T1-T2 Mismatch Sign as a Predictor of Ipsilateral Ischemic Change After Carotid Artery Stenting.

BACKGROUND: Magnetic resonance (MR)-plaque imaging reflects the characteristics of carotid plaque. We evaluated the relationship between MR-plaque images and ischemic change after carotid artery stenting (CAS). METHODS: MR-plaque images were acquired from patients with carotid artery stenosis before CAS treatment. We calculated the relative signal intensity of plaque components compared with that of the sternocleidomastoid muscle and evaluated the presence/absence of T1-T2 mismatch and match sign. We then assessed the appearance of new ischemic lesions after CAS on diffusion-weighted imaging (DWI). Factors associated with the appearance of a high-intensity lesion on DWI were retrospectively analyzed. RESULTS: A total of 64 patients with carotid artery stenoses treated with CAS were included in this study. In univariate analysis, T1-T2 mismatch sign was associated with the appearance of high-intensity lesions on DWI after CAS (odds ratio [OR], 12.00; 95% confidence interval [CI], 3.593-40.072; P < 0.0001), whereas T1-T2 match sign and high intensity on T2-weighted imaging were negatively associated (OR, 0.061, 95% CI, 0.007-0.502, P = 0.009 and OR, 0.085; 95% CI, 0.022-0.334, P = 0.0004, respectively). In multivariate logistic regression analysis, T1-T2 mismatch sign was independently associated with the appearance of a high-intensity lesion on DWI after CAS (OR, 16.695; 95% CI, 1.324-210.52; P = 0.0295). CONCLUSIONS: T1-T2 mismatch sign on MR-plaque imaging is significantly associated with the appearance of new ischemic lesions after CAS. T1-T2 mismatch sign may be useful in considering treatment strategies for carotid artery stenosis.

In-Hospital Complications After Surgery in Elderly Patients with Asymptomatic or Minor Symptom Meningioma: A Nationwide Registry Study.

BACKGROUND: Asymptomatic or minor symptom meningiomas (AMSMs) in the elderly are incidental findings, with no consensus reached on the optimal management strategy. In the present study, we aimed to determine the surgical risk factors for elderly patients with AMSMs using a nationwide registry database in Japan. METHODS: We identified patients with surgically treated AMSMs using the Diagnosis Procedure Combination database from 2010 to 2015 and reviewed the medical records for age (<65 years; pre-elderly, 65-74 years; and elderly, ≥75 years), sex, Barthel index (BI) score, medical history, tumor location, and complications. An AMSM was defined by a BI score of 100 points at admission. The risk factors for all stroke complications, BI deterioration at discharge, and in-hospital mortality were determined using multivariate logistic regression analyses. RESULTS: From a total of 10,535 patients with meningioma, 6628 were included. Advanced age was a significant risk factor (odds ratio, 3.54; 95% confidence interval, 2.80-4.46) for BI deterioration but not for all-stroke complications or in-hospital mortality. Midline and posterior fossa tumors, diabetes mellitus, and chronic heart disease were significant risk factors for in-hospital mortality. CONCLUSIONS: For elderly patients with surgically treated AMSMs, advanced age was a prominent risk factor for functional decline at discharge. Our study identified several factors that should be evaluated before proceeding with surgery for AMSMs in elderly and pre-elderly patients. These findings could, not only improve decision-making among clinicians treating patients with AMSMs, but also help in predicting the results of surgery for elderly patients with AMSMs.

A Patient with Subarachnoid Hemorrhage Related to a Ruptured Aneurysm in Week 8 of Pregnancy: Usefulness of Coil Embolization of Intracranial Aneurysms as a Treatment Option before Delivery.

Object: We report a case of endovascular surgery for subarachnoid hemorrhage (SAH) that developed in early pregnancy. Case Presentations: An 8-week pregnant 35-year-old female was admitted to our hospital with severe headache and loss of consciousness. Cephalic computed tomography (CT) revealed SAH (Hunt and Hess grade II). Digital subtraction angiography (DSA) demonstrated a 2.7 mm aneurysm at the right internal carotid artery-posterior communicating artery (IC-PC) bifurcation. We prioritized maternal treatment. Cerebral aneurysm coil embolization was performed on the 1st day under general anesthesia. During the operation, we tried to avoid irradiating the fetus by limiting the irradiation range and time. She was discharged on the 36th day of illness and gave birth to a 2532-g baby at 36 weeks of gestation. Conclusion: If SAH develops in early pregnancy, it is necessary to prioritize maternal treatment. Endovascular surgery should be considered as a treatment option.

Factors Related to Frailty Associated with Clinical Deterioration After Meningioma Surgery in the Elderly.

BACKGROUND: Older patients are increasingly presenting for surgery with intracranial meningioma because of progress with diagnostic imaging and longer life expectancy. However, older patients have many problems, such as comorbidities and reduced physiological capacity reflected in the frailty index. This study examines the factors affecting clinical deterioration after surgery in older patients, particularly factors associated with frailty. METHODS: Two hundred sixty-five patients older than 65 years underwent surgical resection of meningioma at Hiroshima University and related hospitals between 2000 and 2016. Karnofsky Performance Status (KPS) scores before and after surgery were evaluated. Factors related to the deterioration of KPS were analyzed with multivariate logistic regression modeling, including body mass index and serum albumin. RESULTS: KPS score deteriorated compared with preoperative score in 56 patients at discharge and in 40 patients at 3 months later, and 2 patients died within 1 year after surgery. Multivariate logistic regression analysis in addition to preoperative body mass index and serum albumin indicated skull base tumor location (odds ratio [OR], 4.67; 95% confidence interval [CI], 2.02-10.8) and serum albumin (OR, 2.38; 95% CI, 1.06-5.34) were risk factors for deterioration of KPS score at discharge. Age (OR, 0.91; 95% CI, 0.85-0.98), skull base tumor location (OR, 4.32; 95% CI, 1.45-12.9), tumor size (OR, 1.03; 95% CI, 1.00-1.05), and serum albumin (OR, 3.53; 95% CI, 1.29-9.61) were significant risk factors for perioperative intracranial complications. CONCLUSIONS: Skull base tumor location and serum albumin correlated with deterioration of clinical status after surgery.

[An Elderly Patient with Pilocytic Astrocytoma Operated on 14 Years after Initial Detection:A Case Study].

Pilocytic astrocytomas are found predominantly in the pediatric population and are extremely rare in elderly patients. We describe a case of pilocytic astrocytoma in an elderly patient who presented with the symptoms of an enlarged tumoral cyst. A 70-year-old woman was found to have an asymptomatic small solid tumor with a cystic component in the right frontal lobe at "Ningen Dock(medical checkup)of the Brain". She was hospitalized and underwent further examinations including cerebral angiography. At that time, she was opposed to undergoing an operation for tumor removal owing to lack of symptoms. Approximately fourteen years later, she presented with dizziness upon posture conversion and recent memory disturbance. Computed tomography scanning revealed an enlarged cyst in the frontal lobe and perifocal edematous changes. Gadolinium-enhanced magnetic resonance imaging partially revealed the solid tumor and cystic capsule. The solid tumor had not enlarged substantially. The cystic fluid was aspirated and the solid tumor was resected via a frontal transcortical approach. The histological diagnosis was pilocytic astrocytoma without malignant features. After surgery, the patient's symptoms improved and additional therapy was not provided. After a year of postoperative follow-up, the size of the cystic lesion has reduced, and no recurrence of the solid tumor has been observed.

[A case of occipital diploic dermoid tumor with perforation of the dura].

Along with epidermoid cysts, dermoid cysts are uncommon, benign and slow-growing lesions. We described a case of diploic dermoid cyst of the occipital bone with an intracranial extension in the right posterior fossa diagnosed and subjected to pathological examination. A 63-year-old man presented with dizziness at the time of posture conversion. Magnetic resonance imaging(MRI)showed a heterogenous hypo-intensity area on T1-weighted image, hyper-intensity on T2-weighted image and remarkably-strong intensity on diffusion-weighted image. Gadolinium enhancement was partially seen in the tumor capsule. Bone density computed tomography (CT) and 3-dimensional CT using helical CT scan revealed the osteolytic range with destruction of the inner and outer table. From these findings, this tumor was diagnosed as diploic epidermoid cyst before surgery. The tumor was totally removed and underwent cranioplasty with a titanium plate. However, pathological examination confirmed dermoid cyst with existence of sebaceous gland in some cyst-walls. It was difficult to diagnose this case as dermoid tumor from radiological features before surgery.

[Six cases of organized chronic subdural hematoma].

Surgical procedures for chronic subdural hematoma (CSDH) are performed using various methods on the basis of burr hole irrigation and drainage, but treatment for organized CSDH is rarely required. Primary operation for CSDH was performed in our hospital for 535 patients (391 men, 144 woman; age, 8 months to 104 years) between December 1991 and March 2007. Of these, 6 patients diagnosed with organized CSDH were reviewed. Five patients had a history of burr hole surgery. Computed tomography showed membranous structure and heterogenous distribution of air after burr hole surgery had perforated the subdural space. As for treatment, craniotomy was performed in all cases (small craniotomy, n=4; enlarged craniotomy, n=2), and additional treatment was required in 2 patients. Diagnosis of organized CSDH is not easy before a primary operation, but removal of both organized CSDH and the outer membrane by craniotomy in proportion to hematoma expansion is important once the presence of organized CSDH has been determined.

[Evaluation of ruptured cerebral aneurysms under 5 mm in size on 3D-rotation angiography].

According to the recent guideline of the Japanese Society for Detection of Asymptomatic Brain Diseases, it should be considered that the operative indication for unruptured cerebral aneurysms is larger than 5 mm, but we have often encountered patients with subarachnoid hemorrhage (SAH) caused by small ruptured cerebral aneurysms. The aim of our study was to evaluate retrospectively the characteristics of ruptured cerebral aneurysms under 5 mm in size on 3-dimensional digital rotation angiography (3D-RA). Eighty patients who presented with acute SAH caused by ruptured aneurysms were admitted in our hospital between January 2003 and September 2007. All patients were examined with 3D-RA and divided into two groups by aneurysmal size; group A was under 5 mm (N = 18), group B was larger than 5 mm (N = 62). Of aneurysms under 5 mm, 45% were located in the anterior communicating artery or anterior cerebral artery, 78% were female and 78% were treated with clipping. Clips of mini and/or the slim type were often applied for aneurysmal clipping. 3D-RA images were useful not only in identification of smaller aneurysms, but also in assessing aneurysmal morphology and relationships to neighboring vessels. However, in the cases of small aneurysms, it is necessary to remember that aneurysms become blood blister-shaped or thrombosed. The clipping for the aneurysm should be performed with consideration of choice for clips consisting of various types according to aneurysmal morphology.

Analysis of risk factors for infection in coplacement of percutaneous endoscopic gastrostomy and ventriculoperitoneal shunt.

Patients with severe neurological impairment requiring tube feeding may have concomitant hydrocephalus. Coplacement of percutaneous endoscopic gastrostomy (PEG) and ventriculoperitoneal (VP) shunting is currently standard in such cases. The present study investigated the risk factors for shunt infection in such patients. The medical records of 23 patients with PEG and VP shunting were retrospectively reviewed. Correlations between shunt system infection and potential risk factors were analyzed including order of PEG and VP shunting, position of abdominal shunt catheter, diabetes mellitus, tracheostomy, and activities of daily living. Twelve patients underwent VP shunting after PEG and 11 underwent PEG after VP shunt placement. Four patients experienced shunt infection, and three required shunt revision. Three of these four patients underwent VP shunting after PEG. The period between PEG and VP shunt placement was 18, 19, and 25 days, shorter than the mean period of 29.3 days. VP shunting can be combined with PEG, but a larger study is required to clearly identify the risk factors. Administration of prophylactic antibiotics and a period of at least 1 month between the procedures are recommended, particularly if the shunt is placed after the PEG tube.

[Microvascular decompression for glossopharyngeal neuralgia: case report].

We report the case of a glossopharyngeal neuralgia that was successfully treated using microvascular decompression (MVD). A 61-year-old female reported intermittent piercing pain from tongue to pinna on the left side. Although she had been prescribed carbamazepine and has undergone attempted nerve block on several occasions, no pain relief has been achieved. MVD was thus attempted using a lateral suboccipital approach. The offending vessel, which was PICA, had adhered to the glossopharyngeal nerve and was repositioned laterally away from the nerve by interposition of a felt cushion. Pain disappeared immediately after surgery and has not recurred. In the literature, MVD for glossopharyngeal neuralgia has been performed using a transcondylar approach to achieve minimally invasive surgery. However, the sensory distributions for the floor of the oral cavity and tongue involve 4 overlapping nerves: the trigeminal nerve, sensory components of the facial and vagal nerves, and the glossopharyngeal nerve. In typical cases, it seems that the transcondylar fossa approach is appropriate for glossopharyngeal neuralgia. If the pain occurs in the place involving an overlapping nerve, the lateral suboccipital approach might be necessary.

[A case of atypical meningioma with Lhermitte-Duclos disease].

Lhermitte-Duclos disease is known as an uncommon disease that characterized by a slowly progressive tumor of the cerebellar hemisphere. We present a case of atypical meningioma with Lhermitte-Duclos disease. A 57-year-old female was admitted to our hospital after presenting with general convulsion. CT scan on arrival showed a large mass of the left frontal region and slightly high-density linear lesion in the right cerebellar hemisphere. MRI also revealed well-enhanced mass in the left frontal region and parallel linear striation in the right cerebellar hemisphere. But, the patient had neither cerebellar dysfunction nor signs of increased intracranial pressure. The patient had angioma of the left breast and bilateral benign struma, no typical manifestation of Cowden syndrome. Removal of the frontal tumor caused the convulsion was subsequently performed. The pathological examination was atypical meningioma. After the operation, radiation therapy was not done because of the total removal of tumor and intension on patient side. Fortunately, the patient had no further adverse neurological events postoperatively. However, we should continuously take account to not only the recurrence of meningioma but also the enlargement of the cerebellar lesion and the complication of malignant tumors in whole body.

Internal carotid artery occlusion following correction of atypical aortic coarctation-- case report--.

An 11-year-old boy developed occlusion of the left internal carotid artery (ICA) following surgical correction of atypical coarctation of the aorta. The patient was admitted to our hospital after presenting with severe hypertension secondary to abdominal aortic hypoplasia and renal artery stenosis. Reconstruction of the abdominal aorta with bypass grafting was performed without complication. However, in the postoperative period, the patient experienced recurrent transient ischemic attacks manifesting as paresthesia of the right upper limbs, dysarthria, and right-sided weakness. Cerebral angiography revealed occlusion of the C(2) portion of the left ICA and decreased resting cerebral blood flow in the left hemisphere. Extracranial-intracranial arterial bypass was performed, and the patient suffered no further adverse neurological events. Coarctation of the aorta is an uncommon congenital condition that may result in cerebral ischemic disease. The cerebrovascular circulation should be evaluated, even in patients without a pre-existing history of cerebral ischemic symptoms.

Metastatic leiomyosarcoma of the brain manifesting as multiple hemorrhages. Case report.

A 74-year-old man presented with a rare metastatic leiomyosarcoma of the brain manifesting as subacute development of multiple cerebral hemorrhages. Cerebral angiography demonstrated no tumor staining or vascular malformation. Whole body computed tomography revealed abnormal masses in the liver, left adrenal gland, and duodenum. Histological examination of an open biopsy specimen identified the lesion as metastatic leiomyosarcoma. Whole brain irradiation controlled the intracranial lesions, but the patient's general condition progressively deteriorated and he died of pneumonia. Metastatic leiomyosarcoma is a very uncommon tumor in the central nervous system with a poor response to existing treatment options. Consequently, new approaches to the treatment of this disease are needed.

[A case of aqueductal stenosis with acute progressive hydrocephalus during pregnancy].

The authors present a case of aqueductal stenosis (AS) with acute progressive symptoms during pregnancy. A 39-year-old pregnant woman in 19th gestation week was admitted with headache, nausea and deterioration of consciousness. On admission, computed tomography (CT) scan showed acute hydrocephalus. Ventricular drainage was performed on emergency and her symptoms were resolved in a few days. Postoperative T2-weighted MR images showed enlargement of the lateral and third ventricles with membranous occlusion of the aqueduct. Endoscopic third ventriculostomy was performed uneventfully. A healthy baby was delivered by Cesarean section in 36th gestation week considering her previous extirpation of hysteromyoma. In this case of pregnant woman, increase of total body water, cardiac output, and central venous pressure, and decrease in plasma osmotic pressure might contribute to development and sudden worsing of symptoms of pre-existed hydrocephalus due to aqueductal stenosis. Endoscopic third ventriculostomy, especially in the pregnant case, should be recommended in hydrocephalus due to aqueductal stenosis to avoid shunt malfunction caused by increasing intraabdominal pressure and shunt infecton during Cesarean section.

Shunt malfunction caused by mischievous twisting of the valve by the patient: case report.

OBJECTIVE AND IMPORTANCE: We report an instructive case of repetitive shunt obstruction caused by mischievous turning of the valve by the patient. CLINICAL PRESENTATION: A 7-year-old boy underwent shunt replacement for hydrocephalus caused by intraventricular hemorrhage at birth; the shunt had been revised a month earlier. The boy experienced occasional episodes of headache and vomiting after the revision. A shunt survey revealed a twisted tube just proximal to the valve. INTERVENTION: After the valve was returned to its original position, the symptoms resolved. The patient confessed to a recent habit of turning the valve. CONCLUSION: Although turning of the valve may be a potential cause of shunt obstruction, the use of craniography and/or a shunt series should be able to reveal these changes.

[A case of subependymal giant cell astrocytoma not associated with tuberous sclerosis].

The authors present a case of a subependymal giant cell astrocytoma (SGCA) not associated with tuberous sclerosis. On admission, a six-year-old boy had obstructive hydrocephalus caused by a huge intraventricular tumor. Preoperative T1-weighted MR images with gadolinium showed heterogeneous enhancement of the lesion. The tumor was totally removed through a right transcortical approach with frontal craniotomy. Immunohistochemical staining for glial fibrillary acidic protein (GFAP) showed a positive reaction in some of the large tumor cells and the labeling index of MIB-1 was < 1.0%. Histological examinations revealed SGCA. He has no other evidence of tuberous sclerosis at present, but the patient in this case is an infant, so there is a possibility of his being diagnosed as tuberous sclerosis in the future. Therefore, systemic regular follow-up is recommended, even when his condition is asymptomatic.

A ruptured distal posterior inferior cerebellar aneurysm. Our case and review of the literature.

We present a case of ruptured distal posterior inferior cerebellar artery (PICA) aneurysm, and review the literature and discuss the treatment strategy. A 77-year-old woman presented with the sudden onset of severe headache, nausea and vomiting. Computed tomography revealed an intraventricular hemorrhage, predominantly in the fourth ventricle and hydrocephalus with a thin subarachinoid hemorrhage (SAH). Angiography revealed an aneurysm arising at the turning point of the vessel, from the telovelotonsillar segment of the right PICA. On the 17th day after the onset, repeated angiography revealed a smaller aneurysm than the one detected on the first day at the same place and with no spasm. On the 22nd day, the aneurysm was proved to be partially thrombosed and was safely clipped via a right lateral suboccipital approach. SAH with a fourth ventricular hemorrhage or an isolated fourth ventricle hemorrhage should raise the suspicion of a distal PICA aneurysm. Aneurysms of the distal PICA have often been reported to arise at a turning point of the artery rather than at a junction of the vessel. It is suggested that the pathogenesis could be hemodynamic stress that has developed due to embryological factors. Distal PICA aneurysms have often gone detected in many previous cases because of thrombosis inside the aneurysms. Thus, particularly in the case of intentionally delayed surgery, we recommend repeated angiography under various conditions to identify how the aneurysm develops just before surgery.

Dissecting basilar artery aneurysm growing during long-term follow up--case report.

A 58-year-old male presented with a dissecting aneurysm of the basilar artery manifesting as dysarthria, left hemiparesis, and numbness of the left side. Angiography revealed a double lumen at the midportion of the basilar artery which was consistent with a diagnosis of dissecting basilar artery aneurysm. The patient was treated conservatively, and remained neurologically stable for a 5-year period following initial presentation, but serial magnetic resonance imaging revealed growth of the aneurysm compressing the brain stem. His condition then worsened. Computed tomography revealed obstructive hydrocephalus. Ventriculoperitoneal shunting was performed and the patient's symptoms improved. However, he died of subarachnoid hemorrhage. Autopsy showed the patient had had a type 3 "dolichoectatic dissecting aneurysm." Surgical treatment should be seriously considered for treating the patients with dissecting basilar artery aneurysm causing brain stem ischemia, especially if the aneurysm is growing. High-flow bypass and proximal occlusion may be the choice in patients with poor collateral circulations.