T1-T2 Mismatch Sign as a Predictor of Ipsilateral Ischemic Change After Carotid Artery Stenting.

BACKGROUND: Magnetic resonance (MR)-plaque imaging reflects the characteristics of carotid plaque. We evaluated the relationship between MR-plaque images and ischemic change after carotid artery stenting (CAS). METHODS: MR-plaque images were acquired from patients with carotid artery stenosis before CAS treatment. We calculated the relative signal intensity of plaque components compared with that of the sternocleidomastoid muscle and evaluated the presence/absence of T1-T2 mismatch and match sign. We then assessed the appearance of new ischemic lesions after CAS on diffusion-weighted imaging (DWI). Factors associated with the appearance of a high-intensity lesion on DWI were retrospectively analyzed. RESULTS: A total of 64 patients with carotid artery stenoses treated with CAS were included in this study. In univariate analysis, T1-T2 mismatch sign was associated with the appearance of high-intensity lesions on DWI after CAS (odds ratio [OR], 12.00; 95% confidence interval [CI], 3.593-40.072; P < 0.0001), whereas T1-T2 match sign and high intensity on T2-weighted imaging were negatively associated (OR, 0.061, 95% CI, 0.007-0.502, P = 0.009 and OR, 0.085; 95% CI, 0.022-0.334, P = 0.0004, respectively). In multivariate logistic regression analysis, T1-T2 mismatch sign was independently associated with the appearance of a high-intensity lesion on DWI after CAS (OR, 16.695; 95% CI, 1.324-210.52; P = 0.0295). CONCLUSIONS: T1-T2 mismatch sign on MR-plaque imaging is significantly associated with the appearance of new ischemic lesions after CAS. T1-T2 mismatch sign may be useful in considering treatment strategies for carotid artery stenosis.

Molecular and clinical characterization of H3 K27M-mutant “non-midline” glioblastoma: A case report and literature review / Estudio molecular y presentación clínica del glioblastoma con mutación H3 K27M «no de línea media»: descripción de un caso y revisión de la literatura

The WHO classification of tumors of the CNS in 2016 defined “diffuse midline glioma, H3 K27M-mutant” as a new tumor entity locating in the CNS midline. However, the H3 K27M-mutation in “non-midline” glioblastoma are rare and their characteristics have been rarely reported. A 16-year-old girl presented a hyper-intense lesion at her left temporal stem on T2WI, FLAIR and DWI. Biopsy was performed and molecular pathological diagnosis was glioblastoma with H3 K27M-mutant. Accordingly, the possibility of H3 K27M-mutant should be examined not only for diffuse glioma without IDH mutation that develops at a midline location, but also in non-midline locations (AU)

La clasificación de la OMS de los tumores del SNC en 2016 definió el «glioma difuso de la línea media, H3 K27M-mutante» como una nueva entidad tumoral que se localiza en la línea media del SNC. Sin embargo, la mutación H3 K27M en el glioblastoma «no de línea media» es infrecuente y sus características han sido raramente reportadas. Una niña de 16 años presentó una lesión hiperintensa en el tronco temporal izquierdo en T2WI, FLAIR y DWI. Se realizó una biopsia y el diagnóstico patológico molecular fue de glioblastoma con mutación H3 K27M. En consecuencia, la posibilidad de mutaciones H3 K27M debe examinarse no sólo en el caso de los gliomas difusos que se desarrollan en una localización de la línea media, sino también en gliomas sin mutación de IDH en localizaciones que no son de la línea media entre los pacientes (AU)

Molecular and clinical characterization of H3 K27M-mutant "non-midline" glioblastoma: A case report and literature review.

The WHO classification of tumors of the CNS in 2016 defined "diffuse midline glioma, H3 K27M-mutant" as a new tumor entity locating in the CNS midline. However, the H3 K27M-mutation in "non-midline" glioblastoma are rare and their characteristics have been rarely reported. A 16-year-old girl presented a hyper-intense lesion at her left temporal stem on T2WI, FLAIR and DWI. Biopsy was performed and molecular pathological diagnosis was glioblastoma with H3 K27M-mutant. Accordingly, the possibility of H3 K27M-mutant should be examined not only for diffuse glioma without IDH mutation that develops at a midline location, but also in non-midline locations.

Characteristics and therapeutic strategies of radiation-induced glioma: case series and comprehensive literature review.

INTRODUCTION: The so-called radiation-induced glioma (RIG, a secondary glioma after cranial irradiation), is a serious late effect after cranial radiation therapy. The clinical characteristics of and ideal treatment for these tumors are unclear. We analyzed our case series and conducted a comprehensive literature review to reveal the precise characteristics of RIGs. METHODS: We analyzed the cases of six patients with RIGs treated at our institution and 354 patients with RIGs from the literature. The latency period from irradiation to the development of each RIG and the median overall survival of the patients were subjected to Kaplan-Meier analyses. Spearman's correlation test was used to determine the relationship between age at irradiation and the latency period. RESULTS: The mean age of the 360 patients at the development of RIG was 27.42 ± 17.87 years. The mean latency period was 11.35 ± 8.58 years. Multiple gliomas were observed in 28.4%. WHO grade 3 and 4 RIGs accounted for 93.3%. The latency periods were significant shorter in the higher WHO grade group (p = 0.0366) and the concomitant systemic chemotherapy group (p < 0.0001). Age at irradiation was negatively associated with the latency period (r =- 0.2287, p = 0.0219). The patients treated with radiotherapy achieved significantly longer survival compared to those treated without radiotherapy (p = 0.0011). CONCLUSIONS: Development in younger age, multiplicity, and high incidence of grade 3 and 4 are the clinical characteristics of RIGs. Cranial irradiation at older ages and concomitant chemotherapy were associated with shorter latency for the development of RIG. Radiation therapy may be the feasible treatment option despite radiation-induced gliomas.

A chronic encapsulated expanding hematoma that developed 15 years after gamma knife surgery for a cerebral arteriovenous malformation: A case report and review of the literature.

We report a case of gamma knife surgery (GKS)-induced chronic encapsulated expanding hematoma with extensive literature review. A 17-year-old young man underwent GKS after embolization for arteriovenous malformation (AVM) in the right frontal lobe and the AVM completely disappeared. He developed a generalized convulsion 15 years after GKS. MRI showed a small oedematous change at the AVM site. His epileptic seizure was controlled with anticonvulsant. His epilepsy recurred after three years, and MRI revealed an intracerebral hematoma with extensive surrounding edema at the same lesion. He underwent cerebral angiography and a recurrence of AVM was prevented. The hematoma was surgically removed, and intraoperative finding confirmed an old hematoma with a capsule and capillary hyperplasia, without developing cavernous angioma. The final diagnosis was a secondary chronic encapsulated expanding hematoma after GKS. This is the first report to show the early-stage imaging findings of this late effect after GKS.

A chronic encapsulated expanding hematoma that developed 15 years after gamma knife surgery for a cerebral arteriovenous malformation: A case report and review of the literature.

We report a case of gamma knife surgery (GKS)-induced chronic encapsulated expanding hematoma with extensive literature review. A 17-year-old young man underwent GKS after embolization for arteriovenous malformation (AVM) in the right frontal lobe and the AVM completely disappeared. He developed a generalized convulsion 15 years after GKS. MRI showed a small oedematous change at the AVM site. His epileptic seizure was controlled with anticonvulsant. His epilepsy recurred after three years, and MRI revealed an intracerebral hematoma with extensive surrounding edema at the same lesion. He underwent cerebral angiography and a recurrence of AVM was prevented. The hematoma was surgically removed, and intraoperative finding confirmed an old hematoma with a capsule and capillary hyperplasia, without developing cavernous angioma. The final diagnosis was a secondary chronic encapsulated expanding hematoma after GKS. This is the first report to show the early-stage imaging findings of this late effect after GKS.

[A Case of Carotid Artery Stenosis Associated with Repetitive Stimulation of the Hyoid Bone].

A 40-year-old man presented with left-arm weakness, facial palsy, and dysarthria. Magnetic resonance imaging(MRI)revealed acute-stage cerebral infarction in the internal watershed area of the right hemicerebrum and MR angiography(MRA)demonstrated 56% stenosis of the right common and internal carotid arteries. Computed tomography(CT)scan showed no calcification and a stenotic lesion of the right common carotid artery, adjacent to the prolonged greater horn of the right hyoid bone. Because no other causes were found for the cerebral infarction, the compression of the stenosis of the right carotid artery was suspected as the cause of the cerebral infarction. Carotid arterectomy was performed five months after onset. Intraoperative finding showed tight adhesion between the carotid sheath and the adventitia of the carotid artery. Pathological findings showed a proliferation of fibroblast cells in the resected plaque. Common or internal carotid artery stenosis related to compression from the hyoid bone is rare. These cases hold a potential for tight adhesion around tissues. Therefore, in cases of prolonged hyoid bone, increased attention should be given to the operative procedure.

[Metastasis of Hepatocellular Carcinoma to the Membrane of Chronic Subdural Hematomas:A Case Report].

An 81-year-old man presented with gait disturbance. Two months previously, he suffered from hepatocellular carcinoma and transarterial chemoembolization was performed. A head computed tomography(CT)scan revealed bilateral chronic subdural hematomas. The patient's gait disturbance was improved after achievement of bilateral burr hole drainage. A head CT two months after treatment revealed no recurrence of the hematomas. However, head CT images obtained four months after treatment revealed an abnormal mass in the right parietal region attached to the internal surface of the skull. The mass was located in the same region from where the chronic subdural hematomas were previously removed via burr hole drainage, and was suspected to have originated from the dura mater. We performed craniotomy and total removal of the mass. The dura mater was intact, and macroscopically, the mass originated from the organized membrane of the chronic subdural hematoma. A pathological examination revealed metastasis of hepatocellular carcinoma to the membrane of the chronic subdural hematomas. Head magnetic resonance imaging(MRI)performed 39 days after craniotomy presented a new lesion in the left parietal region attached to the internal surface of the skull. The patient subsequently died 46 days post-operation. When examining chronic subdural hematomas in cancer patients, histological examination of the dura mater, hematoma, and membrane of the hematoma are important. The possibility of metastasis to the capsule of the hematoma should be considered.

[A case of lateral ventricle metastasis from gastric carcinoma].

Metastatic brain tumors of the lateral ventricles are rare. Approximately half of the reported cases have originated from renal carcinoma;to the best of our knowledge, only 1 case originating from gastric carcinoma has been reported. A 57-year-old man presented with dull headache, left hemiparesis, and constructional apraxia of the right upper extremity. He had undergone gastrectomy for gastric carcinoma 8 years previously. Magnetic resonance imaging revealed an enhanced tumor extending from the right caudate nucleus to the right lateral ventricle with peritumoral edema. Complete resection of the tumor was achieved via the right transcallosal approach. The histopathological diagnosis was metastasis from the gastric carcinoma. After the resection, the patient temporarily showed a lack of spontaneity and extrapyramidal signs of the right upper and lower limbs;his condition improved after 3 weeks. He was discharged 2 months after the surgery, without any neurological deficits. Patients with tumors of the lateral ventricles may present with various characteristic neurological symptoms in the perioperative period;therefore, a thorough neurological examination is necessary.

[Case with intracranial pial arteriovenous fistulas].

A 25-year-old man presented with right hemiparesis and was admitted to the local hospital. CT scan revealed an intracerebral hematoma in the left motor cortex. He was treated conservatively, the hematoma passed without increase and his right hemiparesis improved gradually. The cause of hemorrhage was examined at the local hospital without resolution. He came to our hospital for further examination. Angiography revealed pial arteriovenous fistulas near the hematoma. The fistulas were fed by small branches of the left anterior cerebral artery and drained into an abnormal cortical vein. Left parietal craniotomy was performed. A red dilated cortical vein existed under the thickened, cloudy arachnoid membrane. Retrograde observation of the red vein showed some small branches connected directly to the red vein at the central sulcus. There was no nidus. The color of the red vein changed to blue after disconnection of the fistulas by electrocoagulation. The dilated cortical vein was resected. Postoperative angiography revealed the disappearance of the fistulas. He was discharged without any new neurological deficits. Intracranial pial arteriovenous fistulas are rare cerebrovascular lesions. As symptomatic patients managed conservatively have a poor prognosis, radical treatment should be undertaken as soon as possible.

Mirror-image spinal dural arteriovenous fistulas at the craniocervical junction: case report and review of the literature.

BACKGROUND AND IMPORTANCE: We report an extremely rare case with mirror-site spinal dural arteriovenous fistulas (DAVFs) at the craniocervical junction. Although multiple spinal DAVFs have been reported in the literature, complete mirror-site lesions with fistulas and feeding arteries in the symmetric position have not been previously described. CLINICAL PRESENTATION: A 74-year-old man presented with walking disturbance, urinary incontinence, and constipation progressing over a 14-month period. T2-weighted magnetic resonance imaging showed a high-intensity area in the spinal cord at the level from C4 to C6 and multiple flow voids at the surface of the spinal cord. Three-dimensional computed tomographic angiography revealed bilateral DAVFs located in the mirror site of the craniocervical junction. Direct surgery with suboccipital craniectomy and C1 laminectomy revealed dilated tortuous red veins on the dorsal surface of the spinal cord. We found bilateral symmetric red veins around the dural penetration of the vertebral artery. Both red veins were successfully interrupted with the aneurysmal clips. Postoperative 3-dimensional computed tomographic angiography revealed a disappearance of the bilateral fistulas. Magnetic resonance images obtained 6 months after the surgery confirmed the disappearance of the intramedullary high-intensity area and flow voids. The symptoms before the operation improved after surgery, especially urinary incontinence and constipation, with slight walking disturbance. CONCLUSION: Because fistulas in the present case existed at the same spinal level, we found multiple fistulas on the first examination. This early notification resulted in a good outcome from the first operation. If patients with spinal DAVFs have rapidly progressing symptoms, one should suspect multiple fistulas.

Multiple concurrent anastomotic procedures in the management of moyamoya disease: a case report with review of literature.

It has already been proved by many studies that surgical revascularization definitely helps in curing the symptoms of moyamoya vasculopathy. In this regard, we present a case of moyamoya disease which was cured by concurrent multiple anastomotic procedures, namely superficial temporal artery (STA), middle cerebral artery (MCA) anastomosis, encephalomyosynangiosis (EMS) and encephalogaleosynangiosis (EGS). A 24-year-old woman presented with symptoms of cerebral ischemia. Thorough investigation with MRA and MRI revealed moyamoya vasculopathy and was confirmed by cerebral angiogram. Multiple concurrent combined anastomotic procedures on both sides relieved the symptoms, which was also confirmed angiographically. A Combination of multiple direct and indirect procedures covers the whole ischemic cortical area and provides effective neovascularization.

Course of apparent diffusion coefficient values in cerebral edema of dural arteriovenous fistula before and after treatment.

Apparent diffusion coefficient (ADC) values at magnetic resonance imaging (MRI) are useful to distinguish vasogenic and cytotoxic edema due to cerebovascular diseases. Dural arteriovenous fistulas (DAVFs) with retrograde leptomeningeal venous drainage may cause cerebral edema by venous congestion. We report herein the course of ADC values of cerebral edema before and after endovascular treatment in DAVFs. A 65-year-old woman with transverse-sigmoid (T-S) sinus DAVFs with retrograde leptomeningeal venous drainage presented with severe edema in cerebellar hemisphere and brainstem. In preoperative MRI, increased ADC values were observed in the edema area. The isolated sinus was obliterated completely by transvenous embolization. On the following day after treatment, the ADC values in cerebral edema area increased slightly without any new neurological deficits and improved at 1 week later. Rapid resolution of venous congestion due to DAVFs may cause a slight, transient progression of vasogenic edema.

Transient headache related to enlargement of the contralateral vertebral artery after vertebral artery occlusion.

BACKGROUND: Endovascular proximal parent artery occlusion has been performed for VA dissection. We describe a case that presented with headache associated with transient enlargement of contralateral VA after VA occlusion. CASE DESCRIPTION: A 54-year-old man presented with constant occipital headache on the left due to left VA dissection. Proximal parent artery occlusion of the left VA with detachable coils was performed, and the headache disappeared after coil occlusion. However, the patient presented with occipital headache on the right 1 week later. The MRI showed enlargement of the right VA compared with before the procedure. Four weeks later, the right occipital headache disappeared, and MRI showed improvement of enlargement of the right VA. CONCLUSION: The patient might present with right occipital headache related to transient enlargement of contralateral VA after VA occlusion. Careful postoperative neuroradiological examination of the contralateral VA is required because contralateral VA enlargement may be caused by hemodynamic stress after VA occlusion.

Expression of vascular endothelial growth factor in dura mater of patients with moyamoya disease.

Vascular endothelial growth factor (VEGF) has been found to be involved in vasculogenesis in different intracranial lesions. We investigated meningeal cellularity and VEGF expression in dura mater of patients with and without moyamoya disease. Nine dural specimens from nine cerebral hemispheres of seven patients with moyamoya disease and four control dural specimens from four non-moyamoya patients were collected during surgery and investigated. Dural specimens were immunohistochemically stained with VEGF antibody, and then meningeal cellularity and VEGF expression in dural tissue were analyzed. The mean+/-standard error (SE) of total number of meningeal cells (meningeal cellularity) in dural tissue was 21.5+/-3.0 in the moyamoya disease patients, whereas it was 2.7+/-0.7 in control patients. The mean+/-SE of VEGF expression was 51.1+/-4.9% in the moyamoya disease patients, whereas it was 13.8+/-5.9% in control patients. The meningeal cellularity and VEGF expression were statistically significantly higher in the moyamoya group in comparison to control group (p<0.0001). Meningeal cellularity and VEGF expression are significantly increased in dura mater of the patients with moyamoya disease.

Single-stage operation for a giant haemangiopericytoma following intracranial feeder embolization.

Meningeal haemangiopericytomas (HPC) are malignant intracranial neoplasms that commonly recur and metastasize. Large size at diagnosis, abundant intracranial feeders and the risk of intraoperative bleeding can make them difficult to completely remove in one operation. We report here a rare case of a giant HPC which was treated successfully using a one-stage operation following superselective intracranial feeder occlusion. A 30-year-old man presented with a left middle cranial fossa tumour extending to the left temporal lobe and cerebellar tentorium. Angiography revealed supply from a dilated left posterior temporal artery branching from the posterior cerebral artery. The tumour was totally removed in a single-stage excision after embolization of the intracranial major feeding artery. The present case suggests the usefulness of preoperative embolization for HPC, particularly of intracranial feeders, to achieve total resection safely in a single operation.

Angiographic neovascularization after bypass surgery in moyamoya disease: our experience at Hiroshima University Hospital.

In this study, we investigated the effect of different bypass procedures on postoperative neovascularization in patients with moyamoya disease at Hiroshima University Hospital. Fourteen cerebral hemispheres of seven patients with moyamoya disease were investigated. Five of the 14 hemispheres underwent direct bypass surgery and the remaining 9 underwent indirect bypass. The neovascularization after bypass surgery was evaluated by cerebral angiography. The extent of angiographic neovascularization after direct or indirect bypass surgery was graded as good, fair or poor. Postoperative neovascularization status (good, fair or poor) was compared with the bypass procedure (direct and indirect bypass). Good neovascularization was observed in 8 hemispheres and the remaining 6 had poor neovascularization. Direct bypass surgery was significantly more effective for angiographic neovascularization than the indirect procedure in moyamoya patients (chi2-test, p<0.05). Therefore, we concluded that the direct bypass procedure is a better choice for moyamoya disease as evidenced by angiographic neovascularization.

Staged bilateral vertebral artery occlusion for ruptured dissecting aneurysms of the basilar artery: a report of 2 cases.

BACKGROUND: Dissecting aneurysm of the basillary artery BA is rare. Although mortality rate is high, management remains controversial. We report 2 cases of dissecting aneurysm of the BA presenting with subarachnoid hemorrhage (SAH), both of which were successfully treated using staged occlusion of bilateral vertebral arteries (VAs). CASE DESCRIPTION: A 64-year-old man and a 34-year-old woman presented with SAH associated with ruptured dissecting aneurysm of the BA. After endovascular occlusion of a single VA, blood flow in the dissected lumen was reduced. However, one aneurysm rebled and the bleb of the other did not change. Vertebral arteries were also occluded using endovascular techniques at 4 and 2 weeks after initial treatment, respectively. On the second intervention, stump pressure ratios of VAs intended for occlusion were 62.5% and 50.6%, respectively. The patients tolerated temporary occlusion of bilateral VAs well. Subsequent permanent occlusion of bilateral VAs resulted in no neurological complication. Complete obliteration of the aneurysmal lumen was demonstrated on magnetic resonance angiography performed 72 and 5 months later, respectively. CONCLUSION: Staged bilateral VA occlusion might be the last recourse to prevent further hemorrhage from BA dissecting aneurysm. The technique can be safely applied when the stump pressure ratio is 50.6% or greater and when the patient tolerates temporary occlusion, which suggests the existence of sufficient collateral flow from the anterior circulation.

Volume subtraction three-dimensional CT angiography for cerebrovascular disease: report of two cases.

We report two cases in which volume subtraction three-dimensional CT angiography (VS-3DCTA) was used for cerebral aneurysm and vascular stenosis with intramural calcification. Case 1: VS-3DCTA with volume rendering clearly showed carotid cave aneurysm of the internal carotid artery. The location and size of the aneurysm was confirmed by digital subtraction angiography (DSA). In evaluation of the aneurysm, VS-3DCTA was equal to DSA and endovascular findings. Case 2: VS-3DCTA with volume rendering clearly showed stenosis of the middle cerebral artery, and intramural calcification with the cause of the stenosis was subtracted. On the other hand, it was difficult for DSA to reveal the stenosis because of the limitation of the imaging angle. In evaluation of the stenosis, VS-3DCTA was superior to DSA. VS-3DCTA was an important diagnostic tool that enabled visualization of the aneurysm in the area of the skull base and stenosis of the intracerebral artery.

Churg-Strauss syndrome presenting with subarachnoid hemorrhage from ruptured dissecting aneurysm of the intracranial vertebral artery.

Churg-Strauss syndrome (CSS) represents a rare systemic vasculitis that is almost invariably accompanied by bronchial asthma and eosinophilia. We report a case of a 36-year-old woman with previously diagnosed CSS presented with subarachnoid hemorrhage (SAH) from dissecting aneurysm in a vertebral artery (VA). Two months before onset of SAH, the patient had presented with numbness on her right lower leg due to peripheral neuropathy. On admission, angiography revealed dissecting aneurysm of the right intracranial VA and stenosis of the basilar artery. Hematological examination revealed an increased percentage of eosinophils. Ruptured dissecting aneurysm of the intracranial VA was diagnosed. Emergent coil embolization of the dissecting aneurysm and occlusion of the parent artery was performed to prevent repeated hemorrhage from the dissecting aneurysm. Then pharmacotherapy with prednisone was initiated for CSS. The patient recovered well and was discharged without any neurological deficit. As far as we know, this is the first reported case of CSS presented with SAH from dissecting aneurysm on posterior circulation.