A Case of Rheumatoid Meningitis Diagnosed with FLAIR Images and Anti-cyclic Citrullinated Peptide Antibodies Levels.

Rheumatoid meningitis (RM) is a rare but serious extra-articular manifestation of rheumatoid arthritis. Due to the absence of specific biomarkers, imaging findings, or guidelines for its detection, the diagnosis of RM is difficult. This report describes a patient of RM diagnosed with an open biopsy and discusses the utility of anticyclic citrullinated peptide antibodies (ACPA) levels in the serum and cerebrospinal fluid (CSF), and contrast-enhanced (CE) fluid-attenuated inversion recovery (FLAIR) images for screening and monitoring RM. A 65-year-old woman presented with a 2-month history of headaches. Imaging studies showed asymmetric meningeal and leptomeningeal involvement seen on brain magnetic resonance imaging (MRI). An open biopsy of the meninges and leptomeninges depicted palisaded and necrotizing granulomatous inflammation, which suggests rheumatoid nodules. Treatment with prednisolone and tocilizumab led to symptom improvement and reduced lesion intensity on follow-up MRI. Throughout the treatment, the ACPA index in her serum and CSF, and the findings of CE-FLAIR images, rather than the CE T1WI, reflected disease activity. For 6 months, the patient has been stable without symptom recurrence. The ACPA index and the CE-FLAIR images were useful for the diagnosis and monitoring of RM. To validate these findings, further studies are necessary.

Subarachnoid Hemorrhage Confirmed by Magnetic Resonance Imaging in a Patient with Brain Death owing to Hypoxic Encephalopathy Following Suicide by Hanging.

Although true subarachnoid hemorrhage (SAH) is an atypical complication owing to suicide by hanging, pseudo-SAH can often develop because of hypoxic encephalopathy. Therefore, differentiating pseudo-SAH from true SAH using brain computed tomography (CT) is often challenging. In Japan, an individual's cause of brain death must be determined to be eligible for organ donation, regardless of whether true SAH is involved or not. Herein, we report a case of SAH confirmed by magnetic resonance imaging (MRI) in a patient with brain death owing to hypoxic encephalopathy following suicide by hanging. A 48-year-old man attempted suicide by hanging. Upon arrival at the hospital, he developed pulseless electrical activity with apnea. Although spontaneous circulation returned within a few minutes of his arrival, spontaneous breathing did not recover. The patient was in deep comatose state without response to pain stimulation, brainstem reflexes, or electrical activities on an electroencephalogram. Consequently, the patient met diagnostic criteria for clinical brain death based on the Japanese organ transplantation law. Brain CT revealed global hypoxic injury and high density in the basal cisterns and subarachnoid space. Brain MR T2*-weighted imaging revealed low intensity at the left Sylvian fissure underlying the hematoma. These findings indicated brain death owing to hypoxic encephalopathy following hanging, and incidental true SAH was confirmed by MRI. Donor surgery and organ transplantation were performed. Spontaneous SAH can often develop secondary to hanging, and brain MRI can effectively determine whether the cause of brain death involves true SAH.

Delayed blink R1 latency in a patient with trigeminal neuralgia due to a contralateral vestibular schwannoma: An illustrative case.

Background: Although the blink reflex (BR) is effective in objectively evaluating trigeminal neuropathy, few studies have demonstrated its effect on trigeminal neuralgia (TN). The authors report a patient with TN due to contralateral vestibular schwannoma (VS) functionally diagnosed by delayed R1 latency of the BR. Case Description: A 36-year-old man presented with left-sided deafness and paroxysmal facial pain in the right V1-3 area. Magnetic resonance imaging (MRI) showed a solid cystic mass compressing the right pons and left brainstem at the left cerebellopontine angle. Although preoperative BR evoked by right supraorbital nerve stimulation-induced delayed ipsilateral R1 latency and normal ipsilateral and contralateral R2 responses, the BR latency evoked by left supraorbital nerve stimulation was normal, indicating deficits in the principal nucleus of the trigeminal nerve in the right pons. The symptoms of TN disappeared after the removal of the VS. Postoperative MRI showed subtotal removal of the tumor and sufficient decompression of the pons and cerebellopontine cistern. The R1 latency returned to normal 50 days after surgery. Conclusion: The perioperative BR test was not only useful for objective evaluation of the localization of trigeminal neuropathy but also correlated with the symptoms of TN.

Symptomatic subdural hemorrhage following heart valve surgery: a retrospective cohort study.

OBJECTIVE: Subdural hemorrhage (SDH) has been reported to be the most frequent intracranial hemorrhagic complication following open heart surgery; however, its clinical features and pathophysiology remain unclear. The aim of this retrospective study was to elucidate the incidence, clinical course, and factors associated with the development of symptomatic SDH following heart valve surgery. METHODS: A retrospective review of medical records on the development of symptomatic SDH after heart valve surgery involving cardiopulmonary bypass (CPB) from April 2011 to March 2016 was performed. Patients who had undergone preoperative cranial computed tomography (CT) or brain magnetic resonance imaging (MRI) were included in this study, and factors associated with SDH following heart valve surgery were analyzed. When neurological symptoms developed after heart valve surgery, cranial CT or brain MRI was performed. RESULTS: A total of 556 patients who had undergone heart valve surgery were analyzed. Among these patients, symptomatic SDH occurred in 11 (2.0%). The mean duration of symptomatic onset was 10.1 days (range 2-37 days). Ten of 11 patients (90.9%) developed SDH in the posterior fossa or occipital convexity. Logistic regression analysis revealed longer aortic clamp time (95% CI 1.00-1.10, p = 0.04), higher dose of heparin after surgery (95% CI 1.00-1.02, p = 0.001), and higher pulmonary artery pressure (PAP) just before disconnection of the CPB (95% CI 1.01-1.37, p = 0.04) as significantly associated with the development of SDH. CONCLUSIONS: The incidence of symptomatic SDH following heart valve surgery was 2.0%. Symptoms due to SDH usually developed a few days to 1 month after surgery. Surprisingly, most SDHs developed in the posterior fossa or occipital convexity following heart valve surgery. A longer aortic clamp time, higher dose of heparin after surgery, and higher PAP just before disconnection of the CPB were related to the development of symptomatic SDH following heart valve surgery.

[Severe Traumatic Brain Injury due to Repeated Minor Head Injury while Snowboarding:A Report of Two Cases].

Second impact syndrome occurrs when a patient who has sustained an initial head injury, most often a concussion, sustains a second head injury before the symptoms associated with the first have fully resolved, leading to rapid brain swelling and herniation. However, the underlying pathophysiology remains unclear. We report two cases in which acute subdural hematoma with rapid malignant brain swelling developed after repeated head traumas while snowboarding. One patient did not undergo craniotomy and died 21h after symptom onset. The other underwent urgent decompressive craniotomy and experienced prolonged disturbance of consciousness. Axial susceptibility-weighted magnetic resonance imaging performed 1 month after surgery in the second patient revealed multiple microbleeds in the subcortical white matter and parasagittal white matter in the bilateral hemispheres. These findings indicate that axonal injuries from angular acceleration may contribute to the rapid malignant brain swelling and poor outcomes.

A case of chronic subdural hematoma demonstrating the epileptic focus at the area with sulcal hyperintensity on fluid-attenuated inversion recovery image.

Although the sulcal hyperintensity on fluid-attenuated inversion recovery (FLAIR) images is detected in some chronic subdural hematoma (CSDH) cases, its clinical significance remains determined. A 77-year-old man with symptomatic CSDH presented with generalized tonic-clonic seizures at 9 days after surgery. 123I-iomazenil -single photon emission computed tomography revealed transient reduction in cortical benzodiazepine receptors binding potential at the region corresponding to that of the sulcal hyperintensity on FLAIR images. Findings of sulcal hyperintensity on FLAIR imaging under the CSDH may have a relation with the cause of epileptic seizure.

A Case of Cisternal Pilocytic Astrocytoma Diagnosed with the Balanced Steady-State Free Precession Sequence for Magnetic Resonance Imaging: A Rare Cause of Subarachnoid Hemorrhage.

OBJECTIVES: In approximately 15% of cases of spontaneous subarachnoid hemorrhage (SAH), an obvious source of bleeding cannot be identified by angiography; these are considered cases of SAH of unknown etiology. A rare case of cisternal pilocytic astrocytoma (PA) presenting with SAH is reported. The usefulness of the balanced steady-state free precession (bSSFP) sequence for magnetic resonance imaging (MRI) to detect small cisternal lesions is discussed. CASE DESCRIPTION: The case of a 73-year-old woman who developed repeated SAHs owing to a cisternal PA is presented. She experienced sudden onset of headache and vomiting, and brain computed tomography showed diffuse SAH, whereas angiography demonstrated normal vasculature. Follow-up imaging, including T1-weighted, T2-weighted, T1-weighted contrast-enhanced, and diffusion-weighted MRI, did not show any parenchymal or cisternal lesions, although computed tomography and fluid-attenuated inversion recovery MRI showed SAH in the same region. In contrast, the bSSFP sequence, taken as a different sequence on the same day, showed mixed-intensity reticular lesions in the left basal cistern, while neither hematoma nor positive findings were identified with the other sequences. Based on the radiologic finding and the repeated history of SAH, the lesions were partially removed 2 weeks after onset. Histological examination showed a PA. CONCLUSIONS: Despite being extremely rare, a small cisternal lesion should be considered as a cause of SAH of unknown etiology. The bSSFP sequence may be useful for detecting cisternal lesions that may be missed on the routine MRI sequences.

[Preoperative Diagnosis of Spinal Immature Teratoma Associated with Cerebrospinal Fluid Leakage from the Congenital Dermal Sinus Tract in a 0-Day-Old Infant:A Case Report].

We report the case of a patient with spinal immature teratoma and cerebrospinal fluid leakage from the congenital dermal sinus tract. A 0-day-old female infant presented with a subcutaneous soft mass with a dimple in the lumbosacral region at birth. Magnetic resonance imaging revealed a mixed low-intensity mass located in the extraspinal and intraspinal canal with a sinus tract. The reconstructed three-dimensional spinal computed tomography image showed spina bifida and ectopic ossification at the dorsal aspect of the sacrum. Urgent removal of the tumor and dermal sinus tract was then performed under evoked electromyography monitoring. The resected tumor was histopathologically diagnosed as immature teratoma.

Fenestrated Mini-Clip Application to Preserve a Tightly Adhering Branch Artery to a Middle Cerebral Artery Aneurysm: Technical Case Report.

BACKGROUND: Fenestrated mini-clips have been reported as useful for treating dog ear-shaped remnant aneurysms, the small aneurysms to which the efferent artery adheres or is impeded by the surrounding neurovascular structure in the restricted operative corridor, because of the smaller clip head. Here, the alternative utility of fenestrated mini-clip was reported by mentioning the narrower clip blade. METHODS: We report a case of middle cerebral artery aneurysm tightly adhered by the anterior temporal artery (ATA) as well as the efferent arteries and demonstrate the utility of fenestrated mini-clip. RESULTS: During aneurysm dissection, the superior division of the M2 segment of the middle cerebral artery and the ATA adhered tightly to the aneurysm, thereby restricting meticulous aneurysm dissection. To preserve the efferent artery and the ATA, a fenestrated standard clip was applied, transmitting the efferent artery, and the clip blade was applied in the restricted space between the adhering ATA and the aneurysm neck. However, because kinking of the ATA was observed following first clip application, the fenestrated mini-clip was applied in similar fashion to avoid kinking of the ATA instead of a standard clip, thereby preserving the ATA without further aneurysm dissection. Finally, successful obliteration of the aneurysm and preservation of the ATA were achieved with the subsequent clip application. CONCLUSIONS: In selected cases, application of a narrower bladed fenestrated mini-clip in the restricted space may be useful to preserve tightly adhering branch arteries, as well as efferent arteries.

Impact of external carotid artery occlusion at declamping of the external and common carotid arteries during carotid endarterectomy on development of new postoperative ischemic cerebral lesions.

OBJECTIVE: The external carotid artery (ECA) is inadvertently occluded during carotid endarterectomy (CEA). The importance of ECA occlusion has been emphasized as a loss of extracranial to intracranial collaterals, a source of chronic embolization, or a site for extended thrombosis during wound closure. This study aimed to determine whether ECA occlusion that inadvertently developed during endarterectomy and that was eventually detected using blood flow measurement of the ECA after declamping of all carotid arteries is a risk factor for development of new postoperative ischemic lesions at declamping of the ECA and common carotid artery (CCA) while clamping the internal carotid artery (ICA). This study also aimed to determine whether intraoperative transcranial Doppler (TCD) monitoring predicts the risk for development of such lesions. METHODS: This was a prospective observational study that included patients undergoing CEA for severe stenosis (≥70%) of the cervical ICA. When blood flow through the ECA measured using an electromagnetic flow meter decreased rapidly on clamping of only the ECA before carotid clamping for endarterectomy and was not changed by clamping of only the ECA after carotid declamping following endarterectomy, the patient was determined to have developed ECA occlusion. These patients underwent additional endarterectomy for the ECA. TCD monitoring in the ipsilateral middle cerebral artery was also performed throughout surgery to identify microembolic signals (MESs). Brain magnetic resonance diffusion-weighted imaging (DWI) was performed before and after surgery. RESULTS: There were 104 patients enrolled in the study. Eight patients developed ECA occlusion during surgery. The incidence of intraoperative ECA occlusion was significantly higher in patients without MESs at the phase of ECA and CCA declamping (8/12 [67%]) than in those with MESs (0/92 [0%]; P < .0001). Six patients exhibited new postoperative ischemic lesions on DWI. The incidence of intraoperative ECA occlusion (P < .0001) and the absence of MESs at declamping of the ECA and CCA while clamping the ICA (P <. 0001) were significantly higher in patients with development of new postoperative ischemic lesions on DWI than in those without. Sensitivity and specificity for the absence of MESs at declamping of the ECA and CCA while clamping the ICA for predicting development of new postoperative ischemic lesions on DWI were 100% (6/6) and 94% (92/98), respectively. CONCLUSIONS: ECA occlusion at declamping of the ECA and CCA while clamping the ICA during CEA is a risk factor for development of new postoperative ischemic lesions. Intraoperative TCD monitoring accurately predicts the risk for development of such lesions.

Straight Fenestrated Clips in Surgical Management of Internal Carotid Artery Aneurysms: Technical Note.

BACKGROUND: Using angled fenestrated clips for posteromedially projecting internal carotid artery (ICA) aneurysms may allow the surgeon to simultaneously obliterate the aneurysmal neck and preserve the branching artery by applying the blade of the clip parallel to the ICA. However, using these clips when the aneurysm neck involves the branching artery may have a risk of branching artery stenosis, occlusion, or incomplete obliteration of the aneurysm. CASE DESCRIPTION: A 52-year-old woman developed a subarachnoid hemorrhage. Three-dimensional computed tomography angiography showed a saccular aneurysm arising from the left ICA-posterior communicating artery (PCoA) bifurcation. The aneurysmal fundus projected posteromedially, and the PCoA was larger than the ipsilateral P1 segment, in which its origin involved the aneurysmal neck. Tandem straight fenestrated clips were applied across the ICA, followed by reconstruction of the ICA wall with preservation of the PCoA and obliteration of the aneurysm. CONCLUSION: When using angled fenestrated clips is unsuitable because of a risk of branching artery stenosis, occlusion, or incomplete obliteration of the aneurysm, using multiple straight fenestrated clips may be a useful alternative.

Optimal Brain 99mTc-Ethyl Cysteinate Dimer SPECT Imaging and Analysis to Detect Misery Perfusion on 15O PET Imaging in Patients With Chronic Occlusive Disease of Unilateral Major Cerebral Artery.

PURPOSE: Misery perfusion is defined as marginally sufficient cerebral blood supply relative to cerebral metabolic demand. The aim of the present study was to determine the optimal brain Tc-ethyl cysteinate dimer (ECD) SPECT imaging and analysis to detect misery perfusion on O PET imaging in patients with chronic occlusive disease of unilateral internal carotid or middle cerebral artery (MCA). METHODS: For 97 patients, cerebral blood flow, cerebral metabolic rate of oxygen, and oxygen extraction fraction were measured using O PET; Tc-ECD SPECT was performed using dynamic scanning with a scan duration of 10 minutes each for 50 minutes after tracer administration. A region of interest was placed in the bilateral MCA territories and in the bilateral cerebellar hemispheres in all standardized images using a 3-dimensional stereotaxic region-of-interest template and affected-to-contralateral asymmetry ratio in the MCA territory (ARMCA) and contralateral-to-affected asymmetry ratio in the cerebellar hemisphere (ARcbl) were calculated. RESULTS: The ARMCA or ARcbl on Tc-ECD SPECT with a scan time of 20 to 30 minutes after tracer administration (ARMCA20-30 or ARcbl20-30) was correlated with ARMCA on PET cerebral blood flow (r = 0.654) or ARMCA on PET cerebral metabolic rate of oxygen (r = 0.576), respectively, more strongly than with other scan times. The area under the receiver operating characteristic curve for detecting abnormally elevated ARMCA on PET oxygen extraction fraction was significantly greater for ARcbl20-30/ARMCA20-30 (0.947) than for ARMCA20-30 alone (0.780) (difference between areas, 0.167; P = 0.0001) on Tc-ECD SPECT. CONCLUSIONS: Combination of asymmetries in the cerebellar and cerebral hemispheres on Tc-ECD SPECT in a scan time of 20 to 30 minutes after tracer administration optimally detects misery perfusion in unilateral internal carotid artery or MCA occlusive disease.

Effects of uncomplicated carotid endarterectomy on cognitive function and brain perfusion in patients with unilateral asymptomatic severe stenosis of the internal carotid artery by comparison with unoperated patients.

OBJECTIVE: The purpose of the present exploratory study was to evaluate the effects of uncomplicated carotid endarterectomy (CEA) on cognitive function and brain perfusion in patients with unilateral asymptomatic severe stenosis of the internal carotid artery (ICA) by comparison with unoperated patients. METHODS: Patients with age ≤75 years and unilateral asymptomatic severe stenosis (≥70%) of the cervical ICA underwent CEA with antiplatelet therapy (surgically treated group: 116 patients) or antiplatelet therapy alone or neither (medically treated group: 45 patients). For the surgically treated group, neuropsychological testing and brain perfusion measurement using single-photon emission computed tomography were performed within one month before surgery and one month after surgery. For the medically treated group, the same testing and measurement were performed twice at an interval of 1 to 2 months. RESULTS: None of the operated patients developed new major ischemic events after surgery or intraoperative cerebral hyperperfusion. None of the patients in the medically treated group experienced neurological deficits including transient ischemic attacks during the study period. The incidence of patients with interval cognitive improvement was significantly greater in the surgically treated group (11 patients: 9%) than in the medically treated group (0%) (p = 0.0352). The incidence of patients with interval brain perfusion improvement in the ipsilateral cerebral hemisphere was significantly greater in the surgically treated group (24 patients: 21%) than in the medically treated group (0%) (p = 0.0003). CONCLUSIONS: Uncomplicated CEA may improve cognitive function and brain perfusion in patients with unilateral asymptomatic severe stenosis of the ICA when compared with unoperated patients.