Bailout using NBCA for incomplete onyx embolization of tentorial dural arteriovenous fistula.

Transarterial embolization using Onyx (Medtronic, Irvine, CA, USA) results in a high cure rate for complete obliteration of dural arteriovenous fistulas. However, incomplete obliteration occurs in some cases. Reports on the use of bailout therapy in such cases are limited. A 79-year-old man was diagnosed with Borden type III tentorial dural arteriovenous fistulas during a check-up for a headache. We first performed transarterial embolization with Onyx from a tentorial artery, but the fistula was not completely obliterated. We then performed an additional transarterial embolization with n-butyl-2-cyanoacrylate from the same artery in a single session, and the fistula was successfully bailed out, resulting in complete obliteration. Combining different liquid embolic materials, Onyx and n-butyl-2-cyanoacrylate, is an effective strategy for achieving complete obliteration in incomplete transarterial embolization treatment of dural arteriovenous fistulas.

Innovative use of a stent retriever for temporary revascularization in acute internal carotid artery dissection.

Internal carotid artery dissection is rare but can be a cause of stroke in young people. In a case of revascularization for stroke associated with internal carotid artery dissection, we initially used a stent retriever for thrombectomy. Since an appropriately-sized stent for permanent treatment was not available, we innovatively maintained temporary revascularization with the stent retriever for 90 minutes. Here we demonstrate the adaptability of the stent retriever for emergency care. A 49-year-old man suddenly developed severe right hemiplegia and aphasia. Magnetic resonance imaging showed occlusion of a left internal carotid artery with moderate ischemic changes in the left hemisphere cortex. Angiography showed dissection of the left internal carotid artery at the cervical level and secondary thrombus formation extending into the left middle cerebral artery. We initially attempted thrombectomy with a stent retriever and achieved successful reperfusion in the middle cerebral artery. An appropriately-sized stent was not available in the hospital at that time. During the 90-minute wait, the stent retriever was kept in place and temporary angioplasty was performed in the internal carotid artery dissection to maintain blood flow. Eventually, the stent was delivered and permanent revascularization was achieved. While there is no standard treatment for arterial dissection, endovascular strategies like stenting have been demonstrated to be beneficial. The innovative use of stent retrievers for temporary angioplasty of dissected lesions underscores their efficacy in swift deployment and maintenance of uninterrupted blood flow, particularly during emergency thrombectomy.

Stereotactic radiotherapy of radiation-induced meningioma previously irradiated retrobulbar for Graves' ophthalmopathy: A case report.

A 69-year-old woman was diagnosed with an asymptomatic intracranial tumor nine years ago and has been followed with annual MR imaging studies. Two years ago, the tumor had grown in size, requiring treatment. She experienced ophthalmopathy due to hyperthyroidism 27 years ago and was treated with 20 Gy in 10 fractions using parallel opposed beams to her bilateral posterior eyeballs, supplemented with steroid pulse therapy. The tumor originated in the medial aspect of the right sphenoid border and compressed the temporal lobe, while bone infiltration was observed, partially extending to the soft tissue outside the maxillary sinus. The tumor was removed by craniotomy. The pathological diagnosis was atypical meningioma (WHO grade II). Four months postsurgery, the resection cavity's tumor exhibited growth inclination, necessitating Gamma Knife radiosurgery. Radiation planning was executed at a marginal tumor dose of 30 Gy in 5 fractions. Since the optic nerve had been previously exposed to radiation, a plan was devised to minimize radiation exposure. The dose on the optic nerve was limited to 6.9 Gy in 5 fractions. She did not experience any visual or visual field disruptions postradiation. This is a case of radiation-induced meningioma resulting from radiation therapy for Graves' ophthalmopathy and is the first reported case of a grade II meningioma. The patient's condition calls for adjuvant radiation therapy following surgical removal. Accordingly, a radiation treatment plan that safeguards the optic nerve, which was previously exposed to radiation, was deemed indispensable.

Facial Nerve Neurolymphomatosis That Extends to Both the Brainstem and Extracranial Regions.

A 73-year-old female developed right facial paralysis of House-Brackmann (H-B) grade III and was diagnosed with Bell's palsy. After three months of steroid therapy, she developed progressive hearing loss, and an MRI revealed a tumor in the right internal auditory canal. Within a few months, the right facial nerve palsy recurred, and the patient was treated with Gamma Knife radiosurgery. The tumor in the irradiated region disappeared, but new dysphagia was observed, and a right parotid gland tumor was detected for the first time. Tumors of the right parotid gland and the digastric muscle of the jaw were surgically resected, and a diagnosis of diffuse large B-cell lymphoma was made. The tumor had invaded the cranial nerves and brainstem region, and the patient did not wish to undergo further medical therapy. This was a case of malignant lymphoma that started as facial paralysis and invaded the brainstem, and testing for possible lymphoma at an early stage prior to radiotherapy was desirable.

Endovascular Treatment Strategy for Acute Basilar Artery Occlusion with Unexpected Right-Sided Aortic Arch.

A right-sided aortic arch (RAA) is a rare variant of the aortic arch found. We present a case of endovascular treatment (EVT) for acute basilar artery (BA) occlusion with an RAA. A 70-year-old man developed acute ischemic stroke due to BA occlusion. During urgent EVT for BA occlusion with an RAA, which was observed unexpectedly, navigation of the catheter to the target vessel was achieved as a result of an early change in the access route. Flexible treatment strategies are warranted for cases of unexpected anatomical variant in the fight against time for emergent cases, such as acute ischemic stroke.

Long-term recurrence after surgery for schwannoma of the cauda equina.

Background: Cauda equina tumors are rare primary spinal tumors. Histologically, the most common tumor arising from the cauda equina is a schwannoma. However, little is known about the long-term postoperative outcomes of cauda equina schwannoma. Here, we reviewed the median-to-long-term postoperative outcomes of eight of our own patients with schwannomas of the cauda equina. Methods: Between 2007 and 2020, we, retrospectively, reviewed eight patients with cauda equina schwannomas (CESs) undergoing nine operations at our institution. There were five males and three females averaging 56.5 years of age who were followed for over 40 postoperative months. The study included assessment of the following variables: the modified McCormick scale, tumor size, location, extent of resection, treatment of the tumor involving nerve roots, and postoperative observational follow-up. Results: Gross-total resection was achieved in all eight patients; none received adjuvant therapy. The involved nerve roots were completely sacrificed in seven patients and partially resected in one. During a median follow-up of 108 months, only one patient sustained a tumor recurrence 164 months following the index surgery. Conclusion: CESs may recur more than 10 years after the original surgery. Radical resection of the tumor, including complete removal of the involved nerve root during the index surgery, and long-term postoperative follow-up is, therefore, essential.

Gamma knife radiosurgery cured hydrocephalus in non-hemorrhagic brain stem arteriovenous malformation.

A 13-year-old boy, with a history of intermittent headache and transient diplopia, was found to have non-hemorrhagic cerebral arteriovenous malformation in the midbrain tegmental region associated with hydrocephalus. Gamma knife radiosurgery was performed at 16 Gy with 75% marginal dose. Posttreatment course was uneventful. Follow-up MR imaging at one year after the treatment revealed complete disappearance of the abnormal vascular flow voids. The size of each ventricle at the treatment and at one year after treatment were as follows; 60.2 cc and 20.9 cc in the lateral ventricles, 3.7 cc and 2.7 cc in the third ventricle. The hydrocephalus might be caused by obstructive mechanism but mostly by high venous pressure due to the shunt blood flow. The goal of treatment for hydrocephalus should be nidus obstruction and normalizing the vascular flow.

Ostial common carotid artery occlusion and balloon-mounted stenting: Implication of embolic protection device in tandem lesion.

Ostial common carotid artery (CCA) stenosis is rare, compared to extracranial internal carotid artery bifurcation lesions. In cases of a tandem lesion, the proximal lesion usually involves the extracranial internal carotid artery, and the ostial CCA is rarely implicated. A 69-year-old woman who underwent 3 months of antiplatelet therapy for asymptomatic, right ostial, severely calcified CCA stenosis presented with sudden onset left hemiparesis. Radiographic examination revealed an ostial CCA-intracranial artery tandem lesion. After intracranial revascularization using a clot retrieval stent, we performed the endovascular treatment with a balloon-mounted stent using an embolic protection device. This procedure may be superior to others because it is possible to achieve early intracranial revascularization and prevent distal embolism during the complete treatment of proximal lesions.

Understanding of Pathophysiology and Optimal Treatment for Anterior Circulation Large Vessel Occlusion beyond 24 h from Onset of Stroke.

We report three cases in which endovascular treatment (EVT) was performed for anterior circulation large vessel occlusion (LVO) beyond 24 h from the onset of stroke. Case 1 experienced left hemispatial neglect and gait disorder due to right internal cerebral artery (ICA) occlusion and underlying atherosclerosis. After percutaneous transluminal angioplasty (PTA), revascularization with mild stenosis was achieved. Case 2 complained of reduced activity, motor aphasia, and right-sided hemiparesis due to left middle cerebral artery occlusion. After thrombectomy using a retrieval stent, revascularization with M1 stenosis and distal perfusion delay was observed, which improved after PTA. Case 3 arrived at our hospital 30 h after the onset of dysarthria and gait disturbance due to left ICA occlusion. Since the symptoms were mild, medical treatment was started; however, the patient's symptoms deteriorated 6 h later, and EVT was required. After thrombectomy using a retrieval stent, revascularization was achieved. LVO pathophysiology beyond 24 h of stroke onset varies and may require multimodal treatment. Preserving the pyramidal tract may lead to favorable outcomes, even in cases of anterior circulation LVO. EVT may be effective for anterior circulation LVO because, in some patients, infarct volume continues to increase >24 h after stroke onset.

Lumbar Canal Stenosis Caused by Spondylolisthesis and Intraspinal Canal Calcifications Associated with Psoriatic Arthritis: A Case Report.

Soft tissue calcifications are common findings in patients with various diseases, such as malignant tumors, collagen diseases, trauma, and chronic kidney disease. The majority of these lesions are not clinically significant; however, they can cause specific disorders within a limited space, such as the spinal canal. Here, we report the case of a patient undergoing fusion surgery for lumbar canal stenosis due to degenerative spondylolisthesis and multiple intraspinal canal calcifications associated with psoriatic arthritis (PsA). A 55-year-old female patient presented with pain in the left leg and intermittent claudication for 1 month. One year ago, she was diagnosed with PsA and received outpatient treatment, including biological medication, at the Division of Rheumatology, Department of Internal Medicine of our institution. She was referred to our department, and radiological examination revealed lumbar canal stenosis caused by spondylolisthesis and multiple calcifications in the lumbar spinal canal. We performed posterior lumbar interbody fusion (PLIF) with percutaneous pedicle screw fixation concomitant with removal of the calcifications. The postoperative course was uneventful, and her neurological symptoms improved. Although several prior case reports have noted intraspinal canal calcifications due to collagen disease or chronic kidney disease, calcifications associated with PsA are rare. We discuss the diagnosis of PsA and its relationship with intraspinal canal calcifications by reviewing the previous relevant literature.

[Posterior Approach for Cervical Spondylotic Myelopathy in Patients Older than 80 Years of Age].

OBJECTIVE: We aimed to investigate the characteristics and operative results of elderly patients with cervical spondylotic myelopathy(aged ≧80 years)treated using the posterior approach. METHODS: Between April 2010 and December 2018, 21 patients aged ≧80 years(older group:8 men and 13 women;age range, 80-90 years)who underwent laminoplasty were reviewed and compared with 23 patients aged <80 years(younger group;13 men and 10 women;age range, 42-79 years)who underwent laminoplasty. The following data were obtained from chart reviews:age;sex;cervical canal stenosis level;time to operation;symptoms(e.g., gait disturbance);comorbidities(hypertension, diabetes mellitus, cancer, heart disease, ischemic cerebrovascular disease, and lumbar canal stenosis);antithrombotic drug use;cardiac, pulmonary, and renal functions;operative time;volume of blood loss during the operation;postoperative delirium;and follow-up period. Neurological deficits before and after the surgery were assessed using the neurosurgical cervical spine scale(NCSS). Data were statistically analyzed, and p-values <0.05 were considered statistically significant. RESULTS: The operative time, symptoms(hypertension), renal function, and preoperative NCSS score were significantly different between the older and younger groups. Meanwhile, most variables showed no significant differences between the groups. Although the preoperative NCSS score was lower in the older group, there was no significant difference in the degree of improvement in the NCSS score after surgery. CONCLUSIONS: The findings of this study suggest that we should not hesitate to perform surgery for cervical spondylotic myelopathy in elderly patients with favorable cardiorespiratory function.

Treatment of Recurrent Aneurysm of the Internal Carotid Artery-poster Communicating Artery Using the Marathon Microcatheter: A Case Report.

Objective: We report the case of an aneurysm of the recurrent internal carotid artery (ICA)-posterior communicating artery (PCoA) treated using a liquid embolic delivery microcatheter (MC; Marathon). Case Presentation: A 66-year-old female previously presented with subarachnoid hemorrhage, which had been treated using coil embolization for a ruptured ICA-PCoA aneurysm. She was referred to our hospital because the aneurysm recurred 13 years after treatment. Angiography revealed a de novo lobulated aneurysm at the ICA-PCoA bifurcation with a relatively thickened PCoA branching from the neck of the aneurysm. We performed coil embolization after stent placement with the Neuroform Atlas in the range of the ICA terminus and the PCoA. However, the coils were unequally distributed and it was necessary to navigate the MC to the aneurysm within the stent through the PCoA. We successfully approached the aneurysm using the Marathon. We additionally inserted six ED coils into the aneurysm and achieved favorable embolization. Conclusion: The Marathon is useful for passage of a stent deployed in a small-caliber artery.

[Surgical Results of Lumbar Degenerative Disease with Foot Drop].

Drop foot is associated with various diseases, such as peripheral nerve disease, lumbar degenerative disease, metabolic disease, and endocrine disease. Among lumbar degenerative diseases, lumbar disc herniation and lumbar canal stenosis are most commonly reported. We report the surgical outcomes of patients with drop foot caused by lumbar degenerative diseases. Between 2008 and 2018, we encountered 24 cases of drop foot in patients who underwent surgery of the lumbar lesion. The mean age was 69.5 years(49-88 years). Fourteen patients were male and ten were female. The mean time interval between the onset of drop foot and surgery was 51.5 days(from 7 days to 1 year). Drop foot, as a clinically significant muscle weakness, was defined at levels of manual muscle test(MMT)3 or lower. Responsible lesions for drop foot were canal stenosis at L4/5 in 8 cases, disc herniation at L4/5 in 10 cases, disc herniation at L5/S1 in 5 cases, and far-out syndrome in 1. One case involved drop foot bilaterally. Muscle weakness improved by surgery at levels of MMT 4 or greater in 16 cases(66.7%). Six cases of complete paresis or tibialis anterior muscle atrophy preoperatively resulted in no improvement;however, neuralgia was relieved in all. Twelve of 15 cases(80%)of lumbar disc herniation and 4 of 10 cases(40%)of lumbar canal stenosis resulted in improvement. Between disc herniation and canal stenosis, the surgical success rate was not statistically different. Age and the time interval between the onset and surgery were also not significant factors of the outcome. Surgical intervention seems to be beneficial even in cases of severe muscle weakness since pain relief can be expected, which leads to improvement in gait.

[Pseudoaneurysm of Neck External Carotid Artery Related to Chiropractic Manipulation].

A 55-year-old man presented with progressive pain and expanding swelling in his right neck. He had no history of trauma or infectious disease. The patient had undergone chiropractic manipulations once in a month and the last manipulation was done one day before the admission to our hospital. On examination by laryngeal endoscopy, a swelling was found on the posterior wall of the pharynx on the right side. The right piriform fossa was invisible. CT revealed hematoma in the posterior wall of the right oropharynx compressing the airway tract. Aneurysm-like enhanced lesion was also seen near the right common carotid artery. Ultrasound imaging revealed a fistula of approximately 1.2 mm at the posterior wall of the external carotid artery and inflow image of blood to the aneurysm of a diameter of approximately 12 mm. No dissection or stenosis of the artery was found. Jet inflow of blood into the aneurysm was confirmed by angiography. T1-weighted MR imaging revealed presence of hematoma on the posterior wall of the pharynx and the aneurysm was recognized by gadolinium-enhancement. We performed emergency surgery to remove the aneurysm while preserving the patency of the external carotid artery. The pin-hole fistula was sutured and the wall of the aneurysm was removed. Histopathological assessment of the rissue revealed pseudoaneurysm. The patient was discharged after 12 days without deficit. Progressively growing aneurysm of the external carotid artery is caused by various factors and early intervention is recommended. Although, currently, intravascular surgery is commonly indicated, direct surgery is also feasible and has advantages with regard to pathological diagnosis and complete repair of the parent artery.

[Implementation of Penumbra-assisted Half-Stent Thrombectomy for Patients with Acute M2 Occlusion:Results of Initial Experiences].

The benefits of mechanical thrombectomy(MT)for acute M2 occlusion have remained unclear because of unavoidable device-related complications due to vascular morphological characteristics. We developed a Penumbra-assisted half-stent thrombectomy for achieving secure retrieval of thrombus with minimal damage to the small-caliber vessel. In total, 6 patients were treated with MT for acute M2 occlusion using this technique between November 2016 and May 2017, including 3 men and 3 women, mean age 74.8(51-98)years. The mean baseline National Institutes of Health Stroke Scale score was 17.5(6-32), and Alberta Stroke Program Early Computed Tomography Score-Diffusion-Weighted Imaging was 7.5(6-9). After navigation of the microcatheter through the thrombus in M2 supported by a Penumbra 4MAX as a distal access catheter, the stent retriever(SR)was partially deployed to cover the entire thrombus. The 4MAX was then advanced towards the caudal end of the thrombus, and the SR was pulled back into the 4MAX with simultaneous aspiration of the 4MAX. We used the Trevo XP3 in 5 patients and Revive SE in 1 patient. The mean procedure time from groin puncture to recanalization was 60(54-66)min. Successful recanalization(Thrombolysis in Cerebral Infarction score 2b or 3)was achieved in 5(83%)patients. There were no cases of symptomatic intracranial hemorrhage. Good outcome(modified Rankin Scale score 0 to 2)at 3 months was achieved in 3(50%)patients. Penumbra-assisted half-stent thrombectomy appears to be an effective alternative strategy in MT for acute M2 occlusion.

[Two Cases of Bilateral Orbital Metastases of Breast Cancer].

Two cases of breast cancer with bilateral orbital metastases associated with intracranial metastases are presented. Case 1:A 61-year-old woman who was diagnosed with breast cancer 14 years earlier presented with rapid deterioration of visual acuity, eye pain, and limitation of left-sided extraocular motility. Magnetic resonance(MR)images showed an enhanced lesion in the left orbital apex, ethmoid sinus, and right middle fossa. The first gamma knife radiotherapy(35 Gy, 5 Fr)was performed successfully, but was followed by recurrence 18 months later in the right intraorbital, where newly formed iso-intensity masses in the extraconal compartment were found. The second gamma knife radiosurgery was performed for three masses(20 Gy). Case 2:A 35-year-old woman with breast cancer who was diagnosed 22 months earlier was treated for meningeal carcinomatosis by whole-brain radiation(30 Gy, 10 Fr)and intrathecal chemotherapy. Eight months later, swelling in both eyelids and limitation of extraocular motility developed rapidly. MR imaging revealed an infiltrating lesion in the cone with heterogenous signal that was encasing, but not infiltrating the optic nerves. The extraconal lesion extended into the soft tissue of the lower eye lid. She expired one week after diagnosis. With the increasing number of long-term survivors with breast cancer, intraorbital metastases may be found during the course of treatment for intracranial lesions. Understanding the unique clinical presentation and characteristic MR findings of this rare entity are emphasized.

Patients with major depressive disorder exhibit reduced reward size coding in the striatum.

BACKGROUND: Anhedonia is a core symptom of major depressive disorder (MDD). While recent evidence suggests that reduced motivation for reward may be a core feature of anhedonia, the abnormalities in modulatory neural responses to variable reward amounts in MDD patients remain unclear. We investigated whether MDD patients' ability to represent variable-sized monetary rewards in the striatum is disrupted. METHODS: Twelve MDD patients and 12 healthy volunteers completed an assessment of psychometric status and participated in a functional magnetic resonance imaging (fMRI) task that involved the anticipation of financial reward (monetary incentive delay task). The size of the monetary reward was varied among trial conditions and was cued with geometric stimuli. Patients participated in additional fMRI sessions after a 6-week pharmacological treatment with escitalopram, an SSRI. RESULTS: In healthy volunteers, striatal activity increased in proportion to the size of the monetary reward during reward anticipation. This pattern was altered in MDD patients, and significant group-by-reward size interaction effects were observed in the bilateral putamen and the left ventral striatum. Reward sensitivity in motor response and striatum activity at three regions were correlated in healthy controls. In MDD patients, this neurobehavioral coupling was not observed. In addition, changes in the neural reward sensitivity parameter at the left ventral striatum in response to treatment were positively correlated with a reduction of depressive symptoms. CONCLUSIONS: Patients with MDD exhibit reduced ability to modulate neural response when adjusting for variable amount of reward. This result suggests that reward size coding in the striatum may represent a neural correlate of motivational anhedonia in MDD patients.

Increased amygdala reactivity following early life stress: a potential resilience enhancer role.

BACKGROUND: Amygdala hyper-reactivity is sometimes assumed to be a vulnerability factor that predates depression; however, in healthy people, who experience early life stress but do not become depressed, it may represent a resilience mechanism. We aimed to test these hypothesis examining whether increased amygdala activity in association with a history of early life stress (ELS) was negatively or positively associated with depressive symptoms and impact of negative life event stress in never-depressed adults. METHODS: Twenty-four healthy participants completed an individually tailored negative mood induction task during functional magnetic resonance imaging (fMRI) assessment along with evaluation of ELS. RESULTS: Mood change and amygdala reactivity were increased in never-depressed participants who reported ELS compared to participants who reported no ELS. Yet, increased amygdala reactivity lowered effects of ELS on depressive symptoms and negative life events stress. Amygdala reactivity also had positive functional connectivity with the bilateral DLPFC, motor cortex and striatum in people with ELS during sad memory recall. CONCLUSIONS: Increased amygdala activity in those with ELS was associated with decreased symptoms and increased neural features, consistent with emotion regulation, suggesting that preservation of robust amygdala reactions may reflect a stress buffering or resilience enhancing factor against depression and negative stressful events.

One-year outcomes of unipolar depression patients with manic or hypomanic switch during acute antidepressant treatment.

OBJECTIVE: The aim of the study was to investigate one-year outcomes of unipolar depression patients with manic or hypomanic switch during acute antidepressant treatment. METHODS: A review of medical records revealed 37 consecutive patients admitted from 1997 to 2002 who underwent an antidepressant-induced manic or hypomanic switch fulfilling DSM-IV criteria. Their clinical courses were retrospectively investigated after discharge. RESULTS: Of the 37 patients, 33 (89.2%) were followed up for 1 year after discharge. None developed a manic episode, while seven developed a hypomanic episode, including 1 patient who was lost after emerging from a hypomanic episode within 6 months after discharge. Only one of those seven patients developed hypomania during acute antidepressant treatment for a recurrent depressive episode under maintenance mood stabilizer treatment. Furthermore, bipolar conversion occurred in four patients within the first 6 months and in another two patients, including 1 with rapid cycling, over the subsequent 6 months after discharge. Of these 33 patients, 28 received continuous maintenance treatment with mood stabilizers for the one-year period after discharge. CONCLUSIONS: The subjects were considered to have a bipolar nature according to the prevalence rate of bipolar conversion over a one-year period. Longer follow-up studies appear warranted determine the diagnostic issues of antidepressant-induced switch in unipolar depression.