Is the Susceptibility Vessel Sign on 3-Tesla Magnetic Resonance T2*-Weighted Imaging a Useful Tool to Predict Recanalization in Intravenous Tissue Plasminogen Activator?

The aim of this study was to investigate the independent factors associated with the absence of recanalization approximately 24 h after intravenous administration of tissue-type plasminogen activator (IV TPA). The previous studies have been conducted using 1.5-Tesla (T) magnetic resonance imaging (MRI). We studied whether the characteristics of 3-T MRI findings were useful to predict outcome and recanalization after IV tPA. Patients with internal carotid artery (ICA) or middle cerebral artery (MCA) (horizontal portion, M1; Sylvian portion, M2) occlusion and treated by IV tPA were enrolled. We studied whether the presence of susceptibility vessel sign (SVS) at M1 and low clot burden score on T2*-weighted imaging (T2*-CBS) on 3-T MRI were associated with the absence of recanalization. A total of 49 patients were enrolled (27 men; mean age, 73.9 years). MR angiography obtained approximately 24 h after IV tPA revealed recanalization in 21 (42.9 %) patients. Independent factors associated with the absence of recanalization included ICA or proximal M1 occlusion (odds ratio, 69.6; 95 % confidence interval, 5.05-958.8, p = 0.002). In this study, an independent factor associated with the absence of recanalization may be proximal occlusion of the cerebral arteries rather than SVS in the MCA or low T2*-CBS on 3-T MRI.

Carotid Artery Angioplasty and Stenting as a First-choice Revascularization Therapy for Cervical Carotid Artery Stenosis.

SUMMARY: We examined the patients with cervical carotid artery stenosis (> 70%) treated by carotid artery angioplasty and stenting (CAS) as a firstchoice direct revascularization therapy. The patients consisted of 45 men and seven women; their mean age was 70.4 years (range, 54-84 yr), with 60 cervical carotid stenosis (39 symptomatic and 21 asymptomatic). Sixty procedures resulted in successful stent deployment in 55 cases, percutaneous transluminal angioplasty (PTA) only without stenting in three, and failed angioplasty due to inaccessibility in two. Morbidity was seen in three cases associated with thromboembolic complication. Instent restenosis was observed in one case, which was successfully treated with subsequent PTA. CAS seems reasonable treatment for cervical carotid artery stenosis, although further accumulation of the cases will be needed to evaluate the efficacy between CAS and carotid endarterectomy.

Guglielmi detachable coil embolization for ruptured lower-midbasilar trunk aneurysms--a report of five cases.

Detachable coil embolization currently plays an essential role for patients with ruptured basilar artery aneurysms, even though it may have an unfavorable outcome and there may be some technical problems of embolization. We describe Guglielmi detachable coil (GDC) embolization for five ruptured lower-mid basilar trunk aneurysms, using a variety of techniques. The patients' ages ranged from 61 to 78 years; Hunt and Kosnik grade was distributed from 2 to 4, and three patients were found to have fenestrations of the lower basilar arteries. All patients underwent aneurysmal embolization at the subacute or chronic stage. The transfemoral route was used in three patients--one of whom, with a wide-necked aneurysm, was treated by the balloon remodeling technique. The transbrachial approach was chosen for the fourth patient, while vertebral artery origin exposure followed by a direct puncture was achieved in the fifth. All patients were assessed with 80-100% aneurysmal obliteration. No patient re-bled after the embolization. Small cerebellar infarction, possibly due to embolism from the obliterated aneurysmal sac, occurred 11 days after the treatment. Of the five patients, four achieved a good recovery, and one became severely disabled. Ruptured basilar trunk aneurysms can be successfully treated with GDC embolization. In addition to the routine transfemoral route, the transbrachial route, direct vertebral artery puncture, and balloon remodeling technique are also useful for the embolization of this location of aneurysm.

Anterior ischemic optic neuropathy after combined ophthalmic artery embolization and craniofacial surgery--case report.

A 57-year-old man developed visual loss following craniofacial surgery for an inflammatory ethmoidal sinus mass. Surgery was preceded by endovascular occlusion of the ophthalmic artery distal to central retinal artery (CRA). Routine angiography obtained immediately after endovascular ophthalmic artery occlusion showed patency of the CRA. He complained of visual loss one day after craniofacial surgery (2 days after embolization). Repeat emergency angiography confirmed the patent CRA. Ophthalmic examination and fluorescein angiography showed that the visual loss was due to anterior ischemic optic neuropathy (AION). Preservation of the CRA is critical during ophthalmic artery embolization to avoid visual complications. Neurosurgeons should be aware of the possibility of AION as a complication of ophthalmic artery embolization.

Cerebellar hemorrhage caused by dural arteriovenous fistula: a review of five cases.

OBJECT: In this study the authors performed a retrospective analysis of five cases in which the patients (three women and two men) were treated for intracranial dural arteriovenous fistulas (AVFs) associated with cerebellar hemorrhage. On the basis of their findings, the authors evaluated the characteristics of this unusual symptom. METHODS: The dural AVFs were located in the right cavernous sinus in one patient, the left transverse-sigmoid sinus in three patients, and the right superior petrosal sinus (SPS) in one patient. All patients presented with severe headache and/or loss of consciousness. Computerized tomography scans revealed a small cerebellar hemorrhage near the fourth ventricle and hydrocephalus in four cases, and a massive hemispheric cerebellar hemorrhage in the remaining case. The four patients with small hemorrhages underwent ventriculostomy and endovascular treatment; all recovered. The patient suffering from a massive hemorrhage because of a dural AVF in the SPS was treated by suboccipital craniectomy, hematoma evacuation, and removal of the vascular anomaly. This patient remains in a persistent vegetative state. In four cases, results of angiography demonstrated retrograde leptomeningeal venous drainage through the SPS to the anastomotic lateral mesencephalic vein (ALMV) and/or to the vein of the lateral recess of the fourth ventricle (VLR4V). Retrograde leptomeningeal venous drainage to the ALMV and/or VLR4V was responsible for cerebellar hemorrhage in these cases. CONCLUSIONS: Thus, it is important to consider dural AVF in cases in which there is even a small hemorrhage near the fourth ventricle accompanied by intraventricular perforation and a decreased level of consciousness.

Phenotypic modulation of smooth muscle cells in human cerebral aneurysmal walls.

We used immunohistochemical methods to analyze the phenotypes of smooth muscle cells (SMCs) in human cerebral arteries and aneurysmal walls. Thirty-two aneurysmal walls were studied; 31 aneurysmal walls were resected at operation and 1 aneurysm was obtained at autopsy. Seven control arteries were obtained at autopsy. Semiserial sections were subjected to immunohistochemical staining with antibodies to alpha-smooth muscle actin (alpha-SMA), desmin and smooth muscle myosin heavy chain isoforms: SM1, SM2 and SMemb. In control cerebral arteries, SMCs in the media were strongly immunostained for alpha-SMA, desmin, SM1 and SM2; immunoreactivity for SMemb was faint or weakly positive. SMCs in both non-ruptured and ruptured aneurysmal walls showed no staining for desmin; the expression of alpha-SMA was well preserved. Compared with control cerebral arteries, in 4 of 11 non-ruptured aneurysmal walls, the staining intensity of SMCs for SMemb was clearly increased. In ruptured aneurysmal walls, the expression of SM2 was lower than in control cerebral arteries and non-ruptured aneurysmal walls. Our study suggests that the phenotype of SMCs in aneurysmal walls is different from the contractile type in the media of normal cerebral arteries, at least partially changing to the synthetic type in some non-ruptured aneurysms. SMCs in ruptured aneurysmal walls may have lost both phenotypes before rupture. Phenotypic modulation of SMCs in the aneurysmal walls appears to be related to a remodeling of the aneurysmal wall and to a rupture mechanism.

Endovascular treatment using detachable coils for non-ruptured intracranial aneurysm.

Detachable coil embolization was performed on 34 non-ruptured cerebral aneurysms in 33 patients. Patients consisted of 28 females and five males, with an age range of 26 to 77 years. Angiographic examination after coil embolization revealed complete or near-complete occlusion in 24 aneurysms (70.5%) and partial occlusion in three (8.8%). Detachable coil embolization was attempted unsuccessfully in seven aneurysms (20.5%). Transient ischemic attack occurred in one case with coil migration. The combined mortality/morbidity rate was 0%.

Measurement of volume ratio to predict coil compaction, on aneurysmal embolization.

SUMMARY: The relationship between volume embolization ratio and coil compaction on the intracranial aneurysms occluded using Guglielmi detachable coils (GDCs) was determined. From March 1997 to February 1998, 38 intracranial aneurysms were embolized using GDCs. Aneurysm volume was calculated assuming that aneurysms are ellipsoids of the diameter in three planes. Coil volume was calculated assuming that detachable coils are cylinder of primary coil. Coil compaction was observed in aneurysms embolized at a volume embolization ratio under 21%. There was no coil compaction in aneurysms embolized at a volume embolization ratio of over 21%. Measurement of the volume embolization ratio is useful to predict the coil compaction. Intracranial aneurysms should be embolized at a volume embolization ratio of 25-33%.

[Preventive cardiology: lack of exercise and physical training from the epidemiologic and experimental viewpoints]. / Präventive Kardiologie: Bewegungsmangel und körperliches Training aus epidemiologischer und experimenteller Sicht.

A survey is given on epidemiological and experimental results of lack of exercise as a risk factor for coronary heart disease. The consequences of endurance training are described. It is evident that endurance sport or training during leisure time can have a greater effect than heavy muscular professional work. The selectively analysed factor "lack of exercise" may be less important as a risk factor than the protective influence of endurance training. Directions are given for carrying out a preventive program of training, with contraindications included.