Shorter survival time of adolescents and young adult patients than older adults with spinal cord glioblastoma: a multicenter study.

OBJECTIVE: Cancers in adolescents and young adults (AYAs) (age 15-39 years) often present with unique characteristics and poor outcomes. To date, spinal cord glioblastoma, a rare tumor, remains poorly understood across all age groups, including AYAs. This comparative study aimed to investigate the clinical characteristics and outcomes of spinal cord glioblastoma in AYAs and older adults (age 40-74 years), given the limited availability of studies focusing on AYAs. METHODS: Data from the Neurospinal Society of Japan's retrospective intramedullary tumor registry (2009-2020) were analyzed. Patients were dichotomized on the basis of age into AYAs and older adults. Univariate and multivariate Cox proportional hazards regression models were utilized to explore risk factors for overall survival (OS). RESULTS: A total of 32 patients were included in the study, with a median (range) age of 43 (15-74) years. Of these, 14 (43.8%) were AYAs and 18 (56.2%) were older adults. The median OS was 11.0 months in AYAs and 32.0 months in older adults, and the 1-year OS rates were 42.9% and 66.7%, respectively, with AYAs having a significantly worse prognosis (p = 0.017). AYAs had worse preoperative Karnofsky Performance Status (KPS) than older patients (p = 0.037). Furthermore, AYAs had larger intramedullary tumors on admission (p = 0.027) and a significantly higher frequency of intracranial dissemination during the clinical course (p = 0.048). However, there were no significant differences in the degrees of surgical removal or postoperative radiochemotherapy between groups. The Cox proportional hazards regression model showed that AYAs (HR 3.53, 95% CI 1.17-10.64), intracranial dissemination (HR 4.30, 95% CI 1.29-14.36), and no radiation therapy (HR 57.34, 95% CI 6.73-488.39) were risk factors for mortality for patients of all ages. Worse preoperative KPS did not predict mortality in AYAs but did in older adults. The high incidence of intracranial dissemination may play an important role in the poor prognosis of AYAs, but further studies are needed. CONCLUSIONS: The clinical characteristics of AYAs with spinal cord glioblastoma differ from those of older adults. The prognosis of AYAs was clearly worse than that of older adults. The devastating clinical course of spinal glioblastoma in AYAs was in line with those of other cancers in this age group.

Impact of surgical treatment for intramedullary spinal cord metastasis on neurological function and survival: A multicenter retrospective study by the Neurospinal Society of Japan.

BACKGROUND: This retrospective multicenter study aimed to analyze the characteristics and surgical outcomes of intramedullary spinal cord metastasis (ISCM) and to discuss the controversy regarding its surgical indications. METHODS: This study included 29 ISCM patients who underwent surgery between 2009 and 2020. Biopsy cases were excluded from analysis. For functional and neurological functional assessments, Karnofsky Performance Status (KPS, %) and modified McCormick Scale (MMS, 5-grade scale) scores were determined before and after surgery. Patients were divided into two groups: a mild-to-moderate disability group with preoperative MMS grades 1 to 3, and a severe disability group with preoperative MMS grades 4 to 5. RESULTS: The mean preoperative KPS was 45.9, and the mean duration from symptom onset to surgical intervention was 1 month. The ISCM was located in the cervical spine in 10 cases and the thoracic spine in 19 cases. The access route (myelotomy) for ISCM removal was via the posterior median sulcus in 9 cases and via the posterior lateral sulcus in 11 cases, while others were not recorded. The degree of removal was gross total resection in 20 patients (69%), subtotal resection in 0 patients, and partial removal in 9 patients (31%). No significant complications related to the surgical procedures were recorded. Postoperative adjuvant therapy included radiotherapy in 17 patients (58.6%) and chemotherapy or molecular targeted therapy in 13 patients (44.8%). Pathological findings of ISCM showed that colorectal cancer was the most common in 9 cases, followed by lung cancer in 7, renal cell carcinoma in 5, and breast cancer in 2. Twenty-one of the 29 patients (72.4%) were confirmed to have survived 6 months after surgery: 8 of the 10 patients (80%) in the mild-to-moderate disability group and 13 of the 19 patients (68.4%) in the severe disability group. At 6 months after surgery, 3 of the 8 patients (38%) in the mild-to-moderate group were able to maintain or improve their function. Eleven of the 13 patients (85%) in the severe disability group maintained their function despite being severely disabled. CONCLUSIONS: This study suggests that surgical treatment can maintain or improve neurological function in a limited number of patients with ISCM, although it had minimal impact on improving the survival rate after surgery.

Spinal Cord Subependymoma: A Subanalysis of the Neurospinal Society of Japan's Multicenter Study of Intramedullary Spinal Cord Tumors.

OBJECTIVE: This study aimed to analyze the clinical characteristics, treatment strategies, and surgical outcomes of subependymoma patients from the 2022 Neurospinal Society of Japan multicenter intramedullary spinal cord tumor study. METHODS: Twenty-six patients with spinal cord subependymoma who were included in the index study of 1,033 patients were retrospectively analyzed. RESULTS: Mean patient age was 49.4 years. Seventeen patients were men and 9 were women. Sensory disturbance was reported in 22 patients and motor weakness in 18. Median duration of symptoms was 24 months. The tumor was eccentrically located in 19 patients (73.1%) and unilateral in 17 (65.4%). Gross total resection was achieved in 6 patients (23.1%). The same rate for ependymoma patients in the index study was significantly higher (74.8%). Median follow-up was 40.5 months (interquartile range, 18-68 months). In 2 patients who underwent only partial resection, reoperation was required owing to progression 68 and 90 months after surgery, respectively. No recurrence occurred in patients who underwent gross total resection. Five patients experienced neurological worsening after surgery. CONCLUSION: Although spinal cord subependymoma can be difficult to distinguish from other intramedullary spinal cord lesions before surgery, it is characterized by an indolent clinical course and eccentric location. Surgical treatment should prioritize functional preservation because the prognosis is good even after subtotal resection.

The Prediction of Neurological Prognosis for Cervical Spondylotic Myelopathy Using Diffusion Tensor Imaging.

OBJECTIVE: Although cervical spondylotic myelopathy (CSM) can be easily diagnosed using magnetic resonance imaging (MRI), prediction of surgical effect using preoperative radiological examinations remains difficult. In previous studies, it was reported that diffusion tensor imaging (DTI) may be used for the prediction of surgical effect; however, these studies did not consider the influences of spinal cord compression even though the values of DTI indexes can be distorted by compressive lesions in patients with CSM. Therefore, it is uncertain whether preoperative DTI indexes can actually predict the surgical effect. The aim of this study was to investigate DTI metrics that are hardly affected by spinal cord compression and can accurately predict neurological status after decompressive surgery. METHODS: Twenty-one patients with CSM who underwent surgery and 10 healthy volunteers were enrolled in this study. The subjects underwent cervical MRI, and values of DTI indexes including axial diffusivity (AD), radial diffusivity (RD), apparent diffusion coefficient (ADC), and fractional anisotropy (FA) were recorded at each intervertebral level. Further, the Japanese Orthopaedic Association (JOA) score of each patient with CSM was recorded before and after surgery for neurological status evaluation. Preoperative and postoperative values of DTI indexes were compared, and correlations between preoperative DTI parameters and postoperative neurological recovery were assessed. RESULTS: After surgery, the lesion-adjacent (LA) ratios of RD and ADC increased (p = 0.04 and p = 0.062, respectively), while the LA ratio of FA decreased (p = 0.075). In contrast, the LA ratio of AD hardly changed. A negative correlation was observed between preoperative LA ratio of AD and JOA recovery rate 6 months after surgery (r = -0.379, p = 0.091). Based on preoperative LA ratio of AD, the patients were divided into a low AD group and a high AD group, and JOA recovery rate 6 months after surgery was found to be higher in the low AD group than in the high AD group (p = 0.024). CONCLUSION: In patients with CSM, preoperative LA ratio of AD is seldom affected by spinal cord compression, and it negatively correlates with JOA recovery rate 6 months after surgery.

Increased muscle fiber fractional anisotropy value using diffusion tensor imaging after compression without fiber injury.

BACKGROUND: Recent studies have indicated that injuries such as muscle tears modify the microstructural integrity of muscle, leading to substantial alterations in measured diffusion parameters. Therefore, the fractional anisotropy (FA) value decreases. However, we hypothesized that soft tissue, such as muscle tissue, undergoes reversible changes under conditions of compression without fiber injury. PURPOSE: To evaluate the FA change due to compression in muscle tissue without fiber injury. MATERIAL AND METHODS: Diffusion tensor imaging (DTI) was performed on both feet of 10 healthy volunteers (mean age = 35.0 ± 10.39 years; age range = 23-52 years) using a 3.0-T magnetic resonance imaging (MRI) scanner with an eight-channel phased array knee coil. An MRI-compatible sphygmomanometer was applied to the individuals' lower legs and individuals were placed in a compressed state. Then, rest intervals of 5 min were set in re-rest state after compression. The FA value, apparent diffusion coefficient (ADC), and eigenvalues (λ1, λ2, λ3) of the gastrocnemius and soleus muscle were measured at each state. RESULTS: The mean FA values increased in all muscles in a compressed state, while the mean λ3 decreased. In all muscles, significant differences were found between the rest and compressed states in terms of mean FA and λ3 (P < 0.0001). CONCLUSION: We confirmed the reversibility of the DTI metrics, which suggests that there was no muscle injury during this study. In cases of compression without fiber injury, the FA value increases, because fibers are strongly aligned in the longitudinal direction.

Preoperative dorsal disc height is a predictor of indirect decompression effect through oblique lateral interbody fusion in lumbar degenerative stenosis.

The extent of indirect decompression after oblique lateral interbody fusion (OLIF) is one of the most important factors in deciding the strategy. To assess the radiographical predictors of the effect of indirect decompression in patients with lumbar degenerative spondylosis by OLIF. Thirty-two consecutive patients who underwent OLIF at 58 lumbar disc levels were enrolled in this study. The radiographic measurements included central disc height (cDH), dorsal disc height (dDH), right/left foraminal height in sagittal plane computed tomography (CT), and cross-sectional dural sac antero-posterior diameter (CDSD) in axial plane CT. All patients were followed up for 1 year after surgery. All CT parameters (cDH, dDH, CDSD, right foraminal height [RFH], and left foraminal height [LFH]) significantly increased after OLIF (P < .0001). The mean raised height difference was 4.3, 3.4, 3.4, and 2.6 mm for cDH, dDH, RFH, and LFH, respectively. The mean CDSD increase was 1.4 mm. The median values of post/pre-operation (change rates) were 1.5 times in cDH, 1.9 times in dDH, and 1.2 times in CDSD, RFH, and LFH. RFH and LFH change rates were related with both cDH and dDH change rates, while the CDSD change rate was only associated with the dDH change rate (P = .0206*) but not with cDH (P = .2061). There was a significant negative relationship between the CDSD change rate and preoperative dDH (P = .0311*, R2 = 0.0817) but not with preoperative cDH (P = .4864). OLIF should be avoided for patients with preserved high dDH.

[Function and Anatomy of the Spinal Cord].

The spinal cord comprises a crucial neural network, which is connected to the brain. Due to the fragility of the spinal cord, it is surrounded by the spine for protection. It is vital in clinical diagnosis to understand the role of the spinal tracts(lateral corticospinal tract, lateral spinothalamic tract, and posterior column)and the local circuit(anterior and posterior horns).

Identification of plaque location using intraoperative indocyanine green during carotid endarterectomy for patient with near occlusion.

BACKGROUND: Microscope-integrated near-infrared indocyanine green (ICG) videoangiography (VA) is an effective method of intraoperative blood-flow assessment and identification of plaque location during carotid endarterectomy (CEA). However, the validity of ICG-VA during CEA for patient with near occlusion has not been elucidated. METHODS: Thirty-four CEA procedures were performed between June 2009 and December 2017 for patient with near occlusion, which are more than 95% stenosis. The lesions were classified into three groups according to the diameter of distal ICA compared with ipsilateral external carotid artery (ECA), as normal diameter (>100%), moderate diameter reduction (50-100%), severe diameter reduction (<50%). Five mg of ICG was injected intravenously before arteriotomy, and ICG-VA was taken to identify the distal end of the plaque. Depiction of the distal end and its accuracy were retrospectively reviewed. RESULTS: There were 18 cases with normal diameter group, 14 cases with moderate diameter reduction group, and 2 cases with severe diameter reduction group. All but one case in the severe diameter reduction group showed apparent distal end signal which were confirmed by arteriotomy afterward. CONCLUSIONS: The present study clearly denotes that ICG-VA can visualize the carotid plaque distal end during the CEA, even with the patient with near occlusion. However, it should be noted that there may be a difficulty in visualization of the distal plaque end for patient with severely collapsed distal ICA.

The validity of the acute stroke assessment using rapid pseudo-continuous arterial spin labeling (ASAP-ASL) method for acute thrombectomy.

BACKGROUND: Recent clinical trials demonstrated the efficacy of thrombectomy for ischemic stroke against acute large vessel occlusion (LVO). To overcome the problem with excessive examination time for diagnosis of cerebral perfusion and/or the use of contrast agent to determine penumbra, we adopted a new magnetic resonance imaging technique named Acute Stroke Assessment using rapid Pseudo-continuous arterial spin labeling (ASAP-ASL) method. METHODS: The study included healthy volunteers and clinical patients. The signal to noise ratio (SNR) and acquisition time were compared with various numbers of signal average (NSA) of rapid pseudo-continuous arterial spin labeling (pCASL) using the 10-mm thick slice width and narrow scan range focusing the level of basal ganglia by healthy volunteers. After applying clinically acceptable protocol for ASAP-ASL, we then checked image qualities and an accuracy of the method by comparing with the angiographical imaging obtained from the clinical patients regarding the degree of consistency. RESULTS: NSA were compared between two and fourteen, and 10 NSA was decided to be introduced for clinical use (1 minutes and 17 second) for obtaining clinically acceptable image, which was shorter than the time required for ordinary whole brain pCASL (approximately 5 minutes). In the clinical study, the occlusion site estimated by ASAP-ASL showed high correlation with that of digital subtraction angiography (κ=0.63-0.79). CONCLUSIONS: ASAP-ASL method requires approximately one minutes to obtain clinically relevant brain perfusion imaging which can successfully identify ischemic region in LVO patients.

[A Case of Positional Vertebral Artery Occlusion due to Physiological Cervical Extension with Occipital Condylar Spur].

Positional vertebral artery occlusion(PVAO)is a mechanical occlusion of the extracranial vertebral artery(VA)due to physiological movement of the head and neck. However, only a few cases of mechanical VA compression due to routine flexion-extension of the neck have been reported. We present a unique case of PVAO due to neck extension with an occipital condylar spur. A 78-year-old man was admitted to our hospital for sudden onset of right hemiparesis and dysarthria. Magnetic resonance imaging(MRI)revealed bilateral occipital and cerebellar infarctions and vessel occlusion extending from the VA to the basilar artery. Mechanic thrombectomy resulted in partial recanalization. Computed tomography angiography(CTA)performed the next day showed spontaneously recanalized left VA with some wall irregularity. CTA in the neck-extended position revealed a severely compressed left VA in its V3 segment, which was attributed to the left occipital condylar spur with degenerative changes of the condyle-C1 facet. Cervical MRI also showed a pseudotumor from the lower clivus to the odontoid process that indicated mechanical stress on the occipitocervical ligaments. An occiput to C2 fusion was performed to stabilize and avoid dynamic vascular compression. Postoperative CTA revealed no evidence of restricted flow with flexion or extension movements of the neck. It should be noted that physiological head and neck movements accompanied by condylar degenerative changes could be a cause of vertebrobasilar insufficiency.

[Successful Total Resection with Preceding Arterial Coil Embolization of Intradural Extramedullary Tumor at Craniovertebral Junction Encasing Dominant-side Vertebral Artery].

OBJECTIVE: The surgical resection of craniovertebral junction(CVJ)meningioma is challenging because of the neighboring brainstem, lower cranial nerves, and vertebral artery(VA). Moreover, encasement of the VA by the tumor can raise the risk of complications and require cautious manipulation during surgery. CASE: A 46-year-old woman presented with a one-year history of neck pain. She had temporal hemiplegia and numbness on her left side. Magnetic resonance imaging(MRI)showed a CVJ meningioma pushing the brainstem from the right vertebral side and encasing the right VA. Digital subtraction angiography(DSA)showed two feeding arteries arising from the right VA and a sunburst sign. The right VA was the dominant side but did not have the right posterior inferior cerebellar artery(PICA). The anterior spinal artery(ASA)was dominant in the left VA. We performed a balloon test occlusion(BTO)for 20 min and it did not cause any complications;therefore, we occluded the VA using endovascular coils. After 4 days, we removed the meningioma in the prone position, using a far-lateral approach and C1-laminectomy. The laterally located meningioma pushed the brainstem. After detaching the tumor from the dura, we cut the encased VA and the tumor was resected safely(Simpson grade II). Postoperatively, she developed temporal thermal hypoalgesia on the left side of her body. Magnetic resonance imaging showed a microinfarction in the medulla. CONCLUSION: If the VA test occlusion provides a clear result, pre-operative endovascular sacrifice of the VA encased by CVJ meningioma is a feasible treatment strategy.

Decreased Value of Highly Accurate Fractional Anisotropy Using 3-Tesla ZOOM Diffusion Tensor Imaging After Decompressive Surgery in Patients with Cervical Spondylotic Myelopathy: Aligned Fibers Effect.

BACKGROUND: Diffusion tensor imaging (DTI) is widely used; however, most of the prior studies have resulted in presurgical decreased fractional anisotropy (FA) values in patients with cervical spondylotic myelopathy (CSM). We used ZOOM DTI and could acquire highly accurate FA values during perioperative periods, which indicated different insights than preceding studies. The objective of this study was to assess the perioperative FA change in patients with CSM and determine the prognostic factor. METHODS: Twenty-eight patients with CSM and healthy control subjects were enrolled in this study. Twenty patients (71%) had intracordal high intensity before surgery. All patients underwent decompressive surgery. ZOOM DTI and the Japanese Orthopaedic Association (JOA) assessment were performed before and after surgery. The region of interest was manually contoured to omit the surrounding cerebrospinal fluid. The axial plane of the most stenotic cervical level was assessed. RESULTS: FA values before surgery and at 1 week after surgery, and FA values at 1 week after surgery and at 6 months after surgery differed significantly as determined. The FA values of patients with intracordal high intensity significantly decreased after surgery and significantly increased from 1 week to 6 months, whereas those of patients without intracordal high intensity did not significantly change. JOA scores at 6 months after surgery (13.1) improved significantly compared with JOA scores before surgery (10.8). Only FA values at 1 week after surgery had a significant positive relationship with JOA scores presurgery and at 6 months after surgery. CONCLUSIONS: The presurgical FA value in patients with CSM did not differ from that of normal control subjects, but significantly decreased after surgery, and significantly increased 6 months after surgery. We concluded that the postsurgical FA value approximates the proper state of the damaged cord and the presurgical FA value includes a masked effect as an aligned fiber effect because of compression by degenerative construction. Only the FA value at 1 week had a significant positive relationship with the JOA score presugery and at 6 months, which established that the postsurgical FA value may be a more accurate prognostic factor than the presurgical FA value.

The Reliability of Reduced Field-of-view DTI for Highly Accurate Quantitative Assessment of Cervical Spinal Cord Tracts.

PURPOSE: To compare the accuracy of fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values between reduced FOV or so-called zonally oblique multislice (ZOOM) and conventional diffusion tensor imaging (DTI) in the cervical spinal cord. METHODS: Both ZOOM and conventional DTI were performed on 10 healthy volunteers. Intraclass correlation coefficient (ICC) was used to evaluate the reliability of the measurements obtained. Four radiologists evaluated the FA and ADC values at each cervical cord level and classified the visibility by 4 ranks. The geometric distortion ratios of the long axis and short axis were compared between ZOOM and conventional DTI. The imaging parameters were as follows: b-value = 600 s/mm2; TR = 4500 ms; TE = 81 ms; FOV = 70 × 47 mm2 / 200 × 200 mm2; matrix = 80 × 51 / 128 × 126 (ZOOM and conventional DTI, respectively). The region of interest was carefully drawn inside the spinal cord margin to exclude the spinal cord component, without excluding the white matter fiber tracts. RESULTS: The average FA value decreased in both ZOOM and conventional DTI in lower spinal cord levels; in contrast, the ADC value increased in lower spinal cord levels. Zonally oblique multislice DTI was superior to conventional DTI with regard to inter-rater and intra-rater reliability; further, visibility was better and the standard deviation was smaller in ZOOM DTI. On both the long and short axis, the geometric distortion ratio was lower in ZOOM DTI at all cervical spinal cord levels compared with the conventional DTI. There was a significant difference in the distortion ratios of the long and short axis between ZOOM and conventional DTI. CONCLUSION: Conventional DTI is unreliable owing to its susceptibility to the surrounding magnetic field. ZOOM DTI is reliable for performing highly accurate evaluations.

[A Case of Onion-Skin Hemifacial Dysesthesia Caused by Ossification of the Cervical Posterior Longitudinal Ligament].

BACKGROUND: The spinal trigeminal nucleus is a cranial nerve which extends caudally from the medulla to the upper cervical segment of the spinal cord. An upper cervical lesion can cause pain or dysesthesia of the face sparing the central area, which is called onion-skin pattern. CASE PRESENTATION: We present a rare case of a 73-year-old man with cervical ossification of the posterior longitudinal ligament(OPLL)causing onion-skin pattern dysesthesia. No other brain lesion was detected by MRI. He had received adequate medication for six months, but his dysesthesia persisted. Cervical radiographic studies showed OPLL with slight instability at the C2-3 level and mild spinal cord compression at the C3 vertebral level. The lesion was considered solely responsible for the onion-skin pattern dysesthesia, and it resulted in posterior cervical decompression. Immediately after the surgery, his dysesthesia disappeared. CONCLUSION: The onion-skin pattern dysesthesia could have been caused by the C2-3 lesion.

Highly Accurate Analysis of the Cervical Neural Tract of the Elderly Using ZOOM DTI.

OBJECTIVE: To investigate the fractional anisotropy (FA) values of the cervical spinal cord in elderly individuals using zonally magnified oblique multislice (ZOOM) diffusion tensor imaging (DTI). METHODS: Fourteen healthy elderly volunteers (group E) and 10 young volunteers (group Y) were enrolled. We assessed the FA, apparent diffusion coefficient (ADC), and λ1-λ3 values using 3-T magnetic resonance imaging. The region of interest was contoured entirely inside the spinal cord, with no gray/white matter distinction, in order to avoid including the cerebrospinal fluid. RESULTS: As lower cervical levels were approached, the FA values gradually decreased, while the ADC values increased. The mean FA values at each cervical level were as follows in groups E and Y: 0.71 and 0.70 at the C2/3 level, 0.66 and 0.66 at the C3/4 level, 0.63 and 0.62 at the C4/5 level, 0.57 and 0.57 at the C5/6 level, and 0.58 and 0.57 at the C6/7 level, respectively. The mean ADC values in groups E and Y were 1.06 and 0.99 at the C2/3 level, 1.05 and 1.06 at the C3/4 level, 1.14 and 1.06 at the C4/5 level, 1.18 and 1.21 at the C5/6 level, and 1.39 and 1.46 at the C6/7 level, respectively. There were no significant differences between the elderly and young participants. CONCLUSION: In both asymptomatic elderly and young individuals, the FA values gradually decreased and the ADC values increased moving towards lower cervical levels. Age did not affect the FA values, even though mild cord compression was evident due to spondylotic changes. ZOOM DTI has the potential to provide more information than conventional DTI.

Characteristics of Symptomatic Intracerebral Hemorrhage in Patient Receiving Direct Oral Anticoagulants: Comparison with Warfarin.

BACKGROUND: Direct oral coagulants (DOAC) have been shown to decrease the frequency of intracerebral hemorrhage (ICH) compared with warfarin. However, the precise characteristics, such as the size and locations of the hemorrhage, and outcome and onset time of ICH in patient taking DOAC are not fully elucidated. METHODS: We retrospectively analyzed the characteristics of symptomatic patients with ICH taking either DOAC or warfarin between January 2012 and December 2015. RESULTS: Out of 400 consecutive patients with ICH, 15 patients were DOAC-ICH and 24 patients were warfarin-ICH. DOAC-ICH was observed in 6 patients with 10 mg of rivaroxaban, 5 patients with 15 mg of rivaroxaban, and 1 patient with 10 mg of apixaban, 5 mg of apixaban, 30 mg of edoxaban, and 60 mg of edoxaban. Prothrombin time was well controlled in most of the warfarin-ICH patients (83.3%). The locations of ICH were similar in both groups; however, median ICH volume was significantly smaller in DOAC-ICH patients than in warfarin-ICH patients (P < .01) and ICH around basal ganglia seemed to show great difference between the groups. DOAC-ICH patients showed better neurological outcome at the time of discharge than warfarin patients (P < .01), and the ratio of good prognosis was significantly higher in the DOAC-ICH patients than in the warfarin-ICH patients (P < .01). The onset of warfarin-ICH was frequently observed in the morning and evening, whereas DOAC-ICH did not show any specific onset time. CONCLUSIONS: Patients with DOAC-ICH showed smaller ICH volume and better clinical outcomes than patients with warfarin-ICH, and DOAC-ICH did not show any specific onset peak.

Double Crush of L5 Spinal Nerve Root due to L4/5 Lateral Recess Stenosis and Bony Spur Formation of Lumbosacral Transitional Vertebra Pseudoarticulation: A Case Report and Review.

We present a case of double-crushed L5 nerve root symptoms caused by inside and outside of the spinal canal with spur formation of the lumbosacral transitional vertebra (LSTV). A 78-year-old man presented with 7-year history of moderate paresis of his toe and left leg pain when walking. Magnetic resonance imaging (MRI) revealed spinal stenosis at the L3/4 and 4/5 spinal levels and he underwent wide fenestration of both levels. Leg pain disappeared and 6-min walk distance (6MWD) improved after surgery, however, the numbness in his toes increased and 6MWD decreased 9 months after surgery. Repeated MR and 3D multiplanar reconstructed computed tomography (CT) images showed extraforaminal impingement of the L5 root by bony spur of the left LSTV. He underwent second decompression surgery of the L5/S via the left sided Wiltse approach, resulting in the improvement of his symptoms. The impingement of L5 spinal nerve root between the transverse process of the fifth lumbar vertebra and the sacral ala is a rare entity of the pathology called "far-out syndrome (FOS)". Especially, the bony spur formation secondary to the anomalous articulation of the LSTV (LSPA) has not been reported. These articulations could be due to severe disc degeneration, following closer distance and contact between the transverse process and the sacral ala. To our knowledge, this is the first report describing a case with this pathology and may be considered in cases of failed back surgery syndromes (FBSS) of the L5 root symptoms.

Serial Arterial Spin Labeling May Be Useful in Assessing the Therapeutic Course of Cerebral Venous Thrombosis: Case Reports.

We report two cases of cerebral venous thrombosis (CVT) which serial arterial spin labeling (ASL) was useful in evaluating the clinical course of the disease. A 48-year-old female presented with acute seizure, and was diagnosed as transverse-sigmoid sinus thrombosis. ASL imaging revealed low signal intensity in the right temporal lobe, suggesting the decreased perfusion by elevated venous pressure. Soon after the treatment, while the development of venous collateral has not fully observed by magnetic resonance (MR) angiography, low ASL signal within the right temporal lobe have shown remarkable improvement. A 65-year-old female presented with vomiting and subsequent seizure was diagnosed as superior sagittal sinus thrombosis. The low ASL signal within the right frontal lobe seen in the acute stage improved to the normal level by the course of time, before the good collateral can be seen by MR angiography. This is the first report to assess the sequential change of the cerebral perfusion of CVT by ASL, and ASL may provide additional useful information in combination with conventional modalities.

Lateral Position of the External Carotid Artery: A Rare Variation to Be Recognized During Carotid Endarterectomy.

BACKGROUND: External carotid artery (ECA) positioned laterally to the internal carotid artery (ICA) at the level of the common carotid artery (CCA) bifurcation is occasionally encountered during carotid endarterectomy (CEA). This study aimed to determine the frequency of this phenomenon and provide technical tips for performing CEA. METHODS: The study included 199 consecutive patients (209 carotid arteries) who underwent CEA at Otaru Municipal Medical Center in 2007-2014. The position of the ECA with respect to the ICA at the CCA bifurcation was preoperatively rated as either lateral or normal, using three-dimensional computerized tomographic angiography (3-D CTA) anteroposterior projections. Postoperative diffusion-weighted images (DWIs), and postoperative 3-D CTA images were reviewed. RESULTS: Among the 209 carotid arteries with atherosclerosis, 11 instances (5.3 %) of lateral position of the ECA were detected in 11 patients. Ten of these arteries (91 %) were right-sided (odds ratio 11.1; 95 % confidence interval 1.38-88.9). Wider longitudinal exposure of the arteries was used during CEA, and the CCA and ECA were rotated clockwise or counter clockwise. The ICA lying behind the ECA along the surgical access route was then pulled out laterally and moved to the shallow surgical field. Cross-clamping, arteriotomy, plaque removal, and wall suturing were performed as usual. No cerebral infarcts were detected on postoperative DWIs, and 3-D CTA revealed no CCA and ICA kinking. CONCLUSIONS: Lateral position of the ECA is not extremely rare in patients undergoing CEA for atherosclerosis and may be a congenital variation, although this is still controversial. CEA can be performed safely if the arteries from the CCA to the ICA are rotated, and the ICA is moved to the shallow surgical field under wider longitudinal exposure. Although no postoperative cerebral infarcts were detected, the risk of artery-to-artery embolism resulting from artery repositioning prior to plaque removal should be taken into consideration.