Simultaneous combined intravenous recombinant tissue plasminogen activator and endovascular therapy for hyperacute middle cerebral artery m1 occlusion.

We investigated the efficacy and safety of combined intravenous (IV) recombinant tissue plasminogen activator (rtPA) and simultaneous endovascular therapy (ET) for hyperacute middle cerebral artery (MCA) M1 occlusion. Between October 2005 and April 2007, in the combined group, 22 patients eligible for IV rtPA, who were diagnosed as having MCA M1 occlusion, were treated with IV rtPA and simultaneous ET was initiated as soon as possible. The other patients were treated with IV rtPA alone (IV group A: n = 11). Between May 2007 and November 2008, all patients eligible for IV rtPA, who were diagnosed as having MCA M1 occlusion, underwent thrombolysis by IV rtPA alone (IV group B: n = 24). The improvement of the National Institutes of Health Stroke Scale score at 24 hours was highest in the combined group (10 ± 4.1). In contrast, it was 5.1 ± 4.7 in the IV group A (P = 0.017) and 5.6 ± 5.6 in IV group B (P = 0.006). In the combined group, successful recanalization was observed in 18 of 22 patients with one symptomatic intracranial hemorrhage. The rate of mRS0-2 at three months was highest in the combined group, 36% in the IV group A and 33% in the IV group B (P = 0.008).Simultaneous treatment with IV rtPA and ET improved the clinical outcome of MCA M1 occlusion without a significant increase of adverse effects in our study.

"Bonnet" bypass to proximal trunk of middle cerebral artery with a radial artery interposition graft: technical note.

BACKGROUND: Anastomosis of the superficial temporal artery (STA) to the middle cerebral artery (MCA) is useful for treating certain patients with internal carotid artery occlusion or MCA occlusion. However, in the case of common carotid artery (CCA) occlusion, since the blood flow in the STA is insufficient, another artery should be used as the donor artery. The cortical branches of the MCA are usually selected as recipients in the STA-MCA bypass. However, the intracranial vascular filling gradually increases over a few months after conventional cortical MCA bypass grafting, while early or even immediate vascular filling is observed after proximal MCA bypass grafting. This study aims to develop an elongation technique of the contralateral STA to reach the proximal segment of the ipsilateral MCA. METHODS: Anastomosis of the contralateral STA to the secondary trunk of the ipsilateral MCA was performed in 2 patients with occlusion of the CCA and ipsilateral vertebral artery (VA). The contralateral STA was extended with a radial artery (RA) graft in order to supply blood to the ischemic area. Elongation of the STA by using an RA interposition graft sufficiently lengthens the graft to enable its anastomosis with the contralateral M2 segment. Postoperative imaging revealed good bypass patency even at 1 year after the surgery. CONCLUSION: This novel technique of performing the "bonnet" bypass was effective in treating both CCA and ipsilateral VA occlusion; moreover, this procedure of elongation of the STA can increase candidates of the recipient, and enables one to perform a double bypass to the anterior cerebral artery (ACA) or posterior cerebral artery (PCA).

Simultaneous treatment with intravenous recombinant tissue plasminogen activator and endovascular therapy for acute ischemic stroke within 3 hours of onset.

BACKGROUND AND PURPOSE: Because intravenous (IV) recombinant tissue plasminogen activator (rtPA) does not always lead to a good outcome in a considerable proportion of patients, combined IV rtPA and rescue endovascular therapy (ET) have been performed in several recent studies. However, rescue therapy after completion of IV rtPA often results in late ineffective recanalization. We examined the efficacy and safety of combined IV rtPA and simultaneous ET as primary rather than rescue therapy for hyperacute middle cerebral artery (MCA) occlusion. MATERIALS AND METHODS: A total of 29 patients eligible for IV rtPA, who were diagnosed as having MCA (M1 or M2) occlusion within 3 hours of onset, underwent thrombolysis. In the combined group, patients were treated by IV rtPA (0.6 mg/kg for 60 minutes) and simultaneous ET (intra-arterial rtPA, mechanical thrombus disruption with microguidewire, and balloon angioplasty) initiated as soon as possible. In the IV group, patients were treated by IV rtPA only. RESULTS: The improvement of the National Institutes of Health Stroke Scale (NIHSS) score at 24 hours was 11 +/- 4.8 in the combined group versus 5 +/- 4.3 in the IV group (P < .001). In the combined group, successful recanalization was observed in 14 (88%) of 16 patients with no symptomatic intracranial hemorrhage, and 10 (63%) of 16 patients had favorable outcomes (modified Rankin Scale [mRS] 0, 1) at 3 months. CONCLUSIONS: Aggressive combined therapy with IV rtPA and simultaneous ET markedly improved the clinical outcome of hyperacute MCA occlusion without significant adverse effect. Additional randomized study is needed to confirm our results.

Intravenous 3D digital subtraction angiography in the diagnosis of unruptured intracranial aneurysms.

Recent progress in digital subtraction angiography (DSA) devices makes it possible to perform rotational angiography with high resolution and high sensitivity. We tried intravenous (IV) 3D DSA in patients who had undergone MR angiography (MRA) suggestive of unruptured intracranial aneurysms. IV 3D DSA can be used as an alternative method for imaging unruptured intracranial aneurysms suggested on MRA.

Cerebellopontine angle meningioma causing asymptomatic syringomyelia--case report.

A 36-year-old female was admitted with a 3-month history of headache and gait disturbance. Magnetic resonance imaging demonstrated a large tumor in the right cerebellopontine angle and syringomyelia in the upper cervical cord associated with caudal displacement of the cerebellar tonsil. Complete removal of the tumor resulted in disappearance of these associated conditions. Herniation of the cerebellar tonsil and distortion of the brain stem had probably caused disturbance of cerebrospinal fluid flow, which combined with obstruction of the spinal canal, caused the syrinx.

[Symptomatic arteriovenous fistula in a patient with neurofibromatosis type I].

This paper reports the case of a 54-year-old woman who had a history of neurofibromatosis (NF I) presenting progressive quadriplegia and urinary incontinence due to a cervical arteriovenous fistula (AVF). MRI revealed a huge flow void mass in the cervical subcutaneous tissue as well as within the spinal canal. These flow voids originated in the left vertebral artery. A high intensity lesion was observed in the spinal cord adjacent to the flow void. Angiography revealed that the cervical AVF was fed by the third segment of the left vertebral artery with a rich communication with the intraspinal veins. Furthermore, an aneurysmal dilatation of the proximal vertebral artery and occlusion of the right middle cerebral artery with moyamoya vessels were found. Endovascular treatment using a Goldvalve detachable balloon successfully obliterated the AVF. Postoperative MRI and angiography showed evidence of the disappearance of AVF and postoperatively, the patient's neurological signs improved gradually. Sixteen reported AVFs accompanied with NF were reviewed.

Establishment of spontaneously immortalized rat type 1 astroglial cell lines: the role of p53 in astroglial carcinogenesis.

We established five spontaneously immortalized cell lines using purified rat type 1 astroglia on a rigid transfer schedule. All the cell lines maintained their polygonal shape, regular pavement growth, low saturation density, positive glial fibrillary acidic protein expression, and serum requirements, while none were tumorigenic in nude mice. We then obtained a spontaneously transformed cell line by maintaining the cells for 6 months at a high cell density. Since alterations of the tumor suppressor p53 gene have been reported in the immortalization of some cell lines and in transformation of others, we characterized p53 in immortalized, spontaneously transformed, and 5 Nethyl-N-nitrosourea (ENU)-transformed cell lines. While each of the ENU-induced or the spontaneously transformed cell lines exhibited p53 gene mutations that resulted in amino acid alterations, no alterations in the p53 gene were observed in any of the immortalized cell lines. Thus, alterations of the p53 protein correlate more strongly with transformation than with immortalization of type 1 astroglia. Immortalization may be regulated by gene(s) other than p53. Spontaneously immortalized type 1 astroglial cell lines may provide a new tool to investigate an initial step of astroglial carcinogenesis.

[Acute relapsing disseminated encephalomyelitis (ARDEM) mimicking a temporal lobe tumor].

A case of ARDEM presenting as a temporal lobe tumor is reported. A 19-year-old male was admitted to the hospital, because of headache, right homonymous hemianopsia, and general convulsion. CT scan and MR imaging revealed localized right medial temporal enhanced mass lesion with surrounding brain edema. The craniotomy revealed an elastic hard ill-defined subcortical tumor. Histology showed a demyelinating process with perivascular lymphocyte cuffings. The patients' postoperative course was essentially uneventful until the 7th day when he developed fever, persistent hiccup, vertigo followed by obtundation and respiratory distress. Repeated MR imaging revealed extensive lesions in the left thalamus, brain stem, upper spinal cord and cerebellum. The patient responded to steroid pulse therapy well. Six months later, however, he returned to the hospital with severe memory disturbance. Repeated MR imaging showed diffuse bilateral parieto-occipital white matter lesions. He again responded to steroid pulse therapy well. An immunosuppressant Mizoribine was added to his steroid therapy to prevent recurrence. With the advent of MR imaging, more non-surgical diseases such as multiple sclerosis and Behçet disease are visualized on imaging study. The differentiation of these diseases from intraparenchymal neoplasm is difficult when they present as a single mass lesion. ADEM or ARDEM should be included in the list of such lesions requiring differential diagnosis.

Nontraumatic intradiploic arachnoid cysts--report of five cases.

Five cases of nontraumatic intradiploic arachnoid cysts in elderly patients are reported. All cysts were located in the occipital bone and appeared as well-demarcated radiolucent lesions. The cysts were multiple in three cases. Presenting symptoms included headache or dizziness, but most lesions were asymptomatic and found incidentally. In the most recent three cases, magnetic resonance (MR) imaging revealed intradiploic cysts containing cerebrospinal fluid (CSF) with cerebellar herniation. Operation found the cysts filled with CSF and dural defects through which cerebellar tissue was herniating. In two patients, CSF leakage from the outer table occurred. Intradiploic arachnoid cyst seems to be congenital in origin but commonly found in the elderly. MR imaging is the most useful diagnostic method for differential diagnosis from other osteolytic skull lesions.