[Magnetic resonance vessel wall imaging reveals rupture site in subarachnoid hemorrhage with multiple cerebral aneurysms].

We report a case of subarachnoid hemorrhage(SAH)with multiple cerebral aneurysms, in which magnetic resonance vessel wall imaging(MR-VWI)revealed the rupture site. A 68-year-old woman presented with SAH. Computed tomography(CT)showed diffuse SAH(Fisher group 3). 3D-CT angiography revealed two intracranial aneurysms:a 4.2-mm anterior communicating artery aneurysm(Acom An)and a 5.8-mm basilar tip aneurysm(BAtip An). As the BAtip An was the larger of the two, it was deemed the most likely site of rupture;however, high-resolution MR-VWI with gadolinium showed thick wall enhancement in the Acom An and no enhancement in the BAtip An. Thus, we performed a craniotomy for the Acom An. Intraoperative findings confirmed the rupture site at the Acom An. We concluded that high resolution MR-VWI may be useful for identifying the rupture site in patients with spontaneous SAH and multiple cerebral aneurysms.

[A case of calcified chronic subdural hematoma wherein MRI was useful for decision of the treatment strategy].

Calcified chronic subdural hematoma is a rare condition, representing 0.4-2.6% of all chronic subdural hematomas. It is often difficult to remove the hematoma without damaging the brain, owing to the adhesion between hematoma capsule and brain. Therefore, surgical intervention in managing calcified chronic subdural hematoma cases is still considered controversial. We report a case of calcified chronic subdural hematoma, which was successfully performed under microscopic guidance. A 72-year-old man complained of progressive left hemiparesis of 6-month duration. A CT scan revealed a calcified chronic subdural hematoma, 10 cm long and 4.5 cm thick, in the right convexity. On MRI, T2-weighted images showed a thin layer of cerebrospinal fluid intensity between the hematoma capsule and brain. There was no brain edema adjacent to the chronic subdural hematoma. Based on these MRI observations, we believed that adhesion between the hematoma capsule and brain would be mild. We then planned and succeeded in total removal of the calcified chronic subdural hematoma mass under microscopic guidance. The left hemiparesis disappeared after surgery. The patient was discharged without any neurological deficit. While considering surgical management in calcified chronic subdural hematoma cases, it should be important to evaluate adhesion between the hematoma capsule and brain with MRI.

Bilateral carotid and vertebral rete mirabile presenting with subarachnoid hemorrhage caused by the rupture of spinal artery aneurysm.

Rete mirabile (or carotid rete) is a normal structure that plays physiological roles in the lower mammals. However, the rete does not exist in the normal carotid circulation of humans. Carotid rete mirabile (CRM) is a rare condition compensating for congenital dysplastic internal carotid artery. Arterial plexus at the cavernous region, which supplies intradural internal carotid artery instead of the aplastic cavernous portion of internal carotid artery, looks like the "rete mirabile" seen in the lower mammals, and is a characteristic angiographical finding of CRM. In addition to the CRM, existence of segmental occlusion and tortuous collaterals of vertebral artery, so-called carotid and vertebral rete mirabile (CVRM), is a very rare condition. We report a 70-year-old female patient with bilateral CVRM presenting with subarachnoid hemorrhage (SAH) caused by the rupture of a cervical spinal artery aneurysm. Our patient is the oldest, compared with the previously reported four patients with CVRM. Moreover, this is the first report of ruptured spinal artery aneurysm as a cause of SAH associated with CRM/CVRM. To avoid rebleeding in the patient, we successfully treated the patients by performing coil embolization of the remaining spinal aneurysms. In patients with CVRM, aneurysm formation of the cervical spinal artery may be a reasonable consequence because of the hemodynamic stress on the spinal artery as a collateral pathway. Detailed evaluation of the cervical spinal arteries should be performed to detect or to rule out ruptured aneurysm in patients with SAH associated with CVRM.

Superselective intra-arterial chemoradiotherapy with docetaxel-nedaplatin for advanced oral cancer.

Cisplatin-based, superselective, intra-arterial chemotherapy concurrent with radiotherapy (SSIACRT) has gained wide acceptance as a common/curative treatment for advanced head and neck cancer. We combined nedaplatin (CDGP) with docetaxel (DOC) as a new combination in SSIACRT for advanced oral squamous cell carcinoma in 2003. Twenty-two patients with advanced oral cancer were treated by radiotherapy (66 Gy) concurrent with superselective intra-arterial DOC (40 mg/body) and CDGP (80 mg/m²) infusion between 2003 and 2009. Complete response was achieved in 18 (81.8%) of the 22 patients. Of the 17 patients with positive neck disease, 16 (94%) were assessed as disease-free. The 5-year overall survival rate was 78.5%, and the major adverse effects were leukocytopenia and mucositis. Five patients (22.7%) developed distant metastases post-treatment. These results indicate that intra-arterial docetaxel-nedaplatin infusion concurrent with radiotherapy is efficacious for advanced oral cancer. The side effects are easily manageable, and the most important outcome of the treatment is the preservation of patients' quality of life (QOL) and improved prognosis.

Lymphoscintigraphy for sentinel lymph node mapping in Japanese patients with malignant skin neoplasms of the lower extremities: comparison with previously investigated Japanese lymphatic anatomy.

OBJECTIVES: Lymph nodes (LN) and lymphatic drainage were identified by lymphoscintigraphy using 99(m)Tc-phytate in order to map the sentinel lymph nodes (SLNs) in patients with malignant skin neoplasms of the lower extremities, and to compare the results with an atlas of Japanese lymphatic anatomy. METHODS: Sentinel lymphoscintigraphs of 18 patients with malignant skin neoplasms of the lower extremities (9 men, 9 women; age range 45-84 years, mean age 66 years) were analyzed retrospectively, and the LNs detected were identified as SLNs or secondary nodes. RESULTS: The patterns of lymphatic drainage were divided into three different categories: (1) initial drainage into inguinal LN without visualization of popliteal LNs (inguinal type), (2) initial drainage into popliteal LNs and then into intrapelvic LNs (popliteal type), and (3) initial drainage into both popliteal and inguinal LNs (inguinal and popliteal type). More than half of the cases were the inguinal and popliteal type, as both inguinal and popliteal LNs were identified as SLNs. In the cases in which the hallux and its surrounding area were injected, all were the inguinal type and popliteal LNs were not visualized. In one case, only dynamic images detected lymphatic drainage without visualization of popliteal LNs. In contrast to the previously published literature on Japanese lymphatic anatomy, SLN lymphatic drainage from the skin of the lower extremities was wide and overlapping in many areas. However, in agreement with currently accepted anatomy, only the great saphenous lymphatic vessel drained the skin of the hallux and its surrounding area. The present results suggest that it is important to confirm lymphatic drainage in order to identify SLNs in the lower extremities. CONCLUSIONS: The patterns of lymphatic drainage from the skin of the foot were divided into three different categories. In contrast to previously published Japanese lymphatic anatomy, lymphatic drainage from the skin of the lower extremities was wide and overlapping in many areas. However, only the great saphenous lymphatic vessel drained the skin of the hallux and its surrounding area in agreement with currently accepted Japanese lymphatic anatomy. It is important to confirm lymphatic drainage to identify SLNs in the lower extremities.

Dilated outer diameter of the dissected artery: acute bilateral anterior cerebral artery dissection evaluated by repeat magnetic resonance cisternography. Case report.

A 42-year-old male patient presented with an anterior cerebral artery (ACA) dissection manifesting as sudden onset of severe headache. Initial computed tomography revealed faint subarachnoid hemorrhage in the frontal region. Initial angiography showed tapering stenosis at the A(2) segment of right ACA. The patient was admitted to our hospital and treated conservatively. Magnetic resonance (MR) imaging and angiography did not detect intramural hematoma, intimal flap, or double lumen at the stenotic right A(2) segment. The ACA dissection was difficult to confirm based on the findings on day 0. ACA dissection was confirmed by improvement of the right ACA stenosis on follow-up angiography on day 14. On the other hand, MR cisternography revealed a fusiform dilatation of the vascular outer contour at the right A(2) on day 0, which had resolved on day 14. Cerebral angiography and MR cisternography similarly suggested asymptomatic contralateral (left) A(2) dissection on day 14. Fusiform dilatation of the vascular outer contour at the affected segment on MR cisternography may be indicative of arterial dissection in the acute phase.

Incidence of unilateral distal vertebral artery aplasia: evaluation by combining basiparallel anatomic scanning-magnetic resonance imaging (BPAS-MRI) and magnetic resonance angiography.

PURPOSE: The incidence of a unilateral aplastic distal vertebral artery (VA) has been reported as 0.2% of cases on cerebral angiography. During our daily magnetic resonance (MR) examinations, however, we frequently encounter MR angiograms (MRAs) that do not demonstrate unilateral VA. The purpose of this study was to calculate the frequency of aplastic unilateral distal VA by MR images performed for asymptomatic people. MATERIALS AND METHODS: Over a time span of 1 year, 237 asymptomatic people (140 men, 97 women; ages 28-67 years, mean 54.4 years) underwent brain MRI during a "brain check-up examination" in our hospital. To identify an aplastic unilateral distal VA, we retrospectively compared three-dimensional time-of-flight MRA with basiparallel anatomic scanning (BPAS)-MRI which was designed for recognition of the arterial outer contour. RESULTS: Aplasia of the unilateral distal VA was confirmed in 11 persons (4.6%). According to our classification, hypoplastic distal VA in 12 (5.1%) and asymptomatic acquired unilateral distal VA occlusion was also proved in 2 (0.8%). CONCLUSION: We found that the frequency of aplastic unilateral VA was 4.6% in asymptomatic people using a combination of MRA and BPAS-MRI for assessment of an intracranial VA.

Bolus injection of contrast agents with various iodine concentrations and delivery rates for intracranial three-dimensional CT angiography: evaluation of intracranial arteriovenous contrast using a multidetector-row CT scanner.

PURPOSE: We evaluated the difference in computed tomography (CT) attenuation values of the intracranial arterial and venous systems among the various contrast injection protocols (higher iodine delivery rate or higher concentration of the agent) on the source images of intracranial three-dimensional CT angiography (3D-CTA) using a multidetector-row CT (MDCT) scanner. MATERIALS AND METHODS: We used 100 ml of iopamidol 300 at an injection rate of 3.0 ml/s, 100 ml of iopamidol 300 at an injection rate of 3.7 ml/s, and 80 ml of iopamidol 370 at an injection rate of 3.0 ml/s. There were 10 patients in each group. Attenuation values of the bilateral internal carotid arteries (ICAs), basilar artery trunk, bilateral cavernous sinuses (CSs), and Galenic vein were measured quantitatively on the axial CT angiographic source images obtained by four-channel MDCT. RESULTS: Injection of the high-concentration contrast with a higher iodine-delivery rate achieved good arteriovenous contrast at the cavernous portion. With the same rate of iodine delivery, injection of the intermediate concentrate agent increased the CT value of not only the ICAs but also the CSs. CONCLUSION: High-concentration contrast could increase ICA attenuation without intracavernous attenuation gain during the "first-pass" phase.

[A case of direct carotid cavernous fistula, whom three-dimensional computed tomographic angiography was helpful for decision making of selective coil embolization].

We reported the case of an 84-year-old female suffering from chemosis and exophthalmos. Carotid arteriograms revealed a direct carotid-cavernous fistula (CCF) but could not clearly show the fistula point because of its high-flow nature. We then performed three-dimensional computed tomographic angiography (3D-CTA) using a multi detector-row CT (MDCT) scanner. Multi-planar reformatted CT images distinctly revealed a right carotid aneurysm at the cavernous portion and a shunting point between the aneurysm and the cavernous sinus. Based on this information, we opted to performa transvenous coil embolization to treat this patient. Successful selective coil embolization was performed at the fistulous point was done with a smaller number of coils than ordinarily required in sinus packing. Performing 3D-CTA by using a MDCT was helpful in decision making for the selective coil embolization to treat direct CCF.

Attenuation values of the intracranial arterial and venous vessels by bolus injection of various contrast agents: a study with a single-detector helical CT scanner.

PURPOSE: We evaluated the arteriovenous contrast on the source images of intracranial three-dimensional computed tomography (CT) angiography (3D-CTA) using a high-concentration (370 mg I/ml) contrast agent in comparison with intermediate-concentration (300 mg I/ml) contrast. MATERIALS AND METHODS: With a fixed intravenous injection rate and scanning delay, 3D-CTA was performed using a single-detector helical CT scanner in 30 consecutive patients. We used 100 ml of iohexol 300 for 10 patients, 100 ml of iopamidol 300 for 10 patients, and 80 ml of iopamidol 370 for 10 patients. Attenuation values of the bilateral internal carotid arteries, bilateral middle cerebral arteries, basilar artery trunk, bilateral cavernous sinuses, bilateral basal veins, and Galenic vein were measured quantitatively on the axial CT angiographic source images. RESULTS: High-concentration contrast significantly increased the attenuation values of the intracranial arterial system without increasing the attenuation of the venous system. CONCLUSION: High-concentration contrast is helpful for obtaining valuable arteriovenous contrast on source images with intracranial 3D-CTA.

Salivary gland carcinoma treated with concomitant chemoradiation with intraarterial cisplatin and docetaxel.

Malignant neoplasms of the salivary gland are uncommon entities in which surgical resection of the primary lesion has been accepted as a standard therapeutic option. The efficacy of radiation and systemic chemotherapy has been limited for patients with recurrent, metastatic, or unresectable disease because of unfavorable response rates and the short duration of the response. We treated one patient with recurrent adenoid cystic carcinoma arising from the sublingual gland and one patient with primary adenocarcinoma arising from the parotid gland with transfemoral intraarterial chemotherapy, based on full-dose cisplatin and docetaxel and concurrent external-beam radiotherapy. The doses of cisplatin and docetaxel in the two patients were 80-100 mg/m2 and 10-15 mg/m2, respectively. Docetaxel was infused first, followed by cisplatin. Both patients obtained complete responses. Although complications such as mucositis, anorexia, neutropenia, and ischemic colitis were observed, they were well tolerated and manageable. The concomitant chemoradiotherapy of cisplatin and docetaxel seemed to be a practicable option for patients with recurrent and unresectable salivary gland carcinomas.

Surface appearance of the vertebrobasilar artery revealed on basiparallel anatomic scanning (BPAS)-MR imaging: its role for brain MR examination.

PURPOSE: Basiparallel anatomic scanning (BPAS)-MR imaging is a simple MR imaging technique that we designed for visualization of the surface appearance of the vertebrobasilar artery within the cistern. It can clearly show the outer contour of occluded arteries or thrombosed aneurysms. By comparing BPAS-MR imaging with 3D time-of-flight (TOF) MR angiography (MRA), we can precisely evaluate the vertebrobasilar artery condition. The purpose of this study is to determine the value of BPAS-MR imaging for brain MR examination. MATERIALS AND METHODS: We obtained BPAS-MR imaging, in addition to 3D TOF MRA, for 385 consecutive patients who underwent brain MR imaging and MRA in our hospital between April 1 and August 31, 2003. Their complaints varied from mild head symptoms to severe neurologic illness. Comparing BPAS-MR imaging with MRA, we revealed the character of BPAS-MR imaging and determined the role and value of displaying vascular outer contour. RESULTS: Although the cases did not represent a restricted group of vertebrobasilar diseases, BPAS-MR imaging contributed to accurate evaluation of the vertebrobasilar artery in 90 of our 385 patients (23.4%). Of particular note, 16.1% of our patients could not be evaluated accurately by MRA only. BPAS-MR imaging was useful to confirm hypoplastic or occluded vertebral arteries and to reveal the whole appearance of large or partially thrombosed aneurysms of the vertebrobasilar system. CONCLUSION: The combination of the BPAS-MR imaging and the 3D TOF MRA was necessary for accurate diagnosis in 16.1% of our ordinary patients. We should evaluate not only MRA but also the vascular outer contour revealed on BPAS-MR imaging, though its application is limited to the vertebrobasilar system and the screening use.

Extravasation from rupturing aneurysm demonstrated by 3D digital subtraction angiography.

We describe the 3D digital subtraction angiography (3D-DSA) image of extravasation from a rupturing aneurysm. This image clearly showed that the extravasation was coming from a pseudoaneurysm on an aneurysmal wall. To the best of our knowledge, this is the first demonstration of a 3D-DSA image of a rupturing aneurysm.

[Surgical treatment for dissecting aneurysm of the anterior cerebral artery presenting only with headache: a case report].

The authors reported the first case of a dissecting aneurysm of the anterior cerebral artery (ACA) presenting only with headache successfully treated by trapping. A 23-year-old man was admitted to our department due to headache. CT scan and MRI showed neither hemorrhage nor infarction. Angiography demonstrated an aneurysmal dilatation at the right A1 segment with venous pooling which suggested a dissecting aneurysm. We performed trapping and resection of the aneurysm without neurological deficits. The natural history of intracranial dissecting aneurysm without ischemia and/or hemorrhage is still unclear, and therefore it is controversial about the necessity of surgical intervention. Our case and review of the literature suggest that surgical treatment should be considered even in patients without ischemia and/or hemorrhage, if it is possible in consideration of hemodynamic condition.

[Basi-parallel anatomical scanning (BPAS) MRI: a simple MRI technique for demonstrating the surface appearance of the intracranial vertebrobasilar artery].

We modified surface anatomy scanning (SAS) MRI to reveal the surface appearance of the vertebrobasilar artery in the cistern. Two-cm-thick heavily T2-weighted coronal imaging using the fast spin-echo sequence with gray-scale reversal in post-processing was best for our purposes. Basi-parallel anatomical scanning (BPAS) MRI could clearly demonstrate fusiform aneurysm and its disappearance at the acutely occluded segment of the dissected vertebral artery. This simple MRI scanning technique can provide useful information on vertebrobasilar vascular lesions especially in patients with arterial dissection.