Eagle jugular syndrome accompanied by de novo brainstem cavernous malformation: a case-based systematic review.

BACKGROUND: Eagle jugular syndrome (EJS), recently identified as a cause of cerebrovascular disease (CVD) due to venous obstruction by an elongated styloid process (SP), is reported here alongside a case of concurrent de novo cerebral cavernous malformation (CCM). This study aims to explore the potential causal relationship between EJS and de novo CCM through a comprehensive literature review. METHOD: Systematic literature reviews, spanning from 1995 to 2023, focused on EJS cases with definitive signs and symptoms and de novo CCM cases with detailed clinical characteristics. Data on the pathophysiology and clinical manifestations of EJS, as well as potential risk factors preceding de novo CCM, were collected to assess the relationship between the two conditions. RESULT: Among 14 patients from 11 articles on EJS, the most common presentation was increased intracranial hypertension (IIH), observed in 10 patients (71.4%), followed by dural sinus thrombosis in four patients (28.6%). In contrast, 30 patients from 28 articles were identified with de novo CCM, involving 37 lesions. In these cases, 13 patients developed CCM subsequent to developmental venous anomalies (43%), seven following dural arteriovenous fistula (dAVF) (23%), and two after sinus thrombosis (6%). In a specific case of de novo brainstem CCM, the development of an enlarged condylar emissary vein, indicative of venous congestion due to IJV compression by the elongated SP, was noted before the emergence of CCM. CONCLUSION: This study underscores that venous congestion, a primary result of symptomatic EJS, might lead to the development of de novo CCM. Thus, EJS could potentially be an indicator of CCM development. Further epidemiological and pathophysiological investigations focusing on venous circulation are necessary to clarify the causal relationship between EJS and CCM.

Comparison Between Cz-C3/C4 and C3-C4 Montages to Protect Against Peripheral Stimulation in Transcranial Facial Motor-Evoked Potential Monitoring.

INTRODUCTION: In facial motor-evoked potential monitoring, efforts to reduce peripheral stimulation are necessary because it can cause false-negatives. The effects of peripheral stimulation on Cz-C3/C4 and C3-C4 montages were compared. METHODS: Facial motor-evoked potentials were recorded from bilateral orbicularis oculi (Oculi) and oris (Oris) muscles. The double-train approach combining single-pulse and five-train pulse stimulation was used to determine the effect of peripheral stimulation. If the five-train pulse produced a significant waveform, it was defined as "total success." In total success cases, "true success" was defined as a case in which no waveform appeared after the single pulse at the threshold level of the five-train pulse. The total and true success rates and the threshold value of Oculi and Oris were compared between Cz-C3/C4 and C3-C4 montages. RESULTS: Thirty-six muscles each of Oculi and Oris of 18 patients were used for the analysis. True success was more likely to be obtained by the Cz-C3/C4 montage than the C3-C4 montage in Oculi (42% vs. 22%, p = 0.039). Both Oculi and Oris had higher thresholds to elicit facial motor-evoked potentials with the Cz-C3/C4 montage (Oculi: 101.7 vs. 71.4 mA, p = 0.038; Oris: 94.8 vs. 73.1 mA, p = 0.016). CONCLUSIONS: Cz-C3/4 montage is more effective at reducing peripheral stimulation compared with the C3-4 montage. This effect was primarily seen in the orbicularis oculi muscle. It should be noted that the Cz-C3/C4 montage has a higher threshold than the C3-C4 montage in facial muscles. In facial motor-evoked potential monitoring, the Cz-C3/C4 montage may be more suitable to eliminate peripheral stimulation.

Case report: Usefulness of angioscopy in determining antiplatelet drug reduction after carotid artery stenting.

We report a case in which neointima was confirmed by angioscopy and antiplatelet drug administration was reduced 2 months after carotid artery stenting (CAS). A patient in their 80s was scheduled to undergo resection for renal cancer; however, he also had right cervical internal carotid artery stenosis. Because this was a risk for general anesthesia, CAS was performed after first starting dual antiplatelet therapy. Urologically, early reduction of antiplatelet drugs was necessary for a nephrectomy. Although no obvious neointima could be identified on ultrasound 2 months after CAS, thin neointima was observed using angioscopy. Based on the above results, we reduced the antiplatelet drug administration, and then the nephrectomy was performed. Ultimately, no cerebral infarction occurred in the perioperative or postoperative periods. Angioscopy allows for visual confirmation of thin neointima. If sufficient neointima can be confirmed, antiplatelet drug reduction can be performed more safely and reliably.

A Novel Approach for Transvenous Embolization of Dural Arteriovenous Fistula Using a Balloon and a Coil as Walls: Case Presentation.

BACKGROUND: Transvenous embolization (TVE) for dural arteriovenous fistula (DAVF) is difficult depending on an accessible route. Reported herein is a case of transvenous embolization using a balloon and a coil as "walls." Case Description. A 56-year-old male patient presented with a 1-month history of mild motor aphasia. The magnetic resonance imaging showed a hemorrhagic lesion in his left temporal lobe, and the cerebral angiography showed a DAVF, with parasinus shunt points near the torcula and the left transverse sinus. Access to the shunt point was very difficult; however, TVE was performed using a balloon as a wall. Furthermore, all lesion embolization was possible using a coil as a wall. CONCLUSIONS: Using a balloon or coil as a wall during a TVE is useful.

Cerebral vasospasm after coil embolization for unruptured anterior communicating artery aneurysm: illustrative case.

BACKGROUND: Compared with several reports of cerebral vasospasm after clipping for unruptured cerebral aneurysm, only one study to date has reported cerebral vasospasm after coil embolization. Herein, the authors report a rare case of cerebral vasospasm after coil embolization for unruptured cerebral aneurysm. OBSERVATIONS: A 58-year-old woman with an unruptured anterior communicating artery aneurysm was referred to our department. Stent-assisted coil embolization was performed for the aneurysm, and no obvious adverse events were observed on cerebral angiography obtained immediately after the operation. However, the patient developed mild headache and slight restlessness soon after the operation and new-onset disorientation, left hemispatial neglect, and left hemiplegia the day after the operation. Emergency brain magnetic resonance imaging and cerebral angiography indicated vasospasm in the right middle cerebral artery, and intra-arterial injection of fasudil hydrochloride hydrate was performed to dilate the middle cerebral artery. Blood flow in the middle cerebral artery immediately improved, and she was discharged without neurological deficits 8 days after the operation. LESSONS: Immediate intervention is necessary to prevent cerebral infarction in patients with cerebral vasospasm, which may occur even after coil embolization for unruptured cerebral aneurysm.

Navigation-assisted full-endoscopic spine surgery: a technical note.

BACKGROUND: Full-endoscopic spine surgery (FESS) necessitates the use of X-ray fluoroscopy for intraoperative guidance and orientation. However, the two-dimensional X-ray fluoroscopic images do not provide real-time guidance. The authors developed a new real-time three-dimensional (3D) navigation technique for FESS that entails the use of intraoperative cone beam computed tomography (CBCT) in a hybrid operating room (OR). METHODS: A total of 23 patients undergoing FESS using real-time 3D navigation system were enrolled. Preoperative and intraoperative CBCT data were registered in the navigation system. The 3D navigation was used to intraoperatively determine the trajectory and obtain position information. The feasibility and usefulness of the navigation system were retrospectively analyzed. RESULTS: Twenty patients had lumbar spine disease, whereas three patients had cervical spine disease. The 3D navigation was successfully used for intraoperative guidance and provided accurate information in all patients. X-ray fluoroscopy was not required in any of the patients. No complications associated with the use of 3D navigation system were encountered. CONCLUSIONS: The use of real-time 3D navigation system in the hybrid OR was found to be safe and effective in providing intraoperative guidance for FESS.

Optimum concentration of iodine contrast agent injection for best stent visualization using Neuroform Atlas stent during stent-assisted coil embolization: Case reviews based on in vitro experiments.

BACKGROUND: The present study aimed to evaluate the influence of contrast agent concentration (Conc) on the visibility of Neuroform Atlas in vitro and in clinical cases. METHODS: A plastic tube was filled with several Conc. in saline (experiment 1) and blood (experiment 2). Thereafter, the Neuroform Atlas was placed around the plastic tube in an acrylic shield case. In experiment 3, the Neuroform Atlas was placed in the internal carotid artery of the endo vascular evaluator endovascular training system with an injection of several Conc in saline. Five slices of the axial images obtained using the 3D-cone-beam computed tomography (3D-CBCT) with the digital subtraction angiography system were evaluated. A 1-cm2 circular center, which showed the contrast agent in saline or blood, was determined as the region of interest, and its pixels were evaluated. RESULTS: Radiation density (Rd) was directly proportional to the contrast agent in saline and blood (experiment 1: (Rd (pixel)) = 6.8495 × (concentration (%)) + 152.72 (R2 = 0.99), experiment 2: (Rd (pixel)) = 6.2485 × (concentration (%)) + 167.42 (R2 = 0.9966), experiment 3: (Rd (pixel)) = 10.287 × (concentration (%)) + 108.26 (R2 = 0.993)]. Rd calculated similarly in our cases (concentration varied from 5% to 8%) was between the range of "Rd of experiment 2" and "Rd of experiment 3." CONCLUSION: Based on our in vitro experiments, with 5-8% concentration, Neuroform Atlas stent deployment with complete neck coverage by the bulging stent and wall apposition was visualized on 3D-CBCT.

Supratentorial convexity schwannoma unrelated to cranial nerves: Case report and review of the literature.

BACKGROUND: Intracranial schwannoma not related to cranial nerves is rare entity, and difficult to be diagnosed preoperatively. Here, we experienced a case of convexity schwannoma mimicking convexity meningioma, and discuss about the characteristics of such cases based on the past published reports. CASE DESCRIPTION: A 48-year-old man presented with a sudden onset of seizures. Brain magnetic resonance image (MRI) revealed a small mass lesion in the peripheral aspect of the right parieto-frontal lobe. The mass was isointense on T1-weighted and hyperintense on T2-weighted MRI, with homogenous enhancement after contrast medium administration. After the feeder embolization on the previous day, removal of the tumor was performed. The tumor revealed a well-demarcated, firm, spherical tumor beyond, and beneath the dura and was relatively easy to be separated from the brain. Histologically, the tumor was observed to be in subarachnoid space extending to outer space of dura-mater, intimately attached to the pia mater. The histological diagnosis was schwannoma. CONCLUSION: In our case, MRI findings are similar to convexity meningioma; however, the pathological diagnosis was schwannoma. Cerebral convexity is an extremely rare location for schwannoma. We emphasize that schwannoma, not related to cranial nerves, may arise in the subdural convexity space.

Efficacy of endoscopic transsphenoidal surgery for cushing's disease: Case series and review of the literature.

BACKGROUND: This study was performed to examine the efficacy of endoscopic transsphenoidal surgery (ETS) for Cushing's disease at a single institute and to review past reports. MATERIAL AND METHODS: We studied eight consecutive patients who underwent ETS for Cushing's disease. The radiological evaluation comprised a detailed examination of preoperative magnetic resonance images (MRIs), including inferior petrosal sinus sampling, for cases with normal renal function. Remission was evaluated at least three months after surgery and was defined by the presence of hypocortisolemia that required steroid replacement therapy or eucortisolemia with suppression to <1.8 µg/dL after 1mg of dexamethasone. RESULTS: In all cases preoperative MRI was abnormal and included two macroadenomas (25 %). Pathological confirmation of an adenoma was possible in all patients. The mean follow-up period was 5.6 (2-7) years. Remission was confirmed in 75.0% of the cases and was higher in rate for microadenoma (100%) than for macroadenoma (50%). Postoperatively , no cerebrospinal fluid rhinorrhea occurred, but new endocrine deficits were noted in 25% of patients. CONCLUSION: Based on this study, ETS enhanced the intrasellar identification of adenomatous tissue, which led to low remission and complication rates that were comparable with those of traditional microsurgery for Cushing's disease.

Delayed Intracranial Parenchymal Changes After Aneurysmal Coil Embolization Procedures for Unruptured Intracranial Aneurysms.

BACKGROUND: With the recent advances in endovascular treatment devices, it has become standard in wide-neck or large intracranial aneurysms to perform coil embolization with adjunctive techniques. However, device-related perioperative complications have been reported because of the use of more complex systems. OBJECTIVE: To investigate patients who developed multiple parenchymal lesions after undergoing coil embolization for treating an unruptured intracranial aneurysm. METHODS: This study investigated 305 consecutive patients who underwent coil embolization of unruptured intracranial aneurysms between 2015 and 2017. Delayed inflammatory changes referred to the delayed observation of multiple cerebral white matter lesions on follow-up magnetic resonance imaging at an area corresponding to the perfused area of the treatment target vessel. The timing and pattern of onset, device used, the combined use of adjunctive techniques, and the clinical course after steroid treatment were retrospectively investigated. RESULTS: The 7 patients (2.3%) who showed delayed inflammatory changes were all women with a mean age of 59 yr. A mean duration from treatment to onset was 28 d. Symptoms were convulsions in 3 patients, hemiplegia in 2 patients, and homonymous hemianopia in 1 patient. All 7 patients were treated with adjunctive technique including stents, double catheter method, and balloon assist. Response to steroid treatment was satisfactory both clinically and on imaging in all 7 patients. Skin patch test was positive for nickel allergy in 2 patients. CONCLUSION: Clinicians must be fully aware of symptomatic delayed inflammatory changes may occur after endovascular aneurysmal treatment with the use of various devices.

Transdural Indocyanine Green Videography for Superficial Temporal Artery-to-Middle Cerebral Artery Bypass-Technical Note.

BACKGROUND: Neurosurgical application of indocyanine green (ICG) videography before performing a dural opening, known as transdural ICG videography, has been used during surgery of meningiomas associated with venous sinuses as well as cranial and spinal arteriovenous malformations. However, its use for a superficial temporal artery (STA)-to-middle cerebral artery (MCA) bypass has not been reported. METHODS: We performed a retrospective analysis of medical records of patients who underwent transdural ICG videography during STA-MCA bypass performed between January 2012 and March 2015. The primary outcome was visualization of recipient cortical arteries; secondary outcomes were surgical modifications and complications as well as any adverse events associated with transdural ICG videography. RESULTS: We analyzed 29 STA-MCA bypass procedures performed in 30 hemispheres with atherosclerotic steno-occlusive disease and found that the proper recipient was identified in 28 hemispheres. Subsequently modified procedures for those were a tailored dural incision and craniotomy correction. No complications associated with ICG administration were encountered; during the postoperative course, transient aphasia was noted in 1 case, chronic subdural hematoma was noted in 1 case, and subdural effusion was noted in 2 cases. CONCLUSIONS: Transdural ICG videography for atherosclerotic steno-occlusive disease facilitates modifications during STA-MCA bypass procedures. Recognition of the proper recipient cortical arteries before a dural incision allows the neurosurgeon to perform a tailored dural incision and extension of the bone window, although the contribution to surgical outcome has yet to be determined.

Endovascular Therapy for the Steal Phenomenon due to the Innominate Artery Severe Stenosis and Bilateral Internal Carotid Artery Severe Stenosis.

BACKGROUND: Symptomatic innominate artery stenosis presenting as hemodynamic bilateral cerebral ischemia is uncommon. We present a rare case of the severe stenosis of the origin of an innominate artery and severe stenosis of bilateral internal carotid artery that induced hemodynamic cerebral ischemia after ipsilateral axillary artery-bilateral femoral artery bypass and was treated with stent replacement of the innominate artery and right internal carotid artery. CASE REPORT: A 64-year-old woman who previously had undergone right axillary artery-bilateral femoral artery anastomosis for abdominal aorta high obstruction had been suffering from chronic dizziness and so visited our department. Findings of the examination included the severe stenosis of the origin of an innominate artery and severe stenosis of bilateral internal carotid artery, causing hemodynamic cerebral ischemia. She underwent stent replacement of the innominate artery and right carotid artery stenting via a right transbrachial approach. Her symptoms were relieved postoperatively. DISCUSSION: For the sake of improving the hemodynamic cerebral ischemia, we performed stent replacement for innominate artery stenosis and right carotid artery stenting. Endovascular treatment of subclavian and innominate artery disease is a safe procedure. In addition, for the protection of thromboembolic migration, we performed balloon protection of the external carotid artery and filter protection of the internal carotid artery. CONCLUSIONS: Stent replacement for these lesions can be performed safely with the right approach and protection methods, even when the only accessible route is the right brachial artery.

[A Case of a Pituitary Adenoma Diagnosed as Carney Complex Syndrome in an Older Female Patient].

Carney complex syndrome is an autosomal dominant familial tumor syndrome first described by Carney et al. in 1985. The diagnostic criteria include endocrine hyperactivity and spotty skin pigmentation. A 73-year-old woman with cerebral infarction was referred to our department because her brain magnetic resonance imaging(MRI)revealed a pituitary tumor. Her blood tests revealed elevated levels of growth hormone(GH), thyroid stimulating hormone(TSH), and insulin-like growth factor-1(IGF-1). We suspected the presence of a GH-secreting tumor and performed the operation. The pathological finding was a TSH-positive pituitary adenoma. Her cervical computed tomography(CT)revealed a thyroid tumor and the tumor removal was performed. The pathological diagnosis was papillary carcinoma. She had skin pigmentation bilaterally on her face, forearms, hands, and legs. We diagnosed this case as Carney complex syndrome based on these findings.

Effectiveness of Intracranial Percutaneous Transluminal Angioplasty or Stenting for Atherosclerotic Vertebrobasilar Artery Occlusion in the Acute Phase of Ischemic Stroke.

OBJECTIVE: Although short-term clinical outcomes after basilar artery stent placement have been reported previously, effectiveness of intracranial stenting for vertebrobasilar artery occlusion in the acute phase of ischemic stroke is unclear. METHODS: We clinically investigated 8 patients with intracranial percutaneous transluminal angioplasty (PTA) or stenting as our protocol for symptomatic atherosclerotic vertebrobasilar artery occlusion (age range, 54-80 years; mean age, 69 ± 11 years; 6 men and 2 women) who were admitted to our hospital between August 2013 and December 2015. RESULTS: Two patients underwent PTA of the vertebrobasilar artery 2-5 months before stent placement. The other 6 patients underwent intracranial stenting just after PTA. Within the first 30 days after vertebrobasilar artery stent placement, 2 ischemic stroke complications affected patients. Ischemic complications were significantly associated with prestent lesion lumen greater than 0.5 mm. The modified Rankin Scale score and clinical outcome were significantly associated with complications. Clinical outcomes correlate with ischemic complications and vertebrobasilar anatomy. CONCLUSIONS: Stent angioplasty may be a reasonably good treatment option for patients with technically favorable lesions, especially in vertebrobasilar atherosclerotic occlusion with medically or PTA only refractory symptoms. Despite a significant complication rate, most of our patients experienced good to excellent clinical outcomes and were free of vertebrobasilar ischemia at late midterm follow-up.

Coil Embolization for Ruptured Basilar Tip Aneurysm After Mechanical Thrombectomy for Acute Basilar Artery Occlusion.

BACKGROUND: There is no published report of ruptured cerebral aneurysm accompanied by target vessel occlusion. We present a case of ruptured basilar tip aneurysm with concomitant basilar artery (BA) occlusion. CASE DESCRIPTION: A 53-year-old man presented to our emergency room with the acute onset of disturbance. Plain head computed tomography showed diffuse subarachnoid hemorrhage. Computed tomography angiography and digital subtraction angiography showed a BA tip aneurysm with BA trunk occlusion. Endovascular treatment with mechanical thrombectomy using a stent retriever and coil embolization was performed. Clinical and radiologic results were good. The patient was discharged 30 days after onset (modified Rankin Scale score = 1). CONCLUSIONS: We were able to recanalize the BA trunk and perform coil embolization of the ruptured BA tip aneurysm. Our case is the first published report of a ruptured aneurysm with target large-vessel occlusion. Awareness of the issues raised in this case is required to determine the best treatment strategy, and preoperative consideration allows neurointerventionalists to avoid unpleasant surprises in the angiography suite.

Relationship Between Clinical Features and T2-Weighted Magnetic Resonance Images in Symptomatic Rathke Cleft Cysts.

BACKGROUND: It is not known when surgery is appropriate for the treatment for incidental Rathke cleft cysts because knowledge of their natural history is lacking. In this study, we sought to determine whether symptomatic Rathke cleft cysts could be distinguished by their signal intensities in magnetic resonance (MR) images. We analyzed the relationship between these signal intensities and clinical manifestations of the cysts and their patterns of expansion. METHODS: MR signal intensities on T1-weighted (T1W) and T2-weighted (T2W) images for 52 cases were categorized into 3 types. Type 1 (20 cases) showed low signal intensities on T1W images and hyperintensity on T2W images. Type 2 (10 cases) showed hyperintensity on both T1W and T2W images. Type 3 (22 cases) showed hypointensity on T2W images. RESULTS: A significantly higher proportion of patients with type 1 signal intensities had large cysts compressing their third ventricle than patients with the other 2 types of signal intensities. Patients with type 1 signal intensities also frequently had visual disturbances. Anterior pituitary dysfunction was observed more often in patients with type 2 or 3 signal intensities than in patients with type 1 intensities. CONCLUSIONS: We conclude that Rathke cleft cysts that show an MR signal intensity similar to that of cerebrospinal fluid grow slowly and are frequently diagnosed as cysts associated with visual disturbance when they become large. It may be possible to predict the clinical progression of Rathke cleft cysts by assessing MR signal intensities.

Carotid artery stenosis is exacerbated in spontaneously obese model rats with diabetes.

AIM: Population studies have shown obesity and diabetes to be risk factors for atherosclerosis. We assessed changes in the common carotid arteries in rat models of obesity and diabetes without hypertension. METHODS: Twenty 30-week-old male spontaneously diabetic and obese model Otsuka Long-Evans Tokushima Fatty (OLETF) and 20 control Long-Evans Tokushima Otsuka (LETO) rats were used in the experiments. The animals were considered diabetic if the plasma glucose level peaked at >300 mg/dL and remained at >200 mg/dL for 120 minutes. Blood gas physiological parameters were continuously monitored under anesthesia, and the flow of the carotid artery was assessed with ultrasonography. All animals were sacrificed with an overdose of anesthesia at the end of the experiment. Sections of the middle portion of the internal carotid artery were cut and stained with hematoxylin and eosin to assess the overall morphology. RESULTS: All OLETF rats were diabetic, and all LETO rats were non-diabetic. The physiological parameters did not differ significantly between the control and model rats, whereas the carotid artery wall thickness (19.3 ± 3.2 vs. 6.1 ± 4.5 µm) was significantly different between the two groups. The blood flow velocity in the common carotid artery determined using ultrasonography and color Doppler sonography was significantly increased during systole in the model rats compared with that observed in the control rats (203 ± 20.3 vs. 55.3 ± 21.4 cm/sec). CONCLUSIONS: The OLETF rats were obese, and diabetes worsened the degree of carotid artery stenosis. These results indicate the possibility of new therapies for carotid artery stenosis in obese and diabetic patients.

Intradural extramedullary ganglioneuroma associated with multiple hamartoma syndrome.

A 51-year-old woman presented with a rare completely intradural and extramedullary spinal ganglioneuroma associated with multiple hamartoma syndrome and manifesting as complaints of neck pain and dizziness persisting for 8 months. Magnetic resonance imaging of the spinal cord revealed an intradural extramedullary lesion at the C1 level. She underwent right suboccipital craniectomy and C1-2 hemilaminectomy to remove the tumor. Histological examination confirmed ganglioneuroma. She also suffered from multiple facial trichilemmomas, thyroid goiter, multiple polyposis of the gastrointestinal tract, and pulmonary hamartoma indicating multiple hamartoma syndrome. These benign neoplasms were treated conservatively.

Dural repair for intraspinal extradural meningeal cyst.

A 52-year-old woman presented with an intraspinal extradural meningeal cyst in the thoracolumbar region manifesting as progressive sensory disturbance of the bilateral lower extremities. Magnetic resonance imaging and computed tomography myelography showed an extradural meningeal cyst extending from the T-12 to L-4 levels in the thoracolumbar region with a dural defect and a valve-like mechanism developed in the enlarging cyst. Operative findings revealed a dural defect that allowed communication between the extradural cyst cavity and the subarachnoid space. Surgical resection of the cyst wall and repair of the dural defect resolved the symptoms.