A Case of a Perianeurysmal Cyst Following Stent-Assisted Coil Embolization of an Unruptured Vertebral Artery Aneurysm.

Objective: To report the rare case of a patient with a perianeurysmal cyst following stent-assisted coil embolization of an unruptured vertebral artery aneurysm. Case Presentation: A 63-year-old woman underwent stent-assisted coil embolization for an unruptured vertebral artery aneurysm embedded in the brainstem (pons). Complete occlusion of the aneurysm was successfully achieved. However, subsequent magnetic resonance imaging (MRI) conducted 8 months after the procedure showed perilesional edematous changes surrounding the aneurysm, and at 20 months, cyst formation was observed in the vicinity of the aneurysm. Progressive enlargement of the cyst eventually led to the development of paralysis and dysphagia, necessitating cyst fenestration surgery. Although postoperative reduction in the cyst size was achieved, the patient experienced complications in the form of aspiration pneumonia and bacterial meningitis, which resulted in a life-threatening condition. Conclusion: Aneurysms embedded in the brain parenchyma should be carefully followed up, recognizing the risk of perianeurysmal cyst formation after coil embolization.

Preventive Strategies for Perioperative Ischemic Heart Disease during Carotid Artery Stenting.

Objectives: We have been performing preoperative coronary artery assessments and implementing coronary revascularization or intraoperative adjunctive therapies as needed in patients scheduled for carotid artery stenting (CAS) to prevent ischemic heart disease. In this study, we report the results of a retrospective observation of patients who underwent CAS under our treatment strategy to prevent perioperative coronary ischemic complications. Methods: A total of 224 cases from January 2014 to December 2021 were included. Following preoperative coronary artery CTA, preoperative coronary artery treatment or intraoperative adjunctive therapy (temporary transcutaneous cardiac pacemaker [TTCP] or intra-aortic balloon pumping [IABP]) was performed based on the degree of stenosis. We analyzed the outcomes of patients treated with CAS under this strategy at our institution. Results: Coronary artery disease was detected preoperatively in 143 cases (64%), with 91 cases (41%) indicated for coronary revascularization. Preoperative coronary artery treatment was performed in 76 cases (34%) prior to CAS, and adjunctive therapy with TTCP or IABP was provided in 28 cases (13%) during the procedure. No case developed perioperative coronary ischemic complication. Conclusion: In patients who have undergone CAS, perioperative coronary ischemic complications might be reduced by evaluating the risk of ischemic heart disease preoperatively, performing pre-CAS coronary artery intervention based on the severity of the lesions, and administering intraoperative adjunctive therapy.

Impact of Low Ambient Temperature on the Occurrence of Spontaneous Intracerebral Hemorrhage-Analysis of Population-Based Stroke Registry in Toyama, Japan.

OBJECTIVE: Although several studies have reported that some meteorological factors such as ambient temperature and atmospheric pressure, affect the incidence of spontaneous intracerebral hemorrhage (ICH), the correlation remains unclear. This retrospective time-series analysis was aimed to clarify the effects of meteorological parameters on the incidence of ICH. MATERIALS AND METHODS: Data of patients with ICH were obtained from a population-based survey of acute stroke patients between April 2016 and March 2019. All days during the study period were categorized into "no ICH day" when no ICHs occurred, "single ICH day" when only one ICH occurred, and "cluster day" when two or more ICHs occurred. Meteorological data were compared for among the three categories. RESULTS: 1,691 ICH patients from 19 hospitals were registered. In a total of 1,095 days, 250 were categorized as no ICH days, 361 as single ICH days, and 484 as cluster days. Daily ambient temperature declined in parallel with the daily number of ICHs, and it was a significant predictor for single ICH days and cluster days. Furthermore, the incidence of ICH in patients aged 65 years or above, men, those who emerged at home, those with modified Rankin Scale 3-5; and those with hypertension; and ICHs in the basal ganglia, brain stem, and cerebellum were more likely to be affected by low ambient temperature. CONCLUSION: Daily ambient temperature was significantly associated with ICH incidence. Patients' activity, history of hypertension, and location of hemorrhage were also related to the impact of low ambient temperature on the incidence of ICH.

Strategy and effect of repeat bypass surgery for anterior/posterior circulation in refractory moyamoya disease.

OBJECTIVE: In this study the authors aimed to describe clinical features, surgical techniques, and long-term outcomes of repeat bypass surgery required for a certain subset of patients with moyamoya disease. METHODS: The authors retrospectively reviewed a total of 22 repeat bypass surgeries for 20 patients (age range 1-69 years) performed during the last 20 years at their institutions. The patients were classified into 2 groups. Group A included 10 patients who underwent repeat bypass surgery for anterior circulation due to insufficient revascularization on the ipsilateral side. Group B included 10 patients who underwent repeat bypass surgery for posterior circulation due to the involvement of the posterior cerebral artery (PCA) after successful initial surgery for anterior circulation. RESULTS: Preoperative symptoms included headache in 3 patients, transient ischemic attack in 10, cerebral infarction in 3, and intracranial hemorrhage in 4 patients. Intervals between the initial bypass surgery and repeat bypass surgery were 0.3-30 years (median 3 years). In group A, superficial temporal artery to middle cerebral artery (MCA) anastomosis and indirect bypass were performed on 7 hemispheres. Only indirect bypass was performed on 3 hemispheres because of the lack of suitable donor or recipient arteries. In group B, occipital artery (OA) to PCA anastomosis and indirect bypass were conducted on 4 hemispheres, and OA-MCA anastomosis and indirect bypass on 1 hemisphere. Only indirect bypass was conducted on 7 hemispheres because of the lack of suitable recipient arteries. All 22 repeat bypass surgeries were successfully conducted. During follow-up periods (median 4 years), none of the patients suffered repeat stroke except 1 patient who died of recurrent intracerebral hemorrhage 3 years after repeat bypass surgery for anterior circulation. CONCLUSIONS: Repeat bypass surgery was feasible and effective to reduce further incidence of headache attack, transient ischemic attack, and ischemic/hemorrhagic stroke in moyamoya disease patients. Through precise radiological analysis, surgical procedures should be planned to yield maximal therapeutic effects.

Muse Cell: A New Paradigm for Cell Therapy and Regenerative Homeostasis in Ischemic Stroke.

Multilineage-differentiating stress enduring (Muse) cells are one of the most promising donor cells for cell therapy against ischemic stroke, because they can differentiate into any type of cells constructing the central nervous system (CNS), including the neurons. They can easily be isolated from the bone marrow stromal cells (BMSCs), which may also contribute to functional recovery after ischemic stroke as donor cells. In this chapter, we concisely review their biological features and then future perspective of Muse cell transplantation for ischemic stroke. In addition, we briefly refer to the surprising role of Muse cells to maintain the homeostasis in the living body under both physiological and pathological conditions.

Hypoxia accelerates intraplaque neovascularization derived from endothelial progenitor cells in carotid stenosis.

OBJECTIVE: The relationship between intraplaque hypoxia and intraplaque hemorrhage (IPH) has been reported, but the details remain obscure. In this study, the authors aimed to clarify the relationship among intraplaque hypoxia, endothelial progenitor cells (EPCs), and neovascularization, which causes IPH. The histological findings of specimens obtained from carotid endarterectomy were assessed. METHODS: This study included 49 patients who underwent carotid endarterectomy. Magnetic resonance plaque imaging was performed to analyze the components of the carotid plaques, and surgical specimens were subjected to immunohistochemical analysis. The numbers of hypoxia-inducible factor-1 alpha (HIF-1α)-, CD34-, CD133-, and vascular endothelial growth factor receptor-2 (VEGFR-2)-positive cells in the carotid plaques were precisely quantified, as were the number and maximum diameter of CD31-positive microvessels. RESULTS: Plaque components were judged as fibrous in 7 samples, lipid-rich in 22, and IPH in 20. The number of CD34-, VEGFR-2-, and CD133-positive cells as an EPC-specific marker was significantly correlated with the number of HIF-1α-positive cells (r = 0.9, r = 0.82, and r = 0.81, respectively). These numbers varied among the 3 plaque components (IPH > lipid-rich > fibrous). The number and maximum luminal diameter of CD31-positive microvessels were also significantly correlated with the number of HIF-1α-positive cells (r = 0.85 and r = 0.89, respectively) and varied among the 3 plaque components (IPH > lipid-rich > fibrous). CONCLUSIONS: The present findings suggest that intraplaque hypoxia may accelerate abnormal microvessel formation derived from EPCs, which in turn promotes IPH. The results also suggest that microvessel enlargement is a pivotal characteristic of IPH and these enlarged microvessels are immature endothelial tubes with disorganized branching and are fragile and prone to rupture.

[Ultrasound-aided Fixation of a Biodegradable Cranial Fixation System:SonicWeld Rx® System in Pediatric Neurosurgery].

PURPOSE: Ultrasound-aided fixation of a biodegradable cranial fixation system called SonicWeld Rx®, has been widely applied in the fields of craniofacial surgery and plastic surgery. However, there are few reports that denote its use in the field of neurosurgery. This study aimed to evaluate the usefulness of SonicWeld Rx® system in pediatric neurosurgery. METHODS: This study included 11 pediatric patients(10 boys, 1 girl), who underwent craniotomy for moyamoya disease, brain tumor, and arachnoid cyst. Their mean age was 6.4 years, ranging from 4 to 10 years. LactoSorb® system was applied in 6 patients and SonicWeld Rx® system in 5. RESULTS: The time required for screw fixation was significantly shorter in the SonicWeld group(6.5±1.4sec)than in the LactoSorb group(13.4±2.8sec), with p<0.05. The quality of fixation strength was adequate in both groups. There were no perioperative complications related to the absorbable fixation device. A 3-D skull CT detected no malposition of the bone flap 3 months postoperatively. There were no scalp complications noted for an average of 21 months. CONCLUSION: SonicWeld Rx® system can be easy and useful in fixing the bone flap to the cranium in the field of pediatric neurosurgery.

[Computational Fluid Dynamic Analysis of Intracranial Aneurysms Using Newly Developed Software:Can It Predict the Thin-Walled Region of Intracranial Aneurysm Preoperatively?]

OBJECT: Recent studies have shown that computational fluid dynamics(CFD)analysis is useful to evaluate flow dynamics of intracranial aneurysms. However, CFD analysis still requires high costs and substantial time even now. This study aimed to evaluate whether newly developed software can shorten the time for analysis and serve useful information during clipping surgery for intracranial aneurysms. METHODS: CFD analysis was performed in 55 unruptured cerebral aneurysms in 51 patients. The time required for analysis of each aneurysm was recorded. On the basis of CFD analysis, both pressure and wall shear stress(WSS)were calculated as the values at the systolic and diastolic phases, and also the mean value through one cardiac cycle. These data were compared between thin-wall points and other points within each aneurysm. RESULTS: The average time required for analysis was 3 hours, ranging from 1 to 15 hours. The CFD data could be referenced during surgery in each patient. The pressure in about 93% and 80% of the thin-wall points was higher than that at other points within each aneurysm in the systolic and diastolic phases, respectively. However, there was no significant correlation between WSS and wall thickness in each aneurysm. CONCLUSION: This study clearly shows that newly-developed software is simple and requires much shorter time for CFD analysis than previous methods. Higher pressure through the cardiac cycle may efficiently predict a thin-wall region within intracranial aneurysms, which strongly suggests that CFD analysis would be a valuable tool to determine the treatment strategy in patients with unruptured aneurysms.

Novel biomarker, phosphorylated T-LAK cell-originated protein kinase (p-TOPK) can predict outcome in primary central nervous system lymphoma.

This study aimed to assess whether T-lymphokine-activated killer cell-originated protein kinase (TOPK) can be a potent novel biomarker to predict the outcome in patients with primary central nervous system lymphoma (PCNSL). This study enrolled 20 patients who were histologically diagnosed as having diffuse large B-cell type PCNSL between 2005 and 2015. Using surgical specimens, the expression of TOPK and phosphorylated TOPK (p-TOPK) was analyzed on immunohistochemistry. Clinical features such as age, sex, Karnofsky performance status (KPS), ocular involvement, deep brain structure involvement, the number of lesions, chemotherapy and radiation therapy were also collected. Impacts of TOPK/p-TOPK expression on their progression-free survival (PFS) and overall survival (OS) were examined with multivariate analysis. Median PFS/OS were 24.2 and 39.0 months, respectively. On immunostaining, the mean percentage of TOPK-positive cells was 35.5 ± 20.8%, and the mean number of p-TOPK-positive cells was 13.7 ± 15.7 cells/mm2 . The higher expression of p-TOPK was significantly related to multiple lesions (P = 0.003). Multivariate analysis demonstrated that only the higher expression of p-TOPK was an independent predictor to shorten both PFS (P = 0.029; hazard ratio (HR), 5.5; 95% confidential interval (CI), 1.2-25.3) and OS (P = 0.014; HR, 7.7; 95% CI, 1.5-41.3). These findings strongly suggest that p-TOPK may be a potent biomarker to determine the outcome of patients with PCNSL and to develop novel drugs to treat PCNSL.

Targeting the T-Lak cell originated protein kinase by OTS964 shrinks the size of power-law coded heterogeneous glioma stem cell populations.

Glioblastoma resists chemoradiotherapy, then, recurs to be a fatal space-occupying lesion. The recurrence is caused by re-growing cell populations such as glioma stem cells (GSCs), suggesting that GSC populations should be targeted. This study addressed whether a novel anti-cancer drug, OTS964, an inhibitor for T-LAK cell originated protein kinase (TOPK), is effective in reducing the size of the heterogeneous GSC populations, a power-law coded heterogeneous GSC populations consisting of glioma sphere (GS) clones, by detailing quantitative growth properties. We found that OTS964 killed GS clones while suppressing the growth of surviving GS clones, thus identifying clone-eliminating and growth-disturbing efficacies of OTS964. The efficacies led to a significant size reduction in GS populations in a dose-dependent manner. The surviving GS clones reconstructed GS populations in the following generations; the recovery of GS populations fits a recurrence after the chemotherapy. The recovering GS clones resisted the clone-eliminating effect of OTS964 in sequential exposure during the growth recovery. However, surprisingly, the resistant properties of the recovered-GS clones had been plastically canceled during self-renewal, and then the GS clones had become re-sensitive to OTS964. Thus, OTS964 targets GSCs to eliminate them or suppress their growth, resulting in shrinkage of the power-law coded GSC populations. We propose a therapy focusing on long-term control in recurrence of glioblastoma via reducing the size of the GSC populations by OTS964.

Impact of a novel biomarker, T-LAK cell-originating protein kinase (TOPK) expression on outcome in malignant glioma.

This study aimed to evaluate the biological features of T-lymphokine-activated killer cell-originating protein kinase (TOPK) in vitro and to assess clinical impact of TOPK on the outcome in patients with malignant glioma. TOPK protein level and TOPK mRNA and protein levels in six glioma cell lines were examined using Western blot and reverse transcription-polymerase chain reaction (RT-PCR), respectively. Immunohistochemistry was performed to examine their subcellular localization of TOPK. Using surgical specimens from 57 patients with gliomas, TOPK and Ki-67 expressions were examined by immunohistochemistry. Their co-localization was also examined with double immunofluorescence immunohistochemistry. Impacts of TOPK/Ki-67 expression on the overall survival (OS) and progression-free survival (PFS) in 32 patients with glioblastoma multiforme (GBM) were examined, using Kaplan-Meier and Cox proportion hazard models. Immunohistochemistry revealed that approximately 20-30% of glioma cells were positive for TOPK in vitro. TOPK mRNA was identified in all glioma cell lines on RT-PCR. The value of TOPK/GAPDH was 0.27 ± 0.11. TOPK and Ki-67 expressions were significantly higher in GBM patients than in non-GBM patients. A majority of TOPK-positive cells were also positive for Ki-67 and vice versa. Multivariate analysis revealed that a low TOPK expression (≤ 12.7%) was an independent predictor of longer OS (P = 0.0372), and that gross total removal and a low TOPK expression (≤ 12.7%) were independent predictors of longer PFS (P = 0.0470 and P = 0.0189, respectively). The findings strongly suggest biological and clinical importance of TOPK expression in gliomas, indicating a novel therapeutic potential of TOPK inhibitors to treat malignant gliomas.

Surgical and Endovascular Treatments of Extracranial Carotid Artery Aneurysms-Report of Six Cases.

BACKGROUND: Although the natural course of extracranial carotid artery aneurysms (ECAAs) is still unknown, they may cause stroke or cranial nerve dysfunction unless they are treated. In this report, we reviewed the clinical results of 6 patients who underwent endovascular and surgical treatments for ECAAs. METHODS: A total of 6 patients underwent endovascular and surgical treatments for ECAAs for 9 years. The primary causes of ECAAs included Marfan syndrome (1 patient), infection (1 patient), trauma (2 patients), and unknown (2 patients). All 6 ECAAs were symptomatic. RESULTS: One patient underwent surgical resection of the ECAA followed by end-to-end anastomosis of the internal carotid artery (ICA). Another patient underwent proximal ICA ligation combined with high-flow external carotid artery-to-middle cerebral artery bypass using a radial artery graft, because the patient also had a giant thrombosed aneurysm in the cavernous portion of the ipsilateral ICA. Endovascular treatment was selected in the other 4 patients using a covered stent or a bare metal stent combined with coil embolization. Of these patients, one required proximal ICA ligation followed by superficial temporal artery-to-middle cerebral artery anastomosis due to an anatomical problem for stent placement. There was no neurological deterioration at the discharge in all but 1 patient who suffered ischemic stroke during surgery. CONCLUSION: Surgical or endovascular treatment yielded a relatively satisfactory outcome in patients with ECAAs.

[Clinical Features and Findings in Patients with Unruptured Intracranial Aneurysms Aged ≥80 Years].

OBJECTIVE: It is difficult to decide whether to treat unruptured intracranial aneurysm(UIA)in elderly patients aged ≥80 years because they have potentially shorter life expectancy and risks related to treatment. Here, we report the results of the treatment of patients aged ≥80 years. METHODS: A retrospective review was performed in patients who underwent surgical or endovascular treatment between April 2012 and December 2015 at our institution. RESULTS: Between April 2012 and December 2015 we treated 130 UIA patients who presented with 145 aneurysms and 12 patients who presented with 14 aneurysms, who were aged ≥80 years. One patient was male and the others were female. Their mean age was 81.9 years(range: 80-88 years). The aneurysms included ICA aneurysms(n=6), ACA aneurysms(n=1), MCA aneurysms(n=4), and BA aneurysms(n=3). The maximum sizes of the aneurysms were ≤5mm(n=3), 5-10mm(n=8), and ≥10mm(n=3). The reasons for treatment were as follows: symptomatic aneurysms(n=2), strong desire of the patient to treat their aneurysms(n=4), high risk of rupture because of the morphology of the aneurysm(n=4), concomitant presentation with a ruptured aneurysm(n=1), and recurrence after coil embolization(n=1). In the endovascular treatment we used dual anti-platelet drugs in all cases and a stent device in 3 cases. In all cases, we used general anesthesia. There were no complications during the operations or ischemic or hemorrhagic events after surgery. We identified subcutaneous hematoma at the puncture site in 2 cases. The modified Rankin Scale(mRS)score of no patient worsened compared to their preoperative mRS score. The average length of hospital stay was 31 days. In comparison with patients aged ≤79 years, there was no significant worsening of the mRS score. In patients aged ≥80 years, the length of their hospital stay was longer than that of younger patients. CONCLUSION: While caution is warranted when treating UIA patients aged ≥80 years, our findings for the treatment of aged patients were noteworthy. This treatment is meritorious if the indications are well considered and an experienced physician performs the operation. However, there are problems associated with using anti-platelet drugs in elderly patients.

[A Case of Juvenile Cerebral Infarction due to Reversible Cerebral Vasoconstriction Syndrome].

A 19-year-old woman had a thunderclap headache, followed by left hemiparesis and left homonymous hemianopsia. Laboratory tests showed no signs of infection and immunological test results were unremarkable. MRI revealed a cerebral infarction in the right posterior cerebral artery territory, and digital subtraction angiography(DSA)showed right posterior cerebral artery stenosis on day 2. The first follow-up DSA demonstrated an irregular, bead-like appearance on day 9, but the stenotic lesion returned to normal on day 21. Reversible cerebral vasoconstriction syndrome should be suspected in cases of rapid resolution of symptoms.

[Usefulness of Tablet-Type Device Usage during Neurosurgical Practice].

This study aimed to validate the usefulness of intraoperative use of a tablet-type device in neurosurgical field. This study included 80 patients who underwent direct surgery for complex brain and spinal disorders in our hospital between April 2013 and March 2015. The operated disorders included cerebral aneurysm, intracranial and spinal dural arteriovenous fistula, meningioma, and vestibular schwannoma. By using the OsiriX HD software, the DICOM data were directly transferred to a tablet-type device (Apple iPad). Alternatively, by using the OsiriX HD or Amira software, the DICOM data were loaded to create interactive three-dimensional computer graphics on a personal computer and then transferred to a tablet-type device. The device was covered with sterile, translucent packaging bag. As a result, the surgeons could use the touch screen to browse and access radiological data of the patient undergoing surgery, without needing to leave the operation field or requiring external assistance for image browsing. The incidence of postoperative infection did not increase. In conclusion, intraoperative usage of the tablet-type device was easy and useful for surgeons performing surgeries for complex brain and spinal disorders.

Is Quasi-moyamoya Disease a Uniform Disease Entity? A Three-Dimensional Constructive Interference in Steady State Imaging Study.

BACKGROUND: Quasi-moyamoya disease (MMD) or moyamoya syndrome is based on various underlying diseases and radiologically simulates MMD, but its disease entity is still unclear. Recent studies have proven specific shrinkage of the involved arteries in MMD. Using 3-dimensional constructive interference in steady state (3D-CISS), therefore, this study aimed to analyze the outer diameter of the involved arteries in quasi-MMD. METHODS: This study included 9 patients with quasi-MMD (unilateral type, n = 2; bilateral type, n = 7). Using 3D-CISS, the outer diameter was quantified in the internal carotid artery distal to the posterior communicating artery (C1), the horizontal portion of the middle and anterior cerebral arteries (M1 and A1, respectively), and the basilar artery. Control values were obtained from 17 healthy subjects. RESULTS: In 7 of 9 patients, the outer diameters of C1, M1, and A1 were significantly smaller than those of the controls. On the other hand, the values were normal in other 2 patients. There was no significant difference in the underlying disorders between the 2 groups. All 3 pediatric patients are categorized into the arterial shrinkage group, but 2 of 6 adult patients were not. CONCLUSIONS: These findings strongly suggest that quasi-MMD is not a uniform disease entity and includes at least 2 pathophysiologically different groups: the arterial shrinkage group and the nonarterial shrinkage group. A certain subgroup of MMD patients may be misdiagnosed as quasi-MMD because of the patients' comorbid disorders and mixed up with the patients who present angiographic findings similar to MMD in spite of the lack of arterial shrinkage.

[Successful Stent-Assisted Coil Embolization of Fusiform Aneurysm in P2 Segment of Posterior Cerebral Artery:A Case Report].

We report a case of a fusiform aneurysm in the P2 segment of the posterior cerebral artery treated with stent-assisted coil embolization. A 44-year-old woman presented with an unruptured fusiform aneurysm in the left posterior cerebral artery. Stent-assisted coil embolization was performed using a "down-the-barrel" view to preserve the parent artery. The postoperative course was uneventful, and MRI showed no evidence of cerebral infarct. The patient was discharged 12 days after surgery, with no neurological deficit. Complete occlusion of the aneurysm and patency of the parent artery were observed on MR angiography at a 3-months follow up. Stent-assisted coil embolization can therefore be an effective alternative to parent artery occlusion in P2 segment fusiform aneurysms of the posterior cerebral artery.

[Comprehensive Hybrid Strategy for Carotid Artery Stenosis with 8 Rules "Toyama Carotid 8"].

In this paper, the preliminary results of carotid endarterectomy(CEA)and carotid artery stenting(CAS)for patients with carotid artery stenosis based on the 8 Rules "Toyama Carotid 8" are reported. This study included 104 patients who underwent CEA or CAS for carotid artery stenosis between March 2012 and January 2015. Toyama 8 Rules primarily recommend CEA and CAS for symptomatic and asymptomatic lesions, respectively. However, crossover of therapeutic options can be performed in patients at high surgical risk associated with CEA or CAS. Monitoring of platelet function is important prior to CAS. Internal shunting and near infrared spectroscopy monitoring are essential in CEA. Temporary cardiac pacing is essential in CAS. The choice of protection device and stent depends on the results of MR plaque imaging. Cerebral blood flow measurement is mandatory before and after CEA/CAS. Fifty-two CEAs and 52 CASs were performed for 55 symptomatic and 49 asymptomatic lesions. Crossover of therapeutic options was performed in 10(18%)of 55 symptomatic lesions and 7(14%)of 49 asymptomatic lesions. The 30-day morbidity rate was 1.9% in CEA and 1.9% in CAS. Postoperative diffusion-weighted magnetic resonance imaging showed fresh ischemic lesions in 5 patients who underwent CEA(10%)and 9 who underwent CAS(17%). Hyperperfusion syndrome occurred in one patient(1.0%). A management protocol for carotid artery stenosis needs to be established in hospitals to allow sharing of information and improvement in the short-term results of CEA / CAS for carotid artery stenosis. Further studies are warranted to evaluate the long-term outcome.

[Disseminated Nocardiosis Complicated by Multiple Brain Abscesses: A Case Report].

We report a relatively rare case of a disseminated type of nocardiosis without lung involvement. A 75-year-old man developed moderate fever and disturbed consciousness and was admitted to our hospital. Laboratory examinations revealed signs of inflammation. Chest X-rays indicated no abnormalities, but brain MRI showed ring-like enhancement lesions in the right temporal and left frontal lobes. Similar lesions were identified in the left kidney and right leg. The brain lesions were purulent and were surgically irrigated. Gram- and Kinyoun-positive bacteria were identified, and the patient was diagnosed as suffering from a disseminated type of nocardiosis without lung involvement. He was treated with trimethoprim-sulfamethoxazole for over 10 months. The postoperative course was uneventful, and he was discharged without any neurological sequelae two months after surgery. Kinyoun staining was important in early diagnosis and hence providing appropriate therapy for life-threatening nocardiosis.

[Effects of Endovascular Treatment on Cranial Nerve Palsy due to Unruptured Intracranial Aneurysms].

This study aimed to assess the effects of endovascular treatment on cranial nerve palsy due to unruptured intracranial aneurysms. Endovascular coiling was performed in 203 patients with intracranial aneurysms between April 2002 and March 2012 in our hospital. Of these patients, 8(3.9%)presented with cranial nerve palsy due to unruptured intracranial aneurysms. Cranial nerve palsy involved the oculomotor nerve in 8 patients and the optic nerve in 2 patients. Two patients had both optic nerve and oculomotor nerve dysfunction. Patients with incomplete oculomotor nerve palsy at admission were more likely to have full recovery after coiling. Optic nerve dysfunction did not improve after coiling. Incomplete oculomotor nerve palsy, early treatment(≤15 days), and small aneurysms(≤10 mm)were likely to be associated with complete recovery after coiling. This study indicates that endovascular coiling may resolve cranial nerve palsy due to unruptured intracranial aneurysms in patients who have incomplete oculomotor nerve palsy due to small aneurysms and are treated as early as possible after symptom onset.