Oculomotor nerve palsy in pituitary apoplexy associated with pituitary adenoma: a radiological analysis with fast imaging employing with steady-state acquisition.

PURPOSE: Oculomotor nerve palsy (ONP) occasionally occurs in cases of pituitary apoplexy (PA) associated with pituitary adenoma, but its mechanism remains unclear. Intracranial nerves are clearly visualized by fast-imaging employing with steady-state acquisition (FIESTA). Here, we assessed the oculomotor nerve compression in patients with PA associated with pituitary adenoma using FIESTA. METHODS: Twenty-eight cases of PA, with or without ONP, were retrospectively reviewed. All patients had undergone preoperative FIESTA. Two neuroradiologists, unaware of the patient's clinical symptoms, evaluated the presence and location of oculomotor nerve compression due to the tumor. RESULTS: Thirteen of the twenty-eight PA cases were associated with ONP. Tumor size and degree of cavernous sinus invasion were not significantly different between the ONP and non-ONP groups. Even in the ONP group, 8/13 (62%) tumors did not show cavernous sinus invasion. Via FIESTA, the presence of oculomotor nerve compression was confirmed in 11/13 (85%) and 5/15 (33%) cases in the ONP and non-ONP groups, respectively (p = 0.008). The radiologists' diagnoses of laterality of nerve compression (right or left) were consistent with the patient's affected eye. In the ONP group, the location of the nerve compression was located at the entry point to the cavernous sinus, the so-called oculomotor triangle, in 9/11 (82%) cases and intra cavernous sinus in 2/11 (18%) cases. CONCLUSION: Compression at the oculomotor triangle is considered the main cause of ONP with PA in pituitary adenomas.

Long-term predictive factors of the morphology based outcome in bare platinum coiled intracranial aneurysms: Evaluation by pre- and post-contrast 3D time-of-flight MR angiography.

PURPOSE: Our aim was to identify long-term predictive factors of the morphology-based outcome (MBO) of bare platinum coiled intracranial aneurysms. MATERIALS AND METHODS: A retrospective analysis of 96 bare platinum coiled intracranial aneurysms followed up from 1997 to 2016 using pre- and post-contrast 3D time-of-flight MR angiography (MRA) was performed. Logistic regression analysis was used to identify factors associated with a positive history of surrounding coil mass enhancement (SCME) and poor MBO. Spearman's rank correlation test was used to analyze the relationship between the initial angiographic result (IAR) class, sequential change of the SCME category, and MBO grade. RESULTS: Factors independently associated with poor MBO were incomplete IAR (OR=14.94, 95%CI: 2.46, 289.21, P=0.002) and a history of SCME (OR=4.13, 95% CI: 1.05, 18.65, P=0.043). The MBO grade strongly correlated with the IAR class (correlation coefficient [r]=0.84, P<0.0001). MBO grade correlated with sequential change of the SCME category (r=0.56, P<0.0001). The sequential change of the SCME category correlated with IAR class (r=0.53, P<0.0001). CONCLUSION: Although IAR and its class were strong long-term predictive factors of MBO, a history of SCME and upgrading of sequential change of SCME category were also long-term predictive factors of the MBO of bare platinum coiled intracranial aneurysms.

Malignant transformation of diffuse infiltrating glial neoplasm after prolonged stable period initially discovered with hypothalamic hamartoma.

We present a case of malignant transformation of diffuse infiltrating glial neoplasm after a prolonged stable period on magnetic resonance imaging (MRI) and spectroscopy (MRS) initially discovered with a hypothalamic hamartoma. Although MRI and MRS suggest the possibility of malignant transformation in future, they cannot precisely predict the timing of rapid growth.

Common hepatic artery aneurysm treated with an endovascular stent-graft: a case report.

We present the case of a common hepatic artery aneurysm successfully treated with an endovascular stent-graft. Although the long-term usefulness of stent-graft placement is not confirmed, the favorable mid-term course in our patient suggests that stent-graft placement may be considered as the treatment of choice in selected cases with hepatic artery aneurysm.

Detection of hepatocellular carcinoma by CT during arterial portography using a cone-beam CT technology: comparison with conventional CTAP.

BACKGROUND: To evaluate the detectability of hepatocellular carcinoma (HCC) by computed tomography during arterial portography (CTAP) using cone-beam CT technology (CBCTAP) by comparing it with conventional CTAP. METHODS: Forty-four HCC lesions (mean diameter 1.9 +/- 1.1 cm) of 24 patients who sequentially underwent conventional CTAP and CBCTAP during the same angiography session were evaluated. CBCTAP findings of each tumor were classed into three grades as compared to conventional CTAP: optimal; suboptimal; and nondiagnostic. RESULTS: All CBCTAP images had image artifacts from the catheter placed in the superior mesenteric artery and enhanced portal veins. Additionally, the contrast between HCC lesion and surrounding liver parenchyma of CBCTAP images was less than that of CTAP images. Of the 44 tumors, findings of 31 nodules (mean 2.2 +/- 1.2 cm) (70.5%) were classed as optimal. Eight nodules (mean 1.4 +/- 0.8 cm) (18.2%) were classed as suboptimal. Five nodules (mean 1.0 +/- 0.1 cm) (11.4%) including two located in the outside of field of view were classed as nondiagnostic. CONCLUSION: CBCTAP had sufficient image quality to detect almost all small HCC lesions compared to conventional CTAP and could depict approximately 89% of HCC nodules, including eight suboptimal lesions.

Creation of a cleft in an angiography catheter to facilitate catheterization of branches of the aorta arising at an acute angle.

The authors report on the use of a catheter with a cleft for catheterization of a branch artery arising from the aorta with an acute angle. The cleft was created on either the right or cephalad portion at the tip of a seated 4-F shepherd hook catheter in the artery origin, depending on vessel angulation during chemoembolization procedures. This catheter was used in eight arteries-seven inferior phrenic arteries and one right subcostal artery-that could not be catheterized with a conventional coaxial technique. The microcatheter was successfully introduced into all eight vessels through the cleft without complications.

Cranial Pachymeningeal Involvement in POEMS Syndrome: Evaluation by Pre- and Post-contrast FLAIR and T1-weighted Imaging.

PURPOSE: To evaluate the cranial pachymeningeal involvement of polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, skin changes (POEMS) syndrome using pre- and post-contrast fluid-attenuated inversion recovery (FLAIR) and T1-weighted imaging (T1WI). METHODS: The appearance of pachymeningeal involvement in nine cases of POEMS syndrome was evaluated using pre- and post-contrast FLAIR and T1WI. The degree of pachymeningeal thickening was graded as normal or abnormal using pre-contrast FLAIR. The degrees of contrast enhancement effect were evaluated based on pre- and post-contrast images, and recorded in each of three separate anatomical areas, i.e., the falx cerebri, cerebral convexity, and tentorium cerebelli. The degrees of contrast enhancement of pachymeninges were graded as not detected (ND), positive, or prominent on post-contrast FLAIR, and normal range (NR), positive, and prominent on post-contrast T1WI. RESULTS: Pre-contrast FLAIR demonstrated 41% of pachymeningeal anatomical regions as areas of thickening. Post-contrast FLAIR did not detect any contrast enhancement on 26% of the regions but showed positive enhancement on 30% and prominent enhancement on 44%. Post-contrast T1WI showed normal range enhancement on 48%, positive enhancement on 11%, and prominent enhancement on 41% of the regions. Post-contrast FLAIR showed the highest percentage for detection of pachymeningeal abnormalities (74%). CONCLUSION: Post-contrast FLAIR may contribute to objective judgment in the evaluation of pachymeningeal involvement in POEMS syndrome.

MR Spectroscopy to Distinguish between Supratentorial Intraventricular Subependymoma and Central Neurocytoma.

PURPOSE: The purpose of this study was to discriminate supratentorial intraventricular subependymoma (SIS) from central neurocytoma (CNC) using magnetic resonance spectroscopy (MRS). METHODS: Single-voxel proton MRS using a 1.5T or 3T MR scanner from five SISs, five CNCs, and normal controls were evaluated. They were examined using a point-resolved spectroscopy. Automatically calculated ratios comparing choline (Cho), N-acetylaspartate (NAA), myoinositol (MI), and/or glycine (Gly) to creatine (Cr) were determined. Evaluation of Cr to unsuppressed water (USW) was also performed. Mann-Whitney U test was carried out to test the significance of differences in the metabolite ratios. Detectability of lactate (Lac) and alanine (Ala) was evaluated. RESULTS: Although a statistically significant difference (P < 0.0001) was observed in Cho/Cr among SIS, control spectra, and CNC, no statistical difference was noted between SIS and control spectra (P = 0.11). Statistically significant differences were observed in NAA/Cr between SIS and CNC (P = 0.04) or control spectra (P < 0.0001). A statistically significant difference was observed in MI and/or Gly to Cr between SIS and control spectra (P = 0.03), and CNC and control spectra (P < 0.0006). There were no statistical differences between SIS and CNC for MI and/or Gly to Cr (P = 0.32). Significant statistical differences were found between SIS and control spectra (P < 0.0053), control spectra and CNC (P < 0.0016), and SIS and CNC (P < 0.0083) for Cr to USW. Lac inverted doublets were confirmed in two SISs. Triplets of Lac and Ala were detected in four spectra of CNC. CONCLUSION: The present study showed that MRS can be useful in discriminating SIS from CNC.

Striatal hemihypoplasia: an early embryonic variant of cerebral hemiatrophy.

We present a case of hemihypoplasia of the striatum with ipsilateral cerebral hemispheric atrophy. The head of the caudate nucleus and putamen were hypoplastic, and gray matter cell bridges between them located in the anterior limb of the internal capsule were sparse. Cerebral atrophy was accompanied by ipsilateral mesial temporal sclerosis without thalamic atrophy. The anterior limb of the internal capsule showed no signal abnormalities or volume loss. These imaging findings and the hyperintensity at the fundus striati suggest an early embryonic insult of lateral striatal elevation.

Differences between glioblastomas and primary central nervous system lymphomas in 1H-magnetic resonance spectroscopy.

PURPOSE: The present study aimed to distinguish between glioblastomas and primary central nervous system lymphomas (PCNSLs) using (1)H-magnetic resonance spectroscopy (MRS), especially glutamate (Glu)/creatine (Cr) and Glu/Glu+glutamine (Gln) ratios. MATERIALS AND METHODS: A total of 46 patients (31 cases diagnosed with glioblastoma, 15 with PCNSL) were examined by in vivo single-voxel proton (1)H-MRS with a 3-T MR imaging system. Differences in absolute concentration of Cr, choline/Cr, lipid (1.3 ppm)/Cr, Glu+Gln/Cr, Glu/Cr, and Glu/Glu+Gln ratios among groups were evaluated with Mann-Whitney U tests. RESULTS: PCNSLs [3.408 ± 1.194 (standard deviation)] showed significantly higher Glu/Cr ratios as compared to glioblastomas (2.220 ± 0.942; P = 0.003) [Glu/Cr cutoff ratio of 2.509 showed a sensitivity of 88 % (7/8) and a specificity of 92 % (22/24)], while glioblastomas (0.539 ± 0.098) showed significantly lower Glu/Glu+Gln ratios as compared to PCNSLs (0.728 ± 0.147; P < 0.001) [Glu/Glu+Gln cutoff ratio of 0.558 showed a sensitivity of 69 % (18/26) and a specificity of 100 % (13/13)]. And PCNSLs (1.101 ± 0.387) showed significantly higher Cho/Cr ratios as compared to glioblastomas (0.850 ± 0.465; P = 0.026). CONCLUSION: Glu/Cr, Glu/Glu+Gln, and Cho/Cr ratios may be useful in distinguishing between glioblastomas and PCNSLs.

Splenial and white matter lesions showing transiently-reduced diffusion in mild encephalopathy monitored with MR spectroscopy and imaging.

We report the time course of magnetic resonance imaging and spectroscopy of a case with lesions of the splenium and white matter with transiently reduced diffusion in clinically reversible encephalopathy. Initially normal spectroscopy showed slightly elevated choline. Signal abnormality in T2-weighted and fluid-attenuated inversion recovery images persisted for 90 days. Lesions of the splenium and white matter with transiently reduced diffusion in clinically reversible encephalopathy are not always reversible and may reflect heightened glial cell-membrane turnover without neuronal damage.

Acute cholecystitis caused by malignant cystic duct obstruction: treatment with metallic stent placement.

We report the successful management of acute cholecystitis using cystic duct stent placement in 3 patients with inoperable malignant cystic duct obstruction (2 cholangiocarcinoma and 1 pancreatic carcinoma). All patients underwent stent placement in the bile duct, using an uncovered stent in 2 and a covered stent in 1, to relieve jaundice occurring 8-184 days (mean 120 days) before the development of acute cholecystitis. The occluded cystic duct was traversed by a microcatheter and a stent was implanted 4-17 days (mean 12 days) after cholecystostomy. Acute cholecystitis was improved after the procedure in all patients. Two patients died 3 and 10 months later, while 1 has survived without cholecystitis for 22 months after the procedure to date.

Iodized oil accumulation in the hypovascular tumor portion of early-stage hepatocellular carcinoma after ultraselective transcatheter arterial chemoembolization.

PURPOSE: We evaluated iodized oil accumulation in the hypovascular portion of early-stage hepatocellular carcinoma (HCC) after ultraselective transcatheter arterial embolization (TACE). MATERIALS AND METHODS: Forty-seven HCC lesions with hypovascular portions were treated by TACE at the distal level of the sub-subsegmental artery of the liver. Portal blood in the hypovascular portion was classed in two grades by computed tomography (CT) during arterial portography: decreased and preserved. Iodized oil accumulation was classed into three grades on CT obtained 1 week after TACE: (1) dense accumulation in the almost entire tumor, including the hypovascular portion (grade 2); (2) dense accumulation in hypervascular portions but sparse accumulation in hypovascular portion (grade 1); and (3) sparse accumulation or no accumulation (grade 0). Findings on serial follow-up CT images were also analyzed. RESULTS: Portal blood in the hypovascular portion was decreased in 32 lesions, and preserved in 15 lesions. On CT 1 week after TACE, 32 tumors (68.1%)-23 with decreased portal blood and 9 with preserved portal blood-were classed as grade 2. Twelve tumors (25.5%), six with decreased portal blood and six with preserved portal blood, were classed as grade 1. Three tumors (6.4%) with decreased portal blood were classed into grade 0. In total, 25 tumors (53.2%), 22 in grade 2 and 3 in grade 1, were well controlled by ultraselective TACE during the mean follow-up of 15.8 months. CONCLUSIONS: Iodized oil accumulation and retention in the hypovascular portion of early-stage HCC was frequently observed after ultraselective TACE, mainly in the hypovascular portion with decreased portal blood.

Visualization of hepatic lymphatic vessels during transcatheter arterial chemoembolization for hepatocellular carcinoma.

PURPOSE: To analyze visualization of hepatic lymphatic vessels during transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Retrospective review was conducted of 255 tumors in 161 patients treated by TACE with catheterization of the most distal portion of the tumor-feeding branches. All TACE procedures were performed with use of a mixture of iodized oil and anticancer drugs followed by gelatin sponge particles. Arteriograms and spot radiographs obtained during TACE were reviewed to determine whether hepatic lymphatic vessels appeared. Serial computed tomography (CT) images after TACE were evaluated along with clinical symptoms in cases that exhibited lymphatic vessel visualization. RESULTS: Hepatic lymphatic vessels were demonstrated in eight tumors (3.1%) in eight patients during TACE. The mean tumor diameter was 1.7 cm +/- 0.7 (range, 1.0-3.3 cm), and mean volume of injected iodized oil was 1.7 mL +/- 1.0 (range, 1-4 mL). Lymphatic vessels were demonstrated followed by marked portal vein visualization (n = 5) or extravasation of a small amount of contrast material (n = 2). In the remaining patient, these were depicted during the early stage of the TACE procedure. On CT after 1 week, iodized oil in the lymphatic systems in the hepatoduodenal ligament was seen in six patients, and it was shown to have been retained in four of these patients on follow-up CT performed 2, 7, 11, and 21 months later, respectively. None of these patients presented any clinical symptom other than postembolization syndrome. CONCLUSIONS: Hepatic lymphatic vessels were demonstrated in 3.1% of tumors treated by ultraselective TACE. Iodized oil in the lymphatic vessels may be retained for a relatively long time without specific symptoms.

Bronchial artery aneurysm embolization with NBCA.

We present a case of asymptomatic bronchial artery aneurysm that formed a fistula with part of the pulmonary artery (there was no definite fistula with the pulmonary vein). We were able to catheterize the feeding vessel but could not reach the aneurysm. We therefore injected a mixture of N-butyl-2-cyanoacrylate (NBCA; Histoacryl, B. Braun, Melsungen, Germany) and iodized oil (Lipiodol; Guerbet, Aulnay-sous-Bois, France) from the feeding vessel. The fistula, aneurysm, and feeding vessel were almost totally occluded. After embolization, the patient coughed a little; there were no other definite side effects or complications. One and 3 months later, on chest CT, the aneurysm was almost completely occupied with hyperattenuating NBCA-Lipiodol embolization. NBCA is a liquid embolization material whose time to coagulation after injection can be controlled by diluting it with Lipiodol. It is therefore possible to embolize an aneurysm, feeding vessels, and efferent vessels (in our case, it was a fistula) by using an NBCA-Lipiodol mixture of an appropriate concentration, regardless of whether the catheter can reach the aneurysm or not.