The Potential Role of Preoperative Posterior Cerebral Artery Involvement in Predicting Postoperative Transient Neurological Deficits and Ischemic Stroke After Indirect Revascularization in Patients With Moyamoya Disease.

OBJECTIVE: Transient neurological deficits (TNDs) are known to develop after direct bypass for Moyamoya disease and may be risk factors for subsequent stroke. However, the factors involved in the development of TNDs and stroke after indirect revascularization alone, including their association with subsequent stroke, remain unclear. The purpose of this study was to investigate this issue. METHODS: The subjects of the study were 30 patients with Moyamoya disease who underwent a total of 40 indirect revascularization procedures at our institution. Clinical and radiological data were collected retrospectively. To examine factors associated with the development of postoperative TND/stroke/asymptomatic disease, the clinical characteristics of each group were statistically compared. RESULTS: The mean age at surgery was 7 years (range 1-63). TNDs developed after surgery in 9 out of 40 patients (22.5%). Stroke in the acute postoperative period occurred in 3 patients (7.5%), all of whom experienced cerebral infarctions. Demographic data and preoperative clinical information were not different between the groups. However, posterior cerebral artery involvement on preoperative imaging was significantly associated with the development of TNDs and stroke (P = 0.006). Furthermore, postoperative stroke was associated with unfavorable outcomes (P = 0.025). CONCLUSIONS: Posterior cerebral artery involvement is significantly associated with the occurrence of TNDs. In contrast, TNDs after indirect revascularization have little relationship with the subsequent development of stroke. TNDs usually resolve without new strokes, and a better understanding of this particular pathology could help establish an optimal treatment regimen.

Delayed leukoencephalopathy following non-coil embolization flow diverter stent deployment for an intracranial aneurysm.

This report examines delayed leukoencephalopathy as a postoperative complication after the use of flow diverter (FD) devices for endovascular cerebral aneurysm treatment. A case involving a 78-year-old female treated with a pipeline embolization device for a left internal carotid artery aneurysm is presented. Despite adherence to dual anti-platelet therapy, the patient developed intermittent headaches and memory issues 3 months post-operation. MRI revealed T1-enhancing foci and T2 hyperintense signal abnormalities in the left cerebral hemisphere, without new ischemic lesions, indicating potential embolic events or foreign body reactions. Following aphasia, a change from clopidogrel to prasugrel and the initiation of steroid pulse therapy led to the resolution of symptoms and MRI abnormalities over 6 months. This case underscores the reversibility of delayed leukoencephalopathy with appropriate intervention.

Characteristics of donor vessels and cerebral blood flow in the chronic phase after combined revascularization surgery for moyamoya disease.

OBJECTIVE: This study aimed to analyze whether the development of donor vessels after combined revascularization surgery for moyamoya disease (MMD) is related to cerebral blood flow (CBF) changes. METHODS: We retrospectively reviewed the charts of 11 adult (12 hemispheres) and 13 pediatric (19 hemispheres) patients who underwent combined revascularization in our department. The total vessel cross-sectional area (TVA) was the sum of the cross-sectional areas of the superficial temporal, middle meningeal, and deep temporal arteries imaged using time-of-flight magnetic resonance angiography. The ipsilateral relative CBF (RCBF) on the brain surface in the craniotomy area was calculated by single-photon emission computed tomography. ΔTVA and ΔRCBF were defined as the preoperative and postoperative ratios of TVA and RCBF, and their correlations were analyzed in adult and pediatric patients. RESULTS: The TVA and RCBF showed a significant increase after surgery, regardless of the age group. However, there was no significant correlation between ΔTVA and ΔRCBF in either the adult or pediatric groups. While the adult group exhibited significantly higher ΔRCBF values compared to the pediatric group (p < 0.01, r = -0.44), the ΔTVA values were higher in the pediatric group compared to the adult group (p = 0.06). CONCLUSIONS: In the chronic phase after combined revascularization surgery for MMD, the development of measurable TVA of donor vessels does not necessarily correlate with an increase in CBF around the craniotomy area.

Real-world data of clazosentan in combination therapy for aneurysmal subarachnoid hemorrhage: a multicenter retrospective cohort study.

Aneurysmal subarachnoid hemorrhage (aSAH) may lead to cerebral vasospasm, significantly associated with morbidity and mortality. In double-blind, placebo-controlled phase 3 studies, clazosentan reduces cerebral vasospasm-related morbidity and all-cause mortality in patients with aSAH. There are no reports about the clinical efficacy of clazosentan combination therapy with some other drugs. Initially, we explored the efficacy of clazosentan combination therapy with cilostazol, statin, and antiepileptic drugs. Subsequently, we assessed the add-on effect of fasudil to clazosentan combination therapy for aSAH patients. This multicenter, retrospective, observational cohort study included Japanese patients with aSAH between June 2022 and March 2023. The primary outcome was the ordinal score on the modified Rankin Scale (mRS; range, 0-6, with elevated scores indicating greater disability) at discharge. Among the 47 cases (women 74.5%; age 64.4 ± 15.0 years) undergoing clazosentan combination therapy, 29 (61.7%) resulted in favorable outcomes. Overall, vasospasm occurred in 16 cases (34.0%), with four cases (8.5%) developing vasospasm-related delayed cerebral ischemia (DCI). Both hypotension and vasospasm-related DCI were related to unfavorable outcome at discharge. Fasudil were added in 18 (38.3%) cases. Despite adding fasudil to clazosentan combination therapy, the incidence of aSAH-related vasospasm did not decrease. Added-on fasudil to combination therapy related to pulmonary edema, vasospasm, and vasospasm-related DCI, and unfavorable outcomes. Clazosentan combination therapy could potentially result in favorable outcomes for aSAH patients to prevent post-aSAH vasospasm-related DCI. The add-on effect of fasudil to combination therapy did not demonstrate a significant impact in reducing aSAH-related vasospasm or improving outcomes at discharge.

Paroxysmal Sympathetic Hyperactivity in Stroke.

OBJECTIVE: Paroxysmal sympathetic hyperactivity (PSH) is a life-threatening neurological emergency associated with severe brain injury. Stroke-related PSH, particularly post-aneurysmal subarachnoid hemorrhage (aSAH) PSH, has been relatively understudied and is often misdiagnosed as an aSAH-related hyperadrenergic crisis. This study aims to clarify the feature of stroke-related PSH. METHODS: This study discusses the case of a patient with post-aSAH PSH and identifies 19 articles (25 cases) on stroke-related PSH by searching the PubMed database from 1980 to 2021. RESULTS: In the total cohort, 15 (60.0%) patients were male and the average age was 40.1 ± 16.6 years. The primary diagnoses included intracranial hemorrhage (13 cases, 52.0%), cerebral infarction (7 cases, 28.0%), subarachnoid hemorrhage (4 cases, 16.0%), and intraventricular hemorrhage (1 case, 4.0%). The sites of stroke damage were predominantly the cerebral lobe (10 cases, 40.0%), basal ganglia (8 cases, 32.0%), and the pons (4 cases, 16.0%). The median time of PSH onset after admission was 5 (1-180) days. Most cases employed combination therapy with sedation drugs, beta-blockers, gabapentin, and clonidine. On the Glasgow Outcome Scale, outcomes included death (4 cases, 21.1%), vegetative state (2 cases, 10.5%), severe disability (7 cases, 36.8%), and in only one case (5.3%) was a good recovery noted. CONCLUSIONS: The clinical features and treatment of post-aSAH PSH differed from those of aSAH-related hyperadrenergic crises. Early diagnosis and treatment can prevent severe complications. PSH should be acknowledged as a potential complication of aSAH. Differential diagnosis can aid in developing individualized treatment plans and improving patient prognosis.

Concurrent cerebral infarction and intracranial tuberculoma induced by the carotid plaque complicated with miliary tuberculosis.

Cerebrovascular complications of central nervous system tuberculosis (TB) are predictors of poor prognosis and adverse outcomes. These complications are mainly intracranial arterial involvement, with occasional venous involvement. Here, we present a 67-year-old woman with concurrent cerebral infarction and intracranial tuberculoma induced by the carotid plaque complicated by miliary tuberculosis. Mycobacterium tuberculosis was observed on the luminal side of the carotid plaques in pathological specimens. Treatment with anti-TB drugs alone would likely not cure the patient, as M. tuberculosis would continue to disseminate. Endarterectomy could directly remove the embolic source, and a complete cure was achieved.

The preoperative focal cerebral blood flow status may be associated with slow flow in the bypass graft after combined surgery for moyamoya disease.

Background: The aim of this study was to investigate the association between early postoperative slow flow in bypass grafts and preoperative focal cerebral blood flow (CBF) in patients who underwent combined surgery for moyamoya disease (MMD). Methods: The subjects were 18 patients (22 surgeries) who underwent single photon emission computed tomography (SPECT) before surgery. The CBF value of the middle cerebral artery territory was extracted from the SPECT data, and the value relative to the ipsilateral cerebellar CBF (relative CBF, or RCBF) was calculated. The association between RCBF and early postoperative slow flow in the bypass graft was investigated. In addition, the correlation between the revascularization effect and preoperative RCBF was analyzed. Results: In four of 22 surgeries (18.2%), slow flow in the bypass graft was identified in the early postoperative period. Preoperative RCBF in the slow flow and patent groups was 0.86 ± 0.15 and 0.87 ± 0.15, respectively, with no significant difference (P = 0.72). The signal intensity of four slow-flowed bypasses was improved in all cases on magnetic resonance angiography images captured during the chronic phase (mean of 3.3 months postoperatively). The revascularization scores were 2 ± 0.82 and 2.1 ± 0.68 in the slow flow and patent groups, respectively, and did not differ significantly (P = 0.78). A significant correlation was not observed between preoperative RCBF and the revascularization effect. Conclusion: No significant association was observed between preoperative RCBF and early postoperative slow flow in bypass grafts in patients with MMD undergoing combined surgery. Given the high rate of improved depiction of slow-flowed bypass in the chronic postoperative phase, the conceptual significance of an opportune surgical intervention is to maintain CBF by supporting the patient's own intracranial-extracranial conversion function.

The prognosis and treatment effectiveness of de novo aneurysm formation after radiation therapy for brain tumor.

Radiation therapy is a well-established, minimally invasive method of treating brain tumors. In recent years, the number of post-radiotherapy patients has increased, and delayed side effects are evident. De novo aneurysm formation after radiation often manifests as fatal subarachnoid hemorrhage (SAH), resulting in severe clinical outcomes. Nevertheless, the prognosis and therapeutic efficacy of radiation-induced aneurysms (RIAs) remain unclear. Using the PubMed database from 1980 to 2021, we screened 45 articles (53 individual cases) on RIAs; approximately 70% of RIAs were diagnosed after rupture. Of 38 ruptured RIAs, 12 (31.6%) had modified Rankin scale (mRS) 5-6. On the other hand, all unruptured RIAs (15 cases) recovered without neurological deficits (p = 0.012). Ten of the 39 ruptured RIAs were treated surgically, and 22 were treated endovascularly. There was no significant difference in mRS between treatment modalities (p = 0.393), but conservative therapy was significantly related to unfavorable outcomes (p = 0.025). To improve clinical outcomes, RIAs need to be diagnosed before rupture. Surgeons should be aware of de novo aneurysm formation in patients long after radiation therapy.

Blood flow stagnation after treatment of a giant internal carotid artery aneurysm: a computed fluid dynamics analysis.

Balloon test occlusion (BTO) is an angiographic test to evaluate ischemic tolerance after permanent occlusion of an internal carotid artery (ICA). BTO can simulate ischemia caused by parent artery occlusion and can be used to select a suitable bypass surgery using specific criteria. On the other hand, a postoperative thrombus can form despite proper case selection, optimal radiological evaluation, and an appropriate surgical strategy. Postoperative ischemic complications related to perforating branches are clinically significant. This simulation study aimed to analyze postoperative flow characteristics and elucidate the cause of ischemic complications related to the perforating branch using computational fluid dynamics (CFD). An unexpected postoperative thrombus formation related to the perforating branch occurred after treating a giant aneurysm in the cavernous portion of the ICA in a patient. Three-dimensional digital subtraction angiography was used to acquire flow data and set up the CFD simulation. The flow simulations were performed at various bypass flow rates. The CFD analysis indicated flow stagnation in the ICA only when surgical treatment using a low-flow bypass graft was performed. Thrombus formation may lead to ischemic complications related to the perforating branch, such as the anterior choroidal artery. BTO did not reflect the influence of bypass blood flow. Therefore, recognizing that blood flow stagnation may occur and comprehensively deciding on the surgical strategy by CFD analysis can be helpful to prevent ischemic complications in patients with giant aneurysms.

Changes in Vessel Wall Enhancement Related to the Recent Neurological Symptoms in Patients with Moyamoya Disease.

Moyamoya disease (MMD) causes intracranial arterial stenosis progression. The progression of intracranial arterial stenosis will increase the risk of ischemic cerebrovascular events. This study aims to investigate the relationship between intracranial arterial stenosis progression, vessel wall enhancement (VWE), and the recent neurological symptoms. A total of 39 MMD patients (12 male; 37.6 ± 18.0 years old) were registered in this study analysis between April 2016 and July 2018. All patients received MRI at registration and 6, 12, and 24 months post-registration. The incidence of ischemic cerebrovascular events (transit ischemic attacks or cerebral infarction) was checked until December 2018. We evaluated the relationship between the intensity of VWE, intracranial arterial stenosis, and the recent neurological symptoms. During the mean follow-up period of 13.8 ± 5.5 months, the changes in VWE were observed in 33 hemispheres (42.3%), stenosis progression was observed in 21 hemispheres (26.9%), and recent neurological symptoms occurred in 10 hemispheres (12.8%). Stenosis progression was observed in 11 hemispheres (33.3%) in the VWE(+) group and ten hemispheres (22.2%) in the VWE(-) group (p = 0.310). The recent neurological symptoms were observed in eight hemispheres (21.2%) in the VWE(+) group and two hemispheres (4.44%) in the VWE(-) group (odds ratio 6.88, 95% confidence interval 1.35-34.98, p = 0.015). The intensity of VWE sometimes changes. The changes in VWE were significantly associated with the recent neurological symptoms but not with stenosis progression.

Future stroke risk in the chronic phase of post-percutaneous coronary intervention.

A percutaneous coronary intervention (PCI) is widely performed for acute coronary syndromes or chronic coronary syndromes. Periprocedural stroke is a clinically significant complication during PCI. The incidence of cerebrovascular events (CVEs) after PCI in the chronic phase is obscure. This study aimed to investigate the prevalence of CVEs after PCI in the chronic phase and evaluate the usefulness of a simple coronary artery calcification (CAC) evaluation method. This prospective observational study included 179 patients who underwent PCI between January 2016 and December 2018. The incidence of cerebral infarction was examined from one month after PCI to December 2019. In total, 171 individuals (134 men; mean age, 69.8 ± 9.8 years) were recruited. During a median follow-up period of 33 months, the onset of cerebral infarction was observed in 20 individuals (11.7%). More CAC sites (p = 0.009) and post-PCI for the chronic coronary syndrome (p = 0.049) showed a significant association with future CVEs. There was no significant cervical internal carotid artery stenosis for patients who occurred CVEs. The cutoff value for the number of CAC sites for predicting future CVEs was 4.5. The new and easy method accurately reflected future CVEs risk and may be clinically applicable.

Acute Hydrocephalus Requiring External Ventricular Drainage Following Perimesencephalic Nonaneurysmal Subarachnoid Hemorrhage in a Pediatric Patient: Case Report and Review of the Literature.

BACKGROUND: Perimesencephalic nonaneurysmal subarachnoid hemorrhage (PNSAH) is a well-described subset of subarachnoid hemorrhage with an excellent prognosis in adults. However, its characteristics in the pediatric population have not yet been fully understood. We present a case of acute hydrocephalus requiring external ventricular drainage following pediatric PNSAH. CASE DESCRIPTION: A previously healthy 10-year-old girl was admitted to our neurosurgical department after sudden onset of severe headache with vomiting during exercise. Cerebral non-contrast computed tomography detected subarachnoid hemorrhage filling all perimesencephalic cisterns. However, digital subtraction angiography could not locate the hemorrhage source. Her consciousness deteriorated within 7 hours of onset, and a computed tomography scan revealed acute hydrocephalus. We subjected the patient to external ventricular drainage for 10 days. She was discharged after 38 days of hospitalization, when she was physically and neuropsychologically healthy. Repeated digital subtraction angiography performed at the 6-month follow-up did not show any obvious source of hemorrhage except for a variant drainage pattern of the basal vein of Rosenthal. Based on the observations, we diagnosed the patient with PNSAH of a venous origin. CONCLUSIONS: We propose that acute hydrocephalus be suspected in pediatric patients with nonaneurysmal subarachnoid hemorrhage filling all perimesencephalic cisterns, as in adults. We also propose that one of the possible causes of pediatric PNSAH as of venous origin and related to the abnormal drainage pattern of basal vein of Rosenthal and elevation of venous pressure with exercise. Immediate surgical drainage could obtain a good outcome in a symptomatic case.

Posterior Cerebral Artery Reconstruction by In-Situ Bypass with Superior Cerebellar Artery via Occipital Transtentorial Approach.

BACKGROUND: Posterior cerebral artery (PCA) aneurysms are relatively rare, and neck clipping is often difficult due to their fusiform shape. We report a case of a thrombosed aneurysm of the distal PCA for which curative trapping and parent artery reconstruction by in situ bypass were performed through an occipital transtentorial approach (OTA). CASE DESCRIPTION: A 67-year-old woman had been suffering from numbness in the right face and limbs for 4 months. Radiologic imaging demonstrated a thrombosed aneurysm on a distal portion of the left PCA. Curative trapping of the aneurysm and in-situ bypass between the distal PCA and superior cerebellar artery were performed through the OTA. Before surgery, we had evaluated access to the PCA and feasibility of the bypass in a cadaveric simulation. The PCA was well exposed in the posterior half of the ambient cistern, and the proximity of the distal PCA to the superior cerebellar artery through a tentorial incision was confirmed. CONCLUSIONS: This OTA could represent a useful option for definitive treatment of distal PCA aneurysms.

Prediction of Intracranial Arterial Stenosis Progression in Patients with Moyamoya Vasculopathy: Contrast-Enhanced High-Resolution Magnetic Resonance Vessel Wall Imaging.

OBJECTIVE: Moyamoya vasculopathy (MMV) is characterized by progressive stenosis of the intracranial arteries. MMV currently has no curative treatments, and cerebral ischemia and hemorrhage are the major outcomes. Evaluation of the stroke risk of each patient resulting from the progression of intracranial arterial stenosis is clinically important. METHODS: We prospectively reviewed patients with intracranial arterial stenosis and already diagnosed MMV. High-resolution magnetic resonance imaging using contrast agent is the novel vessel wall imaging (VWI) technique for directly evaluating vascular walls and intracranial artery disease. All patients underwent high-resolution vessel wall imaging and magnetic resonance angiography at the time of registration, and they underwent follow-up magnetic resonance angiography. The Fisher exact test was used to assess associations between the degrees of wall enhancement and between stable and progressive intracranial arterial stenosis. RESULTS: A total of 24 patients (17 female; mean age, 36.1 ± 16.8 years; range 3-67 years) with MMV were consecutively recruited to this study. Progression of stenosis was shown in 6 lesions (66.6%) on strong enhancement, 2 lesions (12.5%) on mild enhancement, and 1 lesion (4.3%) on lack of enhancement. Arterial vessel wall enhancement in MMV patients correlated closely with progression of intracranial arterial stenosis (P = 0.002). CONCLUSIONS: Arterial vessel wall enhancement in MMV patients was closely related to progression of intracranial arterial stenosis. Strong enhancement of the intracranial vessel wall was associated with intracranial arterial stenosis progression, and lack of enhancement correlated with the stability of intracranial arterial stenosis.

Intraoperative evaluation of local cerebral hemodynamic change by indocyanine green videoangiography: prediction of incidence and duration of postoperative transient neurological events in patients with moyamoya disease.

OBJECTIVE: Transient neurological events (TNEs) occur frequently in the acute phase after direct bypass surgery for moyamoya disease (MMD), but there is currently no way to predict them. FlowInsight is a specialized software for analyzing indocyanine green (ICG) videoangiography taken with a surgical microscope. The purpose of this study was to investigate whether intraoperative evaluation of local hemodynamic changes around anastomotic sites using FlowInsight could predict the incidence and duration of TNEs. METHODS: From patients who were diagnosed with MMD in our hospital between August 2014 and March 2017 and who underwent superficial temporal artery-middle cerebral artery bypass surgery, we investigated 25 hemispheres (in 22 patients) in which intraoperative ICG analysis was performed using FlowInsight. To evaluate the local cerebral hemodynamics before and after anastomosis, regions of interest were set at 3 locations on the brain surface around the anastomotic site, and the mean cerebral blood flow (CBF), mean gradation (Grad), mean transit time (MTT), and mean time to peak (TTP) were calculated from the 3 regions of interest. Furthermore, the change rate in CBF (ΔCBF [%]) was calculated using the formula (postanastomosis mean CBF - preanastomosis mean CBF)/preanastomosis mean CBF. ΔGrad (%), ΔMTT (%), and ΔTTP (%) were similarly calculated. RESULTS: Postoperative stroke without TNE occurred in 2 of the 25 hemispheres. These 2 hemispheres (in 2 patients) were excluded from the study, and data from the remaining 23 hemispheres (in 20 patients) were analyzed. For each parameter (ΔCBF, ΔGrad, ΔMTT, and ΔTTP) calculated by FlowInsight, the difference between the groups with and without TNEs was significant. The median values for ΔCBF and ΔGrad were significantly higher in the TNE group than in the no-TNE group (ΔCBF 30.13 vs 3.54, p = 0.0106; ΔGrad 62.05 vs 10.78, p = 0.00435), whereas the median values for ΔMTT and ΔTTP were significantly lower in the TNE group (ΔMTT -16.90 vs -7.393, p = 0.023; ΔTTP -29.07 vs -7.02, p = 0.00342). Comparison of the area under the curve (AUC) for each parameter showed that ΔTTP had the highest AUC and was the parameter with the highest diagnostic accuracy (AUC 0.857). The Youden index revealed that the optimal cutoff value of ΔTTP was -11.61 (sensitivity 77.8%, specificity 71.4%) as a predictor of TNEs. In addition, Spearman's rank correlation coefficients were calculated, and ΔCBF, ΔGrad, ΔMTT, and ΔTTP each showed a strong correlation with the duration of TNEs. The larger the change in each parameter, the longer the TNEs persisted. CONCLUSIONS: Intraoperative ICG videoangiography findings were correlated with the occurrence and duration of TNEs after direct bypass surgery for MMD. Screening for cases at high risk of TNEs can be achieved by ICG analysis using FlowInsight.

Postoperative Cerebral Infarction Risk Factors and Postoperative Management of Pediatric Patients with Moyamoya Disease.

OBJECTIVE: Although revascularization surgery for patients with moyamoya disease can effectively prevent ischemic events and thus improve the long-term clinical outcome, the incidence of postoperative ischemic complications affects patients' quality of life. This study aimed to clarify the risk factors associated with postoperative ischemic complications and to discuss the appropriate perioperative management. METHODS: Fifty-eight revascularization operations were performed in 37 children with moyamoya disease. Patients with moyamoya syndrome were excluded from this study. Magnetic resonance imaging was performed within 7 days after surgery. Postoperative cerebral infarction was defined as a diffusion-weighted imaging high-intensity lesion with or without symptoms. We usually use fentanyl and dexmedetomidine as postoperative analgesic and sedative drugs for patients with moyamoya disease. We used barbiturate coma therapy for pediatric patients with moyamoya disease who have all postoperative cerebral infarction risk factors. RESULTS: Postoperative ischemic complications were observed in 10.3% of the children with moyamoya disease (6 of 58). Preoperative cerebral infarctions (P = 0.0005), younger age (P = 0.038), higher Suzuki grade (P = 0.003), and posterior cerebral artery stenosis/occlusion (P = 0.003) were related to postoperative ischemic complications. Postoperative cerebral infarction occurred all pediatric patients using barbiturate coma therapy. CONCLUSIONS: The risk factors associated with postoperative ischemic complications for children with moyamoya disease are preoperative infarction, younger age, higher Suzuki grade, and posterior cerebral artery stenosis/occlusion. Barbiturate coma therapy for pediatric patients with moyamoya disease who have the previous risk factors is insufficient for prevention of postoperative cerebral infarction. More studies are needed to identify the appropriate perioperative management.

Tumor Volume Decrease via Feeder Occlusion for Treating a Large, Firm Trigone Meningioma.

Trigone meningiomas are considered a surgical challenge, as they tend to be considerably large and hypervascularized at the time of presentation. We experienced a case of a large and very hard trigone meningioma that was effectively treated using initial microsurgical feeder occlusion followed by surgery in stages. A 19-year-old woman who presented with loss of consciousness was referred to our hospital for surgical treatment of a brain tumor. Radiological findings were compatible with a left ventricular trigone meningioma extending laterally in proximity to the Sylvian fissure. At initial surgery using the transsylvian approach, main feeders originating from the anterior and lateral posterior choroidal arteries were occluded at the inferior horn; however, only a small section of the tumor could initially be removed because of its firmness. Over time, feeder occlusion resulted in tumor necrosis and a 20% decrease in its diameter; the mass effect was alleviated within 1 year. The residual meningioma was then totally excised in staged surgical procedures after resection became more feasible owing to ischemia-induced partial softening of the tumor. When a trigone meningioma is large and very hard, initial microsurgical feeder occlusion in the inferior horn can be a safe and effective option, and can lead to necrosis, volume decrease, and partial softening of the residual tumor to allow for its staged surgical excision.

Ruptured partially thrombosed anterior inferior cerebellar artery aneurysms: two case reports and review of literature.

Aneurysms arising from the distal anterior inferior cerebellar artery (AICA) are very rare. When the parent artery is an AICA-posterior inferior cerebellar artery (PICA) variant, occlusion of the artery, even distal to the meatal loop, leads to a significant area of cerebellar infarction. We report two cases of ruptured partially thrombosed distal AICA aneurysms. In both cases, the parent artery was an AICA-PICA variant. The aneurysms were clipped in one case and trapped following occipital artery (OA)-AICA anastomosis in another case. It is important to keep the OA as a donor artery for revascularization in the treatment of the AICA-PICA variant aneurysms, especially when the absence of intra-aneurysmal thrombus is not comfirmed preoperatively.

Cerebral Infarction and Subarachnoid Hemorrhage Caused by Central Nervous System Aspergillus Infection.

BACKGROUND: The mortality rate of central nervous system (CNS) Aspergillus infection is >90%. Most cases with ruptured aneurysmal formation resulting from CNS aspergilloma invasion into the arterial wall are difficult to treat with surgical therapy, antifungal drugs, or steroid administration. There is no established therapy for ruptured Aspergillus aneurysms. Both a standardized examination for the diagnosis of CNS aspergillosis and effective treatment of ruptured Aspergillus aneurysms are needed. CASE DESCRIPTION: A 56-year-old man developed prolonged fever and headache. Magnetic resonance imaging showed a mass lesion around the brainstem. No laboratory data were suspicious for inflammatory diseases or autoimmune diseases. Considering the invasiveness of a surgical approach, we initiated steroid pulse therapy to confirm whether the mass would shrink before biopsy or resection for definitive pathologic diagnosis. Cerebral infarction and subarachnoid hemorrhage occurred almost concurrently just after steroid therapy. We first performed decompression surgery to treat the elevated intracranial hypertension. The specimen taken from the mass lesion at the time of surgery showed CNS Aspergillus fungal forms. Endovascular treatment of the ruptured aneurysm was performed, and medical therapy with an antifungal drug was started. After the Aspergillus infection was well controlled, the patient was discharged. Glasgow Outcome Scale score at discharge was 3. CONCLUSIONS: Although most patients with ruptured Aspergillus aneurysm have poor outcomes as reported in the literature, this patient's clinical course and outcome were good. Early recognition of CNS aspergillosis and timely surgical intervention to control the vascular event can improve the prognosis for these patients.

Disrupted-in-schizophrenia 1 regulates transport of ITPR1 mRNA for synaptic plasticity.

Disrupted-in-schizophrenia 1 (DISC1) is a susceptibility gene for major psychiatric disorders, including schizophrenia. DISC1 has been implicated in neurodevelopment in relation to scaffolding signal complexes. Here we used proteomic analysis to screen for DISC1 interactors and identified several RNA-binding proteins, such as hematopoietic zinc finger (HZF), that act as components of RNA-transporting granules. HZF participates in the mRNA localization of inositol-1,4,5-trisphosphate receptor type 1 (ITPR1), which plays a key role in synaptic plasticity. DISC1 colocalizes with HZF and ITPR1 mRNA in hippocampal dendrites and directly associates with neuronal mRNAs, including ITPR1 mRNA. The binding potential of DISC1 for ITPR1 mRNA is facilitated by HZF. Studies of Disc1-knockout mice have revealed that DISC1 regulates the dendritic transport of Itpr1 mRNA by directly interacting with its mRNA. The DISC1-mediated mRNA regulation is involved in synaptic plasticity. We show that DISC1 binds ITPR1 mRNA with HZF, thereby regulating its dendritic transport for synaptic plasticity.