Usefulness of Hybrid Surgery Combining CEA and CAS for Carotid Artery Stenosis with a Large Amount of Vulnerable Plaque.

Objective: For carotid artery stenosis with a large amount of vulnerable plaque in a wide range, we performed a hybrid surgery combining carotid endarterectomy (CEA) and carotid artery stenting (CAS), and report the results of treatment. Methods: Surgical treatment for carotid artery stenosis in 216 patients was performed between January 2016 and June 2018. Of these, 15 patients were treated in a hybrid operating room because both CEA and CAS were judged to be risky. We treated these patients with preparation of stenting for remote lesions far from the CEA arterial incision. The perioperative treatment results were retrospectively examined. Results: Of the 15 patients treated in a hybrid operating room, 10 were stented after CEA. All these cases were treated by retrograde stent placement in the proximal common carotid artery (CCA). Treatment was completed in all patients, and no cerebral infarction, myocardial infarction, or death was observed in the perioperative period. There were no cases of additional neurological events during the follow-up period, but asymptomatic restenosis was observed in one patient. Conclusion: Hybrid surgery combining CEA and CAS was considered to be an effective treatment for carotid artery stenosis with a large amount of vulnerable plaque.

Endovascular treatment for ruptured vertebral artery dissecting aneurysms at the acute stage.

OBJECTIVE: Ruptured vertebral artery dissecting aneurysms (VADA) should be treated promptly because of the high risk of rebleeding. However, it is difficult to treat dissecting aneurysm during the acute stage using microsurgery because of high intracranial pressure or brain edema. Therefore, endovascular treatment of the ruptured VADA may be a better technique. We retrospectively studied the efficacy and outcome of endovascular treatment of ruptured VADA at the acute stage. METHODS: Ten patients with ruptured VADA received endovascular treatment at the acute stage. Eight patients who had dissecting aneurysms were treated by internal trapping of the dissected segment. We performed stent-assisted coiling (SAC) for a case of VADA in contralateral hypoplastic VA and a case of bilateral dissections, ruptured VADA of the right VA and VA dissection of the left VA. RESULTS: Four patients had good recovery, 3 patients had moderate disability, 2 patients had severe disability, and 1 patient died from initial severe SAH. There was no rebleeding or procedure-related complication. However, one patient who was treated by SAC had ischemic complications post-treatment. CONCLUSION: Endovascular treatment of ruptured VADA in the acute stage appears to be safe and effective.

DCX-expressing neurons decrease in the retrosplenial cortex after global brain ischemia.

Many studies have demonstrated cognitive function disorders including space learning disorders after global brain ischemia (GBI). Previous research on space perception and learning has indicated that the retrosplenial cortex (RS) is strongly involved. We performed immunostaining with doublecortin (DCX) for neurons with plasticity potential in the RS and investigated the neuronal numbers to assess the changes of plasticity in the RS following GBI. We employed male Sprague-Dawley rats and carried out bilateral carotid arterial occlusion for 10 min as a GBI model (control, n = 5; GBI model, n = 5). We counted the right and left hemispheres separately on two serial sections, for a total of four regions per animal to examine the differences in expression related to GBI. Additionally, we performed Fluoro-Jade B (FJB) staining to investigate the cause of any DCX-expressing neuron decrease. The total number of DCX-expressing neurons was 1,652 and 912 in the controls and GBI model, respectively. The mean number of DCX-expressing neurons per unit area was significantly lower in the GBI model than in the controls. FJB positive neurons were not found in the RS, while many were present in the -hippocampus CA1 after GBI. The decrease of DCX-expressing neurons in the RS indicated a plasticity decrease following GBI. The lack of FJB positive neurons in the RS after GBI suggested that the decrease of DCX-expressing neurons in the RS was not due to neuronal cell death in contrast to the hippocampus CA1, while the FJB positive neurons in the hippocampus indicated a delayed neuronal cell death as observed in many previous studies.

Decrease in doublecortin expression without neuronal cell death in rat retrosplenial cortex after stress exposure.

Exposure to acute stress by forced swim impairs spatial learning and memory in rats. The retrosplenial cortex plays an important role in spatial learning and memory. A cell population that expresses immature neuronal markers, including doublecortin (DCX), plays a key role in plasticity of the adult brain through formation of new neurons. Here, we aimed to determine whether rats exposed to acute stress showed changes in DCX expression in retrosplenial cortex cells. Twelve male Sprague-Dawley rats were used. Six were subjected to acute stress by forced swim (group S), and the remaining six served as controls (group C). Immunohistochemical staining was performed for DCX, neuron-specific nuclear protein, parvalbumin, calbindin, calretinin, and somatostatin. Newly generated cells were immunohistochemically detected by daily administration of 5-bromo-2'-deoxyuridine for 1 week. Fluoro-Jade B staining was performed to detect cell death. Group S showed lower number of DCX-expressing cells than group C (P<0.001). The proportion of DCX-expressing cells showing neuron-specific nuclear protein co-localization (24% in group S; 27% in group C) or parvalbumin co-localization (65% in group S; 61% in group C) remained unchanged after acute stress exposure. Neither 5-bromo-2'-deoxyuridine-positive nor Fluoro-Jade B-positive cells were found in the retrosplenial cortex of groups S and C. DCX-expressing cells in the retrosplenial cortex decreases markedly without cell death after acute stress exposure. Neuronal differentiation of these cells toward gamma aminobutyric acidergic interneurons appears to be unaltered. The decrease in DCX expression may reduce plasticity potential within the retrosplenial cortex and attenuate spatial learning and memory function.

[Stent-assisted angioplasty using the proximal protection method for intracranial internal carotid artery stenosis].

Percutaneous transluminal angioplasty (PTA) with stenting (PTA/stenting) for intracranial atherosclerotic stenoses is usually performed without any embolic protection devise (EPD). However, we have encountered ischemic complications when performing PTA/stenting without EPD for symptomatic intracranial internal carotid artery stenosis. We report here a case of symptomatic intracranial artery stenosis, which was treated by stenting under proximal protection without ischemic complications. The 54-year-old male was admitted to our hospital complaining of motor weakness. Diffusion-weighted image (DWI) in MRI revealed multiple high intensity lesions in the left frontal and parietal lobe. An angiogram demonstrated 80% stenosis in the C5 portion of the left internal carotid artery. PTA/stenting was performed using an occlusion catheter under proximal protection. The occlusion catheter with balloon was placed in the left internal carotid artery of the cervical segment. The balloon was inflated to intercept blood flow, and a driver stent was placed following PTA. Postoperative angiography demonstrated that the degree of stenosis had decreased to almost 5% after PTA/stenting. The patient did not present other neurological deficits. MRI-DWI did not reveal any ischemic lesions following the treatment. PTA/stenting under proximal protection using an occlusion catheter is a simple technique, and is considered to be effective for intracranial internal carotid stenosis.

[Monostotic fibrous dysplasia of the cranial vault: a case report].

Fibrous dysplasia, when it occurs in the craniofacial region, mostly involves the skull base and is rarely localized in the cranial vault. Although there have been several reports on magnetic resonance imaging (MRI) findings of fibrous dysplasia involving the skull base, cases occurring in the cranial vault have seldom been reported. We describe here a rare case of monostotic fibrous dysplasia that occurred in the parietal bone and discuss the characteristics of the MRI findings. A 47-year-old female was admitted to our hospital with a complaint of vertigo. A computed tomography (CT) scan did not reveal any intraparenchymal lesions in either the infra- or supratentorium, and her vertigo improved immediately without any treatments. However, a solitary osteolytic lesion was found incidentally in the left parietal bone. MRI showed that the lesion demonstrated hypointensity on T1-weighted images and hyperintensity on T2-weighted images, and was enhanced heterogeneously following injection of Gadolinium-DTPA. Removal of the parietal bone containing the lesion was performed according to the patient's wishes. The histopathological findings of the removed tissues corresponded to fibrous dysplasia. Although it is well known that craniofacial fibrous dysplasia demonstrates iso- or hypointensity on T1- as well as T2-weighted images, in the present case, the lesion showed apparent hyperintensity on T2-weighted images. These findings suggest that fibrous dysplasia can display various MR intensities depending on its origin.

[A case of nasal dermal sinus-cyst (NDSC) with intracranial extension].

Nasal dermal sinus-cyst (NDSC) is a rare abnormality consisting of a dermal sinus opening at the nasal skin and dermoid cyst localized in the frontobasal area. A 2-year-old boy was admitted to our hospital due to swelling of the fronto-nasal regions with pus running from an orifice situated in the nasal skin. Bone-image CT and 3D-CT revealed bone defects within the frontal skull base. MRI demonstrated that a dermoid cyst centered in a bone defect was in contact with the dura of the frontobasal area, and a dermal sinus extending to the frontonasal skin could also be detected. Surgical resection was performed by frontobasal craniotomy. The dermal sinus was followed subcutaneously into the orifice of the nasal skin. A small skin incision was made and the sinus was then totally removed. The authors describe in detail this case of NDSC which extended to the intracranium, and review the literature regarding this abnormality.