Neurolymphomatosis secondary to primary central nervous system lymphoma: illustrative case.

BACKGROUND: Neurolymphomatosis (NL) is a rare disease defined as an invasion of lymphoma into peripheral nerves, nerve roots, or nerve plexuses, including the cranial nerves. No clear treatment protocols have yet been defined for this pathology. OBSERVATIONS: A woman in her 40s had a primary central nervous system lymphoma diagnosed from an intracranial tumor biopsy and underwent chemotherapy and radiation therapy. After she complained of pain in the trunk and extremities, magnetic resonance imaging and [18F]fluorodeoxyglucose (FDG) positron emission tomography (PET) performed 25 months after initial diagnosis revealed multiple lesions in the nerve ganglia, plexuses, and peripheral nerves from the cervical to the sacral spinal cord. Cerebrospinal fluid cytology revealed atypical lymphocytes and lymphoma dissemination in the spinal cavity. Based on these findings, NL was diagnosed. An intrathecal antineoplastic regimen temporarily reduced abnormal uptake of FDG, but the lesion recurred. After additional high-dose methotrexate therapy, FDG accumulation in the previously identified lesions disappeared. However, peripheral neuropathic pain and paraplegia remained. The patient died 9 months after the initial diagnosis of NL. LESSONS: The authors reported a case of NL following primary central nervous system lymphoma. In this case, FDG-PET proved useful for diagnosis, and high-dose methotrexate therapy was temporarily effective. https://thejns.org/doi/suppl/10.3171/CASE24107.

Paraclinoid internal carotid artery aneurysm with delayed stent occlusion after deployment of a flow diverter stent involving the orifice of the anterior cerebral artery: illustrative case.

BACKGROUND: In-stent thrombotic occlusion is a serious ischemic complication that can also result in ischemia in the distal perfusion territory and the territory of side branches for the artery in which the flow diverter (FD) stent is deployed. OBSERVATIONS: A 49-year-old female with a large paraclinoid internal carotid artery (ICA) aneurysm was treated with an FD involving the orifice of the anterior cerebral artery (ACA). The antiplatelet dose was reduced because of an increased clopidogrel response postintervention. The patient developed aphasia 2 months later. Emergency magnetic resonance imaging and digital subtraction angiography of the brain indicated FD stent occlusion and a small infarct in the distal vascular territory of the ipsilateral ICA, but the anterior choroidal artery (AChoA) territory was preserved by collateral flow. Emergency superficial temporal artery to middle cerebral artery anastomosis was performed, and she was discharged without neurological deficit 2 weeks after the second operation. LESSONS: In-stent occlusion after FD deployment involving the orifice of the ACA can cause severe cerebral ischemia that requires an adequate antiplatelet effect and careful follow-up. The AChoA territory can be preserved by collateral blood flow even in cases of in-stent occlusion.

Impact of craniotomy area on improvement of cerebral blood flow in combined revascularization surgery for moyamoya disease.

OBJECTIVE: To investigate factors associated with improvements in cerebral blood flow (CBF) and cerebrovascular reactivity (CVR) after combined revascularization surgery for moyamoya disease, with special attention to the size of craniotomy. METHODS: We retrospectively analyzed 35 hemispheres in 27 patients with adult and older pediatric moyamoya disease. CBF and CVR were measured separately in the MCA and ACA territories from acetazolamide-challenged single-photon emission computed tomography before and after 6 months postoperatively, and associations with various factors were analyzed. RESULTS: Postoperative CBF improved in patients with lower preoperative blood flow in both ACA and MCA territories. Postoperative CVR improved in 32 of 35 patients (91.4%) in the MCA territory and in 30 of 35 patients (85.7%) in the ACA territory, with more prominent improvement in the MCA territory than in the ACA territory (MCA territory 29.7% vs ACA territory 21.1%, p = 0.015). Craniotomy area did not correlate with postoperative CBF and only MCA territory was associated with good (≥30%) CVR improvement (odds ratio 9.33, 95% confidence interval 1.91-45.6, p = 0.003). CONCLUSIONS: Postoperative CBF improved in adult and older pediatric cases, reflecting preoperative CBF. Postoperative CVR improved in most cases, although the degree of improvement was more prominent in the MCA territory than in the ACA territory, suggesting a contribution of the temporal muscle. Large craniotomy area was not associated with improved blood flow in the ACA territory and should be applied prudently.

Management of Cervical Internal Carotid Artery Stenosis or Occlusion in Tandem Lesion with Acute Ischemic Stroke: Which Is More Appropriate Percutaneous Transluminal Angioplasty or Stent?

OBJECTIVE: Carotid artery stenting (CAS) is the established treatment strategy of the cervical internal carotid artery (cICA) stenosis, but its use for acute tandem lesions remains controversial. We investigated the clinical and procedural outcomes of management of cICA lesions and evaluated the risk factors for complications. METHODS: Fifty patients who underwent acute mechanical thrombectomy for tandem lesion between January 2014 and June 2022 were included. Treatment of the cICA lesion was classified into the CAS group or the non-CAS group. The risk factors for postoperative ischemic events or symptomatic intracranial hemorrhage (sICH) were analyzed. RESULTS: The CAS group included 36 patients (72%) and the non-CAS group 14 (28%). Postoperative complications were observed in 9 patients (18%). Thromboembolic complications occurred in 4 patients (29%) of the non-CAS group but in 1 patient (3%) of the CAS group. Severe calcification of the cICA (P = 0.04), non-CAS (P = 0.018), and more than 60% residual stenosis (P = 0.016) were significant risk factors associated with thromboembolic complications. sICH occurred in 4 patients (11%) of the CAS group but in none of the non-CAS group. More than 80% stenosis improvement was significantly associated with sICH (P = 0.049). Twenty-nine patients (58%) had a good clinical outcome at 90 days after onset. CONCLUSIONS: Acute CAS is effective for the management for cICA tandem lesions during mechanical thrombectomy, but care not to overextend may be important to reduce the risk of sICH. Severe calcification of the cICA may increase the risk of postoperative thromboembolic complications using non-CAS treatment.

Evaluation of Occluded Distal Vessels with Variable Flip-Angle 3-Dimensional Turbo Spin-Echo Magnetic Resonance Imaging Before Acute Mechanical Thrombectomy.

OBJECTIVE: The aim of this study was to evaluate the course of occluded distal vessels before mechanical thrombectomy (MT) for acute large vessel occlusion (LVO) with non-contrast magnetic resonance imaging (MRI). The variable flip-angle three-dimensional turbo spin-echo (VRFA-3D-TSE) method was used to evaluate the course of occluded distal vessels quickly and clearly in acute LVO cases before MT. METHODS: Patients with acute LVO who were indicated for MT between April 2021 and March 2022 were examined by the VRFA-3D-TSE method to evaluate the distal course of occluded vessels. We included internal carotid artery (ICA) occlusion, M1 occlusion of the middle cerebral artery, and basilar artery (BA) occlusion. Preoperative images were compared to the angiographic findings after recanalization or with follow-up magnetic resonance angiography, and the results were assessed by 2 endovascular treatment specialists as excellent, good, or poor imaging. RESULTS: MT was performed in a total of 27 patients. There were 17 patients with intracranial occlusion of the ICA, M1, and BA. Occlusion was found in the intracranial ICA in 6 patients, the M1 in 7, and the BA in 4. VRFA-3D-TSE MRI was performed in all patients, and the imaging was rated (by the 2assessors) as excellent in 12 of 17 and 14 of 17 cases, good in 5 of 17 and 3 of 17 cases, and poor in 0 of 17 cases. CONCLUSIONS: In patients with acute LVO, VRFA-3D-TSE MRI enabled rapid and good depiction of the course of occluded distal vessels before MT without the use of contrast medium.

Endovascular Treatment Strategy and Clinical Outcomes for Ruptured Blood Blister-Like Aneurysms of the Internal Carotid Artery Using Low-Profile Visualized Intraluminal Support Stent.

OBJECTIVE: It is challenging to safely treat blood blister-like aneurysms (BBAs) of the internal carotid artery. Endovascular surgery has been reported, but the optimal strategy is yet to be established. We report our endovascular treatment strategy using the Low-profile Visualized Intraluminal Support (LVIS) stent. METHODS: Twelve patients with ruptured BBAs including 1 patient with 2 separate aneurysmal bulges were treated from December 2017 to January 2020. Single LVIS stent-assisted coil embolization was performed as the initial treatment. If the coil could not be placed in the aneurysm, or follow-up angiography showed persistent filling or regrowth of the aneurysm, a second LVIS stent was deployed as an overlapping stent. Clinical characteristics, treatment details, and clinical outcomes were retrospectively examined. RESULTS: Single stent-assisted coiling was performed in 8 patients (69%), 2 overlapping stents with coiling in 1 (8%), a single stent in 2 (15%), and 2 overlapping stents in 2 (15%). Three patients with persistent filling or regrowth of the aneurysm were re-treated with overlapping stents. Follow-up angiography confirmed complete occlusion in 12 aneurysms (92%). No re-rupture occurred. Postoperative symptomatic ischemia was confirmed in 4 patients (33%), and all 4 patients suffered severe subarachnoid hemorrhage. Modified Rankin scale was 0-2 in 8 patients (67%). CONCLUSIONS: LVIS stent-assisted coil embolization is effective in preventing re-rupture of BBAs. However, the morphology of the aneurysm may change within a short period, so careful angiographic follow-up is needed. Appropriate preoperative antiplatelet administration and optimal timing of the treatment may reduce the risk of postoperative ischemic complication.

Acute Endovascular Revascularization for Patients with Common Carotid Artery Occlusion Apparent on Cervical Magnetic Resonance Angiography.

OBJECTIVES: In the endovascular treatment of acute cerebral large-vessel occlusion, cervical magnetic resonance angiography (MRA) is a useful modality for assessing the access route. However, we sometimes encounter cases in which not only the internal carotid artery (ICA), but also the common carotid artery (CCA) is poorly visualized, leading to hesitation over which devices and techniques to choose for revascularization. We retrospectively evaluated such cases, focusing on image findings and treatment results. MATERIALS AND METHODS: Data from 96 patients who underwent acute endovascular revascularization from January 2016 to December 2019 were analyzed. We extracted patients with poor CCA visualization on cervical MRA from 35 cases with ICA occlusion, and examined angiographic findings, treatment methods, and outcomes. RESULTS: Poor visualization of the CCA in cervical MRA was observed in 8 cases. All cases displayed atrial fibrillation or sick sinus syndrome. Angiographic findings showed true CCA occlusion in 2 patients and ICA occlusion in 6 patients. Reasons for the inability to visualize the CCA on cervical MRA were speculated to be stenosis of the external carotid artery (ECA), presence of embolism in the ECA, or severe heart failure. In cases of true CCA occlusion, thrombus was aspirated using the balloon guide catheter and good recanalization was obtained. Seven of 8 patients displayed favorable recanalization, with good prognosis after 90 days in 5 patients. CONCLUSIONS: Poor CCA visualization on cervical MRA does not necessarily represent true CCA occlusion. Aspiration of thrombus from a balloon guide catheter is effective for true CCA occlusion.

A Case of Ruptured Anterior Cerebral Artery Dissection Prevented from Re-rupture with Stenting and Modification of Antiplatelet Agents.

A case of ruptured anterior cerebral artery (ACA) dissection was treated with multiple neck-bridge stents, with modification of antiplatelet administration according to changes in the shape of the aneurysm in the acute phase. A 67-year-old woman presented with severe subarachnoid hemorrhage and fusiform dilatation was observed in the left ACA between the A1 and A2 segments. The use of stents in the acute phase is associated with high risk of ischemic complications. Prasugrel administration, which is considered to have low drug resistance, may have allowed safe stent use in the acute phase.

Large Craniotomy Increases the Risk of Minor Perioperative Complications in Revascularization Surgery for Moyamoya Disease.

OBJECTIVE: Larger craniotomy is expected to increase blood flow over a wider range after indirect revascularization. However, the optimal size of craniotomy has not been established. In this study perioperative complications in revascularization surgery for moyamoya disease are evaluated, focusing on craniotomy size. METHODS: We retrospectively analyzed 87 hemispheres in 65 patients with moyamoya disease who had undergone revascularization surgery. Areas and types of craniotomy were classified as 1-piece craniotomy in the middle cerebral artery (MCA) territory (1-piece group) in 54 hemispheres (mean area of craniotomy, 40.6 ± 13.5 cm2); 2-piece craniotomy in the MCA territory with anterior cerebral artery (ACA) territory (2-piece group) in 16 hemispheres (mean area of craniotomy, 55.4 ± 12.0 cm2); and 1-piece craniotomy in both MCA and ACA territories (large group) in 17 hemispheres (mean area of craniotomy, 84.2 ± 11.0 cm2). Perioperative complication rates in each craniotomy group were analyzed. RESULTS: Perioperative complications occurred in 45 hemispheres (52%). Transient, moderate, and severe complications occurred in 38 hemispheres, 3 hemispheres, and 4 hemispheres, respectively. Complication rates in the 1-piece, 2-piece, and large groups were 41%, 63%, and 76%, respectively. Large craniotomy was associated with a significantly higher frequency of complications (P = 0.01). However, no significant difference was found among groups when limiting analysis to moderate and severe complications. Multivariate analysis showed large craniotomy as the only factor independently related to complications (odds ratio, 2.93; 95% confidence interval, 1.08-7.92; P = 0.034). CONCLUSIONS: Large craniotomy is associated with more frequent perioperative complications, especially transient symptoms.

Segmental Aplasia of Bilateral Internal Carotid Arteries Accompanied by Intracranial Aneurysms: A Case Report.

A 68-year-old woman presented with segmental aplasia of bilateral internal carotid arteries accompanied by unruptured intracranial aneurysms. The abnormality was discovered incidentally at the age of 44 years. Cerebral angiography showed occlusion of bilateral internal carotid arteries, and the carotid territory was supplied by each posterior communicating artery with small intracranial aneurysms. Endovascular treatment for the intracranial aneurysms was planned. However, the patient did not want to undergo the endovascular procedure because of the increased risk due to the associated bilateral carotid abnormalities. Cerebral angiography was performed again at the age of 66 years, and the size of the aneurysms had not changed. Based on their segmental identity, aplasia of segment 6 of the internal carotid artery (ICA) including the first portion of the ophthalmic artery was observed bilaterally.

Lifetime Effects of Small Unruptured Intracranial Aneurysms.

BACKGROUND: Recent prospective multicenter studies have shown that the probability of rupture of unruptured aneurysms with maximal diameter <7 mm is rather low. However, the overall risks and long-term impact of unruptured aneurysms on lifetime quality of life are still unknown. METHODS: A mathematical model of the natural history of intracranial aneurysms was constructed, in which the hypothetical individuals with or without unruptured aneurysm transit between discrete health states. The annual rupture rate of small aneurysms was assumed to be 0.5% in the baseline analysis, followed by the subsequent sensitivity analysis. The analyses were continued until cumulative death rate from subarachnoid hemorrhage or other causes reached 1.0. RESULTS: Age-specific ratios of death of subarachnoid hemorrhage in the individuals harboring unruptured aneurysm, if dying at 60 years old, were 25% in men and 43% in women. These ratios decreased rapidly with higher age. Most (more than 90%) patients with small aneurysms were expected to die of diseases other than subarachnoid hemorrhage. In the baseline analysis (60-year-old individuals), lifetime lost to small aneurysms could be estimated as 3.8% for men and 4.2% for women, but a somewhat larger impact could be identified in the young and/or female individuals compared with in the elderly and/or male individuals. CONCLUSIONS: Lifetime effects of small unruptured aneurysms without risk factors increasing the probability of rupture are relatively small, and most patients were expected to die of diseases other than subarachnoid hemorrhage.

[An Extremely Rare Case of Penetrating Head Injury Caused by a Nasal Implant Made of an Ivory Chip and a Review of the Literature].

Although penetrating head injuries are very rare in Japan, an extremely rare case is reported in which an ivory chip, embedded in the subcutaneous tissue by a cosmetic rhinoplasty, penetrated the cranium. A 69-year-old woman with a psychiatric disorder suddenly jumped down from a window and bruised her face. The ivory chip went into her left frontal lobe via the frontal sinus. At surgery, it was completely removed via the nasion. There were no postoperative complications after adequate frontal sinus repair and closure of dura mater with a piece of pericranium. The literature dealing with Japanese penetrating head injuries was also reviewed. (Received May 27, 2015; Accepted December 1, 2015; Published June 1, 2016).

Superficial siderosis of the central nervous system caused by hemorrhagic intraventricular craniopharyngioma: case report and literature review.

Superficial siderosis is a rare condition caused by hemosiderin deposits in the central nervous system (CNS) due to prolonged or recurrent low-grade bleeding into the cerebrospinal fluid (CSF). CNS tumor could be one of the sources of bleeding, both pre- and postoperatively. We report an extremely rare case of superficial siderosis associated with purely third ventricle craniopharyngioma, and review previously reported cases of superficial siderosis associated with CNS tumor. A 69-year-old man presented with headache, unsteady gait, blurred vision, and progressive hearing loss. Brain magnetic resonance (MR) imaging with gadolinium revealed a well enhanced, intraventricular mass in the anterior part of the third ventricle. T2*-weighted gradient echo (GE) MR imaging revealed a hypointense rim around the brain particularly marked within the depth of the sulci. Superficial siderosis was diagnosed based on these findings. The tumor was diffusely hypointense on T2*-weighted GE imaging, indicating intratumoral hemorrhage. The lateral ventricles were dilated, suggesting hydrocephalus. [(18)F]fluorodeoxyglucose positron emission tomography revealed increased uptake in the tumor. The whole brain surface appeared dark ocher at surgery. Histological examination showed the hemorrhagic tumor was papillary craniopharyngioma. His hearing loss progressed after removal of the tumor. T2*-weighted GE MR imaging demonstrated not only superficial siderosis but also diffuse intratumoral hemorrhage in the tumor. Superficial siderosis and its related symptoms, including hearing loss, should be considered in patients with hemorrhagic tumor related to the CSF space. Purely third ventricle craniopharyngioma rarely has hemorrhagic character, which could cause superficial siderosis and progressive hearing loss.

Critical classification of craniostomy for chronic subdural hematoma; safer technique for hematoma aspiration.

Chronic subdural hematoma (CSDH) is generally treated by twist drill, and one and two burr-hole craniostomy. We proposed new classification of the intraoperative condition of CSDH, and present a safer technique for aspiration of CSDH in one burr-hole surgery. The intraoperative condition of CSDH was classified according to the connections between the hematoma cavity and the extracranial space as follows. The "closed condition" represents only a single route consisting of a tube inserted intraoperatively connecting the extracranial space to the hematoma cavity. The "open condition" includes another route or space, which can freely pass air, saline, or old hematoma fluid, in addition to the tube inserted intraoperatively. Twist drill craniostomy and two burr-hole craniostomy clearly involve the intraoperative closed and open conditions, respectively. One burr-hole craniostomy may involve either condition due to the operative procedure. Aspiration and irrigation of the hematoma is basically free and safe in the open condition, but risky in the closed condition. All of the hematoma can be aspirated through one burr hole under certain open conditions with temporary replacement of the hematoma cavity with air followed by replacement of air with saline. Twenty-seven patients with symptomatic CSDH underwent one burr-hole craniostomy by the above mentioned aspiration technique. There were no special complications. The recurrence rate was average. The substitution of saline after complete aspiration of hematoma carries little risk only under the "open condition," shortens the operation time, and achieves good irrigation of the hematoma.

Screening strategy using sequential serum D-dimer assay for the detection and prevention of venous thromboembolism after elective brain tumor surgery.

OBJECTIVE: Venous thromboembolism (VTE) is a life-threatening complication in neurosurgical patients. This study retrospectively analyzed the effectiveness and safety of a screening strategy for the detection and prevention of VTE in patients undergoing elective brain tumor surgery. PATIENTS: A total of 419 consecutive patients who underwent brain tumor surgery during 5 years were enrolled. At the midpoint of the study period, screening for VTE was introduced based on measurement of serum D-dimer level on the day after surgery and then once or twice every week. Anticoagulant therapy was started after the diagnosis of VTE. The two groups with (228 patients) and without (191 patients) screening were compared. RESULTS: Most of the demographic and clinical characteristics were relatively well balanced in the groups. VTE was diagnosed in 23 (5.5%) patients overall; the rate was higher in the screening group (7.0%) than in the non-screening group (3.7%). Although the rate of VTE-related adverse events was lower in the screening group (1.3% vs. 2.6%), the rate of hemorrhagic complications was higher (2.2% vs. 0.5%). Multivariate analysis indicated that malignant histology and preoperative paresis were independent risk factors for the diagnosis of VTE. CONCLUSIONS: Many VTE patients may not exhibit signs or symptoms, so screening using surrogate markers for VTE (D-dimer) may be useful in the early detection of asymptomatic VTE. However, most distal, deep venous thrombosis in isolation is not life-threatening, so the added efficacy of anticoagulant agents at this stage has to be weighed against the risks of hemorrhagic complications, especially in the early postoperative period.