Ruptured anomalous hyperplastic anterior choroidal artery aneurysm: a case report.

A 48-year-old man hospitalized for subarachnoid hemorrhage harbored a ruptured aneurysm arising from an anomalous hyperplastic anterior choroidal artery. Endovascular treatment was performed and the aneurysm was successfully embolized with neck remnant. The anterior choroidal artery is a very important artery supplying critical brain structures in the treatment of intracranial vascular disease. Anomalous hyperplastic anterior choroidal artery is rare, so the embryological perspective is important for its recognition in surgical procedures.

Prognostic Determinants of Anterior Large Vessel Occlusion in Acute Stroke in Elderly Patients.

This study investigated prognostic factors in elderly patients (80 years and older) undergoing mechanical thrombectomy (MT) for anterior circulation large vessel occlusion (LVO) in acute stroke treatment. Of 59 cases, 47.5% achieved a favorable outcome (mRS ≤ 3) at three months, with a mortality rate of 20.3%. Factors associated with better outcomes included younger age, lower admission National Institute of Health Stroke Scale (NIHSS) scores, lower N-terminal pro-brain natriuretic peptide (NT-proBNP) and D-dimer levels, the presence of the first pass effect (FPE), and successful recanalization. However, logistic regression showed that only lower admission NIHSS scores were significantly correlated with favorable outcomes. In addition, this study suggests that lower admission NT-proBNP and D-dimer levels could potentially serve as prognostic indicators for elderly LVO patients undergoing MT.

Ruptured Saccular Aneurysm Caused by Necrotizing Arteritis of the Polyarteritis Nodosa Type in Primary Angiitis of Central Nervous System.

Primary angiitis of central nervous system (PACNS) is a rare idiopathic vasculitis that typically involves small arteries. An 18-year-old woman was operated on for resection of a ruptured aneurysm in a cerebral artery. Multiple aneurysms of cerebral arteries had been detected by neuroimaging examinations since the age of 12, and she had been administered drugs following a diagnosis of PACNS since the age of 15. The resected aneurysm was a ruptured saccular aneurysm occurring in a medium-sized artery. Histologically, necrotizing arteritis of the polyarteritis nodosa (PAN) type was noted in the aneurysmal wall. It consisted of an admixture of acute and healing stages. In the acute stage, fibrinoid necrosis in the intima and media and intense inflammatory cell infiltrate in the entire wall were present. The inflammatory cells mainly consisted of lymphocytes, including plasma cells, neutrophils, and macrophages. In the healing stage, disappearance of fibrinoid necrosis, fibrosis in the intima and media, and scarce inflammatory cells were noted. The acute stage was mainly present near the ruptured site. From these findings, the aneurysm was considered to have been caused by necrotizing arteritis of the PAN type. Although saccular aneurysmal formation in a medium-sized artery is rare in PACNS, an understanding of aneurysms produced by necrotizing arteritis of the PAN type offers useful information for the diagnosis and treatment of PACNS.

Long-term evaluation of the COVID-19 pandemic impact on acute stroke management: an analysis of the 21-month data from a medical facility in Tokyo.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic has caused a global public health crisis and profoundly impacted acute treatment delivery. This study conducted long-term evaluations of the impact of the pandemic on acute stroke management. METHODS: Data from a university-owned medical facility in Tokyo, Japan, were retrospectively analyzed. The number of hospital admissions for stroke and time metrics in the management of patients with acute ischemic stroke were evaluated. A year-over-year comparison was conducted using data from April 2019 to December 2021 to assess the impact of the pandemic. RESULTS: The year-over-year comparison demonstrated that the number of admissions of patients with stroke and patients who underwent magnetic resonance imaging (MRI), intravenous recombinant tissue plasminogen activator (rt-PA), and thrombectomy during the pandemic remained comparable to the pre-COVID data. However, we found a decrease in the number of admissions of patients with stroke alerts and stroke when hospital cluster infection occurred at this facility and when the region hosted the Tokyo Olympics games during the surge of infection. The door-to-computed tomography time in 2021 was affected. This is plausibly due to the reorganization of in-hospital stroke care pathways after hospital cluster infection. However, no significant difference was observed in the onset-to-door, door-to-MRI, door-to-needle, or door-to-groin puncture times. CONCLUSIONS: We did not observe long-term detrimental effects of the pandemic at this site. Prevention of hospital cluster infections remains critical to provide safe and timely acute stroke management during the pandemic.

Older age, carotid artery stenosis, and female sex as factors correlated with twisted carotid bifurcation based on 457 angiographic studies.

BACKGROUND: Twisted carotid bifurcation (TCB) is a well-known anatomical variation of the carotid bifurcation in patients undergoing carotid endarterectomy. However, few investigations of TCB have focused on patients without internal carotid artery (ICA) stenosis. This study was performed to analyze the characteristics of TCB in patients with ICA stenosis and other diverse pathologies. METHODS: All conventional cerebral angiographies performed in our institute for any reason from January 2012 to December 2018 were reviewed. The patients were divided into two groups, the TCB group and the anatomically normal non-TCB group, and the basic characteristics of the groups were analyzed. RESULTS: Both sides of the carotid bifurcation were clearly visualized in 457 patients. TCB was found in 89 of 457 patients (19.5%); among these 89 patients, 74 (83.1%) had TCB only on the right side, 8 (9.0%) only on the left side, and 7 (7.9%) bilaterally. TCB was found more frequently on the right than left [81 (17.7%) and 15 (3.3%), respectively, on each of the 457 sides (p < 0.0001)]. TCB was significantly more frequent in older patients (p = 0.02), female patients (p < 0.001), and patients with ICA stenosis or occlusion at the bifurcation (p = 0.005). The prevalence of TCB was 19.5%, and 84.4% of cases were on the right side in patients with diverse pathologies. CONCLUSIONS: Older patients, female patients, and patients with ICA stenosis or occlusion are more prone to have TCB.

Low-Cost Feedback Program for Reducing the Door-to-Computed Tomography Time.

INTRODUCTION: Early restoration of blood flow in stroke patients can be achieved by reducing the door-to-computed tomography (DTC) time. Previous research has proposed several methods to reduce the DTC time, but the implementation costs limit its transferability. This study aimed to propose a novel, simple, and low-cost method for reducing the DTC time by providing feedback on each patient's DTC time to a small group of medical workers and physicians. METHODS: A field experiment was conducted for 233 days, and the DTC time of 249 patients with stroke symptoms who were transported via ambulance to a medium-sized university hospital in Japan within 24 h after stroke onset was obtained. The first and second feedback reports on the 59th day and 154th day, respectively, were provided at the beginning of the field experiment. Using the data collected during the first 58 days as baseline data, the baseline data were compared with the post-intervention data. As part of the intervention, feedback on the DTC time for each patient was provided to six medical workers and physicians during regular meetings. The primary outcome was a continuous measure of DTC time (in min). The feedback effect hypothesis was formulated prior to data collection. RESULTS: In a sample of 68 patients at baseline, the mean DTC time was 18.16 min with a standard deviation of 7.38 min. As a result of the two feedback reports, in the sample with outliers, the mean and standard deviation decreased to 15.64 min and 5.97 min, respectively. The difference in means was 2.51 min (p = 0.021 in t tests). Results of the test of the equality of the standard deviations suggested that the two standard deviations were not equal (p = 0.065). CONCLUSIONS: The low-cost interventions successfully reduced both the mean DTC time and variation, suggesting an improvement in the quality and consistency of medical services. The result of our fine-grained analysis with a field-experiment design supports the role of feedback in achieving early treatment as suggested in the Target: Stroke initiative.

Supradiaphragmatic intrathoracic migration of ventriculoperitoneal shunt with "double bending sign".

Ventriculoperitoneal shunt (VPS) is a common treatment for hydrocephalus. An 80-year-old woman presented with subarachnoid hemorrhage caused by rupture of an aneurysm of the right middle cerebral artery. Emergency clipping was performed. Hydrocephalus occurred shortly after and VPS placement was performed. She improved and was transferred to a rehabilitation hospital. She presented with dyspnea 5 months later. Chest computed tomography (CT) showed extensive pleural effusion and intrathoracic migration of the distal VPS catheter. Chest CT confirmed that the distal catheter had penetrated into the pleural cavity under the second rib, and the catheter tip was located at the bottom of the right thoracic cavity. Review of chest CT right after the shunt surgery found the distal catheter passing only under the second and third ribs and otherwise located in the subcutaneous layer to the abdominal cavity. Chest radiography showed that the distal shunt tube was distorted in a characteristic "double bending sign." This rare case of supradiaphragmatic intrathoracic migration of VPS indicates a possible mechanism of this migration, based on the anatomical physiology, and that "double bending sign" indicates the need for further investigation.

Stent-Assisted Coil Embolization for Acute Ruptured Dissecting Aneurysm at the P2 Segment of the Posterior Cerebral Artery: A Case Report.

Objective: We report a case of ruptured posterior cerebral artery (PCA) dissecting aneurysm treated with stent-assisted coil embolization in the acute phase of ruptured aneurysm. Case Presentation: A 60-year-old woman presented with sudden onset of severe headache followed by unconsciousness. CT showed severe subarachnoid hemorrhage. Digital subtraction angiography showed a dissecting aneurysm at the P2 segment of the right PCA. Stent-assisted coil embolization was performed for the ruptured dissecting aneurysm. Since thrombus was observed in the stent, ozagrel was administered intravenously, and the thrombus gradually disappeared during the follow-up period. She was discharged without neurological deficit. Conclusion: Parent artery occlusion is widely performed for acute ruptured PCA dissecting aneurysm, but reconstruction with stent-assisted coiling is considered to be an effective therapeutic strategy.

A case of microcystic meningioma associated with acute subdural hematoma in the posterior cranial fossa.

A 53-year-old woman was brought to the emergency room with headache and progressive deterioration of consciousness. Radiological examinations revealed acute subdural hematoma extending along the cerebellar tentorium to the falx cerebri, and a mass lesion with hemorrhage in the left cerebellum, with acute hydrocephalus. Emergency tumor and hematoma removal with decompressive craniectomy of the occiput was performed. Histopathological diagnosis was microcystic meningioma. Postoperatively, the patient recovered to clear consciousness with sequelae of left cerebellar ataxia, cerebellar dysarthria, and vertigo. This case of tentorial microcystic meningioma associated with acute subdural hematoma in the posterior cranial fossa is extremely rare, with only reported 4 similar cases.

A Case of Vertebral Artery Dissecting Aneurysm with Double Origin of the Posterior Inferior Cerebellar Artery Causing Subarachnoid Hemorrhage.

Double origin of the posterior inferior cerebellar artery (DOPICA) is rare but is associated with intracranial aneurysm formation. A 46-year-old man was brought to our hospital with severe subarachnoid hemorrhage (SAH). Digital subtraction angiography revealed right vertebral artery dissecting aneurysm (VADA) and DOPICA. The aneurysm involved the distal component of the posterior inferior cerebellar artery. The proximal component covered the original flow angiographically. Endovascular internal trapping and parent artery occlusion were performed for the aneurysm and the right vertebral artery (VA). Flow of the posterior inferior cerebellar artery was preserved by the proximal component of the posterior inferior cerebellar artery after trapping. The patient unfortunately died and autopsy revealed ischemic change in the right medulla oblongata. The ischemic change was considered to occur at the treatment according to the pathological findings. Sacrifice of one component of DOPICA to treat VADA with the expectation of preserved flow via the other component should be considered cautiously in terms of the neurovascular anatomy.

Surgical Results of Carotid Endarterectomy for Twisted Carotid Bifurcation.

BACKGROUND: The internal carotid artery is normally positioned posterolateral to the external carotid artery at the carotid bifurcation. An anatomic variation with the internal carotid artery positioned medial to the external carotid artery, the so-called twisted carotid bifurcation (TCB), is sometimes encountered in patients undergoing carotid endarterectomy (CEA). Little is known about the TCB or the implications for CEA. OBJECTIVE: The present study investigated the demographics and surgical results of our patients with TCB who underwent CEA, and demonstrates the surgery in a video clip. METHODS: Eleven of our series of 73 consecutive CEA patients (15.1%) had a TCB (TCB group). The basic surgical method was the same for both the TCB and non-TCB groups. RESULTS: The patient demographics were almost identical between the 2 groups. No significant difference was observed in the degree of stenosis, the duration of operation, or the surgery-related complications between the 2 groups. However, 9 of 11 cases were right-sided in the TCB group; the only significant difference between the groups. CONCLUSIONS: CEA for TCB can be safely performed by extension of the normal procedure, but with more meticulous preoperative assessment and gentle maneuvers. The reason for the right-side dominance is still unknown. Further investigation is needed of this anatomic entity.

Chordoid meningioma--case report.

A 69-year-old female presented with a de novo lesion detected incidentally. Computed tomography demonstrated an isodense mass in the left parietal convexity with peritumoral edema, with homogeneous enhancement by contrast medium. Magnetic resonance imaging showed the left parietal convexity tumor as isointense on T(1)-weighted imaging and homogeneously hyperintense on T(2)-weighted imaging, with homogeneous enhancement and dural tail sign after intravenous administration of gadolinium-diethylenetriaminepenta-acetic acid. The tumor was totally removed. The histological diagnosis was chordoid meningioma. Combined immunohistochemical staining was helpful to differentiate chordoid meningioma from other chordoid neoplasm.

Parent artery occlusion for ruptured "true" posterior communicating artery aneurysm.

A case of a patient with a ruptured true posterior communicating artery (PCoA) aneurysm is reported, who had been managed by early endovascular parent artery occlusion with coils. The small blister aneurysm was located at the proximal PCoA itself and directed superiorly. Postoperative course was uneventful. During 1-month follow-up, the patient recovered well and could care for herself. Aneurysms of the PCoA itself are very rare. As reported to date, surgical procedures would favor microsurgical clipping over endovascular coil embolization. Endovascular treatment may be a good alternative to surgical trapping for true PCoA blister aneurysm.

Treatment results of endosaccular coil embolization of asymptomatic unruptured intracranial aneurysms in elderly patients.

BACKGROUND AND PURPOSE: We report the results of endosaccular coil embolization of asymptomatic unruptured intracranial aneurysms (UIAs) in elderly patients (≥65 years). MATERIALS: There were 375 elderly patients with 400 asymptomatic UIAs. Patients were divided into two groups: group A included patients aged 65-74 years and group B patients aged ≥75 years. RESULTS: Endovascular procedures were completed in 97.8% of patients. Immediate anatomical outcomes showed complete occlusion in 53.7%, residual neck in 18.9%, and residual aneurysm in 27.4%. Anatomical follow-ups (mean 36.3±28.1 months) were unchanged in 55.7%, improved in 22.6%, minor recurrence in 11.5%, and major recurrence in 10.2%. Procedure related complications occurred in 31 patients (8.3%). 15 patients had ischemic and 10 hemorrhagic complications. Retreatments were performed in 16 patients (4.3%). Among 366 patients technically completed, 363 (99.2%) showed a favorable clinical outcome (modified Rankin Scale (mRS) score <1) at 30 days. The remaining three patients showed a worsening of mRS >0 at 30 days. The latest clinical follow-up outcomes showed: mRS score 0 in 362 patients; mRS score 1 in one; mRS score 3 in one; mRS score 4 in one; and mRS score 5 in one patient. Permanent morbidity and mortality rates were 1.1% and 0%, respectively. There were no statistically significant differences in gender, comorbidities, aneurysm size, neck width, dome-to-neck ratio, immediate anatomical outcomes, anatomical follow-up outcomes, or procedure related complications between the groups. CONCLUSIONS: Endosaccular coil embolization is safe and feasible for elderly patients with asymptomatic UIAs. Old age itself should not be a contraindication.

Schwannoma of the spinal accessory nerve--case report.

A 60-year-old woman presented with a rare schwannoma arising from a spinal accessory nerve at the C1-2 levels manifesting as cervico-occipital pain. The tumor was removed by surgery with the involved segment of the nerve. She had no postoperative neurological deficit. Histological examination confirmed the diagnosis of schwannoma. Surgical removal is recommended for such cases.

Primary rhabdomyosarcoma associated with tumoral hemorrhage--case report.

A 42-year-old female presented with right hemiparesis. Computed tomography (CT) demonstrated a slightly heterogeneous high density mass over the left frontal convexity with peritumoral edema, with homogeneous enhancement by contrast material. Magnetic resonance imaging showed the left frontal convexity tumor as a heterogeneous low intensity area on the T1-weighted image and a heterogeneous high intensity area on the T2-weighted image, with homogeneous enhancement and dural tail sign after intravenous administration of gadolinium-diethylenetriaminepenta-acetic acid. After admission, the patient suddenly lost consciousness. CT demonstrated aggressive increase in the bulk of the tumor and large peritumoral hemorrhage. The tumor was totally removed. The histological diagnosis was rhabdomyosarcoma. Combined immunohistochemistry and electron microscopy techniques should be used to differentiate rhabdomyosarcoma from malignant meningioma.

Multifocal primary intracerebral malignant fibrous histiocytoma--case report.

A 58-year-old female presented with a unique case of multifocal primary intracerebral malignant fibrous histiocytoma (MFH) manifesting as partial seizure. Neuroimaging showed a mass lesion in the right frontal lobe, which was totally removed. The histological diagnosis was MFH. Follow-up neuroimaging one month after surgery showed another lesion rapidly growing in the left frontal lobe. This lesion was totally removed, and identified as MFH. Her condition gradually worsened. Neuroimaging performed 3 months after first operation revealed bilateral recurrence. She died of respiratory failure 7 months after the initial diagnosis of MFH. Primary intracranial MFH is an extremely rare entity with only 31 cases of solitary tumor previously reported.

Spontaneous carotid-cavernous fistula in a patient with Ehlers-Danlos syndrome type IV--case report.

A 30-year-old female complained of sudden onset of severe proptosis, chemosis, diplopia, and bruit. Right carotid angiography showed a high-flow direct carotid-cavernous fistula (CCF) draining into the engorged superior ophthalmic vein, inferior petrosal sinus, and pterygoid plexus. The patient experienced retroperitoneal bleeding from a ruptured right renal artery after undergoing cerebral angiography. We suspected Ehlers-Danlos syndrome (EDS) type IV, which was confirmed by showing cultured fibroblasts failed to secrete procollagen type III. Endovascular surgery cannot be considered the treatment method of choice in view of the fragility of the arteries and veins in patients with EDS type IV. We treated our patient with extracranial internal carotid artery ligation. Currently, there is no ideal treatment for CCF in patients with EDS type IV. Since CCF is rarely life-threatening, the investigative approach and course of treatment must consider the associated vascular fragility.

Increased serum GP88 (Progranulin) concentrations in rheumatoid arthritis.

GP88 (Progranulin; PGRN) is a secreted glycosylated protein with important functions in several processes, including immune response and cancer growth. Recent reports have shown that PGRN is a therapeutic target for rheumatoid arthritis (RA) because of its capability to bind with tumor necrosis factor receptor (TNFR). However, the serum PGRN level in RA patients has not been investigated. We used enzyme-linked immunosorbent assay (ELISA) to quantify the serum levels of PGRN in 417 healthy subjects, 56 patients with RA and 31 patients with osteoarthritis (OA). In RA patients, we also measured the serum TNF-α and sTNFR concentration. Immunohistochemical staining of PGRN was performed using synovectomy tissue of RA patients. The serum PGRN normal range was established as 40.1 ± 8.7 ng/ml. PGRN levels were not influenced by sex or age. A significant increase in serum PGRN levels was observed in RA (50.2 ± 11.1 ng/ml) and OA (45.4 ± 6.6 ng/ml) groups compared to those in age-matched healthy controls (40.4 ± 9.9 ng/ml) (p<0.05, Tukey). Further, PGRN levels in the synovial fluid of RA patients (68.4 ± 3.4 ng/ml) were found to be significantly higher than those in OA patients (35.9 ± 16.8 ng/ml). Immunohistochemical staining of PGRN revealed that the highest positive signal was detected in macrophages. Circulating PGRN in RA patients was weakly associated with TNF-α and sTNFR 2 concentration. Furthermore, PGRN/TNF-α ratio was correlated the stage of the disease in RA patients. The concentrations of serum PGRN in RA were found to be significantly higher than those in age-matched healthy controls, although it remains to be clarified how blood PGRN is related to the pathogenesis of RA. Our results showed that the serum PGRN may be a useful approach to monitor the disease activity in RA patients.