[Concomitant Surgery for Symptomatic Severe Carotid Artery Stenosis and Aortic Valve Stenosis with Contralateral Internal Carotid Artery Occlusion:A Case Report].

We report a case of concomitant carotid endarterectomy(CEA)and aortic valve replacement(AVR)for symptomatic severe carotid artery and aortic valve stenosis(AS). A 77-year-old man, presented to our hospital with AS complicated by right internal carotid artery(ICA)stenosis and left ICA occlusion, seeking treatment for AS. He suffered from left hemiparesis, and diffusion-weighted magnetic resonance imaging(MRI)showed multiple ischemic lesions in the right cerebral hemisphere. He was admitted to our neurosurgical department and received treatment for acute cerebral infarction caused by severe right ICA stenosis. The symptomatic severe right ICA stenosis was an indication for surgical treatment, but simple carotid revascularization of the stenosed ICA was considered to be deteriorated the cardiac function due to untreated AS. Thus, we decided to perform concomitant carotid and valvular surgery. The patient underwent a combined CEA and AVR procedure with the introduction of an intraoperative intra-aortic balloon pump. His postoperative course was uneventful even 12 months after the surgery. Management and surgical strategies for patients with concomitant ICA stenosis and AS continue to be controversial subjects. Combined carotid and cardiac valve surgery is considered to be effective in such cases, and we discuss its implications and review of literature.

Stent-assisted coil embolization of a recurrent posterior cerebral artery aneurysm following surgical clipping.

Posterior cerebral artery (PCA) aneurysms are rare, and direct surgery of these is considered difficult. Coil embolization of PCA aneurysms is becoming popular. However, it is difficult to completely obliterate the aneurysm while preserving the flow of the parent artery in large or giant PCA aneurysms with a wide neck with this technique. We report a case of a large and wide-necked PCA aneurysm with multiple recurrences following successful surgical clipping and coil embolization. A 77-year-old man with a large unruptured right PCA (P2) aneurysm was successfully treated by surgical clipping. Postoperative digital subtraction angiography (DSA) showed complete aneurismal occlusion. Four years afterward, the aneurysm recurred and grew toward the contralateral. Surgical retreatment of this complicated aneurysm was considered difficult, with a substantial risk of complications. Therefore, the aneurysm was treated with an endovascular procedure. Because simple coil embolization was not expected to achieve satisfactory obliteration of the aneurysm with preservation of parent artery patency, we used stent-assisted coil embolization. The patient tolerated the treatment well. On DSA obtained six months after the first endovascular treatment, coil compaction and recanalization of the aneurysm were detected. A second coil embolization was successfully performed without any complications. The aneurysm was stable during the next six-month follow-up. Stent-assisted coil embolization may be feasible and effective for such postoperatively complicated aneurysms.

Glucagon-Like Peptide-1 Strengthens the Barrier Integrity in Primary Cultures of Rat Brain Endothelial Cells Under Basal and Hyperglycemia Conditions.

The objective of the present study was to determine the effects of glucagon-like peptide-1 (GLP-1) on barrier functions and to assess the underlying mechanism using an in vitro blood-brain barrier (BBB) model comprised of a primary culture of rat brain capillary endothelial cells (RBECs). GLP-1 increased transendothelial electrical resistance and decreased the permeability of sodium fluorescein in RBECs in a dose- and time-dependent manner. The effects on these barrier functions were significantly reduced in the presence of the GLP-1 receptor antagonist exendin-3 (9-39) and the protein kinase A (PKA) inhibitor H-89. Western blot analysis showed that GLP-1 increased the amount of occludin and claudin-5. GLP-1 analogs are approved for treatment of type 2 diabetes mellitus, and thus, we examined the effects of GLP-1 on hyperglycemia-induced BBB damage. GLP-1 inhibited the increase in production of reactive oxygen species under hyperglycemia conditions and improved the BBB integrity induced by hyperglycemia. As GLP-1 stabilized the integrity of the BBB, probably via cAMP/PKA signaling, the possibility that GLP-1 acts as a BBB-protective drug should be considered.

A Ruptured Basilar Tip Aneurysm Showing Repeated Perianeurysmal Edema after Endovascular Coil Embolization: Case Report.

The authors present an extremely rare case of a 48-year-old female who developed repeated perianeurysmal edema at 2, 9, and 16 weeks after endovascular coil embolization for the ruptured intracranial aneurysm. Interestingly, the mechanism for this edema could be different at each time point in this case; acute thrombosis formation, chemical inflammation, and aneurysm recanalization. We have to be aware of this potential complication in the long term after endovascular coil embolization for the intracranial aneurysm, especially with large size or buried into the brain parenchyma. The clinical implications of this case are discussed with a review of the literature.

Cilostazol attenuates ischemia-reperfusion-induced blood-brain barrier dysfunction enhanced by advanced glycation endproducts via transforming growth factor-ß1 signaling.

We investigated the effects of cilostazol, a selective inhibitor of phosphodiesterase 3, on blood-brain barrier (BBB) integrity against ischemia-reperfusion injury enhanced by advanced glycation endproducts (AGEs). We used in vitro BBB models with primarily cultured BBB-related cells from rats (brain capillary endothelial cells, astrocytes and pericytes), and subjected cells to either normoxia or 3-h oxygen glucose deprivation (OGD)/24-h reoxygenation with or without AGEs. Treatment of AGEs did not affect the transendothelial electrical resistance (TEER) in the BBB model under normoxia, but there was a significant decrease in TEER under 3-h OGD/24-h reoxygenation conditions with AGEs. Cilostazol inhibited decreases in TEER induced by 3-h OGD/24-h reoxygenation with AGEs. Immunocytochemical and Western blot analyses showed that AGEs reduced the expression of claudin-5, the main functional protein of tight junctions (TJs). In contrast, cilostazol increased the expression of claudin-5 under 3-h OGD/24-h reoxygenation with AGEs. Furthermore, while AGEs increased the production of extracellular transforming growth factor (TGF)-ß1, cilostazol inhibited the production of extracellular TGF-ß1 and restored the integrity of TJs. Thus, we found that AGEs enhanced ischemia-reperfusion injury, which mainly included decreases in the expression of proteins comprising TJs through the production of TGF-ß1. Cilostazol appeared to limit ischemia-reperfusion injury with AGEs by improving the TJ proteins and inhibiting TGF-ß1 signaling.

[Case of an internal carotid artery aneurysm complicated with coil protrusion during embolization].

Coil migration during cerebral aneurysm embolization is rare, but one of the most troublesome events. A 65-year-old woman was referred to our hospital for the treatment of a cerebral aneurysm. Angiography showed the aneurysm at the C3 portion of the right internal carotid artery. The neck of the aneurysm was wide. A detachable coil was placed into the aneurysm using the balloon neck plasty technique and was detached after confirmation of its stability. However, after detachment, the coil started to migrate. The balloon was inflated to prevent coil migration and another coil was inserted into the aneurysm to stabilize the migrated coil. Finally, the aneurysm was subtotally embolized with 9 coils. The postoperative course was uneventful. Coil migration may occur especially in a wide-neck aneurysm. Appropriate coil selection is important to prevent such migration. Subsequent coil insertion, retrieval of the migrated coil, and stent placement are the treatment options for coil migration.

[Ruptured giant thrombosed aneurysm at the internal carotid artery successfully treated with endovascular internal trapping following emergent balloon occlusion test: a case report].

The authors report a case of ruptured giant thrombosed aneurysm successfully treated with endovascular internal trapping following emergent balloon occlusion test (BOT), and discuss its clinical implications regarding emergent BOT. A 41-year-old female showing massive epistaxis was referred to our institute for the treatment of a giant aneurysm. Computed tomography and digital subtraction angiography revealed a giant thrombosed aneurysm located at the petrous portion of the right internal carotid artery with an erosion of the petrous bone. Emergent BOT was performed under the monitoring of regional oxygen saturation of the brain (rSO2) and stump pressure as well as neurological changes and confirmed tolerance for permanent internal artery occlusion with a little change of rSO2 and stump pressure. Endovascular internal trapping was performed with detachable coils and the postoperative course was uneventful. Magnetic resonance imaging showed a decrease in the size of the aneurysm three month after the treatment, and the aneurysm got organized four years later. For ruptured aneurysms, emergent BOT is sometimes difficult to perform due the neurological deterioration or inability to prepare radioisotope for single photon computed tomography. Nevertheless, monitoring of rSO2 and stump pressure as well as neurological changes can be of help for decision making concerning the treatment strategy. Endovascular treatment following BOT is a feasible and life-saving approach for emergent management of ruptured internal carotid artery aneurysms presented with massive epistaxis.

Assessment of carotid plaque stability based on the dynamic enhancement pattern in plaque components with multidetector CT angiography.

BACKGROUND AND PURPOSE: Recent studies have investigated plaque morphology to determine patients who are at high risk of carotid atherosclerosis. In this study, we investigated whether a difference in dynamic enhancement pattern in plaque components could be useful to assess plaque stability with multidetector CT angiography. METHODS: Fifty-nine lesions with moderate to severe carotid atherosclerosis in 51 patients (33 symptomatic, 18 asymptomatic) were consecutively included. Early- and delayed-phase images were obtained in 3 equivalent axial slices with multidetector CT angiography. Hounsfield units (HU) in the early phase were subtracted from those in the delayed phase in plaques (ΔHU) and compared with clinical features, MRI-based plaque characteristics, and histological findings with 20 surgical specimens acquired from carotid endarterectomy. RESULTS: The ΔHU was significantly higher in asymptomatic than that in symptomatic presentation (P=0.02). With MRI, a higher ΔHU was negatively correlated with signal intensity on T1-weighted imaging (r=-0.56, P<0.0001). Histology confirmed that ΔHU was positively correlated with fibrous tissue (r=0.67, P=0.001) and negatively correlated with a lipid-rich necrotic core with hemorrhage (r=-0.70, P<0.001). Moreover, less neovascularization and inflammation was found in plaques with a higher ΔHU. CONCLUSIONS: Delayed-phase images provide information regarding the dynamic change in contrast media from the early arterial phase. An increase in HU from the early phase on multidetector CT angiography indicates plaque stability with more fibrous tissue and a less lipid-rich necrotic core, intraplaque hemorrhage, and neovascularization.

[A tentorial dural arteriovenous fistula presenting progressive myelopathy: a case report].

Abstract We report a case of a dural arteriovenous fistula (DAVF) at the tentorium cerebelli, which presented progressive myelopathy. A 68-year-old man with neurological deterioration of the cervical myelopathy visited our hospital. T2 weighted magnetic resonance (MR) imaging showed high signal area and edema from the medulla to the upper thoracic spinal cord with flow voids on the dorsal surface of the cord. Angiography showed right tentorial DAVF, which was supplied by the right meningohypophyseal trunk, the middle meningeal artery, the accessory meningeal artery, and was drained into the posterior spinal veins. The patient underwent right retrosigmoid suboccipital craniotomy, then disruption of the fistula was performed by using micro Doppler sonography following endovascular obliteration of the main feeders. Postoperative angiography showed complete obliteration of the fistula. His daily functioning gradually improved up to 6 months after the surgery. Tentorial DAVFs with clinical manifestation of myelopathy are rare. Considering its aggressive nature, early surgical treatment could be necessary. (Received: November 17, 2010, Accepted: December 18, 2010).

Malignant transformation of craniopharyngioma associated with moyamoya syndrome.

A 32-year-old man presented with malignant craniopharyngioma associated with moyamoya syndrome manifesting as right visual disturbance. Magnetic resonance (MR) imaging revealed a parasellar mass lesion diagnosed as adamantinomatous craniopharyngioma. He underwent three surgical procedures and repeated courses of radiotherapy, and was able to resume his daily life. MR imaging demonstrated tumor regrowth and bilateral occlusions of the internal carotid arteries (ICAs) with basal moyamoya phenomenon, which might have been induced by irradiation and/or tumor compression, 10 years after the initial manifestations. Sufficient debulking was safely achieved via the transsphenoidal route and histological examination revealed squamous cell carcinoma, indicating malignant transformation of craniopharyngioma. The tumor relapsed after only one month, so transsphenoidal tumor debulking was tried again. However, the postoperative course was unfavorable because of intraoperative bleeding from the right ICA. Malignant transformation of craniopharyngioma may be included in moyamoya syndrome. The treatment strategy should be carefully considered in such a complicated situation.

Significance of the T2*-weighted gradient echo brain imaging in patients with infective endocarditis.

BACKGROUND: Although aneurysm formation accompanying parenchymal hemorrhage is one of devastating complications in the central nerves system (CNS), imaging studies of the brain are not routinely warranted in patients with infective endocarditis (IE). To assess the clinical importance for detecting silent lesions in the central nervous system, we investigated hypointense signal spots detected on the brain T2*-weighted MR imaging in patients with IE. METHODS AND RESULTS: Eleven patients with IE were retrospectively reviewed. Seven patients (63.6%) showed hypointense signal spots on T2*-weighted MR images. The number of hypointense signal spots increased within only a few weeks in five patients. CONCLUSION: The brain T2*-weighted MR imaging in patients with IE may have a potential role to detect CNS lesions with clinical significance of potentially high risk of intracranial hemorrhage. T2*-weighted hypointense signal spots may be specific to brain involvement, and be quite useful in monitoring CNS lesions associated with IE, even if they are asymptomatic.

[Dural arteriovenous fistulas at the craniocervical junction fed by bilateral vertebral arteries with intracranial drainage: a case report].

We report a case of dural arteriovenous fistulas (DAVFs) at the craniocervical junction, which are supplied by the radicular arteries from bilateral vertebral arteries separately, and drainaged into intracranial sinuses. A 58-year-old man with intermittent neck pain visited our hospital. T2-weighted magnetic resonance (MR) imaging showed flow voids on the dorsal surface of the medulla and upper cervical cord without any signal changes suggesting ischemia. Postcontrast MR digital subtraction angiography (MRDSA) showed early venous filling at the craniocervical junction. Angiography demonstrated bilateral fistulas near each vertebral artery penetration point of the dura matter, which were drainaged into the superior and inferior petrosal sinuses. The patient underwent suboccipital craniotomy and laminectomy of the C1, then disruption of the bilateral fistulas was performed by using micro Doppler sonography after intradural exposure of the shunt points. His symptom subsided post operatively, and MRDSA showed no abnormal vessels. Angiography performed 1 week after surgery confirmed complete obliteration of the fistulas. DAVFs at the craniocervical junction fed by bilateral vertebral arteries is extremely rare. Even in such a case, direct interruption of the fistulas using micro Doppler sonography is the most effective treatment. In addition. MRDSA could be useful for screening and perioperative studies.

Remote cerebellar hemorrhage following thoracic spinal surgery.

A 51-year-old man underwent surgery for ossification of the ligamentum flavum at the T9-T10 levels. Intraoperatively, the dura was opened unintentionally and a subcutaneous suction drain was placed. The patient complained of severe headache and nausea postoperatively. Brain computed tomography obtained 3 days after the surgery demonstrated remote cerebellar hemorrhage and hydrocephalus. Suboccipital decompression, C1 laminectomy, and ventriculostomy were performed and his symptoms subsided 2 months later. Remote cerebellar hemorrhage following spinal surgery is extremely rare, but may occur after any type of spinal surgery resulting in dural tear or intradural manipulation. Early diagnosis is particularly important for the treatment of remote cerebellar hemorrhage following spinal surgery.

[Efficacy of antimicrobial prophylaxis in neurosurgical operations].

OBJECT: It is reported that antimicrobial prophylaxis (AMP) reduces the incidence of surgical site infection (SSI) in neurological surgery. However, a great deal of variation exists regarding the type of antibiotics, dose, timing and duration. In this study, the authors analyzed the incidence of SSI comparing two different AMP protocols. CLINICAL MATERIALS AND METHODS: Five hundred and fifty patients who had undergone neurosurgeries at our institute between April 2005 and August 2007 were reviewed retrospectively. They were divided into the protocol F (309 patients with two or more days AMP) and the protocol P (241 patients with one-day AMP). RESULTS: Baseline characteristics were not statistically different between two protocols. The overall rate of SSI was 1.5%. Although SSI showed a trend of low SSI incidence in the protocol P (0.8%), this was not statistically significant compared with that in the protocol F (1.9%). CONCLUSIONS: The one-day (< 24 hours) administration of AMP is enough to prevent SSI in neurological surgery.

[Case of specific MRI T2* weighted image associated with bacterial endocarditis].

We report a case of multiple signal loss lesions detected by T2* weighted image associated with bacterial endocarditis. A 23 year-old woman, who had undergone surgical closure of ventricular septal defect at age 2, suffered headache and general fatigue after dental treatment. She was admitted to another institution, and examinations revealed bacterial endcarditis. She was transferred to our hospital, and underwent aortic valve replacement. After the valve replacement, CT revealed parenchymal hematoma in the left frontal lobe. CT angiography (CTA) and cerebral angiography (CAG) demonstrated an aneurysm at the distal branch of the left middle cerebral artery. T2* weighted image demonstrated multiple signal loss lesions, which were not revealed by CAG and CTA. We speculated that these signal loss lesions were thrombosed mycotic intracranial aneurysms. She underwent left frontotemporal craniotomy, and the aneurysm was resected. Mycotic aneurysms are rare neurovascular lesions but their mortality and morbidity are high, so careful follow-up examinations are required. T2* weighted image was useful to detect mycotic aneurysms and plan the surgical strategy.

[Skull metastasis of hepatocellular carcinoma successfully treated by intraoperative photodynamic diagnosis using 5-aminolevulinic acid: case report].

There have been no studies on photodynamic diagnosis (PDD) using 5-aminolevulinic acid (5-ALA) in patients with metastatic skull tumors. Here, we present a case of skull metastasis of hepatocellular carcinoma (HCC) successfully treated by intraoperative PDD using 5-ALA. A 63-year-old man with HCC presented with a subcutaneous mass in the left occipital region. CT showed a hyperdensity mass and severe osteolytic change in the left side of the occipital bone. MRI revealed an extra-axial enhanced mass that compressed the left occipital lobe and enhancement was spreading to the adjacent subcutaneous soft tissue. In order to intraoperatively evaluate the extent of tumor invasion, PDD using 5-ALA was performed. Intraoperative PDD comfirmed that the tumor itself was highly fluorescent. Surgery was completed after comfirming the absence of residual fluorescence in the surgical field. The tumor was diagnosed HCC. Histopathological analysis confirmed that PDD accurately assessed the extent of tumor invasion. The patient was discharged home at 10 days after surgery. PDD using 5-ALA is convenient and inexpensive, and because adverse reactions are minimal, it may be useful in not only malignant glioma, but also other brain tumors.