Progress in the treatment of unruptured aneurysms.

Recent technological progress has reduced the complication rate of unruptured aneurysm. We treated 128 unruptured aneurysms between April 2006 and March 2012. Seventy-six aneurysms (59 %) were clipped and 52 (41 %) were coil embolized. After 2010, we applied new instruments, i.e., near-infrared indocyanine-green videoangiography (ICG), an intraoperative endoscope, preoperative detailed MRI, and a stent-assisted coil embolization. In the results: (1) In 60 aneurysms treated before 2009, three patients showed a deterioration of more than two points in mRS (5 %). In 68 aneurysms treated after 2010, no patients showed deterioration (0 %) (p: n.s.). (2) No patients died and 126 patients (98 %) were discharged to home directly. (3) No patients showed rupture after treatment. In conclusion, the appropriate selection of treatment and recent technological progress have facilitated sophisticated treatment of unruptured aneurysms. Recently, the complication rate in surgery and endovascular surgery for unruptured aneurysms has become acceptably low.

Cytoplasmic non-epithelial mucin accumulation associated with CD44 in an astrocytic tumor with signet ring features.

We report a case of an atypical astrocytic tumor rich in signet ring cells with cytoplasmic mucin and glycogen in the left lower temporal lobe of the brain found in a Japanese female tricenarian. The signet ring cell cytoplasm contained bovine testicular hyaluronidase sensitive non-epithelial mucin together with CD44 and laminin. Glycogen was also detected. After subtotal resection, the residual tumor rapidly enlarged; hence, it was finally extirpated 8 months later followed by post-surgical irradiation. The recurrent tumor did not have signet ring cells and was entirely comprised of solid nests of large pale polygonal cells filled with glycogen and hyperchromatic nuclei. Mucin was not demonstrated in their cytoplasm, but their surface was diffusely coated with non-epithelial mucin together with CD44. The results of our analysis revealed that non-epithelial mucin could accumulate in or on the surface of neoplastic astrocytes in close association with CD44, findings that give new insights into the spectrum of non-epithelial mucin metabolism in astrocytic tumors. The tumor has not recurred for more than 3 years after the irradiation therapy following the second surgery, but further clinical observation is needed to evaluate the exact clinical behavior of this unusual tumor.

Relationship between preoperative magnetic resonance imaging and surgical findings: aneurysm wall thickness on high-resolution T1-weighted imaging and contact with surrounding tissue on steady-state free precession imaging.

This study evaluated the aneurysm wall thickness by high-resolution T1-weighted imaging and the contact between the aneurysm and surrounding tissue by steady-state free precession (SSFP) imaging. The surgical findings were prospectively compared with these preoperative magnetic resonance (MR) imaging findings in 35 consecutive patients with 37 unruptured cerebral aneurysms (UCAs). The aneurysm wall was not visible in 13 UCAs, but was visible in 23. Subarachnoid space between the aneurysm and surrounding tissue was visible in 16 UCAs, a visible layer of cerebrospinal fluid (CSF) between the aneurysm and surrounding tissue in 12, and no visible layer in 7. MR imaging predicted the surgical findings in 29 UCAs (78%), showed different findings in six UCAs (16%), and two (5%) could not be evaluated due to insufficient quality of preoperative MR images. Among the UCAs with different findings, five UCAs had a partially thin wall even though high-resolution T1-weighted imaging had shown a visible wall, and one UCA showed less contact with the surrounding tissue even though the SSFP imaging had shown no visible CSF layer. In conclusion, high-resolution T1-weighted imaging and SSFP imaging provided significant additional preoperative information regarding UCAs and the surrounding tissue.

Trigonal cavernous malformation with intraventricular hemorrhage: a case report and literature review.

We reported a case of trigonal cavernous malformation (CM) with intraventricular hemorrhage. This 67-year-old woman experienced sudden onset of loss of consciousness and her Glasgow Coma Scale (GCS) was 5 points (E1V1M3) on admission. CT scan demonstrated intraventricular hemorrhage and acute hydrocephalus. Angiography did not demonstrate any vascular abnormality. Ventricular drainage was performed for acute hydrocephalus and the postoperative course was good. CT showed a hyperdense lesion in the left trigone, which was contrast-enhanced on T1-weighted MR. Removal of CM was performed via the left middle temporal sulcus. We conducted a Pub Med search for trigonal CM and found 17 cases. Herein we discuss the symptoms, CT and MR findings and treatment.

Rare variant of persistent primitive hypoglossal artery, arising from the external carotid artery.

A 63-year-old man presented with an extremely rare variant of persistent primitive hypoglossal artery (PHA), which was found incidentally during examination for a contralateral asymptomatic internal carotid artery (ICA) stenosis. This anastomotic vessel arose from the external carotid artery, not the ICA, and joined the vertebrobasilar artery through the hypoglossal canal. Persistent PHA is rare and the reported incidence is 0.027-0.26%. Recognition of the existence of this variant vessel and preservation during neuroradiologic intervention or surgery is important to prevent possible ischemic complications.

[Two cases of spontaneous intracranial hypotension with bilateral chronic subdural hematomas].

Spontaneous intracranial hypotension (SIH) is characterized by postural headaches without obvious cause and is occasionally related to chronic subdural hematomas (CSHs). Brain sag due to decrease in cerebrospinal fluid, and growing CSHs may occur secondary to a decrease in intracranial pressure. Therapy for this condition differs from that for mere traumatic CSHs and is controversial. We report 2 cases of CSH related to SIH. One patient required drainage of the CSHs and an epidural self-blood patch. Furthermore, this patient had to undergo reoperation for drainage of the CSHs. The other patient was cured after the first time the CSHs were drained.

Treatment selection for ruptured aneurysm and outcomes: clipping or coil embolization.

The International Subarachnoid Aneurysm Trial has shown that coil embolization achieves a better outcome for aneurysms treatable by either clipping or coil embolization. However, many ruptured aneurysms are hardly treatable by either clipping or coil embolization. Selection of either clipping or coil embolization will affect the treatment outcome for ruptured aneurysms. The relationship between patient selection and treatment outcome in a so-called "regional center hospital" in Japan must be clarified. This study included 113 patients with ruptured intracranial saccular aneurysms measuring less than 10 mm. Selection criteria for coil embolization were principally paraclinoid or posterior circulation aneurysm, Hunt and Hess grade IV or over, and patient age 75 years or older. Other aneurysms were principally treated by clipping. Aneurysms with a dome/neck ratio of less than 1.5, distorted aneurysms, Hunt and Hess grades I-III, patient age 74 years or younger, and middle cerebral artery aneurysm were actively treated by clipping. A few exceptional indications were considered in detail. Low invasiveness coil embolization is better than clipping to obtain good neurological outcome for patients with perforators difficult to dissect, aneurysms difficult to dissect due to previous open surgery, and aneurysms requiring bilateral open surgery, despite the slightly higher rebleeding rate in coil embolization. Overall outcomes were modified Rankin Scale (mRS) 0-2 in 82 of 113 patients (73%) and mRS 3-6 in 31 (27%). Appropriate selection of clipping or coil embolization can achieve acceptable treatment outcomes for ruptured aneurysm.

Effects and complications of stereotactic aspiration for spontaneous intracerebral hemorrhage.

Stereotactic aspiration of intracerebral hemorrhage (ICH) improves the general condition of patients, promotes improvement of consciousness, and decreases the incidence of pneumonia, but may induce rebleeding. The present study investigated the effects of stereotactic aspiration and factors that inhibit rebleeding in 70 consecutive patients who underwent stereotactic aspiration for ICH. Consciousness was significantly improved after surgery. Of patients who underwent surgery on day 0 or 1, 5 patients developed pneumonia and 29 patients did not. Of patients who underwent surgery on day 2 or later, 14 patients developed pneumonia and 22 patients did not. Early surgery within 2 days significantly reduced the rate of aspiration pneumonia. Patients with rebleeding tended to have liver dysfunction and hemorrhagic tendency. Early stereotactic aspiration of ICH facilitates better patient management than conservative treatment in patients with moderate consciousness disturbance. Patients with liver dysfunction and hemorrhagic tendency should be identified.

Detection of necrotic neural response in super-acute cerebral ischemia using activity-induced manganese-enhanced (AIM) MRI.

Immediate and certain determination of the treatable area is important for choosing risky treatments such as thrombolysis for brain ischemia, especially in the super-acute phase. Although it has been suggested that the mismatch between regions displaying 'large abnormal perfusion' and 'small abnormal diffusion' indicates a treatable area on an MRI, it has also been reported that the mismatch region is an imperfect approximation of the treatable region named the 'penumbra'. Manganese accumulation reflecting calcium influx into cells was reported previously in a middle cerebral artery occlusion (MCAO) model using activity-induced manganese-enhanced (AIM) MRI. However, in the super-acute phase, there have been no reports about mismatches between areas showing changes to the apparent diffusion coefficient (ADC) and regions that are enhanced in AIM MRI. It is expected that the AIM signal can be enhanced immediately after cerebral ischemia in the necrotic core region due to calcium influx. In this study, a remote embolic rat model, created using titanium-oxide macrospheres, was used to observe necrotic neural responses in the super-acute phase after ischemia. In addition, images were evaluated by comparison between ADC, AIM MRI, and histology. The signal enhancement in AIM MRI was detected at 2 min after the cerebral infarction using a remote embolic method. The enhanced area on the AIM MRI was significantly smaller than that on the ADC map. The tissue degeneration highlighted by histological analysis corresponded more closely to the enhanced area on the AIM MRI than that on the ADC map. Thus, the manganese-enhanced region in brain ischemia might indicate 'necrotic' irreversible tissue that underwent calcium influx.

Percutaneous vertebroplasty under three-dimensional radiography guidance. Technical note.

An accurate, safe, and convenient method for performing percutaneous vertebroplasty (PVP) under three-dimensional (3D) radiography guidance has been developed. Six PVP procedures were performed in 5 elderly stroke patients complaining of back pain caused by compressive fracture which interfered with further rehabilitation. T(1)-weighted magnetic resonance imaging showed low intensity and T(2)-weighted imaging showed high intensity in the fractured vertebral body. The most suitable trajectory for passing the lateral mass of the lamina and pedicle, and reaching the vertebral body was identified on the axial view of 3D radiography. A 13-gauge needle was advanced appropriately in all patients, and improvement of back pain was obtained after injection of polymethylmethacrylate. No major complications occurred in any patient. PVP under 3D radiography guidance is an accurate, safe, and convenient method.