Triple bypass for multisystem smooth muscle dysfunction syndrome due to Arg179His ACTA2 mutation.

Missense mutations in the smooth muscle-specific isoform of the alpha-actin (ACTA2) gene, which encodes smooth muscle actin, congenitally cause systemic smooth muscle dysfunction, leading to multiple systemic smooth muscle dysfunction syndrome. This disease is often diagnosed through the development of congenital mydriasis, patent ductus arteriosus, or thoracic aortic aneurysm at a young age. Some patients develop cerebrovascular lesions, also known as ACTA2 cerebral arteriopathy, which cause ischemic stroke and require surgical revascularization. However, an effective and safe treatment has not yet been established owing to the rarity of the disease. Furthermore, most reports of this disease involve children, with only a few reports on adults and few detailed reports on treatment outcomes published to date. We report a 46-year-old woman with ACTA2 cerebral arteriopathy caused by Arg179His, the most common mutation in this disease; she is the oldest patient reported with this disease to the best of our knowledge. The patient was diagnosed with multiple systemic smooth muscle dysfunction syndrome and ACTA2 cerebral arteriopathy after experiencing a stroke in the right cingulate gyrus. She underwent direct triple bypass with three anastomoses of the right superficial temporal artery to the middle and anterior cerebral arteries. She developed an ischemic stroke as a postoperative complication.The efficacy and safety of this procedure have not been clearly confirmed owing to the frailty of the donor superficial temporal artery and the poor development of collateral circulation; however, direct bypass should be considered a treatment option for patients experiencing progressive multiple strokes.

An Epidermal Growth Factor Motif of Developmental Endothelial Locus 1 Protein Inhibits Efficient Angiogenesis in Explanted Squamous Cell Carcinoma In Vivo.

BACKGROUND: Cancer gene therapy using a nonviral vector is expected to be repeatable, safe, and inexpensive, and to have longterm effectiveness. Gene therapy using the E3 and C1 (E3C1) domain of developmental endothelial locus-1 (Del1) has been shown to improve prognosis in a mouse transplanted tumor model. OBJECTIVE: In this study, we examined how this treatment affects angiogenesis in mouse transplanted tumors. MATERIALS AND METHODS: Mouse transplanted tumors (SCCKN human squamous carcinoma cell line) were injected locally with a nonviral plasmid vector encoding E3C1 weekly. Histochemical analysis of the transplanted tumors was then performed to assess the effects of E3C1 on prognosis. RESULTS: All mice in the control group had died or reached an endpoint within 39 days. In contrast, one of ten mice in the E3C1 group had died by day 39, and eight of ten had died or reached an endpoint by day 120 (p < 0.01). Enhanced apoptosis in tumor stroma was seen on histochemical analyses, as was inhibited tumor angiogenesis in E3C1-treated mice. In addition, western blot analysis showed decreases in active Notch and HEY1 proteins. CONCLUSION: These findings indicate that cancer gene therapy using a nonviral vector encoding E3C1 significantly improved life-span by inhibiting tumor angiogenesis.

Megalin-Mediated Tubuloglomerular Alterations in High-Fat Diet-Induced Kidney Disease.

Obesity, an important risk factor for metabolic syndrome (MetS) and cardiovascular disease, is often complicated by CKD, which further increases cardiovascular risk and causes ESRD. To elucidate the mechanism underlying this relationship, we investigated the role of the endocytic receptor megalin in proximal tubule epithelial cells (PTECs). We studied a high-fat diet (HFD)-induced obesity/MetS model using kidney-specific mosaic megalin knockout (KO) mice. Compared with control littermates fed a normal-fat diet, control littermates fed an HFD for 12 weeks showed autolysosomal dysfunction with autophagy impairment and increased expression of hypertrophy, lipid peroxidation, and senescence markers in PTECs of the S2 segment, peritubular capillary rarefaction with localized interstitial fibrosis, and glomerular hypertrophy with mesangial expansion. These were ameliorated in HFD-fed megalin KO mice, even though these mice had the same levels of obesity, dyslipidemia, and hyperglycemia as HFD-fed control mice. Intravital renal imaging of HFD-fed wild-type mice also demonstrated the accumulation of autofluorescent lipofuscin-like substances in PTECs of the S2 segment, accompanied by focal narrowing of tubular lumens and peritubular capillaries. In cultured PTECs, fatty acid-rich albumin induced the increased expression of genes encoding PDGF-B and monocyte chemoattractant protein-1 via megalin, with large (auto)lysosome formation, compared with fatty acid-depleted albumin. Collectively, the megalin-mediated endocytic handling of glomerular-filtered (lipo)toxic substances appears to be involved primarily in hypertrophic and senescent PTEC injury with autophagy impairment, causing peritubular capillary damage and retrograde glomerular alterations in HFD-induced kidney disease. Megalin could be a therapeutic target for obesity/MetS-related CKD, independently of weight, dyslipidemia, and hyperglycemia modification.

Quality control of PSII: behavior of PSII in the highly crowded grana thylakoids under excessive light.

The grana thylakoids of higher plant chloroplasts are crowded with PSII and the associated light-harvesting complexes (LHCIIs). They constitute supercomplexes, and often form semi-crystalline arrays in the grana. The crowded condition of the grana may be necessary for efficient trapping of excitation energy by LHCII under weak light, but it might hinder proper movement of LHCII necessary for reversible aggregation of LHCII in the energy-dependent quenching of Chl fluorescence under moderate high light. When the thylakoids are illuminated with extreme high light, the reaction center-binding D1 protein of PSII is photodamaged, and the damaged protein migrates to the grana margins for degradation and subsequent repair. In both moderate and extreme high-light conditions, fluidity of the thylakoid membrane is crucial. In this review, we first provide an overview of photoprotective processes, then discuss changes in membrane fluidity and mobility of the protein complexes in the grana under excessive light, which are closely associated with photoprotection of PSII. We hypothesize that reversible aggregation of LHCII, which is necessary to avoid light stress under moderate high light, and swift turnover of the photodamaged D1 protein under extreme high light are threatened by irreversible protein aggregation induced by reactive oxygen species in photochemical reactions.

BEX1/ARF1A1C is required for BFA-sensitive recycling of PIN auxin transporters and auxin-mediated development in Arabidopsis.

Correct positioning of membrane proteins is an essential process in eukaryotic organisms. The plant hormone auxin is distributed through intercellular transport and triggers various cellular responses. Auxin transporters of the PIN-FORMED (PIN) family localize asymmetrically at the plasma membrane (PM) and mediate the directional transport of auxin between cells. A fungal toxin, brefeldin A (BFA), inhibits a subset of guanine nucleotide exchange factors for ADP-ribosylation factor small GTPases (ARF GEFs) including GNOM, which plays a major role in localization of PIN1 predominantly to the basal side of the PM. The Arabidopsis genome encodes 19 ARF-related putative GTPases. However, ARF components involved in PIN1 localization have been genetically poorly defined. Using a fluorescence imaging-based forward genetic approach, we identified an Arabidopsis mutant, bfa-visualized exocytic trafficking defective1 (bex1), in which PM localization of PIN1-green fluorescent protein (GFP) as well as development is hypersensitive to BFA. We found that in bex1 a member of the ARF1 gene family, ARF1A1C, was mutated. ARF1A1C localizes to the trans-Golgi network/early endosome and Golgi apparatus, acts synergistically to BEN1/MIN7 ARF GEF and is important for PIN recycling to the PM. Consistent with the developmental importance of PIN proteins, functional interference with ARF1 resulted in an impaired auxin response gradient and various developmental defects including embryonic patterning defects and growth arrest. Our results show that ARF1A1C is essential for recycling of PIN auxin transporters and for various auxin-dependent developmental processes.

Cross-Correlation of Confocal Images for Excised Breast Tissues of Total Mastectomy.

OBJECT: The purpose of this study is to develop an image artifact removal method for radar-based microwave breast imaging and demonstrates the detectability on excised breast tissues of total mastectomy. METHODS: A cross-correlation method was proposed and measurements were conducted. A hand-held radar-based breast cancer detector was utilized to measure a breast at different orientations. Images were generated by multiplying the confocal image data from two scans after cross-correlation. The optimum reconstruction permittivity values were extracted by the local maxima of the confocal image intensity as a function of reconstruction permittivity. RESULTS: With the proposed cross-correlation method, the contrast of the imaging result was enhanced and the clutters were removed. The proposed method was applied to 50 cases of excised breast tissues and the detection sensitivity of 72% was achieved. With the limited number of samples, the dependency of detection sensitivity on the breast size, breast density, and tumor size were examined. CONCLUSION AND SIGNIFICANCE: The detection sensitivity was strongly influenced by the breast density. The sensitivity was high for fatty breasts, whereas the sensitivity was low for heterogeneously dense breasts. In addition, it was observed that the sensitivity was high for extremely dense breast. This is the first detailed report on the excised breast tissues.

A framework to estimate a long-term power shortage risk following large-scale earthquake and tsunami disasters.

While power shortages during and after a natural disaster cause severe impacts on response and recovery activities, related modeling and data collection efforts have been limited. In particular, no methodology exists to analyze long-term power shortages such as those that occurred during the Great East Japan Earthquake. To visualize a risk of supply shortage during a disaster and assist the coherent recovery of supply and demand systems, this study proposes an integrated damage and recovery estimation framework including the power generator, trunk distribution systems (over 154 kV), and power demand system. This framework is unique because it thoroughly investigates the vulnerability and resilience characteristics of power systems as well as businesses as primary power consumers observed in past disasters in Japan. These characteristics are essentially modeled by statistical functions, and a simple power supply-demand matching algorism is implemented using these functions. As a result, the proposed framework reproduces the original power supply and demand status from the 2011 Great East Japan Earthquake in a relatively consistent manner. Using stochastic components of the statistical functions, the average supply margin is estimated to be 4.1%, but the worst-case scenario is a 5.6% shortfall relative to peak demand. Thus, by applying the framework, the study improves knowledge on potential risk by examining a particular past disaster; the findings are expected to enhance risk perception and supply and demand preparedness after a future large-scale earthquake and tsunami disaster.

The EGF Motif With CXDXXXXYXCXC Sequence Suppresses Fibrosis in a Mouse Skin Wound Model.

BACKGROUND/AIM: Fibrosis is an essential process for wound healing, but excessive fibrosis, such as keloids and hypertrophic scars, can cause cosmetic and functional problems. These lesions are caused by abnormal deposition and shrinkage of collagen fibers. The light chain of FIX, a plasma protein essential for hemostasis, has the amino acid sequence CXDXXXXYXCXC in the EGF domain. Peptides containing this sequence inhibited stromal growth in a mouse transplant tumor model. In this study, the effect of the FIX light chain on wound healing was studied. MATERIALS AND METHODS: A full-layer wound was made on the back of each mouse, and cDNA encoding the light chain of mouse FIX (F9-LC) in an expression vector was injected locally once each week using a non-viral vector. Histochemical analysis of the wound was then performed to assess the effects on wound healing. Moreover, the effect of F9-LC on fibroblasts was studied in vitro. RESULTS: Macroscopic observation showed that wounds with forced expression of F9-LC appeared flatter and had fewer wrinkles than control wounds. Tissue collagen staining and immunostaining revealed that administration of F9-LC suppressed collagen 1 and 3 deposition and decreased α-smooth muscle actin expression. Electron microscopy revealed sparse and disorganized collagen fibers in the F9-LC-treated mice. In experiments using fibroblasts, addition of a recombinant protein of the FIX light chain disrupted the typical spindle shape and alignment of fibroblasts. CONCLUSION: F9-LC is a new candidate for use in treatments to regulate excessive fibrosis and contraction in wound healing.

Optimal guiding catheter position during advancement of the guiding catheter into the carotid artery from the aortic arch via transfemoral approach.

BACKGROUND: Guiding catheter (GC) advancement into the target carotid artery is a crucial step in neuroendovascular therapy. In difficult anatomies, alternative methods have been reported to overcome difficult carotid access for swift GC advancement. However, studies focusing on the positional relationship between the GC and inner catheter (IC) at the aortic arch are lacking. METHODS: We evaluated the impact of the positional relationship between the GC and IC on whether the GC position affects catheter support or system straightening. We retrospectively reviewed 89 patients who underwent neuroendovascular therapy. We assessed the time to carotid access across difficult arch anatomies. The GC position was divided into Position 1, descending aorta level; Position 2, aortic arch level; and Position 3, origin of the left common carotid artery or innominate artery. We also evaluated the GC support and straightening effects in an in vitro vascular model study. RESULTS: The coaxial catheter flexion angle at the aortic arch was significantly larger when the GC was set to Position 3 (p < 0.0001). A significantly shorter time to carotid access was observed with Positions 2 and 3 than with Position 1 in the difficult arch anatomy group. In the in vitro vascular model evaluation, the catheter support effect significantly increased as the GC position became closer to the IC tip (p < 0.0001) and straightening effect significantly increased as the GC moved to Position 2 from Position 1 (p < 0.0001). CONCLUSION: During GC advancement, the GC positional relationship changed the support of the coaxial system with system straightening. The optimal GC position, Position 3, facilitated swift GC advancement.

Full QED+QCD low-energy constants through reweighting.

The effect of sea quark electromagnetic charge on meson masses is investigated, and first results for full QED+QCD low-energy constants are presented. The electromagnetic charge for sea quarks is incorporated in quenched QED+full QCD lattice simulations by a reweighting method. The reweighting factor, which connects quenched and unquenched QED, is estimated using a stochastic method on 2+1 flavor dynamical domain-wall quark ensembles.

Tortuosity of middle cerebral artery M1 segment and outcomes after mechanical thrombectomy.

BACKGROUND: We aimed to quantify the tortuosity of the middle cerebral artery (MCA) and assess its effects on radiological and clinical outcomes in patients with acute MCA occlusions who received mechanical thrombectomy (MT). METHODS: This retrospective study enrolled 53 patients with acute ischemic stroke due to MCA M1 or M2 segment occlusion who underwent MT using stent retrievers (SRs). Tortuosity index (TI) was defined to quantify the tortuosity of the MCA M1 segment using the following formula: (actual distance / straight distance) × 100. For each patient, four TIs were measured in the anteroposterior and caudal views for both ipsilateral and contralateral sides to the occluded site (TI-APi, TI-APc, TI-CAUi, and TI-CAUc, respectively) using magnetic resonance angiography (MRA) or computed tomography angiography (CTA). We defined the first-pass effect (FPE) as first-pass mTICI classification ≥2b reperfusion. RESULTS: Patients who did not achieve FPE had significantly higher TI-APi (112 vs. 106; P = 0.004), TI-APc (111 vs. 105; P = 0.005), TI-CAUi (110 vs. 105; P = 0.002), and TI-CAUc (110 vs. 105; P = 0.001) than those who achieved FPE. In multivariable analysis, higher TI-APi, TI-CAUi, and TI-APc were independently associated with an increased rate of unsuccessful FPE (odds ratio (OR) [95% confidence interval (CI)]: 1.25 [1.02-1.61], 1.21 [1.01-1.45], and 1.27 [1.03-1.73], respectively). TI-CAUi, TI-APc, and TI-CAUc were also independent predictors of the occurrence of intracranial hemorrhage after MT (OR [95% CI]: 1.15 [1.01-1.38], 1.14 [1.01-1.38], 1.25 [1.02-1.52], respectively). CONCLUSIONS: The TIs of the MCA M1 segment on both ipsilateral and contralateral sides were associated with unfavourable outcomes after MT.

Chronic Expanding Hematomas That Occurred 20 Years or More After Primary Total Hip Arthroplasty: A Report of 2 Cases.

CASE: We report 2 patients who developed chronic expanding hematomas (CEHs) more than 20 years after ceramic-on-polyethylene total hip arthroplasty (THA). One CEH occurred after a minor fall, and the other appeared with no obvious injury. Neither of the 2 was on anticoagulation. Each caused extensive osteolysis. CONCLUSION: The only 2 previously reported post-THA cases of CEH involved metal-on-metal THAs and occurred several years after the index THA. Our patients show that CEH also can occur after ceramic-on-polyethylene THA, even after an uneventful clinical course of more than 20 years. Complete removal of both hematoma stopped osteolytic progression, with no recurrence to date.

Spinal cord infarction six months after thoracic endovascular aortic repair- A case report.

Spinal cord infarction is reported to account for less than 1% of all strokes and is a relatively rare disease. In recent years, thoracic endovascular aortic repair (TEVAR) has become a common treatment for aortic aneurysms, and spinal cord ischemia is one of its complications. Most cases occur in the perioperative period; however, a few cases have been reported in the chronic stage. Here, we report a case of spinal cord infarction, 6 months after TEVAR. A 77-year-old man experienced sudden onset paraparesis following dumbbell exercises and defecation. He had a history of an infectious thoracoabdominal aortic aneurysm treated by TEVAR 6 months prior. Paralysis and disturbance of the thermal pain and tactile sensations of the lower limbs were observed, but proprioception and deep sensation were preserved. Computed tomography (CT) showed no evidence of intraspinal hemorrhage, new aortic dissection, or endoleak around the aortic stent placed from Th11 to L3. Magnetic resonance imaging (MRI) showed intramedullary hyperintensity from Th11 to the conus 2 days after onset. Anticoagulant therapy and rehabilitation were performed, and the lower-limb muscle strength gradually improved. After aortic stenting, particularly including the level of the Adamkiewicz artery, the risk of spinal cord ischemia must be monitored, because spinal circulation depends on collateral circulation.

Isolated Posterior Spinal Artery Aneurysm Presenting with Spontaneous Thrombosis After Subarachnoid Hemorrhage.

BACKGROUND: The cause of subarachnoid hemorrhage is more likely to be intracranial than spinal. Bleeding, although common with spinal arteriovenous malformations and spinal cord tumors, rarely occurs with ruptured isolated spinal artery aneurysms. Here, we report a case of isolated thoracic posterior spinal artery aneurysm presenting with thrombosis after subarachnoid hemorrhage. CASE DESCRIPTION: A 67-year-old woman presented with sudden-onset nausea and low back and right thigh pain that worsened with movement. Computed tomography (CT) and magnetic resonance imaging (MRI) scans of the head suggested a small subarachnoid hemorrhage in the high-convexity sulcus, and lumbar puncture showed bloody cerebrospinal fluid. There was no apparent intracranial aneurysm on CT angiography; however, spinal MRI showed a lesion on the right side of the spinal cord at Th10. Contrast-enhanced CT showed an enhancing lesion at this site on day 7 that was not present on day 15. Selective right Th10 intercostal artery angiography on day 22 showed no evidence of aneurysm. The lesion was suspected to be a thrombotic spinal artery aneurysm. Given the unclear natural history of this entity, surgery was performed on day 36. After right Th10 hemilaminectomy and opening the dura, the arachnoid and adhesions were found to be thickened. A fusiform-shaped thrombosed aneurysm continuous with the radiculopial artery was removed. The patient was discharged without neurologic deterioration. CONCLUSIONS: Isolated spinal artery aneurysm is a rare cause of subarachnoid hemorrhage. It is expected that additional cases will clarify the natural history and indications for treatment.

Dietary cycloinulooligosaccharides enhance intestinal immunoglobulin A production in mice.

The purpose of this study was to elucidate the effects of dietary supplemented cycloinulooligosaccharides (CF) on the intestinal immune function and humoral immunity in BALB/c mice. The mice were orally administered with a control diet or a diet containing 5% CF for 6 weeks. The fecal IgA level, an indicator of the intestinal immune response, was increased dramatically by 5% CF feeding, and casein-specific IgA in the feces was also significantly increased. The amounts of short-chain fatty acids (SCFA) in the cecal contents and feces were significantly higher in the 5% CF group than in the control group. On the other hand, CF administration had only a slight affect on the plasma IgA and IgG levels and no effect on the plasma IgE and IgM levels. These results indicate that dietary CF up-regulated the intestinal immune response, but not the humoral immune response. Furthermore, the dose-dependent effect of CF feeding on IgA and SCFA production was examined. Significant increases in the fecal IgA and SCFA levels were observed in the mice fed with 5% CF, but not in the 1% and 2.5% CF-fed groups, indicating that the amount of CF administered was an important factor for up-regulation of the intestinal immune function.

ß 2-Microglobulin and Neutrophil Gelatinase-Associated Lipocalin, Potential Novel Urine Biomarkers in Periodontitis: A Cross-Sectional Study in Japanese.

OBJECTIVES: Several serum biomarkers have been reported to increase in periodontitis patients as possible mediators linking periodontal inflammation to systemic diseases. However, the relationship between periodontitis and urine biomarkers is still unclear. The aim of this cross-sectional study was to investigate potential urine biomarkers of periodontitis in a Japanese population. MATERIALS AND METHODS: This study included 108 male subjects, and microbiological and clinical parameters were evaluated as a periodontitis marker. The correlation between nine urine biomarkers (typically used to diagnose kidney disease) and periodontal parameters was analyzed. Based on the findings, ß 2-microglobulin (ß 2-MG) and neutrophil gelatinase-associated lipocalin (NGAL) were selected for comparison and multivariate regression analysis, and the Kruskal-Wallis test followed by Bonferroni correction was used to identify differences in their concentrations between the three periodontitis groups (severe, moderate, and no/mild periodontitis). RESULTS: ß 2-MG and NGAL exhibited a significant correlation with clinical parameters of periodontitis. The prevalence of clinical parameters such as bleeding on probing and number of sites with probing depth (PD) ≥ 6 mm were greater in the ß 2-MG high group (≥300 µg/g creatinine) than in the normal group (P=0.017 and 0.019, respectively). Multivariate regression analysis indicated that the number of sites with PD ≥ 6 mm was independently associated with urine ß 2-MG. Moreover, the number of sites with the clinical attachment level (CAL) ≥ 6 mm was greater in the NGAL high group (highest quartile) (P=0.041). Multivariate regression analysis showed that the number of sites with CAL ≥ 6 mm was associated independently with urine NGAL. Finally, ß 2-MG was significantly higher in the severe periodontitis subjects compared to the no/mild periodontitis subjects. CONCLUSION: The significant association between urine ß 2-MG or NGAL and periodontitis was revealed. These biomarkers can potentially be used to screen for or diagnose periodontitis. This trial is registered with the UMIN Clinical Trials Registry UMIN000013485.

Enhanced immediate inflammatory response to Streptococcus pneumoniae in the lungs of mice with pulmonary emphysema.

BACKGROUND AND OBJECTIVE: Pulmonary emphysema is associated with frequent respiratory infections but little is known about the reasons for this susceptibility to bacterial infection. We previously demonstrated an impaired inflammatory response to Streptococcus pneumoniae in an experimental emphysema mouse model at 24 h, or longer following bacterial inoculation. Toll-like receptors (TLR) have been recognized as regulators in the inflammatory response. We examined the expression of TLR on alveolar macrophages in experimental emphysema mice and evaluated the immediate inflammatory response of the emphysematous lung to streptococcal infection. METHODS: Elastase was administered once into mice trachea to induce pulmonary emphysema. Three weeks later, expression of TLR-2 and TLR-4 in the BAL cells was examined by immunostaining. Following the intratracheal inoculation of Streptococcus pneumoniae, pro-inflammatory cytokine concentrations were measured in the BAL fluids of the control and emphysema mice. RESULTS: The expression of TLR-2 and TLR-4 was significantly elevated in the alveolar macrophages of emphysema mice. Six hours after infection, neutrophils in the BAL fluid of emphysema mice were significantly increased, and the levels of tumour necrosis factor-alpha, IL-1beta and IL-6 were significantly elevated, compared with the control mice. At 3 h post inoculation, macrophage inflammatory protein-2 levels were significantly elevated. CONCLUSIONS: The immediate inflammatory response in the emphysematous lung is significantly enhanced in response to streptococcal infection. This may be partly attributed to the increased expression of TLR in the alveolar macrophages of emphysema mice.

Extracranial internal carotid artery vasospasm during thrombectomy.

The use of a stent retriever increases the risk of intracranial vasospasm. Here, we report the case of a man who developed severe vasospasm in a long segment of the extracranial internal carotid artery after mechanical irritation by a stent retriever inserted for the treatment of acute cerebral ischemia. A 47-year-old right-handed man presented with sudden-onset right-sided weakness and difficulty speaking. The patient's National Institutes of Health Stroke Scale score was 6 and he had an Alberta Stroke Program Early Computed Tomography Score of 9. The patient was started on intravenous alteplase therapy, and an acute thrombectomy was performed. Left internal carotid digital subtraction angiography showed narrowing of the left common and internal carotid arteries and occlusion of the proximal left M1 segment of the middle cerebral artery. A stent retriever was retracted into a guiding catheter placed at the left carotid bulb under continuous suction. Recanalization of the middle cerebral artery was not achieved and there was significant narrowing in a long segment of the extracranial internal carotid artery associated with exacerbation of the patient's aphasia. The cervical vasospasm improved after nicardipine infusion via the catheter. We encountered vasospasm in a long segment of the extracranial internal carotid artery after mechanical irritation by a stent retriever. If a stent retriever is used in a patient with a narrow extracranial internal carotid artery, consideration should be given to using a Penumbra or smaller guiding catheter located in the distal internal carotid artery to prevent irritation to the cervical vessel wall.

Treatment of Large or Giant Cavernous Aneurysm Associated with Persistent Trigeminal Artery: Case Report and Review of Literature.

BACKGROUND: Primitive trigeminal artery (PTA) is the most common anomaly of primitive carotid-basilar anastomosis and is associated with cerebrovascular anomalies, such as aneurysm. Large or giant cavernous aneurysm associated with PTA is rare, and the treatment strategies differ in comparison with large or giant aneurysm without PTA. In this article, we report an unusual case of a giant cavernous aneurysm associated with PTA and review treatment strategies for large or giant cavernous aneurysm associated with PTA. CASE DESCRIPTION: A 38-year-old woman suffered from double vision. Magnetic resonance imaging revealed a mass lesion in the left cavernous sinus, and magnetic resonance angiography showed a giant aneurysm at the cavernous portion of the left internal carotid artery, associated with PTA. Coil embolization, distal to the PTA, was scheduled after high-flow bypass on the same day. Computed tomography scan showed no definite infarction after treatment. A 3-dimensional computed tomography showed disappearance of the aneurysm and good patency of bypass and PTA. The patient experienced improvements in symptoms and was discharged without neurologic deficits (modified Rankin Scale 0). CONCLUSIONS: The treatment strategy for large or giant cavernous aneurysm associated with PTA is different from strategies used for large or giant cavernous aneurysm without PTA. Simple ligation of internal carotid artery is inadequate because the aneurysm is supplied through the PTA, from the vertebrobasilar system. Furthermore, the treatment strategy has to be revised according to whether the PTA can be occluded. Keeping in mind PTA preservation, an appropriate strategy should be selected.