Impact of Cerebral Microbleeds in Stroke Patients with Atrial Fibrillation.

OBJECTIVES: Cerebral microbleeds are associated with the risks of ischemic stroke and intracranial hemorrhage, causing clinical dilemmas for antithrombotic treatment decisions. We aimed to evaluate the risks of intracranial hemorrhage and ischemic stroke associated with microbleeds in patients with atrial fibrillation treated with vitamin K antagonists, direct oral anticoagulants, antiplatelets, and combination therapy (i.e. concurrent oral anticoagulant and antiplatelet). METHODS: We included patients with documented atrial fibrillation from the pooled individual patient data analysis by the Microbleeds International Collaborative Network. Risks of subsequent intracranial hemorrhage and ischemic stroke were compared between patients with and without microbleeds, stratified by antithrombotic use. RESULTS: A total of 7,839 patients were included. The presence of microbleeds was associated with an increased relative risk of intracranial hemorrhage (adjusted hazard ratio [aHR] = 2.74, 95% confidence interval = 1.76-4.26) and ischemic stroke (aHR = 1.29, 95% confidence interval = 1.04-1.59). For the entire cohort, the absolute incidence of ischemic stroke was higher than intracranial hemorrhage regardless of microbleed burden. However, for the subgroup of patients taking combination of anticoagulant and antiplatelet therapy, the absolute risk of intracranial hemorrhage exceeded that of ischemic stroke in those with 2 to 4 microbleeds (25 vs 12 per 1,000 patient-years) and ≥ 11 microbleeds (94 vs 48 per 1,000 patient-years). INTERPRETATION: Patients with atrial fibrillation and high burden of microbleeds receiving combination therapy have a tendency of higher rate of intracranial hemorrhage than ischemic stroke, with potential for net harm. Further studies are needed to help optimize stroke preventive strategies in this high-risk group. ANN NEUROL 2023;94:61-74.

[Filum Lipoma].

Filum lipomas, a subtype of spinal lipomas, are ectopic fat tissue deposits of the filum terminale categorized as closed spinal dysraphism. They are occasionally and incidentally observed on MRI images, but generally require little surgical treatment. Early untethering surgery is recommended for symptomatic patients, whereas asymptomatic patients presenting normal level of the conus medullaris require no therapy and are regarded as having a normal variation. Prophylactic untethering surgery can be an option for asymptomatic patients with low set conus medullaris. Untethering surgery should be safely conducted using electrophysiological procedures. Herein, we summarize the clinical characteristics of the filum lipoma and describe our routine surgical procedures.

Physiological rapid growth of spinal lipoma in the early postnatal period.

OBJECTIVE: Spinal lipomas are congenital malformations. They do not express tumorous growth but are found to increase in volume like other normal subcutaneous fat tissue during the early postnatal period. To understand the natural course of volume changes in spinal lipomas, the authors measured the changes in size of spinal lipomas together with the normal subcutaneous fat in relation to BMI. METHODS: A total of 27 patients with conus spinal lipoma excluding lipomyelomeningocele who underwent MRI twice before surgery (on initial diagnosis and immediately preoperatively) were included. Patients' ages at the time of the first MRI ranged from 0 to 32 months (mean 2.9 months, median 1 month). Candidates were categorized by age into three groups: < 1 month, 1-2 months, and ≥ 3 months. The growth rate of the spinal lipomas (in three directions), change in thickness of the normal subcutaneous fat, growth rate of the normal spinal canal (dorsoventral direction), and change in BMI were retrospectively analyzed between the three groups. RESULTS: The mean interval between MRI studies was 83.1 days. During this time, the mean lipoma growth rates were 199%, 149%, and 133% in the dorsoventral, lateral, and craniocaudal directions, respectively (with 100% representing the first measurement). The mean change in the thickness of the normal subcutaneous fat was 183%. The mean growth of the normal spinal canal was 111%. The mean increase in BMI was 124%. These rates were all significantly higher in the younger groups. There was no significant difference in the growth rates between the lipoma and the subcutaneous fat in every age group. In contrast, the growth rate of the lipoma significantly exceeded that of the spinal canal in patients younger than 3 months. The subarachnoid space around the lipoma became obstructed in 35.3%, and spinal cord distortion occurred in 48.1% of the patients younger than 3 months. CONCLUSIONS: Spinal lipomas rapidly increase in volume before the age of 3 months and especially in infants younger than 1 month. Their features closely correlate with the physiological growth of the normal subcutaneous fat and the increase in BMI. The rapid growth of lipomas suggests the importance of close observation in this period, keeping in mind the typical anatomical changes of lipomas and their surrounding structures.

Development of imaging-based risk scores for prediction of intracranial haemorrhage and ischaemic stroke in patients taking antithrombotic therapy after ischaemic stroke or transient ischaemic attack: a pooled analysis of individual patient data from cohort studies.

BACKGROUND: Balancing the risks of recurrent ischaemic stroke and intracranial haemorrhage is important for patients treated with antithrombotic therapy after ischaemic stroke or transient ischaemic attack. However, existing predictive models offer insufficient performance, particularly for assessing the risk of intracranial haemorrhage. We aimed to develop new risk scores incorporating clinical variables and cerebral microbleeds, an MRI biomarker of intracranial haemorrhage and ischaemic stroke risk. METHODS: We did a pooled analysis of individual-patient data from the Microbleeds International Collaborative Network (MICON), which includes 38 hospital-based prospective cohort studies from 18 countries. All studies recruited participants with previous ischaemic stroke or transient ischaemic attack, acquired baseline MRI allowing quantification of cerebral microbleeds, and followed-up participants for ischaemic stroke and intracranial haemorrhage. Participants not taking antithrombotic drugs were excluded. We developed Cox regression models to predict the 5-year risks of intracranial haemorrhage and ischaemic stroke, selecting candidate predictors on biological relevance and simplifying models using backward elimination. We derived integer risk scores for clinical use. We assessed model performance in internal validation, adjusted for optimism using bootstrapping. The study is registered on PROSPERO, CRD42016036602. FINDINGS: The included studies recruited participants between Aug 28, 2001, and Feb 4, 2018. 15 766 participants had follow-up for intracranial haemorrhage, and 15 784 for ischaemic stroke. Over a median follow-up of 2 years, 184 intracranial haemorrhages and 1048 ischaemic strokes were reported. The risk models we developed included cerebral microbleed burden and simple clinical variables. Optimism-adjusted c indices were 0·73 (95% CI 0·69-0·77) with a calibration slope of 0·94 (0·81-1·06) for the intracranial haemorrhage model and 0·63 (0·62-0·65) with a calibration slope of 0·97 (0·87-1·07) for the ischaemic stroke model. There was good agreement between predicted and observed risk for both models. INTERPRETATION: The MICON risk scores, incorporating clinical variables and cerebral microbleeds, offer predictive value for the long-term risks of intracranial haemorrhage and ischaemic stroke in patients prescribed antithrombotic therapy for secondary stroke prevention; external validation is warranted. FUNDING: British Heart Foundation and Stroke Association.

Physiological defects of lumbosacral vertebral arches on computed tomography images in children.

OBJECTIVE: Physiological midline defects of the lumbosacral vertebral arches on radiographs must be distinguished from pathological spina bifida. To date, however, this has not been examined, except for some reports based on plain radiography. The aim of this study is to accurately define the rate and distribution of physiological defects by computed tomography (CT) imaging. METHODS: A total of 115 patients aged 0 months to 16 years (median age, 4 years) who underwent CT scans for abdominopelvic disorder not involving the lumbosacral spine were retrospectively analyzed. The lumbosacral spines were collaterally identified on these images. RESULTS: In the lumbosacral spine excluding the sacral hiatus, the rate of physiological defects was 66.1% (95% confidence interval [CI]: 56.7-74.7%), and the mean number of defective vertebral arches was 1.6 per patient (95% CI: 1.3-1.9). The rate and mean number of defects were significantly higher in the group of patients less than 6 years old (84.3%, 2.2/patient) than that of patients 6 years old or older (37.8%, 0.5/patient) (p < 0.001 and p < 0.001, respectively). The defect rates by spinal level were S3 (57.4%), S1 (47.8%), S2 (34.8%), L5 (13.0%), L4 (2.6%), and L3 (0.9%) in descending order. CONCLUSIONS: Physiological defects were found more commonly at an earlier age and predominantly existed adjacent to the sacral hiatus (S3) and around S1. Understanding the detection rate and distribution features of defects more precisely on CT images will contribute clinically supportive information to distinguish between physiological defects and pathological spina bifida.

Cerebral microbleeds and stroke risk after ischaemic stroke or transient ischaemic attack: a pooled analysis of individual patient data from cohort studies.

BACKGROUND: Cerebral microbleeds are a neuroimaging biomarker of stroke risk. A crucial clinical question is whether cerebral microbleeds indicate patients with recent ischaemic stroke or transient ischaemic attack in whom the rate of future intracranial haemorrhage is likely to exceed that of recurrent ischaemic stroke when treated with antithrombotic drugs. We therefore aimed to establish whether a large burden of cerebral microbleeds or particular anatomical patterns of cerebral microbleeds can identify ischaemic stroke or transient ischaemic attack patients at higher absolute risk of intracranial haemorrhage than ischaemic stroke. METHODS: We did a pooled analysis of individual patient data from cohort studies in adults with recent ischaemic stroke or transient ischaemic attack. Cohorts were eligible for inclusion if they prospectively recruited adult participants with ischaemic stroke or transient ischaemic attack; included at least 50 participants; collected data on stroke events over at least 3 months follow-up; used an appropriate MRI sequence that is sensitive to magnetic susceptibility; and documented the number and anatomical distribution of cerebral microbleeds reliably using consensus criteria and validated scales. Our prespecified primary outcomes were a composite of any symptomatic intracranial haemorrhage or ischaemic stroke, symptomatic intracranial haemorrhage, and symptomatic ischaemic stroke. We registered this study with the PROSPERO international prospective register of systematic reviews, number CRD42016036602. FINDINGS: Between Jan 1, 1996, and Dec 1, 2018, we identified 344 studies. After exclusions for ineligibility or declined requests for inclusion, 20 322 patients from 38 cohorts (over 35 225 patient-years of follow-up; median 1·34 years [IQR 0·19-2·44]) were included in our analyses. The adjusted hazard ratio [aHR] comparing patients with cerebral microbleeds to those without was 1·35 (95% CI 1·20-1·50) for the composite outcome of intracranial haemorrhage and ischaemic stroke; 2·45 (1·82-3·29) for intracranial haemorrhage and 1·23 (1·08-1·40) for ischaemic stroke. The aHR increased with increasing cerebral microbleed burden for intracranial haemorrhage but this effect was less marked for ischaemic stroke (for five or more cerebral microbleeds, aHR 4·55 [95% CI 3·08-6·72] for intracranial haemorrhage vs 1·47 [1·19-1·80] for ischaemic stroke; for ten or more cerebral microbleeds, aHR 5·52 [3·36-9·05] vs 1·43 [1·07-1·91]; and for ≥20 cerebral microbleeds, aHR 8·61 [4·69-15·81] vs 1·86 [1·23-1·82]). However, irrespective of cerebral microbleed anatomical distribution or burden, the rate of ischaemic stroke exceeded that of intracranial haemorrhage (for ten or more cerebral microbleeds, 64 ischaemic strokes [95% CI 48-84] per 1000 patient-years vs 27 intracranial haemorrhages [17-41] per 1000 patient-years; and for ≥20 cerebral microbleeds, 73 ischaemic strokes [46-108] per 1000 patient-years vs 39 intracranial haemorrhages [21-67] per 1000 patient-years). INTERPRETATION: In patients with recent ischaemic stroke or transient ischaemic attack, cerebral microbleeds are associated with a greater relative hazard (aHR) for subsequent intracranial haemorrhage than for ischaemic stroke, but the absolute risk of ischaemic stroke is higher than that of intracranial haemorrhage, regardless of cerebral microbleed presence, antomical distribution, or burden. FUNDING: British Heart Foundation and UK Stroke Association.

Pathophysiological consideration of medullary streaks on FLAIR imaging in pediatric moyamoya disease.

OBJECTIVE Medullary streaks detected on fluid-attenuated inversion recovery (FLAIR) imaging have been considered to be reflected ischemic regions in pediatric moyamoya disease. The purpose of this study was to evaluate these medullary streaks both clinically and radiologically and to discuss associated pathophysiological concerns. METHODS The authors retrospectively reviewed data from 14 consecutive pediatric patients with moyamoya disease treated between April 2009 and June 2016. Clinical and radiological features and postoperative imaging changes were analyzed. In 4 patients, hyperintense medullary streaks on FLAIR imaging (HMSF) at the level of the centrum semiovale were detected. RESULTS The HMSF were coincident with hyperintense medullary streaks on a T2-weighted image, though they were not completely coincident with the vasculature on either a T2*-weighted image or contrast-enhanced CT. Analysis revealed significantly higher values in terms of MR angiography scores, number of flow voids of the basal ganglia, and the presence of the medullary artery in the group with HMSF than in those without. In contrast, the presence of white matter damage was significantly less frequent in the HMSF group. All HMSF disappeared after surgery, and the mean apparent diffusion coefficient at the same level was significantly reduced postoperatively. CONCLUSIONS Although HMSF should be associated with collateral circulation in moyamoya disease, other factors may be involved, including stagnated cerebrospinal fluid or vasogenic edema that is relevant to the impaired state of the white matter. Findings in this study provide insight into the pathophysiological basis of the perivascular space in moyamoya disease.

Subcortical heterotopia appearing as huge midline mass in the newborn brain.

INTRODUCTION: We report the case of a 2-year-old boy who showed a huge midline mass in the brain at prenatal assessment. CASE REPORT: After birth, magnetic resonance imaging (MRI) revealed a conglomerate mass with an infolded microgyrus at the midline, which was suspected as a midline brain-in-brain malformation. MRI also showed incomplete cleavage of his frontal cortex and thalamus, consistent with lobar holoprosencephaly. The patient underwent an incisional biopsy of the mass on the second day of life. The mass consisted of normal central nervous tissue with gray and white matter, representing a heterotopic brain. The malformation was considered to be a subcortical heterotopia. With maturity, focal signal changes and decreased cerebral perfusion became clear on brain imaging, suggesting secondary glial degeneration. Coincident with these MRI abnormalities, the child developed psychomotor retardation and severe epilepsy focused on the side of the intracranial mass.

Awareness of folic acid use increases its consumption, and reduces the risk of spina bifida.

The majority of neural tube defects were believed to be folic acid (FA)-preventable in the 1990s. The Japanese government recommended women planning pregnancy to take FA supplements of 400 µg/d in 2000, but the incidence of spina bifida has not decreased. We aimed to evaluate the OR of having an infant with spina bifida for women who periconceptionally took FA supplements and the association between an increase in supplement use and possible promoters for the increase. This is a case-control study which used 360 case women who gave birth to newborns afflicted with spina bifida, and 2333 control women who gave birth to healthy newborns during the first 12 years of this century. They were divided into two 6-year periods; from 2001 to 2006 and from 2007 to 2012. Logistic regression analyses were conducted to compute OR between cases and controls. The adjusted OR of having an infant with spina bifida for supplement users was 0.48 in the first period, and 0.53 in the second period. The proportion of women who periconceptionally consumed supplements significantly increased from 10 % in the first period to 30 % in the second period. Awareness of the preventive role of FA was a promoter for an increase in supplement use, and thus an FA campaign in high school seems rational and effective. The failure of the current public health policy is responsible for an epidemic of spina bifida. Mandatory food fortification with FA is urgent and long overdue in Japan.

Nascent lobar microbleeds and stroke recurrences.

BACKGROUND: Lobar microbleeds (MBs) are occasionally visible on gradient-echo T2*-weighted (T2*-w) magnetic resonance imagings (MRIs) in patients with deep intracerebral hemorrhages (ICHs). This study investigated the contribution of nascent lobar MBs to occurrences of deep ICHs. METHODS: We prospectively analyzed nascent lobar MBs in patients admitted to our hospital who were treated with index strokes between April 2004 and November 2009. Numbers of nascent lobar MBs were counted on T2*-w MRI scans around 1 year after index strokes and compared with previous MRIs on admission. Deep ICH occurrence-free rate curves were generated by the Kaplan-Meier method using the log-rank test. The odds ratio (OR) for deep ICH occurrence was derived from a multivariate logistic regression model using nascent lobar MBs and risk factors. RESULTS: We investigated MRIs (interscan interval: 14.6 ± 5.9 months) of 508 patients (207 women, 68.9 ± 11.5 years), with a follow-up period of 44.1 ± 15.4 months. Repeated T2*-w MRIs demonstrated 157 nascent lobar MBs in 62 of 508 patients. The occurrence rate of deep ICHs (1.9% per year) was significantly higher in patients with nascent lobar MBs than in those without (.5% per year, P = .012). Multivariate analyses revealed that the rate of nascent lobar MBs was significantly elevated in patients with deep ICH-type stroke recurrences (OR: 3.85, P = .020), adjusted by the presence of hypertension, diabetes mellitus, use of antithrombotic drugs, severity of white matter lesions, age, and gender. CONCLUSIONS: Though a cohort study limited the power of analyses, our findings suggested that lobar MBs might be associated with deep ICH.

Nascent deep microbleeds and stroke recurrences.

BACKGROUND: Cerebral microbleeds (MBs) on gradient echo T2*-weighted magnetic resonance imaging (MRI) scans are associated with the severity of cerebral microangiopathies. This study investigated the contributions of nascent deep MBs to stroke recurrence. METHODS: We prospectively analyzed nascent deep MBs in patients admitted to our hospital who were treated for index strokes between April 2004 and November 2009. The number of nascent deep MBs was counted on T2*-weighted MRI scans around 1 year after the index strokes, and compared to previous MRIs on admission. Stroke recurrence-free rate curves were generated using the Kaplan-Meier method using the log-rank test. The odds ratio for nascent deep MBs was derived using a multivariate logistic regression model that was based on recurrent strokes and other risk factors. RESULTS: We evaluated the MRIs (interval between MRIs 14.6 ± 5.9 months) of 508 patients (207 women; 68.9 ± 11.5 years), with a follow-up period of 44.1 ± 15.4 months. Repeated T2*-weighted MRI scans revealed 256 nascent deep MBs in 116 of 508 patients. The incidence of deep intracerebral hemorrhage was significantly greater in patients with nascent deep MBs than those without (2.0% vs 0.4% per year, respectively; P < .0001). Multivariate analyses revealed that the rate of nascent deep MBs was significantly elevated in patients whose stroke recurrences took the form of deep intracerebral hemorrhages (odds ratio 5.41; P = .007), when adjusted for hypertension, preexisting MBs, and other risk factors. CONCLUSIONS: Our findings suggested that nascent deep MBs might be associated with stroke recurrence, in particular with deep intracerebral hemorrhage.

Antithrombotic drug uses and deep intracerebral hemorrhages in stroke patients with deep cerebral microbleeds.

BACKGROUND: It has been suggested that antiplatelet or anticoagulant drugs elevate the rate of intracerebral hemorrhage (ICH) in patients with cerebral microbleeds (MBs). To investigate the mechanism by which antiplatelet drugs or warfarin may contribute to deep ICH occurrences in patients with deep MBs, we prospectively analyzed deep ICH occurrences in 807 consecutive patients (351 females and 456 males; mean age ± standard deviation 69.8 ± 12.0 years) who were admitted to our hospital with strokes. METHODS: Occurrence-free rate curves were generated using the Kaplan-Meier method; deep ICH occurrence-free rates were compared using the log-rank test. The follow-up period was 0.5 to 71 months (mean ± standard deviation 31.6 ± 22.2 months). RESULTS: In patients with deep MBs, the rates (1.0%/year; 6 ICHs in 180 patients) of deep ICH occurrence associated with antiplatelet drugs were not significantly greater than that without the drugs (1.0%/year; 6 ICHs in 167 patients; P = .977). The incidence of deep ICHs associated with warfarin use was not significantly greater than that without warfarin use. CONCLUSIONS: Multivariate analysis revealed that the use of antiplatelet drugs or warfarin did not significantly influence the occurrence of deep ICH in patients with deep MBs. Antiplatelet drugs or warfarin did not significantly elevate the rate of deep ICHs in stroke patients with pre-existing deep MBs.

Pulsatile wall movement of spinal arachnoid cyst deteriorates spinal cord symptoms: report of three cases.

INTRODUCTION: Symptomatic spinal arachnoid cyst is a rare disease and the pathophysiology causing spinal cord symptoms has not been well clarified. PATIENTS AND METHODS: The authors report three symptomatic cases of spinal arachnoid cyst at the thoracic level. These patients, aged from 70 to 73 years, showed progressive gait disturbance for a few months before admission. Phase-contrast cine magnetic resonance imaging demonstrated significant compression at the rostral side of the cyst during the diastolic phase of the cardiac cycle. Intraoperative ultrasonography demonstrated that the maximum expansion of the cyst and compression of the dorsal spinal cord occurred when the cerebrospinal fluid moved rostrally during diastole. All patients showed good improvement of their symptoms after surgical removal of the arachnoid cyst. CONCLUSION: This report proposes the pathophysiology that the pulsatile enlargement of the arachnoid cyst during diastolic cardiac phase can be an important factor for deterioration of spinal cord symptoms.

Radiological findings and clinical course of conus lipoma: implications for surgical treatment.

OBJECTIVE: A significant variety in morphology of conus lipomas may underlie differences in clinical presentation of the patients and controversy in surgical management. We retrospectively studied 58 patients with conus lipomas at our institutions. The purpose of this study was to infer the clinical course from the radiological findings and to provide information for decision-making in planning for surgical treatment. METHODS: The patients underwent untethering surgery between 1984 and 2005. There were 35 transitional and 23 dorsal lipomas. The age at surgery ranged from 1 month to 50 years (median, 4 yr). Preoperative clinical history, radiological findings, and postoperative results were analyzed. RESULTS: Fifteen patients were asymptomatic, and 43 patients were symptomatic preoperatively. Twenty-one patients presented with motor deficits of the lower extremities. In seven patients, motor deficits appeared early, before 1 year of age. Massive lipomas compressing the cord or herniation of the spinal cord into the subcutaneous tissue were characteristic findings of such early deterioration. Motor deficits were present in 73% of patients with lipomas extending to the lumbar level, whereas 88% of patients with lipomas confined to the sacral level had only urinary deficits. During a mean postoperative follow-up period of 7.9 years, 4 (27%) of the 15 asymptomatic patients developed urinary and/or motor deficits, and 12 (28%) of the 43 symptomatic patients showed further neurological deterioration. CONCLUSION: This study demonstrates that the location and morphology of conus lipomas influence the neurological presentation of the patients. Early prophylactic surgery is a reasonable treatment option if early deterioration is predicted by imaging studies.

Dot-like hemosiderin deposition on T2*-weighted MR imaging associated with nonhypertensive intracerebral hemorrhage.

BACKGROUND AND PURPOSE: Microangiopathy, a disorder often related to hypertension, is an important cause of deep intracerebral hematoma (ICH). The microangiopathy is associated with dot-like low-intensity spots (a dot-like hemosiderin spot: dotHS) on gradient-echo T2*-weighted MR images that have been histologically diagnosed as old microbleeds. The locations of dotHS are consistent with deep ICH. METHODS: To investigate how dotHS or other risk factors contribute to nonhypertensive deep ICH, the number and location of dotHSs, as well as other risk factors were examined in 213 deep ICH patients (106 males, 107 females, age: 37-94 (65.8 +/- 11.2) years) consecutively admitted to Hakodate Municipal Hospital. Patients were divided into two subgroups according to the presence or absence of hypertension. DotHSs were also divided into deep and subcortical dotHS and investigated independently. Odds ratios (ORs) were estimated from logistic regression analyses. Furthermore, nonhypertensive ICH patients were compared with nonhypertensive healthy volunteers matched for age and sex. RESULTS: No risk factors were identified in the 31 nonhypertensive deep ICH patients that differed from those found in the 182 hypertensive deep ICH patients. Deep dotHS > or = 1 (OR: 25.5; 95% CI: 4.76-137; P = .0002), subcortical dotHS > or = 1 (OR: 9.0; 95% CI: 1.79-44.9; P = .046), diabetes mellitus (OR: 9.0; 95% CI: 1.53-52.3; P = .015), and smoking (OR, 9.6; 95% CI; 1.8-49.8, P = .007) significantly elevated the risk of nonhypertensive ICH, compared to the healthy volunteers. CONCLUSIONS: Our findings suggest that deep and subcortical dotHSs may be risk factors for the development of non-hypertensive deep ICH.

[Study on hemosiderin deposition after intracerebral hemorrhage].

BACKGROUND AND PURPOSE: Hemosiderin degenerated from intracerebral hematoma (ICH) can be visualized as low intensity on gradient-echo T2*-weighted (T2*-w) MRI, which is sensitive for hemosiderin. We studied the factors associated with the hemosiderin deposition on T2*-w MRI after ICH. METHODS: We analyzed T2*-w MRIs in 72 outpatients with past ICH (46 males, 26 females, 28-89 (60.0 +/- 9.8) years old) consecutively came to our hospital. The odds ratio (OR) for the apparent thickness > or = 2.5 mm of low intensity surrounding ICH cavity was estimated, using the time after the onset of ICH (17 weeks - 26 years), and other factors. RESULTS: All of old ICHs were visible as low intensities on T2*-w MRI. Multivariate logistic regression analysis revealed that an elevated ratio of the apparent thickness > or = 2.5 mm of hemosiderin was found for the patients with time > or =5 years between T2*-w MRI and the onset (odds ratio (OR): 0.24, 95% confidence interval (CI): 0.06-0.99), intraventricular or subarachnoid hemorrhage related to ICH (OR: 0.16, 95% CI: 0.03-0.77), and the diameter of ICH > or =2 cm (OR: 33.7, 95% CI: 4.6-245). CONCLUSION: Though small sample size limited the power of analyses, our findings suggest that the amount of hemosiderin deposition after ICH may be associated with the time after the onset, intraventricular or subarachnoid hemorrhage related to ICH, and the diameter of ICH.

Prediction of prolonged postprocedural hypotension after carotid artery stenting.

OBJECTIVE: Stent placement for the treatment of carotid artery stenosis may cause hemodynamic instability that induces ischemic complications for patients with bilateral carotid lesions. We carried out this study to define predictors of persistent hypotension after carotid stenting. METHODS: Thirty-three lesions in 31 consecutive patients (mean age, 69.2 +/- 8.6 yr) who underwent stent deployment for carotid stenosis were studied. Fourteen lesions were treated with Easy Wall stents (Boston Scientific, Tokyo, Japan) and 19 lesions were treated with Smart stents (Johnson & Johnson, Warren, NJ). We reviewed preoperative angiograms and ultrasonograms of the carotid artery and analyzed the predictive factors of postprocedural prolonged hypotension (systolic blood pressure < 90 mm Hg and periods > 3 h). RESULTS: Postprocedural hypotension was observed in 14 lesions (42.4%), of which medical treatment was necessary in seven (21.2%). A distance between carotid bifurcation and maximum stenotic lesion (< or = 10 mm; P = 0.0028) and type of stenosis (eccentric; P = 0.0287) on angiogram and fibrous plaque morphological features (P = 0.0008) and calcifications at carotid bifurcation (P = 0.0004) on ultrasonograms were determined to be independent risk factors of postprocedural hypotension. We introduced a scoring system for predicting prolonged hypotension that included factors such as the distance from carotid bifurcation to maximum stenotic lesion (< or = 10 mm), type of stenosis (eccentric), plaque morphological features (echogenic), and calcification at carotid bifurcation. The score was determined by adding one point for each of these factors. Three points or more on this score strongly suggested a high risk of prolonged hypotension. CONCLUSION: Our scoring system, which includes angiographic and ultrasonographic findings, may be a good index for the prediction of prolonged hypotension after carotid stenting and may contribute to the reduction of periprocedural ischemic events.

Dotlike hemosiderin spots are associated with past hemorrhagic strokes in patients with lacunar infarcts.

BACKGROUND AND PURPOSE: Dotlike hemosiderin spots ongradient-echo T2(*)-weighted magnetic resonance imaging of the brain have been histologically diagnosed as old microbleeds associated with small vessel disease (SVD). The authors hypothesize that the presence of many dotHSs may be correlated with the fragility of small vessels and the recurrence of SVD, including lacunar infarction and deep intracerebral hemorrhage (ICH). METHODS: To investigate how dotHSs are related to past history of SVD, the number of subcortical or deep dotHSs was investigated in 146 patients with lacunar infarctions (95 men, 51 women, age 38 to 90 [66.6+/-9.4] years). They were divided into 2 subgroups according to history of deep ICHs or lacunar infarctions. The odds ratio (OR) for past history was estimated from logistic regression analyses with the number of subcortical or deep dotHSs as well as other factors. RESULTS: Of 146 patients with lacunar infarctions, 11 had past symptomatic ICHs and 19 had past symptomatic lacunar infarctions. An elevated rate of history of ICH was found for lacunar infarction patients with many deep dotHSs (>or=3; OR, 9.1; 95% confidence interval, 1.6-51, P=.015). However, history of lacunar infarction was not significantly associated with the number of subcortical or deep dotHSs. CONCLUSIONS: Our findings suggest that many deep dotHSs on T2(*)-weighted magnetic resonance imaging may be correlated with deep ICH-lacunar infarction type of SVD recurrence but not lacunar infarction-lacunar infarction type.

[Chiari malformation (type 1) with regeneration of removed C1 lamina after foramen magnum decompression: a case report].

We present the case of a 20-year-old female who underwent foramen magnum decompression and laminectomy of C1-C3 as well as incision of only the outer layer of the dura, for her symptomatic Chiari malformation (type 1) with syringomyelia, at the age of 9 years. She required additional surgery with removal of regenerated bone and dural plasty for the remaining and recurrent stenosis. The remaining stenosis may have been caused by the use of a technique without dural plasty and insufficient decompression of the bony structure. Further, the regeneration of C1 lamina could have been responsible for the recurrent stenosis. Her symptoms, which included gait disturbance, hypesthesia, excessive sweating, and nocturnal enuresis, manifested themselves when she was at the age of 2 years and progressed since that time. These symptoms didn't improve after the first surgery. However, after the second surgery, the gait disturbance and nocturnal enuresis were partially resolved. It is rare for new bone generation to necessitate reoperation. However, it should be noticed that careful follow-up is important after decompressive surgery for Chiari malformation in young patients.