Repeated coil embolization of traumatic basilar artery pseudoaneurysm accompanied by bilateral traumatic internal carotid artery stenosis following severe head injury in a pediatric patient: A case report and literature review.

Background: Few cases of pediatric traumatic intracranial aneurysms (pTICAs) in the posterior circulation involving the basilar artery (BA) following severe head trauma have been reported. Here, we describe a pediatric case of traumatic BA pseudoaneurysm accompanied by bilateral traumatic internal carotid artery (ICA) stenosis following blunt head trauma. Case Description: A 16-year-old boy presented to our emergency department after being hit by a car. The patient was initially diagnosed with multiple skull base fractures underlying traumatic subarachnoid hemorrhage and left acute epidural hematoma. Seven days following emergency craniectomy, magnetic resonance imaging revealed bilateral ICA stenosis, BA stenosis, and BA pseudoaneurysm. We decided to perform coil embolization, resulting in body filling and a volume embolization ratio of 15.7%. Twenty-eight days after coil embolization, digital subtraction angiography revealed aneurysmal rupture. We performed repeated coil embolization, resulting in body filling and a volume embolization ratio of 20.9%. Conclusion: We reported a pediatric case of traumatic BA pseudoaneurysm accompanied by bilateral traumatic ICA stenosis following a severe head injury treated with repeated coil embolization. Considering the risk of further brain injury due to high incidence of rupture, early vascular survey and appropriate treatment may be the most important prognostic factors in pTICAs.

Glial fibrillary acidic protein level on admission can predict severe traumatic brain injury in patients with severe multiple trauma: A single-center retrospective observational study.

Objective: This study aimed to clarify whether the glial fibrillary acidic protein (GFAP) and soluble protein-100ß (S100ß) can predict severe traumatic brain injury (TBI) in patients with severe multiple trauma. Methods: This is a single-center retrospective observational study of 179 patients with severe multiple trauma. The GFAP and S100ß were measured upon patient arrival at the hospital. We divided the patients into the severe TBI group (with a Traumatic Coma Data Bank classification of ≥III), the non-severe TBI group (non-TBI group [absence of abnormality on the computed tomography scan and extracranial injury], and the mild to moderate TBI group [TCDB classification I and II]). We compared biomarker levels between the two groups and then evaluated the accuracy of predicting severe TBI using a receiver operating characteristic curve. Results: A total of 41 patients had severe TBI, and 138 had non-severe TBI. Mean GFAP levels were significantly higher in the severe TBI group (median, 6000 pg/mL; interquartile range [IQR], 651-15,548 pg/mL) than in the non-severe TBI group (median, 149 pg/mL; IQR, 0-695 pg/mL) (p < 0.0001). In contrast, there was no significant difference in S100ß levels between the severe TBI group (median, 64 pg/mL; IQR, 0-536 pg/mL) and non-severe TBI group (median, 117 pg/mL; IQR, 0-403 pg/mL) (p = 0.637). The area under the receiver operating characteristic curve was 0.810 (p < 0.0001) for GFAP and 0.476 (p = 0.908) for S100ß. For the GFAP, the optimal cutoff value for detecting severe TBI was 947 pg/mL (sensitivity, 75.6%; specificity, 78.3%). Conclusions: In patients with severe multiple trauma, the GFAP level at hospital arrival could predict severe TBI, whereas the S100ß level was not a useful predictor.

Favorable management of symptomatic cerebellar hemangioblastoma presenting with obstructive hydrocephalus during pregnancy: A case report and literature review.

Background: Cerebellar hemangioblastoma is a highly vascular benign tumor and the growth rate of hemangioblastomas is believed to often accelerate during pregnancy; however, the reason for this rapid increase in size remains poorly understood. There are several case reports of symptomatic hemangioblastoma during pregnancy; however, the favorable management strategy has not been well established. Case Description: A 35-year-old woman, gravida 2 para 1, with no significant medical history presented with vertigo and difficulty walking at around 11 weeks of pregnancy and was referred to our institute at 30 weeks of gestation because of worsening symptoms. Brain magnetic resonance imaging revealed a 5.6 cm cystic lesion with a mural nodule in the right cerebellar hemisphere and the lesion blocked cerebrospinal fluid drainage from the fourth ventricle and brainstem, resulting in obstructive hydrocephalus. After obtaining the patient's consent, a multidisciplinary team consisting of obstetricians and neurosurgeons decided to perform resection of the intracranial lesion following delivery of the fetus by emergency cesarean section in view of the symptoms of increased intracranial pressure. The patient's general condition was confirmed to be stable postoperatively and she was discharged on the 16th day of her hospitalization without any neurological deficits or fetal complications. Conclusion: Urgent tumor resection combined with cesarean section can be planned once fetal lung maturity is confirmed. Most cases of symptomatic hemangioblastoma during pregnancy have an uneventful gestational course and a favorable outcome for both mother and child.

Usefulness of Adjunctive Technique with a TACTICS Catheter for Coil Embolization of Cerebral Aneurysms.

Objective: We report the usefulness of the adjunctive technique using a 3.4-Fr TACTICS catheter, which is a distal access catheter (DAC) for coil embolization. Methods: Patients who underwent coil embolization with an adjunctive technique using a TACTICS catheter between October 2018 and May 2019 were retrospectively analyzed. Results: In all, 64 aneurysms in 51 patients were treated. Among them, 18 aneurysms in 15 patients (4 ruptured aneurysms and 14 unruptured aneurysms) required an adjunctive technique using a TACTICS catheter. The methods of embolization were the double catheter technique (DCT) for five aneurysms, stent-assisted coiling (SAT) for seven, DCT + SAC for one, and balloon-assisted technique (BAT) for five aneurysms. Aneurysms were located in the anterior communicating artery (Acom A) in three cases, distal anterior cerebral artery (dACA) in one, middle cerebral artery (MCA) in five, internal carotid artery (ICA) in six, basilar artery (BA) in one, and vertebral artery (VA) in two cases. It was easy to access distal intracranial vessels using the TACTICS catheter. In all cases, guiding of the microcatheter, coiling, and stent placement were improved. There were no complications associated with using the TACTICS catheter. Conclusion: Compared with conventional DACs, distal intracranial vessels were more easily accessed using the TACTICS catheter. A TACTICS catheter is useful because DCT and SAC require sufficient operability of the microcatheter.

Optimal surgical indications of endoscopic surgery for traumatic acute subdural hematoma in elderly patients based on a single-institution experience.

Recently, treatment of acute subdural hematoma (ASDH) by minimally invasive surgery with endoscopy has been successfully demonstrated. However, few case series are available on this procedure for ASDH, and the surgical indication has not been established. We retrospectively analyzed the data of patients (n = 26) aged 65 years or older who underwent endoscopic surgery (ES) for ASDH at our institution between January 2011 and March 2019. We then evaluated the surgical outcomes and procedure-related complications in patients who underwent ES. The mean hematoma reduction rate was over 90%. Percentage of favorable outcomes at discharge was 69.2% in ES-treated patients. The presence of a skull fracture, subarachnoid hemorrhage, midline shift/subdural hematoma thickness ratio > 1.0, and early surgery were associated with postoperative IPHs in patients who underwent ES or conventional surgery for ASDH. The present study revealed that ES for elderly patients with ASDH is likely to be an efficient and safe procedure when patients are selected appropriately. However, ES is not recommended in patients with significant IPHs on initial CT scan. Additionally, ES should be carefully considered in cases with the factors, where IPHs may progress following surgery.

Dynamic assessment of internal carotid artery and elongated styloid process in a case of bilateral carotid artery dissection.

BACKGROUND: Vascular Eagle syndrome is that an elongated styloid process causes ischemic stroke due to internal carotid artery (ICA) dissection. Dynamic assessment using radiological imaging has not been well investigated. We assessed the change in the relative positional relationship between the elongated styloid process and the ICA using a cone-beam computed tomography (CBCT). CASE DESCRIPTION: A 46-year-old female presenting with disturbance of consciousness, right hemiparesis, and aphasia was admitted to our hospital. Initial CT analysis showed a bilateral elongated styloid process. Magnetic resonance angiography (MRA) showed occlusion of the left ICA and a near occlusion of the right ICA. MRA also revealed the intimal flap and intramural hematoma in the bilateral ICA. Digital subtraction angiography showed bilateral ICA occlusion and carotid artery stenting was performed subsequently. After that, we visualized the movement of carotid stent with CBCT fusion methods. The stent moved forward and backward at the attachment point of the styloid process during head rotation, and there was a possibility that mechanical stress was emphasized at this point. Styloidectomy was performed after her rehabilitation. The patient did not experience a recurrence of stroke. CONCLUSION: We showed that repeated attachment of the styloid process and ICA may trigger an ICA dissection during head rotation. This finding would be helpful for understanding the causes of vascular Eagle syndrome.

Endovascular Treatment of Ruptured Kissing Aneurysms Arising From the Origin of the Anterior Choroidal Artery and an Aberrant Origin of the Premamillary Artery.

BACKGROUND: The premamillary artery (PMA) usually arises from the posterior communicating artery. Thus, an internal carotid artery (ICA) origin for PMA is rare. We report a rare case of a patient who presented with subarachnoid hemorrhage resulting from kissing aneurysms arising from the origin of the anterior choroidal artery and the aberrant origin of PMA and was successfully treated with coil embolization. CASE DESCRIPTION: A conscious and alert 36-year-old woman arrived at our hospital with a severe headache. Computed tomography (CT) of the head showed a thin subarachnoid hemorrhage. CT angiography revealed kissing aneurysms arising from the ICA. Digital subtraction angiography showed that these kissing aneurysms had arisen from the anterior choroidal artery and the aberrant origin of the PMA. Endovascular coil embolization was performed for both aneurysms. Her clinical course was good, and she was discharged from our hospital 20 days after admission. CONCLUSIONS: To the best of our knowledge, the present study is the first report of a ruptured saccular PMA aneurysm arising from ICA that was successfully treated with coil embolization. Three-dimensional digital subtraction angiography and cone-beam CT were useful for confirming the precise vasculature of the PMA.

Impact of Spot Sign Etiology in Supratentorial Intracerebral Hemorrhage on Outcomes of Endoscopic Surgery.

BACKGROUND: The spot sign (SS) in spontaneous intracerebral hemorrhage has been reported to be a predictive factor of poor outcome; however, how SS is related with the clinical outcome remains unclear. We aimed to investigate how etiology associated with SS affects the clinical outcome of endoscopic surgery. METHODS: We retrospectively analyzed data from 104 patients (43 women and 61 men, mean age: 64.2 ± 11.0 years) who underwent endoscopic surgery for supratentorial intracerebral hemorrhage. The outcome variables analyzed were in-hospital mortality and modified Rankin scale score at 90 days from onset. RESULTS: The prevalence of intraventricular hemorrhage and the mean initial modified Graeb score were greater in SS-positive than in SS-negative patients (100% vs. 47.7%, P < 0.001, and 14.4 ± 5.4 vs. 10.6 ± 6.0, P = 0.03, respectively). Postoperative rebleeding occurred more frequently in SS-positive than -negative patients (25.0% vs. 6.8%, P = 0.045). The in-hospital mortality rate was 7.7% and was not significantly different between the groups (18.8% vs. 5.7%, P = 0.09). There was a significant unfavorable shift in modified Rankin scale scores at 90 days among SS-positive patients compared with SS-negative patients in an analysis with ordinal logistic regression (adjusted common odds ratio, 4.38; 95% confidence interval 0.06-0.79, P = 0.02). CONCLUSIONS: Intraventricular hemorrhage and postoperative rebleeding were considered to be associated with the poor outcome in patients with SS. The SS on computed tomography angiography may be valuable in predicting rebleeding and clinical outcome after surgery.

Distal superior cerebellar artery aneurysm located at the newly formed anastomotic site with the long circumferential artery of the posterior cerebral artery: A case report.

We describe a case of a distal superior cerebellar artery (SCA) aneurysm that arose from a unique collateral pathway between the SCA and long circumferential artery (LCA) of the posterior cerebral artery (PCA). The patient was a 69-year-old male who was admitted to our facility for an asymptomatic and incidentally identified cerebellar aneurysm. Magnetic resonance imaging showed a saccular aneurysm arising from the right SCA in the quadrigeminal cistern. Digital subtraction angiography revealed an unusually dilated branch from the aneurysmal sac. Furthermore, this branch had retrograde flow from the quadrigeminal segment to the anterior pontomesencephalic segment, was connected to the PCA at the P1 segment, and exited from the P2 segment. We attributed this unusual angioarchitecture to collateral circulation secondary to severe P1 stenosis. Thus, the dilated unusual branch is an LCA of the PCA for supplying the distal PCA with blood flow. As a result, the aneurysm is probably formed at the junction between the SCA and LCA. Endovascular coiling for the aneurysm was successfully performed with preserved collateral system.

Three-dimensional spin-echo-based black-blood MRA in the detection of vasospasm following subarachnoid hemorrhage.

BACKGROUND: Black-blood MR angiography (BBMRA), which utilizes a non-T1 contrast spin-echo type technique, has been expected to overcome several issues associated with time-of-flight (TOF) MRA. PURPOSE: To investigate the efficacy of BBMRA to detect vasospasms following subarachnoid hemorrhage (SAH). STUDY TYPE: Retrospective. SUBJECTS: Seventeen patients with SAH in their early posttreatment period. FIELD STRENGTH/SEQUENCE: BBMRA, which uses a volumetric isotropic turbo spin-echo acquisition (VISTA), and TOF-MRA on 1.5T scanners. ASSESSMENT: Visualization of supratentorial arteries and veins in BBMRA was rated on a 4-point scale by two neuroradiologists. Another neuroradiologist independently assessed TOF-MRA. The degree of the vasospasm was then evaluated using a 3-point scale by the same readers. The diagnostic performance of the MRAs was evaluated using computed tomography angiography (CTA) or digital subtraction angiography (DSA) as the standard of reference. STATISTICAL TESTS: Wilcoxon signed rank test, McNemar test, and Cohen's kappa coefficient. RESULTS: BBMRA provided superior visualization of the anterior and middle cerebral arteries than TOF-MRA (P < 0.05). The depiction of the veins was more pronounced on BBMRA (P < 0.01). Of the 166 arterial segments evaluated by CTA or DSA, 23 (13.9%) could not be assessed using TOF-MRA because of high signal hemorrhage, whereas BBMRA enabled visualization of all the segments. Vasospasm was confirmed in 30 segments by CTA or DSA. The sensitivity, specificity, and positive and negative predictive values were 73, 96, 76, and 95 for TOF-MRA and 91, 100, 100, and 98 for BBMRA, respectively (P = 0.13 for sensitivity, P = 0.06 for specificity). The agreement of the degree of vasospasm between MRA and the standard of reference, as indicated by kappa value, was 0.71 (95% confidence interval [CI], 0.55-0.87) for TOF-MRA and 0.91 (95% CI, 0.82-0.99) for BBMRA. DATA CONCLUSION: BBMRA, owing to its contrast properties, may be superior to TOF-MRA for the evaluation of intracranial arteries after SAH. LEVEL OF EVIDENCE: 3 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;49:800-807.

Endoscopic surgery via a combined frontal and suboccipital approach for cerebellar hemorrhage.

BACKGROUND: Spontaneous cerebellar hemorrhages (CHs), which frequently require surgical intervention, are life-threatening and can be complicated by intraventricular hemorrhages (IVHs) and obstructive hydrocephalus. Commonly, endoscopic surgery is performed to remove CHs via a suboccipital approach (SA) alone. At our institution, when patients exhibited supratentorial IVH-associated hydrocephalus, we used a combined frontal and suboccipital approach (CA) to evacuate both CHs and supratentorial IVHs. The present study retrospectively evaluated the effectiveness and safety of this CA, as no prior studies examining this approach currently exist. METHODS: Twenty-six patients with spontaneous CH were surgically treated at our hospital from April 2009 to March 2016. Twenty-two patients who could independently perform activities of daily living before the onset underwent endoscopic surgery to evacuate the CHs; among these, 13 patients underwent the SA alone, while nine underwent the CA. We assessed and compared the patients' baseline characteristics, surgical results, and prognosis at 1 month after the intervention between the SA and CA groups. RESULTS: Patients who underwent the CA had significantly poorer consciousness before the surgery owing to IVH extension and obstructive hydrocephalus. However, the surgical results and prognosis at 1 month were not significantly different between the two approaches. The CH-associated IVHs were successfully removed with the CA and resulted in shorter external ventricular drainage (EVD) placement durations. CONCLUSION: Endoscopic surgery performed via the CA appeared to neutralize the deteriorating effects of CH-associated IVHs. Surgical strategies employing the CA may have the potential to improve the prognosis of patients with CH.

Spot sign as a predictor of rebleeding after endoscopic surgery for intracerebral hemorrhage.

OBJECTIVEIn patients with spontaneous intracerebral hemorrhage (sICH), postoperative recurrent hemorrhage (PRH) is one of the most severe complications after endoscopic evacuation of hematoma (EEH). However, no predictors of this complication have been identified. In the present study, the authors retrospectively investigated whether PRH can be preoperatively predicted by the presence of the spot sign on CT scans.METHODSIn total, 143 patients with sICH were treated by EEH between June 2009 and March 2017, and 127 patients who underwent preoperative CT angiography were included in this study. Significant correlations of PRH with the patients' baseline, clinical, and radiographic characteristics, including the spot sign, were evaluated using multivariable logistic regression models.RESULTSThe incidence of and risk factors for PRH were assessed in 127 patients with available data. PRH occurred in 9 (7.1%) patients. Five (21.7%) cases of PRH were observed among 23 patients with the spot sign, whereas only 4 (3.8%) cases of PRH occurred among 104 patients without the spot sign. The spot sign was the only independent predictor of PRH (OR 5.81, 95% CI 1.26-26.88; p = 0.02). The following factors were not independently associated with PRH: age, hypertension, poor consciousness, antihemostatic factors (thrombocytopenia, coagulopathy, and use of antithrombotic drugs), the location and size of the sICH, other radiographic findings (black hole sign and blend sign), surgical duration and procedures, and early surgery.CONCLUSIONSThe spot sign is likely to be a strong predictor of PRH after EEH among patients with sICH. Complete and careful control of bleeding in the operative field should be ensured when surgically treating such patients. New surgical strategies and procedures might be needed to improve these patients' outcomes.

Intraoperative Active Bleeding in Endoscopic Surgery for Spontaneous Intracerebral Hemorrhage is Predicted by the Spot Sign.

BACKGROUND: Endoscopic evacuation of hematoma (EEH) has recently been applied to treat patients with spontaneous intracerebral hemorrhage (sICH). Intraoperative active bleeding (IAB), which is occasionally observed in EEH, might lead to greater blood loss, further brain damage, and more postoperative recurrent hemorrhage. However, no definite predictor of IAB has been established. Because the spot sign is associated with other hemorrhagic complications, we aimed to evaluate whether it predicts IAB. METHODS: We retrospectively assessed the incidence and risk factors of IAB, including the spot sign, in 127 sICH patients who underwent EEH within 6 hours after computed tomography angiography at our institution between June 2009 and December 2017. RESULTS: The study included 53 women and 74 men with an average age of 66.7 ± 11.8 years. IAB occurred in 40 (31.5%) of the 127 patients, and it was more frequent in patients with the spot sign than in patients without it (14/24 [58.3%] vs. 26/103 [25.2%]; P = 0.003). Multivariable regression analyses suggested that the spot sign was an independent predictor of IAB (odds ratio [OR], 3.02; 95% confidence interval [CI], 1.10-8.30; P = 0.03). In addition, earlier surgery gradually increased the risk of IAB, and surgery within 4 hours of onset was an independent risk factor (OR, 4.34; 95% CI, 1.12-16.9; P = 0.03, referring to postonset 8 hours or more). CONCLUSIONS: The spot sign and early surgery were independent predictors of IAB in EEH for sICH. In patients with sICH and spot sign, complete treatment of IAB by electrocoagulation might be important for minimizing surgical complications.

Efficacy of direct hemoperfusion with a polymyxin B-immobilized fiber column in miliary tuberculosis.

Case: A 75-year-old woman presented with a 10-day history of intermittent fever, general fatigue, and progressive dyspnea. Although she had a low PaO2/FIO2 ratio, the cause of acute respiratory distress syndrome was not clear until day 9 in hospital. Outcome: We treated the patient with direct hemoperfusion with a polymyxin B-immobilized fiber column incidentally; the PaO2/FIO2 ratio improved following this therapy. Acid-fast bacilli, which were not seen in the sputum on admission, were detected in cultures from sputum, urine, bone marrow, liver biopsy, and blood samples, with a real-time polymerase chain reaction assay confirming tuberculosis. She was immediately transferred to a specialized tuberculosis hospital, and after a 3-month treatment, was discharged. Conclusion: Treatment with polymyxin B-immobilized fiber column may provide good results for pulmonary oxygenation in acute respiratory distress syndrome caused by tuberculosis.

Unilateral Trans-cerebellomedullary Fissure Approach for Occipital Artery to Posterior Inferior Cerebellar Artery Bypass during Aneurysmal Surgery.

Occipital artery (OA) to the posterior inferior cerebellar artery (PICA) bypass is indispensable for the management of complex aneurysms of the PICA that cannot be reconstructed with surgical clipping or coil embolization. Although OA-PICA bypass is a comparatively standard procedure, the bypass is difficult to perform in some cases because of the location and situation of the PICA. We describe the usefulness of the unilateral trans-cerebellomedullary fissure (CMF) approach for OA-PICA bypass. Thirty patients with aneurysms in the vertebral artery (VA) or PICA were treated using OA-PICA bypasses between 2010 and 2015. Among them, the unilateral trans-CMF approach was used for OA-PICA anastomosis in 13 patients. The surgical procedures performed on and the medical records of all the patients were retrospectively reviewed. The unilateral trans-CMF approach was performed for two reasons depending on the PICA location or situation: either because the caudal loop could not be used as a recipient artery because of arterial dissection (3 patients) or because the tonsillo-medullary segment that was located in the upper part of the CMF did not have a caudal loop that was large enough (10 patients). The trans-CMF approach provided a good operative field for the OA-PICA bypass and the anastomosis were successfully performed in all patients. When the recipient artery was located in the upper part of the CMF, the unilateral trans-cerebello-medullary fissure approach provided a sufficient operative field for OA-PICA anastomosis.

Patients' characteristics and outcomes depending on complete or incomplete unilateral spatial neglect.

Unilateral spatial neglect (USN) is known to depress the activities of daily living. The purpose of this study was to clarify that categorizing the type of USN using line cancelation and line bisection tests is important when evaluating patients with acute intracerebral hemorrhage (ICH). In this study, patients with ICH were prospectively evaluated for the presence of USN using line cancelation and line bisection tests. They were classified into an incomplete USN group (iUSN = abnormal results in either test) or a complete USN group (cUSN = abnormal findings in both tests). We compared the initial severity of ICH and the outcomes of USN in the two groups. We were able to assess 16 patients, among whom 10 showed USN. Seven were then categorized as having iUSN and three as having cUSN. The median hematoma volume was larger in the cUSN group than in the iUSN group. The USN symptoms of patients in the iUSN group disappeared during the chronic phase, whereas the symptoms of patients in the cUSN group continued. The type of USN was associated with the initial severity of ICH and the persistence of USN.

White-collar sign as a predictor of outcome after endovascular treatment for cerebral aneurysms.

OBJECTIVE The white-collar sign (WCS) is known as a thick neointimal tissue formation at the aneurysm neck after endovascular coil embolization of cerebral aneurysms, which may prevent aneurysm recanalization. The purpose of this study was to evaluate factors involved in the appearance of WCS and to identify radiological and clinical outcomes of treated aneurysms with WCS. METHODS The study included 140 patients with 149 aneurysms in which it was possible to confirm the aneurysm neck between the aneurysm sac and parent artery by using conventional angiography. The WCS was defined as a radiolucent band at the aneurysm neck on the angiogram at 6 months after initial embolization. The radiological outcome was evaluated using MR angiography. RESULTS In 23 of 149 aneurysms (15.4%), a WCS appeared. The WCS-positive group had a significantly smaller neck size (3.3 ± 0.8 mm vs 4.2 ± 1.1 mm, p < 0.001) and smaller aneurysm size (4.3 ± 0.9 mm vs 6.0 ± 2.1 mm, p < 0.001) than the WCS-negative group. Multivariate analysis revealed that WCS appearance was associated with small neck size (OR 0.376, 95% CI 0.179-0.787; p = 0.009). In 106 of 149 aneurysms, the rate of complete occlusion was significantly higher in the WCS-positive group (18/18, 100%) than in the WCS-negative group (n = 54/88, 61.4%; p = 0.001) in the mean follow-up period of 31.0 ± 9.7 months (range 5-52 months). Neither major recanalization nor rupture of the aneurysm occurred in the WCS-positive group. CONCLUSIONS Appearance of the WCS was associated with complete occlusion and good clinical outcome after endovascular coil embolization. The WCS would help to determine the prognosis of cerebral aneurysms after endovascular treatment.

Fusion Technique Using Three-Dimensional Digital Subtraction Angiography in the Evaluation of Complex Cerebral and Spinal Vascular Malformations.

OBJECTIVE: The authors introduce a new fusion technique using 2 three-dimensional digital subtraction angiography images acquired by a flat-panel detector angiographic system to understand the detailed angioarchitecture of complex cerebral and spinal vascular malformations. METHODS: Eleven consecutive cases of arteriovenous fistula or arteriovenous malformation with lesions that involved 2 major vessels (i.e., internal carotid arteries, external carotid arteries, vertebral arteries, or spinal arteries) were included. Three-dimensional rotational angiography was performed in each affected vessel after conventional cerebral or spinal angiography. Subsequently, the 2 three-dimensional digital subtraction angiography images were fused. RESULTS: The fused images provided the accurate three-dimensional angioarchitecture of complex vascular malformations clearly with high spatial resolution. In particular, the relationship between the nidus/fistulous point, the feeding arteries from each major vessel, and the draining veins could be easily delineated from different directions and multiple angles. Surgical or endovascular treatment was performed in all cases based on the information from these fused three-dimensional images. CONCLUSIONS: A fusion technique using two three-dimensional digital subtraction angiography is beneficial for preoperative planning and successful treatment in cases of complex cerebral and spinal vascular malformations.

Hybrid Assistive Limb (HAL) Rehabilitation in Patients with Acute Hemorrhagic Stroke.

The efficacy of hybrid assistive limb (HAL) rehabilitation in the acute phase of stroke remains unclear. The purpose of this study was to evaluate the outcomes of patients with acute intracranial hemorrhage (ICH) who were treated with or without HAL rehabilitation. Among 270 patients with acute ICH from 2009 to 2014, 91 patients with supratentorial ICH were included in this retrospective study. Of these, 14 patients (HAL group) received HAL rehabilitation at approximately 1 week after ICH occurrence, while the remaining 77 patients received usual rehabilitation without HAL (N-HAL group). We obtained various patient data from the hospitals where the patients were moved to for further rehabilitation. Statistical comparisons were performed for the characteristics of the ICH patients, and outcomes between the HAL and N-HAL groups. There were no differences in outcomes between the HAL and N-HAL groups. However, patients with right ICH in the HAL group exhibited a significant association with a functional independence measure (FIM) score of ≥ 110 compared with patients in the N-HAL group (HAL group: 81.8%, N-HAL group: 43.9%, P = 0.04). In patients with right ICH, HAL rehabilitation was associated with improved outcomes as evaluated by the FIM score. Thus, HAL rehabilitation may improve outcomes of acute ICH in appropriately selected patients.