Endovascular Treatment for Aneurysmal Subarachnoid Hemorrhage with Neurogenic Pulmonary Edema in the Acute Stage.

AIM: Severe neurogenic pulmonary edema (NPE) can occur in a variety of brain insults, including subarachnoid hemorrhage (SAH), and severe case of NPE can cause devastating consequences. But the literature on the treatment strategy about aneurysmal SAH with NPE is very scant. We present that SAH patients with severe NPE, who were treated first by embolization of aneurysm followed by insertion of lumbar spinal drainage, had comparatively good outcome. MATERIAL AND METHODS: We present 12 consecutive cases of aneurysmal SAH with NPE in the acute stage, which were treated by endovascular treatment between April 2002 and December 2012. We classified the patients according to the Hunt and Hess grading system as follows: grade-3 (1 patient), grade-4 (4 patients), and grade-5 (7 patients). All patients needed respiratory management, with the assistance of a ventilator, and underwent endovascular treatment for the ruptured aneurysms within 72 hours from onset. For all the patients, immediately after the endovascular treatment, we performed lumbar spinal drainage. RESULTS: The pulmonary edema disappeared rapidly after respiratory management and endovascular treatment. The outcomes were as follows: good recovery (GR; 3 patients), moderate disability (MD; 4 patients), severe disability (SD; 3 patients), and death (D; 2 patients). Five patients (42%) developed pneumonia, and we postponed extubation until recovery from pneumonia. The cause for severe disability and death was symptomatic vasospasm and primary brain damage. No patients had rebleeding from ruptured aneurysms. CONCLUSION: Endovascular treatment for ruptured aneurysm and placement of lumbar spinal drainage is an excellent treatment option for severe SAH with NPE.

Primary pontine hemorrhage in the acute stage: clinical features and a proposed new simple scoring system.

BACKGROUND: It is important to evaluate the likelihood of fatality in patients with acute primary pontine hemorrhage (PPH) in emergency departments. We aimed to evaluate the clinical symptoms and computed tomography findings of PPH to develop a simple grading scale for predicting the mortality of PPH. METHODS: Records of 101 consecutive patients admitted to our hospital with acute PPH between June 1, 2006, and January 31, 2014, were retrospectively reviewed. Independent predictors of 30-day mortality were identified by univariate and multivariate logistic regression analyses. A simple and easy clinical score (PPH score) was developed from independent factors to predict mortality in acute PPH. The PPH score was compared with the established intracerebral hemorrhage (ICH) score, which served as the reference scoring system. RESULTS: Overall mortality rate 30 days after onset was 58.4% (59 of 101). Factors independently associated with 30-day mortality were Glasgow Coma Scale (GCS) score of 6 or less (P = .0051), absence of pupillary light reflex (P = .0003), and blood glucose of 180 mg/dL or greater (P = .0312). The PPH score was the sum of independent factors, which were assigned 1 point each. The area under the receiver operating characteristic curve for predicting 30-day mortality was .90 (95% confidence interval [CI], .84-.95) for PPH score and .86 (95% CI, .78-.93) for ICH score. CONCLUSIONS: GCS score of 6 or less, absence of pupillary light reflex, and plasma glucose of 10 mmol/L or greater are independent mortality predictors of PPH. The PPH score is a simple and reliable clinical grading scale for predicting 30-day mortality.

[Ischemic complications of anterior choroidal artery aneurysm treatment].

Ischemic stroke of the anterior choroidal artery(AChA)is the most common and serious complication after AChA aneurysm treatment. The purpose of this study was to retrospectively evaluate and compare the treatment-related ischemic complications after surgical clipping and endovascular coiling of AChA aneurysms.
Between June 2006 and March 2013, 32 patients with 34 AChA aneurysms were treated in our hospital by surgical clipping or endovascular coiling. There were 12 cases of ruptured aneurysms, seven cases of unruptured aneurysms, and 15 cases of incidentally identified unruptured aneurysms. Of the 34 aneurysms, 19 were managed with surgical clipping and 15 were managed with endovascular coiling. No rebleeding or retreatment occurred in any case during 4-84 months(median, 25 months)of follow-up, and no significant differences in clinical outcome were seen between clipping and coiling cases. Although there were four cases(11.8%;surgical clipping in three;endovascular coiling in one)of postoperative AChA infarction, we believe that we preserved the blood flow of the AChA during the procedure. The occurrence of subarachnoid hemorrhage and premature rupture during surgical clipping were significantly correlated with AChA infarction.

[Embolization of the feeding artery of a meningioma with dangerous vascular anastomosis between the middle meningeal artery and the ophthalmic artery].

Preoperative embolization of intracranial meningioma has been applied to reduce intraoperative blood loss and to facilitate microsurgical removal of a tumor. It is well known that one of the reasons of the neurological risk of embolization is due to dangerous anastomosis between the extracranial and the intracranial arteries. One of the most known and dangerous case of anastomosis is between the middle meningeal artery to the ophthalmic artery. A 48-year-old woman underwent preoperative embolization of a large right middle cranial fossa meningioma. The right external carotid angiogram showed that the tumor was fed by the right middle meningeal artery and there was no branch to the right orbital region. The right internal carotid angiogram showed that the right ophthalmic artery originated from the right internal carotid artery and there was no branch to the tumor. The selective angiogram of the anterior branch of the middle meningeal artery disclosed the anastomosis to the right ophthalmic artery. Following embolization of the anterior branch of the middle meningeal artery, the patient underwent embolization of the main feeding branch of the meningioma. She successfully underwent surgical removal of the tumor without any blood transfusion and was discharged without neurological deficit. In addition, to avoid complication in embolization of the feeding artery of a skull base meningioma, clinicians must be aware of the dangerous anastomosis between the middle meningeal artery and the ophthalmic artery, even if conventional external and internal carotid angiograms do not show any anastomosis.

[Pyoktanin blue injection for resection of cystic brain tumor: a case report].

Pyoktanin blue is an agent that is often used during STA-MCA anastomosis. In this report, we inject it into a cystic tumor for complete resection, and we report its usefulness. The patient was a 57-year-old female. She suffered from progressive cerebellar ataxia. CT and MR showed a cystic metastatic tumor at the right cerebellar hemisphere, 40mm in diameter. Craniotomy was performed, 5cm in diameter, using the right suboccipital approach. After peeling off the tumor from the surface layer of the brain, we injected diluted pyoktanin blue into the tumor to dye the inside wall. After that, the tumor was peeled off completely without exposing the dyed inside wall. We sometimes find it difficult to distinguish tumor from brain if there is tearing of the tumor wall. Tearing of the tumor can be prevented by injecting pyoktanin blue into it, and making the inside wall visible. Using this procedure, we think a tumor can be resected without residual tumor or damage to the brain. Although we have used this method only a few times, we think it is an easy and useful technique to inject pyoktanin blue into a cystic tumor during its resection.

[Harvest of the superficial temporal artery using the Lone Star Retractor System TM: technical note].

Extracranial-intracranial(EC-IC)bypass is an important method of treating ischemic stroke and intracranial disease requiring sacrifice of the parent artery. The most commonly used donor artery for EC-IC bypass surgery is the superficial temporal artery(STA). But there are few reports of details of harvest methods of the STA. We describe our harvest methods of the STA using the Lone Star Retractor SystemTM. After draping, the Lone Star Retractor SystemTM is placed on the head. Skin incision is on the parietal branch of the STA. Under the surgical microscope, the dermis is cut by a scalpel from the distal side of the STA. The incised wound was tensioned by the blunt hooks(elastic stay)of the Lone Star Retractor SystemTM. Connective tissue around the STA was dissected and cut by a high voltage bipolar coagulator from the distal to the proximal side of the STA. The advantage of using of The Lone Star Retractor SystemTM for the STA harvest is that, using a surgical microscope, it is easy to set the elastic stay on the wound.

[ASPECTS-DWI, arterial occlusion sites and subtype of acute ischemic stroke have a relation with outcome following intravenous rt-PA therapy].

PURPOSE: We evaluated the usefulness of rating diffusion weighted images (DWI) using semiquantitative scores modified from the Alberta Stroke Programme Early CT Score (ASPECTS) to predict deterioration of neurological symptoms in patients with hyperacute ischemic stroke who had undergone thrombolytic therapy with recombinant tissue plasminogen activator (rt-PA). SUBJECTS AND METHODS: We examined 84 patients with acute ischemic stroke treated with intravenous rt-PA. Ischemic changes and vascular lesions were identified using DWI, and magnetic resonance angiography. Early ischemic signs were assessed using ASPECTS-DWI (11 points). Independent outcome was defined by NIHSS at 24 hours after intravenous rt-PA therapy. RESULTS: A total of 58 patients were studied, and NIHSS 27 (46.6%) of them had improved by 4 points in 24 hours. CONCLUSION: Cases of 0≦AD≦3, cardioembolic type cases with internal carotid artery occlusion in the group of 4≦AD≦7 and branch atheromatous disease in the group of 8≦AD were poor outcome at NIHSS 24 hours after intravenous rt-PA therapy for acute ischemic stroke patients.

[Transarterial embolization for cranial vault dural arteriovenous fistula: a case report].

A 70-year-old man presented with a rare case of a dural arteriovenous fistula (dAVF) at the cranial vault manifesting as headache. Cerebral angiography disclosed that multiple feeding arteries were immediately draining into the right parietal cortical vein without communication to the superior sagittal sinus, and this dAVF was classified as Borden type III and Cognard type IV. Transarterial embolization was performed using particles of polyvinyl alcohol and glue of n-butyl 2-cyanoacrylate. After embolization, the dAVF had completely disappeared and the patient was discharged without any symptom. Angiogram one year after embolization showed no recanalization of dAVF. Transarterial glue embolization is a safe and effective treatment of dAVF with cortical venous reflux.

[A case of cavernous sinus dural arteriovenous fistula presenting with intracranial hemorrhage].

Intracranial cavernous sinus dural arteriovenous fistula (CS-dAVF) rarely causes intracranial hemorrhage. We report a case of CS-dAVF presenting with intracranial hemorrhage. A 62-year-old man presented tonic clonic convulsion with consciousness disturbance and was transferred to our hospital. CT scan revealed subarachnoid hemorrhage and right frontal subcortical hemorrhage. Angiography revealed right CS-dAVF which drained only into the vein of the right sylvian fissure. Transvenous embolization was performed using detachable coils. After embolization, CS-dAVF had completely disappeared and the patient was discharged without any symptom. We summarized the fourteen reported cases, including ours, of CS-dAVF with intracranial hemorrhage. All of them had retrograde drainage through cerebral veins.

Unusual cisternal coil migration in the follow-up period after aneurysm perforation during endovascular coiling.

A 61-year-old woman suffered cisternal coil migration in the follow-up period after endovascular coil embolization for a ruptured cerebral aneurysm. She presented with sudden onset of headache. Computed tomography demonstrated diffuse subarachnoid hemorrhage, and cerebral angiography disclosed a left anterior choroidal artery aneurysm. The aneurysm was treated by endovascular embolization with Guglielmi detachable coils. During the embolization procedure, the microcatheter perforated the aneurysm. For direct closure of the perforation site with coils, the microcatheter was withdrawn and coils were deployed partially in the subarachnoid space and partially in the aneurysm sac. The coil mass was spread in the subarachnoid space around the aneurysm immediately after embolization. The patient was discharged with no neurological deficit. Three months later, follow-up radiography demonstrated obvious reduction in the size and compaction of the coil mass. Magnetic resonance angiography and digital subtraction angiography demonstrated stable occlusion of the aneurysm. The coil mass probably spread in the cistern around the aneurysm and was compacted by the shape memory of the coils and pulsation of the brain and vessels, as the subarachnoid clots around the aneurysm had disappeared. This case suggests that cisternal coil migration should be considered in the follow up of intracranial aneurysm treated with detachable coils.

[Transient homonymous hemianopsia due to thrombosis of the confluence of sinuses after occipital transtentorial removal of pineal region tumor].

The authors report a case of 74-year-old woman suffering thrombosis of the confluence of sinuses after the left occipital transtentorial removal of a pineal region epidermoid cyst. Four days after the operation, the patient developed left homonymous hemianopsia. Magnetic resonance imaging revealed a venous infarct in the right occipital lobe and magnetic resonance venography disclosed a signal defect of the posterior part of the confluence of sinuses. The patients' neurological symptom recovered soon after anticoagulation treatment, and magnetic resonance venography after the sixth week showed recanalization of the confluence of sinuses. Although it might be rare, thrombosis of the dural sinus should be recognized as a complication of craniotomy.

[Arterial stenosis after coil migration in embolization of an aneurysm].

A case of arterial stenosis after coil migration in intracranial aneurysm embolization is presented. A 51-year-old woman suffered sudden onset of headache and unconsciousness. Computed tomography demonstrated diffuse subarachnoid hemorrhage and cerebral angiography disclosed a right internal carotid artery (ICA) bifurcation aneurysm and a right ICA-anterior choroidal artery aneurysm. The aneurysms were treated by endovascular embolization with Guglielmi detachable coils. During the embolization procedure of the ICA bifurcation aneurysm, a coil strand detached in the sac had migrated into the ICA. We did not retrieve the migrated coil, because the free coil strand was stable in the ICA and did not cause distal flow reduction. The patient suffered vasospasm of the right ICA and underwent intra-arterial infusion of fasudil hydrochloride and percutaneous transluminal angioplasty of the ICA on day 9. The patient experienced infarction in the territory of the right anterior cerebral artery area and needed a ventriculo-peritoneal shunt for hydrocephalus. The patient was discharged with mild right hemiparesis. Follow-up angiography after six months revealed right ICA and middle cerebral artery stenosis, but the free strand of the migrated coil had not moved in the right ICA. We suspect that the coil strand might have induced thrombosis or intimal hyperplasia of the proximal M1 segment and right ICA. Although late stenosis of the parent artery might be rare, it should be recognized as a long term complication of a migrated free coil strand in the endovascular treatment of intracranial aneurysms.

[Catheter-assisted technique for endovascular treatment of a wide-neck aneurysm: a case report].

A catheter-assisted technique is a technical option that has been developed to allow the endovascular treatment of wide-neck aneurysms. We report our experience of the catheter-assisted technique in treating a wide-neck aneurysm in the posterior inferior cerebellar artery.

[Enlargement of cerebral infarction after CBF study with acetazolamide challenge: two case report].

Acetazolamide has been used for a long time for the evaluation of cerebral hemodynamics. Severe side effects as a result of acetazolamide infusion are uncommon. Two patients with unilatral internal carotid artery occlusion presented with enlargement of cerebral infarction after SPECT (single photon emission computed tomography) with acetazolamide challenge. A 60-year-old man and a 72-year-old man suffered from stroke caused by unilateral internal carotid artery occlusion. Both patients underwent SPECT under acetazolamide challenge nine days later and nineteen days later respectively. Neurological symptoms did not change immediately after acetazolamide infusion in either case, but were impaired the next day and two days later respectively. CT and MRI revealed enlargement of the infarction. Both patients had lassitude and loss of appetite after acetazolamide administration, and it was possible that dehydration induced enlargement of the cerebral infarction.

[A case of intrasacular thrombosis during the coil embolization procedure for a ruptured cerebral aneurysm].

A case of intrasacular thrombosis during the coil embolization procedure for a ruptured cerebral aneurysm is presented. A 50-year-old man suffered sudden onset of headache and unconsciousness. Computed tomography demonstrated diffuse subarachnoid hemorrhage and magnetic resonance angiography (MRA) disclosed a basilar-right superior cerebellar artery aneurysm. The aneurysm was treated by endovascular coil embolization with Guglielmi detachable coil (GDC; Boston Scientific Corp., Natick, MA, USA). The diameter of the aneurysm sac was 3.7 mm X 2.7 mm at first, but during the coil delivery the aneurysm size was diminished by thrombosis in the sac. GDC-10 2 mm X 2 cm was able to be placed in the aneurysm successfully after additonal administration of heparin, and postembolization angiography revealed obliteration of the aneurysm. Fortunately, there was no ischemic complication and the patient was discharged without any neurological deficits. MRA study 7 months after treatment revealed no recurrence of the aneursym, but long-term follow-up will be needed because of the low packing density in the aneurysm. Thromboembolic complication is one of the main complications of aneurysm coil placement for ruptured both cerebral aneurysms, and unruptured cerebral aneurysms. The administration of anticoagulant and antiplatelet agents is necessary during coil embolization for ruptured cerebral aneurysms.

Postoperative extradural hematoma after removal of a subgaleal drainage catheter--case report.

A 29-year-old man developed a delayed postoperative extradural hematoma after the craniotomy to treat recurrent malignant glioma and hydrocephalus. The patient became alert on the day after the operation. Computed tomography (CT) 12 hours after the operation showed no intracranial hematoma and the subgaleal drainage catheter was removed 18 hours after the operation. The patient complained of headache and went into a coma 2 hours after removal of the drain. CT demonstrated massive acute extradural hematoma with marked midline shift. Emergency craniotomy revealed that the source of the hematoma was an injured scalp artery along the route of the drainage catheter. He died of acute brain edema 9 days later. Hemostasis should be confirmed at insertion and removal of the drainage catheter.

Ccr2 deficiency impairs microglial accumulation and accelerates progression of Alzheimer-like disease.

Microglia are the principal immune cells of the brain. In Alzheimer disease, these brain mononuclear phagocytes are recruited from the blood and accumulate in senile plaques. However, the role of microglia in Alzheimer disease has not been resolved. Microglia may be neuroprotective by phagocytosing amyloid-beta (Abeta), but their activation and the secretion of neurotoxins may also cause neurodegeneration. Ccr2 is a chemokine receptor expressed on microglia, which mediates the accumulation of mononuclear phagocytes at sites of inflammation. Here we show that Ccr2 deficiency accelerates early disease progression and markedly impairs microglial accumulation in a transgenic mouse model of Alzheimer disease (Tg2576). Alzheimer disease mice deficient in Ccr2 accumulated Abeta earlier and died prematurely, in a manner that correlated with Ccr2 gene dosage, indicating that absence of early microglial accumulation leads to decreased Abeta clearance and increased mortality. Thus, Ccr2-dependent microglial accumulation plays a protective role in the early stages of Alzheimer disease by promoting Abeta clearance.

[Superselective feeder embolization for hemorrhage from cutaneous angiosarcoma in scalp].

A 76-year-old male developed a hemorrhagic nodule and a surrounding purple-red, irregularly shaped macule on his scalp after head trauma. The diagnosis of angiosarcoma was confirmed histologically. A transarterial feeder embolization was performed followed by a surgical excision. It was effective for bleeding from a tumor, and superselective catheterization was important for this specific tumor. The early diagnosis by neurosurgeon may lead to improved survival.

[A case of ruptured true posterior communicating artery aneurysm with neurogenic pulmonary edema treated early by GDC embolization].

A case of ruptured true posterior communicating artery aneurysm with neurogenic pulmonary edema is presented. A 31-year-old male suffered the sudden onset of unconsciousness with respiratory dysfunction and pinkish foamy sputum. Computed tomography demonstrated diffuse subarachnoid hemorrhage and chest roentgenogram disclosed pulmonary edema. An emergency cerebral angiogram under controlled ventilation revealed that an aneurysm had arisen from the right posterior communicating artery itself. Subsequently GDC embolization and lumbar drainage were performed on day 0. The patient showed full recovery from pulmonary edema on day 6. He suffered multiple cerebral infarctions caused by vasospasm but he atlained a full recovery after 7 months. The follow-up angiogram showed complete obliteration of the aneurysm. This case report suggests that endovascular treatment with lumbar drainage is useful for severe aneurysmal SAH complicated with pulmonary edema in the acute stage.

Brain tumor oncolysis with replication-conditional herpes simplex virus type 1 expressing the prodrug-activating genes, CYP2B1 and secreted human intestinal carboxylesterase, in combination with cyclophosphamide and irinotecan.

The treatment of malignant glioma is currently ineffective. Oncolytic viruses are being explored as a means to selectively lyse tumor cells in the brain. We have engineered a mutant herpes simplex virus type 1 with deletions in the viral UL39 and gamma(1)34.5 genes and an insertion of the two prodrug activating genes, CYP2B1 and secreted human intestinal carboxylesterase. Each of these can convert the inactive prodrugs, cyclophosphamide and irinotecan (CPT-11), into their active metabolites, respectively. This new oncolytic virus (MGH2) displays increased antitumor efficacy against human glioma cells both in vitro and in vivo when combined with cyclophosphamide and CPT-11. Importantly, cyclophosphamide, CPT-11, or the combination of cyclophosphamide and CPT-11 does not significantly affect oncolytic virus replication. Therefore, MGH2 provides effective multimodal therapy for gliomas in preclinical models when combined with these chemotherapy agents.