Shaping and navigating methods of microcatheters for endovascular treatment of paraclinoid aneurysms.

OBJECTIVE: To determine whether the use of a specific shape and a navigating method of microcatheters are suitable for placement at paraclinoid aneurysms. METHODS: The clinical data from 122 patients with 132 paraclinoid aneurysms that underwent endovascular treatments during a 2.5-year period were retrospectively reviewed. Microcatheter shapes were classified as "straight," "primary curves" (45, 90, and J), "preshaped-C," "pigtail" (simple, right, and left), and "S" (simple, right, left, and preshaped). The navigating methods were classified as antegrade/retrograde microcatheter shift, wire-steering, looping, and coil/wire guiding. The shapes and navigating methods were compared among 3 aneurysm groups, which were categorized as superior, medial, and other, based on direction. RESULTS: Shapes were significantly different between the 3 groups; the most commonly engaged shape in the superior group, medial group, and other group was S (55%), pigtail (60%), and primary (56%), respectively. The straight and S shapes were used in 5 (83%) and 18 (86%) cases, respectively, in the superior group, whereas the pigtail shape was used in 50 (86%) cases in the medial group. Aside from pigtail-simple shape, the side of pigtail, right vs left, coincided with the side of the internal carotid artery involved in every case of the medial group. The navigating methods were not significantly different among the 3 groups. CONCLUSION: A specific shape by paraclinoid aneurysm direction tends to be suitable for the first trial of microcatheter shapes. Operators may reduce unnecessary struggling time of intra-aneurysmal placement of microcatheters by practicing the use of that shape.

Protease imaging of human atheromata captures molecular information of atherosclerosis, complementing anatomic imaging.

OBJECTIVE: There is hope that molecular imaging can identify vulnerable atherosclerotic plaques. However, there is a paucity of clinical translational data to guide the future development of this field. Here, we cross-correlate cathepsin-B or matrix metalloproteinase-2/-9 molecular optical imaging data of human atheromata or emboli with conventional imaging data, clinical data, and histopathologic data. METHODS AND RESULTS: Fifty-two patients undergoing carotid endarterectomy (41 atheromata) or carotid stenting (15 captured emboli) were studied with protease-activatable imaging probes. We show that protease-related fluorescent signal in carotid atheromata or in emboli closely reflects the pathophysiologic alterations of plaque inflammation and statin-mediated therapeutic effects on plaque inflammation. Inflammation-related fluorescent signal was observed in the carotid bifurcation area and around ulcero-hemorrhagic lesions. Pathologically proven unstable plaques had high cathepsin-B-related fluorescent signal. The distribution patterns of the mean cathepsin-B imaging signals showed a difference between the symptomatic vs asymptomatic plaque groups. However, the degree of carotid stenosis or ultrasonographic echodensity was weakly correlated with the inflammatory proteolytic enzyme-related signal, suggesting that molecular imaging yields complimentary new information not available to conventional imaging. CONCLUSIONS: These results could justify and facilitate clinical trials to evaluate the use of protease-sensing molecular optical imaging in human atherosclerosis patients.

Decreased brain edema after collagenase-induced intracerebral hemorrhage in mice lacking the inducible nitric oxide synthase gene. Laboratory investigation.

OBJECT: Hematoma size and brain edema after intracerebral hemorrhage (ICH) are important prognostic factors. Inducible nitric oxide synthase (iNOS) is induced after cerebral ischemia and is known to be involved in secondary neuronal injury, but its significance in ICH is unknown. The authors tested whether iNOS would influence hematoma size and brain edema after ICH. METHODS: The authors used C57BL/6 and iNOS knockout mice for all the experiments. Experimental ICH was induced by the intrastriatal stereotactic administration of bacterial collagenase. Brain tissue was obtained at 72 hours after ICH. The volume of hematoma was quantified by spectrophotometric assay, and the brain water content was measured. The investigators also measured blood-brain barrier permeability using Evans blue dye. RESULTS: There was no significant difference in hematoma size between the 2 groups. The brain water content of the lesional hemisphere was higher in C57BL/6 mice than in iNOS knockout mice. More Evans blue leakage in the brain was observed in C57BL/6 control mice than in iNOS knockout mice. Immunohistochemistry showed iNOS immunoreactivity in the perihematoma areas of C57BL/6 mice but not in the iNOS knockout mice. CONCLUSIONS: When hematoma size was similar, iNOS knockout mice had significantly less brain edema than their littermates. These results suggest that iNOS modulation might become an antiedematous therapy for ICH.

Idiopathic hypertrophic cranial pachymeningitis presenting with headache.

Idiopathic hypertrophic cranial pachymeningitis is a rare inflammatory disease, usually involving the dura mater of skull base, tentorium, and falx. Chronic headache is the most common clinical manifestations. We report a case of idiopathic hypertrophic cranial pachymeningitis that was, initially, misdiagnosed as acute subdural hematoma along the tentorium cerebelli and posterior falx on the brain precontrast CT scan of a patient with severe headache. Correct diagnosis of pachymeningitis was made only after brain magnetic resonance imaging and meningeal biopsy.

Thunderclap headache after micturition in bladder pheochromocytoma.

A thunderclap headache is a sudden and severe headache and is sometimes a sign of a medical emergency such as aneurysmal subarachnoid hemorrhage and pituitary apoplexy. We report a case of pheochromocytoma in the urinary bladder in a 37-year-old man who presented with recurrent thunderclap headache after voiding and exercises. Bladder pheochromocytoma should be included in the differential diagnosis of recurrent thunderclap headache after micturition or exercises.

Venous-predominant parenchymal arteriovenous malformation: a rare subtype with a venous drainage pattern mimicking developmental venous anomaly.

OBJECT: Considerable confusion exists in the literature regarding the classification of cerebrovascular malformations and their clinical significance. One example is provided by the atypical developmental venous anomaly (DVA) with arteriovenous shunt, because it remains controversial whether these lesions should be classified as DVAs or as atypical cases of other subtypes of cerebrovascular malformations. The purpose of this study was to clarify the classification of these challenging vascular lesions in an effort to suggest an appropriate diagnosis and management strategy. METHODS: The authors present a series of 15 patients with intracranial vascular malformations that were angiographically classified as atypical DVAs with arteriovenous shunts. This type of vascular malformation shows a fine arterial blush without a distinct nidus and early filling of dilated medullary veins that drain these arterial components during the arterial phase on angiography. Those prominent medullary veins converge toward an enlarged main draining vein, which together form the caput medusae appearance of a typical DVA. RESULTS: Based on clinical, angiographic, surgical, and histological findings, the authors propose classifying these vascular malformations as a subtype of an arteriovenous malformation (AVM), rather than as a variant of DVA or as a combined vascular malformation. CONCLUSIONS: Correct recognition of this AVM subtype is required for its proper management, and its clinical behavior appears to follow that of a typical AVM. Gamma Knife radiosurgery appears to be a good alternative to resection, although long-term follow-up results require verification.

Headache as the only presentation of intravascular lymphoma.

Intravascular lymphoma (IVL) is a rare extranodal lymphoma, presenting with confusing clinical presentations and most cases have been diagnosed during the postmortem review. We report a case of IVL diagnosed by cerebrospinal fluid (CSF) examination and bone marrow biopsy in a patient with a daily headache from onset. In case of a daily headache from onset with normal neuroimagings, CSF examination may give any significant diagnostic clue and should be a consideration to exclude such causes as hematolymphoid malignancies, including the very rare IVL.

Transcutaneous temporary cardiac pacing in carotid stenting: noninvasive prevention of angioplasty-induced bradycardia and hypotension.

PURPOSE: To evaluate the feasibility, safety, and effectiveness of prophylactically placed noninvasive transcutaneous temporary pacemakers (NTP) to prevent angioplasty-induced bradycardia and hypotension during carotid angioplasty and stenting (CAS). METHODS: The preventive use of NTPs was evaluated in 31 CAS procedures performed at 3 institutions in 30 patients considered to be at high risk for developing angioplasty-induced bradycardia. Twenty-four cases in 23 patients (20 men; mean age 72 years, range 56-85) requiring intraprocedural pacing due to angioplasty-induced bradycardia were included in this study. Pacemakers were set to capture a heart rate <60 beats/min based on the basal heart rate. RESULTS: Noninvasive pacing was technically effective in producing electrical ventricular responses and was hemodynamically effective in most patients. All patients were easily and comfortably stimulated at amplitudes <50 mA (usually 30). There were no complications related to either pacemaker placement or performance. CONCLUSION: The prophylactic use of a noninvasive transcutaneous pacemaker for expected bradycardia during CAS appears to be safe and effective in preventing intraprocedural bradycardia and hypotension, with a decrease in additional pharmacological support during the procedures.

Ureteral injury after inadvertent violation of the intertransverse space during posterior lumbar diskectomy: a case report.

BACKGROUND: Ureteral injury is a rare complication of posterior lumbar diskectomy and has been associated with the accidental perforation of the ALL by a rongeur-type instrument. Here we report on a case of ureteral injury that is somewhat different than previous reports after a rongeur was inadvertently passed through the intertransverse space by careless use of rongeur during a posterior lumbar diskectomy. CASE DESCRIPTION: A 28-year-old man underwent diskectomy for a recurred herniated disk at the right L4-L5 level. During the removal of soft tissue around the lamina, a pituitary rongeur was inadvertently passed lateral to the spinal canal through the intertransverse space, causing clear fluid to leak. Soon after coming out of anesthesia, the patient complained of abdominal pain that became increasingly more severe. An MRI revealed abnormal signal intensity within the right psoas muscle, and we suspected a ureteral injury. Cystoscopy with RGP demonstrated the extravasation of contrast medium at the L4-L5 level. We then repaired the ureter using end-to-end anastomosis and performed a microdiskectomy. CONCLUSION: Although this injury was caused by our procedural error, one should keep in mind that posterior lumbar procedures that involve the transverse process or the intertransverse space such as far lateral diskectomy, PLF, transpedicular fixation, TLIF, and so on, as well as procedures involving the disk space (diskectomy, PLIF, etc) have a potential risk for causing ureteral injury. The careful use of surgical instruments is the key to preventing this iatrogenic complication, and awareness and suspicion of having created possible injury are essential for early detection and treatment.

CT angiography demonstration of the development of intraventricular hemorrhage during aneurysm rupture.

The authors present the 3D reconstructed CT angiography image of extravasation from a rebleeding aneurysm. Direct hemorrhage of a bleeding aneurysm into the lateral ventricle was detected by CT angiography. This image clearly visualized that extravasated contrast medium spurting from a rupturing anterior communicating artery aneurysm, penetrated the ventricle wall and passed through the lateral ventricle to reach the temporal horn. This case provides a real-time demonstration of the way how an intraventricular hemorrhage develops during rupture of an anterior communicating artery aneurysm.

Coil embolization of "kissing aneurysms" associated with distal basilar artery fenestration.

The authors present an extremely rare case of kissing aneurysms associated with fenestration of the distal basilar artery. The two aneurysms were successfully treated with endovascular coil embolization. We provide two-dimensional (2D) and three-dimensional (3D) angiographic features of the kissing aneurysms, and procedural details of coil embolization. To the best of our knowledge, this is the first demonstration of kissing aneurysms at the fenestrated distal basilar artery.

Double origin of the posteroinferior cerebellar artery: angiographic anatomy and endovascular treatment of concurrent vertebrobasilar dissection.

OBJECTIVE: The aim of this study was to evaluate the anatomic details and therapeutic implications of the double origin of the posteroinferior cerebellar artery (DOPICA). METHODS: A total of 131 patients with intracranial posterior circulation aneurysms were consecutively treated using endovascular techniques during an 8-year period. We retrospectively searched the angiographies of these patients for evidence of DOPICA and evaluated its anatomic and treatment details and outcomes in cases of concurrent vertebral artery dissection. RESULTS: DOPICA was found in eight patients. Five patients had a ruptured dissecting lesion at one posteroinferior cerebellar artery (PICA) channel and/or the vertebral artery of cranial PICA origin. In the remaining three patients, DOPICA was incidentally found in cases of P2 or basilar aneurysm. The cranial channel arose from the V4 segment in all eight patients, whereas the caudal channel arose at the atlantooccipital level in seven patients and at the C1 to C2 level in one patient. Internal trapping was chosen to treat the dissecting lesions, because the remaining channel was expected to serve as a route for the PICA-territorial supply. Four of the five patients fully recovered, and one comatose patient eventually died. CONCLUSION: The cranial and caudal channels of DOPICA mainly arise at the levels of the intracranial and atlantooccipital spaces, respectively. Treatment for a ruptured dissection involving the PICA or a vertebral artery of PICA origin is challenging because of the fear of PICA territorial infarction. In such a case, the presence of DOPICA allows internal trapping of a dissecting lesion with reduced risk, because the other channel functions as an alternative flow-maintaining route.

Craniovertebral junction tuberculosis with atlantoaxial dislocation : a case report and review of the literature.

Craniovertebral junction (CVJ) tuberculosis is a rare disease, potentially causing severe instability and neurological deficits. The authors present a case of CVJ tuberculosis with atlantoaxial dislocation and retropharyngeal abscess in a 28-year-old man with neck pain and quadriparesis. Radiological evaluations showed a widespread extradural lesion around the clivus, C1, and C2. Two stage operations with transoral decompression and posterior occipitocervical fusion were performed. The pathological findings confirmed the diagnosis of tuberculosis. Treatment options in CVJ tuberculosis are controversial without well-defined guidelines. But radical operation (anterior decompression and posterior fusion and fixation) is necessary in patient with neurological deficit due to cord compression, extensive bone destruction, and instability or dislocation. The diagnosis and treatment options are discussed.

Pleomorphic xanthoastrocytoma with an intracystic hemorrhage : a case report and literature review.

Pleomorphic xanthoastrocytoma (PXA) has been considered as a low grade tumor of adolescents and young adults. Although this tumor often shows cystic component, the hemorrhage within the cyst is extremely rare. The authors report a rare case of cystic PXA with a hemorrhage within the cyst and the mural nodule in the left frontal lobe. A 64-year-old male presented with a week history of the right side hemiparesis. After gross total resection of the tumor, the patient was fully recovered from neurological deficit. It is suggested that this typically benign tumor could be presented with hemorrhage, causing a rapid neurological deterioration. Prompt surgical intervention, especially total removal of the tumor can provide an excellent functional recovery.

Moyamoya disease associated with Graves disease: special considerations regarding clinical significance and management.

OBJECT: In moyamoya disease (MMD), ischemic events are usually precipitated by activities associated with hyperventilation or physical strain. The authors report on four patients with a rare combination of Graves disease-associated thyrotoxicosis and MMD, whose cerebrovascular ischemic events occurred while in a thyrotoxic state. The clinical correlation between MMD and Graves' thyrotoxicosis, and outcome after surgical intervention are described. METHODS: Four young women, ages 22 to 25 years, presented with profound cerebrovascular ischemic accidents. They had clinical and radiological features consistent with the diagnosis of MMD and were in the active thyrotoxic state of Graves disease. To prevent a future ischemic event, patients underwent superficial temporal artery-middle cerebral artery anastomosis combined with encephalomyosynangiosis or encephaloduroarteriosynangiosis after normalization of their hormonal conditions. All patients have been neurologically stable since revascularization procedures and lead a normal daily life. In patients with MMD, cerebrovascular ischemic events may be precipitated by thyrotoxicosis. One possible pathomechanism of cerebrovascular ischemic aggravation in the thyrotoxic state may be a hemodynamic compromise induced by an excessive increase in the cerebral metabolism and oxygen demand over the compensation of the cerebral blood flow deficit through collateral supply in MMD. CONCLUSIONS: Surgical revascularization after optimal control of thyrotoxicosis is thought to be an appropriate treatment in patients with MMD concurrent with Graves disease for the prevention of further ischemic events, especially in those with impaired cerebral perfusion and cerebral ischemic symptoms.

11C-methionine PET as a prognostic marker in patients with glioma: comparison with 18F-FDG PET.

PURPOSE: The purpose of this study was to compare the prognostic value of 11C-methionine (MET) and 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) in glioma patients. METHODS: The study population comprised 47 patients with gliomas (19 glioblastoma, 28 others). Pretreatment magnetic resonance imaging, MET PET and FDG PET were performed within a time interval of 2 weeks in all patients. The uptake ratio and standard uptake values were calculated. Univariate and multivariate analyses were done to determine significant prognostic factors. Ki-67 index was measured by immunohistochemical staining, and compared with FDG and MET uptake in glioma. RESULTS: Among the several clinicopathological prognostic factors, tumour pathology (glioblastoma or not), age (> or =60 or <60 years), Karnofsky performance status (KPS) (> or =70 or <70) and MET PET (higher uptake or not compared with normal cortex) were found to be significant predictors by univariate analysis. In multivariate analysis, tumour pathology, KPS and MET PET were identified as significant independent predictors. The Ki-67 proliferation index was significantly correlated with MET uptake (r=0.64), but not with FDG uptake. CONCLUSION: Compared with FDG PET in glioma, MET PET was an independent significant prognostic factor and MET uptake was correlated with cellular proliferation. MET PET may be a useful biological prognostic marker in glioma patients.

Surgical management of an unruptured dural arteriovenous fistula of the anterior cranial fossa: natural history for 7 years.

BACKGROUND: Anterior cranial fossa dural arteriovenous fistulas (DAVFs), unlike those in other locations, form a distinct subgroup because of a high incidence of intracerebral hemorrhage and their unique anatomy. We surgically obliterated an unruptured anterior cranial fossa DAVF because the venous aneurysm in the DAVF increased in size during the follow-up period and we present the clinical symptoms, the natural history for a 7-year period before operation, the radiologic findings, and surgical management. This is the first case report in which the growth of a preexisting venous aneurysm in an anterior fossa DAVF was identified. The possible pathogeneses of the rupture of anterior cranial DAVFs are discussed. CASE DESCRIPTION: A 68-year-old man presented with diplopia, retro-orbital headache, and loss of consciousness. Cerebral angiography revealed an anterior cranial fossa DAVF. The primary source of arterial supply was from the ipsilateral anterior ethmoidal artery in combination with the contralateral anterior ethmoidal artery and other less prominent feeding vessels from the external carotid artery (ECA). Venous drainage was through the superior sagittal sinus via dilated pial veins. In addition, a subfrontal pial vein drained toward the region of the sphenoparietal and cavernous sinuses. The detection of the growth of a venous aneurysm 7 years after the initial evaluation prompted an aggressive therapeutic decision on considering a future catastrophic rupture risk. The vascular malformation was approached via a low-frontal craniotomy. A venous aneurysm with a dural feeder was encountered near the site of the anastomosis. The vascular connection between the dura of the cribriform plate and the pial vessels was completely occluded. Postoperative angiography confirmed the complete obliteration of the DAVF. CONCLUSION: In this case, we confirmed an increase in the size of a venous aneurysm of an anterior cranial fossa DAVF. Our findings support the belief that the catastrophic intracranial hemorrhage in an anterior cranial fossa DVAF may occur in the setting of increased hemodynamic pressure of its draining venous channel.