Case report: isolated trochlear nerve palsy associated with posterior cerebral artery aneurysm.

We describe a case of isolated trochlear nerve palsy caused by an unruptured posterior cerebral artery (PCA) aneurysm in an 82-year-old male who consulted an ophthalmologist after developing diplopia. Magnetic resonance angiography showed a left PCA aneurysm in the ambient cistern, and T2WI showed an aneurysm compressing the left trochlear nerve to the cerebellar tentorium. Digital subtraction angiography revealed that the lesion was located between the left P2a segment. We attributed this isolated trochlear palsy to left PCA unruptured aneurysm pressure. Thus, we performed stent-assisted coil embolization. The aneurysm was obliterated, and trochlear nerve palsy improved completely.

[Microvascular Decompression to Treat Abducens Nerve Paralysis Caused by Compression of the Anterior Inferior Cerebellar Artery:A Case Report].

Microvascular decompression(MVD)is an effective treatment for hemifacial spasm and trigeminal neuralgia. However, there are few reports regarding its use with abducens nerve palsy. Here, we report the case of a 77-year-old male who presented with diplopia and was admitted to our facility for right abducens nerve palsy. MRI constructive interference in steady-state(CISS)showed that the right anterior inferior cerebellar artery(AICA)was curved in a posterior-superior direction at the beginning of the region of origin, causing compression of the root exit zone of the right abducens nerve. In addition, MRI showed an unruptured fusiform aneurysm(5.3mm×7.1mm)of the vertebral artery(VA)involving the posterior inferior cerebellar artery(PICA). However it was not related to abducens nerve paralysis. The aneurysm was successfully treated with an occipital artery-posterior inferior cerebellar artery(OA-PICA)bypass and clipping of the proximal VA and PICA origin. The position of the offending artery was moved using a Teflon® felt fibrin glue and the retrosigmoid transcondylar fossa approach. The patient recovered from abducens nerve paralysis with no new neurological deficit. We emphasize the importance of choosing an appropriate approach as this increases the possibility of treating abducens nerve paralysis in a timely manner.

Efficacy and Safety of a New Delivery Assist Catheter with a Flexible, Spindle-Shaped Shaft in Mechanical Thrombectomy.

OBJECTIVE: Large-bore aspiration catheters (ACs) are used successfully in mechanical thrombectomy (MT). However, tortuous access routes prevent device navigation because of the ledge effect. The AXS Offset Delivery Assist Catheter is designed to reduce the ledge effect. The purpose of this study was to evaluate whether the Offset affects AC navigation compared with standard inner microcatheters in MT. METHODS: We retrospectively investigated 75 MTs for anterior circulation occlusion between January 2018 and May 2022 at our hospital. All MTs were performed using an AC, and 2 types of inner microcatheter (Offset or 0.021-0.027-inch standard microcatheter) were chosen randomly during AC navigation. The patients' characteristics, MT techniques, angiographic findings, and clinical outcomes were compared between the Offset and standard group (Non-Offset). The puncture to first pass of the lesion time was investigated to compare the characteristics of the inner catheters. RESULTS: The Offset group comprised 12 patients versus 63 in the Non-Offset group. Although most baseline clinical characteristics and outcomes were similar between the groups, the puncture to first pass of the lesion time was significantly shorter in the Offset versus Non-Offset group (31 ± 10 vs. 46 ± 24 minutes, respectively; P = 0.032). In the Offset group, all stent retrievers were deployed via the Offset. One artery dissection and 8 symptomatic intracranial hemorrhages occurred in the Non-Offset group; no complications occurred in the Offset group. CONCLUSIONS: The AXS Offset delivery assist catheter permitted faster and safer navigation of various ACs to the occlusions compared with standard delivery microcatheters in MT.

Repeated coil embolization of traumatic basilar artery pseudoaneurysm accompanied by bilateral traumatic internal carotid artery stenosis following severe head injury in a pediatric patient: A case report and literature review.

Background: Few cases of pediatric traumatic intracranial aneurysms (pTICAs) in the posterior circulation involving the basilar artery (BA) following severe head trauma have been reported. Here, we describe a pediatric case of traumatic BA pseudoaneurysm accompanied by bilateral traumatic internal carotid artery (ICA) stenosis following blunt head trauma. Case Description: A 16-year-old boy presented to our emergency department after being hit by a car. The patient was initially diagnosed with multiple skull base fractures underlying traumatic subarachnoid hemorrhage and left acute epidural hematoma. Seven days following emergency craniectomy, magnetic resonance imaging revealed bilateral ICA stenosis, BA stenosis, and BA pseudoaneurysm. We decided to perform coil embolization, resulting in body filling and a volume embolization ratio of 15.7%. Twenty-eight days after coil embolization, digital subtraction angiography revealed aneurysmal rupture. We performed repeated coil embolization, resulting in body filling and a volume embolization ratio of 20.9%. Conclusion: We reported a pediatric case of traumatic BA pseudoaneurysm accompanied by bilateral traumatic ICA stenosis following a severe head injury treated with repeated coil embolization. Considering the risk of further brain injury due to high incidence of rupture, early vascular survey and appropriate treatment may be the most important prognostic factors in pTICAs.

Disappearance of a moyamoya-related distal anterior cerebral artery aneurysm after target bypass revascularization: illustrative case.

BACKGROUND: Aneurysm formation is a complication of moyamoya disease (MMD). Distal anterior cerebral artery (ACA) aneurysms account for approximately 1% of MMD-related aneurysms. We report a case of target bypass for adult patients with MMD who presented with intracranial hemorrhage due to rupture of a distal ACA aneurysm, whose disappearance was confirmed postoperatively. OBSERVATIONS: A 45-year-old woman presented with sudden-onset headache and loss of consciousness. Head computed tomography showed hemorrhage in the genu of the corpus callosum with intraventricular extension. Digital subtraction angiography (DSA) revealed Suzuki stage III MMD and a left A3 segment aneurysm. Superficial temporal artery (STA)-middle cerebral artery (MCA) bypass and STA-ACA target bypass were performed to reduce hemodynamic stress on the left ACA. DSA 6 months after surgery showed patency of both bypasses and disappearance of the aneurysm. At the 20-month follow-up, the patient was asymptomatic and neurologically intact. LESSONS: Bypass revascularization may be an effective treatment to reduce hemodynamic stress and eliminate MMD-related aneurysms.

Manual superficial temporal artery compression using a circular plastic material for embolization of meningioma: illustrative case.

BACKGROUND: In meningiomas that occur in the high-convexity region, the superficial temporal artery (STA) frequently feeds the tumor, and when embolizing from the middle meningeal artery (MMA), the embolic material may not reach the tumor vessels because of the pressure gradient resulting from the STA blood flow, resulting in inadequate embolization. In this case, a circular plastic material was used to apply circumferential pressure around the parietal foramen to control blood flow to the tumor. OBSERVATIONS: A 45-year-old male underwent head magnetic resonance imaging that revealed a 2.2-cm meningioma in the right high-convexity region. Preoperative embolization was performed. When N-butyl-2-cyanoacrylate was injected from the right MMA while using a circular plastic material to compress the skin around the parietal foramen through which the bilateral STAs (the tumor feeders) flow, it was able to fully penetrate the tumor vessel and occlude the other feeders in a retrograde manner. The patient underwent tumor removal after embolization uneventfully. LESSONS: Manual compression of the STA using a circular plastic material is useful when the tumor is fed by the STA through the parietal foramen and is also applicable to transarterial embolization of dural arteriovenous fistulas fed by the STA or occipital artery.

Pooled blood volume measured by final flat-panel detector computed tomography predicts outcome after endovascular thrombectomy for acute ischemic stroke.

Background: Pooled blood volume (PBV), measured in real-time in the angiography room using an angiography system, correlates with cerebral blood volume (CBV). We examined the usefulness of PBV in endovascular thrombectomy (EVT) for acute ischemic stroke (AIS). Methods: EVT for AIS in the anterior circulation (internal carotid artery (ICA) and middle cerebral artery (MCA)) was performed in 31 cases (13 males, 18 females, average age 75.7 years). PBV was acquired using a biplane flat-panel detector (FD) angiographic system. Then, we measured the average PBV value in the M1-6 regions similar to the Alberta Stroke Program Early CT score (ASPECTS) before and after EVT. We investigated factors associated with favorable outcome at 90 days after EVT. Results: There were 13 patients (41.9%) in the good outcome group (mRS (modified Rankin Scale) ≦2) and 18 patients (58.1%) in the poor outcome group (mRS>2). In univariate analysis, NIHSS (National Institutes of Health Stroke Scale) (odds ratio [OR] 0.74, 95% CI 0.57-0.87, p < 0.0001) and post PBV value (odds ratio [OR] 1.13, 95% CI 1.03-1.29, p = 0.0086) were significantly associated with good outcome. The good outcome group had significantly higher post-thrombectomy PBV value (3.69 ± 0.32 ml/100 g versus 2.78 ± 0.93 ml/100 g, P = 0.002) compared to that of the poor outcome group. The relationship between pre-thrombectomy PBV value and outcome at 90 days was not significant. Conclusions: Post-operative PBV value measured by FD-CT (computed tomography) correlated with 90-day outcome after EVT for AIS. FD-CT-PBV would be one of the good predictors of clinical outcome.

Ago-allosteric modulators of human glucagon-like peptide 2 receptor.

Glucagon-like peptide 2 (GLP-2) is an intestinotropic peptide that binds to GLP-2 receptor (GLP-2R), a class-B G protein-coupled receptor (GPCR). Few synthetic agonists have been reported so far for class-B GPCRs. Here, we report the first scaffold compounds of ago-allosteric modulators for human GLP-2R, derived from methyl 2-{[(2Z)-2-(2,5-dichlorothiophen-3-yl)-2-(hydroxyimino)ethyl]sulfanyl}benzoate (compound 1).

Enlargement of preexisting superficial temporal artery pseudo-aneurysm co-incidental to mask wearing during the Covid-19 pandemic.

The superficial temporal artery (STA) pseudo-aneurysm is usually associated with trauma. We report a unique case of an STA pseudo-aneurysm that developed due to mask wearing during the Covid-19 pandemic. A 70-year-old female presented with a 3-month history of a rapidly growing pseudo-aneurysm of the right STA. Over the past 3 months the patient had been wearing a mask for the prevention of Covid-19. The STA aneurysm was located exactly at a pressure point created by the rubber mask. Therefore, we assumed that an enlargement of the preexisting aneurysm had taken pace due to irritation from the elastic band of the mask. Surgical excision of the aneurysm and reconstruction of the STA using STA-STA bypass were performed. To our knowledge, we here report the first case of an STA pseudo-aneurysm that was potentially affected indirectly by the Covid-19 pandemic. Clinicians should be cautious about the preexisting medical condition that is potentially worsened by mask band compression.

Target Embolization of Complex Vertebral Artery Dissecting Aneurysm with Endovascular Reconstructive Technique Using Cone-Beam Computed Tomography Angiography: Technical Note.

OBJECTIVE: Detailed vasculature of vertebral artery dissecting aneurysms (VADAs) is often complicated owing to the irregular structure with the intimal flap/double lumen. Our aim was to present an endovascular reconstructive technique with assessment of detailed vasculature and the relationship between dissection and surrounding vessels using cone-beam computed tomography angiography (CBCT-A). METHODS: The study included 6 cases with complex vertebral artery dissecting aneurysm. Selective digital subtraction angiography initially identified the location and shape of dissection. CBCT-A was then performed with selective injection into the affected vertebral artery. Luminal morphology of the dissection and surrounding arterial anatomy were assessed using CBCT-A. RESULTS: CBCT-A clearly demonstrated luminal morphology of the intimal flap/double lumen, the entrance into the pseudolumen, and the entire dissecting segment. Tiny perforator arteries were also identified. In all 6 cases, target coil embolization for the pseudolumen and stent placement using an LVIS stent for the entire dissecting segment were successfully performed with the aid of information obtained from CBCT-A. No complications occurred in the perioperative period, and improvement of dissection was identified in the follow-up period. CONCLUSIONS: Target embolization of complex vertebral artery dissecting aneurysm with endovascular reconstructive technique with special reference to the detailed anatomy of dissection using CBCT-A would be useful for safe and effective treatment results.

Usefulness of Adjunctive Technique with a TACTICS Catheter for Coil Embolization of Cerebral Aneurysms.

Objective: We report the usefulness of the adjunctive technique using a 3.4-Fr TACTICS catheter, which is a distal access catheter (DAC) for coil embolization. Methods: Patients who underwent coil embolization with an adjunctive technique using a TACTICS catheter between October 2018 and May 2019 were retrospectively analyzed. Results: In all, 64 aneurysms in 51 patients were treated. Among them, 18 aneurysms in 15 patients (4 ruptured aneurysms and 14 unruptured aneurysms) required an adjunctive technique using a TACTICS catheter. The methods of embolization were the double catheter technique (DCT) for five aneurysms, stent-assisted coiling (SAT) for seven, DCT + SAC for one, and balloon-assisted technique (BAT) for five aneurysms. Aneurysms were located in the anterior communicating artery (Acom A) in three cases, distal anterior cerebral artery (dACA) in one, middle cerebral artery (MCA) in five, internal carotid artery (ICA) in six, basilar artery (BA) in one, and vertebral artery (VA) in two cases. It was easy to access distal intracranial vessels using the TACTICS catheter. In all cases, guiding of the microcatheter, coiling, and stent placement were improved. There were no complications associated with using the TACTICS catheter. Conclusion: Compared with conventional DACs, distal intracranial vessels were more easily accessed using the TACTICS catheter. A TACTICS catheter is useful because DCT and SAC require sufficient operability of the microcatheter.

The usefulness of temporary balloon occlusion during transarterial embolization for scalp arteriovenous fistula.

BACKGROUND: We present two cases of scalp arteriovenous fistula (sAVF) treated by transarterial embolization with the aid of a temporary balloon occlusion (TBO) to detect precise vasculature. CASE DESCRIPTION: Case 1: A 59-year-old woman noticed a sudden onset of pulsating bruits. sAVF was fed by the right superficial temporal artery (STA) and drained to the right superficial temporal vein. We performed feeder occlusion using coils after the recognition of a single feeder and a single fistula using TBO. Case 2: A 42-year-old woman noticed a pulsating subcutaneous mass. sAVF was fed by the right occipital artery (OA) and drained to the right occipital vein (OV). We could detect another feeder of the right STA after the TBO of the OA. We performed transarterial feeder occlusion for STA and OA using coil and N-butyl-2-cyanoacrylat including OV and shunt point, because this case was a single fistula with multiple feeders. CONCLUSION: sAVFs are a relatively rare disease with a complex vascular structure. For the adequate transarterial approach, TBO was useful for detecting the precise vasculature of sAVF.

Laparoscopic enucleation of a gastroenteric duplication cyst arising in a pancreatic tail that did not communicate with the pancreatic duct: report of a case.

Gastroenteric duplication rarely occurs in locations such as the pancreas. We report a case of gastroenteric duplication of the pancreatic tail, which was noncontiguous with the stomach and had no communication with the pancreatic duct, in a 3-year-old girl. The cyst was enucleated by laparoscopy, without the need for pancreatic resection. The optimal treatment procedures vary considerably, depending on where the gastroenteric duplication is located in the pancreas and, most importantly, whether there is communication with the pancreatic duct.

Successful mechanical thrombectomy using a combined technique for internal carotid artery occlusion with persistent primitive trigeminal artery.

BACKGROUND: The prevalence of persistent primitive trigeminal artery (PPTA) has been reported to be 0.1-0.6%. We report the successful recanalization of internal carotid artery (ICA) without embolization to new vascular territory (ENT) using a combined technique in a case of ICA occlusion with PPTA. CASE DESCRIPTION: A 65-year-old female presented with sudden consciousness disorder. The Glasgow Coma Scale score was 7 (E1, V1, M5) and National Institutes of Health Stroke Scale score was 28. Magnetic resonance diffusion-weighted imaging showed areas of high signal intensity in the left frontal lobe, parietal lobe, insular cortex, and corona radiata. Magnetic resonance angiography showed occlusion of the left ICA distal to a PPTA. We performed mechanical thrombectomy (MT) using a combined technique with a balloon guide catheter (BGC), aspiration catheter, and stent retriever and achieved complete recanalization without ENT. The patient experienced a good postoperative recovery course. At 6 months, her Modified Rankin Scale score was 2. CONCLUSION: MT using a combined technique with BGC would be useful to prevent embolization to the posterior circulation through the PPTA in cases of ICA occlusion with PPTA.

Patent ductus arteriosus flow patterns in the treatment of congenital diaphragmatic hernia.

BACKGROUND: Congenital diaphragmatic hernia (CDH) mortality still remains high, due to lung hypoplasia and persistent pulmonary hypertension of the neonate (PPHN). Effective management of PPHN and time of operation are quite important to the improvement of CDH treatment. In order to determine the optimal time for operation, we monitored PPHN with cardiac ultrasound. METHODS: PPHN was assessed with three parameters: patent ductus arteriosus flow patterns (PDAFP), %left ventricular diameter at diastole, and left ventricular fraction of shortening (LVFS). Four patients with an antenatal diagnosis were treated under this protocol. Diaphragm repair was performed when PDAFP became left to right shunt dominant and the pre- and postoperative course was analyzed with regular chart reviews. RESULTS: The alveolar-arterial oxygen difference levels of four patients were 590, 335, 613 and 530 mmHg, and operations were carried out when the patients were 2, 2, 3 and 2 days old, respectively. In three of the four patients (all except case 3) the PDAFP changed from right to left shunt dominant or bidirectional (BD), to left to right shunt dominant within 48 h. The %left ventricular diameter at diastole was relatively stable around the time of operation. The LVFS of all patients decreased after the operation. Only the LVFS of case 3 decreased temporarily to less than 30% (which indicates poor left ventricular function) but recovered. No patients needed extracorporeal membrane oxygenation support. All patients survived the procedure and were extubated. Case 3, who took 10 days to become left to right shunt dominant after the operation, needed home oxygenation therapy for 10 months. CONCLUSIONS: PDAFP was a reliable marker of PPHN on a high-frequency oscillatory ventilator to determine the optimal time for the operation for CDH. The optimal time for operation is supposed to be the time when PDAFP become left to right shunt dominant.

Comparison of the postoperative bowel function between transanal endorectal pull-through and transabdominal pull-through for Hirschsprung's disease: a study of the feces excretion function using an RI-defecogram.

PURPOSE: Herein, we compared the bowel function after a transabdominal and a transanal procedure for Hirschsprung's disease (HD) using the clinical score and a quantitative evaluation of the feces excretion function based on the findings of an RI-defecogram. MATERIALS AND METHODS: The subjects included 35 patients with short segment aganglionosis. In the two groups with transabdominal Z-shaped anastomosis (open group) and transanal endorectal pull-through (TEPT) (transanal group), the postoperative bowel function were evaluated based on the clinical score. In the RI-defecogram study, a time-activity curve was drawn for the (99m)Tc remaining in the rectum on defecation. The feces excretion function was thus quantified, with the time until the (99m)Tc in the rectum became 50% as T0.5 and the time until 90% of the feces were excreted from the rectum as T0.9. RESULTS: The clinical score could be evaluated in 9 cases in the open group and in 15 cases in the transanal group. No significant difference was observed in the total clinical score between the two groups, but the urge to defecate and the constipation scores in the subcategories were significantly lower in the open group. The defecogram was performed included seven cases in the open group and five cases in the transanal group. When an analysis of covariance of the two groups was conducted for the T0.5 and T0.9 values using the postoperative months as a covariate, there was a significantly negative slope, and moreover, there was a significant difference between the two groups. CONCLUSIONS: The RI-defecogram showed that feces excretion time improves with the postoperative months in both the groups, but the transanal group has higher feces excretion function in the early postoperative period compared with the open group. We consider the RI-defecogram to therefore be a useful examination method for evaluating the feces excretion function.

Laparoscopic repair of late-presenting Bochdalek hernia in 2 infants.

Laparoscopic repair was performed on 2 infants with late-presenting Bochdalek hernia. Intraoperatively, the entire small intestine was herniated in 1 case and the stomach, small intestine, and part of the colon and spleen were herniated in the other case. Laparoscopic repair of Bochdalek hernia was successfully completed in both the cases. On the basis of our experience, 4 points seem important in laparoscopic surgery for Bochdalek hernia: (1) avoiding damage to the spleen while reducing organs back into the abdominal cavity; (2) ensuring visualization of diaphragmatic defect after reducing the spleen and intestinal tract; (3) ensuring sufficient width to suture the dorsal side of the diaphragm; and (4) identifying intestinal malrotation. We believe that the fourth point represents an advantage of a laparoscopic approach, which seems superior to the thoracoscopic approach and could represent a useful therapy for Bochdalek hernia in infants and older patients.

Extensive Multilocular Spinal Extradural Meningeal Cyst That Developed 16 Years After Traumatic Brachial Plexus Injury: A Case Report.

BACKGROUND: Symptomatic extensive spinal extradural meningeal cyst (SEMC) developing after traumatic brachial plexus injury (TBPI) is rare. We discuss the mechanism of extensive SEMC development, surgical strategies, and preventive measures against SEMC after TBPI. CASE DESCRIPTION: A 58-year-old man with TBPI 16 years previously developed spastic paraparesis of the lower limbs, sensory disturbance below the periumbilical level, and dysfunction of bladder and bowel over 2 years. The patient couldn't walk and was wheelchair bound. Magnetic resonance imaging (MRI) revealed an extensive multilocular extradural cyst posterior to the spinal cord ranging from the C4 to Th6 level, associated with severe spinal cord compression. On constructive interference in steady-state MRI, the cyst was divided, with many septa, and extended to the root sleeves. During the operation, transdural communication sites of cerebrospinal fluid (CSF) into the cyst were revealed at C5/6, C6/7, and C7/Th1 levels around the nerve root sleeves. Treatment involved unroofing of the cyst wall and closure of the transdural CSF communication without cyst removal. Autologous muscle pieces were placed over the defect to close the transdural communication. Two weeks postoperatively, MRI showed decreased cyst size and reduced spinal cord compression, and the patient could walk without support. It was thought that the patient's daily lifting of heavy weights at work and an excessive exercise regimen increased CSF pressure and cyst size after TBPI. CONCLUSION: For patients with TBPI, it is necessary to prevent greater CSF pressure and to perform long-term follow-up MRI after injury.

Identification of ER-000444793, a Cyclophilin D-independent inhibitor of mitochondrial permeability transition, using a high-throughput screen in cryopreserved mitochondria.

Growing evidence suggests persistent mitochondrial permeability transition pore (mPTP) opening is a key pathophysiological event in cell death underlying a variety of diseases. While it has long been clear the mPTP is a druggable target, current agents are limited by off-target effects and low therapeutic efficacy. Therefore identification and development of novel inhibitors is necessary. To rapidly screen large compound libraries for novel mPTP modulators, a method was exploited to cryopreserve large batches of functionally active mitochondria from cells and tissues. The cryopreserved mitochondria maintained respiratory coupling and ATP synthesis, Ca2+ uptake and transmembrane potential. A high-throughput screen (HTS), using an assay of Ca2+-induced mitochondrial swelling in the cryopreserved mitochondria identified ER-000444793, a potent inhibitor of mPTP opening. Further evaluation using assays of Ca2+-induced membrane depolarisation and Ca2+ retention capacity also indicated that ER-000444793 acted as an inhibitor of the mPTP. ER-000444793 neither affected cyclophilin D (CypD) enzymatic activity, nor displaced of CsA from CypD protein, suggesting a mechanism independent of CypD inhibition. Here we identified a novel, CypD-independent inhibitor of the mPTP. The screening approach and compound described provides a workflow and additional tool to aid the search for novel mPTP modulators and to help understand its molecular nature.