The Usefulness of CT-Diffusion Weighted Image Mismatch in Patients with Mild to Moderate Traumatic Brain Injury.

Traumatic brain injury (TBI) has a complex and heterogeneous pathology. It is frequently difficult to predict the neurological deterioration of patients with TBI, and unpredictable change may occur even when TBI is mild to moderate. When computed tomography (CT) findings are considered to be inconsistent with the traumatic origin or with the neurological deterioration of patients observed on admission, magnetic resonance imaging (MRI) is employed based on the standards of our ethical committee. In this retrospective study, we compared CT and diffusion weighted imaging (DWI) of patients with mild to moderate TBI in the very acute phase. When the high-intensity lesions on DWI are larger than the high-density lesions on CT images, we defined the imaging finding as a 'CT-DWI mismatch'. Between January 2010 and December 2013, 92 patients were inspected using both CT and MRI at admission, and we detected a CT-DWI mismatch in 35 patients. CT-DWI mismatch was 92.6% (95% confidence interval 79.8-97.9) sensitive and 84.6% (95% confidence interval 79.3-86.3) specific for the prediction of enlargement of the hemorrhagic lesions on repeat CT. CT-DWI mismatch is considered to be useful as one of the predictors of the enlargement of hemorrhagic lesions in patients with mild to moderate TBI.

[A Case of Transorbital Penetrating Brain Injury Caused by a Steel Wire Entirely Embedded in the Brain Parenchyma].

Penetrating brain injury(PBI)is very rare in Japan. Because there is a very wide variety of pathological condition of PBI, the guideline for the treatment of PBI has not been established yet. We report the unique case of PBI caused by a steel wire piece completely embedded in the brain parenchyma. A 75-year-old man was brought to the emergency department due to ocular injury caused by a steel wire piece. Neurological examination revealed only left visual disturbance. CT scan revealed a steel wire piece located intraparenchymally between the left frontal lobe and the ventricles, but digital subtraction angiography showed no significant vascular injury in the surrounding structures. We performed an open surgery and removed the steel wire piece. Because the steel wire piece was completely embedded in the brain, we used intraoperative X-ray fluoroscopy to choose a less invasive approach for the brain. The patient suffered no additional neurological deficit and no sign of cerebral infection or seizure after surgery. He was discharged after a 4-week administration of antibiotics. In most cases of PBI caused by low velocity injury, foreign bodies are not completely embedded in the brain except for remnants after surgical removal. This is the first report of low velocity PBI caused by a foreign body completely embedded in the brain.

[A case of intracranial invasion from sinonasal small cell neuroendocrine carcinoma].

Sinonasal neuroendocrine carcinomas (NECs) are rare tumors. We present a rare case of intracranial invasion of sinonasal small-cell NEC. A 61-year-old woman with nasal obstruction and bleeding was referred to our hospital. Computed tomography showed a polyp-like tumor occupying her left nasal cavity and extending to the paranasal sinuses and anterior cranial fossa. The tumor was removed using a transfacial approach by otolaryngologists and a bifrontal cranial approach by neurosurgeons. In histopathological analyses, we found that the tumor presented with both an epithelial and neuroendocrine nature, and was diagnosed as a small-cell NEC. Post-surgery, she received localized radiation therapy and chemotherapy, and is alive, 18 months after diagnosis. In cases where it is difficult to perform a differential diagnosis of tumors arising from the frontal cranial base and extending to the nasal and cranial sides, NEC should be considered as a possibility.

[A case of intracranial primary leptomeningeal lymphoma].

Primary leptomeningeal lymphoma(PLML)is a neoplastic meningitis of lymphomatous origin without parenchymal central nervous system(CNS)disease or a systemic tumor. We report a case of PLML that presented with epileptic seizure, and review relevant literature. A 27-year-old man was brought to the emergency department with an epileptic seizure. Two months later, he was again brought to the emergency department with an epileptic seizure. MRI showed enhanced lesions on the surface of the right cerebellar hemisphere, right parietal sulci, and interhemispheric surface of the frontal lobes. We performed an open biopsy and diagnosed the patient with diffuse large B-cell lymphoma of the leptomeninges on the basis of histological findings. The patient was initially treated with chemotherapy including high-dose methotrexate(MTX). Because remission was not achieved by chemotherapy, the patient was treated with whole-brain radiation therapy. After onset, the patient survived for 2 years without recurrence. PLML is a particularly rare type of primary CNS lymphoma. The outcome of PLML, compared with general primary CNS lymphoma, is reported to be very poor because chemotherapy including MTX is ineffective.

Mutations in the spike gene of porcine epidemic diarrhea virus associated with growth adaptation in vitro and attenuation of virulence in vivo.

Previously, we have reported that a serial passage of 83P-5 strain of porcine epidemic diarrhea virus (PEDV) in Vero cells resulted in a growth adaptation of the virus in cultured cells at the 22nd passage. In this study, we further maintained the 83P-5 in Vero cells up to the 100th passage and analyzed changes in the spike (S), membrane (M), and nucleocapsid (N) gene sequences and pathogenicity of the virus at the 34th, 61st, and 100th passage levels. Sequence analyses revealed a strong selection for the S gene of 83P-5 in Vero cells, and virtually all mutations occurring at the 34th and 61st passages had been carried over to the 100th-passaged virus. In contrast, the viral M and N genes showed a strong conservation during the serial passage. Pigs experimentally infected with the 34th- or 61st-passaged virus, but not the 100th-passaged virus, exhibited diarrhea, indicating an attenuation of the 83P-5 at the 100th passage. Interestingly, S protein of the attenuated 100th-passaged 83P-5 showed a remarkable sequence similarity to that of previously reported DR-13 strain of attenuated PEDV that also had been established by serial passage in Vero cells. Further studies will be required to define whether the mutations in the S gene of 83P-5 that had been selected and accumulated during the serial passages are indeed the causalities of the growth adaptation in vitro and the attenuation of virulence in vivo.

[A case of progressive multifocal leukoencephalopathy with alcoholic liver dysfunction].

Progressive multifocal leukoencephalopathy (PML) is caused by opportunistic infection by JC virus and presents with progressive demyelinating lesions in the central nervous system. A 59-year-old man with a history of alcoholic liver dysfunction presented with progressive weakness of his left leg over a period of one month. MRI showed multiple white matter lesions that were of low intensity on the T1 image and high intensity on the T2 image, heterogeneously high intensity on the diffusion image, and were not enhanced with contrast media. The patient underwent open biopsy of the right parietal lesion. The histological findings were the demyelination and the enlargement of nuclei of oligodendrocytes. Electron microscopic examination showed numerous viral particles in the nuclei of the oligodendrocytes. Infection by JC virus in the central nervous system was diagnosed with the polymerase chain reaction (PCR) products sampled from the cerebrospinal fluid. The incidence of PML has significantly increased in immunosuppressive patients, such as AIDS (acquired immunodeficiency syndrome). We presented the first case of PML in an immune-compromised state with alcoholic liver dysfunction.

Lymph Drainage from the Chylocyst-Induced Hemodilution in an In Vivo Rabbit Study.

To confirm our previous study that abdominal respiration has induced hemodilution in human subjects, we performed in-vivo experiments involving anesthetized rabbits. Fifteen 6- to 7-month-old male Japanese white rabbits were used in the animal experiments. Anesthesia was maintained with 2.5%-3.0% isoflurane under N2O + 100% O2 inhalation. Ventilation was maintained at 40 mL/breath for 20 breaths/min. Physiological saline solution was administered at rated 18 mL/h during the experiments. First, we attempted to evaluate lymph flow through the thoracic duct using Sonazoid-based contrast-enhanced ultrasound (CEUS)-guided method and then investigated the effects of manual lymph drainage of the chylocyst on the numbers of red blood cells (RBC), hematocrit (Ht) levels, and the blood concentrations of total protein (TP) and hemoglobin (Hb). In this study, we established surgical methods for identifying the left venous angle and chylocyst using Evans blue dye in anesthetized rabbits. We also confirmed that a Sonazoid-based CEUS-guided method was the most useful technique for producing real-time images of lymph flow through the thoracic duct in anesthetized rabbits. In addition, in present experiments involving anesthetized rabbits, we confirmed that manually massaging the chylocyst produced significant hemodilution. Thus, the procedure produced significant reductions of TP, RBC, Hb, and Ht level in the rabbits.

[Intracranial internal carotid artery aneurysm associated with extracranial occlusion of the ipsilateral internal carotid artery in a patient with polycystic kidney disease].

We report a rare case with polycystic kidney disease (PKD) having an intracranial internal carotid artery aneurysm associated with extracranial occlusion of the ipsilateral internal carotid artery. A 55-year-old man with chronic renal failure due to PKD presented with headache. CT scan and MRI showed no abnormal findings. MRA showed cervical occlusion of the right internal carotid artery and an ipsilateral intracranial carotid aneurysm. At surgery, the saccular aneurysm protruded anterolaterally at the C2 portion of the right internal carotid and was clipped. Hemodynamic stress of the blood flow through the posterior communicating artery and the fragility of arteries because of PKD were considered to be two main causes of aneurysmal formation in this case.

[Aneurysms at the early branch of middle cerebral artery].

The cortical arteries arising from the proximal (Ml) segment of the middle cerebral artery (MCA) are called "early branches". We retrospectively analyzed clinical features in 10 patients with aneurysms located at the early branches of MCA. The incidence of these aneurysms was 9.5% among 95 MCA aneurysms. Patients consisted of 4 males and 6 females. Ages were 33-77 years old (average of 54.4). Four patients presented with subarachnoid hemorrhage (2 of them had intracerebral hematoma). The aneurysms were classified into 2 groups, the group of the early frontal branch (EFB: 7 cases) and the early temporal branch (ETB: 3 cases). All aneurysms were smaller than 6mm in diameter. The surgical treatment was performed through the pterional approach. Poor outcome occurred in 3 ruptured aneurysms of EFB (MD 1, SD 1, and D 1). At surgery, it is necessary to produce the working space by dissecting sylvian fissure sufficiently and to prevent ischemic complication by avoiding injury of the lenticulostriate arteries (LSA).

Visualization of aneurysmal contours and perianeurysmal environment with conventional and transparent 3D MR cisternography.

We have developed conventional and transparent 3D MR cisternography to investigate the spatial relationship between the contours of aneurysmal complex and the perianeurysmal structures including the cranial nerves, dural fold, cranial base bone, and brain parenchyma. Volume data obtained by a T2-weighted 3D fast spin-echo sequence were reconstructed by using a perspective volume-rendering algorithm with a transluminal imaging technique. 3D MR cisternograms provide useful anatomic information in the therapeutic and follow-up management of unruptured cerebral aneurysms.

Influence of perianeurysmal environment on the deformation and bleb formation of the unruptured cerebral aneurysm: assessment with fusion imaging of 3D MR cisternography and 3D MR angiography.

BACKGROUND AND PURPOSE: Surface irregularity and bleb formation are anatomical factors that are associated with aneurysm rupture. The perianeurysmal environment has been proposed as one factor that may influence aneurysm morphology. We have developed a fusion imaging technique of 3D MR cisternography and angiography that allows clear visualization of an aneurysm and its environment. This technique may prove useful in further understanding of the natural history of intracranial aneurysms. METHODS: Fusion images of 3D MR cisternography and angiography were reconstructed by a perspective volume-rendering algorithm from the volume datasets of MR cisternography, obtained by a T2-weighted 3D fast spin-echo sequence, and coordinated MR angiography, by a 3D time-of-flight sequence. On the fusion images, the anatomic relationship of an aneurysm to the perianeurysmal structures was assessed, and the influence of perianeurysmal environment on the deformation and bleb formation of the aneurysm was investigated. RESULTS: Marked and minor deformation and bleb formation of the aneurysmal dome were found at the areas confronted or adjacent to a certain contact with perianeurysmal structures, including cranial nerves, brain parenchyma, cranial base bones, petroclinoidal dural folds, and dura mater. CONCLUSION: Fusion images of 3D MR cisternography and angiography can depict the contact of an aneurysm with its perianeurysmal environment; this may provide an additional parameter in consideration for the natural history of cerebral aneurysms.

Enhanced brain angiogenesis in chronic cerebral hypoperfusion after administration of plasmid human vascular endothelial growth factor in combination with indirect vasoreconstructive surgery.

OBJECT: Vascular endothelial growth factor (VEGF) is a secreted mitogen associated with angiogenesis. The conceptual basis for therapeutic angiogenesis after plasmid human VEGF gene (phVEGF) transfer has been established in patients presenting with limb ischemia and myocardial infarction. The authors hypothesized that overexpression of VEGF using a gene transfer method combined with indirect vasoreconstruction might induce effective brain angiogenesis in chronic cerebral hypoperfusion, leading to prevention of ischemic attacks. METHODS: A chronic cerebral hypoperfusion model induced by permanent ligation of both common carotid arteries in rats was used in this investigation. Seven days after induction of cerebral hypoperfusion, encephalomyosynangiosis (EMS) and phVEGF administration in the temporal muscle were performed. Fourteen days after treatment, the VEGF gene therapy group displayed numbers and areas of capillary vessels in temporal muscles that were 2.2 and 2.5 times greater, respectively, in comparison with the control group. In the brain, the number and area of capillary vessels in the group treated with the VEGF gene were 1.5 and 1.8 times greater, respectively, relative to the control group. CONCLUSIONS: In rat models of chronic cerebral hypoperfusion, administration of phVEGF combined with indirect vasoreconstructive surgery significantly increased capillary density in the brain. The authors' results indicate that administration of phVEGF may be an effective therapy in patients with chronic cerebral hypoperfusion, such as those with moyamoya disease.

[Assessment of the signal intensity distribution pattern within the unruptured cerebral aneurysms using color-coded 3D MR angiography].

To evaluate the interaction between the MR signal intensity distribution pattern and bleb formation/ deformation of the aneurysmal dome, fifty cases of the unruptured cerebral aneurysms were investigated with the color-coded 3D MR angiography. Patterns were categorized into central-type, neck-type and peripheral-type according to the distribution of MR signals with low-, moderate- and high signal intensity areas. Imaging analysis revealed the significant relationship (P < 0.02) of the peripheral-type aneurysms to the bleb formation and deformation of the dome, compared with those of central- and neck-type. Additionally, peripheral-type signal intensity distribution pattern was shown with aneurysms harboring relatively large dome size and lateral-type growth including internal carotid aneurysms. Prospective analysis of intraaneurysmal flow pattern with the color-coded 3D MR angiography may provide patient-specific analysis of intraaneurysmal flow status in relation to the morphological change of the corresponding aneurysmal dome in the management of unruptured cerebral aneurysms.

[Assessment of the perianeurysmal environment of unruptured internal carotid-posterior communicating artery aneurysms with fusion imaging of three-dimensional magnetic resonance cisternography and angiography].

The anatomical relationship of an unruptured internal carotid-posterior communicating artery aneurysm and the perianeurysmal environment was investigated by using three-dimensional (3D) magnetic resonance cisternography (MRC), angiography (MRA) and newly developed fusion images of 3D MRC and 3D MRA. Contact of an aneurysm with the adjacent intra- and pericisternal structures was observed in cases with the aneurysm developing and extending beyond the capacity of the surrounding subarachnoid space. Deformation and bleb formation of the aneurysmal dome was depicted at the dome in contact with the perianeurysmal environment, including the tentorial edge, the anterior petroclinoid dural fold, the oculomotor nerve, the posterior clinoid process, the dorsum sellae and the cranial base bone. By using the fusion imaging technique of 3D MRC and 3D MRA, assessment of the contact of an unruptured cerebral aneurysm with its perianeurysmal environment can be made. Such contact gives ride to risk of deformation and bleb formation of the aneurysmal dome; and may result in cranial nerve symptoms and accelerate rupture from an unruptured cerebral aneurysm.

Angioplasty and coiling of ruptured aneurysm with symptomatic vasospasm: technical case report.

BACKGROUND: Treating a ruptured cerebral aneurysm during symptomatic vasospasm is very difficult. We describe the successful endovascular treatment of such a case and discuss its efficacy. CASE PRESENTATION: A 34-year-old man had a sudden onset of severe headache. One week later, he was referred to our institute with gradually progressing right hemiparesis and global aphasia. Cerebral angiography demonstrated severe vasospasm of the left internal carotid artery system and an anterior communicating artery aneurysm. With the patient under general anesthesia, 90% occlusion of the aneurysm was achieved with detachable coils after successful dilatation of the spastic vessels. The patient had an uneventful postoperative course and his neurologic symptoms were improved. Seven months after the endovascular treatment, the enlarged neck remnant of the aneurysm was successfully clipped without difficulty. CONCLUSION: The simultaneous treatment of a ruptured aneurysm and vasospasm with percutaneous transluminal angioplasty and coils can produce a better outcome for the patient.

Evaluation of contour of unruptured cerebral aneurysm using three-dimensional CT cisternogram.

Angiography is gold standard technique as preoperative examination for unruptured aneurysmal surgery. Neurosurgeons have observed the unexpected irregular shape and size of the aneurysmal dome and neck in many cases of unruptured cerebral aneurysms during aneurysmal microsurgery, and known the discrepancy between the findings of angiography and operative view. We could not find out the report described the preoperative evaluation of outer-wall (contour) of aneurysm. In the present study, we attempted to evaluate the outer-wall of an unruptured cerebral aneurysm using three-dimensional CT cisternogram (3D-CTC) to provide useful preoperative information. The study was performed on three cases of unruptured cerebral aneurysm that were identified incidentally by MR angiography. We performed three-dimensional CT aniography (3D-CTA) and 3D-CTC for each patient. In the present study, we visualized the contours of vessels and aneurysms using a 3D-CTC in three cases of unruptured cerebral aneurysm. We found the discrepancy between the 3D-CTC contour image and the intra-luminal image 3D-CTA image. This method may be useful for the decision of the surgical approach and have the potential to evaluate the anatomical structure of aneurysmal dome and neck preoperatively.

Combined use of electrolytically and mechanically detachable platinum coils for endovascular treatment of cerebral aneurysms--technical note.

The combined use of Guglielmi detachable coils (GDCs) and newly developed mechanically detachable platinum coils (Detach Coil System: DCS) was evaluated for the endovascular treatment of 10 patients with cerebral aneurysms. The number and total length of detachable coils placed into the aneurysms, the detaching time for each coil, and any technical problems were recorded and evaluated. Sixty GDCs and 60 DCSs were used. The detachment time for the DCS (mean 21 seconds) was faster than that for the GDC (mean 2 minutes 35 seconds). One DCS moved inside the aneurysm during the mechanical detachment maneuver, but was successfully placed. Neither detachment system influenced the behavior of the other system during coil implantation. The DCS includes a useful J-shape coil, whereas the GDC can be detached safely in fragile aneurysms. The DCS is also cheaper. The coil systems complemented one another and the combination optimized cost and operating time.

[A review of dural arteriovenous fistulas with hemorrhagic onset].

The majority of dural arteriovenous fistulas are considered to have a benign clinical course, but some behave more aggressively, causing progressive neurological symptoms and/or intracranial hemorrhage. Several classifications of angiographic findings have been reported to predict what findings might result in catastrophic presentation. Cortical venous drainage has been described as one of the major risk factors of hemorrhage. We reviewed the records of 50 patients with dural arteriovenous fistulas admitted to our institution from 1991 to 2001 and analyzed their venous drainage patterns with reference to Cognard's classification. Six patients had hemorrhagic episodes caused by dural arteriovenous fistula and all of them had retrograde drainage through cerebral veins. The frequency of hemorrhage in Type I and IIa was 0%, in Type IIb it was 33.3%, in Type IIa + b it was 9.1%, in Type III and Type IV it was 50%, and in Type V it was 100%. These results agreed with those of Cognard reported in 1994, and we reconfirmed the usefulness of Cognard's classification. In order to adapt a firm strategy and treat them promptly and aggressively, it is important to be able to recognize what type of dural arteriovenous fistulas are perilous.

[Usefulness of dynamic digitized cerebral parenchymography for cerebral vascular disease].

Aortic arch injections according to Theron's method have been performed in patients with cerebral ischemia. Digital subtraction angiograms with modified windowing (low and narrow) have been used for better visualization of cerebral parenchymal condition. This "cerebral parenchymography" allows much easier understanding of cerebral parenchymal vascularization on angiographic imaging. Although further study is necessary to estimate accurate cerebral blood flow, this technique can enable an easy and quick understanding of the overall cerebral hemodynamics.

[Evaluation of the contours and perianeurysmal environment of unruptured cerebral aneurysms, using three-dimensional magnetic resonance cisternogram].

To evaluate the anatomical relationship between cerebral aneurysm and the perianeurysmal environment within a cisternal space, the contours of an unruptured cerebral aneurysm and pericisternal structures were depicted on a three-dimensional (3D) MR cisternogram. By using perspective volume-rendering algorithm, the 3D MR cisternograms were reconstructed from the source axial volume data set obtained by the T2-weighted 3D fast spin-echo sequence. Those images were shown together with the coordinated 3D MR angiograms through similar visual projections, and then compared with the intraoperative findings. The outer wall configurations of cerebral aneurysms within the cisternal space were shown in conjunction with the accompanying surface veins, adjacent cranial nerves, dura mater and tentorial edge, cranial base bone, and surrounding pericisternal brain surfaces. With application of 3D MR cisternograms in the management of unruptured cerebral aneurysm, the anatomical relationship between the aneurysmal contours and the perianeurysmal environment could be evaluated the within the cisternal space. This might provide another clinical factor when considering the potential risk of growth, rupture, and symptomatic cranial nerve signs of an unruptured cerebral aneurysm.