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BACKGROUND AND OBJECTIVES: Although intraprocedural rupture (IPR) is rare, it is a devastating complication of endovascular treatment (EVT) for intracranial aneurysms. Very few studies have been conducted on IPR, and the safety and efficacy of management techniques of IPR have not been investigated. METHODS: Patients who experienced IPR during EVT between 2013 and 2022 were enrolled from a multicenter observational registry. We examined the safety and efficacy of the management of IPR using imaging markers, including increased hemorrhage and ischemic lesions, which were evaluated using postoperative computed tomography and diffusion-weighted imaging, respectively. RESULTS: Of the 3269 EVTs for intracranial aneurysms, 74 patients who experienced IPR (2.26%) were analyzed. Fifty-five patients (3.36%) experienced IPR among 1636 EVT cases for ruptured aneurysms. Multivariate analysis revealed that increased hemorrhage was significantly associated with poor outcomes (odds ratio [OR], 6.37 [95% CI, 1.00-40.51], P = .050), whereas ischemic lesions were not. Regarding management techniques of IPR, antihypertensive medication use was significantly associated with increased hemorrhage (OR, 14.16 [95% CI, 2.35-85.34], P = .004). Heparin reversal was an independent factor for ischemic lesions (OR, 8.92 [95% CI, 1.54-51.58], P = .014). CONCLUSION: Although the setting of IPR may be miscellaneous, and optimal management varies depending on individual cases, heparin reversal might be associated with ischemic complications, and its role in the successful hemostasis in IPR during EVT for ruptured aneurysms remains unclear.
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OBJECTIVES: Distal anterior cerebral artery (DACA) aneurysms account for 1%-9% of all intracranial aneurysms. Microsurgical treatment is generally preferred for DACA aneurysms; however, it presents challenges owing to the anatomical complexities. Advances in neuro-interventional techniques have yielded promising results. This study aims to compare the clinical outcomes of DACA aneurysms treated with microsurgery and endovascular treatment (EVT) to elucidate the efficacy of EVT. MATERIALS AND METHODS: A multicenter observational registry comprising 16 stroke centers was utilized for this study. Data was retrospectively and prospectively analyzed from 166 patients with DACA aneurysms in our database, which included 4,552 consecutive patients with ruptured or unruptured intracranial aneurysms who underwent microsurgical or endovascular treatment between January 2013 and December 2021. RESULTS: Surgical clipping was performed in 115 patients, and 51 underwent coil embolization. The median follow-up duration was 15.3 months. No significant differences were observed in patient characteristics between the two treatment modalities. There were no differences in complication-related morbidity between the microsurgical treatment and EVT groups in either unruptured (10.5% vs. 9.1%, p=1.00) or ruptured aneurysms (5.2% vs. 6.9%, p=0.66). Coil embolization resulted in higher recurrence and retreatment rates than surgical clipping did, especially for ruptured aneurysms (2.6% vs. 27.6%, p<0.01). CONCLUSIONS: Endovascular treatment is an alternative to microsurgery for DACA aneurysms especially in unruptured cases or the patients who have difficulty undergoing craniotomy due to their general condition, albeit with considerations for higher recurrence and retreatment rates, particularly in ruptured cases. Close follow-up is crucial for the effective management of these challenges. Further studies are needed to refine the treatment strategies for DACA aneurysms.
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Objective: Embolic protection devices are useful for preventing distal embolism during carotid artery stenting (CAS); however, complications have been reported. The successful removal of a filter fragment trapped at the distal edge of a carotid stent during the retrieval procedure is described. Case Presentation: CAS was performed for internal carotid artery stenosis in a patient in his 70s, and the carotid stent was successfully placed. During the retrieval procedure, the tip of the filter was trapped at the distal edge of the stent and detached from the filter. Using a snare kit, the filter tip was successfully retrieved, and no postoperative neurological symptoms occurred. Conclusion: The edge of a carotid stent can potentially trap devices. When trapping or fragmentation of a device is suspected, it is necessary to evaluate the situation and cause, and the device should be appropriately retrieved without using force.
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AIM: Assessing the indication for elective neuro-endovascular treatment (EVT) in older patients requires consideration of the impact of systemic comorbidities on their overall reduced life expectancy. The objective of this study was to determine the long-term outcomes of elective neuro-EVT in patients aged ≥80 years, and to investigate the impact of pre-existing cancer on their long-term outcomes. METHODS: Of the patients enrolled in multicenter observational registry, those aged ≥80 years undergoing elective neuro-EVT between 2011 and 2020 were enrolled. A history of cancer was defined as a pre-existing solid or hematologic malignancy at the time of EVT. The primary outcome was time to death from elective neuro-EVT. RESULTS: Of the 6183 neuro-EVT cases implemented at 10 stroke centers, a total of 289 patients (median age, 82 years [interquartile range 81-84 years]) were analyzed. A total of 58 (20.1%) patients had a history of cancer. A total of 78 patients (27.0%) died during follow up. The 5-year survival rate of enrolled patients was 64.6%. Compared with patients without a history of cancer, those with a history of cancer showed significantly worse survival (log-rank test, P = 0.001). Multivariate Cox proportional hazards analysis showed history of cancer was an independent predictor of time to death from elective neuro-EVT (HR 1.74, 95% CI 1.01-3.00, P = 0.047). Cancer was the leading cause of death, accounting for 25.6% of all deaths. CONCLUSIONS: The present study showed that history of cancer has a significant impact on time to death from elective neuro-EVT in patients aged ≥80 years. Geriatr Gerontol Int 2024; 24: 211-217.
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Isquemia Encefálica , Procedimentos Endovasculares , Neoplasias , Acidente Vascular Cerebral , Humanos , Idoso , Idoso de 80 Anos ou mais , Resultado do Tratamento , Acidente Vascular Cerebral/etiologia , Estudos Retrospectivos , Isquemia Encefálica/etiologiaRESUMO
PURPOSE: We aimed to investigate the impact of baseline infarct area and collateral status (CS), which are imaging predictors of clinical outcome following stroke, after endovascular treatment (EVT) in MRI-selected patients with acute basilar artery occlusion (BAO). METHODS: Patients with acute BAO who underwent EVT within 24 h after stroke from December 2013 to February 2021 were included in this retrospective, multicenter, observational study. The baseline infarct area was evaluated by the posterior circulation of Acute Stroke Prognosis Early Computed Tomography Score (pc-ASPECTS) using diffuse-weighted imaging (DWI), and CS was assessed by measuring the computed tomography angiography of the basilar artery (BATMAN) score and the posterior circulation collateral score (PC-CS) using magnetic resonance angiography (MRA). A Good outcome was defined as a modified Rankin scale score ≤ 3 at 3 months. For each imaging predictor, a multivariate logistic regression analysis was performed to evaluate its impact on good outcomes. RESULTS: A total of 86 patients were analyzed, and 37 (43.0%) had a good outcome. The latter showed significantly higher pc-ASPECTS than those without good outcomes. In multivariate analyses, a pc-ASPECTS ≥ 7 was significantly associated with good outcomes (OR, 2.98 [95% CI, 1.10-8.13], P = 0.032), while PC-CS ≥ 4 (OR, 2.49 [95% CI, 0.92-6.74], P = 0.073) and BATMAN score ≥ 5 (OR, 1.51 [95% CI, 0.58-3.98], P = 0.401) were not. CONCLUSIONS: In MRI-selected patients with acute BAO, pc-ASPECTS on DWI was an independent predictor of clinical outcomes after EVT, while the MRA-based CS assessments were not.
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Arteriopatias Oclusivas , Procedimentos Endovasculares , Acidente Vascular Cerebral , Insuficiência Vertebrobasilar , Humanos , Artéria Basilar/diagnóstico por imagem , Artéria Basilar/cirurgia , Insuficiência Vertebrobasilar/diagnóstico por imagem , Insuficiência Vertebrobasilar/cirurgia , Resultado do Tratamento , Estudos Retrospectivos , Acidente Vascular Cerebral/terapia , Procedimentos Endovasculares/métodos , Arteriopatias Oclusivas/diagnóstico por imagem , Arteriopatias Oclusivas/cirurgia , Arteriopatias Oclusivas/etiologia , Trombectomia/métodos , Infarto , Imageamento por Ressonância MagnéticaRESUMO
OBJECTIVE: To investigate the chronological changes in the clinical presentation and long-term prognosis of pediatric-onset moyamoya disease in our institute over 40 years. METHODS: We evaluated 282 pediatric-onset (≤ 15 years old) moyamoya disease patients who visited our institute from 1981 to 2020 (divided into the former period, 1981-2000, and the latter period, 2001-2020). Differences in the clinical presentation and the long-term outcome were compared between the periods. Multivariate analysis was also performed to reveal the risk factors for poor long-term outcomes. RESULTS: Compared to the former period, the total number of patients, the onset age and both the number of patients with family history and relatively older patients without symptoms or with headache were greater in the latter period (p < 0.05). The number of patients with poor long-term outcomes was significantly lower in the latter period (24.9% vs. 6.7%, p < 0.01). Multivariate analysis revealed that stroke onset, late cerebrovascular events and postoperative complications were independent risk factors for poor long-term outcomes (odds ratio = 31.4, 40.8 and 5.4, respectively). CONCLUSIONS: Over the last 40 years, the number of pediatric moyamoya disease patients has increased, especially in relatively older patients with mild presentation and favorable long-term outcomes. In clinical studies, these chronological changes and the inclusion period of the participants need to be accounted for. Whether the increased diagnostic rate in the recent era has led to a decrease in late cerebrovascular events and favorable outcomes throughout life remains unknown and should be evaluated in the future.
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Doença de Moyamoya , Adolescente , Adulto , Criança , Humanos , Pessoa de Meia-Idade , Idade de Início , Transtornos Cerebrovasculares/epidemiologia , Seguimentos , Cefaleia/epidemiologia , Doença de Moyamoya/diagnóstico , Doença de Moyamoya/epidemiologia , Doença de Moyamoya/fisiopatologia , Prognóstico , Fatores de Risco , Acidente Vascular Cerebral/epidemiologia , Fatores de Tempo , Resultado do Tratamento , Masculino , FemininoRESUMO
BACKGROUND AND PURPOSE: To investigate the associations of perioperative P2Y12 reaction units (PRU) measured using VerifyNow with ischemic and bleeding events, and to determine the PRU threshold in the setting of elective neuro-endovascular treatment (EVT) for intracranial/extracranial vascular disease in patients taking aspirin and clopidogrel. METHODS: Of the patients undergoing elective neuro-EVT while taking aspirin and clopidogrel, those taking both antiplatelet agents for 7 days or more and whose PRU and aspirin reaction units (ARU) were measured were included. The primary and safety outcomes were defined as symptomatic ischemic and major bleeding events within 30 days after EVT. RESULTS: A total of 197 patients were available for the analyses. Higher PRU was associated with symptomatic ischemic events on multivariable logistic analysis (odds ratio per 10 increase 1.14 [95% confidence interval 1.03-1.27], p=0.011). Receiver operating characteristic curve analysis showed that PRU ≥212 was the threshold to predict symptomatic ischemic events (area under the curve=0.73; sensitivity, 62.5%; specificity, 82.0%). Lower PRU was also associated with major bleeding events (odds ratio per 10 increase 0.87 [0.78-0.96], p=0.004), and the threshold to predict major bleeding events was PRU ≤46 (area under the curve=0.76; sensitivity, 70.0%; specificity, 87.2%) CONCLUSIONS: The PRU value was associated with symptomatic ischemic and major bleeding events after elective neuro-EVT in patients taking aspirin and clopidogrel. PRU ≥212 and PRU ≤46 appeared to be the threshold values to predict symptomatic ischemic and major bleeding events, respectively.
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Procedimentos Endovasculares , Antagonistas do Receptor Purinérgico P2Y , Ticlopidina , Aspirina/efeitos adversos , Clopidogrel/efeitos adversos , Hemorragia/induzido quimicamente , Humanos , Inibidores da Agregação Plaquetária/efeitos adversos , Testes de Função Plaquetária , Antagonistas do Receptor Purinérgico P2Y/efeitos adversos , Ticlopidina/efeitos adversos , Resultado do TratamentoRESUMO
It has been reported that bevacizumab, an agent administered as an adjuvant therapy for high-grade gliomas, causes thromboembolic complications. We report a cerebral infarction with newly developed cerebral artery stenosis occurring during treatment with bevacizumab for an anaplastic astrocytoma. A 48-year-old female underwent excision surgery for an anaplastic astrocytoma on the right temporal lobe and received radiation therapy and chemotherapy with temozolomide. Twenty months after the maintenance therapy, treatment with bevacizumab was introduced for tumor recurrence. After the 14th course of bevacizumab at 6 months, 27 months after radiation therapy, the patient began experiencing mild right hemiparesis. Magnetic resonance imaging revealed scattered cerebral infarcts on the left frontal lobe and diffuse cerebral artery stenosis of the bilateral internal carotid artery system both inside and outside the radiation-treated area. Antiplatelet medication was commenced, and there was no recurrence of ischemic stroke. The morphological transition of the cerebral arteries should be carefully monitored via magnetic resonance angiography during post-radiation treatment with bevacizumab.
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Branch-like enhancement (BLE) on contrast-enhanced (CE) magnetic resonance imaging (MRI) was found to be effective in differentiating primary central nervous system lymphoma (PCNSL) from high-grade glioma (HGG) in the cerebellum. However, whether it can be applied to assessments of secondary central nervous system lymphoma (SCNSL), or other cerebellar lesions is unknown. Hence, we retrospectively reviewed cerebellar masses to investigate the use of BLE in differentiating cerebellar lymphoma (CL), both primary and secondary, from other lesions. Two reviewers qualitatively evaluated the presence and degree of BLE on CE-T1 weighted imaging (T1WI). If multiple views were available, we determined the view in which BLE was the most visible. Seventy-five patients with the following pathologies were identified:17 patients with CL, 30 patients with metastasis, 12 patients with hemangioblastoma, 9 patients with HGG, and 7 patients with others. Twelve patients presented with PCNSL and five with SCNSL. Of 17 patients with CL, 15 (88%) had BLE, whereas three (5%) out of 58 patients in the non-CL group showed BLE. In patients who underwent three-dimensional-CE-T1WI, BLE was the most visible on the sagittal image. In conclusion, BLE is a highly specific finding for CL and the sagittal image is important in evaluating this finding.
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Neoplasias Encefálicas , Glioma , Linfoma , Neoplasias Encefálicas/patologia , Diagnóstico Diferencial , Glioma/patologia , Humanos , Linfoma/diagnóstico por imagem , Linfoma/patologia , Imageamento por Ressonância Magnética/métodos , Estudos RetrospectivosRESUMO
Objective: There are few detailed reports on abducens nerve palsy due to a ruptured vertebral artery dissecting aneurysm (VADA). We investigated the clinical characteristics and long-term course of abducens nerve palsy in ruptured VADA patients treated by endovascular surgery. Methods: Of the 51 cases of ruptured VADA treated by endovascular intervention from 2011 to 2019, 31 with a good/fair outcome, in which ocular motility disorder was able to be followed, were included and investigated. Results: In all, 11 patients (35.5%) had abducens nerve palsy, and the World Federation of Neurological Surgeons (WFNS) grade and Hunt & Hess (H&H) grade at the time of arrival of patients with abducens nerve palsy were significantly higher than those of patients without abducens nerve palsy. Of the 10 patients who were able to be followed, abducens nerve palsy in 3 completely recovered in 7-180 days. Abducens nerve palsy improved in five patients and remained in two patients. Conclusion: More severe neurological findings on admission reflect a higher rate of abducens nerve palsy. Diplopia induced by abducens nerve palsy is one of the most important sequelae of ruptured VADA, which impairs the daily activities of the patients. Some cases of abducens nerve palsy improve over a long period. Therefore, appropriate diagnosis and follow-up should be concerned.
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BACKGROUND AND PURPOSE: Bilateral T2 hyperintensities in the medial part of the globus pallidus (GP) are sometimes incidentally observed in patients without a known history of diseases that present with such lesions. The purpose of this study was to evaluate the frequency of this finding and the association between this finding and age, lifestyle diseases and GP calcification. METHODS: We retrospectively investigated the brain magnetic resonance imaging (MRI) of 742 patients, which included between 104 and 108 consecutive patients from each decade of life between the 20s and 80s. The signal intensity ratio of the medial part to the lateral part of the GP in T2-weighted images (T2 medial/lateral ratio) was evaluated. For cases in which brain computed tomography images were available (N=437), GP calcifications were also evaluated. The associations between the T2 medial/lateral ratio and age, sex, history of lifestyle diseases and GP calcification were investigated. RESULTS: Bilateral T2 medial/lateral ratios >1.10, 1.30 and 1.50 were observed in 29.8%, 7.1% and 1.8% of all cases, respectively. A high bilateral T2 medial/lateral ratio was observed less frequently in young patients (p<0.01), more frequently in elderly patients and those with hypertension or dyslipidaemia (p<0.05) and more frequently in patients with a calcified GP (p<0.01). CONCLUSION: Incidental bilateral T2 hyperintensities in the medial part of the GP on brain MRI are most likely an age-related physiological finding.
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Globo Pálido , Imageamento por Ressonância Magnética , Idoso , Encéfalo/diagnóstico por imagem , Globo Pálido/diagnóstico por imagem , Humanos , Estudos RetrospectivosRESUMO
Objective: The purpose of this study was to evaluate the combination of a 100-cm long balloon-guiding catheter (BGC) and 40-cm long sheath in patients treated by mechanical thrombectomy for anterior circulation acute ischemic stroke. Methods: The subjects were 77 consecutive patients treated by endovascular recanalization for anterior circulation occlusion from January 2011. After February 2018, 24 patients were treated by mechanical thrombectomy using a long BGC and long sheath (L-BGC group), and were compared with 53 patients treated before January 2018 using a normal BGC and sheath (S-BGC group). The baseline angiographical/clinical characteristics, main procedures, BGC insertion time, internal carotid artery (ICA) cartelization rate, recanalization rate, and clinical outcome were compared between L-BGC and S-BGC groups. Results: There was no significant difference in angiographical/clinical characteristics except for intravenous thrombolysis with recombinant tissue plasminogen activator (IVrtPA) treatment. In all, 22 patients were treated by combined technique (CoT) thrombectomy in the L-BGC group. The BGC insertion time was significantly shorter in the L-BGC group than in the S-BGC group (19 vs 13 minutes), and ICA catheterization of BGC was successful in the L-BGC group, whereas there were seven failures in the S-BGC group (100% vs 84%). The puncture-to-recanalization (PtoR) time was significantly shorter in the L-BGC group (90 vs 44 minutes). The successful recanalization (SR) rate was higher in the L-BGC group (96% vs 72%). Good outcomes (mRS 0-2) slightly increased in the L-BGC group (64% vs 49%). In the multivariable analysis, only CoT thrombectomy was associated with PtoR and SR. Conclusion: The combination of a long BGC and long sheath results in rapid and stable BGC insertion to the ICA. CoT thrombectomy with these devices may be useful for SR and reducing the PtoR in anterior circulation mechanical thrombectomy.
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Objective: The natural course of chronic carotid artery total occlusion (CTO) is poor. Previous reports suggested that carotid artery stenting (CAS) improves the clinical outcome of CTO. However, its long-term efficacy has not been established. This study assessed the mid- and long-term clinical outcome of CAS for CTO. Methods: We evaluated the clinical outcome of 15 patients who underwent CAS for CTO between September 2010 and October 2019. Results: The technical success rate of recanalization was 93.3% (14 of 15 patients). Eight patients were treated using self-expanding stents, and six were treated using self-expanding coronary stents. Symptomatic procedure-related complications developed in two patients (13.3%). During the follow-up period (mean 34.9 months), symptomatic ipsilateral stroke was not noted. One patient (7.1%) developed asymptomatic re-occlusion, but stent patency was preserved in 13 patients (92.9%). Conclusion: CAS for CTO may be safe and feasible based on the mid- and long-term outcome.
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Objective: Although Onyx has made effective embolization possible in the endovascular treatment of arteriovenous malformation (AVM), its infusion requires a high level of skill and experience. The purpose of this study is to create a simulation model that will help to solve this technical issue. Model Presentation: Using data of 3D DSA images of a clinical case, an acrylonitrile-butadiene-styrene (ABS) resin model of the AVM was created with a 3D printer. Then, a hollow elastic model was created by applying silicone and eluting the ABS resin, which was finally connected to the human vascular model. Simulation of angiography and Onyx embolization using the model showed similar angiographic features and flow dynamics of contrast media and Onyx. During Onyx embolization, the plug and push technique could be performed as in a clinical case. Conclusion: 3D AVM model created with 3D printer enabled us to stimulate Onyx embolization of AVM.
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Objective: We report a patient with chronic headache due to idiopathic intracranial hypertension (IIH) associated with transverse sinus (TS) stenosis. The symptom improved after stent placement at the site of stenosis. Case Presentation: The patient was a 37-year-old woman with progressive headache and diplopia as chief complaints. She had severe bilateral papilledema. Magnetic resonance imaging (MRI) and angiography revealed stenosis of the bilateral TS. Lumbar puncture demonstrated raised intracranial pressure and IIH was tentatively diagnosed. Visual impairment progressed despite oral acetazolamide therapy. A venous pressure gradient was monitored during stent placement. The pressure gradient improved after stenting. Dual antiplatelet therapy was initiated 1 week before the procedure. Papilledema and headache resolved immediately after the procedure. No in-stent stenosis or occlusion occurred during the follow-up period. Conclusion: Stent placement for TS stenosis can improve the cerebral venous return in IIH patients. Although restenosis is possible, venous sinus stenting is considered an effective treatment.
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Distal anterior cerebral artery(DACA)aneurysms are relatively rare. The detection of the surgical trajectory of DACA aneurysmal clipping is difficult because DACA aneurysms are located at various sites in the ACA. The purpose of this study was to evaluate the effectiveness of intraoperative use of color Doppler ultrasonography for the surgery of DACA aneurysms. DACA aneurysms of ten patients(three men, seven women;64.5 years old on median)were examined using intraoperative color Doppler imaging(CDI), which was performed before microscopic procedures, to detect the location of the aneurysms. Among them, six patients had ruptured aneurysms with diameters ranging from 2.5 to 10.8mm, and four of them had intracerebral hematomas. All the aneurysms and surrounding arteries were clearly detected using CDI. Moreover, in larger aneurysms, blood flow dynamics inside the aneurysm were also observed using CDI. As a result, we concluded that the intraoperative use of color Doppler ultrasonography was effective of detecting the trajectory for the DACA aneurysms without causing any damage to the brain by redundant dissections.
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Artéria Cerebral Anterior , Aneurisma Intracraniano , Idoso , Angiografia Cerebral , Feminino , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/cirurgia , Masculino , Resultado do Tratamento , Ultrassonografia Doppler em CoresRESUMO
Many neuroendovascular treatments are supported by real-time anatomical and visual hemodynamic assessments through digital subtraction angiography (DSA). Here we used DSA in a single-center prospective randomized crossover study to assess the intracranial hemodynamics of patients undergoing coiling for cerebral aneurysm (n = 15) during sevoflurane- and propofol-based anesthesia. Color-coded DSA was used to define time to peak density of contrast medium (TTP) at several intravascular regions of interest (ROIs). Travel time at a particular ROI was defined as the TTP at the selected ROI minus TTP at baseline position on the internal carotid artery (ICA). Travel time at the jugular bulb on the anterior-posterior view was defined as the cerebral circulation time (CCT), which was divided into four segmental circulation times: ICA, middle cerebral artery (MCA), microvessel, and sinus. When bispectral index values were kept between 40 and 60, CCT (median [interquartile range]) was 10.91 (9.65-11.98) s under propofol-based anesthesia compared with 8.78 (8.32-9.45) s under sevoflurane-based anesthesia (P < 0.001). Circulation times for the ICA, MCA, and microvessel segments were longer under propofol-based anesthesia than under sevoflurane-based anesthesia (P < 0.05 for all). Our results suggest that, relative to sevoflurane, propofol decreases overall cerebral perfusion.
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Anestesia/métodos , Artérias Cerebrais/cirurgia , Circulação Cerebrovascular/efeitos dos fármacos , Aneurisma Intracraniano/cirurgia , Propofol/administração & dosagem , Sevoflurano/administração & dosagem , Idoso , Anestésicos Intravenosos/administração & dosagem , Angiografia , Angiografia Digital , Velocidade do Fluxo Sanguíneo , Artéria Carótida Interna/cirurgia , Artérias Cerebrais/diagnóstico por imagem , Artérias Cerebrais/efeitos dos fármacos , Estudos Cross-Over , Feminino , Hemodinâmica , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Período Intraoperatório , Masculino , Microcirculação , Pessoa de Meia-Idade , Perfusão , Período Pré-Operatório , Estudos ProspectivosRESUMO
We describe the case of a 75-year-old man with pharyngeal hemorrhage caused by a pseudoaneurysm of the lingual artery after accidentally swallowing his dentures. He developed sudden oral and nasal hemorrhage and was transported to a hospital near his residence. The doctors at the hospital diagnosed the case as epistaxis and treated the symptom with nasal packing. However, the bleeding did not stop and his blood pressure decreased. He was then transported to our hospital. We assumed that the bleeding was caused by epistaxis from branches of the internal maxillary artery, and tried to stop bleeding with the endovascular treatment using coils or liquid embolus materials. Angiography showed a pseudoaneurysm of the lingual artery. Coil embolization against the artery was effective in controlling bleeding. Correct diagnosis and appropriate treatments based on the correct diagnosis are essential in this case of swallowed dentures and bleeding of pseudoaneurysm of the lingual artery.
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Falso Aneurisma , Embolização Terapêutica , Epistaxe , Idoso , Falso Aneurisma/complicações , Angiografia , Artérias , Epistaxe/etiologia , Epistaxe/terapia , Humanos , MasculinoRESUMO
We describe an adult case of radiation-induced meningioma(RIM)that was identified within a short interval from the initial treatment for brain tumor. A 45-year-old woman, who had tumor resection followed by radiation therapy for right frontal oligodendroglioma, showed a small enhanced lesion on the right frontal region 3 years and 6 months after the initial radiation therapy. The pathological diagnosis was meningioma(World Health Organization(WHO)grade I)and the Ki-67 labeling index was 3.2%. Most RIMs occur after a long period of time(18.7-24.0 years on average)following radiation therapy. Several studies have suggested that the period before the occurrence of RIM is correlated with both the age of a patient and the radiation dose at the time of radiation therapy. A patient that receives a higher dose of radiation at a younger age has a higher risk of RIM occurrence. In this case, the patient was middle aged;however, she was exposed to a high dose of radiation(54 Gy). High-dose radiation might induce the early onset of RIM. Recently, treatments for glioma have been developed, thus resulting in an increased long-term survival rate among patients. Physicians must pay attention not only to the recurrence of gliomas but also to the occurrence of RIMs.
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Neoplasias Meníngeas , Meningioma , Neoplasias Induzidas por Radiação , Neoplasias Encefálicas/radioterapia , Feminino , Humanos , Neoplasias Meníngeas/diagnóstico , Neoplasias Meníngeas/etiologia , Meningioma/diagnóstico , Pessoa de Meia-Idade , Recidiva Local de Neoplasia , Neoplasias Induzidas por Radiação/diagnóstico , Oligodendroglioma/radioterapiaRESUMO
BACKGROUND: The aim of this study was to identify the unique morphological arterial features in patients with moyamoya disease on 3-dimensional rotational digital subtraction angiography. MATERIALS AND METHODS: One hundred seven hemispheres of 58 consecutive patients with moyamoya disease that were analyzed with fused 3-dimensional images of internal carotid angiograms and vertebral angiograms that were marked with different colors were reviewed. Angiographic findings in the posterior watershed area were classified, and the utility of the classification was analyzed by comparing it with clinical presentations and quantitative hemodynamic parameters obtained with positron emission tomography. RESULTS: Two unique angiographic appearances were identified. A vacant vessel appearance (no arterial inflow despite absence of cortical infarction) was observed mostly in transient ischemic attack hemispheres. In hemispheres with a vacant vessel appearance, cerebral blood flow was decreased, cerebral blood volume was increased, and mean transit time was prolonged significantly (P = .00017, P = .0061, and P = .00026, respectively). A cocktail vessel appearance (mixture of carotid and vertebral arterial flow) was most commonly observed in asymptomatic cases, as well as in ischemic hemispheres. Cerebral blood volume increased and mean transit time was prolonged significantly (P = .036 and P = .014, respectively) in hemispheres with a cocktail vessel appearance. The trend of progression in hemodynamic severity in the order of normal appearance, cocktail vessel appearance, and vacant vessel appearance in the watershed area was statistically significant. CONCLUSION: Fused 3-dimensional digital subtraction angiography demonstrated unique angiographic features in the watershed area, and this represented the degree of cerebral hemodynamic impairment in moyamoya disease.