The prognostic values of plasma desmosines, crosslinking molecules of elastic fibers, in the disease progression of Moyamoya disease.

Moyamoya disease (MMD) is a cerebrovascular disease which is characterized by the chronic progression of steno-occlusive changes at the terminal portion of internal carotid arteries and the development of "moyamoya vessels." Dysregulation of the extracellular matrix is regarded as a key pathophysiology underlying unique vascular remodeling. Here, we measured the concentration of elastin crosslinkers desmosine and isodesmosine in the plasma of MMD patients. We aimed to reveal its diagnostic values of desmosines in the progression of steno-occlusive lesions. The concentrations of plasma desmosines were determined by liquid chromatography-tandem mass spectrometry. The temporal profiles of steno-occlusive lesions on magnetic resonance angiography were retrospectively evaluated, and the correlation between the progression of steno-occlusive changes in intracranial arteries and plasma desmosines concentrations was further analyzed. Plasma desmosines were significantly higher in MMD patients with disease progression compared to MMD patients without disease progression. Also, the incidence of disease progression was higher in MMD patients with plasma desmosines levels over limit of quantitation (LOQ) than those with plasma desmosines levels below LOQ. In conclusion, plasma desmosines could be potential biomarkers to predict the progression of steno-occlusive changes in MMD patients.

Brain Temperature Measured by Magnetic Resonance Spectroscopy to Predict Clinical Outcome in Patients with Infarction.

Acute ischemic stroke is characterized by dynamic changes in metabolism and hemodynamics, which can affect brain temperature. We used proton magnetic resonance (MR) spectroscopy under everyday clinical settings to measure brain temperature in seven patients with internal carotid artery occlusion to explore the relationship between lesion temperature and clinical course. Regions of interest were selected in the infarct area and the corresponding contralateral region. Single-voxel MR spectroscopy was performed using the following parameters: 2000-ms repetition time, 144-ms echo time, and 128 excitations. Brain temperature was calculated from the chemical shift between water and N-acetyl aspartate, choline-containing compounds, or creatine phosphate. Within 48 h of onset, compared with the contralateral region temperature, brain temperature in the ischemic lesion was lower in five patients and higher in two patients. Severe brain swelling occurred subsequently in three of the five patients with lower lesion temperatures, but in neither of the two patients with higher lesion temperatures. The use of proton MR spectroscopy to measure brain temperature in patients with internal carotid artery occlusion may predict brain swelling and subsequent motor deficits, allowing for more effective early surgical intervention. Moreover, our methodology allows for MR spectroscopy to be used in everyday clinical settings.

Prediction of Functional Outcome in Patients with Acute Stroke by Measuring tRNA Derivatives.

BACKGROUND AND PURPOSE: Transfer RNA (tRNA) is a noncoding RNA that delivers amino acids to ribosomes for protein synthesis. tRNA is also involved in cell stress response programs. Oxidative stress induces direct conformational change in tRNA structure that promotes subsequent tRNA fragmentation. Using an antibody against tRNA-specific modified nucleoside 1-methyladenosine (m1A), we can detect tRNA derivatives such as conformationally changed tRNA, tRNA-derived fragments, and mononucleotide-free m1A. Based on these findings, tRNA derivatives may have potential as an early tissue damage marker. The purpose of this study was to investigate the plasma tRNA derivatives in stroke patients to clarify whether tRNA derivatives in the acute phase can detect early brain damage and then predict the functional outcome. METHODS: Patients (75 patients with ischemic and 66 with hemorrhagic stroke) and 22 healthy volunteers were prospectively enrolled for this study between November 2016 and February 2019. Plasma samples were collected within 24 h and at 1 day, 7 days, and 30 days from the onset. Plasma tRNA derivative concentrations were measured by ELISA kit using the anti-m1A antibody. RESULTS: The plasma tRNA derivative level on admission was significantly increased in both ischemic (mean ± standard error, 232.2 ± 33.1 ng/mL) and hemorrhagic stroke patients (212 ± 23.4 ng/mL) compared to the healthy volunteers (86.0 ± 7.9 ng/mL) (p = 0.00042 and p = 0.00018, respectively). The infarction size (r = 0.445, p = 0.00018) and hematoma volumes (r = 0.33, p = 0.0072) were also significantly correlated with tRNA derivatives. The concentrations of tRNA derivatives were associated with poor functional outcome (Modified Rankin Scale score 3-6 at 30 days from the onset) in patients with ischemic stroke at 7 days after onset (p = 0.020). CONCLUSIONS: Stress-induced tRNA derivatives can detect brain tissue damage, predicting functional outcome in patients with ischemic stroke.

Lectin-Like Oxidized Low-Density Lipoprotein Receptor-1 Levels as a Biomarker of Acute Intracerebral Hemorrhage.

BACKGROUND: Correct diagnosis of cerebral stroke type, hemorrhagic or ischemic, is essential in the early stage to establish the optimum treatment. The diagnosis is mainly determined based on imaging studies. Other more available diagnostic methods are desirable, such as blood sample examination. Lectin-like oxidized low-density lipoprotein receptor-1 (LOX-1) is very important in vascular dysfunction induced by oxidized low-density lipoprotein, including cell apoptosis. The present study evaluated LOX-1 as a biomarker for cerebral stroke. SUBJECTS AND METHODS: Patients with newly diagnosed stroke were prospectively enrolled between February and July 2014. LOX-1 serum values were measured twice, within 24 hours and 2 months after the onset. RESULTS: A total of 16 patients were enrolled; 7 patients with intracerebral hemorrhage (ICH) and 9 patients with cerebral infarction. Median LOX-1 values of patients with ICH and infarction in the acute phase were 1825.8 and 593.9 pg/mL, respectively, significantly higher in patients with ICH than in patients with infarction (P < .0001). CONCLUSION: LOX-1 serum level has potential as a biomarker of ICH.

Zymosan and lipopolysaccharide decrease gene expression of neuronal nitric oxide synthase in peripheral organs in chicks.

Nitric oxide (NO) is gaseous bioactive molecule that is synthesized by NO synthase (NOS). Inducible NOS (iNOS) expression occurs in response to pathogenic challenges, resulting in the production of large amounts of NO. However, there is a lack of knowledge regarding neuronal NOS (nNOS) and endothelial NOS (eNOS) in birds during pathogenic challenge. Therefore, the present study was conducted to determine the influence of intraperitoneal (IP) injection of zymosan (cell wall component of yeast) and lipopolysaccharide (LPS, a cell wall component of gram-negative bacteria) on NOS expression in chicks (Gallus gallus). Furthermore, the effect of NOS inhibitors on the corresponding behavioral and physiological parameters was investigated. Zymosan and LPS injections induced iNOS mRNA expression in several organs. Zymosan had no effect on eNOS mRNA expression in the organs investigated, whereas LPS increased its expression in the pancreas. Zymosan and LPS decreased nNOS mRNA expression in the lung, heart, kidney, and pancreas. The decreased nNOS mRNA expression in pancreas was probably associated with the NO from iNOS provided that such effect was reproduced by IP injection of sodium nitroprusside, which is a NO donor. Furthermore, pancreatic nNOS mRNA expression decreased following subcutaneous injection of corticosterone. Furthermore, IP injections of a nonspecific NOS inhibitor, NG-nitro-L-arginine methyl ester, and an nNOS-specific inhibitor, 7-nitroindazole, resulted in the significant decreases in food intake, cloacal temperature, and feed passage via the digestive tract in chicks. Collectively, the current findings imply the decreased nNOS expression because of fungal and bacterial infections, which affects food intake, body temperature, and the digestive function in birds.

Efficacy of selective transarterial chemoembolization for recurred liver metastases from intracranial meningioma: A case report.

Extracranial metastases from intracranial meningioma involve multiple organs with repeatedly recurrence. Due to the rarity of these metastases, management remains to be established, especially in cases that are not amenable to surgery, such as postsurgical relapse and multiple metastases. We present the case of a right tentorial meningioma with multiple extracranial metastases, including postsurgical recurrent liver metastases. The intracranial meningioma was surgically resected when the patient was 53 years of age. The patient was 66 years of age when the hepatic lesion was first revealed, for which an extended right posterior sectionectomy was performed. Histopathology demonstrated a metastatic meningioma. Twelve months after liver resection, multiple local recurrences in the right hepatic lobe were revealed. Because additional surgical resection would put the patient at risk of declining residual liver function, we performed selective transarterial chemoembolization, resulting in a reduction in size and good control without relapse. Selective transarterial chemoembolization for incurable liver metastatic meningiomas could be valuable in palliating patients unsuitable for surgery.

Stent-Assisted Embolization for Acutely Ruptured Aneurysm.

Objective: The purpose of this study was to report the results of stent-assisted embolization performed at our hospital for acutely ruptured aneurysms. Methods: This study consisted of 19 patients (4 men and 15 women) with acutely ruptured wide neck aneurysm who underwent stent-assisted coil embolization in acute stage between December 2016 and October 2020. Stent-assisted embolization in the acute stage was performed for very wide neck ruptured aneurysm only when balloon-assisted embolization was failed or was thought to be impossible. Factors related to poor clinical outcome were examined. Results: There were nine internal carotid artery (ICA) aneurysms, four anterior communicating artery (AcomA) aneurysms, three basilar artery (BA) aneurysms, two vertebral artery (VA) aneurysms and one anterior cerebral artery (ACA) aneurysm. The stents used were one Neuroform EZ and 18 Neuroform Atlas (Stryker). The contrast of the bleb disappeared in all cases with obvious bleb. Complete obliteration was achieved in two cases, neck remnant was in ten, and body filling was in seven. Both of the complete obliteration cases developed thrombotic complications. Modified Rankin score of 0-2 was observed in eight patients (good clinical outcome), whereas that of 4-6 was observed in 11 patients (poor clinical outcome). Several factors possibly affected to poor clinical outcome were examined and only age over 80 years was statically different. Complications related to procedure occurred in five patients; two cases of in-stent thrombosis, one case each of MCA perforation, stent occlusion, and coil fracture. Conclusion: Stent-assisted coil embolization using Neuroform EZ and Neuroform Atlas could be considered as an emergency treatment for acutely ruptured cerebral aneurysms with very wide neck. It is rarely indicated in patients with age over 80 years.

Rescue of distally placed stents in the setting of internal carotid artery dissection: A report of 2 cases with mechanistic insights.

Potential procedural complications of endovascular therapy for carotid artery dissection have not been clarified. Herein, we present the cases of a 46-year-old woman and a 59-year-old man who underwent carotid artery stenting for left cervical internal carotid artery dissection. During the procedure, intramural hematoma was squeezed out by stent placement, causing further extension of the pseudolumen and a prominent stenosis proximal to the stent. Additional stent deployment was subsequently performed to fully cover the newly arising stenosis, resulting in good recanalization. In cases with a long-affected lesion, we should consider the potential risk of dissection advancement following stent deployment. Using longer stents or additional rescue stenting would be efficient in counteracting this rare complication.

Potential hemorrhagic risk of endovascular revascularization therapy due to recanalization of the dissected perforator in intracranial internal carotid artery dissection: A case report.

BACKGROUND: Intracranial internal carotid artery (ICA) dissection manifesting as ischemic stroke is rare. Although endovascular revascularization therapy is effective in preventing the progression of stroke, little is known about the potential risk of this therapeutic approach. CASE DESCRIPTION: We report a case of a 38-year-old woman who presented with acute ischemic infarcts in the territory of the left anterior choroidal artery (AChA) due to intracranial ICA dissection. She underwent balloon angioplasty, resulting in the complete resolution of the stenosis. The AChA, which was nearly occluded preoperatively, was unexpectedly recanalized after the procedure. Four hours later, she developed a parenchymal hemorrhage in the left basal ganglia without subarachnoid hemorrhage. The AChA, suspected as the hemorrhagic source during surgical hematoma removal, was revealed to have a disrupted internal elastic lamina on pathological examination, suggesting that the dissection of the ICA extended to the AChA. CONCLUSION: To the best of our knowledge, this is the first case report demonstrating that the intracranial ICA dissection extends to the associated perforator. Considering the potential risk of subsequent hemorrhagic complications by recanalization of the dissected perforator, prudent postoperative management, including strict blood pressure control, is advisable following endovascular revascularization therapy against intracranial artery dissection involving perforators.

Functional Outcome in Patients with Chronic Subdural Hematoma: Postoperative Delirium and Operative Procedure.

Chronic subdural hematoma (CSDH) is a common neurosurgical condition and neurological condition improves after treatment in most patients. Recently more patients have poor prognosis because of aging of the population and presence of multiple comorbidities. The risk factors for poor prognosis, including postoperative delirium, were retrospectively evaluated to assess appropriate operative procedures. This study included 108 patients who underwent primary surgery from 2016 to 2017 at a single center. Operative procedures were drainage with or without irrigation. Functional outcome at discharge assessed the effect of various factors including postoperative delirium and operative procedure. Twenty-nine of 108 patients (27%) had worsened modified Rankin Scale (mRS) score at discharge, most with mobility disturbance or deteriorated cognitive function. Multivariate analysis found higher age (odds ratio [OR] = 5.13; 95% confidence interval [CI] = 1.0-1.14), poor pre-hospital mRS score (OR = 1.57; 95% CI = 1.0-2.46), and preoperative consciousness disturbance caused by CSDH (OR = 5.13; 95% CI = 1.27-20) were significant predictors of poor outcome. Operative procedure was not significantly related to functional outcome or recurrence, but irrigation was significantly related to postoperative delirium (OR = 4.83; 95% CI = 1.09-21.7). Patients with postoperative delirium were likely to require longer hospitalization stays (P = 0.028). Higher age, poor pre-hospital mRS, and preoperative consciousness disturbance caused by CSDH are the risk factors for poor recovery after CSDH. Irrigation is significantly likely to cause postoperative delirium and longer hospital stay.

Marked Reduction of Cerebral Vasospasm with Intrathecal Urokinase Infusion Therapy after Endovascular Coil Embolization of the Aneurysmal Subarachnoid Hemorrhage: A Case Series.

Delayed cerebral vasospasms after subarachnoid hemorrhage (SAH) are a risk factor for poor prognosis after successful treatment of ruptured intracranial aneurysms. Different strategies to remove clots from the subarachnoid space and prevent vasospasms have different outcomes. Intrathecal urokinase infusion therapy combined with endovascular treatment (EVT) can reduce the incidence of symptomatic vasospasms. To analyze the relationship between symptomatic vasospasms and residual SAHs after urokinase infusion therapy, we retrospectively reviewed the records of 348 consecutive patients managed with EVT and intrathecal urokinase infusion therapy for aneurysmal SAH at our institution between 2010 and 2021. Among them, 163 patients met the study criteria and were classified into two groups according to the presence of residual SAH in the cisterns, Sylvian fissures, and frontal interhemispheric fissure. The incidence of symptomatic vasospasms and the clinical outcomes were assessed. In total, eight (5.0%) patients developed symptomatic vasospasms. Patients with symptomatic vasospasms had a significantly higher incidence of residual SAH in the Sylvian or frontal interhemispheric fissures than those without (P <.0001). No patient with SAHs resolved by urokinase infusion therapy developed symptomatic vasospasms. However, the two groups did not differ significantly in terms of modified Rankin scale scores at discharge. Treatment with intrathecal urokinase infusion after EVT for aneurysmal SAH can substantially reduce the risk of clinically evident vasospasms.

Plasma tRNA derivatives concentrations for detecting early brain damage in patients with acute large vessel occlusion and predicting clinical outcomes after endovascular thrombectomy.

OBJECTIVE: Transfer RNA (tRNA) is involved in the acute stress response, which results in conformational changes and subsequent fragmentation. Using an antibody against tRNA-specific modified nucleoside 1-methyladenosine, we can selectively detect blood tRNA derivatives from damaged tissues, including neuronal tissue, which serves as a potential marker of early tissue damage. This preliminary study aimed to investigate the correlation between tRNA derivatives and clinical outcomes in patients with acute anterior large vessel occlusion, especially those who underwent endovascular thrombectomy (EVT). METHODS: Patients with acute ischemic stroke due to anterior circulation large vessel occlusion were prospectively enrolled in this study. Plasma tRNA derivatives were measured using an enzyme-linked immunosorbent assay with an anti-modified nucleoside 1-methyladenosine antibody. RESULTS: Seventeen patients were included. The plasma tRNA derivatives concentrations on admission increased significantly, corresponding to the infarction size (r = 0.492, p = 0.038), and were associated with clinical outcomes (p = 0.00309). A good clinical outcome (90-day modified Rankin scale score: 0-2) was achieved in seven patients (41.2%), and all had undergone EVT. Among these patients, tRNA derivatives concentrations were the only preoperative predictor, which was associated with good outcomes (modified Rankin scale score: 0-2) and was significantly lower than those with poor outcomes (modified Rankin scale score: 3-6) (p = 0.0333). Receiver operating characteristic analysis revealed that a tRNA derivative value of ≤ 142.0 mg/mL was associated with good clinical outcomes, with a sensitivity of 85.7% and a specificity of 100% (area under the curve, 0.952; 95% confidence interval: 0.82-1). CONCLUSION: tRNA derivatives concentration may be a sensitive marker of early brain damage in patients with acute large vessel occlusion. Patients with low levels of tRNA derivatives on arrival are likely to benefit from thrombectomy and have the potential to achieve good clinical outcomes.

Isotope-dilution LC-MS/MS analysis of the elastin crosslinkers desmosine and isodesmosine in acute cerebral stroke patients.

Utilizing chemically synthesized an isotopically labeled internal standard, isodesmosine-13C3,15N1, an isotope-dilution LC-MS/MS method was established. Concentrations of desmosine and isodesmosine in plasma of acute cerebral stroke patients and healthy controls were determined. The concentration of desmosines was markedly higher in plasma from acute stroke patients compared with healthy controls. Desmosines are thus novel biomarkers for evaluating the extent of vascular injury after acute cerebral stroke.

Different functions of vitamin E homologues in the various types of cell death induced by oxysterols.

24(S)-Hydroxycholesterol (24S-OHC) and 25-hydroxycholesterol (25-OHC) are produced by cholesterol 24-hydroxylase and cholesterol 25-hydroxylase, respectively. The purpose of the present study was to determine the type of cell death induced by these oxysterols in neuronal cells, hepatic cells, and keratinocytes, and to elucidate the inhibitory effect of vitamin E homologues on various types of cell death. In human neuronal cells (SH-SY5Y cells), 24S-OHC and 25-OHC caused a cell death that was independent of caspase activation. We reported previously that the esterification of 24S-OHC by acyl-CoA:cholesterol acyltransferase 1 (ACAT1) and the resulting formation of a lipid droplet (LD)-like structure are responsible for the 24S-OHC-induced neuronal cell death. Here, we found that 25-OHC also induced ACAT1-mediated 25-OHC esterification and LD formation in neuronal cells. 25-OHC-induced cell death was inhibited by α-tocopherol (α-Toc) but not by α-tocotrienol (α-Toc3), as observed for 24S-OHC-induced cell death in SH-SY5Y cells. In human hepatic cells (HepG2 cells), these oxysterols caused a cell death that was caspase- and oxysterol-esterification-independent. This cell death was suppressed by both α-Toc and α-Toc3, suggesting the involvement of free-radical-mediated lipid peroxidation in the cell death induced by these oxysterols in hepatic cells. In human keratinocytes (HaCaT cells), these oxysterols caused a caspase-dependent but oxysterol-esterification-independent cell death that was inhibited by α-Toc but not by α-Toc3. These results suggest that α-Toc and α-Toc3 act as radical-scavenging antioxidants against oxysterol-induced cell death in the same way in hepatic cells, whereas their behavior is different in inhibition of cell death in neuronal cells and keratinocytes. Collectively, these results demonstrated that 24S-OHC and 25-OHC induced the same type of cell death in each of the cell types examined, and that α-Toc and α-Toc3 exerted different effects, depending on the type of cell death.

Carotid Artery Stenting Using Balloon-Expandable Coronary Stent: Intentional Use for Staged Angioplasty.

Objective: We report carotid artery stenting (CAS) using balloon-expandable coronary (BECo) stent. The materials in this study consist of 15 cases of high-grade stenosis in internal carotid artery (ICA) in which self-expanding carotid (SECa) stent was not utilized. There were two groups why BECo stent was used instead of SECa stent: alternative group and intentional group. The alternative group was subdivided into two groups: access difficulty of guiding catheter and access difficulty of SECa stent. Case Presentation: The alternative group included 11 cases (access difficulty of guiding catheter in 10 and access difficulty of SECa stent in 1), and the intentional group included 4 cases. There were four cases using transbrachial approach. All the intentional group cases were the first stage of staged angioplasty (SAP). The second stage of SAP was PTA in two and SECa stent over the BECo stent in two. There was no complication related to CAS. Conclusion: CAS using BECo stent is one of the choices for the first stage of SAP, if stent placement instead of PTA is required at the first stage. It is also the useful alternative for the patient having difficulty of SECa stent.

Intraaneurysmal Neck Plasty: Efficacy of a Super Compliant Double-Lumen Balloon Microcatheter.

Objective: While wide-neck aneurysms can be treated with several methods, we report the specific technique of intraaneurysmal neck plasty (IANP) with a super compliant double-lumen balloon microcatheter (Super-Masamune). Methods: The Super-Masamune was inflated inside 18 aneurysms. Cases in which the tip of the Super-Masamune was located in the aneurysm were included. Embolization methods were the same as those used in the application of other balloons/stents. The use of the Super-Masamune for the performance of IANP followed two patterns: (1) the Super-Masamune was used not only as a balloon but also for coil insertion (simple IANP); (2) the Super-Masamune was used only as a balloon, and a microcatheter for coil insertion was separately introduced coaxially (coaxial IANP). Results: The aneurysms were located in the anterior communicating artery (n = 6), middle cerebral artery (MCA; n = 4), anterior cerebral artery (n = 1), internal carotid artery (n = 5), basilar artery (n = 1), and vertebral artery (n = 1). Eight of the aneurysms were ruptured, while 10 were unruptured. Simple and coaxial IANP were both performed in seven cases. Embolization was not performed after inflating the Super-Masamune inside the aneurysm in four cases. Embolization grades following the procedure included eight neck remnants (NRs) and six body fillings (BFs). There was one complication of intraoperative rerupture; however, there was no rupture/rerupture in the follow-up period. Retreatment of the target aneurysm was performed in two cases. The embolization grade assessed in the follow-up period reached complete occlusion for one patient, NR for five, and BF for two patients. Conclusion: IANP using the Super-Masamune is useful for the treatment of wide-neck aneurysms in which the introduction of a guidewire and/or microcatheter into the branching artery is difficult.

Preservation of Branching Vessel Using Super Compliant Double-Lumen Balloon Microcatheter: Bulging Neck Plasty Technique and Other Options.

Objective: There are several methods to treat wide-neck aneurysms. We survey the cases that were treated using a super-compliant double-lumen balloon microcatheter (Super-Masamune) for preservation of the branching vessel originating proximal to the aneurysm, especially in the bulging neck plasty (BNP) technique. Methods: We assessed 10 cases in which branching vessel preservation was performed using Super-Masamune. The cases were categorized into three groups: (1) ordinary neck plasty (ONP): balloon microcatheter was navigated to the branch that should be preserved; (2) BNP: another branch was preserved by inflating balloon bulging without cannulation; (3) protection during parent artery occlusion (PPO): the balloon microcatheter was navigated to the vessel to be occluded. The balloon preserves a branch originating near the aneurysm without cannulating to the branch. Results: The aneurysm locations were as follows: internal carotid artery (ICA), three cases; anterior communicating artery (AcomA), one case; basilar artery (BA), three cases; and vertebral artery (VA), three cases. Four cases were ruptured aneurysms, while six cases were unruptured or ruptured in chronic stage. The ONP, BNP, and PPO groups contained two, five, and three cases, respectively. Embolization resulted in complete obliteration in six cases, neck remnant in two cases and body filling in two cases. No rupture/rerupture was noted in this series. One case showed an intraoperative rupture. Conclusion: Super-Masamune is useful for neck plasty, especially BNP, in wide-neck aneurysms. Super-Masamune is also useful for parent artery occlusion when an important branch originates proximal to the aneurysm.

Carotid artery stenting in a patient with an incidentally found double aortic arch: A case report.

Double aortic arch is a type of congenital vascular ring, which rarely presents in adults. Herein, we report a case of carotid artery stenting (CAS) accompanied by an incidentally found double aortic arch. A 77-year-old man presented with bilateral severe carotid artery stenosis. The patient underwent truncal 3D-computed tomography angiography (CTA) to evaluate the access route before CAS, which lead to the diagnosis of an asymptomatic double aortic arch. Referring to the 3D-CTA images, a guiding catheter was successfully navigated to the targeted common carotid artery via the transfemoral approach despite the challenging, complex anatomy of the aortic arch. CAS was performed in both carotid arteries under distal balloon protection, without any neurological deficits. Considering the possible presence of anatomical variants such as double aortic arch, preoperative evaluation of the access route would be efficient for prospective CAS patients.

Intentional Stent Herniation Technique Using Neuroform Atlas Stent System for Embolization of a Wide-Necked Basilar Tip Aneurysm.

Objective: Endovascular treatment for complex wide-necked basilar tip aneurysms is challenging. Multiple stenting may be an option to deal with such aneurysms; however, the risk of ischemic complications is reported to be relatively high. Here, we report a case of unruptured basilar tip aneurysm treated using the intentional stent herniation technique to preserve the aneurysmal neck branches. Case Presentation: A 65-year-old woman presented with a growing unruptured basilar tip aneurysm associated with bilateral posterior cerebral arteries (PCAs) arising from the aneurysmal dome. We intentionally selected a large-sized Neuroform Atlas stent (Stryker, Kalamazoo, MI, USA) compared to the parent artery and deployed it along the right PCA to the basilar artery. The stent was herniated into the aneurysmal dome near the origin of the left PCA, resulting in the preservation of the left PCA. Successful coil embolization was achieved with acceptable obliteration. Conclusion: The intentional stent herniation technique may be an effective approach to treat complex wide-necked basilar tip aneurysms.

A surgical case of cerebellar tuberculoma caused by a paradoxical reaction while on therapy for tuberculosis spondylitis.

BACKGROUND: A paradoxical reaction (PR) is a phenomenon in which the primary tuberculous lesion worsens or another de novo tuberculous lesion appears while on anti-tuberculosis therapy. Here, we report a rare case of cerebellar tuberculoma caused by a PR during therapy for lumbar tuberculous spondylitis (Pott's disease). CASE DESCRIPTION: A 47-year-old male with human immunodeficiency virus seronegative was diagnosed with lumber tuberculous spondylitis (Pott's disease) and prescribed anti-tuberculous agents. His lower back pain and inflammatory condition recovered after initiation of anti-tuberculous therapy. Two months later, he complained of headache, nausea, and staggering. Magnetic resonance images revealed a ring-enhanced lesion located at the cerebellar hemisphere extending to the vermis, which caused perifocal edema and bilateral ventriculomegaly. These findings were consistent with his symptoms of hydrocephalus. He did not have preceding clinical findings of meningitis, and a PR was suggested to cause de novo aggregation of cerebellar tuberculoma. A lesionectomy was performed, and the surgical specimen was pathologically diagnosed as a tuberculoma. He recovered well from neurological disorders after the resection. CONCLUSION: De novo formation of intracranial tuberculoma alone caused by a PR without preceding meningitis is very rare. Lesionectomy is needed for intracranial tuberculoma, which manifests as a mass effect, as well as antituberculous therapy.