[Evaluation of cerebral hemodynamics using arterial spin labeling perfusion MR imaging in a patient with cervical internal carotid artery vasospasm].

57-year-old woman with sequelae of cerebral infarction was admitted to our hospital because her left-sided hemiparesis was worsened. The right internal carotid artery (ICA) was not visualized by carotid duplex sonography and brain MRA. Arterial spin labeling (ASL) perfusion MR images showed reduced signals in the bilateral ICA territories at post labeling delay 1,525 ms. Her neurological symptoms improved on the day after hospitalization. On day 3, the bilateral ICAs were well visualized on MRA, while cerebral perfusion in the ICA territories appeared to be normalized on ASL. We diagnosed cervical ICA vasospasm, based on the findings of cervical MRA and cerebral angiography. Three months later, the recurrence of ICA vasospasm occurred. ASL was useful for the serial non-invasive evaluation of cerebral hemodynamics from the onset to improvement in a patient with ICA vasospasm.

A Case of Huge Scrotal Hematoma during Mechanical Thrombectomy.

Objective: We report a case of huge scrotal hematoma during emergency mechanical thrombectomy. Case Presentation: An 85-year-old man presented with sudden aphasia and right-sided hemiplegia. He was diagnosed with cerebral infarction due to left M1 occlusion and underwent an emergency mechanical thrombectomy. The treatment was completed with full recanalization, but when replacing the long sheath in the right femoral artery with a short sheath, the patient flexed his leg. The sheath could not be replaced, resulting in a massive scrotal hematoma. Shortly after, the patient went into cardiopulmonary arrest but recovered spontaneous circulation after cardiopulmonary resuscitation. The puncture site was treated hemostatically with manual compression, and the scrotal hematoma was not enlarged. He was transferred to another hospital with a modified Rankin Scale score of 5. Conclusion: Scrotal hematoma is a rare but potentially fatal puncture site complication that should be considered during neuro-endovascular treatment.

Multiple Thrombectomies for Cerebral and Coronary Artery Occlusion in Trousseau Syndrome.

Objective: Trousseau syndrome (TS) is a condition of systemic thrombosis generally associated with an underlying malignancy. An ischemic stroke is a representative thrombotic event. Thrombectomy is a useful procedure for the treatment of cerebral large vessel occlusion, and anticoagulation therapy is the main preventive treatment for TS. This case report describes a woman with terminal pancreatic tumor presenting with repeated occlusions of cerebral and coronary arteries necessitating multiple thrombectomies. Case Presentation: A 67-year-old woman was admitted to our hospital with severe right hemiplegia and global aphasia. MRI revealed left M1 occlusion; therefore, a thrombectomy was performed. Her symptoms recovered completely. Body contrast CT revealed pancreatic cancer with multiple metastases, and she was diagnosed with TS. On day 4 after thrombectomy, the same neurological symptoms occurred and re-occlusion of the left M1 was confirmed. Endothelial injury was suspected, and thrombectomy was repeated. Despite continuing anticoagulation therapy, the coronary artery was occluded and she underwent percutaneous coronary intervention on day 13. To treat the primary pancreatic lesion, she was transferred to the Surgery unit on day 20. Conclusion: Hypercoagulability associated with TS and endothelial damage due to rough procedure resulted in repeated vessel occlusions in this case. Careful thrombectomy and anticoagulation therapy with strict monitoring are needed in TS patients.

Effectiveness of the 'hoisting method' for shunt placement.

PURPOSE: The abdominal procedure of ventriculoperitoneal or lumboperitoneal shunt is difficult because of a deep and narrow operative view, especially for obese patients. We have developed the 'Hoisting method,' which enables us to make abdominal procedures easy and safe. MATERIAL AND METHODS: We report our experience with five cases between April 2020 and March 2021. RESULTS: The placement of the shunt was easy and safe in all patients without any complications. CONCLUSION: The shunt method is very effective and easy without requiring additional devices.

Massive Ossification with Hematopoietic Marrow on Both Surfaces of the Expanded Polytetrafluoroethylene Artificial Dura Mater.

BACKGROUND: Artificial dural substitute made from an expanded polytetrafluoroethylene (ePTFE) sheet has been widely used in surgical application. CASE DESCRIPTION: We describe a 19-year-old woman in whom massive ossification with hematopoietic marrow was noted on both surfaces of an ePTFE sheet during epilepsy surgery. At age 8, she underwent decompressive craniectomy for a ruptured arteriovenous malformation in the right frontal lobe, followed by duraplasty with an ePTFE sheet and autologous cranioplasty fixed with titanium miniplates. CONCLUSIONS: Since the ossification was prominent in the wrinkle dents of the ePTFE sheet and fibrotic membrane with repetitive hemorrhagic events was noted under the ePTFE sheet, the most plausible mechanism of ossification development is the organization of epiartificial and subartificial dural hematoma. Surgeons should be aware of the possibility of ossification development when working with ePTFE sheets for duraplasty.

Comparison of pseudocontinuous arterial spin labeling perfusion MR images and time-of-flight MR angiography in the detection of periictal hyperperfusion.

BACKGROUND: Magnetic resonance imaging (MRI), including perfusion MRI with three-dimensional pseudocontinuous arterial spin labeling (ASL) and diffusion-weighted imaging (DWI), are applied in the periictal (including ictal and postictal) detection of circulatory and metabolic consequences associated with epilepsy. Our previous report revealed that periictal hyperperfusion can firstly be detected on ASL, and cortical hyperintensity of cytotoxic edema secondarily obtained on DWI from an epileptically activated cortex. Although magnetic resonance angiography (MRA) using three-dimensional time-of-flight is widely used to evaluate arterial circulation, few MRA studies have investigated the detection of periictal hyperperfusion. METHODS: To compare the ability of ASL and MRA to detect the periictal hyperperfusion on visual inspection, we retrospectively selected 23 patients who underwent ASL and MRA examination on both periictal and interictal periods. Patients were divided into the following three groups according to periictal ASL/DWI findings: positive ASL and DWI findings (n = 13, ASL+/DWI+ group), positive ASL and negative DWI findings (n = 5, ASL+/DWI- group), and negative ASL and DWI findings (n = 5, ASL-/DWI- group). RESULTS: Periictal hyperperfusion on MRA was detected in 6 out of 13 patients (46.2%) in the ASL+/DWI+ group, but not in all patients in the ASL+/DWI- and ASL-/DWI- groups. Furthermore, in 5 out of these 6 patients, the diagnosis of periictal MRA hyperperfusion could not be made without referring to interictal MRA and/or periictal ASL findings, because the periictal MRA findings were so minute. CONCLUSION: The minimum requirement for the development of periictal MRA hyperperfusion is that its epileptic event is intense enough to induce the uncoupling between metabolism and circulation, with the induction of glutamate excitotoxity, and severe cytotoxic edema on DWI. ASL is vastly superior to MRA in the detection of periictal hyperperfusion.

Arterial Spin Labeling Magnetic Resonance Imaging for Differentiating Acute Ischemic Stroke from Epileptic Disorders.

BACKGROUND: Differential diagnosis between acute ischemic stroke (AIS) and epilepsy-related stroke mimics is sometimes difficult in the emergency department. We investigated whether a combination of diffusion-weighted imaging (DWI) and arterial spin labeling imaging (ASL) is useful in distinguishing AIS from epileptic disorders. METHODS: The study included suspected AIS patients who underwent emergency MRI including both DWI and ASL, and who exhibited DWI high-intensity lesions corresponding to neurological symptoms. We investigated the relationship between the ASL results from within and/or around DWI lesions and the final clinical diagnosis. RESULTS: Eighty-five cases were included (mean age, 71 ± 13 years; 47 men). The time from onset to the MRI examination was 493 ± 536 minutes. ASL showed hyperintensity in 13 patients, isointensity in 43, and hypointensity in 29. All ASL hyperintensities were observed in the cortex, with 4 patients (31%) presenting with AIS and 9 (69%) with an epileptic disorder. All of the AIS patients with ASL hyperintensity were diagnosed with cardioembolic stroke (4/4, 100%), with magnetic resonance angiography demonstrating recanalization of the occluded artery in all cases (4/4, 100%). In the 9 patients with an epileptic disorder, the area of ASL hyperintensity typically extended beyond the vascular territory (7/9, 78%) and involved the ipsilateral thalamus (7/9, 78%). All patients with ASL isointensity and hypointensity were diagnosed with AIS; none had epileptic disorders. CONCLUSIONS: Although cortical ASL hyperintensity can indicate cardioembolic stroke with recanalization, hyperintensity beyond the vascular territory may alternatively suggest an epileptic disorder in suspected AIS patients with DWI lesions.

Subtraction of arterial spin-labeling magnetic resonance perfusion images acquired at dual post-labeling delay: Potential for evaluating cerebral hyperperfusion syndrome following carotid endarterectomy.

Arterial spin-labeling magnetic resonance perfusion imaging is a promising tool for the diagnosis of cerebral hyperperfusion syndrome after carotid endarterectomy. However, arterial spin-labeling with a single post-labeling delay has been reported to show a higher incidence of increased arterial spin-labeling signals in the bilateral hemisphere, probably due to a shortening of the arterial transit time or an arterial transit artifact caused by intravascular stagnant magnetically-labeled spin. To overcome these shortcomings, we used two post-labeling delay settings (1.0 and 1.5 s) in 8 patients who had undergone carotid endarterectomy. In addition, we created a subtraction image between the mean perfusion maps at post-labeling delays of 1.0 and 1.5 s. This also decreased arterial transit artifacts, as these appeared in nearly the same configuration in both post-labeling delay settings. In all eight cases examined, increased arterial spin-labeling signals were observed bilaterally on both dual post-labeling delay settings. Subtraction images revealed that these increased signals were attributable to arterial transit artifacts in seven cases. However, in one patient who developed clinical symptoms, the subtraction method demonstrated post-carotid endarterectomy hyperperfusion. This preliminary study demonstrates that the subtraction method might decrease arterial transit artifacts and yield a map that can better represent true perfusion, thus enabling the detection of post-carotid endarterectomy hyperperfusion.

The Microsurgical Relationships between Internal Carotid-Posterior Communicating Artery Aneurysms and the Skull Base.

Objective This study aimed to review the anatomical and clinical characteristics of internal carotid-posterior communicating artery (IC-PC) aneurysms, especially those located close to the skull base. Methods The microsurgical anatomy around the posterior communicating artery (PComA) was examined in a dry skull and five formalin-fixed human cadaveric heads. The clinical characteristics of 37 patients with 39 IC-PC aneurysms, who were treated microsurgically between April 2008 and July 2016, were retrospectively reviewed. Results The anterior clinoid process (ACP), as well as the anterior petroclinoidal dural fold (APF), which forms part of the oculomotor triangle, are closely related to the origin of the PComA. Among the 39 IC-PC aneurysms, anterior clinoidectomy was performed on 4 (10.3%) and a partial resection of the APF was performed on 2 (5.1%). Both of these aneurysms projected inferior to the tentorium, or at least part of the aneurysm's dome was inferior to the tentorium. Conclusion Proximally located IC-PC aneurysms have an especially close relationship with the ACP and APF. We should be familiar with the anatomical relationship between IC-PC aneurysms and the structures of the skull base to avoid hazardous complications.

Hemodynamic state of periictal hyperperfusion revealed by arterial spin-labeling perfusion MR images with dual postlabeling delay.

BACKGROUND: Magnetic resonance imaging (MRI), including perfusion MRI with arterial spin labeling (ASL) and diffusion-weighted imaging (DWI), are applied in the periictal detection of circulatory and metabolic consequences associated with epilepsy. Although previous report revealed that prolonged ictal hyperperfusion on ASL can be firstly detected and cortical hyperintensity of cytotoxic edema on DWI secondarily obtained from an epileptically activated cortex, the hemodynamic state of the periictal hyperperfusion has not been fully demonstrated. METHODS STUDY-1: We retrospectively analyzed the relationship between seizure manifestations and the development of periictal MRI findings, in Case 1 with symptomatic partial epilepsy, who underwent repeated periictal ASL/DWI examination for three epileptic ictuses (one examination for each ictus). Study-2: We evaluated the hemodynamic state of periictal hyperperfusion with the ASL technique using a dual postlabeling delay (PLD) of 1.5 and 2.5 s in nine patients, according to the presence or absence of the localized epileptogenic lesion (EL) on conventional 3 T-MRI, who were divided into Group EL+ (six patients) and Group EL- (three patients). RESULTS: Study-1 confirmed that the stratified representation of the periictal MRI findings depends on the time interval between the ictal cessation and MRI examination in addition to the magnitude and duration of the epileptic activity. In Study-2, two types of periictal hyperperfusion were noted. In all six Group EL+ patients, periictal ASL findings showed "fast flow type". Markedly increased ASL signals were noted at the epileptically activated cortex, having a tight topographical relationship with EL, on ASL with a PLD of 1.5 s, which is decreased on ASL with a PLD of 2.5 s. In all three Group EL- patients, periictal ASL findings showed "gradual flow type", which is characterized by gradual signal increase of the epileptically activated cortex on ASL with a PLD of 1.5 and 2.5 s. CONCLUSION: We confirmed that ASL hyperperfusion is superior to DWI in the periictal detection of epileptic events. ASL with dual PLD offers the ability to document two types of hemodynamics of periictal hyperperfusion.

[Ruptured Dissecting Aneurysm of the Fenestrated Vertebral Artery:A Case Report].

Fenestration of a vertebral artery(VA)is a rare anomaly that has occasionally been associated with the formation of saccular aneurysms, whereas dissection of a limb of the fenestrated artery is an extremely rare occurrence. We report the case of a ruptured dissecting aneurysm of a fenestrated VA. A 56-year-old man presented with acute-onset headache followed by respiratory failure. Computed tomography(CT)revealed diffuse subarachnoid hemorrhage, and CT angiography(CTA)demonstrated fenestration of the left VA and a fusiform aneurysm of the dorsolateral limb of the fenestrated VA. CT after injection of contrast medium revealed dissection of a limb of the fenestrated VA. A comparison of the 3-dimensional digital subtraction angiogram obtained 2 days later with the initial CTA showed that the dissecting aneurysm had shrunk. Coil embolization of the dissecting limb of the fenestrated VA was achieved, and the patient was discharged without neurologic deficit. Further advancements in neuroimaging modalities will provide more opportunities to treat dissecting aneurysms of fenestrated VAs. The relevant clinical characteristics of VA fenestration and the treatment options for a dissecting aneurysm of a limb of the fenestrated VA are also discussed in this report.

Sequential changes of arterial spin-labeling perfusion MR images with dual postlabeling delay following reconstructive surgery for giant internal carotid artery aneurysm.

BACKGROUND: Arterial spin-labeling magnetic resonance perfusion imaging (ASL-MRI) allows noninvasive measurement of cerebral blood flow (CBF) but depends on arterial transit time (ATT). To overcome this problem, we developed a simple ASL technique with dual postlabeling delay (PLD) settings. In addition to the routinely used PLD of 1.5 seconds, we selected another PLD of 2.5 seconds to assess slowly streaming blood flow and detect arterial transit artifacts (ATAs) resulting from stagnant intravascular magnetically labeled spins. CASE DESCRIPTION: We validated the dual PLD method with digital subtraction angiography (DSA) findings in a patient with an unruptured right giant internal carotid artery (ICA) aneurysm who underwent proximal ligation of the right cervical ICA followed by right superficial temporal artery-middle cerebral artery anastomosis. The giant aneurysm was detected as a strongly hyperintense signal area of ATA using both values of PLD. Decreased signal in the right hemisphere at PLD 1.5 seconds was somewhat improved at PLD 2.5 seconds. DSA revealed that this laterality resulted from the different ATT values between hemispheres due to stagnation of the labeled spin within the aneurysm. Postoperatively, with gradual but complete thrombosis and regression of the aneurysm, the size of the ASL hyperintense signal area decreased markedly. At postoperative 2 years, the aneurysm was not demonstrated as an ATA; furthermore, the decreased signals in the right hemisphere at PLD 1.5 seconds had mostly improved. CONCLUSION: Serial ASL-MRI with dual PLDs could show dynamic changes of giant aneurysms and the associated hemodynamic state following the surgery.

Impact of low coagulation factor XIII activity in patients with chronic subdural hematoma associated with cerebrospinal fluid hypovolemia: A retrospective study.

BACKGROUND: Cerebrospinal fluid hypovolemia (CSFH) is sometimes associated with chronic subdural hematomas (CSHs). Affected patients often develop enlargement and recurrence of the CSH, even if appropriate treatments such as epidural blood patch (EBP) and/or burr-hole surgery for the CSH are performed. This situation may lead to subclinical coagulopathy, including low coagulation factor XIII (CFXIII) activity. We retrospectively analyzed whether CFXIII activity was involved in the development of CSHs and post-treatment exacerbation of CSHs in patients with CSFH. METHODS: We diagnosed CSFH by radioisotope (RI), magnetic resonance imaging (MRI) and computed tomography (CT) findings, and CSH by CT and/or MRI findings. The plasma CFXIII activity was assessed on admission. All patients with CSFH initially received conservative treatments. When these treatments were ineffective, the patients underwent EBP and/or CSH surgery according to previously reported therapeutic strategies. RESULTS: Among 206 patients with CSFH, 19 developed CSHs. Fourteen patients with a thin hematoma underwent EBP and three with a thick hematoma underwent CSH surgery immediately after EBP on the same day. We were unable to diagnose two patients with CSFH at the time of admission, and one of these two patients underwent repeated CSH surgery before obtaining the correct diagnosis. Seven patients (36.8%) developed CSH exacerbation after the treatment. The CFXIII activity was significantly lower in patients with than without a CSH (42.1% vs. 12.8%, respectively; P = 0.003). The CFXIII activity was significantly lower in patients with than without post-treatment CSH exacerbation (P = 0.046). All five patients with low CFXIII activity who developed CSH exacerbation received intravenous injection of CFXIII and had no recurrence of CSH after the additional treatment. CONCLUSION: In patients with CSFH, low CFXIII activity is one of the risk factors for both the development of a CSH and the post-treatment exacerbation CSH.

The initial use of arterial spin labeling perfusion and diffusion-weighted magnetic resonance images in the diagnosis of nonconvulsive partial status epileptics.

BACKGROUND: In the diagnosis of nonconvulsive status epilepticus (NCSE), capture of ongoing ictal electroencephalographic (EEG) findings is the gold standard; however, this is practically difficult without continuous EEG monitoring facilities. Magnetic resonance imaging (MRI), including diffusion-weighted imaging (DWI) and perfusion MRI with arterial spin labeling (ASL), have been applied mainly in emergency situations. Recent reports have described that ictal MRI findings, including ictal hyperperfusion on ASL and cortical hyperintensity of cytotoxic edema on DWI, can be obtained from epileptically activated cortex. We demonstrate the characteristics and clinical value of ictal MRI findings. METHODS: Fifteen patients diagnosed as having NCSE (eight had complex partial status epilepticus (SE) and seven subtle SE) who underwent an initial MRI and subsequent EEG confrmation, participated in this study. Follow-up MRI and repeated routine EEG were performed. RESULTS: In 11 patients (73%), ictal MRI findings were obtained on both DWI and ASL, while in four (27%) patients, ictal hyperperfusion was found on ASL without any DWI findings being obtained. In all 10 patients with an epileptogenic lesion, there was a tight topographical relationship between the lesion and the localization of ictal MRI findings. In the other five patients, ictal MRI findings were useful to demonstrate the pathophysiological mechanism of NCSE of non-lesional elderly epilepsy, or 'de novo' NCSE of frontal origin as situation-related NCSE. Ictal MRI findings are generally transient; however, in three cases they still persisted, even though ictal EEG findings had completely improved. CONCLUSION: The present study clearly demonstrates that the initial use of ASL and DWI could help to diagnose partial NCSE and also combined use of the MRI and EEG allows documentation of the pathophysiological mechanism in each patient.

[Rapid Progression in Early-Stage Primary Glioblastoma Multiforme:A Case Report].

The signs and features of early-stage primary glioblastoma multiforme(GBM)are not well-characterized. Here, we report a case of GBM that was presented at an early stage and showed extremely rapid progression within a short period. A 63-year-old woman was incidentally revealed to have a tiny lesion in her right parietal lobe. Magnetic resonance imaging(MRI)showed a hyperintense signal on T2WI, with a ring-enhancement on gadolinium(Gd)-enhanced T1WI. Two weeks later, she was admitted to our hospital for neurosurgical intervention;the MRI at that time showed rapid tumor growth, immediately followed by progressive neurological deterioration. The tumor was urgently removed;its histopathological diagnosis was GBM. This case indicates that primary GBM, even at an early stage, can rapidly progress within an extremely short period. Scheduling prompt neuroradiological assessments and neurosurgical interventions in possible cases of early-stage GBM are important, especially if a Gd-enhancement is seen on MRI.

Optimal perioperative management of antithrombotic agents in patients with chronic subdural hematoma.

OBJECTIVE: The use of antithrombotic agents such as anticoagulants and antiplatelet agents is widespread, and the opportunities to treat patients with chronic subdural hematoma (CSDH) under antithrombotic therapy are growing. However, whether antithrombotic therapy contributes to postoperative complications and recurrences of CSDH and how these agents should be managed in the surgical treatment of CSDH remains unclear. METHODS: We retrospectively analyzed 150 consecutive patients with CSDH who underwent neurosurgical interventions at Kyushu Rosai Hospital from 2011 to 2015 and followed them for more than 3 months. RESULTS: Of the 150 study patients, 44 received antithrombotic therapy. All anticoagulants and 76% of the antiplatelet agents were discontinued before surgical treatment of CSDH and resumed within 1 week except in 4 patients whose treatment was terminated and 7 patients who developed postoperative complications or underwent reoperations before resumption of these agents. Postoperative hemorrhagic complications associated with surgical treatment of CSDH occurred in 8 patients (5.3%), and there was no significant difference in the incidence of these complications between patients with and without antithrombotic therapy (6.8% vs. 4.7%, respectively; p=0.90). Postoperative thromboembolic complications occurred in 5 patients (5.4%), including 4 patients with antithrombotic therapy; these complications developed before resumption of antithrombotic agents in 2 patients. There was a significant difference in the incidence of postoperative thromboembolic complications between patients with and without antithrombotic therapy (9.1% vs. 0.9%, respectively; p=0.04). There were no significant differences in the incidence of radiographic deterioration or reoperation of ipsilateral or contralateral hematomas between patients with and without antithrombotic therapy after surgical treatment of unilateral CSDH. CONCLUSION: A history of antithrombotic therapy was significantly correlated with the incidence of postoperative thromboembolic complications in patients with CSDH. Antithrombotic agents should be resumed as soon as possible when no hemorrhagic complication is confirmed after neurosurgical intervention for CSDH.

Arterial Spin-Labeling Magnetic Resonance Perfusion Imaging with Dual Postlabeling Delay in Internal Carotid Artery Steno-occlusion: Validation with Digital Subtraction Angiography.

BACKGROUND: Arterial spin-labeling magnetic resonance perfusion imaging (ASL-MRI) allows noninvasive measurement of cerebral blood flow (CBF) but depends on the arterial transit time (ATT). With the commonly used single postlabeling delay (PLD) of 1.5 seconds, slow flow through collateral vessels may be underestimated. We used both 1.5 and 2.5 seconds to overcome this problem. We validated these PLD settings by measuring the ATT and identifying the angiographic circulation using digital subtraction angiography (DSA). METHODS: We retrospectively selected 5 patients with unilateral occlusion or stenosis of the internal carotid artery (ICA) in whom ASL-MRI showed low CBF with 1.5-second PLD in the target area and improved CBF with 2.5-second PLD. We then compared the ASL-MRI findings visually with DSA findings at 1.5 and 2.5 seconds after injection of the contrast. When arterial transit artifacts (ATAs), attributed to stagnant intravascular spin-labeled blood, were observed, DSA findings were analyzed visually at 4.5 seconds. RESULTS: DSA revealed that the hypovascular area seen at 1.5 seconds was improved via the primary and secondary collaterals and delayed anterograde flow at 2.5 seconds. Serpiginous or round-shaped ATAs, which appeared in nearly the same configuration on dual PLD ASL-MRI, were attributed to stagnant collaterals and flow in the M2 portion of the middle cerebral artery and ICA during the late venous phase. CONCLUSIONS: Use of dual PLD times was validated by the DSA findings. ATA detection using the dual PLDs also differentiated well-developed and stagnant collateral vessels from focal hyperperfusion.

[Brain Abscess due to Infection with Dematiaceous Fungi Cladophialophora bantiana Associated with Hypogammaglobulinemia Following Gastrectomy: A Case Report].

Dematiaceous fungi have melanin-like pigment in the cell wall and usually cause a variety of dermal infections in humans. Infections of the central nervous system(cerebral phaeohyphomycosis)are rare but serious, since they commonly occur in immunocompromized patients. A 76-year-old man was admitted with mild motor aphasia and underwent total excision of a mass in the left frontal lobe. With the postoperative diagnosis of brain abscess due to infection with dematiaceous fungi (C. bantiana) associated with hypogammaglobulinemia following gastrectomy, intravenous antifungal drugs including amphotericin B and fluconazole were administered. Regrowth of the abscess with intraventricular rupture was noted at about the 88th day after the initial surgery, and the patient underwent neuroendoscopic aspiration of the pus and placement of a ventricular drain. Following intraventricular administration of miconazole through ventricular drainage or an Ommaya reservoir, neuroradiological findings improved, but general and neurological conditions worsened. Further treatment was discontinued and the patient died 9 months after onset. The poor outcome in this patient is attributed to 1)intractability of dematiaceous fungi, 2)development of ventriculitis and the need for intraventricular administration of antifungal drugs, and 3)untreatable hypogammaglobulinemia following gastrectomy.

Signal changes on magnetic resonance perfusion images with arterial spin labeling after carotid endarterectomy.

BACKGROUND: Cerebral hyperperfusion after carotid endarterectomy (CEA) is defined as an increase in ipsilateral cerebral blood flow (CBF). Practically, however, prompt and precise assessment of cerebral hyperperfusion is difficult because of limitations in the methodology of CBF measurement during the perioperative period. Arterial spin labeling (ASL) is a completely noninvasive and repeatable magnetic resonance perfusion imaging technique that uses magnetically-labelled blood water as an endogenous tracer. To clarify the usefulness of ASL in the management of cerebral hyperperfusion, we investigated signal changes by ASL with a single 1.5-s post-labeling delay on visual inspection. METHODS: Thirty-two consecutive patients who underwent CEA were enrolled in this retrospective study. RESULTS: On postoperative day 1, 22 (68.8%) and 4 (12.5%) patients exhibited increased ASL signals bilaterally (Group A) and on the operated side (Group B), respectively. Follow-up ASL showed improvement in these findings. Six (18.8%) patients showed no change (Group C). There was no apparent correlation between ASL signals on postoperative day 1 and the preoperative hemodynamic state, including the cerebrovascular reserve (P = 0.2062). Three (9.4%) patients developed cerebral hyperperfusion syndrome (two in Group A and one in Group B). Coincidence in the localization of increased ASL signals and electroencephalographic abnormalities was noted in these patients. CONCLUSION: Visual analysis of ASL with a single post-labeling delay overestimates CBF and cannot identify patients at risk of cerebral hyperperfusion syndrome probably because of the strong effect of the shortened arterial transit time immediately after CEA. However, ASL may be used as for screening.

Arterial Spin Labeling Perfusion Magnetic Resonance Image with Dual Postlabeling Delay: A Correlative Study with Acetazolamide Loading (123)I-Iodoamphetamine Single-Photon Emission Computed Tomography.

BACKGROUND: Perfusion magnetic resonance image with arterial spin labeling (ASL) provides a completely noninvasive measurement of cerebral blood flow (CBF). However, arterial transient times can have a marked effect on the ASL signal. For example, a single postlabeling delay (PLD) of 1.5 seconds underestimates the slowly streaming collateral pathways that maintain the cerebrovascular reserve (CVR). To overcome this limitation, we developed a dual PLD method. SUBJECTS AND METHODS: A dual PLD method of 1.5 and 2.5 seconds was compared with (123)I-iodoamphetamine single-photon emission computed tomography with acetazolamide loading to assess CVR in 10 patients with steno-occlusive cerebrovascular disease. RESULTS: In 5 cases (Group A), dual PLD-ASL demonstrated low CBF with 1.5-second PLD in the target area, whereas CBF was improved with 2.5-second PLD. In the other 5 cases (Group B), dual PLD-ASL depicted low CBF with 1.5-second PLD, and no improvement in CBF with 2.5-second PLD in the target area was observed. On single-photon emission computed tomography, CVR was maintained in Group A but decreased in Group B. CONCLUSIONS: Although dual PLD methods may not be a completely alternative test for (123)I-iodoamphetamine single-photon emission computed tomography with acetazolamide loading, it is a feasible, simple, noninvasive, and repeatable technique for assessing CVR, even when employed in a routine clinical setting.