The Usefulness of the 3.1-mm-diameter 4K Rigid Endoscope for Intracerebral Hematoma Evacuation.

The indication for surgical intervention in spontaneous intracerebral hemorrhage remains controversial. Although many clinical trials have failed to demonstrate its efficacy over medical treatment, less invasive endoscopic treatment is expected to demonstrate its superiority. A novel endoscopic system for hematoma removal consisting of a 3.1-mm-diameter 4K high-resolution rigid endoscope was used.The system was used in eight cases of spontaneous intracerebral hemorrhage. It provided improved maneuverability of the surgical instrument while maintaining satisfactory image quality. The surgical goal was achieved in all cases without any complications, including perioperative rebleeding.Endoscopic hematoma removal using the 3.1 mm high-resolution endoscope is an alternative minimally invasive approach to spontaneous intracerebral hemorrhage with improved reliability.

Treatment Outcomes of PED for Unruptured Aneurysms of Internal Carotid Artery: Comparison of PED-Flex and PED-Shield.

There is a lack of data regarding the safety and effectiveness of implanting the Pipeline Embolization Device with Shield technology (PED-Shield) compared with the previous generation of Pipeline (PED-Flex). This retrospective single-center study aimed to compare treatment outcomes between the PED-Shield and PED-Flex for treating unruptured internal carotid artery aneurysms. The PED-Flex was used in 62 procedures (67 aneurysms, 59 patients) and the PED-Shield in 53 procedures (59 aneurysms, 58 patients). The mean aneurysm diameter was significantly lower in the PED-Shield group than in the PED-Flex group (11.9 ± 7.0 mm vs. 15.2 ± 6.9 mm, p < 0.001). At the 12-month follow-up, the complete angiographic occlusion rate was 72.1% and 72.3% in the PED-Flex and PED-Shield groups, respectively (p = 0.9808). Limited to aneurysms larger than 10 mm, 70.6% and 68.0%, respectively (p = 0.8175). The incidence of more than three high signal intensity areas on diffusion-weighted imaging after treatment was significantly lower in the PED-Shield group than in the PED-Flex group (27.7% vs. 67.7%; p < 0.001). Limited to aneurysms larger than 10 mm, 41.1% and 69.6%, respectively (p < 0.0117). Symptomatic ischemic complications occurred within 30 days of four PED-Flex procedures (6.5%) and one PED-Shield procedure (2.0%) (p = 0.2315). Limited to aneurysms larger than 10 mm, 1.8% and 3.2%, respectively (p = 0.6677). The incidence of mRS score worsening at 6 months was 3.2% and 1.9% in the PED-Flex and PED-Shield groups, respectively (p = 0.6534). The PED-Shield can achieve outcomes equivalent to or better than the PED-Flex. Further large-scale studies are warranted to confirm our findings.

Extracranial internal carotid artery-dissecting aneurysm having a re-entry tear and causing lower cranial nerve palsies treated with flow-diverting stent: A case report.

Background: Extracranial internal carotid artery (ICA)-dissecting aneurysms (DAs) rarely cause re-entry tears and lower cranial nerve palsies. The therapeutic strategies for these pathologies are not well established. This report presents a case of an extracranial ICA -DA with a re-entry tear that caused lower cranial nerve palsy. Case Description: A 60-year-old man presented with left neck pain, hoarseness, and dysphagia. Physical examination and laryngoscopy determined palsies of the left cranial nerves IX, X, and XII. Digital subtraction angiography (DSA) revealed a DA in the left extracranial ICA, and three-dimensional DSA showed entry and re-entry tears in the intimal flap. Flow-diverting stents (FDSs) were placed on the lesion that covered the entry and re-entry tears because the symptoms did not improve after five weeks of conservative treatment. A post-procedural angiogram indicated flow stagnation in the DA. Symptoms improved remarkably immediately after the procedure, and the aneurysm was almost completely occluded six months later. Conclusion: Herein, an extracranial ICA -DA with a re-entry tear that caused lower cranial nerve palsy did not improve after five weeks of conservative treatment. FDS placement promptly resolved the aneurysm and symptoms. Thus, FDS placement may be an effective treatment option for extracranial ICA-DAs with re-entry tears or lower cranial nerve palsies.

Three-year follow-up analysis of phase 1/2 study on tirabrutinib in patients with relapsed or refractory primary central nervous system lymphoma.

Background: The ONO-4059-02 phase 1/2 study showed favorable efficacy and acceptable safety profile of tirabrutinib, a second-generation Bruton's tyrosine kinase inhibitor, for relapsed/refractory primary central nervous system lymphoma (PCNSL). Here, we report the long-term efficacy and safety after a 3-year follow-up. Methods: Eligible patients were aged ≥ 20 years with histologically diagnosed PCNSL and KPS of ≥ 70. Patients received oral tirabrutinib once daily at 320 or 480 mg, or 480 mg under fasted conditions. Results: Between October 19, 2017, and June 13, 2019, 44 patients were enrolled: 33 and 9 had relapsed and refractory, respectively. The 320, 480, and 480 mg fasted groups included 20, 7, and 17 patients, respectively. The median follow-up was 37.1 months. The overall response rate was 63.6% (95% CI: 47.8-77.6) with complete response (CR), unconfirmed CR, and partial response in 9, 7, and 12 patients, respectively. The median duration of response (DOR) was 9.2 months, with a DOR rate of 19.8%; the median progression-free survival (PFS) and median overall survival (OS) were 2.9 months and not reached, respectively, with PFS and OS rates of 13.9% and 56.7%, respectively. Adverse events occurred in 38 patients (86.4%): grade ≥ 3 in 23 (52.3%) including 1 patient with grade 5 events. KPS and quality of life (QoL) scores were well maintained among patients receiving long-term treatment. Conclusions: The results demonstrated the long-term clinical benefit of tirabrutinib, with deep and durable response in a subset of patients and acceptable safety profile, while KPS and QoL scores were maintained.

First-in-human trial of a self-expandable, temporary dilation system for intracranial atherosclerotic disease in patients presenting with acute ischemic stroke.

BACKGROUND: Intracranial atherosclerotic disease (ICAD) significantly contributes to ischemic stroke, especially among Asian populations. Large vessel occlusion (LVO) due to underlying ICAD accounts for 15-35% of acute ischemic stroke cases requiring endovascular therapy. However, the successful recanalization rate of ICAD-related LVO remains lower. The TG dilator is a self-expandable device, temporarily dilating ICAD-related blocked blood vessels. OBJECTIVE: To demonstrate TG dilator safety and efficacy for ICAD-related acute ischemic stroke. METHODS: This was a single-arm, open-label, non-randomized, prospective, multicenter, and investigator-initiated trial that involved patients undergoing TG dilator application for acute ischemic stroke caused by ICAD-related LVO or severe stenosis. RESULTS: We enrolled 10 patients in this trial between November 2022 and April 2023. The median (IQR) age was 68 (59.3-75.3) years. Before using the dilator, seven patients received stent retriever treatment. All 10 patients were prescribed a loading dose of aspirin with prasugrel. The median application time was 10 (10-12) min. At the end of the procedure, we achieved significant recanalization immediately in all patients. The stenosis/occlusion decreased from 100% (100-100) to 68% (56.3-75.3). No patient experienced recurrent ischemic stroke or reocclusion within 90 days. We achieved a modified Rankin scale score of 0-2 in 8 patients by day 90. We detected no cases of intracranial hemorrhage, equipment failure, distal embolism, vasospasm, dissection, or perforation requiring intervention. CONCLUSIONS: Acute revascularization using the TG dilator on patients with ICAD-related LVO or severe stenosis did not cause any significant adverse event, and consistently improved blood flow at 90 days.

Karnofsky Performance Status and quality of life in patients with relapsed or refractory primary CNS lymphoma from a phase I/II study of tirabrutinib.

Background: Tirabrutinib, a second-generation inhibitor of Bruton's tyrosine kinase, was approved in March 2020 for the treatment of relapsed or refractory primary central nervous system lymphoma (r/r PCNSL) based on phase I/II studies in Japan. We previously reported the overall response rate and safety profile. We describe Karnofsky Performance Status (KPS) and the quality of life (QoL) in patients with r/r PCNSL receiving tirabrutinib based on more than 1-year follow-up data. Methods: Patients with r/r PCNSL, age ≥20 years, and KPS ≥70 were treated with tirabrutinib once daily at a dose of 320, 480, or 480 mg under fasted conditions. QoL was assessed using questionnaires issued by the European Organization for Research and Treatment of Cancer (EORTC), namely EORTC QLQ-C30, EORTC QLQ-BN20, and EuroQol 5 dimensions 3-level (EQ-5D-3L) along with KPS. Results: Forty-four patients (mean age, 60 years [range 29-86]) were enrolled. The median follow-up period was 14.9 months (range, 1.4-27.7). The median KPS of the patients at baseline was 80.0 (range, 70-100), and this remained constant during the treatment. The global health status/QoL in the QLQ-C30 showed significant improvements from baseline through cycles 3-17 and remained relatively constant thereafter until cycle 23. Improvements were also seen in emotional functioning and constipation in the QLQ-C30 segments. Other items of QLQ-C30 and QLQ-BN20, EQ-5D visual analog scales, and EQ-5D index were maintained during the treatment. Conclusions: Tirabrutinib generally maintains KPS and QoL scores with some improvements in specific QoL items in patients with r/r PCNSL.

Safety and Efficacy of Prasugrel Administration in Emergent Endovascular Treatment for Intracranial Atherosclerotic Disease.

Objective: Intracranial atherosclerosis disease (ICAD) is one of the most common causes of acute ischemic stroke. In endovascular treatment (EVT) for acute large vessel occlusion stroke-related ICAD, reocclusion of the recanalized artery due to in situ thrombosis is problematic. In this study, the safety and efficacy of prasugrel administration to avoid reocclusion of emergent EVT for ICAD was investigated. Methods: All consecutive emergent EVTs for ICAD between September 2019 and December 2022 were included in this study. The procedures were divided into two groups as receiving periprocedural prasugrel (PSG group) or not (non-PSG group). Target vessel patency on follow-up, postprocedural intracranial hemorrhage (ICH), and clinical outcome were compared between PSG and non-PSG groups. Results: A total of 27 procedures were included in this analysis. Nineteen target vessels were patent on follow-up and eight were non-patent. Fifteen patients received prasugrel (18.75 mg: 11 cases, 11.25 mg: 4 cases), and twelve patients did not receive prasugrel. The target vessel patency rate was better in the PSG group vs. non-PSG group (100% vs. 33.3%, respectively; p = 0.0002). The postprocedural ICH rate was not different between the groups (PSG: 40.0% vs. non-PSG: 25.0%; p = 0.68), and all ICHs were asymptomatic. Good clinical outcome (modified Rankin Scale score of 0 to 3 at discharge) was more frequent in the PSG group than that in the non-PSG group (66.7% vs. 16.7%, respectively; p = 0.019). Conclusion: Prasugrel administration was significantly associated with target vessel patency and good clinical outcome after emergent EVT for ICAD without increasing the symptomatic ICH rate. Prasugrel administration might be safe and effective to avoid reocclusion during and after emergent EVT for ICAD.

Dysbiosis of Gut Microbiome Is Associated With Rupture of Cerebral Aneurysms.

BACKGROUND AND PURPOSE: Environmental factors are important with respect to the rupture of cerebral aneurysms. However, the relationship between the gut microbiome, an environmental factor, and aneurysm rupture is unclear. Therefore, we compared the gut microbiome in patients with unruptured intracranial aneurysms (UIAs) and ruptured aneurysms (RAs) to identify the specific bacteria causing the rupture of cerebral aneurysms. METHODS: A multicenter, prospective case-control study was conducted over one year from 2019 to 2020. The fecal samples of patients with stable UIAs and RAs immediately after onset were collected. Their gut microbiomes were analyzed using 16S rRNA sequencing. Subsequently, a phylogenetic tree was constructed, and polymerase chain reaction was performed to identify the specific species. RESULTS: A total of 28 RAs and 33 UIAs were included in this study. There was no difference in patient characteristics between RAs and UIAs: age, sex, hypertension, dyslipidemia, diabetes status, body mass index, and smoking. No difference was observed in alpha diversity; however, beta diversity was significantly different in the unweighted UniFrac distances. At the phylum level, the relative abundance of Campylobacter in the RA group was larger than that in the UIA group. Furthermore, the gut microbiome in the RA and UIA groups exhibited significantly different taxonomies. However, Campylobacter was focused on because it is widely known as pathogenic among these bacteria. Then, a phylogenetic tree of operational taxonomic units related to Campylobacter was constructed and 4 species were identified. Polymerase chain reaction for these species identified that the abundance of the genus Campylobacter and Campylobacter ureolyticus was significantly higher in the RA group. CONCLUSIONS: The gut microbiome profile of patients with stable UIAs and RAs were significantly different. The genus Campylobacter and Campylobacter ureolyticus may be associated with the rupture of cerebral aneurysms.

Safety and efficacy of depatuxizumab mafodotin in Japanese patients with malignant glioma: A nonrandomized, phase 1/2 trial.

INTELLANCE-J was a phase 1/2 study of a potent antibody-drug conjugate targeting epidermal growth factor receptor (EGFR), depatuxizumab mafodotin (Depatux-M), as a second- or first-line therapy, alone or combined with chemotherapy or chemoradiotherapy in 53 Japanese patients with World Health Organization (WHO) grade III/IV glioma. In second-line arms, patients with EGFR-amplified recurrent WHO grade III/IV glioma received Depatux-M plus chemotherapy (temozolomide) or Depatux-M alone regardless of EGFR status. In first-line arms, patients with newly diagnosed WHO grade III/IV glioma received Depatux-M plus chemoradiotherapy. The study was halted following lack of survival benefit with first-line Depatux-M in the global trial INTELLANCE-1. The primary endpoint was 6-month progression-free survival (PFS) in patients with EGFR-amplified tumors receiving second-line Depatux-M plus chemotherapy. Common nonocular treatment-emergent adverse events (TEAEs) with both second-line and first-line Depatux-M included lymphopenia (42%, 33%, respectively), thrombocytopenia (39%, 47%), alanine aminotransferase increase (29%, 47%), and aspartate aminotransferase increase (24%, 60%); incidence of grade ≥3 TEAEs was 66% and 53%, respectively. Ocular side effects (OSEs) occurred in 93% of patients receiving second-line Depatux-M plus chemotherapy and all patients receiving second-line Depatux-M alone or first-line Depatux-M plus chemoradiotherapy. Most OSEs were manageable with dose modifications and concomitant medications. The 6-month PFS estimate was 25.6% (95% confidence interval [CI] 11.4-42.6), and median PFS was 2.1 months (95% CI 1.9-3.9) with second-line Depatux-M plus chemotherapy in the EGFR-amplified subgroup. This study showed acceptable safety profile of Depatux-M alone or plus chemotherapy/chemoradiotherapy in Japanese patients with WHO grade III/IV glioma. The study was registered at ClinicalTrials.gov (NCT02590263).

Magnetic Resonance Relaxometry for Tumor Cell Density Imaging for Glioma: An Exploratory Study via 11C-Methionine PET and Its Validation via Stereotactic Tissue Sampling.

One of the most crucial yet challenging issues for glioma patient care is visualizing non-contrast-enhancing tumor regions. In this study, to test the hypothesis that quantitative magnetic resonance relaxometry reflects glioma tumor load within tissue and that it can be an imaging surrogate for visualizing non-contrast-enhancing tumors, we investigated the correlation between T1- and T2-weighted relaxation times, apparent diffusion coefficient (ADC) on magnetic resonance imaging, and 11C-methionine (MET) on positron emission tomography (PET). Moreover, we compared the T1- and T2-relaxation times and ADC with tumor cell density (TCD) findings obtained via stereotactic image-guided tissue sampling. Regions that presented a T1-relaxation time of >1850 ms but <3200 ms or a T2-relaxation time of >115 ms but <225 ms under 3 T indicated a high MET uptake. In addition, the stereotactic tissue sampling findings confirmed that the T1-relaxation time of 1850-3200 ms significantly indicated a higher TCD (p = 0.04). However, ADC was unable to show a significant correlation with MET uptake or with TCD. Finally, synthetically synthesized tumor load images from the T1- and T2-relaxation maps were able to visualize MET uptake presented on PET.

Efficacy of endovascular intratumoral embolization for meningioma: assessment using dynamic susceptibility contrast-enhanced perfusion-weighted imaging.

BACKGROUND: In preoperative embolization for intracranial meningioma, endovascular intratumoral embolization is considered to be more effective for the reduction of tumorous vascularity than proximal feeder occlusion. In this study, we aimed to reveal different efficacies for reducing tumor blood flow in meningiomas by comparing endovascular intratumoral embolization and proximal feeder occlusion using dynamic susceptibility contrast-enhanced perfusion-weighted imaging (DSC-PWI). METHODS: 28 consecutive patients were included. DSC-PWI was performed before and after embolization for intracranial meningiomas. Normalized tumor blood volume (nTBV) of voxels of interest of whole tumors were measured from the DSC-PWI data before and after embolization. ΔnTBV% was compared between the cases that received intratumoral embolization and proximal feeder occlusion. RESULTS: ΔnTBV% in the intratumoral embolization group (42.4±29.8%) was higher than that of the proximal feeder occlusion group (15.3±14.3%, p=0.0039). We used three types of embolic materials and ΔnTBV% did not differ between treatments with or without the use of each material: 42.8±42.4% vs 28.7±20.1% for microspheres (p=0.12), 36.1±20.6% vs 28.1±41.1% for n-butyl cyanoacrylate (p=0.33), and 32.3±37.3% vs 34.1±19.0% for bare platinum coils (p=0.77). CONCLUSIONS: The flow reduction effect of intratumoral embolization was superior to that of proximal feeder occlusion in preoperative embolization for intracranial meningioma in an assessment using DSC-PWI.

Phase I/II study of tirabrutinib, a second-generation Bruton's tyrosine kinase inhibitor, in relapsed/refractory primary central nervous system lymphoma.

BACKGROUND: The safety, tolerability, efficacy, and pharmacokinetics of tirabrutinib, a second-generation, highly selective oral Bruton's tyrosine kinase inhibitor, were evaluated for relapsed/refractory primary central nervous system lymphoma (PCNSL). METHODS: Patients with relapsed/refractory PCNSL, Karnofsky performance status ≥70, and normal end-organ function received tirabrutinib 320 and 480 mg once daily (q.d.) in phase I to evaluate dose-limiting toxicity (DLT) within 28 days using a 3 + 3 dose escalation design and with 480 mg q.d. under fasted conditions in phase II. RESULTS: Forty-four patients were enrolled; 20, 7, and 17 received tirabrutinib at 320, 480, and 480 mg under fasted conditions, respectively. No DLTs were observed, and the maximum tolerated dose was not reached at 480 mg. Common grade ≥3 adverse events (AEs) were neutropenia (9.1%), lymphopenia, leukopenia, and erythema multiforme (6.8% each). One patient with 480 mg q.d. had grade 5 AEs (pneumocystis jirovecii pneumonia and interstitial lung disease). Independent review committee assessed overall response rate (ORR) at 64%: 60% with 5 complete responses (CR)/unconfirmed complete responses (CRu) at 320 mg, 100% with 4 CR/CRu at 480 mg, and 53% with 6 CR/CRu at 480 mg under fasted conditions. Median progression-free survival was 2.9 months: 2.1, 11.1, and 5.8 months at 320, 480, and 480 mg under fasted conditions, respectively. Median overall survival was not reached. ORR was similar among patients harboring CARD11, MYD88, and CD79B mutations, and corresponding wild types. CONCLUSION: These data indicate favorable efficacy of tirabrutinib in patients with relapsed/refractory PCNSL. TRIAL REGISTRATION: JapicCTI-173646.

A novel protocol for three-dimensional rotational venography with low-dose contrast media in preoperative angiography of brain tumours.

AIM: The most appropriate imaging protocol for three-dimensional rotational venography (3D RV) has not been established. The aim of this study was to optimise the protocol for 3D RV with low-dose contrast media using time-density curve analysis. METHODS: Twenty-five consecutive patients with brain tumours who received preoperative assessment with 3D RV were retrospectively collected and included in this study. To optimise the imaging delay time of 3D RV with low-dose contrast media, time-density curve analysis was performed on two-dimensional conventional angiography. The image quality for depicting cortical veins and venous sinuses was compared to that of magnetic resonance (MR) venography in five cases. RESULTS: A total of 27 3D RVs were performed in 25 patients. The time-density curves of cortical veins were different from those of cerebral arteries or sinuses. The mean time to peak of cortical veins was significantly longer than the time to peak of cerebral arteries (2.47 ± 0.35 seconds vs. 6.44 ± 1.14 seconds; p < 0.0001) and shorter than the time to peak of venous sinuses (6.44 ± 1.14 seconds vs. 8.18 ± 1.12 seconds; p < 0.0001). The optimal imaging delay time could be determined as the phases in which cortical arterial opacities disappeared and cortical veins started to appear. The mean dose of injected contrast media was 5.3 mL. The image quality of cortical veins in 3D RV was superior to that in MR venography in all cases. CONCLUSIONS: Three-dimensional RV with low-dose contrast media was useful for the preoperative assessment of cortical veins in patients with brain tumours.

Endovascular treatment for large vessel occlusion stroke in patients with ventricular assist devices.

BACKGROUND: Embolic stroke with large vessel occlusion (LVO) is a major adverse event during ventricular assist device (VAD) support. In this study we aimed to clarify the efficacy of, and problems associated with, endovascular treatment (EVT) of LVO in patients with VAD support. METHODS: We retrospectively reviewed EVT for LVO in patients with VAD support between 2006 and 2017 at our institute and evaluated baseline characteristics, treatment variables, outcomes, and complications. RESULTS: The study cohort comprised 12 consecutive patients (age 35.4±20.4 years), with 15 LVO events involving 20 arterial occlusions, who had undergone EVT. The median Alberta Stroke Program Early CT score was 10 and good collaterals were observed in 10 of 17 occluded middle cerebral artery areas. No study patients had received intravenous thrombolysis therapy. EVT was performed on 18 of the 20 occluded arteries and mechanical thrombectomy on 13 vessels. The successful reperfusion (modified Thrombolysis in Cerebral Infarction grade ≥2 b) rate was 67% in all EVTs and 85% with mechanical thrombectomy. Histological analysis showed fibrin-rich thrombi in four of five samples. Seven of 12 patients (58%) maintained their neurological function (modified Rankin Scale score ≤2 or equal to pre-stroke score) at 90 days. Periprocedural complications comprised two symptomatic intracranial hemorrhages and the 90-day mortality rate was 13%. Seven of 10 cardiac transplant candidates (70%) returned to the waiting list and three of them received transplants. CONCLUSIONS: Endovascular therapy for acute LVO stroke is feasible even in patients with VAD support.

Comparison of practical methods in clinical sites for estimating cerebral blood flow during balloon test occlusion.

OBJECTIVE: The authors sought to compare methods of measurement for venous phase delay (VPD) or mean stump pressure (MSTP) to rank their potential to predict ischemic tolerance during balloon test occlusion in the internal carotid artery, exploring a more correlative and convenient way to measure cerebral blood flow (CBF) that could be utilized even in the acute phase or in institutions not adequately equipped to measure CBF during the test. METHODS: X-ray angiography perfusion analysis using diagnostic digital subtraction angiography (DSA) equipment enables 1-step examination (without any room-to-room transfer of patients) to measure CBF, VPD, and MSTP completely simultaneously, which has not been accomplished by any previous perfusion studies. RESULTS: This analysis was applied to 17 patients and resulted in successful estimation of all 3 parameters in each case. The average VPD of several cortical veins had a strong correlation with relative CBF (rCBF) between bilateral hemispheres with a correlation coefficient of 0.89443, a correlation as strong as that (0.90357) of the "approximate VPD," which is interpreted based on the trend line of the scatterplot of the time to peak contrast opacification in cortical veins and their spatial positioning from the median sagittal plane. MSTP and classic visual determination of VPD have weaker correlation coefficients with rCBF (0.56119 and 0.70048, respectively). Overall, subjective visual determination in combination with the calculation of the trend line to estimate VPD provided a considerably strong correlation with rCBF (R = 0.86660) without any dedicated software or hardware. CONCLUSIONS: VPD has a stronger correlation with rCBF than MSTP. rCBF could be successfully predicted on common DSA equipment, even by visual determination without expensive software, if the trend line is adopted for processing to estimate VPD.

X-ray angiography perfusion imaging with an intra-arterial injection: comparative study with 15O-gas/water positron emission tomography.

BACKGROUND: X-ray angiography perfusion (XAP) is a perfusion imaging technique based on conventional DSA. OBJECTIVE: In this study, we aimed to validate parameters derived from XAP by comparing them with 15O-gas/water positron emission tomography (PET), using data from patients with chronic ischemic cerebrovascular disease. METHODS: 18 consecutive patients were included. XAP was performed with intra-arterial infusion of contrast media, and a time-density curve was constructed for each cerebral hemisphere. From the curves, the relative values of mean transit time (rMTT) and wash-in rate (rWiR) were obtained by dividing the values of the right hemisphere by those of the left hemisphere. These were then compared with the relative values of cerebral blood flow (rCBF) and rMTT calculated from the PET data. RESULTS: XAP rWiR correlated strongly with PET rCBF (r=0.86, P<0.0001). rMTT measurements from the two modalities were also strongly correlated (r=0.85, P<0.0001). Bland-Altman analysis revealed a bias of 0.14±0.18 (95% limits of agreement -0.22 to 0.51) for PET rCBF versus XAP rWiR, and 0.016±0.093 (95% limits of agreement -0.17 to 0.20) for rMTT between the two modalities. CONCLUSIONS: The relative values obtained from XAP were validated across a population of patients with chronic ischemic cerebrovascular disease.

Transarterial Sinus Embolization for a Dural Arteriovenous Fistula in a Sinus of the Lesser Sphenoid Wing: A Case Report.

Dural arteriovenous fistula (DAVF) in a sinus of the lesser sphenoid wing (SLSW) is rarely reported. Here, we report a case of an isolated SLSW DAVF treated by coils placed into the sinus through the feeding artery. A 68-year-old man was admitted to our hospital with headache. Magnetic resonance images and an angiogram showed a varix in the right middle cranial fossa. A DAVF, consisting of three main feeders and the isolated SLSW, was diagnosed based on the angiogram findings. Retrograde leptomeningeal venous drainage to the deep middle cerebral vein was observed. Given the remarkable extent of cortical venous ectasia together with the presence of headache and right abducens nerve paralysis, endovascular treatment was initiated. A transvenous approach through the right inferior petrosal sinus was not feasible because of difficulty associated with inserting the microcatheter into the SLSW. Thus, we tried a transarterial approach and were able to advance the microcatheter beyond the fistula into the isolated SLSW, through the artery of the foramen rotundum. The isolated sinus and feeding arteries were embolized with coils. The postoperative angiogram showed the total occlusion of the SLSW DAVF. This case demonstrates the feasibility of transarterial sinus packing for an isolated SLSW DAVF.

[Two Cases of Ruptured Blood Blister-like Aneurysm Treated with X-ray Angiography Perfusion(XAP)Analysis].

Two cases of ruptured blood blister-like internal carotid artery aneurysms for which low flow bypass was sufficient to attain successful treatment of trapping are reported. In the acute stage of rupture, it is troublesome to perform accurate examinations of tolerance to ischemia like balloon occlusion test(BOT)for estimating the required amount of bypass flow. In our cases, X-ray angiography perfusion(XAP)analysis was introduced, which could be performed in a couple dozen seconds without room-to-room transfer of patients, following the ordinary examination of diagnostic digital subtraction angiography. The perfusion index(PI)ratio measured in this analysis is equivalent to the laterality of cerebral blood flow between the right and left hemispheres. The PI ratio of 0.85 approximately corresponds to the mean stump pressure(MSTP)of 40mmHg, on the basis of the correlation diagram between the PI ratio and MSTP(approximate straight line:PI ratio%=0.6×MSTP+60). Even though the PI ratio of the cases was superior to this threshold of tolerance for parent artery occlusion, complementary low flow bypass was added in the acute case for the overwhelming succeeding vasospasm and for securing the flow to peripheral perforators, which resulted in a successful treatment without any ischemic events.

Brachial-Ankle Pulse Wave Velocity as a Predictor of Silent Cerebral Embolism after Carotid Artery Stenting.

BACKGROUND: In neuroendovascular therapy, the effect of arterial stiffness on postprocedural cerebral thromboembolism is unknown. In this observational study, we examined the relationship between cerebral thromboembolism after carotid artery stenting and arterial stiffness. METHODS: From April 2015 to February 2017, we enrolled consecutive patients undergoing scheduled carotid artery stenting in our institution. In all patients, preprocedural brachial-ankle pulse wave velocity was used to assess arterial stiffness, whereas the number of new cerebral ischemic lesions on diffusion-weighted magnetic resonance imaging was assessed after treatment. We also analyzed patient data and details of procedures in patients with carotid artery stenting. RESULTS: Twenty-one patients completed the study. The mean brachial-ankle pulse wave velocity was 1879 cm/s. There was no association of cerebral thromboembolisms with age, unstable plaque, protection device, or type of stent. However, the brachial-ankle pulse wave velocity was an independent predictor of cerebral thromboembolisms (P = .0017). CONCLUSIONS: Brachial-ankle pulse wave velocity is predictive of silent cerebral embolisms on diffusion-weighted magnetic resonance imaging after carotid artery stenting.