Wall Enhancement of the Intracranial Aneurysms Revealed by Magnetic Resonance Vessel Wall Imaging Using Three-Dimensional Turbo Spin-Echo Sequence with Motion-Sensitized Driven-Equilibrium: A Sign of Ruptured Aneurysm?

PURPOSE: Wall enhancement of saccular cerebral aneurysms has not been researched sufficiently. Our purpose of this study was to investigate the incidence of aneurysmal wall enhancement by the three-dimensional turbo spin-echo sequence with motion-sensitized driven equilibrium (MSDE-3D-TSE) imaging after gadolinium injection. METHODS: We retrospectively reviewed the pre- and postcontrast MSDE-3D-TSE images of 117 consecutive patients with intracranial aneurysms from September 2011 to July 2013. A total of 61 ruptured and 83 unruptured aneurysms of 61 patients with subarachnoid hemorrhage (SAH) and 56 non-SAH patients were enrolled in this study. We evaluated the wall enhancement of each aneurysm on postcontrast MSDE-3D-TSE images compared with precontrast images. We classified the aneurysmal wall enhancement into three groups as "Strong enhancement," "Faint enhancement," and "No enhancement." RESULTS: "Strong/Faint enhancement" of the aneurysm was detected in 73.8/24.6 % of the ruptured aneurysms and 4.8/13.3 % of the unruptured aneurysms. "No enhancement" was found in 1.6 % of the ruptured aneurysms and 81.9 % of the unruptured aneurysms. CONCLUSIONS: By magnetic resonance vessel wall imaging using the MSDE-3D-TSE sequence, wall enhancement was frequently observed on ruptured aneurysms. Therefore, aneurysmal wall enhancement may be an indicator of the ruptured condition, which is useful information for managing patients with SAH.

Which factors increase procedural thromboembolic events in patients with unruptured paraclinoid internal carotid artery aneurysm treated by coil embolization?

We analyzed the factors which increase the frequency of procedural thromboembolic events during coil embolization of unruptured paraclinoid internal carotid artery aneurysms. Neurologically symptomatic complications did not occur in our series. Silent hyperintense lesions on postoperative DWI were frequently detected after the coiling procedure in which we needed to withdraw the unreleased coil. Patient's age, sex, aneurysm diameter, packing density, use of balloon-assisted technique, and exchanging maneuver of microcatheter during the procedure did not increase the frequency of silent thromboembolic events.

Morphological Change of Unruptured Vertebral Artery Dissection on Serial MR Examinations. Evaluation of the Arterial Outer Contour by Basi-parallel Anatomical Scanning (BPAS)-MRI.

SUMMARY: Basi-parallel anatomical scanning (BPAS)- MRI is a simple MRI technique to reveal the surface contour of the intracranial vertebrobasilar artery. The purpose of this study was to investigate the usefulness of BPAS-MRI for observing the temporal course of unruptured vertebral artery (VA) dissection in patients by means of serial MR examinations. Since April 2003, we performed serial MR examinations in four patients with unruptured acute vertebral artery dissection. The frequency of the MR examinations during the follow-up period in each patient varied from twice within seven months to five times within 19 months. Both MRA and BPAS-MRI were obtained in each MR examination. We investigated the course of morphological changes within the dissected artery on BPASMRI (outer contour) and on MRA (inner lumen). Although the initial MRA showed fusiform dilatation, irregular stenosis or normal caliber at the dissected lesion, the initial BPAS-MRI disclosed fusiform dilatation in all of the four patients. In two patients, MRA finding of the VA lesion had changed, though the fusiform appearance had been stationary on BPAS-MRI. Then both dissolution of the fusiform dilatation on BPAS-MRI and normalization of the inner luminal caliber on MRA were confirmed within nine months. In one patient, fusiform dilatation on both BPAS-MRI and MRA resolved simultaneously on the MR examination at eight months after the initial symptom. In another patient, fusiform dilatation of the outer contour was still enlarging on BPAS-MRI ten months after the onset, though the fusiform dilatation on MRA had been stationary since the eighth week. We performed endovascular coil embolization in this patient eleven months after the initial symptom. Resolution of the fusiform dilatation on BPAS-MRI should be a healing sign of VA dissection. Persisting the fusiform dilatation or progressively enlarging outer contour on BPASMRI may be an unstable sign. BPAS-MRI provides more information about the instability of the dissected lesion. We should obtain not only MRA but also BPAS-MRI for the course observation of unruptured VA dissection.

Rescue use of endovascular snare for acute basilar artery embolic occlusion resistant to balloon angioplasty and fibrinolysis therapy.

A rescue clot disruption using a basket snare is described for acute basilar artery embolic occlusion resistant to balloon angioplasty and fibrinolysis therapy. In spite of failed balloon angioplasty in conjunction with fibrinolysis, a basket-shaped snare connected to a microguide wire could be used to catch and crush the clot in the upper basilar artery. The rescue use of a snare may be effective for angioplasty-resistant acute embolic stroke.

Successful staged treatment for ruptured blister-like dissecting aneurysm of the intracranial internal carotid artery: acute GDC embolization for the blister-like aneurysm followed by proximal occlusion with extracranial-intracranial bypass in the chronic stage.

The surgical treatment of ruptured blister-like dissecting aneurysm on the internal carotid artery (ICA) is still controversial. We report a case of this disease successfully managed by a staged treatment: GDC packing into the blister-like aneurysm in the acute stage followed by proximal occlusion in the chronic stage. The merit of this staged treatment is to prevent rerupture in the acute stage and to allow the proximal occlusion in the chronic stage with or without an extracranial-intracranial bypass, after assessment of tolerance of the ICA occlusion.

Basi-Parallel Anatomical Scanning (BPAS) - MRI: a Simple and Useful MRI Technique for Pre-Procedural Evaluation in Cases of Basilar Artery Occlusion.

SUMMARY: Basi-parallel anatomical scanning (BPAS)-MRI is a simple MRI technique that we designed to reveal the surface appearance of the vertebrobasilar artery within the cistern. Because it requires only 2 cm-thick heavily T2-weighted coronal imaging with gray-scale reversal, we can obtain BPAS-MRI with any MR machine of any company. BPAS-MRI can easily show the outer contour of the vertebrobasilar artery even if occluded. Therefore, BPAS-MRI can also reveal the occluded basilar trunk and the shape of basilar top branching that we cannot see with any other imaging modality before the recanalizing interventional procedure. To avoid a dangerous blind manipulation of guidewires or micro-catheters, BPAS-MRI should be obtained prior to the interventional procedure in cases of acute basilar artery occlusion.

The choice of treatment method for unruptured cerebral aneurysm. Investigation from clinical outcome, angiographical result, duration of hospital stay, and cost for treatment.

SUMMARY: To compare complications, anigographical results, duration of postoperative hospital stay and cost for treatment of surgical clipping and coil embolization in the treatment of unruptured cerebral aneurysm. One hundred and nine non-giant saccular aneurysms in 90 patients were treated by either endovascular treatment (E group) or direct surgery (S group) in our Neurosurgical Department between April 1996 and April 2002. The complications and angiographical results were reviewed. The duration of postoperative hospital stay and cost for the treatment were calculated from bills for health insurance for 38 operations and 12 embolizations in 47 patients whose aim of hospitalization was only treatment for their unruptured aneurysm. Neck clipping was performed for 89 aneurysms (S group), wrapping for four (S group), embolization using Guglielmi's detachable coils (GDCs) for 15 (E group), and failed embolization followed by clipping for one (E group). The postoperative temporary deficit (disappeared within one month) and permanent deficit was seen in five cases (6.7%) and in three cases (morbidity: 4.0%) of S group, and in one case (6.7%) and none (morbidity; 0%) of E group, respectively. No death was seen in both group (mortality; 0% in both group). The rate of angiographical complete occlusion of the aneurysm was significantly higher in S group (P = 0.015, 88% in S group vs 50% in E group). The postoperative hospital stay was significantly shorter in E group (P= 0.000013, mean days: 17.1 in S group vs 6.3 in E group), but cost for treatment was rather cheep in S group (N.S., mean cost: 1684329 yen in S group vs. 2259011 in E group). This retrospective study suggested that surgical treatment may be less expensive treatment with higher rate of postoperative angiographical complete occlusion than coil embolization, and treatment-related complication rate was similar in both treatment.

Retinal embolization and cerebellar asymptomatic embolization after carotid stenting using distal balloon protection. A case report.

SUMMARY: We describe a rare case of having both symptomatic ipsilateral retinal embolization and asymptomatic cerebellar embolization occurring after carotid stenting with use of distal protect device. In this case, external carotid angiograms revealed accessory meningeal arteryophthalmic artery and occipital artery-vertebral artery anastomoses. This case suggested that the protection for external carotid artery should be considered during carotid stenting to avoid retinal embolization and cerebellar or cerebral embolization in cases showing angiographical anastomoses between external carotid artery and ophthalmic artery or intracranial arteries.

Contralateral inferior petrosal sinus approach for transvenous embolization of a dural arteriovenous fistula at isolated jugular bulb. Technical case report.

A contralateral inferior petrosal sinus approach is described for the successful treatment of a case of a dural arteriovenous fistula at an isolated right jugular bulb presenting with chemosis. A microcatheter could be inserted into the right jugular bulb from the left jugular bulb through the left inferior petrosal sinus, basilar sinus on the dorsum sellae, and the right inferior petrosal sinus. This unusual approach represents an alternative route to the jugular bulb.

[A case of vertebrobasilar dissection which was associated with progressing stroke and was successfully treated by intravascular surgery in the acute stage].

A case of vertebrobasilar dissection which deteriorated in the acute stage and was successfully treated by intravascular surgery is described. A 26-year-old male presented with sudden onset of occipitalgia, weakness of the right upper and lower extremities, and speech disturbance. He was transferred to our hospital 3 hours after the onset. On admission, neurological examination showed right hemiparesis including the face and dysarthria. CT of the head showed no definite abnormality and left vertebral angiograms (VAG) revealed only slight wall irregularity of the basilar artery. T2-weighted MR imaging demonstrated an area of high intensity in the left side of the pons. He was treated conservatively under a diagnosis of pontine infarction. On the 8th hospital day, he developed left hemiparesis. T2-weighted MR imaging revealed a new high intensity lesion in the opposite side of the pons. 3D-SPGR images showed double lumen of the left vertebral artery. Angiography showed that the wall irregularity of the basilar artery had become more obvious. These findings strongly suggested a dissection extending from the left vertebral artery to the basilar artery. Progression of the dissection was presumed to have caused the worsening in clinical symptoms, and further progression of the dissection would involve perforators of the basilar artery top and would be fatal. To prevent further progression of the dissection, the left vertebral artery was occluded at the proximal site of the orifice of the dissection with platinum coils after a test occlusion on the same day. Postoperatively, further deterioration of the clinical symptoms ceased. Left VAG on the 33rd postoperative day demonstrated improvement in the wall irregularity of the basilar artery. His clinical symptoms improved markedly and he was ambulatory at discharge and returned to his previous occupation. We emphasize that a progressive vertebrobasilar dissection that causes clinical deterioration in the acute stage can be prevented from progressing further by occlusion at the proximal site of the orifice of the dissection.

Edema along the optic tract: a useful MR finding for the diagnosis of craniopharyngiomas.

BACKGROUND AND PURPOSE: The pattern of edema caused by craniopharyngiomas and other common suprasellar masses could be useful for determining the differential diagnosis of lesions in this region. The purpose of this study was to ascertain whether the pattern of edema spread on MR images can be used in the diagnosis of craniopharyngiomas. METHODS: The preoperative MR images in eight consecutive patients with craniopharyngiomas, 15 patients with large pituitary adenomas compressing the optic chiasm, and six patients with tuberculum sellae meningiomas were evaluated. All the patients were treated surgically at our hospital and a pathologic diagnosis was obtained. We analyzed the spread of edema surrounding the tumor on the coronal dual-echo fast spin-echo images and compared this finding with tumor location and size as seen on contrast-enhanced T1-weighted images. RESULTS: Not only peritumoral edema but also edema spreading along the optic tracts was observed in five patients with craniopharyngiomas, one of whom also had edema within one optic nerve. The location of edema in the visual pathway was not always associated with the degree of visual disturbance. None of the patients with large pituitary adenomas or with tuberculum sellae meningiomas had such edema along the visual pathway. CONCLUSION: Edema caused by craniopharyngiomas tends to spread along the optic tracts. It is a useful MR finding for distinguishing craniopharyngiomas from other common parasellar tumors.

[A case of a ruptured lingual artery aneurysm treated with endovascular surgery].

A rare case of a ruptured lingual artery aneurysm treated with endovascular procedure in presented. A 67-year-old woman undergoing treatment in our hospital for right thalamic hemorrhage complained of sudden swelling in the submandibular area and breathlessness. The swelling was so rapid and progressive that her breathing was disturbed. She was intubated as soon as possible. Computed tomography (CT) showed a massive subcutaneous hematoma, extending from the left submandibular area to the neck, which had compressed the trachea to the right. CT with contrast medium showed extravasation of the medium for this lesion. Angiography showed that the aneurysm was located on the periphery of the left ingual artery. Extravasation of contrast medium from the aneurysm was also observed. We considered that direct surgery was difficult to perform safely, so we chose an endovascular procedure to treat this lesion. The lingual artery was successfully embolized using four platinum coils. No rebleeding or other complication occurred after the coil embolization. Disturbance of breathing due to air way obstruction is an important symptom of a ruptured lingual artery aneurysm. Endovascular surgery may be the first choice for treatment of the bleeding origin.

Arterial dissection of the vertebrobasilar systems: a possible cause of acute sensorineural hearing loss.

OBJECTIVE: Our goal was to describe three cases of acute sensorineural hearing loss (ASNHL) that might be caused by arterial dissection of the vertebrobasilar system. DESIGN: Retrospective case review. SETTING: Yamagata University Hospital, Yamagata, Japan. PATIENTS: Thirty-seven patients with ASNHL underwent magnetic resonance (MR) imaging between September 1993 and March 1995. INTERVENTIONS: Proton density and T2-weighted axial images and three-dimensional spoiled gradient-recalled acquisition in steady state (3-D SPGR) imaging with gadopentetate dimeglumine were obtained with a 1.5 T MR system in all patients. T1-weighted images were obtained in 23 patients. Vertebral angiography (VAG) was performed in 4 of the 37 patients. RESULTS: In 3 of the 37 patients, the presence of vertebrobasilar dissection was confirmed: contrast-enhanced 3-D SPGR images disclosed double lumen of the proximal basilar artery and/or the ipsilateral vertebral artery in all of the 3 patients. In two of them, the vertebrobasilar dissection was also confirmed by VAG. The hearing loss of all three patients improved after the onset. Audiograms revealed no characteristic pattern of the initial hearing loss among them. CONCLUSIONS: Vertebrobasilar dissection may cause an intramural hematoma involving the orifice of the anterior inferior cerebellar artery or a distal thromboembolism reducing the blood flow of the labyrinthine artery; these conditions can lead to onset of hearing loss. Arterial dissection of the vertebrobasilar system might be one of the causes of ASNHL.

Magnetic resonance imaging in acute optic neuropathy by sphenoidal mucocele.

A 45-year-old man suffered sudden visual loss with Marcus-Gunn pupil and a central scotoma in the right eye as evaluated by visual field examination. The patient's right visual acuity was 0.02 (0.08 x -4.5 D). T1-weighted magnetic resonance imaging (MRI) demonstrated a cystic lesion of high intensity in the right sphenoid sinus. Short T1 inversion recovery (STIR) images presented a cystic lesion of high intensity in the right sphenoid sinus. In addition, a ring-shaped high intensity signal was seen surrounding the right optic nerve. Post-contrast fat suppression T1-weighted images did not demonstrate any enhancement within the right optic nerve. After intranasal sphenoidectomy, good recovery of the right visual acuity was noted. On subsequent MRI, the cystic lesion in the sphenoid sinus disappeared. Also, the ring of high intensity surrounding the right optic nerve became unclear. It was thought that the ring of hyperintensity seen on the STIR images demonstrated cerebrospinal fluid in the dilated perioptic subarachnoid space. Therefore, these MRI findings suggested that the acute visual loss resulted from a disturbed blood supply to the optic nerve due to compression by the sphenoidal mucocele, and not due to an inflammatory process.

Abducens neuropathy detected by three-dimensional magnetic resonance imaging using a multiplanar reconstruction technique with gadolinium-DTPA enhancement.

Three-dimensional magnetic resonance imaging (3D MRI) using a multiplanar reconstruction technique with gadolinium diethylenetriamine pentaacetic acid (DTPA) enhancement was used for assessment of a 20-year-old woman who had sudden complete restriction of abduction in the right eye. The 3D MRI revealed abducens nerve enhancement in the cisternal portion. An enhanced lesion was also observed in the right lower pons at the pontomedullary junction. These clinical and 3D-MRI findings were diagnosed as right abducens palsy due to abducens neuropathy. Observation of the entire pathway of the cisternal portion of the cranial nerves can be extremely useful in patients with ophthalmoplegia.

Prevalence of vertebral artery dissection in Wallenberg syndrome: neuroradiological analysis of 93 patients in the Tohoku District, Japan.

To assess the prevalence of vertebral artery dissection in Wallenberg syndrome (lateral medullary syndrome), records of 93 patients (70 men, 21 women, and 2 patients not identified by gender; mean age at ictus, 58.1 years) with symptoms of Wallenberg syndrome who underwent MRI and/or vertebral angiography were reviewed retrospectively. Study items included the following: (A) headache; (B) arterial intramural hematoma on T1-weighted images as an MR finding; and (C) double lumen, intimal flap, pearl and string sign, and string sign as angiographic findings. These abnormal findings suggesting vertebral artery dissection were scored as 1 or 2 points. According to his or her total score, each patient was classified as "definite dissection." "probable dissection," "suspected dissection," or "no dissection." Twenty-three of 93 patients were classified as "definite dissection," 23 as "probable dissection," 27 as "suspected dissection," and 20 as "no dissection." The frequency of definite or probable dissection in Wallenberg syndrome was estimated at 50% or more. Thus, vertebral artery dissection is a frequent cause of Wallenberg syndrome.

[Clinical usefulness of three-D cerebral mensional MR imaging in the diagnosis of medullary venous malformation].

Medullary venous malformation (MVM) is one of the most common vascular malformations encountered pathologically. In fact, it is generally discovered incidentally during the workup of other disorders. In 18 cases (19 lesions) of MVM, we evaluated retrospectively the diagnostic value of CT and MRI. We set four evaluations, excellent, good, fair and poor, to assess the diagnostic value of each imaging method. Contrast enhanced CT and pre-contrast MRI could detect the abnormality in 80% of the cases, but it was difficult to demonstrate the umbrella like medullary vein. Contrast enhanced MRI showed the umbrella sign in 60%. Images reformated with three-dimensional (3-D) MR imaging were better able to demonstrate this structure. Medullary vein collection, drainage into a single central vein and termination into a superficial cortical vein or a dural sinus were clearly demonstrated in all cases. Thus, all cases were diagnosed correctly as MVM. Contrast enhanced 3-D MR imaging was superior to other imaging techniques except angiography.

[Habilitation for handicapped children, mainly for children with visual and hearing impairment, speech-language disorder, and hyperkinetic disorder].

This symposium was focused on habilitation for children with visual and hearing impairment, speech-language disorder, and hyperkinetic disorder. New and variable approaches were reported in topics of habilitation for these handicapped children by an ophthalmologist, an otorhinolaryngologist, a child neurologist, a speech therapist and an educational psychologist. Many points of these approaches were then discussed.

[Neuropsychological and psychiatric problems in epileptic children].

In the treatment of epileptic children, it is important to give considerations to the child's psychological aspects. One of considerations should be given to the neuropsychological disorders, since it is sometimes observed that learning disabilities coincide with epilepsy. Another consideration should be given to psychiatric disorders. Mental retardation occurs about 20% of epileptic children. Among personality and behavioral problems, hyperactivity is observed in younger children, while a viscous tendency is seen after puberty. The incidence of these two problems is related to the severity of mental retardation. In the course of the treatment of epileptic children, puberty is an important period. It is necessary to assist epileptic children to cope with the disease they have. Although the incidence is small, an acute or chronic epileptic psychosis is observed after puberty. An existence of pseudoseizures should not be forgotten. Cognitive or behavioral problems may occur as a result of anti-epileptic drugs.