Clinical Experience of Using an 8 French Newton Shaped Catheter (Neuro-EBU) During Endovascular Treatment: A Case Series of 21 Patients.

The first step in endovascular treatment is the stable placement of a guide catheter (GC) into the target parent vessel. However, sufficient GC stabilization is sometimes difficult to obtain when the approach route has severe tortuosity. Here, we report our experience with and the usefulness of the 8 French (Fr) Newton-shaped Neuro-EBU vascular catheter (SILUX Co., Ltd., Kawaguchi City, Saitama Prefecture, Japan), which is rigid over its entire length except near the tip, in a case series of 21 patients. Of the 21 cases, 19 cases were successfully treated using the Neuro-EBU. The 8 Fr Newton-shaped Neuro-EBU might be useful both as a special GC and as a wire exchange catheter when placement of the conventional GC is difficult due to severe tortuosity of the access route. Although rarely used, the Neuro-EBU catheter can serve as a practical alternative when the access route is challenging. To the best of our knowledge, there are no detailed reports on the technical use of the Newton-shaped vascular catheter in the field of neurointervention. We present the usefulness of the specially shaped 8 Fr guide catheter.

Predictors of Cardioembolic Stroke in Japanese Patients with Atrial Fibrillation in the Fushimi AF Registry.

BACKGROUND: Large-scale clinical trials have analyzed risk factors for any ischemic stroke in patients with atrial fibrillation (AF). However, the risk factors for cardioembolic stroke (CES), specifically, have not been reported. To clarify the risk factors for CES and clinically significant cardioembolic infarction, we examined the incidence of CES and larger infarct volume (IV) (> 30 mL) CES, employing the Fushimi AF Registry, a community-based prospective cohort of AF patients in the Fushimi ward, Kyoto, Japan. METHODS: A total of 4,182 Fushimi AF patients were enrolled from March 2011 to December 2014. The risk factors for CES were evaluated using multivariate analysis. RESULTS: Of 4,182 patients enrolled, 3,749 patients were observed for ≥1 year. During the follow-up period (mean duration, 979 ± 7.7 days), 91/3,749 patients experienced a CES (2.43%). Significant risk factors associated with CES were older age (odds ratio [OR], 1.31; 95% confidence interval [CI], 1.01-1.72; p = 0.046), low body weight (OR, 1.30; 95% CI, 1.03-1.65; p = 0.033), sustained AF (OR, 1.67; 95% CI, 1.05-2.71; p = 0.034), and previous stroke or transient ischemic attack (TIA) (OR, 1.94; 95% CI, 1.22-3.06; p = 0.004). Predictors of a large IV were chronic kidney disease (CKD) (OR, 2.08; 95% CI, 1.09-4.05; p = 0.027) and previous stroke/TIA (OR, 2.27; 95% CI, 1.19-4.24; p = 0.011). CONCLUSIONS: In this population-based cohort of Japanese patients with AF, in addition to previous stroke/TIA and older age, sustained AF and low body weight emerged as risk factors for CES, as opposed to any stroke, which may have a different risk profile. Patients with CKD or previous stroke/TIA who developed cardioembolic infarction exhibited more advanced severity. There is a need for direct oral anticoagulants that can be used safely in patients with comorbid AF and CKD.

Pazopanib-mediated Long-term Disease Stabilization after Local Recurrence and Distant Metastasis of Primary Intracranial Leiomyosarcoma: A Case Report on the Efficacy of Pazopanib as a Salvage Therapy.

Primary intracranial leiomyosarcoma (LMS) is an extremely rare tumor of the central nervous system. Only sporadic case reports have been published, and therefore data regarding long-term prognosis remain scarce. A 76-year-old woman presented with a right parietal mass, which had grown rapidly in the month prior to admission. Neuroimaging showed a resemblance to intraosseous meningioma. Gross total resection of the tumor was achieved, and histological diagnosis confirmed LMS. Because positron emission tomography (PET) with fluorodeoxyglucose (FDG) just after the resection showed no abnormal uptake, we diagnosed the tumor as primary intracranial LMS. Follow-up PET at 16 months after treatment showed two foci of FDG uptake in the bilateral lungs. Histological diagnosis by surgical resection identified the lesions as lung metastases of LMS. In addition, follow-up head magnetic resonance imaging (MRI) at 31 months showed local recurrence, and we conducted salvage therapy using CyberKnife system (Accuray incorporated) and pazopanib. To date, for 15 months after local recurrence, she is alive with intracranial recurrent disease remained inactive.

Endovascular embolization of branch-incorporated cerebral aneurysms.

Objectives The aim of this study was to examine the feasibility, technique, and clinical and angiographic outcomes of endovascular coiling to treat a cerebral aneurysm with a branch incorporated into the aneurysmal wall. Methods From 2012 to 2016, 25 patients with 26 cerebral aneurysms having a branch incorporated into the aneurysm (9 unruptured, 17 ruptured) were treated to prevent rupture or re-bleeding from the sac while preserving the incorporated branch by using single-catheter ( n = 18), balloon-remodeling ( n = 4), stent-assisted coiling ( n = 3), or double-catheter ( n = 1) techniques. Results Endovascular coiling was conducted in 26 procedures without angiographic occlusion of the incorporated branch. Post-embolization angiography revealed near-complete occlusion ( n = 8; 30.7%), neck remnant ( n = 13; 50%), and incomplete occlusion ( n = 5; 19.3%) aneurysms. Thromboembolisms were observed in four (15.4%) patients during or after the procedure. A procedure-related neurological deficit was observed in one (3.8%) patient. When patients with a preictal modified Rankin Scale (mRS) score of 3 presenting with grade 5 subarachnoid hemorrhage were excluded, all patients had favorable outcomes (mRS 0-2). Six (23.1%) recurrent aneurysms were observed during follow-up, five of which were treated endovascularly at 5-22 months without complication. The location of an aneurysm at the ICA-posterior communicating artery associated with the dominant-type posterior communicating artery was significantly associated with recurrence ( p = 0.041). Conclusions Cerebral aneurysms with an incorporated branch were safely treated using conventional endovascular coiling. However, treatment durability was unsatisfactory, especially for dominant-type ICA-posterior communicating artery aneurysms.

Successful endovascular treatment of a dissecting aneurysm of vertebral artery associated with double origin of the posterior inferior cerebellar artery.

BACKGROUND: Double origin of the posterior inferior cerebellar artery (DOPICA) has been rarely reported in the literature, with a reported incidence of 1.45%. In contrast, a high concurrence rate of DOPICA and vertebral artery dissecting aneurysm has been reported. CLINICAL PRESENTATION: A 61-year old woman presented with vomiting and diplopia with preceding headache. Magnetic resonance imaging (MRI) showed fresh infarction of the left lateral medulla and a vertebral artery dissecting aneurysm of the left vertebral artery. The next day, she exhibited transient loss of consciousness and worsening of headache, and MRI depicted subarachnoid hemorrhage. Four-vessel digital subtraction angiography showed a posterior inferior cerebellar artery (PICA) arising both intracranially and extracranially from the left vertebral artery. Although the dissecting lesion involved the V3 and V4 portion, it did not involve an extracranially originating PICA. Internal trapping of the V3 and V4 portion was chosen as the extracranial channel was expected to supply the PICA territory. This procedure was safely performed. CONCLUSION: Early endovascular intervention should be considered in the treatment of dissecting aneurysm of vertebral artery associated with DOPICA for patients with relatively long lesions even in unruptured cases.

Global aphasia without hemiparesis caused by a dural arteriovenous fistula.

A 61-year-old Japanese woman with chronic renal failure suddenly became silent at the end of hemodialysis. On a neurological examination, she was unable to respond to one-step commands, state the names of objects, repeat single words, read words aloud or write her name. Because she exhibited no paralysis of the extremities, we diagnosed her as having global aphasia without hemiparesis (GAWH). Cerebral angiography showed a dural arteriovenous fistula (AVF) in the left isolated transverse sinus with leptomeningeal venous drainage (Borden type 3, Lalwani grade 4). This case highlights dural AVF as an etiology of GAWH.

Conversion of a molecular classifier obtained by gene expression profiling into a classifier based on real-time PCR: a prognosis predictor for gliomas.

BACKGROUND: The advent of gene expression profiling was expected to dramatically improve cancer diagnosis. However, despite intensive efforts and several successful examples, the development of profile-based diagnostic systems remains a difficult task. In the present work, we established a method to convert molecular classifiers based on adaptor-tagged competitive PCR (ATAC-PCR) (with a data format that is similar to that of microarrays) into classifiers based on real-time PCR. METHODS: Previously, we constructed a prognosis predictor for glioma using gene expression data obtained by ATAC-PCR, a high-throughput reverse-transcription PCR technique. The analysis of gene expression data obtained by ATAC-PCR is similar to the analysis of data from two-colour microarrays. The prognosis predictor was a linear classifier based on the first principal component (PC1) score, a weighted summation of the expression values of 58 genes. In the present study, we employed the delta-delta Ct method for measurement by real-time PCR. The predictor was converted to a Ct value-based predictor using linear regression. RESULTS: We selected UBL5 as the reference gene from the group of genes with expression patterns that were most similar to the median expression level from the previous profiling study. The number of diagnostic genes was reduced to 27 without affecting the performance of the prognosis predictor. PC1 scores calculated from the data obtained by real-time PCR showed a high linear correlation (r=0.94) with those obtained by ATAC-PCR. The correlation for individual gene expression patterns (r=0.43 to 0.91) was smaller than for PC1 scores, suggesting that errors of measurement were likely cancelled out during the weighted summation of the expression values. The classification of a test set (n=36) by the new predictor was more accurate than histopathological diagnosis (log rank p-values, 0.023 and 0.137, respectively) for predicting prognosis. CONCLUSION: We successfully converted a molecular classifier obtained by ATAC-PCR into a Ct value-based predictor. Our conversion procedure should also be applicable to linear classifiers obtained from microarray data. Because errors in measurement are likely to be cancelled out during the calculation, the conversion of individual gene expression is not an appropriate procedure. The predictor for gliomas is still in the preliminary stages of development and needs analytical clinical validation and clinical utility studies.