Diffuse-Type Tenosynovial Giant Cell Tumor Arising in the Temporomandibular Joint Extending to the External Auditory Canal: A Case Report and Literature Review.

A 74-year-old Japanese woman with a 1-year history of right preauricular pain and a 2-month history of bleeding from the right ear was admitted to our department. Tumor was observed in the anterior wall in the right external auditory canal. Bony swelling of the right preauricular area was palpated. Computed tomography revealed an ill-defined, osteogenic tumor around the mandibular condyle with a destructive bony lesion involving the temporal bone. Magnetic resonance imaging revealed a 2.0 × 1.5 × 1.3-cm solid tumor around the mandibular condyle, exhibiting a low-intensity signal on T1-weighted imaging and an isointense central area surrounded by low-signal intensity on T2-weighted imaging. Histological examination of biopsy specimens revealed diffuse-type tenosynovial giant cell tumor (D-TGCT). After the feeding arteries for the tumor were embolized, the patient underwent surgery with combined temporal craniotomy and mandibular condylectomy. The soft and cystic tumor with calcification located in the extradural space was totally resected along with the mandibular condyle. No facial paralysis or recurrence was evident as of 6 months postoperatively. To date, only 23 cases of D-TGCT arising in the temporomandibular joint (TMJ) with ear involvement have been reported since 2011. We report successful resection of a rare case of D-TGCT arising in the TMJ.

Vasospasm as a major complication after acute mechanical thrombectomy with stent retrievers.

OBJECTIVE: Mechanical thrombectomy using a stent retriever for acute large vessel occlusion is indispensable in stroke treatment, however, vasospasm may occur. The objective of this retrospective study was to investigate which cases are more likely to experience vasospasm after thrombectomy with stent retrievers. METHODS: We included 29 patients diagnosed with acute cardiogenic cerebral embolism who were treated with stent retrievers at our facility from December 2014 to December 2017. Atherothrombotic brain infarction cases were excluded because it was difficult to evaluate for vasospasms. Vasospasm was defined as reversible arterial narrowing of <80% of the normal vessel diameter after usage of the stent retriever. The age, sex, type of stent retriever, occlusion site, number of procedures, thrombolysis in cerebral infarction (TICI) grade, degree of vasospasm, intracranial hemorrhage by the procedure, and neurological outcomes were analyzed. RESULTS: Among the 29 cases, 12 (41.4%) resulted in vasospasm; nine cases were mild (20-50% stenosis) and 3 cases were severe (≥50% stenosis). Vasospasm frequently occurred in the distal part of the anterior circulation when compared to the proximal part. In addition, the frequency of vasospasm increased as the number of procedures increased. Pooled analysis showed significant difference in the intravenous tissue-type plasminogen activator group (P = 0.029). There was no significant difference in the other groups. CONCLUSION: Stent retrievers appear to cause vasospasm more than expected when including mild cases. Vasospasm tends to occur especially in cases with IV-tPA; prognosis is generally good, and it rarely requires any treatment.

Aberrant left subclavian artery occlusion in right-sided aortic artery associated with left cerebral infarction: A case report.

Purpose Right-sided aortic arch is a rare vessel anomaly with an incidence of 0.1% worldwide. Supra-aortic branches form a mirror image of the left-sided aortic arch or an aberrant left subclavian artery associated with Kommerell diverticulum. Most patients are diagnosed by a difference in blood pressure in each upper extremity or by the presence of left subclavian steal syndrome in their younger age. The diagnosis of onset of ischemic stroke in middle age is rare. Methods We present the case of a female patient who presented with an ischemic stroke in the left posterior circulation area. She had no history of congenital heart malformation. We performed head magnetic resonance imaging, cerebral angiography, and enhanced computed tomography of the aortic arch and major branches. Results The patient had a right-sided aortic arch and an aberrant left subclavian artery. The left subclavian artery was occluded at the proximal portion with a fibrous string. Collateral flow in the anterior cervical subcutaneous area supported left limb perfusion. Conclusion An atheromatous change reduced shunt flow via collateral networks at the anterior cervical region. Congenital subclavian steal supported the ischemic stroke.

Choroid plexus AVM with anomalous origin of the capsulothalamic artery: A case report.

Background and importance Traditionally, it has been believed that the plexal segment of the anterior choroidal artery (AChoA) can be sacrificed safely. Here, we present a case of choroid plexus arteriovenous malformation (AVM) in which the capsulothalamic artery originated from distal plexal segment of the AChoA. Clinical presentation A 45-year-old man was diagnosed with arteriovenous malformation involving the left inferior horn in screening MRI. Preceding stereotactic radiosurgery, transarterial target embolization was performed. In this procedure, 20% n-butyl-2-cyanoacrylate (NBCA) was successfully injected from the lateral plexal branch of the AChoA. After embolization, right homonymous hemianopsia developed due to cerebral infarction on the left optic radiation. This infarction was considered to be within the territory of the capsulothalamic artery. Conclusion This anomalous capsulothalamic artery might be formed by hemodynamic compromise of the brain surrounding AVM in early gestation. We must be aware of this unusual anatomical variation to avoid ischemic complication in embolization of the AChoA.

Usefulness of 18F-fluorodeoxyglucose-Positron Emission Tomography in Comparison with Methionine-Positron Emission Tomography in Differentiating Solid Hemangioblastoma from Adult Cerebellar Tumors.

BACKGROUND AND PURPOSE: Among adults with posterior fossa tumors, an intraaxial location of the tumor is less common than an extraaxial location. Moreover, the differential diagnosis of a single cerebellar tumor in adults is sometimes difficult by conventional magnetic resonance imaging. We aimed to report the findings of positron emission tomography (PET) using 18F-fluorodeoxyglucose (FDG) and methionine in adult patients with intraaxial and solitary metastatic brain tumors. MATERIALS AND METHODS: FDG-PET was performed on 12 patients with posterior fossa tumors: 4 had solid hemangioblastoma (HB), 3 had primary central nervous system lymphomas, 1 had a glioblastoma, and 4 had single metastatic brain tumors (METs). Methionine-PET was performed on 9 patients except for 1 patient with a MET. The maximum standardized uptake value (SUVmax) of the tumor was measured and compared with pathologic findings. RESULTS: The SUVmax of FDG in HB was lower compared with that of other tumors (P = 0.001). On the other hand, the SUVmax of methionine in the HB cases was almost the same as that in other tumors (P = 0.07). CONCLUSION: FDG-PET was helpful in differentiating HBs from adult cerebellar tumors.

Usefulness of interventional embolization of the middle meningeal artery for recurrent chronic subdural hematoma: Five cases and a review of the literature.

PURPOSE: Although several strategies against recurrent chronic subdural hematoma (CSDH) have been proposed, no consensus has been established. Recently, middle meningeal artery (MMA) embolization has been proposed as radical treatment for recurrent CSDH. We wanted to estimate the usefulness of MMA embolization for recurrent CSDH. METHODS: From February 2012 to June 2013, 110 patients with CSDH underwent single burr-hole surgery with irrigation and drainage. Among these patients, 13 showed recurrent hematoma formation and were retreated surgically. Furthermore, repeated recurrence of CSDH was observed in six patients. Five of these six patients underwent middle meningeal artery (MMA) embolization with polyvinyl alcohol particles. All five patients with interventional treatment were observed for four to 60 weeks. RESULTS: No more recurrence of CSDH was observed in any of the patients. During the follow-up period, no patients suffered from any side effects or complications from the interventional treatment. CONCLUSION: MMA embolization with careful attention paid to the procedure might be a treatment of choice for recurrent CSDH.

An innovative technique for detecting the caudal end of occluded inferior petrosal sinus in cavernous arteriovenous fistula using intravascular ultrasonography--technical note.

INTRODUCTION: Although cavernous sinus (CS) dural arteriovenous fistulas (d-AVFs) are usually treated with transvenous embolization (TVE) via the inferior petrosal sinus (IPS), IPSs are sometimes thrombosed and angiographically invisible. In such cases, the first obstacle to TVE is detecting the entry to the IPS. We report a new technique for TVE via IPS using intravascular ultrasonography (IVUS). METHODS: Three consecutive cases of CS d-AVF with ipsilateral or bilateral IPS occlusion were involved in this study. On TVE, the orifice of the IPS was investigated with IVUS placed in the jugular vein or jugular bulb. RESULTS: This technique has been successfully adapted in all three cases. In two of these cases, IPS was well visualized with the help of IVUS, and TVE was successfully performed. CONCLUSION: To our knowledge, this is the first report to mention the usefulness of IVUS for detecting angiographically occult IPS.

The usefulness of subcutaneous infiltration of epinephrine-containing lidocaine for curative transarterial embolization of dural arteriovenous fistula. A technical note.

Recently, transarterial embolization (TAE) with liquid embolic materials has been recognized as one of the curative therapeutic options for non-sinus type dural arteriovenous fistula (d-AVF). To prevent glue fragmentation and incomplete obliteration, flow reduction of transosseous high-flow feeders is one of the key points of this therapy. However, flow reduction of transosseous feeders is sometimes difficult with previously reported techniques such as particle embolization, manual compression, or proximal balloon occlusion. This report introduces a new technique to reduce the flow of transosseous feeders using epinephrine-containing lidocaine, and describes a case of intracranial d-AVF successfully treated with this technique. The usefulness and efficacy of the technique are discussed.

Post-embolisation susceptibility changes in giant meningiomas: multiparametric histogram analysis using non-contrast-enhanced susceptibility-weighted PRESTO, diffusion-weighted and perfusion-weighted imaging.

PURPOSE: To investigate imaging characteristics of post-embolised meningioma and to determine if SW imaging can delineate tumour ischaemia. MATERIALS AND METHODS: Sixteen patients were studied before and after preoperative embolisation therapy (8 histopathologically determined with ischaemia, 8 with non-ischaemia). In each patient, a slice-wise ROI for the entire tumour was established, and histogram variables (mean, SD, minimum, maximum, histogram width, mode, and peak height) of SW, ADC, CBV, CBF, MTT, and TTP maps were compared between ischaemic and non-ischaemic groups. Changes in SW histogram were correlated with histopathological characteristics. RESULTS: Signal intensity on the SW map tended to decrease in the ischaemic group and partially increased in the non-ischaemic group. A similar trend was observed on the ADC map. The PW histogram showed an MTT increase in ischaemic group; however, CBV did not show significant changes between ischaemic and non-ischaemic groups. Microhaemorrhage was slightly correlated with Δpeak height in the SW histogram. CONCLUSION: Post-embolisation changes of intrinsic T2-weighted MR contrasts on SW map are most likely associated with alterations in deoxyhaemoglobin levels and arterial blood flow.

Ruptured internal carotid artery bifurcation aneurysm presenting with only intracerebral hemorrhage without subarachnoid hemorrhage--case report.

A 55-year-old man presented with intracerebral hemorrhage (ICH) without subarachnoid hemorrhage (SAH) manifesting as acute onset of consciousness disturbance and right hemiparesis. Computed tomography showed ICH mainly localized in the left putamen, but no evidence of SAH. Magnetic resonance angiography demonstrated a cerebral aneurysm originating from the bifurcation of the left internal carotid artery, which was considered to be responsible for the ICH. The patient underwent emergent intravascular surgery for coil embolization of the aneurysm, and his neurological symptoms gradually recovered with rehabilitation after surgery. Although ICH without SAH is a rare presentation of cerebral aneurysm, ruptured cerebral aneurysm should be considered as a potential cause of ICH. The localization and extent of ICH may be suggestive of latent cerebral aneurysm in such cases.

Protection of anastomotic pathways to the vertebral artery during stenting of external carotid artery stenosis.

A 61-year-old man presented with a severe external carotid artery (ECA) stenosis with concomitant ipsilateral internal carotid artery (ICA) occlusion manifesting as amaurosis fugax. The left ophthalmic artery was supplied from the left ECA. The left intracranial ICA was supplied by the collateral flow from the contralateral ICA and ipsilateral ECA through the ophthalmic artery. The left vertebral artery also participated in the latter collateral pathway through the left occipital artery and ascending pharyngeal artery. Percutaneous revascularization of the ECA was performed using a nitinol self-expanding stent. To prevent embolic complications through the ophthalmic or vertebral arteries, distal protection was performed using a balloon. During a 22-month follow-up period, the patient was completely free from any ocular or neurological symptoms. The present case of severe ECA stenosis with ipsilateral ICA occlusion showed that percutaneous balloon angioplasty with stenting is feasible and effective. This intervention requires cautious evaluation of the anastomotic pathways connecting the ECA to the cerebral circulation to avoid embolic complications.

Mechanical clot disruption following intravenous recombinant tissue plasminogen activator administration in non-responders.

The efficacy of selecting non-responders to intravenous recombinant tissue plasminogen activator (rt-PA) for mechanical clot disruption (MCD) was investigated based on cerebral angiography in the acute stage following rt-PA therapy. rt-PA therapy using 0.6 mg/kg was performed in eligible patients within 3 hours of onset. Patients who did not show recanalization on cerebral angiography 1 hour after rt-PA initiation immediately underwent MCD. Clinical outcome was evaluated by National Institutes of Health Stroke Scale (NIHSS) score at baseline, 24 hours, and 1 month, and by modified Rankin scale (mRS) score at 3 months. Eighteen patients were initially treated with intravenous rt-PA, with mean time from stroke onset to rt-PA therapy of 120 +/- 27 minutes. Eight of these patients underwent MCD. Seven of these eight patients had complete recanalization. Time to recanalization by percutaneous transluminal angioplasty from stroke onset was 258 +/- 59 minutes. Final recanalization was achieved in 16 of the 18 patients. Baseline NIHSS score improved significantly at 1 month (median from 22.5 to 4). Twelve of the 18 patients treated according to our protocol were classified as independent (mRS scores 0-2). No patients had symptomatic hemorrhage. MCD for non-responders determined by cerebral angiography at the end of intravenous rt-PA infusion can decrease the time to recanalization and improve recanalization rates, leading to good clinical outcome after acute stroke.

Usefulness of intravascular ultrasonography monitoring of coil embolization for traumatic direct carotid-cavernous fistula-case report-.

A 61-year-old woman was admitted for head injury after a traffic accident. Two months later, she developed abducens nerve palsy, chemosis, and pulsatile tinnitus. Right internal carotid angiography demonstrated a high flow direct carotid-cavernous fistula (CCF) at the C(5) portion with reflux into the superficial and deep sylvian veins, superior ophthalmic vein, superior petrosal sinus, and inferior petrosal sinus. Intravascular ultrasonography (IVUS) revealed a large fistula at the C(5) portion of the internal carotid artery (ICA). Coil embolization via transarterial and transvenous approaches under IVUS monitoring was performed. During the procedure, IVUS accurately detected protrusion of a coil into the parent ICA, and the parent artery could be preserved. IVUS monitoring is useful for embolization of direct CCF with coils.

New pull-through technique using the superficial temporal artery for transbrachial carotid artery stenting.

Carotid artery stenting (CAS) is an effective and less invasive alternative to carotid endarterectomy for internal carotid artery (ICA) stenosis, but the guiding catheter is often technically difficult to introduce into the common carotid artery (CCA) in patients with concomitant atherosclerotic disease in the peripheral vessels or aorta. A new pull-through technique between the superficial temporal artery (STA) and the brachial artery was used to deliver the guiding catheter into the CCA safely and steadily. An 83-year-old male presented with repeated transient left hemiparesis caused by severe stenosis of the origin of the right ICA. He also had severe systemic atherosclerotic disease with occlusion of the bilateral femoral arteries. The innominate artery branched at an acute angle from the aorta. Therefore, catheterization of the right CCA seemed to be impossible using a conventional approach. The guidewire introduced from the right STA was lassoed by a loop snare wire and pulled out of the left brachial artery, forming the pull-through system. The guiding catheter could be introduced into the CCA from the left brachial artery over this guidewire. Subsequently, successful stent placement was performed under the distal protection. This new technique may facilitate safe and stable CAS even in patients with a severely tortuous access route due to concomitant atherosclerotic disease.

Surgical management of petroclival chordomas: report of eight cases.

In the management of skull base chordomas, surgical treatment is essential to achieve long-term control. A petroclival chordoma growing laterally in the skull base is one of the most challenging tumors for neurosurgeons. We have treated petroclival chordomas based on the principle of maximal surgical resection of the tumor with minimal morbidity. Lateral skull base approaches were used to approach petroclival chordomas in eight patients. The surgical procedure involved removal of soft tumor tissue and extensive drilling of adjacent bony structures. Gross total resection of the tumor was achieved in six patients. Subtotal resection in the remaining two patients was associated with acceptable morbidity. In cases of petroclival chordomas, lateral skull base approaches can be used as a primary procedure, although those approaches may be associated with high rates of morbidity and mortality.

Histological characteristics of arterialized medullary vein in spinal dural arteriovenous fistulas related with clinical findings: report of five cases.

The histological features of arterialized medullary vein (MV) in spinal dural arteriovenous fistulas (SDAVF) were studied in five consecutive patients who presented with progressive congestive myelopathy. Retrograde venous filling on preoperative angiography was recognized as being severe in 3 cases and moderate in 2 cases. Direct intradural interruption of the arterialized MV was performed in all patients. The arterialized MV was sampled and examined histologically to determine the percentage of the hyperplasia of venous wall (hypertrophic ratio). Histological examination of arterialized MV showed that hypertrophic alteration of venous wall structure was due to hyperplasia of elastic fibers, ranging from 41 to 82%. Patients with angiographically severe venous hypertension tended to have a higher hypertrophic ratio than patients with moderate venous hypertension. Our observations support the clinical concept that long-standing arterial stress in the spinal venous circulation causes histological alterations of spinal vascular structure associated with the progression of venous hypertension. We suggested that possibly the histological parameter can be used for predicting neurological recovery after occlusion of the fistulas.

Falcotentorial meningioma: surgical outcome in 14 patients.

OBJECT: The authors evaluated their surgical experience over 20 years with 14 treated falcotentorial meningiomas. METHODS: In the past 20 years, 14 patients with falcotentorial junction meningiomas were surgically treated. There were seven men and seven women, whose ages ranged from 34 to 79 years. On the basis of neuroimaging studies, the authors analyzed the influence of the anatomical relationship of the tumor to the vein of Galen, patency of the vein of Galen, tumor size, and the signal intensities on the magnetic resonance images to determine possible difficulties that might be encountered during surgery and to prognosticate the outcome of surgery. Depending on the relationship with the vein of Galen, tumors were labeled as either a superior or an inferior type. All tumors were resected via an occipital transtentorial approach. The surgical outcome in eight patients was excellent; in the remaining six patients, it was fair. Of the prognostic factors, tumor location especially seemed to be the most important (p < 0.01, Fisher exact test). The outcome associated with the inferior type of tumor was significantly less optimal probably due to the relationship to the deep veins and the brainstem. In this series, the occlusion of deep veins did not significantly influence outcome. CONCLUSIONS: . Classification of the tumor location by preoperative neuroimaging studies can be helpful in estimating the surgical difficulty that might be encountered in treating the falcotentorial junction meningioma.