (39.5%), with best supportive care provided for 10.5%. Median survival was 6 months, the neurological death rate was 28%, and the rate of brain hemorrhage was high (39.5%). Overall survival was analyzed for correlations with age, etiology of chronic liver disease, albumin–bilirubin (ALBI) grade, RPA classification, control of the primary tumor, number of brain metastases, brain hemorrhage, surgical resection, and radiotherapy. In multivariate analysis, ALBI grade, number of brain metastases and brain hemorrhage showed statistically significant correlation. A multivariate analysis extracted three items—ALBI grade, number of brain metastases, and brain hemorrhage—as prognostic factors for survival of brain metastases from hepatocellular carcinoma.

Background Pseudoaneurysm of the internal carotid artery (ICA) is a very rare but potentially fatal complication of deep neck space infection. Methods This paper describes a very rare case of an ICA pseudoaneurysm rupture in the sphenoid sinus caused by a deep neck abscess. Results A 62-year-old male with a deep neck space infection underwent surgical drainage. On the postoperative 21st day, however, he suddenly had massive epistaxis. A transnasal endoscopic examination found massive bleeding out of the sphenoid sinus. Immediate intra-arterial angiography revealed two pseudoaneurysms of the left ICA at the cavernous segment (C4) and the clinoid segment (C5), which were embolized with coils. The patient made an uneventful recovery after the embolization. Conclusion We found no reports in the literature that pseudoaneurysms associated with a deep neck infection rupture in the sphenoid sinus. Prompt treatment along with accurate diagnosis is essential for successful management of such cases. J. Med. Invest. 66 : 188-189, February, 2019.

The present study retrospectively analyzed the database of the Japanese Registry of Neuroendovascular Therapy 1 and 2 (JR-NET1&2) to determine annual trends, including adverse events and clinical outcomes at 30 days after undergoing neuroendovascular therapy. JR-NET1&2 are surveys that targeted all patients in Japan who underwent neuroendovascular therapy delivered by physicians certified by the Japanese Society of Neuroendovascular Therapy (JSNET) between 2005 and 2009. Medical information about the patients was anonymized and retrospectively registered via a website. Data from 32,608 patients were analyzed. The number of treated patients constantly increased from 5,040 in 2005 to 7,406 in 2009 and the rate of octogenarians increased from 7.0% in 2005 to 10.4% in 2009. The proportion of procedures remained relatively constant, but ratios of angioplasty slightly increased from 32.8% in 2005 to 33.7% in 2009. Procedural complications were associated more frequently with acute stroke (9.6%), ruptured aneurysms (7.4%), intracranial artery disease (ICAD) (5.4%), and arteriovenous malformation (AVM, 5.2%). The number of patients requiring neuroendovascular treatment in Japan is increasing and the outcomes of such therapy are clinically acceptable. Details of each type of treatment will be investigated in sub-analyses of the database.

Background and Purpose The analysis of the pulsation of unruptured intracranial aneurysms might improve the assessment of their stability and risk of rupture. Pulsations can easily be concealed due to the small movements of the aneurysm wall, making post-processing highly demanding. We hypothesized that the quantification of aneurysm pulsation is technically feasible and can be improved by computer-aided post-processing. Materials and Methods Images of 14 cerebral aneurysms were acquired with an ECG-triggered 4D CTA. Aneurysms were post-processed manually and computer-aided on a 3D model. Volume curves and random noise-curves were compared with the arterial pulse wave and volume curves were compared between both post-processing modalities. Results The aneurysm volume curves showed higher similarity with the pulse wave than the random curves (Hausdorff-distances 0.12 vs 0.25, p0.05) and inter-observer (r = 0.45 vs r = 0.54, p>0.05) reliability. Time needed for segmentation was significantly reduced in the computer-aided group (3.9 ± 1.8 min vs 20.8 ± 7.8 min, p

Ischemic preconditioning (IPC), a procedure consisting of transient ischemia and subsequent reperfusion, provides ischemic tolerance against prolonged ischemia in the brain. Although the blood flow changes mediated by IPC are primarily perceived by vascular endothelial cells, the role of these cells in ischemic tolerance has not been fully clarified. In this study, we found that the P2X4 receptor, which is abundantly expressed in vascular endothelial cells, is required for ischemic tolerance following middle artery occlusion (MCAO) in mice. Mechanistically, the P2X4 receptor was stimulated by fluid shear stress, which mimics reperfusion, thus promoting the increased expression of osteopontin, a neuroprotective molecule. Furthermore, we found that the intracerebroventricular administration of osteopontin was sufficient to exert a neuroprotective effect mediated by preconditioning-stimulated P2X4 receptor activation. These results demonstrate a novel mechanism whereby vascular endothelial cells are involved in ischemic tolerance.

We, as a group of international multi-disciplinary neurointerventional societies involved in the endovascular management of acute ischemic stroke, have put forth these training guidelines. We believe that a neuroscience background, dedicated neurointerventional training, and stringent peer review and quality assurance processes are critical to ensuring the best possible patient outcomes. Well-trained neurointerventionalists are a critical component of an organized and efficient team needed to deliver clinically effective mechanical thrombectomy for acute ischemic stroke patients.

Background and Purpose— The hemodynamic factors of aneurysms were recently evaluated using computational fluid dynamics in a static vessel model in an effort to understand the mechanisms of initiation and rupture of aneurysms. However, few reports have evaluated the dynamic wall motion of aneurysms due to the cardiac cycle. The objective of this study was to quantify cardiac cycle-related volume changes in aneurysms using 4-dimensional CT angiography. Methods— Four-dimensional CT angiography was performed in 18 patients. Image data of 1 cardiac cycle were divided into 10 phases and the volume of the aneurysm was then quantified in each phase. These data were also compared with intracranial vessels of normal appearance. Results— The observed cardiac cycle-related volume changes were in good agreement with the sizes of the aneurysms and normal vessels. The cardiac cycle-related volume changes of the intracranial aneurysms and intracranial normal arteries were 5.40%±4.17% and 4.20±2.04%, respectively, but these did not differ statistically ( P =0.12). Conclusions— We successfully quantified the volume change in intracranial aneurysms and intracranial normal arteries in human subjects. The data may indicate that cardiac cycle-related volume changes do not differ between unruptured aneurysms and normal intracranial arteries, suggesting that the global integrity of an unruptured aneurysmal wall is not different from that of normal intracranial arteries.