Impact of immediate general anesthesia in the emergency room on prevention of rebleeding after subarachnoid hemorrhage.

BACKGROUND: Aneurysm rebleeding is fatal in patients with aneurysmal subarachnoid hemorrhage (aSAH). We aimed to investigate whether immediate general anesthesia (iGA) management in the emergency room, upon arrival, prevents rebleeding after admission and reduces mortality following aSAH. METHODS: The clinical data of 3033 patients with World Federation of Neurosurgical Societies (WFNS) grade 1, 2, or 3 aSAH from the Nagasaki SAH Registry Study between 2001 and 2018 were retrospectively analyzed. iGA was defined as sedation and analgesia using intravenous anesthetics and opioids combined with intubation induction. We calculated crude and adjusted odds ratios to evaluate the associations between iGA and the risk of rebleeding/death using multivariable logistic regression models with fully conditional specification for multiple imputations. In the analysis of the relationship between iGA and death, we excluded patients with aSAH who died within 3 days after the onset of symptoms. RESULTS: Of the 3033 patients with aSAH who met the eligibility criteria, 175 patients (5.8%) received iGA (mean age, 62.4 years; 49 were male). Heart disease, WFNS grade, and lack of iGA were independently associated with rebleeding in the multivariable analysis with multiple imputations. Among the 3033 patients, 15 were excluded due to death within 3 days after the onset of symptoms. After excluding these cases, our analysis revealed that age, diabetes mellitus, history of cerebrovascular disease, WFNS grade, Fisher grade, lack of iGA, rebleeding, postoperative rebleeding, no shunt operation, and symptomatic spasm were independently associated with mortality. CONCLUSIONS: Management by iGA was associated with a 0.28-fold decrease in the risks of both rebleeding and mortality in patients with aSAH, even after adjusting for the patient's history of diseases, comorbidities, and aSAH status. Thus, iGA can be a treatment for the prevention of rebleeding before aneurysmal obliteration treatment.

Characteristics of aneurysmal subarachnoid hemorrhage associated with rheumatic disease.

Spontaneous subarachnoid hemorrhage (SAH) occurs due to intracranial aneurysm rupture in most cases. Rheumatic disease may cause vessel wall inflammation, which can increase the risk of rupture. However, the characteristics of SAH with rheumatic disease are unknown. This study aimed to evaluate SAH features in patients with rheumatic disease. We retrospectively analyzed clinical data of 5066 patients from the Nagasaki SAH Registry Study who had been diagnosed with aneurysmal SAH between 2001 and 2018. We evaluated the SAH characteristics in patients with rheumatic disease using multivariable logistic regression analysis. In total, 102 patients (2.0%, 11 men and 91 women, median age 69.0 [57.0-75.5]) had rheumatic disease. In these patients, univariate logistic regression analysis showed that sex, hypertension, family history of SAH, smoking history, World Federation of Neurosurgical Societies grade on admission, aneurysm size, multiple aneurysms, treatment, and symptomatic spasms were associated with SAH. Multivariable logistic regression analysis showed that characteristics independently associated with SAH in rheumatic disease were female sex (odds ratio [OR] 3.38; 95% confidence interval [CI] 1.81-6.93, P < 0.001), hypertension (OR 0.60; 95% CI 0.40-0.90, P = 0.012), family history of SAH (OR 0.18; 95% CI 0.01-0.80, P = 0.020), small ruptured aneurysms (OR 1.50; 95% CI 1.02-2.24, P = 0.048), and multiple aneurysms (OR 1.69; 95% CI 1.09-2.58, P = 0.021) in comparison with SAH without rheumatic disease. In conclusion, SAH in patients with rheumatic disease was characterized by small multiple aneurysms, regardless of the low incidence of hypertension and family history of SAH.

[A Ruptured Aneurysm at the Origin of a Duplicated Middle Cerebral Artery, Treated by Coil Embolization:A Case Report].

Duplication of the middle cerebral artery(MCA)is an anatomical variant of the MCA, originating from the distal portion of the internal carotid artery(ICA)and supplying blood flow to the tip of the temporal lobe. Cerebral aneurysms rarely develop at the bifurcation of the ICA and the duplicated MCA, but when they do develop, they may result in subarachnoid hemorrhage. We treated a 41-year-old man, who was urgently brought to our hospital because of severe headache. A computed tomography(CT)scan showed subarachnoid hemorrhage due to the rupture of an aneurysm at the origin of the duplicated MCA. The aneurysm was small and projected laterally, and coil embolization was performed employing a balloon catheter. The neck of the aneurysm was not embolized to preserve the origin of the duplicated MCA. The patient had an uneventful postoperative course, and he returned to his usual daily activities. Coil embolization is rapidly developing for treatment of cerebral aneurysms and may be the first-line treatment for duplicated MCA aneurysms. Owing to the relatively small size of such aneurysms, the risk of intraprocedural rupture should be considered, and a carefully performed balloon-assisted procedure is recommended.

[A Case of Metastatic Brain Tumor Complicated by Multiple Repeated Hemorrhages].

Metastatic brain tumor occasionally results in multiple cerebral hemorrhages. Here, we report a case of metastatic brain tumor complicated by multiple repeated cerebral hemorrhages. An 80-year-old man with a history of removal of lung cancer was admitted to our hospital because of disturbed consciousness following headache. A brain CT revealed a mass lesion of 40-mm diameter in the left cerebellum and a mass lesion of 2-mm diameter in the right temporal lobe. The cerebellar mass lesion showed homogeneous iso-density, indicating a subacute phase hemorrhage. Two days later, a follow-up CT revealed that the mass lesion had become high-density, indicating complication by a fresh hemorrhage. Hematoma was removed and histological examination was performed on the cerebellar lesion. There was leakage of dark-red liquid intraoperatively, and histological examination revealed an adenocarcinoma, indicating metastasis of the lung cancer. Additionally, necrosis and hemorrhage were identified. Postoperatively, whole brain irradiation was performed. The right temporal lesion gradually enlarged but disappeared after irradiation. In conclusion, multiple brain metastases may result in multiple cerebral hemorrhages. Repeated hemorrhage from necrosis of the carcinoma causes a slowly growing hematoma.

[A Case of Vertebral Artery Stenosis Presenting with Progressing Stroke and Treated by Percutaneous Transluminal Angioplasty].

A 75-year-old man with a history of diabetes mellitus and hypertension was suffered from dizziness and vomiting and brought to the near-by hospital. MRI showed cerebellar infarction due to right vertebral artery stenosis. Despite best medical treatment, the infarction progressed day by day and he was transferred to our hospital five days later. Neurological examination showed mild disturbance of consciousness and right hemiparesis. Right vertebral angiography revealed high-grade stenosis accompanied with atherosclerosis at the V3-V4 portion. Percutaneous transluminal angioplasty (PTA) was performed with 2.5 mm×14 mm balloon with 6 atm dilation. Postoperative course was uneventful and no further stroke occurred after the treatment. PTA was effective for vertebral artery stenosis manifested with progressing stroke. The indication of stent placement for the cerebral artery should be prudent.

Impact of perioperative aneurysm rebleeding after subarachnoid hemorrhage.

OBJECTIVE: Aneurysm rebleeding is a major cause of death and morbidity in patients with aneurysmal subarachnoid hemorrhage (SAH). Recognizing the predictors of rebleeding might help to identify patients who will benefit from acute management. This study was performed to investigate the predictors of aneurysm rebleeding and their impact on clinical outcomes in the preoperative, intraoperative, and postoperative periods. METHODS: The incidence of rebleeding, demographic data, and clinical data from 4933 patients with aneurysmal SAH beginning in the year 2000 were retrospectively analyzed in the Nagasaki SAH Registry Study. The authors performed multiple logistic regression analyses to identify the risk factors contributing to rebleeding and outcome after SAH. RESULTS: Preoperative rebleeding occurred in 7.2% of patients. Patient age (p = 0.01), multiple aneurysms (p < 0.01), aneurysm size (p < 0.0001), and heart disease (p = 0.03) were significantly associated with preoperative rebleeding. Conversely, intraoperative rebleeding occurred in 11.2% of patients. Aneurysm location (anterior communicating artery [ACoA]), family history (p = 0.02), preoperative rebleeding (p < 0.01), and clipping/coiling (p < 0.0001) were significantly associated with intraoperative rebleeding. Interaction analysis showed that clipping significantly affected intraoperative rebleeding at the ACoA (OR 4.00; 95% CI 1.82-8.80; p < 0.001). Postoperative rebleeding occurred in 2.4% of patients. Coiling/clipping (p < 0.0001) and intraoperative rebleeding (p < 0.01) were significantly associated with postoperative rebleeding. Rebleeding in all time periods examined significantly contributed to the clinical outcome after SAH. CONCLUSIONS: Aneurysm rebleeding after SAH has specific characteristics in the preoperative, intraoperative, and postoperative periods, and all of these characteristics contribute to the clinical outcome. The ACoA has a higher risk of intraoperative rebleeding, and endovascular coiling could be a good candidate in terms of techniques for preventing intraoperative rebleeding, although complete aneurysm obliteration should be accomplished.

Agenesis of the internal carotid artery with transcavernous anastomosis presenting with an anterior communicating artery aneurysm--a case report and review of the literature.

Arterial communication between cavernous segments of the carotid arteries associated with unilateral agenesis of the internal carotid artery (ICA) is extremely rare. We herein present a case of unilateral ICA agenesis with transcavernous anastomosis that presents with an anterior communicating artery (ACoA) aneurysm, and discuss its embryogeny and clinical implications. A 55-year-old woman with no significant medical history was admitted to our hospital for further examination of agenesis of the left ICA, which was detected in a routine medical examination. She was free of clinical symptoms and had no neurological deficits. Radiological evaluation revealed agenesis of the left ICA with transcavernous anastomosis. Moreover, an incidental multilobulated aneurysm was detected at the ACoA. She underwent microsurgical clipping for this aneurysm, and the post-operative course was uneventful. Investigation of collateral pathways helps our understanding of the segmental nature of carotid artery development. Recognition of this anomaly also has important implications in the surveillance and detection of associated cerebral aneurysms.

Recanalization after endovascular occlusion of a dissecting aneurysm of the posterior cerebral artery--A case report and review of the literature.

Endovascular occlusion has been accepted as a safe, minimally invasive, and reliable treatment for ruptured dissecting aneurysms. Occlusion of the entire affected area is ideally the most complete treatment for such lesions. However, it is difficult to occlude the entire dissected lesion when it involves side branches due to the short-term risk of side branch occlusion, emboli dislodgement, and the long-term risk of parent artery recanalization. We herein present an extremely rare case where recanalization occurred after endovascular occlusion of a ruptured dissecting aneurysm of the posterior cerebral artery, and discuss its clinical implications. There are three mechanisms of recanalization: coil compaction due to loose or short segment packing, secondary dissection and occlusion of the false lumen. In endovascular occlusion of dissecting aneurysms that involve side branches, it is important to consider the risk of both recanalization and ischemic complications. We should attempt to insert the microcatheter into the true lumen and maintain dense packing as long as possible, unless the coils occlude the side branches following the procedure. Careful follow-up is necessary in all patients that received endovascular treatment.

Progressive perianeurysmal edema induced after endovascular coil embolization. Report of three cases and review of the literature.

The authors report three cases of progressive vasogenic brain edema surrounding a cerebral aneurysm after endovascular coil embolization. In all three cases embolization was incomplete due to the aneurysms' large sizes and wide necks. Follow-up magnetic resonance imaging revealed de novo vasogenic brain edema surrounding the aneurysms 3 to 6 months after the initial treatment. The edema progressed in parallel with regrowth of the aneurysms. All three aneurysms were deep in the brain parenchyma and showed intramural enhancement, suggesting hemorrhage or inflammation. Each patient underwent a second embolization for the aneurysm regrowth, which resulted in improvement of the edema. Based on the findings in these cases and review of the literature, it is suggested that incomplete occlusion of larger aneurysms that are deep within the brain may lead to a disorganized intraluminal thrombosis, aneurysm pulsing, and intramural hemorrhage or inflammation, all of which are associated with brain edema following aneurysm recanalization and regrowth. It should be kept in mind that incomplete embolization of larger aneurysms may cause such malignant change and that this complication may occur after endovascular treatment.

Giant thrombosed fusiform aneurysm at the basilar trunk successfully treated with endovascular coil occlusion following bypass surgery: a case report and review of the literature.

OBJECTIVE: Giant fusiform aneurysms at the basilar trunk tend to have a poor natural history, and the surgical management for these aneurysms remains controversial. For these aneurysms, basilar trunk occlusion may offer a potentially long-lasting cure. However, the strategy for these aneurysms is difficult when the collateral supply from the carotid circulation is poor. The authors herein present a successful case of a thrombosed giant fusiform aneurysm at the basilar trunk with a poor collateral supply using repeated balloon test occlusion (BTO) and a second bypass surgery. CASE REPORT: A 46-year-old female was admitted to our institute because of progressing double vision. A radiologic examination revealed a thrombosed giant fusiform aneurysm at the upper basilar trunk, and the collateral supply from carotid circulation was poor. We attempted to perform a second bypass surgery before the basilar trunk coil occlusion due to intolerance after the repeated BTO. After confirmation of her tolerance against the third BTO, the aneurysm was successfully trapped using the endovascular technique. CONCLUSION: Various kind of bypass surgery should be tried for endovascular trapping of giant fusiform basilar trunk aneurysms, and repeated BTO is necessary to confirm the tolerance after bypass surgery especially for the complex aneurysms without a sufficient collateral supply.

Aneurysmal embolization of a blisterlike aneurysm of the internal carotid artery: a case report and review of the literature.

BACKGROUND: Little is known regarding the optimal management of a ruptured blisterlike aneurysm of the ICA. Because of the high risk for intraoperative bleeding, direct surgical treatments of these fragile lesions have generally been associated with a poor outcome. We herein report a very rare case of a ruptured blisterlike aneurysm that was successfully treated with coil embolization in the late period. CASE DESCRIPTION: The patient was 21 years old when he had a Hunt and Hess grade IV subarachnoid hemorrhage. At the time of the hemorrhage, 3D-CTA demonstrated a minimal aneurysmal enlargement located in the left C2 portion of the ICA. Because of his poor neurological condition and the risk for a premature rupture during early surgery, delayed surgery was thus scheduled. Cerebral angiography, 13 days later, revealed the shape and size of the aneurysm to have changed in form from a blisterlike aneurysm to a saccular-type one. Initially, we planned to treat the aneurysm by trapping with bypass surgery on the 15th day. However, we instead performed coil embolization on the 19th day because a thick thrombus was found to cover the aneurysm at the time of surgery on the 15th day. CONCLUSION: This is the first report of a ruptured blisterlike aneurysm that was successfully treated with coil embolization in the late period of a subarachnoid hemorrhage after operative confirmation of thrombus formation around the aneurysm. Our findings suggest that coil embolization in the late period appears to be an effective option in the management of selective cases of ruptured blisterlike aneurysms.

Linear accelerator radiosurgery for vestibular schwannoma: measuring tumor volume changes on serial three-dimensional spoiled gradient-echo magnetic resonance images.

OBJECT: The authors report on a series of 46 patients harboring vestibular schwannomas (VSs) treated using linear accelerator (LINAC) radiosurgery and an analysis of serial magnetic resonance (MR) imaging data, specifically the changes in tumor volume. METHODS: Fifty-three consecutive patients underwent LINAC radiosurgery for VS between 1993 and 2002. Seven of these patients were lost to follow up. Three-dimensional (3D) spoiled gradient-echo (SPGR) MR imaging was performed at 3- to 4-month intervals after radiosurgery. Tumor volume was measured on Gd-enhanced MR images of each slice. The median duration of follow-up MR imaging studies was 56.5 months (range 12-120 months). Follow-up imaging studies were conducted for longer than 1 year in 42 of 53 patients. Tumor volume changes were categorized into four types: enlargement (eight lesions [19%]), no change (two lesions [4.8%]), transient enlargement followed by shrinkage (19 lesions [45.2%]), and direct shrinkage (13 lesions [31%]). Two cases (4.8%) with twice the initial tumor volume required repeated radiosurgery. All cases of transient enlargement had subsequent shrinkage within 2 years after radiosurgery. Nine (21.4%) of 42 patients demonstrated ventricular enlargement on MR images obtained after radiosurgery. Three patients (7.1%) required placement of a ventriculoperitoneal shunt because of symptomatic hydrocephalus, and another four cases (9.5%) spontaneously resolved. CONCLUSIONS: Volume measurement on 3D-SPGR MR imaging was a suitable method to assess tumor changes. Volume changes beyond twofold or continuous enlargement for longer than 2 years after radiosurgery are key criteria in rating the effects of radiation. Some cases of hydrocephalus after radiosurgery resolved spontaneously and their rates of occurrence were similar to the typical incidence of hydrocephalus associated with VS.

Magnetic resonance angiography evaluation of external carotid artery tributaries in moyamoya disease.

BACKGROUND AND PURPOSE: High-resolution magnetic resonance (MR) image has been introduced to diagnose and follow-up moyamoya disease and visualized moyamoya vessels and internal carotid artery stenosis. This study was performed to assess the utility of MR angiography (MRA) for the evaluation of anastomotic channels through the external carotid artery (ECA) in moyamoya disease patients. METHODS: Twenty patients with moyamoya disease were reviewed. The cortical anastomosis and superficial temporal artery (STA), middle meningeal artery, and deep temporal artery by MRA were evaluated and were compared with those by digital subtraction angiography if obtained. Fifteen patients (24 hemispheres) underwent bypass surgery, including encephaloduroarteriosynangiosis in 14 hemispheres and STA-middle cerebral artery anastomosis with encephalomyosinangiosis in 10 hemispheres. Five patients did not undergo any surgery. RESULTS: MRA could show these vessels and the patency of anastomosis formed by the surgery and also showed naturally formed anastomosis and ECA tributaries in the patients who did not undergo any surgery. CONCLUSION: MRA provides useful information for follow-up evaluation on the development of the ECA system in moyamoya disease.

Rapidly growing microcystic meningioma of the middle fossa floor. Case report.

A 74-year-old woman presented with a microcystic meningioma which manifested as mental disturbance. A rapidly growing tumor in the left middle fossa had not been detected by examination 10 months before. The tumor was remarkably enhanced by contrast medium on both computed tomography and magnetic resonance imaging and was associated with massive perifocal edema. Cerebral angiography revealed that the tumor was mainly fed by the left middle meningeal artery, which was embolized preoperatively. The tumor was completely removed and no postoperative adjuvant therapy was administered. The histological diagnosis was microcystic meningioma with many mitotic figures and a MIB-1 labeling index of 12.8%. Four months later, the tumor recurred and invaded the paranasal sinus. Focal irradiation successfully controlled further regrowth. This case suggests that microcystic meningioma may have aggressive features, and close observation is necessary even after gross total removal.

Cilostazol may prevent cardioembolic stroke in patients undergoing antiplatelet therapy.

OBJECTIVES: Randomised trials have shown the efficacy of antiplatelet therapy with cilostazol to prevent secondary ischaemic stroke. Recently, cilostazol has been reported to prevent the development and/or recurrence of atrial fibrillation (AF), which can potentially prevent cardioembolic stroke in patients undergoing antiplatelet therapy. Herein, we examined the impact of prior antiplatelet therapy with cilostazol on the incidence of cardioembolic stroke, which had not been fully investigated. METHODS: Using the multicenter retrospective study of stroke risk in antithrombotic therapy (RESTATE) database, we analysed consecutive patients with primary or secondary stroke under single antiplatelet therapy. We evaluated the characteristics of ischaemic stroke based on the type of antiplatelet agent used: aspirin, ticlopidine/clopidogrel or cilostazol. RESULTS: Of 1069 consecutive patients with primary or secondary stroke during antithrombotic therapy from January to December 2012, 615 patients received single antiplatelet therapy (293 and 322 cases of primary and secondary strokes, respectively). Interestingly, the percentage of cardioembolic infarction was significantly lower in patients taking cilostazol compared with other agents. Multivariate regression analysis found that age (OR: 1.03, 95% CI: 1.01-1.06, P = 0.0029), serum creatinine (OR: 1.17, 95% CI: 1.03-1.34, P = 0.0198), aspirin (OR: 1.75, 95% CI: 1.00-3.22, P = 0.0486), cilostazol (OR: 0.19, 95% CI: 0.03-0.73, P = 0.0125), and smoking (OR: 1.86, 95% CI: 1.16-2.94, P = 0.0102) were independently associated with cardioembolic stroke. CONCLUSIONS: Cilostazol may prevent cardioembolic stroke in patients undergoing antiplatelet therapy. This could be a novel strategy for cardioembolic stroke prevention potentially by affecting cardiac remodelling, in contrast to secondary anticoagulant therapy.

Incidence and outcome of multiple intracranial aneurysms in a defined population.

BACKGROUND AND PURPOSE: Proportions of patients with single and multiple aneurysms among patients suffering from subarachnoid hemorrhage (SAH) are not well established. We evaluated these proportions and the differences in outcome between SAH patients with a single aneurysm and those with multiple aneurysms in a defined population. METHODS: Between 1989 and 1998, 2037 patients (age, 20 to 89 years) with ruptured intracranial aneurysm were treated in 11 hospitals in Nagasaki Prefecture. Multiple aneurysms were found in 361 of these patients. Age- and sex-specific incidences of ruptured aneurysm per 100 000 people were calculated. RESULTS: For both single and multiple aneurysms, the incidences were significantly higher in women than in men 60 to 69 and 70 to 79 years of age. In every age category except 80 to 89 years, the frequency of multiple aneurysms was higher in women than in men. The overall frequency of multiple aneurysms was 20.2% in women, which was significantly higher than the 12.4% in men (P<0.0001). In patients 70 to 89 years of age, outcome was significantly worse (in terms of surgical complications) in patients with multiple aneurysms (12.1%) than in patients with a single aneurysm (6.0%). CONCLUSIONS: Among all patients with SAH, women >or =50 years of age outnumber other age and sex categories. Female sex itself is also associated with an increased rate of multiple aneurysms among SAH patients. Among the elderly > or =70 years of age, prognosis is less favorable for SAH patients with multiple aneurysms than for those with a single aneurysm.

Depicting cerebral veins by three-dimensional CT angiography before surgical clipping of aneurysms.

BACKGROUND AND PURPOSE: Cerebral veins show wide variation, and unexpected veins occasionally limit surgical procedures for clipping of cerebral aneurysms. This study was undertaken to assess the utility of three-dimensional CT angiography (3D-CTA) in the evaluation of venous anatomy before surgical clipping of cerebral aneurysms. METHODS: 3D-CTA was performed in 19 patients before pterional craniotomy. The venous anatomy visualized by use of 3D-CTA was compared retrospectively with intraoperative findings. RESULTS: 3D-CTA clearly depicted the superficial sylvian veins (SSVs) in 17 of 19 cases. In three of these 17 cases, 3D-CTA failed to reveal the additional connecting veins from SSVs to the midportion of the sphenoid wing. 3D-CTA also depicted bridging veins from: 1) the basal vein of Rosenthal to the sphenoparietal sinus (SPS) (three cases); 2) a junction of the anterior cerebral vein and the deep middle cerebral vein to the SPS (two cases); 3) the anterior cerebral vein into the cavernous sinus (one case); and 4) the deep middle cerebral vein to the cavernous sinus in one case. Surgical findings corresponded well with the angiographic findings. 3D-CTA depicted bridging veins from the frontal base into the SPS in two cases; retraction of the frontal lobe was severely limited in these cases. 3D-CTA also exhibited anatomic variation of deep cerebral veins, which suggests the utility of 3D-CTA in evaluating the risks carried by sacrifice of some bridging veins. In two patients, aneurysmal dissection was restricted because of adhering veins. 3D-CTA depicted these cerebral veins to be lying in contact with the aneurysm. In one case, the contiguous vein was hidden behind a large middle cerebral artery aneurysm; 3D-CTA was helpful for visualization of this vein. CONCLUSION: 3D-CTA can clearly depict the venous anatomy of the brain and is useful for surgical planning of a pterional or temporopolar approach for cerebral aneurysms.

Immunohistochemical expression of E-cadherin in metastatic brain tumors.

The adhesion molecule E-cadherin has been shown to influence malignant transformation of tumors, including local and distant metastases. We examined the expression of E-cadherin to determine its relationship to the development of metastasis in metastatic brain tumors. Immunohistochemistry for E-cadherin and Ki-67 was carried out in 76 formalin-fixed, paraffin-embedded archival specimens of metastatic brain tumors and in 14 corresponding available primary tumors from patients who received treatment for metastatic brain tumors. The primary tumors were mainly lung cancers (51.3%), followed by gastrointestinal tumors (28.9%). E-cadherin was expressed in 62 (81.5%) of 76 cases examined. In metastatic adenocarcinomas, a consistent tendency for E-cadherin expression was noted, regardless of the degree of differentiation or the extent of spread of the disease (P = 0.04). There was a direct correlation between E-cadherin expression and high MIB-1 index in all metastatic brain tumors (P = 0.0007). Pairwise analysis in 14 primary tumors and the corresponding metastatic specimens revealed high E-cadherin and MIB-1 staining in metastatic brain tumors. These results provide a unique association between E-cadherin, systemic metastasis, and proliferation potential in metastatic brain tumors.

A case of intimal hyperplasia induced by stenting for vertebral artery origin stenosis: assessed on intravascular ultrasound.

We report a case of proximal vertebral artery restenosis following stent placement. Intravascular ultrasound study helped delineate its characteristics. A 69-year-old man was admitted because of dysarthria and dysphagia. Angiography revealed hypoplasia of left vertebral artery (VA) and remarkable stenosis of the proximal right VA with inadequate collateral flow from the anterior circulation. Balloon angioplasty and stent placement at the VA was performed to an excellent angiographic result with recovery of neurological symptoms. His condition deteriorated six months later due to intimal hyperplasia, which we evaluated by intravascular ultrasound (IVUS). Balloon angioplasty was then performed. Stent placement may induce intimal hyperplasia and IVUS is useful to assess the lesion.

Proton MR spectroscopy and diffusion-weighted MR imaging for the diagnosis of intracranial tuberculomas. Report of two cases.

With the current prevalence of tuberculosis, the incidence of intracranial tuberculoma may be on the rise in industrialized nations. However, clinical findings suggestive of systemic tuberculosis are frequently subtle or absent in patients with intracranial tuberculoma, and no specific neuroradiologic characteristics of tuberculoma have been defined as yet. We report two cases of ring-enhanced intracranial tuberculoma in which magnetic resonance (MR) proton spectroscopy and diffusion-weighted (DW) imaging were useful in the differential diagnosis between tuberculoma and other ring-enhanced mass lesions. Pulmonary tuberculosis had been diagnosed in one patient, but radiologic lung study and tuberculin skin test were negative in the other. DW imaging showed bright signal intensity in the core of all lesions in both patients. Malignant gliomas and metastatic brain tumors do not have this characteristic. Proton MR spectroscopy of lesion cores showed lipid peaks and a choline peak in one, and a lipid/lactate mixture pattern in the other, which differed distinctively from those of the pyogenic brain abscess. in each case, one lesion was surgically removed. Antituberculosis drugs were started before surgery for one patient and after surgery for the other. In both, the remaining lesions were reduced significantly in size. We discuss the diagnostic potential of these MR techniques and management options of intracranial tuberculoma.