Predictors of Clopidogrel Hyper-Responsiveness in Neuro-Interventional Procedures.

BACKGROUND: Hyper-responsiveness to clopidogrel abnormally inhibits platelet aggregation and increases hemorrhagic complications. The present study investigated clinical factors related to clopidogrel hyper-responsiveness in neuro-interventional procedures. METHODS: Two hundred twenty-four patients receiving clopidogrel for coil embolization to treat unruptured cerebral aneurysm or carotid artery stenting to treat carotid artery stenosis at the internal carotid artery origin were retrospectively reviewed for their P2Y12 reactivity unit (PRU) values and clinical characteristics. Hyper-responsiveness to clopidogrel was defined as a PRU of <95. RESULTS: The mean PRU was 218.2 ± 77.8. Hyper-responsiveness to clopidogrel was observed in 12 patients (5.4%). Hyper-responsiveness was observed in younger patients, patients with a lower concentration of hemoglobin A1c, and patients with a higher low-density lipoprotein cholesterol (LDL-C) concentration compared with non-hyper-responsive patients (P = 0.01, P < 0.01, P < 0.01, respectively). On analysis of concomitant drugs, the patients in the hyper-responsive group were less frequently administered calcium channel blockers (CCBs) compared with the non-hyper-responsive group (P = 0.01). No significant differences in the usage of proton pump inhibitors or statins were observed. A LDL-C concentration of >120 mg/dL and no usage of CCBs were significant independent predictors of hyper-responsiveness to clopidogrel with a multivariate analysis (OR; 6.16, 95% CI, 1.57-26.64, P = 0.01, OR; 0.09, 95% CI, 0.01-0.82, P = 0.03, respectively). CONCLUSION: The present study shows that a higher LDL-C concentration and no usage of CCBs are independent predictors of clopidogrel hyper-responsiveness. These results are useful to predict perioperative hemorrhagic complications. Considering dose reduction of clopidogrel or alternative drugs in high risk cases is necessary to prevent perioperative hemorrhagic complications.

Increased Twist and ZEB2 expression in a cutaneous metastasis of high-grade glioma.

Extra-central nervous system metastasis of gliomas is extremely rare, and the biological mechanism underlying it remains poorly understood. Epithelial-to-mesenchymal transition (EMT) has received attention as one of the important processes of cancer metastasis. Here we describe the case of a 32-year-old man with cutaneous metastasis of high-grade glioma, together with the analysis of EMT-related molecules. Our patient presented with a high-grade glioma in the right frontal lobe. Cutaneous metastasis under the surgical scar developed 17 months after complete resection of the intracranial tumor. Histopathology of both the original and metastatic tumors revealed hypercellularity; the tumors predominantly comprised glial tumor cells with poor cellular processes. Immunohistochemical analysis demonstrated intense expression of nestin, focal expression of glial fibrillary acid protein, and absence of expression of oligodendrocyte transcription factor 2, endothelial membrane antigen, or neurofilament. Genetic analyses could not provide definitive diagnostic information of glioma subtypes. Immunohistochemical analysis for EMT-related biomarkers demonstrated increased Twist, zinc finger E-box-binding homeobox 2 (ZEB2), matrix metalloproteinase 2 (MMP2), and MMP9 expressions in tumor cells of the metastatic lesion compared with those of the primary lesion. Slug, E-cadherin, and N-cadherin expression were absent in both primary and metastatic lesions; however, ZEB1 expression was present in both. Our results suggest that Twist, ZEB2, MMP2, and MMP9 facilitate cutaneous metastasis of gliomas.

[Spontaneous Retroclival Subdural Hematoma Diagnosed Using Magnetic Resonance Imaging in an Adult Patient:A Case Report].

Spontaneous retroclival subdural hematoma is rare among adults. To the best of our knowledge, only six cases have been reported. A 73-year-old man presented with sudden severe headache, diplopia, and dysarthria, with no history of trauma. Head CT revealed a retrociliary hematoma. No obvious causes of bleeding, such as cerebral aneurysms or malformations, were detected. Conservative treatment was provided to the patient. MRI showed an intraventricular hemorrhage and a space between the basilar artery and hematoma three days after onset. The hematoma almost disappeared on day 7. MRI, particularly T2-weighted sagittal MRI, is effective in localizing hematomas and confirming intraventricular hemorrhages.

Transvenous Coil Embolization for the Treatment of Carotid Cavernous Fistula after Pipeline Placement: A Case Report.

The Pipeline embolization device (PED), a type of flow diverter, has become an appealing alternative treatment option for large or giant and wide-necked intracranial aneurysms. Carotid cavernous fistula (CCF) resulting from delayed aneurysmal rupture is a rare complication of PED placement with unknown pathophysiology. Here, we describe a case of CCF resulting from aneurysmal rupture following PED placement, and present the details of treatment by transvenous coil embolization. An 81-year-old woman was referred to our hospital for treatment of an 18.0 × 10.3 mm intracranial aneurysm located in the cavernous segment of the left internal carotid artery, noted during an examination of her diplopia. Endovascular treatment was conducted by positioning a single PED (4.75 × 25 mm) across the neck of the aneurysm. The postoperative course was uneventful, and the patient was discharged 8 days post procedure. On post-procedure day 10, her left oculomotor nerve palsy had worsened and she had developed left abducens nerve palsy, left exophthalmos, and left chemosis. Angiography demonstrated left direct CCF because of rupture of the aneurysm that had been treated with PED. Transvenous coil embolization was performed on post-procedure day 11 to treat the CCF, and complete resolution of the CCF and significant thrombus formation within the aneurysm sac were confirmed 11 days after the second procedure. Our angiographic results suggest that the aneurysmal rupture was caused by aneurysmal volume expansion associated with PED-induced thrombosis. Transvenous coil embolization for the treatment of CCF following PED placement constitutes a new challenge.

Convexity dural chondroma: a case report with pathological and molecular analysis.

Chondromas are rare benign tumors that commonly originate from the base of the skull, while those arising from the dura mater are less common. Although the molecular mechanism underlying its pathogenesis remains largely unknown, 12q13-15 rearrangements followed by the activation of HMGA2, which is associated with cell proliferation, have been reported in soft tissue chondromas. A recent comprehensive analysis of mesenchymal tumors identified an IDH1/2 mutation in cartilaginous tumors. However, these alterations have not yet been examined in dural chondromas. We here described clinical and pathological features in a new case of convexity dural chondroma with the wildtype IDH1/2 and expression of HMGA2 and reviewed the relevant literature.

[A Case of Subgaleal Hematoma with Exophthalmos and Diplopia].

A 9-year-old girl struck the left side of her head on a doorknob, after which she gradually developed swelling. She was treated conservatively at another hospital before being referred and admitted to our hospital 9 days after injury, with complaints of exophthalmos and diplopia. Computed tomography (CT) scanning and magnetic resonance imaging (MRI) revealed a subgaleal hematoma (SGH). We therefore attempted to treat the patient by aspiration of the hematoma via needle puncture through the skin, for which we wrapped an elastic band around the head while infusing a hemostatic agent. No vascular anomalies and no abnormal shunts were identified by angiography under general anesthesia 13 days after injury. The patient was treated surgically due to increased head swelling and deteriorated exophthalmos. The liquefied, dark-red SGH was aspirated via a few cm of skin and a galeal incision on the left side of her head. A multiperforated drainage catheter was introduced into the hematoma cavity and the drainage catheter was connected to the vacuum-drain pump. After the surgery, the left exophthalmos disappeared. Twenty-three days after injury, she was discharged from our hospital without any neurological deficits.

Thromboembolic events associated with single balloon-, double balloon-, and stent-assisted coil embolization of asymptomatic unruptured cerebral aneurysms: evaluation with diffusion-weighted MR imaging.

INTRODUCTION: The introduction of the balloon remodeling and stent-assisted technique has revolutionized the approach to coil embolization for wide-neck aneurysms. The purpose of this study was to determine the frequency of thromboembolic events associated with single balloon-assisted, double balloon-assisted, and stent-assisted coil embolization for asymptomatic unruptured aneurysms. METHODS: A retrospective review was undertaken by 119 patients undergoing coiling with an adjunctive technique for unruptured saccular aneurysms (64 single balloon, 12 double balloon, 43 stent assisted). All underwent diffusion-weighted imaging (DWI) within 24 h after the procedure. RESULTS: DWI showed hyperintense lesions in 48 (40%) patients, and ten (21%) of these patients incurred neurological deterioration (permanent, two; transient, eight). Hyperintense lesions were detected significantly more often in procedures with the double balloon-assisted technique (7/12, 58%) than with the single balloon-assisted technique (16/64, 25%, p = 0.05). Occurrence of new lesions was significantly higher with the use of stent-assisted technique (25/43, 58%) than with the single balloon-assisted technique (p = 0.001). Symptomatic ischemic rates were similar between the three groups. The increased number of microcatheters was significantly related to the DWI abnormalities (two microcatheters, 15/63 (23.8%); three microcatheters, 20/41 (48.8%) (p = 0.008); four microcatheters, 12/15 (80%) (p = 0.001)). CONCLUSION: Thromboembolic events detected on DWI related to coil embolization for unruptured aneurysms are relatively common, especially in association with the double balloon-assisted and stent-assisted techniques. Furthermore, the number of microcatheters is highly correlated with DWI abnormalities. The high rate of thromboembolic events suggests the need for evaluation of platelet reactivity and the addition or change of antiplatelet agents.

[A case of glioblastoma multiforme in the pineal region with intraventricular hemorrhage].

INTRODUCTION: Glioblastoma multiforme (GBM) is a very rare type of tumor involving the pineal region. No case of pineal region GBM with tumoral hemorrhage has ever been reported. Here, we present the first such case report. CASE REPORT: A 65-year-old man presented with sudden-onset disturbance of consciousness. CT revealed intraventricular hemorrhage and acute hydrocephalus. The patient was treated by an emergent operation for ventricular drainage. MRI with contrast media showed a heterogeneous enhanced area in the pineal region. The patient underwent endoscopic biopsy surgery and a third ventriculostomy for non-communicating hydrocephalus. The pathological diagnosis was high-grade glioma, indicating the need for tumor removal via the occipital transtentorial approach. The tumor was removed subtotally and radiation and chemotherapy courses were then started. CONCLUSION: Pineal GBM with tumoral hemorrhage has never been reported before. Endoscopic operations are useful for rapid decision making prior to radical surgery.

A case of cribriform plate dural arteriovenous fistulas with a rare complication after endovascular therapy.

Background: Cribriform plate dural arteriovenous fistulas (dAVFs) are rarely encountered. Here, we report a case of cribriform plate dAVF with a rare complication after endovascular therapy. Case Description: A 60-year-old man presented with severe sudden headache. Head computed tomography showed right subdural hematoma, and magnetic resonance angiography showed dilated bilateral frontal cortical vein. Digital subtraction angiography revealed cribriform plate dAVF fed by the anterior and posterior ethmoidal branches of the bilateral ophthalmic arteries. Transarterial embolization with liquid embolic material was performed and the fistula disappeared. Although magnetic resonance imaging showed the disappearance of the cribriform plate dAVF and subdural hematoma, the patient complained of anosmia after the procedure. Conclusion: Endovascular embolization is an effective treatment option for treating cribriform plate dAVFs. However, anosmia is a possible complication, and endovascular surgeons should take care of this complication, especially in cribriform plate dAVFs supplied with blood bilaterally.

Target Coil Embolization Using the Combined Transarterial and Transvenous Balloon-assisted Technique for Traumatic Direct Carotid Cavernous Fistula.

Herein, we describe a case of traumatic direct carotid cavernous fistula (DCCF) treated with target coil embolization using the combined transarterial and transvenous balloon-assisted technique. The patient was a 59-year-old woman who had been involved in a vehicular accident. She was admitted to the hospital due to chemosis and exophthalmos. Cerebral angiography revealed a shunt from the internal carotid artery (ICA) to the cavernous sinus (CS), which indicated DCCF. Thus, target coil embolization using the combined transarterial and transvenous balloon-assisted technique was performed. Angiography was performed 1 week after surgery to confirm the disappearance of DCCF. No recurrence was observed during the 1-year follow-up after treatment. Thus, target coil embolization using the combined transarterial and transvenous balloon-assisted technique is safe and effective for the treatment of traumatic DCCF.

Rare clinical presentations of pleomorphic xanthoastrocytoma with a high proliferative index: Two case reports.

INTRODUCTION: Pleomorphic xanthoastrocytomas (PXA) are rare, typically benign, slow-growing tumors that commonly occur in the cerebral hemispheres. We describe two cases of clinically aggressive PXA with uncommon locations; one was in the tectal plate, and the other had simultaneous multicentric lesions. PATIENT CONCERNS: The both cases presented with severe headache with no significant past medical history. DIAGNOSIS: PXA World Health Organization grade II were histopathologically diagnosed from surgically resected specimens, and immunohistochemical and sequence analysis revealed a high Ki-67 proliferative index and BRAF V600E mutation in both the cases. INTERVENTIONS: The first case presented with multicentric lesions and underwent partial resection, whereas the second case presented with a tectal plate tumor that was managed by gross total surgical resection. Strong 5-aminolevulinic acid (5-ALA)-induced fluorescence was observed in both the lesions. Postoperative radiotherapy plus concomitant and adjuvant temozolomide was administered to both the patients. OUTCOMES: Despite completing adjuvant chemo-radiotherapy, both the patients had local tumor recurrence at 2 and 5 months after the operation, respectively. CONCLUSION: The progressive clinical courses in our cases suggest that additional postoperative therapy should be considered during the treatment of PXA with a high Ki67 index, and that temozolomide with radiotherapy, followed by temozolomide maintenance therapy, may not prevent recurrence in such tumors. Importantly, our experience implies that unlike other subtypes of low grade gliomas, 5-ALA fluorescence is useful for intraoperative visualization of PXA.

A Patient with a Ruptured Blood Blister-like Aneurysm of the Internal Carotid Artery in Whom Two LVIS Stents Were Inserted.

Objective: We report a case in which multiple overlapping low-profile visualized intraluminal support (LVIS) stents were used as monotherapy for ruptured blood blister-like aneurysm (BBA) of the internal carotid artery (ICA). Case Presentation: A 48-year-old female presented to the emergency room with acute-onset headache. She was alert without neurological deficit with subarachnoid hemorrhage (SAH) Hunt and Kosnik grade I. Emergency angiography revealed a BBA from the supraclinoid ICA. This aneurysm had a small diameter, which makes coil embolization difficult. Therefore, we planned to use multiple overlapping LVIS stents as monotherapy for the ruptured aneurysm. The postoperative course was uneventful without rebleeding. The patient exhibited no neurological deficits on the clinical follow-up at 1 year. Conclusion: Multiple overlapping LVIS stents as monotherapy is useful for ruptured BBAs of the ICA.

A Patient with an Unruptured Aneurysm in the Internal Carotid Artery-duplicated Middle Cerebral Artery on Whom Coil Embolization with Balloon Remodeling Was Performed.

Objective: Treatment of an unruptured aneurysm at the origin of duplicated middle cerebral artery (DMCA) by coil embolization using balloon remodeling has not been reported. We report a case of coil embolization using balloon remodeling for an unruptured aneurysm at the origin of DMCA. Case Presentation: A 71-year-old female was found to have an unruptured aneurysm at the origin of DMCA during an examination for headache. Coil embolization using balloon remodeling for the wide neck aneurysm to preserve both the internal carotid artery (ICA) and DMCA was successful. The perioperative course was uneventful. Conclusion: This treatment enables complete embolization, and preserves both the ICA and DMCA. Thus, it is useful for aneurysms at the origin of DMCA.

Carotid surgical cut-down technique for neuroendovascular therapy.

BACKGROUND: Neuroendovascular therapy is typically performed via the femoral artery, but there are rare cases in which a tortuous upstream angioarchitecture makes it difficult to access the intracranial circulation via this route. METHODS: In this case series, we describe six cases treated by surgical cut-down in the neck, with puncture of the carotid artery. Antiplatelet and anticoagulation agents were used in all cases. The indications for the technique were postsurgical thoracic aortic aneurysm (two cases), postsurgical abdominal aortic aneurysm (one case), major vessel tortuosity of the common carotid artery (two cases) and aortic arch anomaly (one case). RESULTS: The surgical cut-down technique permitted successful neuroendovascular therapy. Although one patient had a small cervical haematoma, he was treated without surgical evacuation. CONCLUSION: Overall, our findings indicate that the surgical cut-down technique is safe and useful for patients in whom the femoral approach is unsuitable.

Undifferentiated sarcoma of the sphenoid sinus.

Paranasal sinuses sarcomas are rare and no treatments have been established. We report a young-adult case of sphenoid sinus sarcoma treated by carbon-ion radiotherapy. The patient presented with progressive left-sided visual impairment. A tumor was then identified and partial resection by transnasal approach was performed. The resected mass showed typical morphology of mesenchymal tumor, and morphological and molecular analyses ruled out a predominant-differentiation phenotype. The pathological diagnosis was undifferentiated sarcoma. The residual lesion was treated with carbon-ion radiotherapy, and tumor progression was absent for one year. The patient died of the tumor regrowth 20 months after initial diagnosis. Although this case had a poorer outcome compared with cases of the more-common sarcoma types, our experience suggested that carbon-ion radiotherapy is potentially beneficial in unresectable undifferentiated sarcomas cases of sphenoid sinus.

A Single Center Experience with Coil Embolization for Cerebral Aneurysms Greater than 10 mm in the Internal Carotid Artery.

We investigated endovascular treatment for 10 mm or larger aneurysms in the internal carotid artery (IC), including the cavernous portion, the paraclinoid portion, and the posterior communication artery (PC). Between 2011 and 2014 at our hospital, there were 35 cases of aneurysms that were 10 mm or larger in the carotid artery. We analyzed these 35 cases retrospectively based on the size and location of the aneurysms, method of treatment, number of coils implanted, use of a stent, complications, rupture after treatment, ophthalmologic symptoms, and need for re-treatment. There was no bleeding after treatment. Of the 35 cases, four cases (11%) had permanent complications. Re-treatment was indicated in 11 cases (31%), including eight cases localized in the paraclinoid portion, two cases in the IC-PC, and one case in the cavernous portion. Among these re-treatment cases, two cases required a third treatment. Of the 16 cases with paraclinoid aneurysms, half required re-treatment. Of the 12 cases with ophthalmologic symptoms prior to treatment, 9 (75%) improved or had no change and 3 (25%) became worse. There were no complications in the 13 re-treatment procedures. Re-treatment is not uncommon, and a scheduled follow-up is needed. Coil embolization has been one of the main options for aneurysms that are 10 mm or larger in the IC. In the future, these large aneurysms will be treated with a flow diverter stent (FD).

Clinicopathological and molecular features of malignant optic pathway glioma in an adult.

Malignant gliomas of the optic pathway are rare, and their genetic alterations are poorly understood. We describe a 64-year-old woman with anaplastic astrocytoma originating from the optic pathway, together with the molecular features. She presented with progressive visual field loss, and a biopsy sample was obtained from the lesion in the optic chiasm. She underwent radiosurgery concomitant with temozolomide chemotherapy, and subsequently remained stable for 10 months after initial presentation. Molecular analysis indicated that the mass may have shared common molecular genetic features with conventional primary astrocytic gliomas but not pilocytic gliomas, which supported the morphologic diagnosis of anaplastic astrocytoma. Molecular analysis of malignant optic pathway gliomas in adults is useful for distinguishing between high-grade gliomas and anaplastic pilocytic astrocytomas, and for determining further therapy.

Double-balloon remodeling for coil embolization of a primitive trigeminal artery variant aneurysm. A case report.

Here we describe the case of a patient with a wide-necked unruptured aneurysm arising at origin of a persistent primitive trigeminal artery (PTA) variant from the right internal carotid artery (ICA), supplying the territory of the right superior cerebellar artery and the anterior inferior cerebellar artery. To preserve the ICA and the PTA variant, coil embolization of the aneurysm was performed using a double-balloon remodeling technique (HyperForm™ and HyperGlide™ Occlusion Balloon Systems; ev3 Endovascular Inc., Irvine, CA, USA). The association of a PTA variant with an aneurysm is very rare. To our knowledge, this is the first description of the use of coil embolization using double-balloon remodeling to treat a PTA variant aneurysm. This technique permits complete embolization and reduces the risk of cerebral and cerebellar ischemia.

Treatment of traumatic acute subdural hematoma in adult hydrocephalus patients with cerebrospinal fluid shunt.

OBJECTIVE: The presence of a cerebrospinal fluid (CSF) shunt is a predisposing factor for the development of subdural hematoma (SDH) in patients with hydrocephalus. However, few reports have addressed how patients with a CSF shunt should be treated in the event of traumatic acute SDH. The purpose of this study was to show how post-traumatic management of CSF shunt affects acute SDH in adult patients with hydrocephalus. METHODS: Twelve patients were studied retrospectively. Pressure settings of shunt valve prior to head injury (HI), severity of HI, treatment on admission, changes in SDH thickness and subsequent hydrocephalus were mainly analyzed. RESULTS: Ten patients experienced mild HI, with nine showing neurological deterioration until admission. Five patients needed surgical hematoma removal soon after admission. SDH recurred in four cases where shunt pressure levels were kept relatively low. Shunt ligation or raising the pressure level in the programmable valve proved effective for controlling postoperative SDH in such cases. Six of the remaining seven patients underwent only shunt ligation or readjustment of pressure level in the programmable valve on admission. SDH thickness was reduced as ventricles dilated without major neurological complications. Four patients showed delayed development of SDH even though shunts were kept ligated. CONCLUSIONS: Hematoma removal alone may result in hematoma recurrence and require a second treatment comprising shunt management to effectively control hematoma. Using shunt management as the only initial treatment can reduce hematoma volume, but some patients may suffer delayed SDH development and require surgery.

Intracerebral hemorrhage in patients with chronic liver disease.

The characteristics of intracerebral hemorrhage (ICH) accompanying chronic liver disease (CLD) were investigated in ICH patients hospitalized between 1998 and 2008 divided into the CLD group (55 ICHs in 49 patients) and the idiopathic group without CLD (668 ICHs in 648 patients). The CLD group included a subgroup with liver cirrhosis (LC). Age, sex, history of hypertension, Glasgow Coma Scale (GCS) score on admission, and hematoma locations were reviewed. Outcomes on discharge and causes of in-hospital death were also studied. Factors associated with life prognosis in CLD patients were investigated using uni- and multivariate analyses. History of hypertension and deep cerebral hemorrhage were less frequent in the LC subgroup compared to the idiopathic group. Distributions of GCS scores on admission were not significantly different, but incidence of in-hospital death was significantly higher in the CLD group than in the idiopathic group. LC was an independent prognostic factor for CLD patients, but hematoma enlargement was not. Death primarily due to ICH was less frequent in the CLD group than in the idiopathic group. In conclusion, hemostatic disorders seemed to be related to site of hemorrhage, but not to life prognosis in the CLD group. Prognosis was mainly worsened by non-neurological complications.