Combined Anatomical Anomalies of Direct Aortic Arch Origins of the Left Internal Carotid, Left External Carotid, and Left Vertebral Arteries: A Case Report.

Various branch anomalies of the aortic arch have been reported, but cases with separate origins of the internal and external carotid arteries with combined direct aortic arch origin of the left vertebral artery are extremely rare. Herein, we present a rare case of aplasia of the left common carotid artery with separate origins of the ipsilateral internal and external carotid arteries and vertebral artery from the aortic arch in a 10-year-old girl. In addition, we review the embryological development and clinical implications of these anatomical variations.

Persistent Trigeminal Artery Variant Terminating in the Ipsilateral Superior Cerebellar Artery.

Persistent trigeminal artery (PTA) represent an unusual remnant of the fetal carotid-basilar anastomosis. Persistent trigeminal artery variant (PTAV) is a rare anastomosis between the internal carotid artery and cerebellar artery, without an interposing basilar artery segment. We report the case of 49-year-old female with an incidentally discovered, rare variation of PTA that directly terminated in the ipsilateral superior cerebellar artery. The variation was observed on CT angiography, digital subtraction angiography, and MR angiography. Additionally, we reviewed the embryogenesis of PTA and PTAV and discussed the clinical implications of this variation.

Delayed phase computed tomography angiography ASPECTS predicts clinical outcome and final infarct volume.

BACKGROUND AND PURPOSE: Non-contrast computed tomography (NCCT) Alberta Stroke Program Early CT Score (ASPECTS) and assessment of collateral flow with multiphase computed tomography angiography (CTA) have been investigated as predictors of clinical outcome in patients with acute ischemic stroke. This study assessed the value of multiphase CTA ASPECTS in predicting final infarction core and clinical outcome in patients undergoing endovascular treatment of acute ischemic stroke. METHODS: We retrospectively studied consecutive patients who underwent multiphase CTA prior to endovascular treatment of acute stroke due to anterior circulation large artery occlusion. Multiphase CTA and final diffusion-weighted imaging (DWI) scans were evaluated by two independent observers for NCCT ASPECTS, acute phase CTA (CTA-AP) ASPECTS, delayed phase CTA (CTA-DP) ASPECTS, and final DWI ASPECTS. Modified Rankin Scale score ≤2 at 3 months was considered a favorable outcome. RESULTS: A total of 74 patients were analyzed. We found that CTA-DP ASPECTS (r = 0.82; 95% CI, 0.73-0.91; p < 0.001) correlated with final DWI ASPECTS better than NCCT ASPECTS (r = 0.49; 95% CI, 0.39-0.59) and CTA-AP ASPECTS (r = 0.71; 95% CI, 0.64-0.78). Interobserver agreement was higher for CTA-DP ASPECTS (k = 0.84). Good CTA-DP ASPECTS was an independent predictor of favorable outcome (odds ratio, 8.71; 95% CI, 3.71-17.3; p < 0.001). CONCLUSION: CTA-DP ASPECTS is a reliable predictor of final infarction core and neurological outcome.

Clinical analysis of spinal stereotactic radiosurgery in the treatment of neurogenic tumors.

OBJECT: In this study the authors sought to evaluate clinical outcomes after using stereotactic radiosurgery (SRS) to treat benign and malignant spinal neurogenic tumors. METHODS: The authors reviewed a total of 66 procedures of spinal SRS performed between 2001 and 2013 for 110 tumors in 58 patients with spinal neurogenic tumors, which included schwannomas, neurofibromas, and malignant peripheral nerve sheath tumors (MPNSTs). The clinical and radiological findings were evaluated in patients with benign neurogenic tumors. For the 4 patients with MPNSTs, the authors reported overall survival and results of additional immunohistochemical staining to predict the survival difference among the patients. RESULTS: Of the 92 benign neurogenic tumors, 65 tumors that were serially followed up using MRI after SRS showed significant change in mean tumor volume, from a mean of 12.0 ± 2.6 cm3 pre-SRS to 10.8 ± 2.5 cm3 post-SRS (p = 0.027), over an average of 44 months. The local control rate of benign neurogenic tumors was 95.4%. The 34 patients who presented with clinical symptoms of pain showed a significant symptomatic improvement. The initial mean visual analog scale (VAS) score was 6.0 and decreased dramatically to 1.0 after SRS during an average follow-up period of 10.9 months (median of 8.1 months). Although the proportions of transient swelling and loss of intramural enhancement were significantly different among the groups, there was no statistically significant correlation between those 2 factors and local tumor control (p = 0.253 and 0.067, respectively; Fisher's exact text). Cross-table analysis also indicated that there was no statistically significant relationship between groups with loss of intramural enhancement and transient swelling. The median survival of neurofibromatosis Type 1 (NF1)-related and sporadic MPNSTs was 1.13 and 5.8 years, respectively. Immunohistochemical results showed that S100 was expressed in a sporadic MPNST or neurofibroma, whereas topoisomerase-IIa was expressed in NF1-related MPNSTs. CONCLUSIONS: SRS is an effective treatment modality for benign neurogenic tumors, while MPNSTs showed heterogeneity in their responses to SRS.

Assessment of the treatment response of spinal meningiomas after radiosurgery focusing on serial MRI findings.

PURPOSE: This study evaluated the response of spinal meningiomas to treatment, by monitoring changes in magnetic resonance imaging (MRI) findings after stereotactic radiosurgery (SRS). MATERIALS AND METHODS: Serial follow-up MRIs of 11 patients with spinal meningiomas who underwent SRS were retrospectively reviewed. Changes in tumor volume, T2 signal intensity (T2SI), and contrast enhancement were evaluated. RESULTS: The mean MRI follow-up period was 46.9 months (range 13-108 months). The local tumor control rate was 100 % in overall tumor volume, although boost SRS was performed for marginal recurrence in case 8 and rapid decompression in case 5. Seven tumors showed decreased T2SI. Each of the remaining four tumors showed variable T2SIs. In most tumors, the enhancement patterns did not change. Two of three patients with en plaque type meningiomas showed increased intramedullary T2SI, thought to be due to compressive myelopathy and peritumoral edema. CONCLUSIONS: SRS resulted in successful local tumor control in all patients, although the follow-up period was not long. Changes in T2SI and contrast enhancement patterns of the tumors were evaluated on serial MRI. In addition, close follow-up with MRI is desirable to monitor intramedullary signal changes in cases of spinal meningiomas with a wider contact area with the spinal cord.

Delayed-phase CT angiography is superior to arterial-phase CT angiography at localizing occlusion sites in acute stroke patients eligible for intra-arterial reperfusion therapy.

We compared the accuracy for localizing arterial occlusion sites between delayed-phase computed tomography angiography (CTA) and arterial-phase CTA in acute stroke patients with large vessel occlusion. Institutional Review Board approval was obtained, and informed consent was waived. For patients treated with intra-arterial thrombolysis within a 6 hour window between January 2009 and November 2011, we retrospectively assessed the arterial occlusion sites of pre-treatment, delayed-phase and arterial-phase CTA and compared these with digital subtraction angiography (DSA) findings. The positive predictive value for detection of vessel occlusion for both CTA methods was derived using DSA as a reference standard. The outcomes were compared using the McNemar test. Inter-observer disagreement within each modality was assessed using the Kendall W test. Among 73 patients treated with intra-arterial thrombolysis, 24 (32.9%) underwent both arterial-phase and delayed-phase CTA, and 66 (90.4%) underwent arterial-phase CTA only. For 24 patients undergoing both arterial-phase and delayed-phase CTA, the delayed-phase CTA detected concordant occlusion sites with DSA in 21 patients, yielding a positive predictive value of 87.5%, whereas the arterial-phase CTA detected this in 14 patients, for a positive predictive value of 58.3% (p=0.013). When discordant with DSA, arterial-phase or delayed-phase CTA indicated occlusions in more proximal sites than DSA. Delayed-phase CTA more precisely localized the occlusion site than arterial-phase CTA in acute stroke patients with large vessel occlusion. Thus, delayed-phase CTA findings could guide neurointerventionists in selecting intra-arterial thrombolysis modalities.

Serial CT findings of a rapidly calcified epidural hematoma in a young adult: a case report.

We report serial computed tomography (CT) findings in a rare case of a rapidly calcified epidural hematoma. A 21-year-old female patient was admitted to our hospital after being involved in a motor vehicle accident. An initial cranial CT revealed a right frontal bone fracture. She complained of right frontal headache, but showed no neurological deficit or tendency for bleeding. Therefore, she was treated conservatively without surgical intervention. Follow-up CT revealed an ossified epidural hematoma (EDH) 17 days after the head injury, and the ossification later thickened. However, a decrease in the width of the EDH was observed during the 9 months of follow-up during which serial CT images were acquired. The EDH resolved 9 months after the initial trauma, but the calcification layer remained thickened.

Efficacy and safety of an early Solitaire stent retrieval technique for acute ischemic stroke.

PURPOSE: The aim of this study was to retrospectively evaluate the efficacy and safety of early pull-back of a Solitaire stent as a thrombectomy device in patients with acute ischemic stroke. METHODS: The study group comprised 23 consecutive cases presenting with acute ischemic stroke who were treated with intra-arterial therapy using the Solitaire device as a first-line endovascular procedure. The stent was deployed to cover the thrombus and then left in place for 1-2 min. Immediate angiographic results are presented. Neurologic status was assessed according to the NIH Stroke Scale score (NIHSS) and the modified Rankin Scale (mRS) score. RESULTS: Successful recanalization (TICI grade ≥ 2b) was achieved in 21 of the 23 (91.3 %) treated vessels, and 6 of the patients showed immediate flow restoration after the deployment of the first stent. The mean number of passes for maximal recanalization was 1.96. There were no symptomatic procedure-related complications. Of the cases, 34.8 % improved by >10 points on the NIHSS at discharge; 30.4 % of cases revealed good functional outcome (mRS score 0-2) at 90 days. CONCLUSIONS: The early retrieval technique with the Solitaire stent appears to be a safe and effective method in patients with acute ischemic stroke.

Follow-up MR findings of spinal foraminal nerve sheath tumors after stereotactic irradiation.

PURPOSE: The purpose of this study was to investigate follow-up MR findings of spinal foraminal nerve sheath tumors after stereotactic irradiation. MATERIALS AND METHODS: Thirty-five foraminal nerve sheath tumors in 28 patients who underwent stereotactic radiosurgery (SRS) (n = 28) or stereotactic radiotherapy (SRT) (n = 7) were included. The MR images were reviewed to identify serial changes in tumor volume and intratumoral necrosis. Growth and shrinkage were defined as volume changes of ±19.7 % or more; stability was within ±19.7 %. Transient swelling was defined as shrinkage preceded by significant growth. A tumor with shrinkage or stability was regarded as tumor control. RESULTS: Of 35 tumors, 16 (46 %) were stable, 14 (40 %) shrunk, and 5 (14 %) grew. Transient swelling was seen for 13 (37 %) lesions. Newly developed intratumoral necrosis was observed for 19 (54 %) of 35 tumors and was significantly associated with transient swelling (p = 0.039) and with tumor control (p = 0.017). SRS was not significantly associated with transient swelling. CONCLUSION: In follow-up MR images of spinal foraminal nerve sheath tumors after stereotactic irradiation, newly developed intratumoral necrosis and transient swelling were often seen. Intratumoral necrosis was associated with transient swelling and tumor control.

Cytogenetic and molecular genetic study on granular cell glioblastoma: a case report.

Granular cell astrocytoma is a rare infiltrative malignant glioma with prominent granular cell change. Granular cell astrocytomas are biologically aggressive compared with conventional infiltrating astrocytomas of similar grades, but their genetic alterations are poorly known. We report a case of granular cell glioblastoma and its genetic and molecular features. Histologically, the tumor not only showed features typical of granular cell astrocytoma but also demonstrated frequent mitoses, pseudopalisading necrosis, and vascular endothelial hyperplasia, compatible with glioblastoma. Array-based comparative genomic hybridization and focused molecular genetic analyses demonstrated gain of chromosome 7; losses of chromosome 1p, 8p, 9p, 10, 13q, and 22q; amplification of epidermal growth factor receptor; and homozygous deletion of CDKN2A as well as MGMT promoter methylation. However, neither isocitrate dehydrogenase 1 mutation nor codeletion of 1p/19q was found. Our results indicate that granular cell glioblastomas, despite having its peculiar granular cell changes, share common molecular genetic features with conventional glioblastoma, especially the classical subtype.

Follow-up CT and MR findings of osteoblastic spinal metastatic lesions after stereotactic radiotherapy.

PURPOSE: We retrospectively analyzed pre and post-stereotactic radiotherapy CT and MRI findings and volume changes for osteoblastic spinal metastatic lesions. MATERIALS AND METHODS: Of 114 lesions in 72 patients, 11 were osteoblastic. CT and MR images were reviewed to determine tumor volume, CT attenuation, T2 signal intensities, and contrast enhancement. RESULTS: Tumor volume did not change for 10 lesions and increased for 1 lesion. CT attenuation increased for 8 lesions with heterogeneous T2 signal intensities. Of these 8 lesions, 4 had patterns of dark signal foci and the other 4 had patterns of both dark and bright signal foci. T2 signal intensity became heterogenous, with dark and bright foci, for 2 of 3 lesions for which CT attenuation decreased, and normalized for the third lesion. The degree of contrast enhancement decreased for 6 lesions and did not change for 5 lesions. CONCLUSION: There were no changes in volume except for one case. On CT images, sclerotic changes were more common than loss of sclerotic foci. On T2-weighted images, dark signal intensities with or without bright signal foci developed and the degree of enhancement decreased for more than half of the cases.

WITHDRAWN: Cytogenetic and molecular genetic study on glioblastoma arising in granular cell astrocytoma: a case report.

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Multidetector computed tomography (MDCT) images with soft tissue and bone algorithm reconstruction in head and facial trauma.

We aimed to evaluate the usefulness of multidetector CT (MDCT) scan images with soft tissue and bone algorithm reconstruction in nine patients for investigation of head and facial trauma. We compared these MDCT scans with the conventional brain CT scans and facial bone CT scans of eight patients with head and facial trauma. The overall radiation dose did not differ significantly between the two groups (Mann-Whitney test, p=0.370) but the MDCT scans with soft tissue and bone algorithm reconstruction avoided overlapping scan range radiation exposure, especially to the eye and lower half of the brain.

Serial computed tomography and magnetic resonance imaging findings of biphasic acute hemorrhagic leukoencephalitis localized to the brain stem and cerebellum.

Acute hemorrhagic leukoencephalitis (AHL) is a rare and usually fatal disease characterized by an acute onset of neurological abnormalities. We describe the case of a 37-year-old man with biphasic AHL with a focus on the rare involvement of the brain stem and cerebellum. Initial computed tomography (CT) and magnetic resonance imaging revealed two hemorrhagic foci in the left middle cerebellar peduncle. After 15 days multifocal hematomas in the contralateral cerebellar hemisphere were imaged using CT. The pathological diagnosis was AHL. Following high-dose steroid treatment, the patient recovered with minor neurological sequelae.

Atypical appearance of a neural foraminal elastofibroma of the lumbar spine mimicking a schwannoma on computed tomography and magnetic resonance imaging.

Elastofibromas are rare benign lesions that are most commonly found in the periscapular region. We describe a rare case of a 40-year-old woman presenting with right buttock radiating pain. Computed tomography and magnetic resonance imaging revealed a homogeneously enhanced mass occupying the right neural foramen at the L4/5 level. The clinical and radiological presentation suggested a schwannoma. Pathology examination of the tissue indicated elastofibroma.

Findings from CT, MRI, and PET/CT of a primary malignant melanoma arising in a spinal nerve root.

Primary spinal malignant melanoma is an extremely rare condition. We here describe a case of a 71-year-old Asian female presenting with left upper extremity tingling sensation. Computed tomography (CT) showed a homogeneously enhanced mass occupying the left neural foramen at the C6-7 level. Magnetic resonance imaging revealed enhanced mass in intra- and extradural space compressing the spinal cord at this level. It also widened the neural foramen mimicking neurofibroma or schwannoma. Partial resection of the mass was performed. Pathologic diagnosis of the mass was malignant melanoma. Postoperative whole body positron emission tomography/CT scan demonstrated an intense (18)F-FDG uptake at the residual mass site without abnormal uptake at other sites in the body.

The effective application of segmental image fusion in spinal radiosurgery for improved targeting of spinal tumours.

PURPOSE: As a result of experiences of failed image fusion, an improved protocol for effective CT and MRI image fusion was developed. Image fusion is a critical part of image-guided stereotactic radiosurgery (IG-SRS) and greatly influences the accurate measurement of gross tumour volume (GTV) and optimal dosimetry. Avoidance of any positional discrepancy is vital for optimal image fusion and results in improved targeting, which improves clinical results. This paper describes a protocol for effective image fusion and how it impacted on the clinical outcome of stereotactic radiosurgery for spinal tumours. METHODS: Fused MRI/CT images from 20 patients were examined and compared. A protocol for fusing images from thin slice MR images and CTs was developed for improved identification and measurement of tumour volume. Differences in individual GTV values both before and after image fusion were evaluated. The effectiveness of tumour targeting was also assessed by comparing discrepancies in individual and overall GTV values. RESULTS: Differences in mean GTVs using either CT or MRI alone compared with the mean found through combined CT/MR image fusion showed a difference of 30.5 +/- 4.8% and 14.5 +/- 3.3% respectively. Additionally, the median GTV values from CT- and MR-based imaging were 11.64 +/- 7.8 cm(3) and 11.72 +/- 6.6 cm(3) vs 14.06 +/- 8.0 cm(3). Median GTV from CT-MR fusion was 14.06 +/- 8.0 cm(3). Improved information provided by the fused images enabled us to prescribe more effective dosages, as the fused images gave more accurate information about tumour se due to better delineation of tumour perimeters. CONCLUSIONS: This protocol provides improved visualisation of spinal tumours and enables better treatment planning. Segmented image fusion was shown to provide significant advantages for planning stereotactic radiosurgery. Fused images provided more precise and accurate data and allowed better targeting of tumours, with improved tumour coverage that resulted in better clinical outcomes.

Coronary-to-bronchial artery fistula: demonstration by 64-multidetector computed tomography with retrospective electrocardiogram-gated reconstructions.

OBJECTIVE: The aim of this study was to evaluate the incidence of coronary-to-bronchial artery fistula (CBF) and clinical significance in 1300 patients examined with 64-multidetector computed tomography (MDCT) coronary angiography. METHODS: One thousand three hundred ten patients underwent coronary MDCT for atypical chest pain or screening. Volume-rendering and multiplanar reconstruction images were reviewed, and subsequent cineangiographies were compared. RESULTS: Eight cases of CBF were detected-6 originated from the left circumflex artery, and 2 originated from the right coronary artery. A hypertrophied anomalous branch of left circumflex artery was observed in 1 case, and underlying bronchiectasis was noted. Seven cases had a thin-wall communicating vessel. Subsequent cineangiography revealed identical appearance with MDCT reconstruction images. CONCLUSIONS: The incidence of CBF (0.61%) in this study is similar to those of a few cineangiographic studies in the literature. Our study showed that 64-MDCT coronary angiography is an accurate and noninvasive tool for detection of CBF.

Primary extraskeletal mesenchymal chondrosarcoma arising from the pancreas.

We report here on a case of primary extraskeletal mesenchymal chondrosarcoma that arose from the pancreas. A 41-year-old man was evaluated by CT to find the cause of his abdominal pain. The CT scans showed a heterogeneously enhancing necrotic mass with numerous areas of coarse calcification, and this was located in the left side of the retroperitoneal space and involved the body and tail of the pancreas. Portal venography via the celiac axis also showed invasion of the splenic vein. Following excision of the mass, it was pathologically confirmed to be primary extraskeletal mesenchymal chondrosarcoma that arose from the pancreas.