Angiomatous meningioma associated with rapidly aggravated peritumoral leptomeningitis: A case report.

Background: A special type of meningioma is known to have infiltrated inflammatory cells within the tumor, associated with peritumoral inflammation. However, there have been no reports of meningioma with inflammatory response only around the tumor, without inflammatory cells within the tumor itself. Case Description: A 70-year-old woman presented with transient right hemiparesis due to an extra-axial tumor on the left frontal convexity. The tumor appeared hypointense on T1-weighted magnetic resonance images and hyperintense on T2-weighted images without peritumoral edema, and was homogenously enhanced associated with the peritumoral leptomeningeal enhancement. Cerebrospinal fluid examination showed an increase in the number of inflammatory cells with a predominance of mononuclear cells. During the following 1 month, the tumor size was unchanged, but the peritumoral leptomeningeal enhancement was remarkably enlarged with uncontrolled focal seizures. The tumor was subtotally removed and semisolid substances in the subarachnoid space were biopsied. Pathological examination with immunostaining revealed angiomatous meningioma: the tumor had no inflammatory cell infiltration within it, but was associated with the infiltration of immunoglobulin G4-negative lymphocytes into the border zone between the tumor and the dura mater, as well as numerous neutrophils and fibrinous exudates in the peritumoral subarachnoid space. The tumor removal rapidly improved the leptomeningeal enhancement and inflammatory reactions. Conclusion: The authors reported the first case of angiomatous meningioma associated with massive peritumoral inflammation without inflammatory infiltrates within the tumor itself.

Advantages of Extradural Anterior Clinoidectomy and Extradural Approach with Dural Incision for Blood Blister Aneurysm or Pseudoaneurysm in the Internal Carotid Artery: Two Case Reports.

Blood blister aneurysms (BBAs) or pseudoaneurysms (PAs) in the internal carotid artery (ICA) have fragile necks; therefore, conventional neck clipping is difficult. The standard treatment for BBAs or PAs is trapping with high or low flow bypass. However, there is no consensus on whether or not anterior clinoidectomy should be performed together. Two patients with ruptured ICA PA (anterior protrusion) or BBA (posterior protrusion) were presented to our hospital. Complete trapping was safely performed for both types of aneurysms via extradural anterior clinoidectomy and the extradural approach with dural incision. The advantages of the procedure are 1) safe proximal clipping, 2) early identification of the ICA C3 portion, 3) minimized frontal lobe retraction, 4) optic canal opening to allow mobility of the optic nerve, and 5) dural ring incision to allow mobility of the ICA.

Endovascular therapy for cardiocerebral infarction associated with atrial fibrillation: A case report and literature review.

Background: Cardiocerebral infarction (CCI) is a rare entity that refers to the simultaneous occurrence of acute myocardial infarction and acute ischemic stroke. The management of CCI patients remains unclear. Case Description: An 86-year-old woman with a medical history of paroxysmal atrial fibrillation presented with a sudden onset of consciousness disturbance and right hemiplegia. Computed tomography of the head revealed no intracranial hemorrhage but the left hyperdense middle cerebral artery sign, associated with ST-segment elevation in II, III, and aVF noted on a routine 12-lead electrocardiogram at admission. The patient was immediately brought to the catheterization laboratory and percutaneous coronary intervention (PCI) was performed first, followed by mechanical thrombectomy, resulting in successful revascularization of the both diseases. Conclusion: Although the treatment strategy of CCI may depend on the condition of coronary and cerebral ischemia, it may be appropriate to prioritize coronary angiography and PCI if not acute ischemic stroke is critical.

A case of traumatic acute interhemispheric subdural hematoma due to injured dural branch of anterior cerebral artery.

Background: The precise causes of traumatic acute interhemispheric subdural hematoma (AISDH) are unclear in most cases, and there are few cases, where the sources of bleeding are directly confirmed intraoperatively. We report a rare case of traumatic AISDH, in which a damaged dural branch of anterior cerebral artery (ACA) to the cerebral falx was identified as the cause of bleeding during hematoma removal. Case Description: A 61-year-old man with a history of craniotomy for the left putaminal hemorrhage at the age of 50 fell from a bed, bruised his head, and lost consciousness. Computed tomography of the head showed AISDH of 2.5cm in thickness, which was removed through a parietal parasagittal craniotomy under the microscope. Intraoperatively, the bleeding source was revealed to be a damaged dural branch from ACA to the cerebral falx. There was no rebleeding during his stay in our hospital. Conclusion: In this case, intraoperative findings revealed that the cause of bleeding was a damage to the dural branch of ACA. A vascular study is mandatory to rule out a vascular malformation in similar cases.

Contrast extravasation from basilar artery without aneurysm formation on digital subtraction angiography in computed tomography angiogram-negative subarachnoid hemorrhage: A case report.

BACKGROUND: The causes of angiogram-negative subarachnoid hemorrhage (SAH) on initial angiography, which accounts for 10-30% of spontaneous SAH, are heterogeneous and still unclear. We report a case of nonaneurysmal SAH, in which initial computed tomographic angiography (CTA) showed no source of bleeding, but the subsequent digital subtraction angiography (DSA) revealed contrast extravasation from the basilar artery without aneurysms. CASE DESCRIPTION: A 67-year-old woman with a medical history of hypertension presented as SAH of World Federation of Neurological Surgeons Grade II. CTA on admission did not show any cause of bleeding and DSA was subsequently performed to show contrast extravasation from a perforator of the middle third of the basilar artery without aneurysms during the subsequent DSA, resulting in profound deterioration SAH and neurological status. The patient was conservatively treated. Follow-up DSAs on days 2 and 16 showed no source of bleeding as well. CONCLUSION: Although the precise cause of bleeding in this case is uncertain, SAH might be caused by local dissection of the basilar artery perforator, and the bleeding site might heal spontaneously without forming of a pseudoaneurysm.

Machine Learning Classification of Cerebral Aneurysm Rupture Status with Morphologic Variables and Hemodynamic Parameters.

PURPOSE: To construct a classification model of rupture status and to clarify the importance of morphologic variables and hemodynamic parameters on rupture status by applying a machine learning (ML) algorithm to morphologic and hemodynamic data of cerebral aneurysms. MATERIALS AND METHODS: Between 2011 and 2019, 226 (112 ruptured and 114 unruptured) cerebral aneurysms in 188 consecutive patients were retrospectively analyzed with computational fluid dynamics (CFD). A random forest ML algorithm was applied to the results to create three classification models consisting of only morphologic variables (model 1), only hemodynamic parameters (model 2), and both morphologic variables and hemodynamic parameters (model 3). The accuracy of rupture status classification and the importance of each variable or parameter in the models were computed. RESULTS: The accuracy was 77.0% in model 1, 71.2% in model 2, and 78.3% in model 3. The three most important features were projection ratio, size ratio, and aspect ratio in model 1; low shear area ratio, oscillatory shear index, and oscillatory velocity index in model 2; and projection ratio, irregular shape, and size ratio in model 3. CONCLUSION: Classification models of rupture status of cerebral aneurysms were constructed by applying an ML algorithm to morphologic variables and hemodynamic parameters. The model worked with relatively high accuracy, in which projection ratio, irregular shape, and size ratio were important for the discrimination of ruptured aneurysms.Supplemental material is available for this article.© RSNA, 2020.

Erythrocyte-Rich Thrombus Is Associated with Reduced Number of Maneuvers and Procedure Time in Patients with Acute Ischemic Stroke Undergoing Mechanical Thrombectomy.

BACKGROUND: Only few studies have investigated the relationship between the histopathology of retrieved thrombi and clinical outcomes. This study aimed to evaluate thrombus composition and its association with clinical, laboratory, and neurointerventional findings in patients treated by mechanical thrombectomy due to acute large vessel occlusion. METHODS: At our institution, 79 patients were treated by mechanical thrombectomy using a stent retriever and/or aspiration catheter between August 2015 and August 2016. The retrieved thrombi were quantitatively analyzed to quantify red blood cells, white blood cells, and fibrin by area. We divided the patients into two groups - a fibrin-rich group and an erythrocyte-rich group - based on the predominant composition in the thrombus. The groups were compared for imaging, clinical, and neurointerventional data. RESULTS: The retrieved thrombi from 43 patients with acute stroke from internal carotid artery, middle cerebral artery, or basilar artery occlusion were histologically analyzed. Erythrocyte-rich thrombi were present in 18 cases, while fibrin-rich thrombi were present in 25 cases. A cardioembolic etiology was significantly more prevalent among the patients with fibrin-rich thrombi than among those with erythrocyte-rich thrombi. Attenuation of thrombus density as shown on computed tomography images was greater in patients with erythrocyte-rich thrombi than in those with fibrin-rich thrombi. All other clinical and laboratory characteristics remained the same. Patients with erythrocyte-rich thrombi had a smaller number of recanalization maneuvers, shorter procedure times, a shorter time interval between arrival and recanalization, and a higher percentage of stent retrievers in the final recanalization procedure. The occluded vessels did not differ significantly. CONCLUSIONS: In this study, erythrocyte-rich thrombus was associated with noncardioembolic etiology, higher thrombus density, and reduced procedure time.

The Safety of Carotid Artery Stenting for Patients in the Acute Poststroke Phase.

BACKGROUND: The efficacy of carotid artery stenting (CAS) for patients in the acute poststroke phase has not been established. We investigated the outcome of CAS for patients with symptomatic internal carotid artery (ICA) stenosis in the acute poststroke phase. METHODS: We performed a retrospective analysis of all patients who underwent CAS for symptomatic ICA stenosis in our institution. Patients in whom the time interval between neurological deterioration and the CAS procedure was less than 3 days were included in the early group, and the other patients were included in the delayed group. Perioperative complications including major adverse events (MAEs) were compared between the early and the delayed groups. RESULTS: One hundred five patients were included in the study. Forty patients were assigned to the early group and 65 patients were assigned to the delayed group. The overall MAE rate was 4.8%. There was no significant increase in the perioperative MAE in the early group compared with the delayed group (early group 2.5% versus delayed group 6.5%, P = .65). In the early group, 25 of 40 patients (62.5%) were functionally independent (modified Rankin scale [mRS] score of 0-2) at discharge. Significant differences between the independent patients and the disabled patients (mRS score of 3-6) included age (independent 72 versus disabled 79, P < .01) and prevalence of transient ischemic attack (36.0% versus .0%, P = .02). CONCLUSIONS: CAS performed within 3 days from the last ischemic event did not increase the risk of perioperative complication. Early CAS may be a useful option for the treatment of symptomatic carotid artery stenosis.

Delayed Onset of Isolated Unilateral Oculomotor Nerve Palsy Caused by Post-Traumatic Pituitary Apoplexy: A Case Report.

Post-traumatic pituitary apoplexy is uncommon, most of which present with a sudden onset of severe headache and visual impairments associated with a dumbbell-shaped pituitary tumor. We experienced an unusual case of post-traumatic pituitary apoplexy with atypical clinical features. A 66-year-old man presented with mild cerebral contusion and an incidentally diagnosed intrasellar tumor after a fall accident with no loss of consciousness. The patients denied any symptoms before the accident. After 4 days, the left oculomotor nerve palsy developed and deteriorated associated with no severe headache. Repeated neuroimages suggested that pituitary apoplexy had occurred at admission and showed that the tumor compressed the left cavernous sinus. The patient underwent endonasal transsphenoidal surgery at 6 days after head injury, and the mass reduction improved the oculomotor nerve palsy completely within the following 14 days. The pathologic diagnosis was nonfunctioning pituitary adenoma with hemorrhage and necrosis.

Characteristics of Blood Blister-Like Aneurysms with a Saccular-Shape Appearance.

BACKGROUND: Blood blister-like aneurysms (BBAs) are a subgroup of aneurysms located on nonbranching sites of the internal carotid artery (ICA) and characterized by small size, a fragile wall, and a poorly defined broad-based neck. Both direct surgery and endovascular treatment for BBAs are often challenging. Some of the BBAs have been reported to look like true saccular aneurysms, and the misdiagnosis of BBA might result in catastrophic outcomes. The purpose of this study is to clarify the clinical and intraoperative findings of saccular BBAs. METHODS: We analyzed clinical and intraoperative findings in consecutive 11 patients with subarachnoid hemorrhage caused by ruptured BBA. BBAs were divided into typical BBAs, which were defined as typical tiny, broad-based, blister-like aneurysms, and saccular BBAs, which seemingly looked like true saccular aneurysms but were demonstrated to be BBAs by the intraoperative findings of the laceration of the ICA. The characteristics of saccular BBAs were analyzed. RESULTS: There were 4 patients with saccular BBAs in which the admission day was diverse from the onset day to several days after the onset. The origin of saccular BBAs was the medial (n = 2) or anterior (n = 2) walls of the ICA. Three of the 4 saccular BBAs pointed toward the optic nerve, whereas none of the typical BBAs pointed toward the optic nerve. CONCLUSIONS: Saccular BBAs may not merely develop secondarily from typical BBAs, but also form by the surrounding structures-dependent mechanisms when an aneurysm points toward the optic nerve. The findings in this study suggest that saccular-shaped aneurysms at nonbranching sites of the ICA toward the optic nerve should be considered as saccular BBAs.

Positional Occlusion of Vertebral Artery Due to Cervical Spondylosis as Rare Cause of Wake-up Stroke: Report of Two Cases.

BACKGROUND: Positional compression of the vertebral artery (VA) owing to cervical spondylosis is an uncommon cause of stroke. We report two cases of cervical spondylosis causing wake-up stroke, which is extremely rare. CASE DESCRIPTION: The first patient was a 78-year-old woman with vertigo and vomiting lasting from waking up. Magnetic resonance imaging (MRI) and angiography documented right cerebellar infarction, and stenosis of the right cervical VA. Dynamic angiography revealed that the right VA was occluded when her neck was extended or rotated to the right. Computed tomography (CT) angiography revealed the right VA compression by the right C5 superior articular process osteophytes. The second patient was a 77-year-old man with dysarthria from waking up. MRI and angiography revealed right cerebellar infarction associated with the right VA stenosis and the left VA occlusion at C5-C6, whose cause was diagnosed as compression caused by bilateral uncovertebral osteophytes on CT angiography. Dynamic angiography showed that neck rotation to the right aggravated the right VA stenosis while recanalizing the left VA. Both patients were treated with a free radical scavenger (edaravone) and heparin, and underwent surgical decompression of VAs 14 or 18 days after onset. No recurrent ischemic events occurred thereafter. CONCLUSIONS: Magnetic resonance angiography of extracranial cervical VAs may be useful as an initial screening test for VA compression secondary to cervical spondylosis as a rare cause of wake-up stroke, especially in cases of cerebral infarction in the posterior circulation with no evidences of causative arrhythmia and intracranial lesions.

[Vertebral artery dissection due to a bone anomaly of the superior facet of C6: a rare cause of embolic stroke].

We report a rare case of repeated vertebral artery (VA) occlusion. The VA occlusion was due to a distal embolism originating from traumatic VA dissection resulting from mechanical compression due to excessive bone formation of the superior facet of C6. A 39-year-old male suffered from two embolic events in the right VA with a 4-month intervals. Three-dimensional computed tomography (3D-CT) revealed abnormal bone of the superior facet at the level of C6 and the verterbral artery compression. Angiography demonstrated the irregularity and the late clearance of the contrast material at the stenosis of VA, which was diagnosed as the dissection. Dynamic angiography showed right VA occlusion when rotating the patients head to the left and extending it backwards. External orthosis using a cervical collar for 1 month was undertaken, but the dissection remained, so coil embolization of the right VA was performed using an intravascular procedure. Because of the age of the patient, location, radiological features and clinical course, the authors considered the excessive bone formation was a bone anomaly rather than a cervical spondylotic change.

Role of image fusion combining three-dimensional digital subtraction angiography with magnetic resonance imaging in evaluation of unruptured cerebral aneurysms.

OBJECTIVES: The goal of this study was to evaluate the usefulness of a recently developed image fusion of three-dimensional digital subtraction angiography (3D DSA) and magnetic resonance (MR) images, DSA-MR fusion, in the pre-treatment assessment of cerebral aneurysm. METHODS: Eighteen patients with 21 unruptured anterior or posterior circulation aneurysms underwent pre-treatment DSA-MR fusion. The authors independently assessed whether DSA-MR fusion images provided any useful additional information compared with analysing 3D DSA and MR images separately, and if this had an impact on the therapeutic decision-making of unruptured aneurysms. RESULTS: DSA-MR fusion images were obtained within 30 minutes for all patients. In 19 of 21 aneurysms, it provided the following additional information to the findings of 3D DSA, MR images or both: the passing course in the brain tissues of perforating arteries near or originating from an aneurysm, and/or the spatial relationship between an aneurysm and an oculomotor nerve. This information from DSA-MR fusion images was useful for diagnosis, therapeutic decision-making and the risk assessment associated with the treatment, as well as patient education regarding cerebral aneurysm. DISCUSSION: DSA-MR fusion images were useful for the pre-treatment evaluation of unruptured cerebral aneurysms as a supplement to DSA and MR images.

A case of Lhermitte-Duclos disease presenting high FDG uptake on FDG-PET/CT.

Lhermitte-Duclos Disease (LDD) is a rare cerebellar lesion that has long been controversial as to whether the entity is a hamartoma, a malformation, or a neoplasm. Recent advances in metabolic imaging and molecular biology have unveiled biological features of LDD and a close relationship between LDD and Cowden disease. Adult onset LDD is now considered identical to Cowden disease in a US guideline. We present a case of LDD, in which high fluorodeoxy glucose (FDG) uptake was shown on PET/CT. We performed dual time point scans, in which a delayed scan exhibited more intense FDG uptake by the hamartomatous lesion than an early scan. We must remain aware of the possibility of LDD when intense accumulation is observed in a cerebellar lesion on FDG-PET/CT imaging.

Visualization of the intracisternal angioarchitecture at the posterior fossa by use of image fusion.

OBJECTIVE: Magnetic resonance (MR) images most clearly visualize intracranial tissues but have some limitations in terms of detailed analysis of the intracisternal vasculature. To compensate for these shortcomings, an image fusion of three-dimensional digital subtraction angiography (DSA) and MR images, DSA-MR fusion, has been developed. The goal of this study was to evaluate the usefulness of DSA-MR fusion for the visualization of the intracisternal arteries and veins at the posterior fossa. METHODS: Ten consecutive patients (five with neurovascular compression syndrome and five with brain tumors) underwent preoperative DSA-MR fusion. The DSA-MR fusion images were compared with intraoperative findings. RESULTS: Image fusion was performed within 20 minutes, and the registration error was insignificant in all cases. Image fusion successfully visualized the clear three-dimensional relationships among the intracisternal arteries and veins, cranial nerves, brain tissues, and a lesion, and a specific vessel was easily identified. The findings of the DSA-MR fusion images were surgically confirmed in all patients. CONCLUSION: Using this advanced image fusion technique coupled with its reasonable postprocessing time, neurosurgeons may more easily and precisely understand the surgical anatomy before surgery than analyzing three-dimensional DSA and MR images separately.

A novel image fusion visualizes the angioarchitecture of the perforating arteries in the brain.

We report a novel technique that fuses 3D digital subtraction angiograms and MR images. Image fusion was successfully performed within 20 minutes each in 11 consecutive cases. Our initial experience showed that this image fusion enabled clear and simultaneous visualization of perforating arteries and surrounding tissues. The relation between perforating arteries and normal brain or lesions was easily understood in a clinical setting by using this image fusion.

[Cranioplasty using autogenous bone cryopreserved with dimethylsulfoxide (DMSO)].

It is generally agreed that the autogenous bone flap which has been removed at the time of external decompression would be superior to any artificial material if it can be used in cranioplasty. Cranioplasty using autogenous frozen bone graft has been reported and showed good results except for infection and severe bone absorption. We conducted 39 cases of cranioplasty with cryopreserved autogenous bone in the presence of 10% of Dimethylsulfoxide (DMSO), which has been reported as a cryoprotective agent. Although no remarkable histological effects have been recognized in frozen bone with or without DMSO, we have obtained excellent clinical results without bone absorption in 24 of the cases. These results suggest that DMSO is helpful for frozen bone preservation.