Mucinous adenocarcinoma arising from supratentorial intramedullary neuroenteric cyst with broncho-pulmonary differentiation.

Neuroenteric cysts are benign intradural endoderm cysts lined by gastrointestinal (GI) or tracheobronchial epithelial cells. Their malignant transformation is extremely rare and only six cases have been reported. In these cases, tissue lineage of the cystic endoderm cells giving rise to carcinoma was not clearly identified either as respiratory or as GI type. Herein, we report a case of mucinous adenocarcinoma arising from the neuroenteric cyst with broncho-pulmonary differentiation in the right cerebral hemisphere of a Japanese woman in her late 50s. The cyst wall was entirely lined by the following respiratory epithelial components: stratified bronchial ciliated columnar epithelium with basal cells positive for CK5 and p63, terminal bronchiolar Clara cells positive for thyroid transcription factor (TTF)-1, surfactant B and negative for surfactant C, type I pneumocytes positive for TTF-1, negative for surfactant B and C, and type II pneumocytes positive for TTF-1 and surfactant B and C. In addition, nests of hyperplastic single layered mucinous epithelial cells with bronchial goblet cell phenotype were also demonstrated, and histologic features were almost the same as the pulmonary type I congenital adenomatoid malformation (CCAM) with mucinous epithelial proliferation. The mucinous epithelial nests of type I CCAM are liable to develop mucinous adenocarcinoma and frequently accompany K-ras mutation and expression of p16. However, K-ras mutation and p-16 expression were not detected in this case.

Progress in the treatment of unruptured aneurysms.

Recent technological progress has reduced the complication rate of unruptured aneurysm. We treated 128 unruptured aneurysms between April 2006 and March 2012. Seventy-six aneurysms (59 %) were clipped and 52 (41 %) were coil embolized. After 2010, we applied new instruments, i.e., near-infrared indocyanine-green videoangiography (ICG), an intraoperative endoscope, preoperative detailed MRI, and a stent-assisted coil embolization. In the results: (1) In 60 aneurysms treated before 2009, three patients showed a deterioration of more than two points in mRS (5 %). In 68 aneurysms treated after 2010, no patients showed deterioration (0 %) (p: n.s.). (2) No patients died and 126 patients (98 %) were discharged to home directly. (3) No patients showed rupture after treatment. In conclusion, the appropriate selection of treatment and recent technological progress have facilitated sophisticated treatment of unruptured aneurysms. Recently, the complication rate in surgery and endovascular surgery for unruptured aneurysms has become acceptably low.

Morphological Factors affecting Coil-Only Embolization of Small Unruptured Aneurysms.

Objective When small unruptured aneurysms (SUA) are embolized by coils, manipulation of the microcatheter and coil is limited because of their small size. Previous studies suggested that the morphology of the artery and aneurysm is important. In the present study, we clarified the morphological factors affecting coil-only embolization of SUA. Patients and Methods We retrospectively identified 17 patients who underwent embolization for unruptured aneurysm with a maximum diameter less than 5 mm. We investigated the following: (1) the relationships among dome/neck ratio (D/N), height/neck ratio (H/N), height/dome ratio (H/D), projection of aneurysm-parent artery, and adverse events, (2) immediate and late occlusion, and (3) number of coils. Results (1) Adverse events developed in three cases in which the H/D was smaller than 1 ( p < 0.02). There was a significant difference in the rate of adverse events by projection of the aneurysm-parent artery ( p < 0.03), (2) Occlusion rate: Immediately after coil embolization, 71% (12/17) were neck remnant; however, 88% (15/17) of SUA became complete occlusion in the follow-up term, and (3) 1.5 ± 0.6 coils were used. Conclusion To achieve successful coil-only embolization in SUAs, it is important to select aneurysms for which the projection of the parent artery is suitable for embolizing and the H/D ratio is larger than 1. In SUAs, occlusion develops naturally after coil embolization.

Histopathological Composition of Thrombus in Acute Ischemic Stroke May Vary Even Within the Same Patient: A Preliminary Study Examining Clots According to Their Area of Retrieval.

Objective: Mechanical thrombectomy enables histopathological examination of clots in patients who have suffered acute ischemic strokes. Many studies have described about the relationship between the histopathological compositions of retrieved thrombi and imaging findings, clinical outcomes, and stroke etiology without consensus. In this study, we examined the histological composition of thrombi according to their retrieval site and methods. Methods: We divided retrieved clots into three parts (those retrieved from the proximal and distal parts of the stent retriever, and those aspirated through the guiding catheter) and then histopathologically analyzed their compositions by measuring the area occupied by red blood cells (RBCs), fibrin/platelets (F/Ps), and white blood cells (WBCs). Results: Each specimen showed various composition even within the same patient. For example, the area occupied by RBCs was 20.9% ± 12.1%, 30.5% ± 13.5%, and 41.3% ± 16.1% in the clot retrieved from the proximal and distal parts of the stent retriever, and those aspirated through the guiding catheter, respectively. Conclusion: Histopathological clot composition may vary even within the patient. Further research is needed to investigate more objective methods of histopathological analysis and their clinical significance.

The Histopathological Findings of Two Nonbranching Saccular Cerebral Aneurysms.

Cerebral aneurysms arising from nonbranching sites are different from ordinary branching aneurysms in clinical course and histology. We pathologically examined two cases of saccular aneurysm occurring at nonbranching sites. One was a pseudoaneurysm arising at a branch of the right pericallosal artery. The other had an entirely hyalinized and thickened aneurysmal wall. Despite similar angiographical findings, our two cases had different pathological features as described above. Based on the pathological findings obtained from these cases, we believe that aneurysms in nonbranching sites are caused by injury to the internal elastic lamina. A ruptured aneurysm may be discovered as a blood blister-like aneurysm, whereas an unruptured one may develop into a "nonbranching true aneurysm."

Complications and Predictors of Hypotension Requiring Vasopressor after Carotid Artery Stenting.

A significant controversy exists regarding the clinical impact of hemodynamic depression on major adverse events after carotid artery stenting (CAS). The purpose of this study was to evaluate the incidence, predictors, and clinical significance of hypotension after CAS. A total of 118 cases of carotid artery stenosis were treated with CAS. Hypotension was defined as sustained systolic blood pressure <80 mmHg and requiring intravenous administration of vasopressor to maintain adequate systolic blood pressure after the procedure. Baseline characteristics, procedural characteristics, and periprocedural major adverse events were retrospectively compared between postprocedural hypotension group and non-hypotension group. Morphological and procedural characteristics were not significantly different between the two groups. Periprocedural major adverse events, presence of new ischemic lesions, and number of new ischemic lesions were not significantly different between the two groups (P = 1, P = 0.36, P = 0.68). Hypertension was an independent protective factor (P = 0.037), and use of proximal protection and the distance from carotid bifurcation to maximum stenotic lesion ≤ 10 mm were independent risk factors for developing hypotension after CAS (P = 0.034, P = 0.027). There was no significant relationship between hypotension after CAS and major adverse events in this study. Maintenance of periprocedural adequate cerebral perfusion is thought to be important to prevent ischemic complications due to hypotension after CAS, especially in these cases.

Midterm prevention of rebleeding by Guglielmi detachable coils in ruptured intracranial aneurysms less than 10 mm.

The midterm effects of coil embolization for ruptured aneurysm remain unknown. We investigated the prevention of rebleeding by GDC in ruptured aneurysms. Between March 1998 and April 2003, we treated 38 ruptured aneurysms measuring less than 10 mm in diameter. The patients were followed for a median of 37.3 months. During the follow-up term, aneurysms treated by coil embolization did not develop rebleeding after 1 month. We conclude that an embolized aneurysm measuring 10 mm or less remains quite stable over 3 years.

Factors for Achieving Safe and Complete Treatment for Unruptured Saccular Aneurysm Smaller Than 10 mm by Simple Clipping or Simple Coil Embolization.

OBJECTIVE: Reducing complications from unruptured aneurysms (UAs) treatment is important. We clarify the criteria for achieving safe and complete treatment for UAs ≤10 mm by clipping or coil embolization. METHODS: This study included 59 newly treated UAs in the past 2 years. We prospectively decided on criteria to recommend active treatment. UAs ≤10 mm and in ≤75 year-olds, located at in the internal carotid artery at the paraclinoid portion and the posterior circulation aneurysms except for a vertebral artery-inferior posterior cerebellar artery aneurysm were mainly treated by coil embolization, and those in the internal carotid artery except at the paraclinoid portion, in the anterior or middle cerebral artery, and in the vertebral artery-inferior posterior cerebellar artery were treated preferably by clipping. UAs with a height/neck ratio or a dome/neck ratio ≤1.4 were treated preferentially by clipping. Specific preoperative imaging and careful manipulation were adopted for clipping. RESULTS: Fifty-seven (96.6%) achieved modified Rankin scale (mRS) 0-1, 2 (3.4%) mRS 2-5, and 0 had mRS 6. Fifty-three UAs (89.8%) achieved complete occlusion (CO) and 7 (10.1%) had neck remnants (NR). Forty-one UAs (100%) within the criteria achieved mRS 0-1, 40 (98%) achieved CO, and 1 (2%) NR. The odds ratio of NR for those outside the criteria was 18.5 (95% confidence interval, 1.83-186.6) (P < 0.05). CO treated within the criteria was 39 and NR was 1. CO treated outside the criteria was 14 and NR was 5 (P < 0.05). The mRS 0-1 with age ≤75 years was 55 and the mRS 2-6 was 0. The mRS 0-1 with age ≥76 years was 2 and the mRS 2-6 was 2 (P < 0.01). CONCLUSIONS: The treatment for UAs within the criteria, with the most recent points of concern, can lead to safe and complete results.

Coil embolization of vertebro-vertebral arteriovenous fistula: a case report.

BACKGROUND: Vertebro-vertebral arteriovenous fistulas (VVFs) are not uncommon, but they usually present with benign symptoms such as neck murmur. We report a case of VVF presenting with myelopathy which was successfully treated by embolization with detachable coils. CASE PRESENTATION: A 72-year-old woman was admitted with complaint of bilateral leg weakness. Cervical magnetic resonance image showed compression of the spinal cord by a large vascular lesion. Right vertebral angiogram showed a vertebro-vertebral fistula draining into ectatic epidural veins. From a transfemoral arterial approach, the fistula site was selected with a microcatheter, and embolization was performed by placement of several Guglielmi detachable coils until flow arrest was obtained. The patient made a full recovery, and long-term angiographic follow-up demonstrated complete cure. CONCLUSION: We present a case of VVF treated using detachable coils with good long-term results.

Hemodynamic and metabolic changes after carotid endarterectomy in patients with high-degree carotid artery stenosis.

In symptomatic stenosis of the internal carotid artery (ICA), the predominant mechanism of ischemic event is considered thromboembolic. Carotid endarterectomy (CEA) removes the embolic source and is accepted as the major benefit from the surgery. Even in high-degree stenosis, hemodynamic compromise as a causal factor for cerebral ischemia remains controversial, however. We used positron emission tomography (PET) to evaluate possible hemodynamic and/or metabolic changes caused by a severe ICA stenosis and the subsequent changes after CEA. Subjects consisted of 10 patients with recent transient ischemic attack and/or minor stroke whose carotid stenosis exceeded 80% (mean, 92%). We measured regional cerebral blood flow (CBF), oxygen extraction fraction (OEF), oxygen metabolic rate (CMRO2), and regional cerebral blood volume (CBV) before and after the CEA. In addition, we calculated CBF/CBV value as an indicator of tissue perfusion reserve. We compared these PET values to those of 15 age-matched normal controls. Significant reductions in CBF, CBF/CBV, and CMRO2 values were observed in the hemisphere not only ipsilateral, but also contralateral to the stenosis. In 4 patients, an increase in OEF and decrease in CBF/CBV were also detected. These variables significantly recovered after CEA. High-degree carotid stenosis in the tested range reduces cerebral hemodynamic and metabolic reserve and forms a vulnerable environment in the brain. Successful CEA benefits not only by removing embolic source, but also by improving hemodynamic status, which may be seen in even the contralateral hemisphere.

Evaluation of intra-aneurysmal blood flow by digital subtraction angiography: blood flow change after coil embolization.

BACKGROUND: The natural course of cerebral aneurysms is related to many factors, and it is very important that intra-aneurysmal blood flow is considered. Our group developed a method that allowed the simultaneous evaluation of blood flow in human cerebral aneurysms using digital subtraction angiography (DSA) with no special devices. The intra-aneurysmal blood flow measurement would also be very useful for coil embolization. Since the Guglielmi detachable coil (GDC) was developed, many patients with cerebral aneurysm have been treated with GDC, but coil compaction has sometimes caused a problem after the coil embolization of a cerebral aneurysm. We believed that an intra-aneurysmal flow measurement would suggest the final result of embolization during the procedure. METHODS: We performed DSA to examine 17 aneurysms in 17 patients. The video signal of serial DSA images was stored on a personal computer, and time-density curves were obtained for each individual pixel. The formula, determined by a two-exponential model, was fitted to the time-density curve 1000 times by least square approximation for each individual pixel. We indirectly substituted the coefficient of the flow-in curve for the blood flow. We were therefore able to display the distribution of intra-aneurysmal blood flow in color. We could compare the blood flow in each portion of the cerebral aneurysm and parent artery during coil embolization. RESULTS: The blood flow k(a) in a small aneurysm was faster than that in a large aneurysm, and it slowed in accordance with the coil embolization. The blood flow in a large aneurysm was sometimes accelerated by incomplete coil embolization. CONCLUSION: We can detect the flow distribution in cerebral aneurysms and the flow change during coil embolization, using existing equipment. Our method would be useful in elucidating the natural history of cerebral aneurysms, treating cerebral aneurysms with coils, and following patients after treatment.

[A chronic intracerebral hematoma for which corticosteroid was effective: case report].

Chronic intracerebral hematoma is rare. Computerized tomography almost consistently demonstrates ring-shaped lesions with mass effect and perifocal edema. All patients in published studies have been treated surgically. Most of the hematomas have been encapsulated and contained blood in various stages of organization. The thick capsule has usually consisted of an outer layer of collagenous tissue and an inner layer of granulation tissue. A 60-year-old male, who had had sudden neurological symptoms, left hemiparesis and aphasia, was admitted to our hospital. Fourteen days after admission, CT revealed an expanding low density mass with brain edema. He was treated surgically and with corticosteroid. In this case, the surgical treatment was not effective but the corticosteroid medication was effective. Strategies of treatment are discussed.

Cytoplasmic non-epithelial mucin accumulation associated with CD44 in an astrocytic tumor with signet ring features.

We report a case of an atypical astrocytic tumor rich in signet ring cells with cytoplasmic mucin and glycogen in the left lower temporal lobe of the brain found in a Japanese female tricenarian. The signet ring cell cytoplasm contained bovine testicular hyaluronidase sensitive non-epithelial mucin together with CD44 and laminin. Glycogen was also detected. After subtotal resection, the residual tumor rapidly enlarged; hence, it was finally extirpated 8 months later followed by post-surgical irradiation. The recurrent tumor did not have signet ring cells and was entirely comprised of solid nests of large pale polygonal cells filled with glycogen and hyperchromatic nuclei. Mucin was not demonstrated in their cytoplasm, but their surface was diffusely coated with non-epithelial mucin together with CD44. The results of our analysis revealed that non-epithelial mucin could accumulate in or on the surface of neoplastic astrocytes in close association with CD44, findings that give new insights into the spectrum of non-epithelial mucin metabolism in astrocytic tumors. The tumor has not recurred for more than 3 years after the irradiation therapy following the second surgery, but further clinical observation is needed to evaluate the exact clinical behavior of this unusual tumor.

Relationship between preoperative magnetic resonance imaging and surgical findings: aneurysm wall thickness on high-resolution T1-weighted imaging and contact with surrounding tissue on steady-state free precession imaging.

This study evaluated the aneurysm wall thickness by high-resolution T1-weighted imaging and the contact between the aneurysm and surrounding tissue by steady-state free precession (SSFP) imaging. The surgical findings were prospectively compared with these preoperative magnetic resonance (MR) imaging findings in 35 consecutive patients with 37 unruptured cerebral aneurysms (UCAs). The aneurysm wall was not visible in 13 UCAs, but was visible in 23. Subarachnoid space between the aneurysm and surrounding tissue was visible in 16 UCAs, a visible layer of cerebrospinal fluid (CSF) between the aneurysm and surrounding tissue in 12, and no visible layer in 7. MR imaging predicted the surgical findings in 29 UCAs (78%), showed different findings in six UCAs (16%), and two (5%) could not be evaluated due to insufficient quality of preoperative MR images. Among the UCAs with different findings, five UCAs had a partially thin wall even though high-resolution T1-weighted imaging had shown a visible wall, and one UCA showed less contact with the surrounding tissue even though the SSFP imaging had shown no visible CSF layer. In conclusion, high-resolution T1-weighted imaging and SSFP imaging provided significant additional preoperative information regarding UCAs and the surrounding tissue.

Rare variant of persistent primitive hypoglossal artery, arising from the external carotid artery.

A 63-year-old man presented with an extremely rare variant of persistent primitive hypoglossal artery (PHA), which was found incidentally during examination for a contralateral asymptomatic internal carotid artery (ICA) stenosis. This anastomotic vessel arose from the external carotid artery, not the ICA, and joined the vertebrobasilar artery through the hypoglossal canal. Persistent PHA is rare and the reported incidence is 0.027-0.26%. Recognition of the existence of this variant vessel and preservation during neuroradiologic intervention or surgery is important to prevent possible ischemic complications.

Trigonal cavernous malformation with intraventricular hemorrhage: a case report and literature review.

We reported a case of trigonal cavernous malformation (CM) with intraventricular hemorrhage. This 67-year-old woman experienced sudden onset of loss of consciousness and her Glasgow Coma Scale (GCS) was 5 points (E1V1M3) on admission. CT scan demonstrated intraventricular hemorrhage and acute hydrocephalus. Angiography did not demonstrate any vascular abnormality. Ventricular drainage was performed for acute hydrocephalus and the postoperative course was good. CT showed a hyperdense lesion in the left trigone, which was contrast-enhanced on T1-weighted MR. Removal of CM was performed via the left middle temporal sulcus. We conducted a Pub Med search for trigonal CM and found 17 cases. Herein we discuss the symptoms, CT and MR findings and treatment.

[Two cases of spontaneous intracranial hypotension with bilateral chronic subdural hematomas].

Spontaneous intracranial hypotension (SIH) is characterized by postural headaches without obvious cause and is occasionally related to chronic subdural hematomas (CSHs). Brain sag due to decrease in cerebrospinal fluid, and growing CSHs may occur secondary to a decrease in intracranial pressure. Therapy for this condition differs from that for mere traumatic CSHs and is controversial. We report 2 cases of CSH related to SIH. One patient required drainage of the CSHs and an epidural self-blood patch. Furthermore, this patient had to undergo reoperation for drainage of the CSHs. The other patient was cured after the first time the CSHs were drained.

Treatment selection for ruptured aneurysm and outcomes: clipping or coil embolization.

The International Subarachnoid Aneurysm Trial has shown that coil embolization achieves a better outcome for aneurysms treatable by either clipping or coil embolization. However, many ruptured aneurysms are hardly treatable by either clipping or coil embolization. Selection of either clipping or coil embolization will affect the treatment outcome for ruptured aneurysms. The relationship between patient selection and treatment outcome in a so-called "regional center hospital" in Japan must be clarified. This study included 113 patients with ruptured intracranial saccular aneurysms measuring less than 10 mm. Selection criteria for coil embolization were principally paraclinoid or posterior circulation aneurysm, Hunt and Hess grade IV or over, and patient age 75 years or older. Other aneurysms were principally treated by clipping. Aneurysms with a dome/neck ratio of less than 1.5, distorted aneurysms, Hunt and Hess grades I-III, patient age 74 years or younger, and middle cerebral artery aneurysm were actively treated by clipping. A few exceptional indications were considered in detail. Low invasiveness coil embolization is better than clipping to obtain good neurological outcome for patients with perforators difficult to dissect, aneurysms difficult to dissect due to previous open surgery, and aneurysms requiring bilateral open surgery, despite the slightly higher rebleeding rate in coil embolization. Overall outcomes were modified Rankin Scale (mRS) 0-2 in 82 of 113 patients (73%) and mRS 3-6 in 31 (27%). Appropriate selection of clipping or coil embolization can achieve acceptable treatment outcomes for ruptured aneurysm.

Effects and complications of stereotactic aspiration for spontaneous intracerebral hemorrhage.

Stereotactic aspiration of intracerebral hemorrhage (ICH) improves the general condition of patients, promotes improvement of consciousness, and decreases the incidence of pneumonia, but may induce rebleeding. The present study investigated the effects of stereotactic aspiration and factors that inhibit rebleeding in 70 consecutive patients who underwent stereotactic aspiration for ICH. Consciousness was significantly improved after surgery. Of patients who underwent surgery on day 0 or 1, 5 patients developed pneumonia and 29 patients did not. Of patients who underwent surgery on day 2 or later, 14 patients developed pneumonia and 22 patients did not. Early surgery within 2 days significantly reduced the rate of aspiration pneumonia. Patients with rebleeding tended to have liver dysfunction and hemorrhagic tendency. Early stereotactic aspiration of ICH facilitates better patient management than conservative treatment in patients with moderate consciousness disturbance. Patients with liver dysfunction and hemorrhagic tendency should be identified.

Percutaneous vertebroplasty under three-dimensional radiography guidance. Technical note.

An accurate, safe, and convenient method for performing percutaneous vertebroplasty (PVP) under three-dimensional (3D) radiography guidance has been developed. Six PVP procedures were performed in 5 elderly stroke patients complaining of back pain caused by compressive fracture which interfered with further rehabilitation. T(1)-weighted magnetic resonance imaging showed low intensity and T(2)-weighted imaging showed high intensity in the fractured vertebral body. The most suitable trajectory for passing the lateral mass of the lamina and pedicle, and reaching the vertebral body was identified on the axial view of 3D radiography. A 13-gauge needle was advanced appropriately in all patients, and improvement of back pain was obtained after injection of polymethylmethacrylate. No major complications occurred in any patient. PVP under 3D radiography guidance is an accurate, safe, and convenient method.