Intracerebral Hematoma in Patients With Impella Ventricular Assist Device Placement for Cardiogenic Shock: Report of Three Cases.

Despite the clear benefits of Impella in patients with cardiogenic shock, bleeding is a possible complication. Herein, we report three cases of intracerebral hemorrhage in patients with Impella implantation for cardiogenic shock, which were treated with hematoma evacuation. We present the clinical features, diagnosis, and management (hematoma evacuation) of patients with the Impella device (Abiomed, Danvers, Massachusetts) who developed intracerebral hemorrhage. Case one was a 56-year-old man who presented with chest pain and loss of consciousness, was diagnosed with acute myocardial infarction, and underwent urgent percutaneous coronary intervention and Impella placement. After eight days, the patient developed anisocoria. Computed tomography revealed a left intracerebral hemorrhage. An emergency hematoma evacuation was successfully performed (intraoperative blood loss: 2600 mL). Case two was a 54-year-old male who presented with persistent chest pain and loss of consciousness, was diagnosed with acute myocardial infarction, and underwent an emergency percutaneous coronary intervention with Impella implantation and venoarterial extracorporeal membrane oxygenation. The patient developed intracerebral hemorrhage after 26 days. Hematoma evacuation was successfully performed (intraoperative blood loss: 380 mL). Case three was a 52-year-old male who presented with dyspnea and hypotension, was diagnosed with dilated cardiomyopathy, and underwent Impella implantation and venoarterial extracorporeal membrane oxygenation, followed by which the patient developed subcortical hematoma. An emergency hematoma evacuation was performed (intraoperative blood loss: 3205 mL). The patient died 14 days after admission. Intracerebral hemorrhage is a potential cause of morbidity associated with Impella placement. Although hematoma evacuation is optimal, the bleeding tends to increase.

Negative Remodeling of Carotid Canal during Spontaneous Disease Progression in Moyamoya Disease.

OBJECTIVE: This study was designed to observe the changes in the carotid canal over time by measuring the carotid canal diameter longitudinally in adult patients with moyamoya disease in whom disease stage progressed spontaneously. METHODS: Of 70 adult patients with moyamoya disease, 10 adult patients on 15 sides with spontaneous progression of the disease stage during conservative follow-up were included in this study. Another 10 moyamoya cases on 15 sides were selected as the controls without disease progression. All patients were followed up for at least 60 months after the progression of disease stage was confirmed. In addition, 5 patients who underwent microvascular decompression were included as healthy controls. The carotid canal diameter was measured with bone window computed tomography (CT) and source images of time-of-flight magnetic resonance angiography at initial presentation, and then were serially monitored with the latter. RESULTS: There was a significant correlation between the values obtained from CT and magnetic resonance imaging (R2 = 0.992, P < 0.001). The carotid canal diameter in moyamoya disease at initial presentation was 4.29 ± 0.61 mm, being smaller than 5.20 ± 0.51 mm in healthy controls (P < 0.01). In response to disease progression, the carotid canal diameter started to decrease at 6 months after disease progression was confirmed, and reduced to about 85% of the original level during 60 months (P < 0.01). The phenomenon was not observed in patients without disease progression. CONCLUSIONS: The carotid canal diameter can decrease in response to disease progression even in adult moyamoya disease. "Negative" bone remodeling may play a key role in this unique phenomenon.

Long-term Outcomes of Non-syndromic and Syndromic Craniosynostosis: Analysis of Demographic, Morphologic, and Surgical Factors.

In this study, we analyzed the outcomes of patients (followed for 5-38 years, average 17.3 years) with craniosynostosis and evaluated their long-term prognosis. In all, 51 patients who underwent surgery for craniosynostosis between 1982 and 2015, including 12 syndromic and 39 non-syndromic cases, were included. The average age at the initial surgery was significantly lower in the syndromic group than that in the non-syndromic group (9.8 months old vs. 19.9 months, respectively). The surgical procedures did not significantly differ between the two groups, but repeat surgery was significantly more common in the syndromic group than in the non-syndromic group (4 children [30.8%] and 3 children [7.7%], respectively). The children requiring repeat surgery tended to be younger at the initial surgery than those who did not. Those patients who required repeat surgery did not have significantly different surgical procedures initially. The incidence of developmental retardation was 49.0% (43.5% in the non-syndromic group and 66.7% in the syndromic group), and only two children in the non-syndromic group displayed recovery. This study is the first to analyze the prognosis for patients who were followed for at least 5 years after cranioplasty. Repeat surgery was common, especially in syndromic patients. Severity of skull deformity and early initial surgery may be important factors determining the need for repeat surgery. Developmental retardation was also common, and improvement was rare even after surgery.

Intracranial, Intra-parenchymal Capillary Hemangioma - Case Report.

We report a very rare case of intracranial capillary hemangioma. This 15-year-old girl complained of pulsating headache in the temple area that aggravated with change of body positions. This headache usually lasted for 5 min and resolved without any treatment. Preoperative computed tomography (CT) and magnetic resonance imaging (MRI) strongly suggested cavernous hemangioma in the right deep parietal lobe. She underwent complete resection of the tumor through right parietal craniotomy. Postoperative course was uneventful. Histologic examinations demonstrated a densely grown numerous capillary-like vascular structure with endothelial cells, hemosiderin deposition, and hemorrhage. Intracranial, intra-parenchymal capillary hemangioma is a very rare vascular tumor or tumor like lesions. Only four cases with intracranial, intra-parenchymal capillary hemangioma were reported previously. Differential diagnosis includes other vascular tumors such as cavernous hemangioma, but it is not so easy to differentiate capillary hemangioma from other lesions. Therefore, surgical excision and histologic diagnosis would be important to diagnose it if possible.

Repeated Deterioration of Consciousness Resulting from Spontaneous Intracranial Hypotension Associated with Deep Cerebral Vein Stagnation.

BACKGROUND: Although the clinical course of spontaneous intracranial hypotension (SIH) is generally benign, in unusual cases it can result in deterioration of consciousness. The exact mechanisms involved have not always been described in previously reported cases. CASE DESCRIPTION: Herein we describe the case of a 36-year-old man who presented complaining of orthostatic headache. Brain magnetic resonance imaging depicted typical findings associated with SIH. He initially underwent conservative treatments, but he subsequently began to exhibit deterioration of consciousness. Magnetic resonance imaging revealed progressive brain sagging, swelling of the brainstem, and focal hyperintensity in the left side of the thalamus on diffusion-weighted imaging. The vein of Galen was stretched downwards, creating a narrow angle between it and the straight sinus. We concluded that deep venous hypertension had occurred due to functional venous stenosis. He underwent epidural blood patch twice and ultimately recovered without any neurologic deficits. CONCLUSIONS: SIH should be recognized as a possible cause of coma as a result of deep cerebral vein stagnation due to severe brain sagging. A change in the vein of Galen/straight sinus angle may be an anatomic marker associated with functional venous stenosis.

Impact of Plaque Composition on Risk of Coronary Artery Diseases in Patients with Carotid Artery Stenosis.

OBJECT: Recent clinical studies have recently demonstrated a strong association between carotid artery stenosis and coronary artery disease (CAD). However, the clinical impact of carotid plaque composition on CAD remains unclear. This study was aimed to determine the relationship between carotid plaque composition and CAD in patients who underwent carotid endarterectomy (CEA) or carotid artery stenting (CAS). METHODS: This prospective cohort study included a total of 97 patients who were admitted to our institution between January 2012 and April 2016. Magnetic resonance (MR) imaging was performed to semi-quantitatively analyze the components of carotid plaques by calculating the ratio of plaque intensity to muscle intensity on T1-weighted image. Diagnosis of CAD was based on patient history and clinical examinations during preoperative, postoperative and follow-up periods. Multivariate logistic analysis was performed to determine the risk factors for CAD. The relationship between contralateral plaque composition and CAD was also investigated. RESULTS: Of 97 patients, 33 were diagnosed as having 44 episodes of CAD. Multivariate logistic analysis revealed that ASO (odds ratio [OR], 5.7; 95% confidence interval [CI], 1.8-18.9), contralateral carotid occlusive disease (OR, 6.5; 95%CI, 1.7-22.9), and plaque/muscle ratio (OR, 3.0; 95%CI, 1.4-10.1) were independent factors for predicting CAD. The patients diagnosed as having CAD during the follow-up period had significantly higher plaque/muscle ratio than those with CAD on preoperative evaluations (2.29 ± .21vs. 1.97 ± .33, P < .01). CONCLUSIONS: This study clearly demonstrates that ASO, contralateral carotid artery stenosis, and high-intensity carotid plaque on T1-weighted MRI independently predict CAD. Contralateral carotid plaque composition was also associated with concomitant CAD. Moreover, high-intensity carotid plaque may predict the future development of CAD. Therefore, unstable carotid plaque should be considered as the clinical phenotype of systemic inflammation and a novel, robust marker for future CAD.

[Hemorrhage from an Angiographically Obliterated Arteriovenous Malformation after Gamma Knife Radiosurgery:An Immunohistochemistry Study].

A 24-year-old woman was diagnosed with a cerebral arteriovenous malformation(AVM)in the right parietal lobe(Spetzler-Martin grade I). The AVM was treated with stereotactic radiosurgery and was observed to have completely disappeared 3 years after radiosurgery. At the age of 35 years, the patient complained of a headache, and was referred to our hospital. A plain CT scan demonstrated a large cyst with niveau formation in the right parietal lobe. Cerebral angiography identified no recurrence of AVM. However, contrast MRI revealed an enhanced lesion on the surface of the cyst. The patient underwent cyst fenestration and total removal of the obliterated nidus through a right parietal craniotomy. Residual blood flow was confirmed in the obliterated nidus during surgery. The postoperative course was uneventful, and the headache was completely resolved. The patient was discharged without any neurological deficits. On pathological examination, a large number of small vessels were observed within the obliterated nidus. Immunohistochemistry demonstrated that these vessels were positive for CD31, CD34, and VEGFR-2, suggesting that endothelial progenitor cells may be involved in occult recurrence, cyst formation, and late bleeding after stereotactic radiosurgery targeting cerebral AVMs.