Stent implantation in a patient with non-hemorrhagic vertebral artery dissection associated with severe, continuously progressive stenosis in the posterior inferior cerebellar artery bifurcation region: A case report.

Generally, the prognosis of non-hemorrhagic vertebral artery dissection is good. Treatment should be considered when stenosis progresses or when an aneurysm is formed. However, no clear treatment policy has been established. The purpose of this case report was to describe the treatment policy for non-hemorrhagic onset vertebral artery dissection with severe stenosis around the posterior inferior cerebellar artery (PICA) bifurcation and aneurysm, where stent placement in the vertebral artery was difficult. This report describes healing without complications with stent implantation in the PICA performed to treat non-hemorrhagic vertebral artery dissection with associated severe, continuously progressive stenosis in the PICA bifurcation region. A 36-year-old woman was examined at the authors' hospital for persistent pain in the left posterior neck. Left vertebral arteriography revealed stenosis due to dissection around the PICA bifurcation and aneurysm formation at the distal position. Due to the progression of stenosis, there were concerns about PICA occlusion, and stent implantation in the vertebral artery was performed via the PICA. Neck pain ceased immediately after surgery, and 3 months later, cerebral angiography showed favorable patency of the PICA and decreased aneurysm size. This case suggests that stent implantation in the PICA might be a useful treatment option for non-hemorrhagic vertebral artery dissection with associated severe stenosis in the PICA bifurcation region.

An anomalous hyperplastic anterior choroidal artery associated with an unruptured internal carotid-posterior communicating artery aneurysm.

The anterior choroidal artery (AChA) injuries can result in severe neurologic deficits, so requiring careful observation to avoid inadvertent damage during neuroendovascular procedures. In this case report, we present the unusual case of an anomalous hyperplastic AChA associated with a fetal-type posterior communicating artery (PCoA), and an unruptured internal carotid artery (ICA) -PCoA aneurysm. A 54-year-old woman presented with persistent headache. Brain magnetic resonance imaging (MRI) showed an unruptured cerebral aneurysm in the right ICA, and cerebral angiography revealed a proximal fetal-type PComA and a distal anomalous hyperplastic AChA. Coil embolization was performed with no neurologic deficits and the target lesion was embolized with a total of 6 coils. An anomalous hyperplastic AchA has a lengthy course with numerous choroidal and perforating branches, and therefore, an abundant perfusion region. Thorough knowledge of the development and anatomy of anomalous arteries is important for safely performing endovascular procedures without causing any ischemic complications.

Functional connectivity analysis and prediction of cognitive change after carotid artery stenting.

OBJECTIVE: The neurocognitive course of patients who have undergone cerebral revascularization has been the subject of many studies, and the reported effects of carotid artery stenting (CAS) on cognitive function have varied from study to study. The authors hypothesized that cognitive amelioration after CAS is associated with alteration of the default mode network (DMN) connectivity, and they investigated the correlation between functional connectivity (FC) of the DMN and post-CAS changes in cognitive function in order to find a clinical marker that can be used to predict the effect of cerebral revascularization on patients' cognitive function in this preliminary exploratory study. METHODS: The authors examined post-CAS changes in cognitive function in relation to FC in patients treated for unilateral carotid artery stenosis. Resting-state functional MRI (rs-fMRI) was performed with a 3-T scanner before and 6 months after CAS in 8 patients. Neuropsychological tests (Wechsler Adult Intelligence Scale III and Wechsler Memory Scale-Revised) were administered to each patient before and 6 months after CAS. The DMN was mapped for each patient through independent component analysis of the rs-fMR images, and the correlation between FC of the DMN and post-CAS change in cognitive function was analyzed on a voxel level. Multivariable regression analysis was performed to identify preoperative factors associated with a post-CAS change in cognitive function. RESULTS: Post-CAS cognitive function varied between patients and between categories of neuropsychological tests. Although there was no significant overall improvement in Working Memory scores after CAS, post-CAS Working Memory scores changed in negative correlation with changes in FC between the DMN and the precentral/superior frontal gyrus and between the DMN and the middle frontal gyrus. In addition, the preoperative FC between those areas correlated positively with the post-CAS improvement in working memory. CONCLUSIONS: FC between the DMN and working memory-related areas is closely associated with improvement in working memory after CAS. Preoperative analysis of FC of the DMN may be useful for predicting postoperative improvement in the working memory of patients being treated for unilateral stenosis of the extracranial internal carotid artery.Clinical trial registration no.: UMIN000020045 (www.umin.ac.jp/ctr/index.htm).

Pituitary dysfunction after aneurysmal subarachnoid hemorrhage in Japanese patients.

To elucidate the pituitary function of Japanese patients after aneurysmal subarachnoid hemorrhage (aSAH) and implicative factors related to growth hormone deficiency (GHD) after aSAH. We evaluated basal pituitary hormone levels among 59 consecutive aSAH patients with a modified Rankin Scale (mRS) ⩽4 at 3months after aSAH onset. Patients with low insulin-like growth factor 1 (IGF-1) SD score (SDS) or who seemed to develop pituitary dysfunction underwent provocative endocrine testing during a period of 3-36months after SAH onset. The relationship between IGF-1 SDS and clinical factors of the patients such as severity of SAH, aneurysm location, and treatment modalities, were assessed. Six patients (10.2%) demonstrated their IGF-1 SDS less than -2. Multiple logistic regression analyses revealed that patients who underwent surgical clipping had a significantly lower IGF-1 SDS (<-1SD) than patients who underwent endovascular embolization with an odds ratio of 5.83 (p=0.032). Thirty-three patients took provocative tests and five (15.6%) patients were identified as having GHD. The mean IGF-1 SDS of these five GHD patients was 0.08 SD. The aneurysms in all GHD patients were located in internal carotid artery (ICA) or anterior cerebral artery (ACA). To the best of our knowledge, this is the first report describing the prevalence of GHD in Japanese patients after aSAH, and it was not as high as that of previous European studies. We recommend that screening pituitary dysfunction for aSAH survivors with their aneurysms located in ICA or ACA.

Prediction of Malignant Middle Cerebral Artery Infarction in Elderly Patients.

BACKGROUND: We evaluated the clinical outcomes of malignant middle cerebral artery (MCA) infarction (MMI) and determined an infarcted brain volume (BV) threshold value for accurate MMI prediction in elderly patients. METHODS: We analyzed 69 consecutive patients (mean, 75.6 ± 11.7) with internal carotid artery or MCA infarction within 48 hours from onset. Diffusion-weighted high-intensity volume (DHV) and BV were measured in all patients. The percentage of DHV within BV (DHV/BV ratio) was calculated to standardize the DHV difference for each individual BV. Patients were stratified based upon their MMI status and age, compared with the following: (1) MMI versus non-MMI groups and (2) age ≥75 years group versus age <75 years group, based on DHV values, DHV/BV ratio, Glasgow Coma Scale (GCS) scores on admission, and modified Rankin Scale (mRS) scores at 3 months after onset. RESULTS: The MMI group (n = 14) showed significantly larger DHV values (P < .001), larger DHV/BV ratios (P < .001), lower GCS scores on admission (P < .01), and higher mRS scores at 3 months (P < .001) than the non-MMI group. The DHV threshold value predicting MMI was 102 cm(3) (sensitivity 85%, specificity 91%, P < .01) and DHV/BV threshold ratio was 7.8% (sensitivity 86%, specificity 87%, P < .01). Both the age ≥75 years group and the age <75 years group with MMI showed equally poor outcomes (mRS 5.7 ± .7 versus 5.3 ± 1.3). CONCLUSIONS: DHV and DHV/BV can provide reliable information for MMI prediction in elderly patients.

[A case of peritoneal carcinomatosis due to recurrence of primary adenocarcinoma of the ureter treated with weekly paclitaxel].

This report describes the case of a patient with peritoneal carcinomatosis due to recurrent adenocarcinoma of the ureter who was chemo-sensitive to weekly paclitaxel. A 73-year-old man was admitted to our hospital for pain in the right back in September 2009. Drip infusion pyelography(DIP)showed right hydronephrosis. Cytologic examination of the urine revealed many carcinoma cells in the urothelial tract. The patient underwent right nephroureterectomy, and examination of the resected specimen revealed a primary enteric-type adenocarcinoma of the ureter. Six months after surgery, he visited our hospital because of abdominal pain and distension. Abdominal computed tomography(CT)showed massive ascites. Cytologic examination of the ascitic fluid revealed many adenocarcinoma cells resembling those of the primary lesion. The patient received chemotherapy with S-1 as first-line treatment; however, he experienced severe anorexia and diarrhea. Subsequently, the patient received chemotherapy with uracil/tegafur(UFT)but abdominal distension worsened. Next, he received chemotherapy with weekly paclitaxel(80mg/m2 on days 1, 8, and 15, every 4 weeks). Thereafter, the ascitic fluid disappeared rapidly. After 6 courses of treatment with paclitaxel, abdominal CT revealed no ascitic fluid collection. The treatment was discontinued because of sensory neuropathy. Approximately 10 months later, the patient experienced massive ascites again. At 25 months after recurrence, he died of peritoneal carcinomatosis.

Prevalence of cerebral aneurysm in patients with acromegaly.

The prevalence of cerebral aneurysm was retrospectively investigated in 208 patients with acromegaly relative to the rate of cerebral aneurysm in a group of control subjects. Neuroradiological examinations of the cerebral vascular system were conducted in 208 acromegaly patients (101 men; mean age, 48.8 years). The prevalence of cerebral aneurysm in the acromegaly patients was compared to that in a control group consisting of 7,390 subjects who underwent "brain checkup" between 2006 and 2008 (mean age, 51.6 years). In the acromegaly group, cerebral aneurysm was detected in 4.3 % of patients. By sex, the prevalence was 6.9 % in males, a significantly proportion than that in the control group with an odds ratio of 4.40. The prevalence in females did not differ between the two groups. In the acromegaly group, the rate of hypertension was significantly higher in the patients with aneurysm compared to those without aneurysm. Multiple logistic regression identified acromegaly as a significant factor related to the prevalence of cerebral aneurysm in all male subjects; other factors, such as age, hypertension and smoking, were not found to be significant. A significantly higher prevalence of cerebral aneurysm was detected in male patients with acromegaly. This finding indicates that excess growth hormone or insulin-like growth factor 1 affects the cerebral vascular wall, resulting in aneurysm formation. In addition to known systematic complications in the cardiovascular, respiratory, metabolic, and other systems, the risk of cerebral aneurysm should be considered in the management of acromegaly.

Cilostazol attenuates cerebral vasospasm after experimental subarachnoid hemorrhage.

BACKGROUND AND PURPOSE: Cerebral vasospasm is a major cause of morbidity and mortality in patients with subarachnoid hemorrhage (SAH). Cilostazol, a selective inhibitor of phosphodiesterase 3, is a peripheral vasodilator, an anti-inflammatory, and causes antiplatelet aggregation. We investigated these effects on cerebral vasospasm after rat SAH. METHODS: Thirty-eight Sprague-Dawley rats were randomly divided into three groups: SAH + normal feed (SAH group; n=14), SAH + feed containing 0·1% cilostazol (cilostazol group; n=12) and sham-operated rats (sham group; n=12). The basilar arteries (BA) of all groups were analysed by measuring wall thickness, internal luminal perimeter and cross-sectional area on day 7. Immunohistochemical study with RM-4, an anti-rat macrophage/dendritic cells monoclonal antibody and ultrastructural study with transmission electron microscopy were performed. RESULTS: Although most animals in the SAH group presented with typical vasospasm, the means of inner perimeter and cross-section area of the BA in the cilostazol group were significantly greater than the SAH group (836 ± 134 µm versus 771 ± 125 µm and 39 177 ± 15 405 µm(2) versus 33 098 ± 13 871 µm(2), respectively). Wall thickness of the BA in the cilostazol group demonstrated significant decrease, compared with the SAH group (17·4 ± 2·3 versus 21·0 ± 2·7 µm). In immunohistological study, SAH induced an obvious increase in mean perivascular RM-4-positive cell count, whereas cilostazol significantly reduced it by 59%. Ultrastructural study depicted cilostazol markedly attenuating structural deterioration of the vascular wall due to SAH. CONCLUSIONS: This work demonstrates that cilostazol attenuates cerebral vasospasm after SAH in rat, possibly in part due to the anti-inflammatory effect.

Adrenal androgen levels as predictors of outcome in castration-resistant prostate cancer patients treated with combined androgen blockade using flutamide as a second-line anti-androgen.

OBJECTIVES: To analyze the clinical effects of flutamide as a second-line anti-androgen for combined androgen blockade in patients with castration-resistant prostate cancer (CRPC) initially treated with bicalutamide as a first-line anti-androgen. METHODS: Our study population consisted of 16 patients with CRPC who were treated with flutamide (375 mg daily) as second-line hormonal therapy. Dehydroepiandrosterone (DHEA), androstenedione, androstenediol, testosterone and dihydrotestosterone were measured to investigate the relationship between plasma androgens and outcome following treatment. Furthermore, adrenal androgen levels in a medium of adrenal cancer cell line were also measured. RESULTS: Second-line hormonal therapy using flutamide resulted in a reduction of the prostate-specific antigen (PSA) level in 14 (87.5%) of 16 patients. A PSA decline greater than 50% was observed in 8 (50%) of the 16 patients. The duration of median responsiveness was 6.25 months. PSA elevation of baseline androstenediol level was a predictive factor of PSA responsiveness. The lower DHEA group improved the duration of responsiveness to flutamide. In vitro, 3 micromol/L flutamide suppressed DHEA, androstenedione and androstenediol synthesis compared with bicalutamide in a medium of adrenal cancer cell line. CONCLUSIONS: Our data show that flutamide suppresses the adrenal androgens in comparison with bicalutamide. The responsiveness and response duration of flutamide can be predicted in patients with a higher baseline androstenediol level and a lower DHEA level. Metabolites from adrenal androgens contribute to the progression of prostate cancer.