Case of Cerebrospinal Fluid Leakage Nine Years after Pituitary Gamma Knife Surgery for Poststroke Thalamic Pain Syndrome.

Pituitary gamma knife surgery (GKS) is a treatment option for poststroke thalamic pain syndrome. Complications such as hypopituitarism, transient enuresis, and transient hyponatremia have been reported. However, cerebrospinal fluid (CSF) leakage has not yet been reported as a complication of pituitary GKS for poststroke thalamic pain syndrome. Herein, we report a case of delayed CSF rhinorrhea that developed 9 years after GKS for poststroke thalamic pain syndrome. A 64-year-old man presented to our hospital with bacterial meningitis and CSF rhinorrhea. Pituitary GKS for poststroke thalamic pain had been performed 9 years prior to his admission to our hospital. Computed tomography revealed pneumocephalus, fluid in the sphenoid and maxillary sinuses, and a partial bony defect of the sella turcica floor with communication between the paranasal and intracranial spaces. The CSF rhinorrhea resolved with bed rest and a lumbar CSF drain but recurred several days later. The patient underwent direct endoscopic surgical repair of the skull base. The sellar floor was covered with an autologous fascia graft harvested from the rectus sheath, and the sphenoid sinus was packed with abdominal fat grafts. The patient recovered, and the CSF rhinorrhea has not recurred for 2 years. Long-term follow-up is necessary after pituitary GKS, considering the complication of delayed CSF leakage.

Transarterial embolization for convexity dural arteriovenous fistula with or without pial arterial supply: A report of four patients.

Background: Convexity dural arteriovenous fistulae (dAVF) usually reflux into cortical veins without involving the venous sinuses. Although direct drainage ligation is curative, transarterial embolization (TAE) may be an alternative treatment. Case Description: Between September 2018 and January 2021, we encountered four patients with convexity dAVFs. They were three males and one female; their age ranged from 36 to 73 years. The initial symptom was headache (n = 1) or seizure (n = 2); one patient was asymptomatic. In all patients, the feeders were external carotid arteries with drainage into the cortical veins; in two patients, there was pial arterial supply from the middle cerebral artery. All patients were successfully treated by TAE alone using either Onyx or N-butyl cyanoacrylate embolization. Two patients required two sessions. All dAVFs were completely occluded and follow-up MRI or angiograms confirmed no recurrence. Conclusion: Our small series suggests that TAE with a liquid embolic material is an appropriate first-line treatment in patients with convexity dAVFs with or without pial arterial supply.

Coil embolization with overlapping horizontal low-profile stents to treat a giant thrombosed fetal posterior cerebral artery aneurysm using contralateral approach through anterior communicating artery: Case report.

BACKGROUND: The treatment of internal carotid artery (ICA) - posterior communicating artery aneurysms (ICPC aneurysms) is challenging when a fetal posterior cerebral artery (PCA) arises from the saccular neck. This complex angioarchitecture renders endovascular approaches difficult. Giant thrombosed IC-PC aneurysms are also hard to treat by endovascular coiling because its flow-diversion effect is insufficient. CASE DESCRIPTION: We report the first case of a ruptured giant thrombosed IC-PC aneurysm associated with a fetal PCA that was successfully treated by coil embolization with retrograde overlap horizontal stenting using low-profile stents introduced through the contralateral ICA. The aneurysm was completely occluded and follow-up MRI scans demonstrated the reduction of the aneurysmal size. CONCLUSION: Our technique is advantageous because low-profile stents can be used to treat lesions not accessible with flow-diverter stents due their presence in complex angioarchitectures, and overlap stenting may have flow-diversion effects that can result in the complete occlusion of giant thrombosed aneurysms.

Subarachnoid Hemorrhage Due to Rupture of Vertebral Artery Dissecting Aneurysms: Treatments, Outcomes, and Prognostic Factors.

BACKGROUND: Mortality rate after subarachnoid hemorrhage due to rupture of vertebral artery dissecting aneurysms (VADAs) is high; endovascular coil trapping is the first-line therapy to prevent rerupture. To select optimal treatments, the positional relationship between the VADA and posterior inferior cerebellar artery (PICA) and the morphology of the contralateral vertebral artery must be considered, and outcome predictors of different treatment methods and their possible complications must be identified. METHODS: We retrospectively studied 44 patients with ruptured VADAs who had undergone endovascular or surgical treatment. VADA morphology was assessed on conventional preoperative angiograms, and VADAs were categorized based on their site in relation to the PICA. VADA site, treatment method, and complications were used to identify prognostic factors. RESULTS: The sites of the 44 VADAs were PICA-proximal (n = 3), PICA-distal (n = 22), PICA-absent (n = 7), and PICA-involved (n = 12). Treatments included internal coil trapping (n = 30), proximal coil occlusion (n = 5), and stent placement (n = 3); surgical flow alteration via an occipital artery-PICA bypass and ligation at the proximal vertebral artery and the PICA origin was performed in 6 patients. Periprocedural rebleeding was associated with a poor outcome. Internal coil trapping prevented the rerupture of PICA-proximal and PICA-absent VADAs, and flow alteration prevented rerupture of PICA-involved VADAs; there were no complications directly attributable to these procedures. CONCLUSIONS: Periprocedural rebleeding was a poor prognostic factor. Internal trapping of PICA-proximal and PICA-absent VADAs and flow alteration in PICA-involved VADAs prevented rerupture.

Prognostic Links Between OCT-Delineated Coronary Morphologies and Coronary Functional Abnormalities in Patients With INOCA.

OBJECTIVES: Whether there are prognostic links between coronary morphologies and coronary functional abnormalities was examined in ischemia and nonobstructive coronary artery disease (INOCA) patients. BACKGROUND: Although INOCA has attracted much attention, little is known about the prognostic impact of coronary morphologies in this disorder. METHODS: A total of 329 consecutive INOCA patients were enrolled and underwent spasm provocation testing combined with lactate sampling for diagnosis of epicardial and microvascular spasm (MVS). On the basis of the functional tests, the patients were classified into 4 groups: a control group without epicardial spasm or MVS (n = 32), MVS alone (n = 51), diffuse spasm in ≥2 coronary segments (n = 204), and focal spasm in 1 segment (n = 42). In this population, optical coherence tomography imaging of the left anterior descending coronary artery was performed for evaluation of adventitial vasa vasorum (AVV) and intraplaque neovessels (IPN). Index of microcirculatory resistance was also measured. RESULTS: MVS frequently coexisted with diffuse (70%) and focal spasm (68%) with a good correlation between AVV and index of microcirculatory resistance (R = 0.353; p = 0.022). For a median follow-up of 1,043 days, focal spasm showed the worst prognosis (log rank p = 0.005), for which IPN was a significant prognostic factor. By contrast, diffuse spasm showed the greatest AVV with an intermediate prognosis. The prognostic value of INOCA was significantly enhanced by adding AVV and IPN to the physiological indices (area under the curve = 0.88 vs. 0.76; p = 0.048). CONCLUSIONS: These results provide the first evidence that there are important prognostic links between coronary morphologies (evaluated by optical coherence tomography) and coronary functional abnormalities in patients with INOCA, indicating the importance of both evaluations in this population.

Transarterial Sinus Coiling for Dural Arteriovenous Fistula: Two Case Reports.

Objective: We report two cases of dural arteriovenous fistula (DAVF) treated by coil embolization of the affected sinus and fistula via a feeding artery instead of transvenous embolization (TVE) due to the difficulty of the transvenous approach. Case Presentation: An 82-year-old man was diagnosed with transverse sinus (TS) DAVF. A microcatheter was inserted into the isolated TS through the fistula via the middle meningeal artery (MMA), which was the feeding artery of the DAVF. The DAVF was occluded by coil embolization of the isolated sinus and fistula. A 79-year-old man was diagnosed with cavernous sinus (CS) DAVF. A microcatheter was inserted into the CS through the fistula via an accessory meningeal artery (AMA), which was the feeding artery of the DAVF. The DAVF was occluded by coil embolization of the affected sinus and fistula. Conclusion: These cases suggested that transarterial sinus coiling is one of the effective treatment options for DAVF.

[A Case Report of Subacute Thrombosis after Carotid Stenting Caused by Food Allergy].

An 89-year-old man underwent carotid artery stenting for symptomatic left internal carotid artery stenosis. His postoperative course was uneventful;however, on postoperative day 4, he developed a food allergy rash throughout his body after consuming sushi. He developed right hemiplegia and aphasia the following day, and magnetic resonance imaging revealed left internal carotid artery occlusion. Angiography revealed stent thrombosis, and endovascular thrombectomy achieved partial recanalization;however, right hemiplegia and aphasia persisted. Eosinophilia and increased platelet aggregation suggested allergic stent thrombosis(Kounis syndrome type 3).

Ruptured Aneurysm Originating from a Posterior Inferior Cerebellar Artery Communicating Artery: A Case Report and Review of the Literature.

This report presents a rare case of such an aneurysm arising from such a communicating artery. A 66-year-old woman presented with a subarachnoid hemorrhage located predominantly in the cisterna magna with intraventricular hemorrhage. Angiography showed hypoplasia of the right posterior inferior cerebellar artery. Its vermian territory was supplied by the communicating artery from the posterior medullary segments of the left posterior inferior cerebellar artery. An aneurysm was on that communicating artery itself at a nonbranching site. The aneurysm was trapped the next day. Postoperative computed tomography showed no infarct in the right posterior inferior cerebellar artery territory. Trapping is applicable when other collateral vessels supply the contralateral posterior inferior cerebellar artery territory. J. Med. Invest. 67 : 197-199, February, 2020.

[A Case Report of Endovascular Thrombectomy for Internal Carotid Artery Thromboembolism after Left Upper Lobectomy of Lung Cancer].

A 76-year-old man underwent a left upper lobectomy due to lung cancer. On postoperative day 3, he developed a cerebral infarction(NIHSS:17). MR and right carotid angiography demonstrated a right internal carotid artery occlusion. The patient underwent an endovascular thrombectomy without intravenous administration of recombinant tissue plasminogen activator. Complete recanalization was achieved and the symptoms almost disappeared except for a slight dysarthria. The patient subsequently continued cancer treatment by administration of edoxaban. Reports of cerebral emboli due to a thrombus migrating from the stump of the pulmonary vein after a left upper lobectomy are increasing. Several reports indicate that left upper lobectomy carries a high risk of thromboembolism. The current prospective study demonstrates that a mechanical thrombectomy can significantly improve both neurological and cognitive functions of patients after acute ischemic stroke. Endovascular neurosurgeons should prepare for and await an opportunity for thrombectomy for patients undergoing pulmonary resection.

[A Case of Spontaneous Intracranial Hypotension Successfully Treated with Repetitive Epidural Blood Patch after Warfarin Reversal].

We report a case of spontaneous intracranial hypotension successfully treated with repetitive epidural blood patch after warfarin reversal. A 75-year-old man presented with a 2-week history of headache. He was being treated with warfarin for atrial fibrillation. Neurological examination on admission showed mild disorientation. Prothrombin time-international normalized ratio(PT-INR)was elevated to 2.43. Initial magnetic resonance images of the brain demonstrated bilateral subdural hematomas, distortion of midbrain and diffuse pachymeningeal enhancement. Conservative treatments with bed rest and hydration were administered. On the third posthospital day, he became lethargic and emergently underwent epidural blood patch(EBP)at lumbar level. Consciousness disturbance improved immediately but reappeared 12 hours after the EBP. The second EBP was performed but consciousness level decreased again 12 hours later. The effect of warfarin was reversed by administration of vitamin K and fresh frozen plasma before the third EBP. After the procedure, he became alert. The findings of neurological examination did not change but a CT on day 12 revealed increase in volume of left-sided subdural hematoma. He underwent EBP and evacuation of hematoma. The neurological findings remained unchanged. A CT on the 17th posthospital day showed increase of right-sided subdural hematoma, and EBP and evacuation of hematoma were then performed. After the 5th EBP, the clinical course was uneventful. Predictors for successful EBP are not fully clarified. In patients who undergo anticoagulation therapy, EBP may be ineffective and normalization of coagulability required.

[A Case Report of Basilar Artery Thromboembolism from Severe Stenosis of the Vertebral Artery Ostium].

We report a case of basilar artery embolism from the large thrombus of the right vertebral artery with severe stenosis of the vertebral artery ostium. Intravenous recombinant tissue plasminogen activator treatment and thrombectomy by catheter with reverse blood flow using a proximal subclavian artery blocking balloon(intentional subclavian artery steal phenomenon)were performed. A large thrombus along with other small thrombi were removed by an aspiration catheter. Additional stent placement was performed for residual vertebral artery stenosis, at ten days after the thrombectomy. Finally, the patient was discharged without any neurological deficits.

[A Case Report of Congenital Protein C Deficiency with Cerebral Venous Sinus Thrombosis during Early Pregnancy Period].

A 35-year-old woman at eight weeks of gestation in her second pregnancy presented with generalized seizures. Magnetic resonance images revealed a small hemorrhagic infarction in the left frontal lobe, and magnetic resonance venography indicated cerebral venous sinus thrombosis. After hospitalization, anticoagulant therapy was continued, and a low protein C level was confirmed, which was also confirmed in both her mother and her sister. Follow-up magnetic resonance venography performed on day 27 confirmed that the cerebral venous sinuses had undergone recanalization. After a completed gestation period, the patient gave birth to healthy girl uneventfully.

[Cerebral Venous Sinus Thrombosis Following Cisplatin-Based Chemotherapy for Testicular Tumor].

A man in his 30s who presented with an enlarged right testicle was diagnosed with a germ cell tumor via orchiectomy. Adjuvant chemotherapy with cisplatin, etoposide and bleomycin(BEP)was initiated. He developed a headache 8 days later, followed by neurological deficits 10 days later. Magnetic resonance imaging(MRI)and magnetic resonance venography(MRV)showed thrombotic occlusion at the superior sagittal sinus. Anticoagulant therapy with heparin was initiated. However, a generalized epileptic seizure occurred 11 days later, and an antiepileptic drug therapy was initiated. The headache and neurological deficits gradually improved, and MRI findings showed that the superior sagittal sinus had re-canalized. The main cause of the sinus thrombosis in this patient was considered dehydration and cisplatin-induced hypercoagulability. Five courses of BEP therapy were carried out with care to avoid dehydration. The patient has remained free of testicular tumor recurrence, metastasis, and cerebral sinus thrombosis for 2 years. Cisplatin-based chemotherapy is an established risk factor for venous thromboembolism(VTE), and cerebral sinus thrombosis is a rare but dangerous complication. Therefore, cerebral sinus thrombosis should be considered when patients with testicular cancer who undergo cisplatin-based chemotherapy start to develop neurological symptoms. Clinicians should be aware of this treatable complication.

Treatment Outcome of Carotid Artery Stenting Underwent within 14 Days of Stroke Onset - Consideration of Safety and Efficacy of Urgent Carotid Artery Stenting for Neurologically Progressing Patients.

As the safety and effectiveness of urgent carotid artery stenting (CAS) for neurologically progressing patients remain controversial, we retrospectively analyzed the outcome of urgent CAS based on the patients' pathophysiological condition and neuroimaging findings. We divided 71 patients who underwent CAS within 14 days of stroke onset into two groups. Group 1 (n = 35) was comprised of patients with progressing neurologic signs and a reversible ischemic penumbra on magnetic resonance images (MRI). They were treated by urgent CAS. Group 2 (n = 36) was neurologically stable and underwent prophylactic CAS. In all patients we recorded the National Institutes of Health Stroke Scale (NIHSS) score and the modified Rankin scale (mRS). Urgent CAS resulted in significant improvement in the NIHSS score, when compared before and after CAS in group 1 (5.3 ± 4.3, P < 0.01). The rate of good outcomes (mRS 0-2 at 3 months post-CAS) was 48.6% in group 1, and 75% in group 2. The cumulative incidence of ipsilateral stroke between 31 days and 1 year was 5.9% in group 1, and 0% in group 2. The procedural complication rate was similar in both groups (group 1: 5.7%, n = 2; group 2: 5.6%, n = 2). No patient suffered a symptomatic intracerebral hemorrhage. When the pathophysiological status and neuroimaging findings are used to determine patient eligibility for urgent CAS, this treatment improve neurologic outcome and can be performed as safely as prophylactic CAS in our cohort of patients with acute ischemic stroke.

The utility of vacuum-assisted closure therapy for skin necrosis secondary to cervical abscess in the elderly.

Vacuum-assisted closure (VAC) systems have been used as negative-pressure dressings in various fields, including decubitus ulcer, trauma, and wound dehiscence. To the best of our knowledge, few reports have examined the utility of VAC therapy for neck abscess in an oldest-old patient. We present here a rare case of neck abscess secondary to parotid abscess, resulting in extensive skin necrosis. Successful management included emergency drainage following epithelial induction through a VAC system without using skin grafting. Two months after surgical intervention, the cervical wound was completely healed without a solid scar. We consider the VAC therapy to be a key factor leading to the complete healing in the elderly under low serum albumin condition.

Predictors of the necessity for lymph node biopsy of cervical lymphadenopathy.

PURPOSE: Enlargement of cervical lymph nodes is required for early and accurate diagnosis of malignant lymphoma (ML). Lymph node biopsy is still indispensable for accurate diagnosis of lymph node enlargement in the lateral neck. MATERIAL AND METHODS: We retrospectively investigated the characteristics of lymph nodes on both ultrasonography (US) and computed tomography (CT), and blood biomarkers including serum thymidine kinase (TK) and soluble interleukin-2 receptor (sIL-2R) in 19 patients who underwent cervical lymph node biopsy. RESULTS: Pathological diagnosis was ML in 8 patients, reactive lymphadenopathy (RL) in 8, and purulent lymphadenitis (PL) in 3. TK levels were significantly higher in patients with ML than in patients with RL, demonstrating positive correlations with sIL-2R and lymph node size on CT image. The shape of lymph nodes on US in all of the 8 patients diagnosed with RL was flat, whereas the shape in 7 of 8 patients diagnosed with ML was round. Lymph node size ≥19.5 mm at an axial section on CT image was used as a cut-off value to differentiate ML from other pathologies, offering 90.9% sensitivity and 87.5% specificity. CONCLUSION: Sonographic and CT evaluation combined with high TK level might be useful in determining the need for early biopsy.

[A Case of Paradoxical Cerebral Embolism Developed during in vitro Fertilization Treatment].

A 35-year-old woman with a history of infertility, was presented to our hospital because of impaired consciousness and cerebellar ataxia, 14 days after in vitro fertilization. She received an embryo transfer under controlled ovarian hyper-stimulation. Magnetic resonance images revealed acute infarction in the cerebellum and brainstem. Magnetic resonance angiography showed a basilar artery occlusion at the end point. Following immediate intravenous rt-PA treatment, the symptoms disappeared completely. A transesophageal echocardiography revealed an atrial septal defect with a continuous left to right shunt. In addition, a Valsalva maneuver trans-esophageal echocardiography with injected saline showed the presence of jet bubbles in the left atrium crossing via the atrial septal defect. She was diagnosed with paradoxical cerebral embolism. Anticoagulant therapy was continued and she gave birth to a healthy baby. Deep vein thrombosis was associated with the ovarian hyper-stimulation syndrome that occurred during infertility treatment. As anti-phospholipid antibodies were weakly positive, the possibility of anti-phospholipid antibody syndrome was suggested. If a woman of childbearing age is presented because of stroke, it is important to administer initial therapy by keeping fertility in mind. Thrombolytic therapy for pregnant women should be carefully considered, because of the associated hazards; however, it is a very important treatment for maternal function after birth.

Prevention of Retrograde Blood Flow Into Large or Giant Internal Carotid Artery Aneurysms by Endovascular Coil Embolization with High-Flow Bypass: Surgical Technique and Long-Term Results.

BACKGROUND: Recanalization has been reported in large or giant aneurysms of the internal carotid artery (ICA) addressed by high-flow bypass and endovascular treatment. Aneurysmal recanalization may be attributable to retrograde blood flow into the aneurysm through the ICA branches, such as the ophthalmic artery or the meningohypophyseal trunk, or through the surgically created bypass. We modified the endovascular treatment of aneurysms to prevent retrograde flow and evaluated the long-term efficacy of our method. METHODS: We used a hybrid operative/endovascular technique to treat 5 patients with large or giant aneurysms arising from the C2-C4 segment of the ICA who presented with visual symptoms due to the mass effect of the aneurysm. To prevent retrograde flow into the aneurysm our modified endovascular treatment involves coil embolization of the aneurysmal orifice and the ICA, including the origin of the ophthalmic artery and meningohypophyseal trunk, and placement of a high-flow bypass using a radial artery graft. RESULTS: During the 5- to 12-year follow-up period, 4 aneurysms disappeared, and the other decreased in size. There were no subarachnoid hemorrhages. All bypass grafts remained patent. Visual preservation was achieved in 2 patients; 1 patient manifested visual improvement. Although 2 patients experienced transient neurological deficits we encountered no permanent complications in this series. The final modified Rankin scale of the 5 patients was 0 or 1. CONCLUSIONS: Prevention of retrograde flow into the aneurysm by coil embolization with high-flow bypass is a safe and effective method. It prevents the recanalization of large or giant ICA aneurysms.

Clinical characteristics of angioleiomyoma of the hard palate: report of a case and an analysis of the reported cases.

Angioleiomyoma is a rare, benign tumor often found in the uterine myometrium, gastrointestinal tract, and skin and seldom observed in the oral and maxillofacial region. The most common site of occurrence in the oral cavity is the lip, followed by the palate, buccal mucosa, and tongue. The number of reports associated with angioleiomyoma arising from the hard palate is very small. The tumor is histologically characterized by the proliferation of mature smooth muscle cells and numerous blood vessels. When the diagnosis is difficult, specific immunohistochemistry is used. This report describes a case of angioleiomyoma in which there was a chronically increasing lesion for 5 years on the left hard palate and the means for making a definitive diagnosis was based on previous reports on angioleiomyoma of the palate.

Recent trends in neuroendovascular therapy in Japan: analysis of a nationwide survey--Japanese Registry of Neuroendovascular Therapy (JR-NET) 1 and 2.

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.