Successful Treatment of Symptomatic Epilepsy with Oral Valproic Acid and Levetiracetam in a Patient with Short-bowel Syndrome.

Valproic acid (VPA) and levetiracetam (LEV) are used in epilepsy treatment. However, their use to treat short-bowel syndrome has not been reported. We herein report a 68-year-old man who was hospitalized for symptomatic epilepsy following cerebral infarction. He had a history of superior mesenteric arterial occlusion, and only 30 cm of his jejunum was intact. VPA and LEV were administered, and good blood levels were achieved at clinical doses. This suggests that the gastrointestinal tract absorption of LEV and VPA is good even in patients with short-bowel syndrome and a 30-cm jejunum.

In-Stent Restenosis of Carotid and Vertebral Arteries Treated by Angioplasty Using a Cutting Balloon: A Case Report.

Objective: We treated a patient with internal carotid artery and vertebral artery ostium in-stent restenosis (ISR) treated by cutting balloon (CB) angioplasty. Case Presentation: A 79-year-old man developed dizziness and right homonymous upper quadrantanopia. On arrival, magnetic resonance imaging (MRI) revealed acute-stage brain infarction. Angiography demonstrated left internal carotid artery and vertebral artery ostium stenosis (VAOS), which was thought to be related to the infarction. We performed stenting for both lesions, but 5 months later, restenosis occurred. The patient was successfully retreated by CB angioplasty for both lesions. Conclusion: When treating carotid or vertebral artery ISR, plain balloon (PB) and stent-in-stent (SIS) procedures may induce insufficient dilatation, and hamper re-retreatment because of neointimal hyperplasia. Using CB should be considered as an option in such cases.

[The pathology of the thrombi obtained by endovascular thrombectomy were useful for diagnosis of two cases of cardiogenic cerebral embolism due to infective endocarditis and nonbacterial thrombotic endocarditis].

Patient 1 was a 55-year-old male with cerebral infarction due to obstruction of the left middle cerebral artery during treatment for bacteremia, along with a verruca of infectious endocarditis harvested from endovascular thrombectomy. Patient 2 was a 59-year-old female suffering from cerebral infarction at the terminal branch during intrahepatic cholangiocarcinoma chemotherapy who thereafter developed cerebral infarction again due to obstruction of the left middle cerebral artery, along with a verruca of nonbacterial thrombotic endocarditis (NBTE) harvested from endovascular thrombectomy. In tumor-bearing patients, while NBTE may be more closely related to the development of cerebral infarctions than previously assumed, we also need pay attention to the onset of infectious endocarditis. We need further studies on the effectiveness and safety of thrombolysis therapy and endovascular thrombectomy for cerebral infarctions due to endocarditis in both patients. The harvested emboli may provide clues to the differentiation thereof.

Treatment Strategies for Basilar Top Syndrome Caused by Acute Vertebral Artery Occlusion.

Objective: We report a patient with basilar artery embolism caused by vertebral artery stenosis who was successfully treated using simultaneous percutaneous transluminal angioplasty (PTA) and mechanical thrombectomy. Case Presentation: A 64-year-old male, who had undergone medical treatment for cerebellum infarction at another hospital, was referred to our hospital due to disturbance of consciousness. Angiography revealed acute occlusion of the first part of the right vertebral artery and an embolism of the top of basilar artery. After performing PTA to create an approach route for the embolism, we collected it using a clot recovering device. The postoperative course was good, and the patient was discharged with mild ataxia and dysarthria. Conclusion: We report the successful treatment of progressive cerebral infarction of the posterior circulation with revascularization 30 hours after symptom onset. Unlike the anterior circulation, the posterior circulation consists of smaller arteries and fewer collateral arteries, making it vulnerable to ischemic attack. Therefore, shortening the time until treatment may improve the outcome.

[Internal Carotid Artery-Cavernous Sinus Fistula in a Patient with Masked Hypertension Caused by Bilateral Subclavian Artery Stenosis:A Case Report].

We herein report a case of direct carotid-cavernous fistula(direct CCF)in a patient with masked hypertension caused by bilateral subclavian artery stenosis. A 74-year-old woman presented with headache, right-sided proptosis, double vision, and pulsatile tinnitus since past 10 days. The patient was diagnosed with direct CCF. Transarterial embolization in the region of the right internal carotid artery was performed, after which her symptoms resolved. However, additional interventions in the form of subclavian artery stenting were required, because of the complications of left subclavian artery occlusion and right subclavian artery stenosis. Satisfactory dilatations were achieved, and the angiographic 'steal' phenomenon disappeared. The patient had terminated antihypertensive treatment because of the normalization of her brachial blood pressure; however, this was merely pseudo-normalization due to subclavian artery insufficiency. We consider this a case of direct CCF occurring as a complication of masked hypertension caused by bilateral subclavian artery stenosis.

Recurrent Embolic Stroke Caused by Large Cavernous Carotid Aneurysm: Stroke Recurrence Prevention with High-Flow Bypass Followed by Proximal Occlusion.

Intracranial aneurysms may cause embolic stroke. Medical or surgical management is selected on an individual basis, as the optimal treatment strategy has not been established. A 79-year-old woman with a large cavernous carotid aneurysm suffered repeated embolic stroke after enlargement and partial thrombosis of the aneurysm, in spite of antiplatelet therapy. Coil embolization of the primitive trigeminal artery and ligation of the internal carotid artery (ICA) at the cervical portion followed by high-flow bypass from the cervical external carotid artery to the middle cerebral artery were performed. The aneurysm was thrombosed, and prevention of further stroke was achieved. Acute enlargement and thrombosis of large or giant cavernous carotid aneurysm may cause repeated embolic stroke, and requires emergent exclusion of the aneurysm from circulation by proximal ICA occlusion together with distal revascularization before devastating embolic stroke occurs.

Swine model of in-stent stenosis in the iliac artery evaluating the serial time course.

The aim of this study was to propose a new animal model evaluating the serial time course of in-stent stenosis by repeated carotid artery catheterization in the same animal. 16 bare-metal stents were implanted in the normal external and internal iliac artery of 8 miniature pigs. Repeated measurements were performed in the same animal every 2 weeks for 12 weeks through carotid artery catheterization. The time course and peak neointimal proliferation were evaluated by intravascular ultrasound. Health of all animals was assessed by clinical and hematological examinations. As a result, 7 times of carotid artery catheterization was performed per pig, but all animals remained healthy without both any complications and hematological inflammatory abnormalities. The time course of neointimal proliferation of each stent was observed from the stage of hyperplasia to partial regression. The peak neointimal proliferation varied from 6 to 12 weeks despite implantation of identical stents using the same deployment method. In conclusion, repeated carotid artery catheterization to the same animal is feasible without animal health deterioration. This model should be useful to evaluate the time course of neointimal proliferation after stent deployment in preclinical study.

Stent-assisted Coiling for Ruptured Basilar Artery Dissecting Aneurysms: An Initial Experience of Four Cases.

No treatment strategy has been established for subarachnoid hemorrhages due to basilar artery (BA) trunk dissecting aneurysms. Our aim was to report our initial experience performing stent-assisted coiling (SAC) for ruptured BA dissecting aneurysms to validate the effectiveness of this treatment. We experienced four consecutive cases of ruptured dissecting BA trunk aneurysm treated with SAC between 2008 and 2014 at three institutions. Aneurysm rebleeding was prevented without causing severe brainstem ischemia in all cases. In our opinion, both the blockage of the inflow to aneurysms and the preservation of the antegrade flow of the BA can be achieved by SAC, although controversies regarding long-term stability and appropriate antiplatelet therapy remain.

Clot-clearance rate in the sylvian cistern is associated with the severity of cerebral vasospasm after subarachnoid hemorrhage.

Rapid clot removal and clearance has been proposed as an effective tool for preventing cerebral vasospasm after subarachnoid hemorrhage (SAH). We examined the relationship between clot-clearance rate and the severity of cerebral vasospasm in 110 consecutive patients with aneurysmal SAH. We measured clot-clearance rates per day in the basal and Sylvian cisterns, and evaluated the presence of symptomatic vasospasm based on changes in clinical symptoms and the appearance of a new low-density area on a computed tomography (CT) scan. The severity of symptomatic cerebral vasospasm was associated with age and the SAH grade on admission; however, we observed no significant difference between these variables in patients with urokinase irrigation or fasudil hydrochloride treatment. The mean clot-clearance rates per day for patients with asymptomatic and permanent delayed ischemic neurological deficit were 41.9 and 41.5 %, respectively, in the basal cistern (P = 0.7358) and 37.7 and 23.9 %, respectively, in the Sylvian cistern (P = 0.0021). The reduced clot-clearance rate in the Sylvian cistern increased the risk of vasospasm-related infarction (P = 0.0093) and markedly reduced unfavorable outcomes (P = 0.0115).

Endovascular treatment of cerebral hemorrhage in a patient with a left ventricular assist device: report of a case.

Cerebral hemorrhage is a common lethal complication associated with left ventricular assist device (LVAD) management. We performed cerebral angiography on patients with LVAD who developed cerebral hemorrhage and determined that ruptured aneurysms were the cause in some cases. Endovascular management of patients with LVAD can be a therapeutically useful approach for cerebral hemorrhage caused by aneurysm rupture.

Staged surgical treatment for symptomatic vertebrobasilar artery stenosis: combined treatment with endovascular angioplasty and bypass surgery.

OBJECTIVE: Because the early risk of stroke recurrence in patients with posterior circulation infarctions is high, patients with vertebrobasilar events require active preventive treatment. Previous reports have described the use of balloon angioplasty and stenting or surgical revascularization to the vertebrobasilar artery area. To compensate for the disadvantages of these techniques, we combined endovascular and surgical treatments in a patient with symptomatic vertebrobasilar artery stenosis. METHODS: After endovascular surgery, we continued medical therapy to stabilize the blood flow in the posterior circulation. Superficial temporal artery-superior cerebellar artery bypass was planned for the chronic stage (∼1-2 months). RESULTS: Three cases (2 vertebral artery stenosis, 1 basilar artery stenosis) presented with recurrent transient ischemic attacks or deteriorating symptoms under intensive medical treatment. We conducted staged therapy using balloon angioplasty followed by superficial temporal artery-superior cerebellar artery bypass. All patients were symptom-free after treatment with the combined therapy. CONCLUSIONS: Our staged therapy may be an effective treatment for symptomatic vertebrobasilar artery stenosis.

Successful treatment of cerebral hemorrhage using computed tomography angiography in a patient with left-ventricular-assist device.

Cerebral hemorrhage is one of the common complications associated with left-ventricular-assist device (LVAD) treatment and leads to a high mortality rate because of excessive bleeding due to frequently unknown causes. Cerebral angiography is used to diagnose cerebrovascular events and is well recognized as being very useful for this purpose. We performed a cerebral angiography for a patient with an LVAD who developed cerebral hemorrhage, and the hemorrhagic source was clearly identified. The patient underwent successful neurosurgical treatment, which was followed by heart transplantation.

The use of 3D computer graphics in the diagnosis and treatment of spinal vascular malformations.

OBJECT: Digital subtraction (DS) angiography is the gold standard for diagnosing spinal vascular malformations. Recently, multidetectorrow spiral CT and contrast-enhanced MR angiography have been introduced as screening examinations before DS angiography. These methods, however, do not always determine the accurate location of an arteriovenous shunt because the resulting images lack information about the spinal cord or the dura mater. METHODS: Between April 2009 and December 2010, 13 patients underwent imaging evaluations for spinal vascular malformations at the authors' university hospital. This group included 8 patients with spinal dural arteriovenous fistulas (AVFs), 3 with perimedullary AVFs, and 2 with intramedullary arteriovenous malformations. Using data from these patients, the authors attempted to develop 3D computer graphics (CG) based upon the fusion of 3D rotational angiography and postmyelographic CT. They subsequently verified the accuracy of this imaging method. Ten of these 13 patients underwent surgical treatment for their lesions (11 AVFs), and for these 11 lesions the authors compared the diagnoses obtained using 3D CG with those obtained using conventional DS angiography. RESULTS: In all 13 cases, 3D CG images of the spinal lesions were successfully developed using the patients' actual data. Four (36%) of 11 AVFs were correctly identified using DS angiography, whereas 10 (91%) were correctly identified using 3D CG. Results from 3D CG of spinal AVFs corresponded well with operative findings, and 3D CG was significantly better than conventional DS angiography at predicting AVF location (p = 0.024, Fisher exact test). CONCLUSIONS: To the authors' knowledge, this is the first reported case series in which 3D CG of spinal vascular malformations was used to provide simultaneous, stereoscopic visualization of the spinal vascular system, spinal cord, dura mater, and bone. The 3D CG method provides precise visual images for the diagnosis and treatment of these lesions.

Treatment of a cervical carotid pseudoaneurysm that occurred years after laryngectomy and irradiation of a neck tumor.

A 62-year-old man presented with rupture of a pseudoaneurysm of the left common carotid artery (CCA) that was induced after radiation therapy and neck surgery. The initial treatment was an endovascular procedure to obliterate the aneurysm with coils, and a covered stent was placed in the parent artery. However, the patient presented with subsequent coil migration, wound infection, and left CCA stenosis. Direct surgical procedures were then performed, including resection of the pseudoaneurysm with coils and stent; replacement of the carotid artery with a saphenous vein graft; and operative wound reinforcement with a pedicle flap. Endovascular treatments may be chosen for vascular diseases after irradiation, because of the low risk of wound infection and fragility of the vessels, but the long-term outcomes of intravascular treatments are still unclear. In direct surgery, dissection of the adhesive tissue and adequate wound healing are difficult. Musculocutaneous flaps with vascular pedicles can achieve good results.

Diagnosis of Eagle syndrome with 3-dimensional angiography and near-infrared spectroscopy: case report.

BACKGROUND AND IMPORTANCE: Elongated styloid processes sometimes compress the cervical carotid artery, causing transient ischemic attacks. Most patients with Eagle syndrome who experience transient ischemic attacks have bilateral elongated styloid processes; therefore, it is necessary to determine which side is causing the Eagle syndrome to treat it. This is the first report of the usefulness of 3-dimensional angiography and near-infrared spectroscopy (NIRS) for the diagnosis of Eagle syndrome. CLINICAL PRESENTATION: A 40-year-old man experienced transient loss of consciousness when flexing his neck. On 3-dimensional computed tomography, bilateral elongated styloid processes were revealed. We were able to determine the side of concern using 3-dimensional angiography and NIRS. Three-dimensional angiography with his neck flexed showed a compressive dent in the cervical portion of the left internal carotid artery. On NIRS, during neck flexion, the concentrations of oxygenated hemoglobin and total hemoglobin decreased in his left motor area, which was resolved immediately when he returned his neck to its natural position. This led to decreased cerebral blood flow in the left hemisphere of his brain. After partial removal of left styloid process, he was symptom free, even when keeping his neck flexed. NIRS showed that the concentrations of oxygenated hemoglobin increased in the left motor area during neck flexion. CONCLUSION: We report the usefulness of 3-dimensional angiography and NIRS for diagnosing Eagle syndrome. Three-dimensional angiography and NIRS can visualize anatomic structures and provide hemodynamic information for an appropriate surgical strategy.

Vegetative propagation and its possible role as a genetic bottleneck in the shaping of the apple fruit crinkle viroid populations in apple and hop plants.

Apple fruit crinkle viroid (AFCVd) infects apples and hops. To analyze the genetic diversity of AFCVd, nine apple and six hop isolates were collected from several locations in Japan. In total, 76 independent cDNA clones were used for sequencing and phylogenetic analyses. Two major population clusters were identified. The first consisted of all four hop isolates from Akita and some from Yamagata. The second cluster consisted of some Yamagata hop and all apple isolates. On the basis of the polymorphism found in the nucleotide insertion between positions 142/143 of the AFCVd genome and the history of hop cultivation in the region, it appears likely that one of the AFCVd populations that pre-existed in the Yamagata hops served as a "founder" for the Akita hop cluster. In this scenario, a genetic bottleneck caused by vegetative propagation played an important role in the shaping of viroid populations in a cultivated crop.

Lymphoplasmacyte-rich meningioma with atypical invasive nature.

A 12-year-old boy presented with a lymphoplasmacyte-rich (LPR) meningioma in the posterior fossa. The tumor was subtotally removed. Histological examination showed the tumor had invaded the normal brain tissue despite its benign grade in the World Health Organization classification. The Ki-67 staining index using MIB-1 monoclonal antibody was relatively high. (18)F-2-fluoro-2-deoxy-D-glucose positron emission tomography revealed high uptake in the tumor. These findings indicate the atypical nature of LPR meningioma.

Urgent treatment of severe subarachnoid hemorrhage caused by ruptured traumatic aneurysm of the cavernous internal carotid artery using coil embolization followed by superficial temporal artery-middle cerebral artery anastomosis: a case report.

BACKGROUND: Traumatic aneurysm of the cavernous internal carotid artery (ICA) with extension into the subarachnoid space is associated with increased risk of fatality especially when it is accompanied by severe subarachnoid hemorrhage (SAH). Only cases of patients who survived the acute stage and who were treated in a delayed setting have been reported. There has been no successfully treated case immediately after an injury. CASE DESCRIPTION: We encountered a 48-year-old man who presented with dense SAH immediately after being involved in a motor vehicle accident. Emergent angiography revealed traumatic aneurysm of the left cavernous ICA with extension beyond the superior wall of the cavernous sinus into the subarachnoid space and concomitant direct high-flow carotid cavernous fistula. Detachable platinum coil occlusion of the cavernous ICA followed by superficial temporal artery-middle cerebral artery anastomosis on day 0 and aggressive therapy to SAH, including ventriculocisternal irrigation and drainage, was performed. The patient eventually made a good recovery. CONCLUSION: Considering the extremely poor prognosis and unstable nature of a ruptured traumatic aneurysm with extensive SAH in the acute stage, definitive and immediate prevention of rebleeding in conjunction with proper revascularization would be warranted, such as in the present case.

Endovascular treatment with coils of 149 middle cerebral artery berry aneurysms.

PURPOSE: To retrospectively evaluate the immediate and long-term clinical results, as well as the angiographic results, of occlusion of middle cerebral artery (MCA) berry aneurysms with coils. MATERIALS AND METHODS: This retrospective study had institutional review board approval, and informed consent was obtained. One hundred fifty-four MCA aneurysms in 142 patients were intended to be treated. Complications, patient clinical outcomes, and immediate postprocedural and follow-up angiography results were retrospectively evaluated. RESULTS: One hundred forty-nine (96.8%) of 154 MCA aneurysms (72 ruptured, 77 unruptured) were occluded with coils in 137 patients (99 women and 38 men; age range, 28-76 years; mean, 48 years). Thromboembolic events occurred in 20 (13.4%) and aneurysm perforation occurred in seven (4.7%) of 149 procedures. Endovascular treatment (EVT) was performed without complications for 121 (81.2%) of the treated aneurysms. For ruptured aneurysms, the treatment-related mortality rate was 6% (four of 72 aneurysms) and the treatment-induced permanent morbidity rate was 1% (one aneurysm). For unruptured aneurysms, the treatment-induced mortality rate was 1% (one of 77 aneurysms) and the procedure-related permanent morbidity rate was 3% (two aneurysms). One hundred five (70.5%) of the 149 aneurysms were examined with follow-up angiography at least once. Recurrences were found for 21 (20%) of the 105 aneurysms that were followed up for a cumulative period of 1564 months (mean, 15 months). Of these 21 recurrent aneurysms, 10 increased in size in the interval between follow-up angiography examinations and 11 remained stable. A second treatment was required for 12 aneurysms, and a third treatment was required for one. After repeat EVT, total aneurysm occlusion was attained for nine aneurysms, and a residual neck was seen in two aneurysms. One recurrent aneurysm was surgically clipped. The nine other aneurysms with small recurrences were not candidates for additional treatment. CONCLUSION: EVT of MCA aneurysms with coils can be successfully performed without inducing neurologic deficits in most patients with ruptured or unruptured aneurysms.