[Vascular Anatomy of the Middle Cerebral Artery and Cerebral Large Vessel Occlusion].

The middle cerebral artery divides into the cortical and perforating branches that supply blood to the extensive cerebral cortex and basal ganglia. In addition to an understanding of the normal vessel diameter and length, endovascular physicians should be familiar with anatomical variations. Understanding the perfusion territory is important for accurate diagnosis of the disease type.

First-in-human trial of a self-expandable, temporary dilation system for intracranial atherosclerotic disease in patients presenting with acute ischemic stroke.

BACKGROUND: Intracranial atherosclerotic disease (ICAD) significantly contributes to ischemic stroke, especially among Asian populations. Large vessel occlusion (LVO) due to underlying ICAD accounts for 15-35% of acute ischemic stroke cases requiring endovascular therapy. However, the successful recanalization rate of ICAD-related LVO remains lower. The TG dilator is a self-expandable device, temporarily dilating ICAD-related blocked blood vessels. OBJECTIVE: To demonstrate TG dilator safety and efficacy for ICAD-related acute ischemic stroke. METHODS: This was a single-arm, open-label, non-randomized, prospective, multicenter, and investigator-initiated trial that involved patients undergoing TG dilator application for acute ischemic stroke caused by ICAD-related LVO or severe stenosis. RESULTS: We enrolled 10 patients in this trial between November 2022 and April 2023. The median (IQR) age was 68 (59.3-75.3) years. Before using the dilator, seven patients received stent retriever treatment. All 10 patients were prescribed a loading dose of aspirin with prasugrel. The median application time was 10 (10-12) min. At the end of the procedure, we achieved significant recanalization immediately in all patients. The stenosis/occlusion decreased from 100% (100-100) to 68% (56.3-75.3). No patient experienced recurrent ischemic stroke or reocclusion within 90 days. We achieved a modified Rankin scale score of 0-2 in 8 patients by day 90. We detected no cases of intracranial hemorrhage, equipment failure, distal embolism, vasospasm, dissection, or perforation requiring intervention. CONCLUSIONS: Acute revascularization using the TG dilator on patients with ICAD-related LVO or severe stenosis did not cause any significant adverse event, and consistently improved blood flow at 90 days.

[A case of genetic Creutzfeldt-Jakob disease that required differential diagnosis of acute encephalopathy associated with Sjogren's syndrome].

An 86-year-old female was admitted to our hospital with acute progressive gait disturbance and cognitive impairment. Brain MR diffusion weighted imaging revealed abnormal high signal intensities in the bilateral hemispheres, dominantly in the frontal lobe. We first suspected acute encephalopathy due to Creutzfeldt-Jakob disease (CJD) from her clinical information. At the same time, we could not negate the possibility of Sjögren's syndrome (SjS) -related encephalopathy based on the abnormal findings on brain MRI and positive anti-SS-A antibody in the serum. After consulting with an otorhinolaryngologist and a pathologist, biopsy of the salivary gland was performed with a strict precaution against infection of prion virus. Pathological examination of the biopsy specimen showed accumulation of many lymphocytes around the gland, which satisfied grade 4 in the Greenspan classification. A definite diagnosis of SjS was made based on the pathological findings, and intravenous high dose methylprednisolone followed by oral prednisolone were administered for suspected SjS-related encephalopathy. However, the neurological symptoms did not improve and we judged that SjS-related encephalopathy was unlikely. The poor response to steroid therapy and the presence of tau protein, strongly positive 14-3-3 protein and a codon 180: Val/Ile mutation in the cerebrospinal fluid finally led to a clinical diagnosis of genetic CJD. In-hospital cooperation in terms of infection prevention is important when performing invasive procedure in the case of suspected CJD to distinguish treatable encephalopathy.

Endovascular Treatment for Anterior Communicating Artery Aneurysms.

Previously, anterior communicating artery aneurysms were considered unsuitable for endovascular treatment. In recent years, however, endovascular treatment has been increasingly performed due to the fact that it is less likely to cause high dysfunction compared to surgery and the treatment has been improved. The International Subarachnoid Aneurysm Trial reported anterior communicating artery aneurysms comprise 45.4% of cerebral aneurysms on which both endovascular treatment and surgery are suitable. The use of the endovascular treatment for anterior communicating artery aneurysms is expected to increase in the future. In this paper, we present cases from our institution based on the characteristics of anterior and distal communicating artery aneurysms, treatment strategies, and treatment indications.

Effectiveness of Retrograde Angiography via the Contralateral Carotid Artery in Mechanical Thrombectomy for Carotid Non-T Occlusion by Dual Puncture Technique.

Objective: We report the effectiveness of retrograde angiography via the contralateral carotid angiography using a dual puncture technique in mechanical thrombectomy (MT) for non-T occlusion in patients with acute internal carotid artery (ICA) occlusion not involving the ICA terminus. Case Presentation: In the dual puncture technique, arterial puncture is performed at two sites: a balloon guiding catheter (BGC) is navigated to the ICA on the affected side and another catheter is navigated to the unaffected side. Thrombus retrieval is performed by manual aspiration through the BGC and MT using a stent retriever and/or aspiration device. Reperfusion is confirmed by retrograde angiography via the carotid artery on the unaffected side, with manual aspiration through the BGC on the affected side. Throughout the procedure, the BGC blocks the blood flow in the ICA on the affected side until reperfusion is confirmed. No distal embolization was occurred in our three patients treated using this technique. Conclusion: Application of the dual puncture technique on MT is recommended for non-T occlusion to prevent distal embolization.

Experimental Safety Evaluation of Inflated Assisting Balloons for Endovascular Surgery.

Objective: The balloon-assisted technique is one of the methods used for cerebral aneurysm embolization. There are several applications of assisting balloons such as remodeling the neck of cerebral aneurysms, protecting blood vessel branches, and stabilizing the microcatheter. In this study, we measured the pressure inside inflated assisting balloons to assess safety or procedure. Methods: A T-junction silicone model was used. The pressure inside the balloon inflated to the set herniation levels in the T-junction model was measured using a fiber pressure sensor. We compared the pressure and difference between each assisting balloon. Results: The pressure required for inflating the balloon to the set herniation level in the T-junction model varied depending on the type of assisting balloon. The results suggest that differences in pressure among inflated balloons are likely attributable to differences in the materials used in the lumens of the balloons. Conclusion: The pressure inside various inflated assisting balloons was measured for comparison and differences were found. This experiment contributes to the safety of the balloon-assisted technique.

[Autopsy case of cerebral embolism with lung cancer and atrial fibrillation in which the left atrium may have become an incubator for a tumor embolus].

An 82-year-old man with advanced lung cancer who had declined aggressive therapy was transferred to our hospital due to sudden-onset consciousness disturbance, global aphasia, and right hemiplegia. An electrocardiogram showed atrial fibrillation, and brain MRI and MRA revealed acute ischemic lesions of the left hemisphere and occlusion of the left internal carotid artery (ICA), respectively. We diagnosed acute ischemic stroke due to left ICA occlusion and performed endovascular thrombectomy, which resulted in complete recanalization of the left ICA after retrieval of the culprit embolus. Pathological examination of the retrieved thrombus revealed the presence of tumor tissue, as well as fibrin or red blood cells. Treatment was continued after admission, but the patient died of respiratory failure on day 40 of hospitalization. Autopsy revealed invasion of the tumor in the pulmonary vein, but not in the wall of the left atrium where thrombi were present. However, pathological examination of these thrombi in the left atrium revealed tumor tissue, along with fibrin or red blood cells. These findings suggest that the wall of the left atrium, in which lung cancer had not invaded, may be an incubator of a mixed embolus containing tumor tissue and thrombi in a case of cerebral embolism associated with both lung cancer and atrial fibrillation.

Gastric lymphoma complicated by phlegmonous gastritis and Guillain-Barré syndrome: A case report.

INTRODUCTION: Complications such as severe infection may occur during the chemotherapy of malignant lymphoma. Phlegmonous gastritis (PG) is a rare acute bacterial infection associated with high mortality, requiring early diagnosis, and prompt management. In addition, Guillain-Barré syndrome (GBS) occasionally requires early treatment and intensive care management due to the occurrence of severe neuropathy and respiratory failure. PATIENT CONCERNS: A 70-year-old male was diagnosed with primary gastric diffuse large B-cell lymphoma (DLBCL) after the detection of several polypoid tumors with ulcers. The patient underwent chemotherapy for DLBCL and exhibited adverse effects (i.e., fever, vomiting, epigastric pain, and neutropenia). Computed tomography indicated widespread thickening in the gastric wall. Furthermore, approximately 2 weeks later, the patient presented with gradual symmetric lower extremity weakness and respiratory failure due to paralysis of the respiratory muscle. DIAGNOSES: DLBCL was diagnosed through a gastric tumor biopsy. On the basis of the computed tomography findings, a culture of gastric juice, nerve conduction studies, and clinical symptoms, this case of gastric lymphoma was complicated with PG and GBS. INTERVENTIONS: The patient was treated with antimicrobial therapy and administration of granulocyte colony-stimulating factor for PG, and with intravenous immunoglobulin and intensive care management for GBS. OUTCOMES: Despite the aggressive progress of the condition, the patient improved without relapse of DLBCL. CONCLUSION: PG was regarded as a precedent infection of GBS. In this article, we present the first reported case of gastric lymphoma complicated with PG and GBS.

[Sudden-onset monoplegia of the upper limb due to traumatic subclavian artery pseudoaneurysm after an interval of three days from tumbling].

A 66-year-old woman was admitted to our institution with sudden-onset weakness of her left upper limb. Neurological examination revealed monoplegia and sensory loss of the limb. A brain MRI did not find evidence of an acute ischemic stroke. Her medical history revealed that she had fallen and bruised her shoulder 3 days earlier. Detailed physiological examination revealed that there was a mild subcutaneous ecchymosis with tenderness in the left shoulder. An additional contrast-enhanced chest CT scan showed a fracture of the clavicle diaphysis and a pooling contrast agent demonstrating a 60*40 mm mass near the left subclavian artery (SUB-A) which suggested a pseudoaneurysm. We determined that her symptoms were due to compression of the brachial plexus by immediate growth of a traumatic SUB-A pseudoaneurysm (TSAP) due to her earlier fall. For reduction of pressure to the brachial plexus by the TSAP and prevention of rupture, an endovascular treatment team performed endovascular internal trapping of the left SUB-A just distal to the orifice of the left vertebral artery and a cardiovascular surgeon performed percutaneous drainage of the pseudoaneurysm. After the procedure, the palsy and sensory loss of the left hand gradually improved. A TSAP could be one of the causes of sudden-onset palsy of the upper limb within a few days after a fall.

[A case of paraneoplastic limbic encephalitis associated with neck neuroendocrine carcinoma].

A 69-year-old man presented with a history of personality change for several years. He was admitted to our hospital due to partial seizure. A cerebrospinal fluid test and an electroencephalogram showed no specific abnormalities, but brain magnetic resonance imaging revealed abnormal findings in the right temporal pole, bilateral amygdala to hippocampus, and insular cortex. He was diagnosed with limbic encephalitis accompanied by partial seizure, and received infusion of an antiepileptic agent and acyclovir. Additional examinations for malignancy and autoimmune disease were performed, and neck CT and MRI revealed a neck tumor. Neck lymph node biopsy suggested lymph node metastasis of a neuroendocrine neoplasm derived from other organs. He did not want aggressive treatment involving surgical resection and chemotherapy, and thus, conservative treatment was chosen by an otorhinolaryngologist and immunotherapy was not used. After discharge, the neck tumor grew gradually. To manage the focal mass effect, chemotherapy and surgical resection followed by chemoradiotherapy were performed by the otorhinolaryngologist on days 244 and 325 of the disease course, respectively. Histology of resected tissues disclosed neck neuroendocrine carcinoma derived from a submandibular gland. His personality change improved temporarily after surgical resection, but then worsened again with regrowth of the tumor. He died on day 723. After death, a blood test revealed the presence of anti-amphiphysin antibody. This case suggests that neck neuroendocrine carcinoma can induce paraneoplastic limbic encephalitis, and in such cases, early surgical resection of the neck tumor with suspected lymph node metastasis is necessary both to control symptoms associated with encephalitis and to exclude carcinoma derived from the neck itself.

[A case of motor dominant neuropathy and focal segmental glomerulosclerosis associated with Sjögren's syndrome].

A 49-year-old woman was admitted to our hospital with gradually progressive weakness of the limbs for about 20 days. She presented with weakness of the limbs, predominantly in the proximal portion, and slight dysesthesia of the limbs, predominantly in the distal portion. Repeated nerve conduction examination revealed axonopathy dominantly in the motor neurons. Therefore, we suspected her as having Guillain-Barré syndrome, and initiated intravenous administration of high-dose immunoglobulin. However, her symptoms progressed gradually and finally she found it difficult to walk. Her urine analysis simultaneously demonstrated albuminuria, and a kidney biopsy indicated focal segmental glomerulosclerosis. At that point, laboratory examination showed high levels of anti SS-A antibody and salivary gland biopsy revealed infiltration of a significant number of lymphocytes around the gland, which led to the diagnosis of Sjögren's syndrome. We considered the etiology of the neural and renal dysfunction as due to the inflammatory mechanism associated with Sjögren's syndrome. Therefore, we administered a second course of immunoglobulin therapy and steroid therapy, which included both pulse and oral administration. Her neurologic symptoms and albuminuria improved rapidly after steroid therapy. The present case indicates that both motor dominant neuropathy and focal segmental glomerulosclerosis can occur in patients with Sjögren's syndrome.

[A case of acute progressive myelopathy due to intravascular large B cell lymphoma diagnosed with only random skin biopsy].

A 64-year old woman was admitted to our hospital with subacute onset paraparesis and sensory disturbance at a level below Th10. Spinal MRI showed a T2 weighted high-signal intensity lesion at a level from Th5 to Th12, and an abdominal CT showed a mass in the left kidney. Her paraparesis deteriorated rapidly, and administration of high dose methyl prednisolone followed by oral steroid therapy was started before obtaining of a definitive diagnosis. However her symptoms did not improve after the beginning of treatment. At the same time, a bone marrow puncture, and biopsies from kidney and spinal cord were performed. These biopsies demonstrated no clues, diagnostically. Therefore a random skin biopsy was performed at the five sites on the 17th day after the steroid dosage end. From this, pathological evidence of intravascular large B cell lymphoma (IVLBCL) was shown. For rapid diagnosis of acute myelopathy with mass lesion of another organ due to IVLBCL, a biopsy is taken not only from spinal cord or mass lesions, but is also taken of multiple sites in skin randomly. This must be performed without a delay before a sudden deterioration of neurologic symptoms can occur from ischemic events not responsive to steroid therapy.

[Neurologist and emergency neuroendovascular revascularization -training programs for endovascular procedures-].

Emergency neuroendovascular revascularization is a reperfusion therapy for acute stroke. The operator for this therapy has to obtain a license as a specialist in endovascular procedures. For neurologists wishing to acquire this license, there are two kinds of training programs: full-time training and concurrent training. Full-time training was chosen by the first author of this review, while concurrent training will be performed by staff in the author's department. The advantage of full-time training is the acquisition of a lot of experience of various diseases that are treated with endovascular procedures and managed in the periprocedural period. However, full-time training has the disadvantages of a requirement to discontinue medical care of neurological diseases except for stroke and employment at a remote institution. The advantages and disadvantages of concurrent training are the reverse of those of full-time training. Neither training system can succeed without cooperation from Departments of Neurology in neighboring universities and the institutional Department of Neurosurgery. It is particularly important for each neurologist to establish a goal of becoming an operator for recanalization therapy alone or for all fields of endovascular procedures because training will differ for attainment of each operator's goal.