Pediatric pial arteriovenous fistula located at the bottom of the callosal sulcus presenting with intraventricular hemorrhage: a case report and literature review.

BACKGROUND: A pial arteriovenous fistula (pAVF) is a rare condition characterized by a direct connection between a cerebral artery and cerebral vein without an intervening nidus. The prognosis is poor in untreated cases with hemorrhagic manifestations, indicating that surgical treatment is desirable. We describe a successful endovascular treatment for a pediatric case of ruptured pAVF located at the bottom of the sulcus. CLINICAL DESCRIPTION: An 11-year-old girl presented with severe headache and mild disturbance of consciousness. Head computed tomography showed hemorrhage in the callosal sulcus and ventricle. Cerebral angiography showed an arteriovenous shunt without a nidus. The branching artery from the pericallosal artery was connected directly to the thalamostriate vein without varix, and the shunt point was located at the bottom of the callosal sulcus. The patient was diagnosed with pAVF involving a single feeder and single drainer. Emergency endovascular transarterial embolization was performed using 20% N-butyl cyanoacrylate, and the shunt disappeared completely without complications. The patient was discharged with no neurological deficits. CONCLUSION: Endovascular treatment is feasible, safe, and effective for pediatric cases of deeply located pAVF.

In-hospital mortality and poor outcome after surgical clipping and endovascular coiling for aneurysmal subarachnoid hemorrhage using nationwide databases: a systematic review and meta-analysis.

There has never been evidence for aneurysmal subarachnoid hemorrhage (aSAH) by endovascular coiling compared to surgical clipping with all grade. The present study and meta-analysis aimed to clarify the in-hospital mortality and poor outcome in the nationwide databases of patients with all grade aSAH between them. The outcome of modified Rankin scale (mRS) at discharge was investigated according to the comprehensive nationwide database in Japan. The propensity score-matched analysis was conducted among patients with aSAH in this database registered between 2010 and 2015. Meta-analysis of studies was conducted based on the nationwide databases published from 2007 to 2018. According to this propensity score-matched analysis, no significant association for poor outcome of mRS > 2 was shown between surgical clipping and endovascular coiling (47.7% vs 48.3%, p = 0.48). However, significantly lower in-hospital mortality was revealed after surgical clipping than endovascular coiling (7.1% vs 12.2%, p < 0.001). Meta-analysis of propensity score-matched analysis in the nationwide database showed no significant association for poor outcome at discharge between them (odds ratio [OR], 1.08; 95% confidence interval [CI], 0.93 to 1.26; p = 0.31). Meta-analysis of propensity score-matched analysis for in-hospital mortality was lower after surgical clipping than after endovascular coiling, however, without significant difference (OR, 0.74; 95% CI, 0.52 to 1.04; p = 0.08). Further prospective randomized controlled study with all grade aSAH should be necessary to validate the in-hospital mortality and poor outcome.

Decreased Antiatherogenic Protein Levels are Associated with Aneurysm Structure Alterations in MR Vessel Wall Imaging.

OBJECTIVE: Thickened intracranial aneurysm wall with atherosclerotic remodeling is a part of its degenerative scenario. Current magnetic resonance (MR)-vessel wall imaging enables the detection of atherosclerotic wall thickening as aneurysm wall enhancement. The purpose of this study was to examine the correlation between identified atherosclerotic remodeling in vessel wall imaging, and systemic atherosclerosis-related risk factors. METHODS: A total of 39 aneurysms in 38 consecutive patients scheduled to undergo microsurgical clipping or endovascular coiling of intracranial aneurysms were prospectively evaluated. All patients underwent aneurysm MR-vessel wall imaging and the presence of aneurysm wall enhancement on contrast-enhanced vessel wall imaging was evaluated. The relationship between aneurysm wall enhancement and patient demographic data, aneurysm morphology and atherosclerosis-related risk factors including blood laboratory data were assessed. RESULTS: Aneurysm wall enhancement was detected in 19 of 39 intracranial aneurysms (48.7%). The maximum diameter of the intracranial aneurysm (P < .01), apolipoprotein A2 (P < .01) and apolipoprotein C2 (P = .01) was significantly associated with the presence of aneurysm wall enhancement. In multivariate logistic regression analyses, the maximum diameter of the intracranial aneurysm (odds ratio: 1.67, 95% confidence interval: 1.17-3.05) and decreased apolipoprotein A2 (odds ratio: 0.62, 95% confidence interval: 0.34-0.97) was significantly correlated with aneurysm wall enhancement. CONCLUSIONS: Rather than atherosclerotic factors, antiatherogenic proteins reduction was associated with aneurysm wall enhancement in vessel wall imaging. To elucidate antiatherogenic factors might to help find out promoting factor of unruptured intracranial aneurysms instability.

[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.

Assessment of Intraoperative Spinal Angiography via the Popliteal Artery for Spinal Vascular Diseases.

OBJECTIVE: Intraoperative spinal angiography via the popliteal artery for patients in the prone position has been reported only twice in 4 patients. This study aimed to clarify the safety precautions to be taken with this technique in a larger patient cohort. METHODS: Seven patients with spinal vascular disorders underwent intraoperative spinal angiography in the prone position via the popliteal artery. Ultrasound was used to evaluate the neurovascular anatomy in the popliteal fossa and guide the arterial puncture. Patient characteristics, features of angiography devices, puncture attempts, and angiography-related complications, such as hematoma formation and injury to the neurovascular bundle, were analyzed. RESULTS: The average number of arterial puncture attempts was 1.3 times (range: 1-2). Sheaths (4 and 4.5 Fr) with different ineffective lengths were used. In 1 case, a 4.5-Fr sheath was replaced with a 4-Fr sheath with a shorter noneffective length as the length of the catheter limited access to the target. Catheters with Type-JB2 tip shapes were used for craniocervical junction lesions, and those with Type-KAGAWA tip shapes were used for thoracic and lumbar spinal lesions. No puncture site complications were observed in any patient. CONCLUSIONS: Intraoperative spinal angiography via the popliteal artery was an effective tool in surgeries for spinal vascular diseases. The introduction of the ultrasound enabled atraumatic puncture of the popliteal artery. Spinal targets above T5 to T6 may be inaccessible from the popliteal fossa when using a 100-cm-long catheter.

[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.

Access-route Visualization Using Ultrasonography and CT Angiography to Predict the Feasibility of Transvenous Embolization via the Facial Vein for Cavernous Sinus Dural Arteriovenous Fistulas.

Objective: Transvenous embolization (TVE) is an effective treatment for cavernous sinus dural arteriovenous fistulas (CS-DAVFs). The facial vein (FV) can be used as an access route for TVE when a trans-inferior petrosal sinus (IPS) approach is difficult. We evaluated the usefulness of combining ultrasonography (US) with computed tomography angiography (CTA) for confirming that the FV is a suitable access route for treating CS-DAVFs. Methods: Trans-FV TVE was planned for five CS-DAVF patients in whom the shunt point was located in the posterior compartment of the CS and anterior venous drainage predominantly occurred via the superior ophthalmic vein (SOV). The anterior drainage route was examined with CTA and US. We reviewed the relationships between preoperative CTA/US findings and the accessibility of CS-DAVFs via the FV. Results: The periorbital and perimandibular drainage pathways were clearly more visible on US than on CTA, and the cervical and thoracic drainage pathways were more visible on CTA than on digital subtraction angiography (DSA). CS-DAVFs were accessible via the FV when (1) the entire drainage pathway could be confirmed on CTA and US, (2) the periorbital and perimandibular pathways were unclear on CTA, but could be confirmed on US, or (3) the FV pathway drained into the internal jugular vein (IJV) or external jugular vein (EJV). On the other hand, TVE was challenging to perform via the FV when (1) the periorbital pathway was unclear on CTA and US, (2) the FV pathway drained into the brachiocephalic vein, or (3) the SOV thrombosed intraoperatively. In all five patients, TVE for CS-DAVFs performed via the FV or IPS was successful. Conclusion: CTA and US are useful for confirming the anterior access route for trans-FV TVE for CS-DAVFs and predicting the feasibility of such treatment. Our findings suggest that CS-DAVFs can be accessed via the FV if the periorbital drainage pathway can be confirmed on US, even if the pathway is unclear on CTA.

Safety of simultaneous bilateral carotid artery stenting for bilateral carotid artery stenosis.

BACKGROUND: Bilateral carotid artery stenting (BCAS) is often performed in two stages (staged BCAS) but it is also an option to be performed in one stage (simultaneous BCAS). To confirm the safety of simultaneous BCAS, we retrospectively analyzed perioperative and postoperative course of simultaneous BCAS compared with staged BCAS. MATERIALS AND METHODS: Patients with symptomatic stenosis of ≥50% or asymptomatic stenosis of ≥80% of bilateral carotid arteries underwent BCAS. Procedure time, symptomatic ischemic complications, presence/absence of high-intensity spots on postoperative diffusion-weighted image, duration of postoperative hospital stays and 30 days outcome of patients performed with simultaneous BCAS (group A, 8 patients with 16 stenotic lesions (8 procedures)) were compared with those of staged BCAS (group B, 4 patients with 8 stenotic lesions (8 procedures)). RESULTS: In groups A and B, procedure time was 146.0 ± 53.8 and 103.5 ± 39.4 min; intraoperative hypotension was observed in 62.5% and 50.0%; postoperative hypotension occurred in 37.5% and 50.0%; diffusion-weighted image showed high-intensity spots in 37.5% and 12.5%; and duration of postoperative hospital stays was 5.1 ± 1.8 and 5.3 ± 2.3 days. No patients suffered symptomatic ischemic complications. In simultaneous BCAS, there was a tendency that procedure time was longer and high-intensity spots on postoperative diffusion-weighted image was more frequent, but there was no increase in symptomatic ischemic complications and duration of hospital stays compared to staged BCAS. CONCLUSIONS: Safety of simultaneous BCAS may not be inferior to staged BCAS. In terms of duration of hospital stays, simultaneous BCAS can be superior to staged BCAS for patients with bilateral carotid artery stenosis.

Safety of carotid artery stenting for elderly patients with cervical carotid artery stenosis.

BACKGROUND: Several recent randomized controlled trials have reported that perioperative complications of carotid artery stenting increase with age, and Japan has the highest proportion of elderly in the world. We retrospectively compared clinical factors, treatment outcomes, and adverse events between younger and elderly carotid artery stenting patients at a single institution in Japan to assess carotid artery stenting safety for the aged population. METHODS: A total of 150 consecutive patients treated with carotid artery stenting using the dual protection (simultaneous flow reversal and distal filter) and blood aspiration method were enrolled. Patients were classified into an elderly (O) group ≥75 years (54/150, 36.0%) and a younger (Y) group <75 years (96/150, 64%) for comparison of demographics, clinical background, incidence of captured debris during the procedure, outcome, minor stroke, major adverse events (major stroke, myocardial infarction, or death) within 30 days, hyperintense spots on diffusion-weighted images after carotid artery stenting, and postoperative hospitalization days. RESULTS: The carotid artery stenting procedure was successful in all cases. No major adverse events occurred within 30 days in the Y group, and only one occurred in the O group (P = 0.348). Visible debris was captured in a significantly greater proportion of O group patients than in Y group patients (33/54 (63.5%) vs. 40/96 (42.1%), P = 0.016), but there was no significant difference in the frequency of hyperintense spots on diffusion-weighted images between Y and O groups (23/96 (24.0%) vs. 16/52 (30.8%), P = 0.435). CONCLUSIONS: Carotid artery stenting using dual protection and blood aspiration is equally safe for younger and elderly patients.

Management of post-puncture bleeding after neurointerventional procedures performed with a large-bore sheath introducer.

Various adjunctive techniques for neurointerventional procedures require a large-bore sheath introducer, but there is concern that this could result in more puncture site hemorrhagic complications despite using a vascular closure device. The purpose of this study was to assess the relationship between use of large-bore sheath introducer and post-procedural complications. Between January 2016 and April 2018, 126 neurointerventional procedures were performed in our hospital using 8 or 9 Fr sheath introducer in size and the Angio-Seal STS PLUS (St. Jude Medical, Minnetonka, USA). Hemorrhagic complications were defined as obvious swelling or bleeding at the puncture site or as extravascular bleeding detected by ultrasonography or contrast-enhanced computed tomography. The procedures were divided into a group with post-puncture bleeding (group B, n = 21) and a group without bleeding (group N, n = 105). Risk factors were compared between the groups according to the incidence of post-puncture bleeding. In addition, we assessed the outcome and approach to hemostasis in the procedures with bleeding. In result, hemorrhagic complications occurred in 21 procedures (17%), and pseudoaneurysm was detected in 4 procedures (3.2%). In 20 of group B (16%), manual compression was performed for an average of 36.4 min. One patient (0.79%) required surgical angioplasty. Risk factors for bleeding were not significantly different between the two groups. None of the patients with bleeding showed a decrease on the modified Rankin Scale. In conclusion, use of a large-bore sheath introducer may increase the incidence of post-puncture bleeding, but the outcome of this complication is acceptable.

Early Transplantation of Human Cranial Bone-derived Mesenchymal Stem Cells Enhances Functional Recovery in Ischemic Stroke Model Rats.

We analyzed the cell characteristics, neuroprotective, and transplantation effects of human cranial bone-derived mesenchymal stem cells (hcMSCs) in ischemic stroke model rats compared with human iliac bone-derived mesenchymal stem cells (hiMSCs). The expressions of brain-derived neurotrophic factor (BDNF) and vascular endothelial growth factor (VEGF ) as neurotrophic factors were analyzed in both MSCs. hiMSCs or hcMSCs were intravenously administered into ischemic stroke model rats at 3 or 24 h after middle cerebral artery occlusion (MCAO) and neurological function was evaluated. The survival rate of neuroblastoma × glioma hybrid cells (NG108-15) after 3 or 24 h oxidative or inflammatory stress and the neuroprotective effects of hiMSCs or hcMSCs-conditioned medium (CM) on 3 or 24 h oxidative or inflammatory stress-exposed NG108-15 cells were analyzed. The expressions of BDNF and VEGF were higher in hcMSCs than in hiMSCs. hcMSCs transplantation at 3 h after MCAO resulted in significant functional recovery compared with that in the hiMSCs or control group. The survival rate of stress-exposed NG108-15 was lower after 24 h stress than after 3 h stress. The survival rates of NG108-15 cells cultured with hcMSCs-CM after 3 h oxidative or inflammatory stress were significantly higher than in the control group. Our results suggest that hcMSCs transplantation in the early stage of ischemic stroke suppresses the damage of residual nerve cells and leads to functional recovery through the strong expressions of neurotrophic factors. This is the first report demonstrating a functional recovery effect after ischemic stroke following hcMSCs transplantation.

Factors other than body weight predicting heparin loading to acquire optimal activated clotting time in endovascular neurointerventions.

OBJECTIVES: The aim of this study was to investigate the relationship between the activated clotting time (ACT) and heparin loading based on body weight (BW), and factors other than BW that may contribute to the ACT after heparin loading to establish a more accurate regimen for achieving ACT targets during endovascular neurointerventions. PATIENTS AND METHODS: Japanese patients who underwent endovascular coiling of unruptured intracranial aneurysms or carotid artery stenting in our institution between January 2014 and November 2017 were enrolled. The ACT was measured before (pre-ACT) and 3 min after heparinization (post-ACT). The correlation between ACT and heparin loading based on BW and factors that may contribute to the ACT after heparin loading were analyzed retrospectively. RESULTS: A total of 199 cases (109 males, age: 66 ±â€¯12 years) were analyzed. There were positive correlations between the heparin loading per kg of BW and post-ACT, post-ACT - pre-ACT (ΔACT) (Spearman's r = 0.2946, 0.2633, P: <0.0001, 0.0002, respectively). Heparin loading per kg of BW, gender, hematocrit (Ht), estimate glomerular filtration rate (eGFR) were significant confounding factors to ΔACT. The calculated predicted ΔACT based on these significant factors was found to be highly correlated with ΔACT compared with the heparin loading per kg of BW. (Spearman's r = 0.5820, P = <0.0001). CONCLUSION: Initial BW-based heparin loading is a simple way in endovascular neurointerventions. ACT after heparin loading based on BW has individual differences greatly, it is possible to estimate more accurately the heparin loading for acquiring the optimal ACT considering not only BW but also gender, Ht and eGFR.

A Pial Arteriovenous Fistula in Infancy as the Presenting Manifestation of Hereditary Hemorrhagic Telangiectasia.

BACKGROUND: Pial arteriovenous fistulas (PAVFs) are rare, accounting for 1.6%-4.7% of all intracranial vascular malformations. Often diagnosed in childhood, about 30% are associated with hereditary hemorrhagic telangiectasia. A case of PAVF diagnosed soon after birth and given cerebrovascular therapy 4 months after birth is reported. CASE DESCRIPTION: The patient presented with heart failure immediately after birth. Ultrasonography of the head showed abnormal blood flow in the brain. On digital subtraction angiography performed 4 months after birth, a PAVF with a dural feeder shunt and a giant varix at the posterior temporal part was confirmed. After transarterial embolization (TAE), shunt blood flow disappeared. New shunt flow from the right posterior cerebral artery into the varix was confirmed by magnetic resonance imaging 3 months after the operation. A second TAE procedure using a liquid embolic material was performed and confirmed the complete disappearance of the shunt. CONCLUSIONS: This report describes a case of infant PAVF with heart failure, a giant varix, hydrocephalus, and intraventricular hemorrhage treated by TAE using platinum coils and liquid embolic material.

Navigation of a 6-French guiding sheath into the common carotid artery using a tri-axial catheter system in transbrachial carotid artery stenting.

BACKGROUND AND PURPOSE: Placement of a large-bore guiding sheath or catheter into the common carotid artery (CCA) is crucial in transbrachial carotid artery stenting (CAS). Herein, we describe technical tips for the navigation of a 6-French guiding sheath into the CCA using a tri-axial catheter system in transbrachial CAS. MATERIALS AND METHODS: A total of 27 patients underwent transbrachial CAS. For the right side, a 6-French straight guiding sheath was navigated directly into the CCA using a tri-axial catheter system, with a 4-French Simmons catheter placed through a 6-French straight guiding catheter. For the left side, a 6-French Simmons guiding sheath was navigated into the CCA using a tri-axial catheter system, with a 4-French Simmons catheter placed through a 6-French Simmons guiding catheter. After the placement of a 6-French guiding sheath into the CCA, CAS was performed under distal filter or balloon protection. RESULTS: Fifteen patients had a right carotid stenosis and 12 patients had a left carotid stenosis. The 6-French guiding sheath was safely placed with ease and provided adequate stabilization for CAS. All procedures were successfully performed without any complications. CONCLUSION: The use of a tri-axial catheter system for the navigation of a 6-French guiding sheath into the CCA appears safe and efficient, allowing transbrachial CAS, with 6-French guiding sheath stabilization, to be performed without any complication.

Primary angiitis of the central nervous system mimicking dissemination from brainstem neoplasm: a case report.

BACKGROUND: Diagnosis of PACNS is very difficult because of the variety of clinical manifestation, especially neurologic and MRI findings. We report the case of a 68-year-old woman with PACNS. CASE DESCRIPTION: Her clinical symptoms mimicked malignant brainstem neoplasm disseminated to third and fourth ventricles and cervical spinal cord. Brain biopsy could not be correctly diagnostic. In spite of a trial of high-dose steroids, repeated MRI showed an increasing number of lesions. Two weeks after surgery, she died of respiratory dysfunction. Postmortem examination suggested PACNS, after consideration of histories, laboratory and radiologic findings, and the lack of systemic disease. CONCLUSION: Although brain biopsy represents the gold standard measure, combination with several other examinations might be necessary to arrive at an early and definitive diagnosis. PACNS should be considered the differential diagnosis of intracranial tumors.

Chronic Dilatation of Superficial Temporal Artery and Middle Meningeal Artery Associated with Development of Collateral Circulation After Bypass Surgery for Moyamoya Angiopathy.

OBJECTIVES: Dilatation of the superficial temporal artery (STA) and middle meningeal artery (MMA) were occasionally observed after bypass surgery for moyamoya angiopathy. The purpose of this study was to examine the correlation between angiographic outcomes and magnetic resonance imaging (MRI), specifically focusing on the postoperative dilatation ratio of the STA (rSTA) and MMA (rMMA). METHODS: Fifty-six hemispheres in 36 consecutive patients who underwent revascularization for moyamoya angiopathy were evaluated. All patients underwent angiography and MRI before surgery and during the chronic phase. Angiographic outcomes were classified as good or poor according to the extent of the blood supply through direct or indirect bypass. The rSTA and rMMA was calculated in time-of-flight magnetic resonance angiography (MRA). The signal changes of ivy signs and flow voids in basal ganglia were also evaluated. RESULTS: Postoperative collaterals through direct and indirect bypass was good in 30 (53.6%) and 33 (58.9%) patients, respectively. The mean rSTA and rMMA were 36.04 ± 28.79% and 29.15 ± 22.01%, respectively. Ivy signs and flow voids were decreased in 9 (16.1%) and 26 (46.4%) patients, respectively. Univariate analyses demonstrated no significant correlation between the angiographic outcomes and postoperative signal changes on MRI. However, rSTA was significantly correlated with good collaterals through direct bypass (P = 0.04), whereas rMMA was significantly correlated with good collaterals through indirect bypass (P < 0.001). CONCLUSIONS: MRA may be an alternative to angiography. Both rSTA and rMMA estimated the development of collaterals after bypass surgery for moyamoya angiopathy.

Marked Changes in Blood-Brain Barrier Biomarkers After Direct Bypass Surgery for Moyamoya Angiopathy: Preliminary Study.

OBJECTIVE: The blood-brain barrier (BBB) of patients with moyamoya angiopathy (MMA) is unstable, which may contribute to transient neurologic symptoms (TNS) after direct bypass surgery. However, BBB-related proteins have never been investigated. The purpose of this study was to evaluate the perioperative serum levels of biomarkers representing BBB function in MMA patients based on the hypothesis that postoperative hemodynamic change may disrupt the BBB. METHODS: A total of 12 hemispheres in 11 patients with MMA were prospectively examined. Direct revascularization surgery was performed for all cases. The serum levels of tight junction (occludin and claudin 5), adherens junction (vascular endothelial-cadherin) proteins, and matrix metalloproteinase (MMP)-2 and MMP-9 were measured quantitatively 1 day before surgery and on postoperative days 1, 4, and 7. RESULTS: Successful patency of the direct bypass was achieved in all. The serum level of occludin was significantly increased on postoperative day 1, and the levels in 2 cases with TNS were markedly elevated over 10-fold higher than baseline. Furthermore, the postoperative MMP-9 levels were significantly elevated on each day. On the other hand, there was no significant fluctuation in claudin 5, vascular endothelial-cadherin, and MMP-2 level. CONCLUSIONS: Marked changes in biomarkers representing the tight junction of the BBB were observed. These preliminary results suggest that marked hemodynamic change and TNS in some patients are associated with disruption of the BBB after direct bypass surgery for MMA.

Rat Cranial Bone-Derived Mesenchymal Stem Cell Transplantation Promotes Functional Recovery in Ischemic Stroke Model Rats.

The functional disorders caused by central nervous system (CNS) diseases, such as ischemic stroke, are clinically incurable and current treatments have limited effects. Previous studies suggested that cell-based therapy using mesenchymal stem cells (MSCs) exerts therapeutic effects for ischemic stroke. In addition, the characteristics of MSCs may depend on their sources. Among the derived tissues of MSCs, we have focused on cranial bones originating from the neural crest. We previously demonstrated that the neurogenic potential of human cranial bone-derived MSCs (cMSCs) was higher than that of human iliac bone-derived MSCs. Therefore, we presumed that cMSCs have a higher therapeutic potential for CNS diseases. However, the therapeutic effects of cMSCs have not yet been elucidated in detail. In the present study, we aimed to demonstrate the therapeutic effects of transplantation with rat cranial bone-derived MSCs (rcMSCs) in ischemic stroke model rats. The mRNA expression of brain-derived neurotrophic factor and nerve growth factor was significantly stronger in rcMSCs than in rat bone marrow-derived MSCs (rbMSCs). Ischemic stroke model rats in the rcMSC transplantation group showed better functional recovery than those in the no transplantation and rbMSC transplantation groups. Furthermore, in the in vitro study, the conditioned medium of rcMSCs significantly suppressed the death of neuroblastoma × glioma hybrid cells (NG108-15) exposed to oxidative and inflammatory stresses. These results suggest that cMSCs have potential as a candidate cell-based therapy for CNS diseases.

Local administration of amphotericin B against aspergilloma in the prepontine cistern--case report.

A 21-year-old man presented with aspergilloma in the prepontine cistern that developed after treatment for cerebellar hematoma following rupture of an arteriovenous malformation. He became bedridden with neurological signs of tetraparesis, disturbed ocular movement, and bulbar palsy, despite alert consciousness. Repeat magnetic resonance imaging 1 year later revealed a space-occupying lesion in the prepontine cistern along the clivus. This multilobular enhanced mass lesion gradually enlarged towards the brainstem over the following 4 years, resulting in loss of spontaneous breathing and dependence on a mechanical respirator. Surgical treatment via a lateral suboccipital approach was selected to reduce the size of the mass lesion and confirm the diagnosis. Histological examination revealed the presence of Aspergillus fumigatus. Treatment with amphotericin B (1 mg/kg/day) and fluconazole (100 mg/kg/day) injected into the peripheral veins was initiated, but was stopped due to the appearance of renal dysfunction. An Ommaya tube was then inserted into the prepontine cistern via a transsylvian approach to provide high concentrations of amphotericin B around the granulomatous lesion. He gradually improved, corresponding to the decreased size of the aspergilloma just after surgery. Surgical reduction of granuloma combined with local administration of antifungal agent is a good treatment option in patients with aspergilloma refractory to systemic administration.