A dural metastatic small cell carcinoma of the gallbladder as the first manifestation: a case report.

BACKGROUND: A dural metastasis is one of the essential differential diagnoses of meningioma. In general, carcinomas of the breast and lung in females and prostate in males have been the most commonly reported primary lesions of dural metastases. However, dural metastasis of gallbladder carcinoma is extremely rare. Here, we report a unique case of a dural matter metastasis of gallbladder carcinoma as the first manifestation, which was autopsy-defined as small cell carcinoma. CASE PRESENTATION: A 78-year-old man came to our hospital complaining of left hemianopia. Brain computed tomography (CT) revealed a sizeable parasagittal dural-based extra-axial tumor. However, the findings for meningioma were atypical by magnetic resonance imaging, suggesting a meningioma mimic. A contrast-enhanced CT scan of the abdomen revealed a large gallbladder carcinoma. The patient opted for the best supportive care and died 2 months later. The post-mortem examination revealed small cell carcinoma in gallbladder carcinoma. Moreover, an immunologically similar carcinoma was detected in the dural metastasis. CONCLUSIONS: To the best of our knowledge, this is the first case of a dural metastasis of gallbladder small cell carcinoma. A systemic examination is essential for clinicians when atypical findings of meningioma are observed, suggesting a meningioma mimic. We present this rare case with a review of the literature.

Structure of the Medullary Veins of the Cerebral Hemisphere and Related Disorders.

Deep medullary veins drain into subependymal veins with four convergence zones and show parallel distribution patterns adjacent to the body or inferior horn and a radial pattern in the frontal horn or trigon of the lateral ventricle. As white matter imaging develops such as diffusion tensor imaging or susceptibility-weighted imaging, requirements for understanding of white matter structures are increasing, not only for understanding of neuronal tracts but also for that of other structures including the fine anatomy of white matter vessels. Some disorders are related to deep medullary veins and show characteristic distributions of the lesions indicating the relationship to the medullary veins. When lesions show a parallel or radial distribution pattern in the certebral deep white matter, disorders related to deep medullary veins should be considered for differential diagnosis. In this review, we discuss disorders related to deep medullary veins, including (a) anomalies of the medullary veins, (b) hemorrhagic disorders related to the medullary veins (diffuse vascular injury due to high-energy trauma, deep medullary vein engorgement/thrombosis in neonates), (c) inflammatory changes that spread along the medullary veins, (d) neoplasms within the medullary veins, and (e) metabolic changes that lead to altered visualization of medullary veins. Understanding the anatomic structure of medullary veins in the cerebral hemisphere and becoming familiar with disorders in which the medullary veins play a major role in disease development may be helpful in the interpretation of brain images. ©RSNA, 2017.

Diffuse vascular injury: convergent-type hemorrhage in the supratentorial white matter on susceptibility-weighted image in cases of severe traumatic brain damage.

INTRODUCTION: Susceptibility-weighted image (SWI) is one of the most sensitive methods for detect microbleeding and useful for evaluation of traumatic brain damage. The purpose of this study is to delineate the characteristics and importance of supratentorial deep white matter hemorrhages detected by SWI in cases of traumatic brain damage. METHODS: Twenty-one consecutive cases with severe traumatic head injury were included in the current study. MRI examinations were made within 1 month after injury. We evaluated the degree and distribution of the supratentorial hemorrhages on SWI retrospectively. We classified the degree of bleeding into four grades: "small hemorrhage," "single bead-like hemorrhage," "convergent-type hemorrhage," and "massive hemorrhage." We then correlated the degree and distribution of the hemorrhage to clinical outcomes. We also evaluated the apparent diffusion coefficient (ADC) image of lobes with "convergent-type hemorrhage." RESULTS: Existence of "massive hemorrhage" correlated with a poor outcome, that is, worse than "severely disabled" on the Glasgow Outcome Scale. The number of lobes affected by "convergent-type hemorrhage" also correlated with poor outcome. There were 45 lobes with "convergent-type hemorrhage" and 27 of them showed increased diffusivity on ADC images. CONCLUSION: Supratentorial massive hemorrhages and supratentorial convergent-type multiple hemorrhages were associated with poor prognosis after traumatic brain injury. The increased diffusivity in lobes with convergent-type hemorrhages may indicate that congestion of the proximal medullary vein may play some role for these hemorrhages.

Usefulness of contrast-enhanced magnetic resonance angiography for follow-up of coil embolization with the enterprise stent for cerebral aneurysms.

OBJECTIVE: The aim of this study was to determine the feasibility and usefulness of contrast-enhanced magnetic resonance angiography (CE-MRA) and 3-dimensional (3D) time-of-flight (TOF) MRA for follow-up of intracranial aneurysms treated using the Enterprise stent. METHODS: Five aneurysm cases using the Enterprise stent were prospectively analyzed and were followed up with CE-MRA, 3D TOF MRA, and digital subtraction angiography (DSA). Depictions of parent artery lumen and the aneurysm neck with 3D TOF MRA and CE-MRA were compared with those of DSA. RESULTS: In all cases, on 3D TOF MRA, it was difficult to evaluate the parent artery lumen and aneurysm neck owing to the significant artifacts from the stent. Contrast-enhanced MRA sufficiently demonstrated parent artery lumen and aneurysm neck distinctly and as clear as DSA did in all cases. CONCLUSIONS: For follow-up after coiling with an Enterprise stent, CE-MRA may be necessary to avoid susceptibility artifacts caused by the stent.

Magnetic resonance plaque imaging to predict the occurrence of the slow-flow phenomenon in carotid artery stenting procedures.

INTRODUCTION: The purpose is to investigate the feasibility of magnetic resonance (MR) plaque imaging in predicting the arterial flow impairment (slow-flow phenomenon) during carotid artery stenting (CAS) using a filter-type protection device. METHODS: Thirty-one carotid artery stenotic lesions in 30 patients (28 men and two women; mean age, 71.8 years) were evaluated by MR plaque imaging with black blood T1- and T2-weighted and time-of-flight sequences before CAS. Main plaque components were classified as vulnerable (intraplaque hemorrhage and lipid-rich/necrotic core) or stable (fibrous tissue and dense calcification) from the signal pattern. The plaque classification was statistically compared with the occurrence of slow-flow phenomenon. RESULTS: The slow-flow phenomenon was observed in ten CAS procedures (five flow arrests and five flow reductions). Flow arrests consisted of four vulnerable and one stable plaque, and flow reductions consisted of four vulnerable and one stable plaque. The slow-flow phenomenon occurred significantly (P<0.01) more frequently in patients with vulnerable plaque. CONCLUSIONS: Vulnerable carotid plaques have a significantly higher risk of slow-flow phenomenon than stable plaques. The occurrence of the slow-flow phenomenon can be predicted by MR plaque imaging before CAS.

Multiple cerebral aneurysms associated with Takayasu arteritis successfully treated with coil embolization.

The cerebrovascular complications of Takayasu arteritis are primarily related to the presence of occlusive lesions. Cerebral aneurysms rarely occur as complications; only 18 cases have been reported thus far. The use of coil embolization to treat cerebral aneurysms occurring as a complication of Takayasu arteritis has not been previously reported. We report a case of Takayasu arteritis with a basilar tip aneurysm and a P1 segment aneurysm of the left posterior cerebral artery that were successfully treated with coil embolization. Because coil embolization for cerebral aneurysms associated with Takayasu arteritis requires the use of limited access routes that have extremely curved and tortuous courses, catheter navigation was difficult. The guide catheter, microcatheter, and guidewire must be selected and navigated with greater care than is usually required for common aneurysm embolization.

Initial experience of using the filter protection device during carotid artery stenting in Japan.

PURPOSE: No filter protection devices for carotid artery stenting (CAS) have been formally approved for use in Japan; however, as of April 2008, the Angioguard XP (AGXP) was approved. This article describes our initial results using the AGXP during CAS for the treatment of carotid artery stenosis. MATERIAL AND METHODS: A group of 15 patients (14 men) with a mean age of 72.3 years (range 53-81 years) were treated by CAS using the AGXP. Among them, 10 were symptomatic with >50% stenosis of the common or internal carotid artery (ICA), and 5 were asymptomatic with >70% stenosis. The rates of technical success, periprocedural stroke, ICA flow impairment, filter movement, and development of new ischemic lesions on diffusion-weighted imaging (DWI) were assessed. RESULTS: CAS using the AGXP was successful in all cases. There was one minor stroke, and flow impairment occurred in six patients. Filter movement averaged 1.9 vertebral bodies. DWI showed new ipsilateral ischemic lesions in eight of the patients. CONCLUSION: Initial clinical experience using the AGXP for CAS has been generally sufficient. However, attention must be paid to three problems when using the AGXP: the filter may move after placement; the filter may disturb blood flow in the ICA; and debris may pass around the filter.

Cerebral hemorrhage with angiographic extravasation immediately after carotid artery stenting.

Recognizing cerebral hyperperfusion syndrome with intracerebral hemorrhage following carotid artery stenting is critical because the mortality rate is high. This type of hemorrhage usually arises from within several hours to a few days after the procedure. Here we describe a putaminal hemorrhage with extravasation during angiography that developed immediately after carotid artery stenting. A search of the literature revealed only one other similar case report. The etiology of the intracerebral hemorrhage immediately after carotid stenting might be analogous to that of hypertensive hemorrhage.

Successful percutaneous transluminal angioplasty and stenting for symptomatic intracranial vertebral artery stenosis using intravascular ultrasound virtual histology.

This is the first report of percutaneous transluminal angioplasty (PTA) of an intracranial artery applying intravascular ultrasound virtual histology (IVUS-VH), which has been recently developed for tissue characterization of coronary artery plaque. We report a case of successful PTA and stenting for symptomatic intracranial vertebral artery stenosis using IVUS-VH.

A case of uterine torsion concurrent with a ruptured ovarian endometrial cyst.

The patient was a 54-year-old female presented with severe abdominal swelling and intermittent pain. On emergent CT, massive ascites with thickened peritoneum and intra-pelvic cystic mass approximately 20 cm in diameter were observed. The cyst wall showed redundant irregular shape. The uterus was enlarged with intramural mass located at its right anterior fundus. MRI showed this pelvic cyst as high intensity on T1-weighted images, so that it was suspected as an endometrial cyst. The operation revealed the rupture of endometrial cyst and the uterine torsion of 180° around the long axis. Retrospectively, the X-shaped configuration of the upper vagina was observed on MRI and both the adnexa, including right ovarian cyst, were connected to the opposite side ovarian vein. Torsion of a non-gravid uterus is rare. In this case, the uterine torsion seemed to be caused by enlarged uterine body and ruptured endometrial cyst. Radiologists should be aware of this potential complication of huge ovarian mass and enlarged uterus and its appearance.

Diffusion tensor imaging in cases with visual field defect after anterior temporal lobectomy.

BACKGROUND AND PURPOSE: Visual defect due to optic radiation injury is a complication of temporal lobectomy for temporal epilepsy. To investigate whether diffusion tensor imaging can delineate the changes in optic radiations after lobectomy, we evaluated parameters on tensor images for optic radiations and correlated them with visual defect. METHODS: We examined 14 cases after temporal lobectomy. Durations after surgeries ranged from 3 weeks to 9 years. The cases were classified into three groups on the basis of the severity of visual field defect (A-C, with group C the most severe). We evaluated signals on T2-weighted images and parameters of tensor images, including fractional anisotropy (FA) and apparent diffusion coefficient (ADC), for the optic radiation in both the operated and intact side. RESULTS: On T2-weighted images, high signals in optic radiations were seen in four cases, occurring more than 4 weeks after surgery. The mean operated-to-intact side FA ratio in the optic radiation decreased according to severity of visual defect (group A, 0.88; group B, 0.89; group C, 0.73). The mean operated-to-intact side ADC ratio showed no significant difference in the overall cases. The ratio for ADC, however, tended to increase according to visual defect in cases after 10 weeks postsurgery. CONCLUSION: Optic radiation showed a decreased FA value in cases after temporal lobectomy. In later stages, ADC values tended to increase and high signal intensities on T2-weighted images were observed. The FA value can be used for evaluating Wallerian degeneration of optic radiation even in the early stages after surgery.

Distinguishing between anterior cerebral artery and middle cerebral artery perfusion by color-coded perfusion direction mapping with arterial spin labeling.

The purpose of this study was to evaluate collateral circulation by describing anterior cerebral artery and middle cerebral artery perfusion areas. Pairs of image sets spin labeled on the medial and lateral side were used. A pixel-by-pixel t test was performed, with blue gradation used to display lateral perfusion (ie, middle cerebral artery) and orange gradation for anterior cerebral artery perfusion. Extensions of anterior cerebral artery perfusion areas in cases of middle cerebral artery stenosis were described. This method may aid in estimation of collateral circulation for stroke treatment.

Paradoxical parasellar high signals resembling shunt diseases on routine 3D time-of-flight MR angiography of the brain: mechanism for the signals and differential diagnosis from shunt diseases.

BACKGROUND AND PURPOSE: We occasionally encounter phenomena in which venous flow signals of the cavernous sinus (CS) and/or inferior petrosal sinus (IPS) are visualized paradoxically in patients without arteriovenous shunt in 3D time-of-flight magnetic resonance angiography (3D-TOF MRA) of the brain. The aims of this study are to examine the frequency and cause of this phenomenon ("pseudo-shunt" image) and to determine points of differentiation from definite arteriovenous shunt images ("real shunt"). METHODS: We retrospectively examined 85 maximum intensity projection images obtained by MRA in the absence of arteriovenous shunts to detect pseudo-shunt images, and evaluated source images of pseudo-shunt studies for venous structures. Four real-shunt MRA studies were compared with pseudo-shunt studies on three points: (1) extension of sinuses, (2) extension of cortical veins, and (3) signal intensity of sinuses as assessed by the scoring method (1 point when these findings exist, 0 when they do not). RESULTS: We detected five CS (3%) and six IPS (4%) signals in 9 (11%) of the 85 cases. In the source images of four pseudo-shunt images in the CS, we detected signals from the sphenoparietal sinus (SPS). The average score was significantly lower in the pseudo-shunt (0.22) than the real-shunt (2.75) images (P < .0001). CONCLUSION: In cerebral 3D-TOF MRA, pseudo-shunt images were seen in 11% (9/85) of the study population, with antegrade upward blood flow of the SPS considered as one of the causes. Real-shunt signals can be distinguished from pseudo-shunt signals by evaluation of source images.

Signal characteristics of FLAIR related to water content: comparison with conventional spin echo imaging in infarcted rat brain.

To examine the correlation between tissue water content and signal intensity on fluid-attenuated inversion recovery (FLAIR) images, we analyzed infarcted rat brain, verified the results by theoretical simulation, and compared them with conventional spin-echo images. We produced brain infarction with cavitation in five rats by middle cerebral artery occlusion. After in vivo MRI, histologic sections of the MRI plane were obtained. We measured the signal intensity of regions on FLAIR and spin-echo images, and measured the area of cavitation on histologic sections. We plotted curves of cavity percentage to signal intensity. Theoretical values were calculated using a two-compartment model. On the curve of cavity area to signal intensity, the signal on FLAIR images peaked in tissues with 20% to 30% area of cavitation. On the theoretical curve, the signal on FLAIR images peaked at 90% tissue water content. These results seem to be characteristic of FLAIR.

[The posterior inferior cerebellar artery arising from the internal carotid artery directly: a variant of the persistent primitive hypoglossal artery].

We reported a rare case of the posterior inferior cerebellar artery arising from the internal carotid artery directly. A 33-year-old male was admitted to our hospital with the complaint of throbbing type headache. CT showed no abnormal findings. A saccular aneurysm at the bifurcation of the left middle cerebral artery was revealed by MR angiography and the left internal carotid angiography. The right internal carotid angiography demonstrated an anomalous branch originating at the level of the C1/2 in the cervical portion of the internal carotid artery. This branch terminated as the posterior inferior cerebellar artery without an interposed segment of the vertebro-basilar artery. The ipsilateral vertebral artery was aplasia. T2-weighted MR image showed a flow-void penetrating the right hypoglossal canal. This vessel was confirmed an artery passing through the hypoglossal canal with the source images of the three-dimensional time-of-flight MR angiography. We diagnosed it as a kind of variant of the persistent primitive hypoglossal artery. The persistent primitive hypoglossal artery is composed of the proximal segment derived from the primitive hypoglossal artery, and the distal segment consisting of portions of the lateral anastomotic channels (primitive lateral basillo-vertebral anastomosis) which give rise to the posterior inferior cerebellar artery. We speculated that this variant resulted from the persistence of the proximal segment, which communicated with the stem of the posterior inferior cerebellar artery via the distal segment, and next, the disconnection of the posterior inferior cerebellar artery origin with the vertebral artery due to the aplasia of right vertebral artery and the involution of the distal segment connected to the basilar artery.

Initial experience of carotid artery stenting using the Carotid WALLSTENT and FilterWire EZ in Japan.

PURPOSE: The Carotid WALLSTENT (CWS) and Filter-Wire EZ (FWEZ) embolic protection devices for use in carotid arterial stenting (CAS) were newly approved for national health insurance coverage in Japan in April 2010. This article describes our initial experience of CAS using the CWS and FWEZ. MATERIAL AND METHODS: A group of 14 patients (12 men, 2 women; mean age 70.1 years, range 59-83 years) with 15 carotid artery stenoses at high risk for carotid endarterectomy were treated by CAS using the CWS and FWEZ. Of these stenoses, 5 were symptomatic with ≥50% stenosis of the common or internal carotid artery (ICA), and 10 were asymptomatic with ≥80% stenosis. The rates of technical success, ICA flow impairment during filter protection, periprocedural ischemic stroke, 30-day major adverse events (MAEs) (stroke, death, myocardial infarction), and development of new ischemic lesions on diffusion-weighted imaging (DWI) were assessed. RESULTS: CAS was successful in all cases. There was no ICA flow impairment, periprocedural ischemic stroke, or MAEs. DWI showed new ipsilateral ischemic lesions in only one patient (6.7%). CONCLUSION: Our initial clinical experience using the CWS and FEWZ for CAS was generally excellent, and the incidence of postprocedural ischemic lesions was low.

Anatomical evaluation of the dural sinuses in the region of the torcular herophili using three dimensional CT venography.

RATIONALE AND OBJECTIVES: The torcular herophili, or "confluence of the sinuses," shows various configurations with other venous sinuses, as revealed by angiography. The aims of this study were to evaluate anatomic variations of this confluence and to assess their clinical relevance using three-dimensional (3D) computed tomographic (CT) venography. MATERIALS AND METHODS: The torcular herophili and its relevant venous sinuses were analyzed using 3D CT venography in 120 adults, consisting of 76 patients who were proven to have aneurysms and 44 patients who were proven to have no vascular malformations or aneurysms after the examinations. Three-dimensional CT venography was performed following the arterial phase of 3D CT angiography without any additional injection of contrast material. Three-dimensional volume-rendered venous images were reconstructed on a workstation and reviewed. RESULTS: The superior sagittal sinus (SSS) drained into the transverse sinus (TS) in four patterns: the SSS reached the centrally located confluence, where it divided into the bilateral TS (20.0%); the SSS was prematurely duplicated into the right and left limbs and drained into the same side TS (26.7%); the SSS drained exclusively into the right TS (44.2%); or the SSS drained exclusively into the left TS (9.2%). The draining pattern of the straight sinus was also classified into four types. The right TS was larger than the left TS. The right TS were higher compared to the left TS. Persistent occipital sinuses were recognized in 57.5% of the subjects. Finally, persistent falcial sinuses were seen in 2.5% of the subjects. A septum in the SSS and complicated venous channels in the confluence were each seen in only one case. CONCLUSION: Three-dimensional CT venography is useful as a noninvasive method to evaluate the confluence and its relevant dural sinuses and can provide useful information for surgical intervention.

Evaluation of arteriosclerotic changes in the intracranial carotid artery using the calcium score obtained on plain cranial computed tomography scan: Correlation with angiographic changes and clinical outcome.

PURPOSE: This study evaluated the correlation between quantified calcification of the carotid siphon and arteriosclerotic changes on angiography as well as clinical outcome. We used the calcium score obtained from intracranial carotid arteries viewed on plain CT. METHOD/MATERIALS: We examined carotid siphons of 72 consecutive patients who had undergone both plain CT and angiography of the brain. We calculated calcium scores of the carotid siphon. Arteriosclerotic changes on angiography were categorized as "smooth," "irregular," or "stenosis." We assessed the correlation between the scores and arteriosclerotic changes both in the carotid siphon and the bifurcation. We reviewed clinical records approximately 2 years after examination and evaluated the scores of patients who did and did not experience cerebral strokes. RESULTS: In the evaluation between angiographic findings of siphon and calcium score of the siphon, there were statistically significant differences between the "smooth" and "irregular", "irregular" and "stenosis" and the "smooth" and "stenosis". In the evaluation between angiographic findings of bifurcation and the score of the siphon, a statistically significant difference was only seen between "smooth" and "stenosis". No significant differences in calcium scores were observed between patients groups who did or did not experience a cerebral stroke. CONCLUSIONS: There were a positive correlation between calcium scores on CT and angiographic changes of arteriosclerosis in the siphon as well as bifurcation, indicating angiographic changes can be predicted using calcium scores. However, the degree of calcification in the siphon cannot be used to predict the possibility of a future cerebral stroke.

Evaluation of extraocular muscles using dynamic contrast enhanced MRI in patients with chronic thyroid orbitopathy.

OBJECTIVE: The purpose of the current study is to investigate the underlying pathophysiological changes of extraocular muscle (EOM) in Graves orbitopathy using dynamic contrast MR imaging and to correlate these MR functional changes with the anatomic abnormalities. METHODS: EOMs of 16 patients with Graves disease and 12 normal volunteers were examined by dynamic enhanced MRI. We quantified the peak enhancement ratio of EOMs and calculated the ratio versus temporalis muscle and the ratio of maximum upslope versus temporalis muscle. We compared the ratios between normal volunteers and patient groups. RESULTS: Mean of peak enhancement ratio values for the EOMs in patients with Graves disease tends to decrease according to the severity of the anatomic and clinical changes. The mean maximum upslope also decreased according to the severity of the disease for EOMs. CONCLUSION: Hemodynamic information obtained by dynamic contrast enhanced MRI is useful in evaluating the clinical course of thyroid orbitopathy.