吉野 義一

BACKGROUND: Endovascular treatment has become the preferred approach for managing unruptured cerebral aneurysms, with simple and balloon-assisted coil embolization as the standard first-line therapy. However, recanalization after coil embolization remains a major clinical concern. This study aimed to evaluate the predictive factors for recanalization using time-of-flight magnetic resonance (TOF-MR) angiography. METHODS: This retrospective multicenter study analyzed data from 241 patients with unruptured cerebral aneurysms who underwent coil embolization at five stroke centers. Aneurysms were evaluated using TOF-MR angiography within 7 days post-procedure and at follow-up. The study investigated the role of aneurysm characteristics and the Postoperative TOF-MR Angiography (PTMA) classification in predicting recanalization. RESULTS: Of the 241 aneurysms analyzed, 79 (32.7%) exhibited recanalization, and 15 (6.2%) required retreatment. Aneurysms with a maximum diameter of ≥10 mm were associated with a higher risk of recanalization (odds ratio (OR), 3.27; 95% confidence interval (CI), 1.38-7.75; p<0.01). The PTMA classification, which indicated incomplete occlusion (SN/RN/PO), also showed a significant association with recanalization (OR, 4.82; 95% CI, 2.17-10.7; p<0.01). The modified Raymond-Roy classification (Class IIIb) also contributed to the prediction of recanalization (OR, 3.09; 95% CI, 1.50-6.38; p<0.01). CONCLUSIONS: Aneurysm size, the modified Raymond-Roy classification, and PTMA classification within 7 days of coil embolization were significant predictors of recanalization. This study suggests that TOF-MR angiography may be accurate, and that PTMA classification may serve as an appropriate predictor of aneurysm recanalization. Further prospective studies with larger cohorts are required to validate our findings.

OBJECTIVES: Distal anterior cerebral artery (DACA) aneurysms account for 1%-9% of all intracranial aneurysms. Microsurgical treatment is generally preferred for DACA aneurysms; however, it presents challenges owing to the anatomical complexities. Advances in neuro-interventional techniques have yielded promising results. This study aims to compare the clinical outcomes of DACA aneurysms treated with microsurgery and endovascular treatment (EVT) to elucidate the efficacy of EVT. MATERIALS AND METHODS: A multicenter observational registry comprising 16 stroke centers was utilized for this study. Data was retrospectively and prospectively analyzed from 166 patients with DACA aneurysms in our database, which included 4,552 consecutive patients with ruptured or unruptured intracranial aneurysms who underwent microsurgical or endovascular treatment between January 2013 and December 2021. RESULTS: Surgical clipping was performed in 115 patients, and 51 underwent coil embolization. The median follow-up duration was 15.3 months. No significant differences were observed in patient characteristics between the two treatment modalities. There were no differences in complication-related morbidity between the microsurgical treatment and EVT groups in either unruptured (10.5% vs. 9.1%, p=1.00) or ruptured aneurysms (5.2% vs. 6.9%, p=0.66). Coil embolization resulted in higher recurrence and retreatment rates than surgical clipping did, especially for ruptured aneurysms (2.6% vs. 27.6%, p<0.01). CONCLUSIONS: Endovascular treatment is an alternative to microsurgery for DACA aneurysms especially in unruptured cases or the patients who have difficulty undergoing craniotomy due to their general condition, albeit with considerations for higher recurrence and retreatment rates, particularly in ruptured cases. Close follow-up is crucial for the effective management of these challenges. Further studies are needed to refine the treatment strategies for DACA aneurysms.

PURPOSE: The quick establishment of adequate vascular access is essential for the technical success of mechanical thrombectomy (MT). Focusing on shifts in aortic arch geometry and aging-related changes, we propose an imaging parameter for predicting access difficulty using chest CT. METHODS: Patients with acute anterior circulation large-vessel occlusion who underwent MT from April 2020 to September 2021 were included in this retrospective multicenter observational study. The distance from the sternum to the ascending aorta (S-AAD) was defined as the surrogate marker of access difficulty. Access was defined as difficult when the time from femoral sheath placement to guiding catheter induction (guiding time: GT) ≥ 30 minutes, and the patients were dichotomized into groups with short GT (sGT: GT < 30 min) and long GT (lGT: GT ≥ 30 min). RESULTS: One hundred fifteen patients were included. There were 12 patients (10.4 %) in lGT group. The median (IQR) S-AAD was 11.9 mm (6.3, 18.3 mm) in sGT group and 6.6 mm (4.0, 10.3 mm) in lGT group, and a significant difference in S-AAD was observed (P = 0.026). In multivariate analyses, dyslipidemia and S-AAD < 5 mm were significantly associated with difficult access (OR, 5.938 [95 % CI, 1.468, 24.022], P = 0.012 for dyslipidemia; OR, 5.147 [95 % CI, 1.267, 20.917], P = 0.022 for S-AAD < 5 mm). CONCLUSION: S-AAD is a simple and reliable imaging parameter to predict access difficulty. This parameter may be helpful in selecting the appropriate devices and access routes in preinterventional practice.

Introduction  Predicting the shape of the occluded middle cerebral artery (MCA) from the contralateral MCA might help catheterization in endovascular mechanical thrombectomy (EMT). Materials and Methods  We analyzed magnetic resonance (MR) angiography in 100 consecutive patients who had MR imaging for diseases other than acute ischemic stroke. To assess the symmetricity of MCA, the shape of M1, length of M1, number of M2, number of early branches (EBs), and distance from the top of the internal carotid artery to EB were investigated. Results  The shape of M1 was upward in 42%, horizontal in 47%, and downward in 11%. The M1 shape was the same on both sides in 64%, which exceeded the probability assumed to be left-right independent. The number of M2 trunks and EBs matched left and right in 86 and 55% of patients, respectively; however, these agreement rates were not higher than those with independent left and right sides. No left-right correlation was found between the M1 length and the distance from the internal carotid artery to EB. Conclusion  Based on our data, the symmetry of MCA was observed only in the shape of the M1 segment. This finding could be beneficial for EMT targeting MCA embolisms.

AIM: Assessing the indication for elective neuro-endovascular treatment (EVT) in older patients requires consideration of the impact of systemic comorbidities on their overall reduced life expectancy. The objective of this study was to determine the long-term outcomes of elective neuro-EVT in patients aged ≥80 years, and to investigate the impact of pre-existing cancer on their long-term outcomes. METHODS: Of the patients enrolled in multicenter observational registry, those aged ≥80 years undergoing elective neuro-EVT between 2011 and 2020 were enrolled. A history of cancer was defined as a pre-existing solid or hematologic malignancy at the time of EVT. The primary outcome was time to death from elective neuro-EVT. RESULTS: Of the 6183 neuro-EVT cases implemented at 10 stroke centers, a total of 289 patients (median age, 82 years [interquartile range 81-84 years]) were analyzed. A total of 58 (20.1%) patients had a history of cancer. A total of 78 patients (27.0%) died during follow up. The 5-year survival rate of enrolled patients was 64.6%. Compared with patients without a history of cancer, those with a history of cancer showed significantly worse survival (log-rank test, P = 0.001). Multivariate Cox proportional hazards analysis showed history of cancer was an independent predictor of time to death from elective neuro-EVT (HR 1.74, 95% CI 1.01-3.00, P = 0.047). Cancer was the leading cause of death, accounting for 25.6% of all deaths. CONCLUSIONS: The present study showed that history of cancer has a significant impact on time to death from elective neuro-EVT in patients aged ≥80 years. Geriatr Gerontol Int 2024; 24: 211-217.

INTRODUCTION: Hybrid emergency room systems (HERSs) have shown promise for the management of severe trauma by reducing mortality. However, the effectiveness of HERSs in the treatment of acute ischemic stroke (AIS) remains unclear. This study aimed to evaluate the impact of HERSs on treatment duration and neurological outcomes in patients with AIS undergoing endovascular therapy. MATERIALS AND METHODS: This single-center retrospective study included 83 patients with AIS who were directly transported to our emergency department and underwent endovascular treatment between June 2017 and December 2023. Patients were divided into the HERS and conventional groups based on the utilization of HERSs. The primary outcome was the proportion of patients achieving a favorable neurological outcome (modified Rankin Scale score 0-2) at 30 days. The secondary outcomes included door-to-puncture and door-to-recanalization times. Univariate analysis was performed using the Mann-Whitney U test for continuous variables and the chi-squared test or Fisher's exact test for categorical variables, as appropriate. RESULTS: Of the 83 eligible patients, 50 (60.2%) were assigned to the HERS group and 33 (39.8%) to the conventional group. The median door-to-puncture time was significantly shorter in the HERS group than in the conventional group (99.5 vs. 131 min; p = 0.001). Similarly, the median door-to-recanalization time was significantly shorter in the HERS group (162.5 vs. 201.5 min, p = 0.018). Favorable neurological outcomes were achieved in 16/50 (32.0%) patients in the HERS group and 6/33 (18.2%) in the conventional group. The HERS and conventional groups showed no significant difference in the proportion of patients achieving favorable neurological outcomes (p = 0.21). CONCLUSION: Implementation of the HERS significantly reduced the door-to-puncture and door-to-recanalization times in patients with AIS undergoing endovascular therapy. Despite these reductions in treatment duration, no significant improvement in neurological outcomes was observed. Further research is required to optimize patient selection and treatment strategies to maximize the benefits of the HERS in AIS management.

RATIONALE: Thromboembolism is a serious complication of endovascular treatment for ruptured cerebral aneurysms. The administration of antiplatelet agents before endovascular treatment for ruptured cerebral aneurysms may reduce the risk of thromboembolic complications. AIM: This study aimed to assess the safety and efficacy of preoperative aspirin administration in endovascular treatment for ruptured cerebral aneurysms. SAMPLE SIZE ESTIMATES: Assuming a 15% incidence rate of both intraoperative thromboembolic morbidity and symptomatic ischemic lesions on magnetic resonance imaging diffusion-weighted imaging scans assessed by an Independent Review Committee, a sample size of 484 will be required to detect a 10% improvement with aspirin administration with 90% power using the Pearson's chi-square test at a two-sided significance level of 2.5% for each primary outcome, after accounting for a 5% dropout rate. METHODS AND DESIGN: ASTOP is a multicenter, randomized, double-blind, placebo-controlled clinical trial. A total of 484 patients with ruptured cerebral aneurysms receiving coil embolization within 72 h of onset will be randomly assigned 1:1 to receive 200 mg of aspirin or placebo before the procedure. STUDY OUTCOMES: The primary outcomes will be the incidence rates of intraoperative thromboembolic complications and symptomatic ischemic lesions on magnetic resonance imaging diffusion-weighted imaging scans evaluated by the Independent Review Committee. The secondary outcomes will be the incidence rate of cerebral ischemic events and all bleeding events within 14 days of enrollment and functional outcomes defined by the modified Rankin Scale score at 90 days. DISCUSSION: This trial will provide valuable data on the role of antiplatelet agents during endovascular treatment for ruptured cerebral aneurysms. TRIAL REGISTRATION: Registration: Japan Registry of Clinical Trials, Identifier: jRCTs031210421.

A flow-diverter (FD) device is a well-established tool for the treatment of unruptured intracranial aneurysms. Time-of-flight (TOF) MR angiography (MRA) is widely used for postoperative assessment after the treatment with FD; however, it cannot fully visualize intra-aneurysmal and intrastent flow signals due to the magnetic susceptibility from the FD. Recently, the utility of MRA with ultra-short TE (UTE) sequence and arterial spin labeling technique in assessing the therapeutic efficacy of intracranial aneurysms treated with metallic devices has been reported, but long image acquisition time is one of the drawbacks of this method. Herein, we introduce a novel UTE MRA using the subtraction method that enables the reduction in susceptibility artifacts with a short image acquisition time.

A 68-year-old man received hemodialysis (HD) for the treatment of end-stage renal failure for 6 years. Five years prior to carotid artery stenting (CAS), a neck ultrasound performed to screen for carotid atherosclerosis revealed an asymptomatic right internal carotid artery stenosis. One month prior, the stenotic lesion progressed to 74% by cerebral angiography; therefore, CAS was performed. To evaluate the influence of right internal carotid artery stenosis on the intradialytic cerebral circulation and oxygenation, cerebral regional oxygen saturation (rSO2) at bilateral forehead was measured using the INVOS 5100c oxygen saturation monitor (Covidien Japan, Japan) during HD before and after CAS. Before CAS, right cerebral rSO2 was maintained during HD, whereas left cerebral rSO2 gradually increased from the initiation to end of HD. However, the differences of intradialytic cerebral rSO2 changes between bilateral sides disappeared after CAS. In the present case, before CAS, the intradialytic increase in left cerebral rSO2 might reflect the increase in the left cerebral blood flow to compensate for the ultrafiltration-associated decreases in the right cerebral blood flow and perfusion pressure. Furthermore, the preserved right cerebral rSO2 before CAS might reflect the mechanism maintaining the right cerebral blood flow from the collateralized circle of Willis during HD. Throughout our experience, cerebral oxygenation monitoring during HD might disclose intradialytic changes in cerebral blood flow distribution between the ipsilateral and contralateral side in HD patients with carotid artery stenosis.

BACKGROUND: Postoperative cerebral embolic stroke is a serious complication of pulmonary lobectomy, occurring in 1.1% of patients undergoing lobectomy through video-assisted thoracoscopic surgery (VATS). The mechanism of this complication is thought to be embolic stroke caused by thrombus formed due to stagnation in the pulmonary vein stump after VATS lobectomy. There have been few reports demonstrating the utility of endovascular treatment (EVT) for cerebral embolic stroke after VATS lobectomy. CASE DESCRIPTION: In our case series, cerebral embolic stroke occurred after VATS pulmonary lobectomy for lung cancer, including the left upper lobe in three cases and the right lobe in one. The median duration of ischemic stroke after VATS was 4.5 days (interquartile range, 2-9 days). The median time from stroke onset to puncture was 130 min. Successful recanalization was achieved in all cases, and two patients achieved favorable clinical outcomes (modified Rankin scale, 0-2). CONCLUSION: We report a case series of four patients who underwent EVT for acute embolic stroke after VATS lobectomy for lung cancer. EVT is considered a reasonable and feasible therapeutic option for this condition.

OBJECTIVE: We report a patient with chronic headache due to idiopathic intracranial hypertension (IIH) associated with transverse sinus (TS) stenosis. The symptom improved after stent placement at the site of stenosis. CASE PRESENTATION: The patient was a 37-year-old woman with progressive headache and diplopia as chief complaints. She had severe bilateral papilledema. Magnetic resonance imaging (MRI) and angiography revealed stenosis of the bilateral TS. Lumbar puncture demonstrated raised intracranial pressure and IIH was tentatively diagnosed. Visual impairment progressed despite oral acetazolamide therapy. A venous pressure gradient was monitored during stent placement. The pressure gradient improved after stenting. Dual antiplatelet therapy was initiated 1 week before the procedure. Papilledema and headache resolved immediately after the procedure. No in-stent stenosis or occlusion occurred during the follow-up period. CONCLUSION: Stent placement for TS stenosis can improve the cerebral venous return in IIH patients. Although restenosis is possible, venous sinus stenting is considered an effective treatment.

Acute ischemic stroke (AIS) caused by major vessel occlusion has potentially poor outcomes. Early successful recanalization after symptom onset is an important factor for favorable outcomes of AIS. We present the case of a 74-year-old man with AIS who underwent the entire process from diagnosis to thrombolysis and endovascular treatment in a hybrid emergency room (ER) equipped with a multidetector computed tomography (CT) scanner and an angiography suite set-up. A hybrid ER can facilitate evaluation and definitive interventions in patients with AIS more quickly and safely and in one place, without the requirement for transfer to a CT scanner or angiography suite set-up. In the present case, the door-to-puncture time and door-to-reperfusion time were 85 and 159 min, respectively, which were shorter than those in the group conventionally treated for stroke in our institution. Further study is needed to confirm the effect of the hybrid ER system.

血管内治療において現在一般的に使用されている全身麻酔薬のプロポフォールとセボフルランについて、これら麻酔薬の違いが脳血管の脳循環にどのような違いを及ぼすのか、頸部内頸動脈から各脳血管(眼動脈(OA)、前大脳動脈(ACA)、中大脳動脈(MCA)、深部静脈(Galen)、頭頂静脈(PV))までの循環時間を、脳血管造影画像を用いて評価した。対象は、当院で全身麻酔下に定時コイル塞栓術を受ける米国麻酔学会術前状態分類クラス3以下の前方循環脳動脈瘤患者20例とした。試験デザインはクロスオーバーデザインとし、麻酔導入前にセボフルラン-プロポフォール群(SP群)またはプロポフォール-セボフルラン群(PS群)に1:1に無作為に割り付けた。データ解析は15名(SP群7名、PS群8名)において行われた。血管造影画像解析をトレーニングした2名の解析者によって、匿名化されたDigital Subtraction Angiography(DSA)画像を用いて頸部内頸動脈の基準点と5点の関心領域(OA:眼動脈の最初の屈曲点、ACA:ACAの膝部、MCA:最

未破裂脳動脈瘤に対し外来で経過観察を行い、脳動脈瘤破裂によるクモ膜下出血で入院し、少なくとも2回以上画像検査を行った4例を対象とした。症例1は74歳女性で、右前大脳動脈遠位部に4mm、右中大脳動脈に2mmの動脈瘤を指摘された。大きさに変化はなく経過していたが、106ヵ月後に右ACAの動脈瘤が破裂した。破裂の動脈径は6mmと増大を認めた。症例2は73歳女性で、左内頸動脈後交通動脈(IC-PC)のinfundibular dilatationを指摘された。74ヵ月の経過で3.3mm大に増大した。経過観察していたが、93ヵ月目に破裂した。破裂時の動脈径は4.5mmと増大を認めた。症例3は52歳女性で、IC-PCの破裂動脈瘤でneck clippingを施行した。その際、右IC-PCにも2.0mm大の動脈瘤を指摘された。52ヵ月後、3.1mm大に増大した。109ヵ月の経過で破裂、破裂時の動脈径は6.6mmと増大を認めた。症例4は82歳女性で、脳底動脈に10mm大の動脈瘤を指摘され、18mm大に増大した。170ヵ月の経過で破裂し、破裂時の動脈径は18.8mmとさらなる増大

Ruptured intracranial aneurysms are rare in the pediatric population compared to adults. This has incited considerable discussion on how to treat children with this condition. Here, we report a child with a ruptured saccular basilar artery aneurysm that was successfully treated with coil embolization. A 12-year-old boy with acute lymphoblastic leukemia and accompanying abdominal candidiasis after chemotherapy suddenly complained of a severe headache and suffered consciousness disturbance moments later. Computed tomography scans and cerebral angiography demonstrated acute hydrocephalus and subarachnoid hemorrhage caused by saccular basilar artery aneurysm rupture. External ventricular drainage was performed immediately. Because the patient was in severe condition and did not show remarkable signs of central nervous system infection in cerebrospinal fluid studies, we applied endovascular treatment for the ruptured saccular basilar artery aneurysm, which was successfully occluded with coils. The patient recovered without new neurological deficits after ventriculoperitoneal shunting. Recent reports indicate that both endovascular and microsurgical techniques can be used to effectively treat ruptured cerebral aneurysms in pediatric patients. A minimally invasive endovascular treatment was effective in the present case, but long-term follow-up will be necessary to confirm the efficiency of endovascular treatment for children with ruptured saccular basilar artery aneurysms.

Ruptured intracranial aneurysms are rare in the pediatric population compared to adults. This has incited considerable discussion on how to treat children with this condition. Here, we report a child with a ruptured saccular basilar artery aneurysm that was successfully treated with coil embolization. A 12-year-old boy with acute lymphoblastic leukemia and accompanying abdominal candidiasis after chemotherapy suddenly complained of a severe headache and suffered consciousness disturbance moments later. Computed tomography scans and cerebral angiography demonstrated acute hydrocephalus and subarachnoid hemorrhage caused by saccular basilar artery aneurysm rupture. External ventricular drainage was performed immediately. Because the patient was in severe condition and did not show remarkable signs of central nervous system infection in cerebrospinal fluid studies, we applied endovascular treatment for the ruptured saccular basilar artery aneurysm, which was successfully occluded with coils. The patient recovered without new neurological deficits after ventriculoperitoneal shunting. Recent reports indicate that both endovascular and microsurgical techniques can be used to effectively

Dural arteriovenous fistulas (DAVFs) of the anterior cranial fossa are rare anomalies that invariably present with cortical venous reflux because of the absence of dural sinus in the affected region. Previous reports have identified intracranial hemorrhage as the major symptom and have confirmed that good surgical outcome can be obtained by open surgery. Recently, however, the widespread use of MRI has led to an increase in the incidental detection of asymptomatic DAVFs of the anterior cranial fossa. Treatments for these asymptomatic lesions are now a focus of discussion.<br> We treated four patients with anterior cranial fossa DAVFs between 2005 and 2010. One of the patients presented intracranial hemorrhage and the other three were asymptomatic.<br> The three patients with intracranial hemorrhage underwent open surgery and the other asymptomatic patient underwent endovascular surgery. The latter patient initially underwent transarterial embolization with only partial success. The patient was completely cured by the transvenous approach with platinum coils. All four patients were successfully treated without any adverse events.<br> Previous papers reported similarly high annual intracranial hemorrhage rates from DAVFs with cortical venous reflux. This suggests that surgical treatment for asymptomatic patients with anterior cranial fossa DAVFs should be considered. Direct surgery has been the treatment of choice for this disease so far. For asymptomatic patients, however, endovascular treatment with transvenous embolization may serve as an effective alternative to open surgery.<br>

OBJECTIVE: This report presents 12 consecutively managed patients with aneurysmal subarachnoid hemorrhage (SAH) associated with acute subdural hematoma (ASDH) who underwent decompressive craniectomy (DC) with special attention to their clinical characteristics and surgical outcomes. METHODS: We retrospectively reviewed medical charts, radiologic findings, surgical notes, and video records. RESULTS: Among these 12 patients (mean age 59.1 years, 4 men, 8 women), the Hunt and Kosnik clinical grade was grade V in 7 patients (58.3%), grade IV in 2 patients (16.7%), grade III in 2 patients (16.7%), and grade II in 1 patient (8.3%). The aneurysms were located on the internal carotid artery in four patients, the middle cerebral artery in six patients, and the anterior communicating artery in two patients. Computed tomography findings on admission revealed ASDH in all patients. In addition, SAH was seen in 11 patients. An intracerebral hematoma was found in eight patients, intraventricular hemorrhaging occurred in four, and an acute hydrocephalus was seen in one patient. All patients underwent a microsurgical clipping procedure and an additional DC. Symptomatic vasospasm was confirmed in six (50%), and eight patients with chronic hydrocephalus received a ventriculoperitoneal shunt (67%). The Glasgow Outcome Scale at discharge showed good recovery in five patients (41.7%), severe disability in four (33.3%), vegetative state in two (16.7%), and death in one patient (8.3%). A favorable outcome was achieved in five patients (41.7%). CONCLUSIONS: We suggest that the DC was effective for reducing morbidity and mortality in poor grade patients with SAH presenting with ASDH.

Hypereosinophilic syndrome (HES) is a rare disorder that can cause ischemic stroke. We present a patient with middle cerebral artery (MCA) occlusion resulting from HES. Transarterial thrombolysis resulted in MCA recanalization and adjuvant therapy may have contributed to stabilization of the underlying HES in our patient. (C) 2009 Elsevier Ltd. All rights reserved.

Acute subdural hematoma (ASDH) patients presenting in a severe condition tend to have poor outcomes due to the significant brain edema required to maintain the ICP at less than 20-25 mmHg. This study compared the surgical outcomes of 16 critically ill patients with ASDH who underwent hematoma irrigation with trephination therapy (HITT) based on their initial ICP values. The initial mean GCS score upon admission was four. A unilateral dilated pupil was seen in one and bilateral dilated pupils were seen in seven patients. The co-existence of a brain contusion was seen in seven patients, brain swelling was noted in six patients, and both basal cistern effacement and a midline shift greater than 5 mm were observed in all patients. The mean initial ICP value was 45 mmHg (range: 3 to 85 mmHg). Ten patients (62.5%) underwent a rapid external decompression to evacuate the hematoma. By using the Glasgow Outcome Scale upon discharge a score of good recovery (GR) was assigned to two (12.5%), moderate disability (MD) to four (25.0%), vegetative state (VS) to two (12.5%), and death (D) to eight (50.0%) patients. All six patients who showed an initial ICP greater than 60 mmHg died despite intensive care. Eight patients who showed an initial ICP less than 40 mmHg had a favorable outcome, but two patients deteriorated due to a traumatic cerebrovascular disorder. It seems that the initial ICP monitoring with HITT for ASDH patients in critical condition may be an important factor for predicting both surgical outcome and clinical course.

Acute epidural hematomas (AEDH) are generally managed with rapid surgical hematoma evacuation and bleeding control. However, the surgical outcome of patients with serious brain edema is poor. This study reviewed the clinical outcome for AEDH patients and evaluated the efficacy of the DC, especially in patients with associated massive brain swelling. Eighty consecutive patients surgically treated with AEDH were retrospectively assessed. The patients were divided into two groups: (a) hematoma evacuation (HE: 46 cases) and (b) HE+ an external decompression (ED: 34 cases). The medical charts, operative findings, radiological findings, and operative notes were reviewed. In the poor outcome group, there were 18 patients (72%), with a GCS score of less than 8 (severe injury), and 22 patients (88%) who showed pupil abnormalities. Many more patients showed a midline shift, basal cistern effacement, and brain contusion in comparison to the favorable outcome group. In the favorable outcome group, almost all of the patients (98%) showed less than 12 mm of a midline shift. The influential factors may be age, GCS, pupil abnormalities, size, midline shift, basal cistern effacement, coincidence of contusion and swelling. We conclude that an A DC may be effective to manage the AEDH patients with cerebral contusion or massive brain swelling.

Purpose Decompressive craniectomy for traumatic brain injury patients has been shown to reduce intracranial hypertension, while it often results in increased brain edema and/or contralateral space-occupied hematoma. The purpose of this study was to determine the prognosis of bilateral decompressive craniectomy in severe head injury patients with the development of either bilateral or contralateral lesions after ipsilateral decompressive craniectomy. Methods Twelve patients underwent bilateral decompressive craniectomy among 217 individuals who had been treated with decompressive craniectomy with dural expansion from September 1995 to August 2006. The following patient data were retrospectively collected: age, neurological status at admission, time between injury and surgical decompression, time between first and second decompression, laboratory and physiological data collected in the intensive care unit, and outcome according to the Glasgow Outcome Scale. Results Patient outcomes fell into the following categories: good recovery (three patients); mild disability (one patient); severe disability (two patients); persistent vegetative state (one patient); and death (five patients). Patients with good outcomes were younger and had better pupil reactions and neurological statuses on admission. Other factors existing prior to the operation did not directly correlate with outcome. At 24 h post-surgery, the average intercranial pressure (ICP), cerebral perfusion pressure (CPP), glucose level, and lactate level in patients with poor outcomes differed significantly from those of patients with a good prognosis. Conclusion Head injury patients with either bilateral or contralateral lesions have poor prognosis. However, bilateral decompressive craniectomy may be a favorable treatment in certain younger patients with reactive pupils, whose ICP and CPP values are stabilized 24 h post-surgery.

Epstein-Barr virus (EBV) encephalitis is a rare neurological complication, usually only reported in pediatric patients. We present a 20-year-old, previously healthy male who developed hemorrhagic encephalitis caused by EBV. He was admitted to our hospital with a I-week history of fever, diarrhea, headache, and confusion, Brain T2-weighted MRI showed a focal area of increased signal in the right temporal lobe. Brain MRI and CT scans on day 2 revealed progression of the lesion, with partial hemorrhagic change, acute brain swelling, and severe midline shift. The patient underwent external decompression and external ventricular drainage. EBV DNA was identified in brain biopsy specimens by polymerase chain reaction. The postoperative course was uneventful. To Our knowledge, this is the second report of hemorrhagic EBV encephalitis in an adult. Published by Elsevier Ltd.

Computed tomography (CT) is an important tool for the evaluation of subarachnoid hemorrhages caused by ruptured aneurysms. However, an unusual radiologic presentation of blood can result in the misdiagnosis of the rupture site. We report a case of ruptured right internal carotid-posterior communicating (IC-PC) artery aneurysm with an unusual radiologic presentation of hemorrhage. The CT scans images of this patient were indicative of blood clots in the cisterna magna and the ventricles with no blood collection in the suprasellar cistern or sylvian fissure. The intraventricular clots were mainly distributed in the fourth ventricle, with few clots in the lateral ventricles. On the basis of these findings, we suspected the origin of the hemorrhage was an unknown ruptured posterior fossa aneurysm. However, angiography revealed a right internal carotid-posterior communicating (IC-PC) artery aneurysm. Twenty-three days after onset, a repeat CT confirmed that the origin of the hemorrhage was the right IC-PC aneurysm. Possible factors involved in this case were: (1) formation of adhesions in the subarachnoid cisterns due to an earlier minor leakage, (2) the orientation of the aneurysm (posteroinferior direction), and (3) early wash out of the blood clot.

We report a rare case of chronic encapsulated intracerebral hematoma (CEIH) after radiosurgery for a cerebral arteriovenous malformation (AVM). Seven years after radiosurgery, magnetic resonance imaging revealed a high-intensity mass in the right basal ganglia with a peripheral low signal ring and fluid level on both T1- and T2-weighted images, which was compatible with CEIH. Stereotactic evacuation and placement of an Ommaya reservoir were performed. The concentration of vascular endothelial growth factor was high in the hematoma, suggesting that CEIH may be similar to chronic subdural hematoma.

Dolichoectasia is an angiopathy characterized by dilatation, elongation, and tortuosity of the brain arteries. It most frequently involves the vertebral and basilar arteries; involvement of both the vertebrobasilar and carotid systems is rare. We present a patient with fatal dolichoectasia involving both the vertebrobasilar and carotid artery systems. (C) 2009 Elsevier Ltd. All rights reserved.

Ruptured aneurysms typically present as subarachnoid hemorrhage (SAH) however, they can also cause intracerebral hemorrhage (ICH) that can be mistaken for hypertensive hemorrhage. We report a rare case of a ruptured middle cerebral artery bifurcation aneurysm presenting as putaminal hemorrhage without subarachnoid hemorrhage (SAH). A 47-year-old man, with a past history of hypertension, presented with a decreased level of consciousness. Neurological examination revealed hemiparesis of the right side. A CT scan on admission demonstrated left putaminal hemorrhage without SAH. Three-dimensional CT and conventional angiograms demonstrated a superiorly directing aneurysm of the M1/M2 portion of the left middle cerebral artery (MCA). We performed aneurysmal clipping and hematoma evacuation. The postoperative course was uneventful. This case suggested that ruptured aneurysms situated on the middle cerebral artery can present as putaminal hemorrhage without SAH.

A rare case of a traumatic middle meningeal arteriovenous fistula on the side of the head opposite to the injured side was reported. A 21-year-old man was admitted to our hospital after a traffic accident in which the right side of his head was hit. CT scans and MR images on admission showed a right temporal bone fracture, traumatic subarachnoid hemorrhage, and a left frontal lobe contusion. Three months after the head injury, he complained of tinnitus and exophthalmos. One year after the head injury, left external carotid angiograms showed a dural arteriovenous fistula fed by the left dilated middle meningeal artery and draining into the middle meningeal vein. Early filling of the sphenoparietal sinus, cavernous sinus, superior ophthalmic vein, and the cortical vein were also detected. Transarterial embolization of the left middle meningeal fistula was performed, resulting in the disappearance of the lesion. The postoperative course was uneventful.

Ruptured aneurysms located at the non-branching sites of the internal carotid artery, including blister-like aneurysms, possess unique clinical and technical features. This report presents nine consecutively managed patients with these types of aneurysm, detailing the clinical and radiological characteristics and surgical Outcomes. The initial angiography identified aneurysmal lesions in six of the nine patients with two of these patients requiring additional three-dimensional (3D) angiography. In three patients the aneurysm was only diagnosed on second or third angiograms. Six patients had blister-like aneurysms, and two had saccular-shaped aneurysms diagnosed on the basis of intraoperative findings. One patient with a saccular aneurysm died without surgery. Eight patients underwent a microsurgical procedure: clipping in five, clipping on wrapping with suturing in two and trapping in one. Three of these eight patients had an intraoperative rupture. A favorable Outcome was obtained in seven patients. Advances in microsurgical techniques to prevent premature rupture and 3D radiological diagnosis with careful pre-operative consideration of the surgical Strategies will be required for a further improvement of the clinical outcome. (C) 2008 Elsevier Ltd. All rights reserved.

A rare case of cerebral venous thrombosis associated with thrombocythemia is reported. A 47-year-old man presented with headache, papilledema, and diplopia. Complete blood count showed an increased number of platelets. MR images and venography showed the thrombosis from the superior sagittal sinus (SSS) to the bilateral transverse sinuses (TS). The patient was treated with thrombolysis, continuous heparin infusion, and oral warfarin. On day 2, angiography demonstrated partial recanalization of the SSS and the left TS. Since CSF pressure was 30 cmH(2)O at day 11, a spinal drainage catheter was installed. Nevertheless, the patient presented with left hemiparesis, seizure, and loss of consciousness on day 12. Angiography revealed thrombosis from the SSS to the left TS and the right sigmoid sinus. Mechanical thrombolysis with a balloon was performed, and partial recanalization was obtained. In order to control the intracranial pressure, barbiturate coma therapy was performed for 1 week. On day 19 aspirin therapy was initiated become of continuous thrombocythemia. On day 25, the patient recovered completely. This case suggests that thrombocythemia may be able to cause refractory cerebral venous thrombosis.

Optimal surgical management of ruptured aneurysms of the distal anterior cerebral artery continues to provide unique technical challenges. This study presents 20 consecutively managed such patients, with special attention given to the clinical and radiological characteristics, as well as the surgical outcomes. Intracerebral hematoma was seen in 11 of the 20 patients, and intraventricular hemorrhage occurred in 4 (20%). Angiography revealed that 9 (45%) patients had multiple aneurysms. Three patients (15%) had "mirror" distal anterior cerebral arterial aneurysms on the contralateral side. Eleven patients (55%) had aneurysms located at the supracallosal portion of the anterior cerebral artery, while 9 patients (45%) had aneurysms located below the genu of the corpus callosum. The mean aneurysmal diameter was 3.85 mm; 18 aneurysms (90%) were less than 6 mm in diameter. Eighteen patients (90%) underwent a microsurgical procedure; 2 (10%) underwent endovascular coiling due to poor clinical grade. A favorable outcome was achieved in 14 (70%) patients. Advances in microsurgical techniques will be required to further improve clinical outcome. Published by Elsevier Ltd.

A rare case of meningitis complicated by brainstem infarction is reported. A 64-year-old, previously healthy female was admitted to our hospital because of a 1-week history of fever and headache. Cefdinir was orally administered for several days before admission. Analysis of cerebrospinal fluid (CSF) on admission showed a white blood cell (WBC) count of 9,013 cells/mu/(97% polynuclear cells), a protein level of 212.8 mg/d/, and a glucose level of 3 mg/d/. CSF culture was negative for bacteria, including tubercle bacilli, and fungi. A brain computed tomography (CT) scan on admission showed acute hydrocephalus. Six hours after admission, the patient developed tetraplegia. Diffusion-weighted magnetic resonance (MR) images on day 2 revealed elevated diffusion coefficients with high signal intensity in the pons and the medulla oblongata. MR angiography demonstrated a narrowing change of the cerebral arteries. Followup MR angiography two months after admission showed normalization of the cerebral arteries. The patient remained tetraplegic at eight months after admission. We speculated that brainstem infarction in our case might have been caused by vascultis or brain edema.

The recurrence or metastasis of intracranial pure germinomas as germ cell tumours of different histological types has rarely been reported. The present report concerns the first case in the literature of intracranial recurrence of a germinoma transformed into a choriocarcinoma. A 17-year-old man presented with a 1 month history of headache. MRI revealed a homogeneously enhanced mass within the pineal and suprasellar regions. The tumour was resected, and histological examination identified it as a pure germinoma. After resection, the patient underwent chemotherapy and radiotherapy and the mass disappeared. At 5 years and 5 months later, the patient presented with nausea and headache, and recurrence of the tumour was revealed in the left lateral ventricle. The tumour was resected and histological diagnosis identified it as a choriocarcinoma. The patient was treated with chemotherapy and radiotherapy, but died due to dissemination 1 month later. An autopsy was not performed.

We report a rare case of dissecting aneurysm of the distal anterior inferior cerebellar artery (AICA). A 63-year-old woman who complained of severe headache and nausea was admitted to our hospital. A computed tomography (CT) scan revealed subarachnoid hemorrhage, intraventricular hemorrhage, and acute hydrocephalus. Left vertebral angiogram revealed a dissecting aneurysm at the meatal loop of the distal AICA. On the next day, left suboccipital craniotomy was performed, and the fusiform aneurysm was trapped. The patient did not exhibit cranial nerve palsy after the operation. A left vertebral angiogram obtained after the operation showed that the dissecting aneurysm of the distal AICA had completely disappeared. Dissecting aneurysm of the distal AICA is a rare condition. Thus far, only 9 cases have been reported in the literature. We reviewed these cases and discussed the treatment for and outcome of dissecting aneurysms of the distal AICA.

Object. A miltimodal neuronavigation system using metabolic images with PET and anatomical images from MR images is described here for glioma surgery. The efficacy of the multimodal neuronavigation system was evaluated by comparing the results with that of the conventional navigation system, which routinely uses anatomical images from MR and CT imaging as guides. Methods. Thirty-three patients with cerebral glioma underwent 36 operations with the aid of either a multimodal or conventional navigation system. All of the patients were preliminarily examined using PET with L-methyl-[(11)C] methionine (MET) for surgical planning. Seventeen of the operations were performed with the multimodal navigation system by integrating the MET-PET images with anatomical MR images. The other 19 operations were performed using a conventional navigation system based solely on MR imaging. Results. The multimodal navigation system proved to be more useful than the conventional navigation system in determining the area to be resected by providing a clearer tumor boundary, especially in cases of recurrent tumor that had lost a normal gyral pattern. The multimodal navigation system was therefore more effective than the conventional navigation system in decreasing the mass of the tumor remnant in the resectable portion. A multivariate regression analysis revealed that the multimodal navigation systern-guided Surgery benefited patient survival significantly more than the conventional navigation-guided surgery (p = 0.016, odds ratio 0.52 [95% confidence interval 0.29-0.88]). Conclusions. The authors&apos; preliminary intrainstitutional comparison between the 2 navigation systems suggested the possible premise of multimodal navigation. The multimodal navigation system using MET-PET fusion imaging is an interesting technique that may prove to be Valuable in the future. (DOI: 10.3171/2008.4.17569)

Aneurysms of lenticulostriate artery (LSA) have rarely been reported. We present an extremely rare case of bilateral aneurysm of LSA, which spontaneously disappeared. A 59-year-old man presented to us with a decreased level of consciousness. Twice repeated blood culture was negative. Computed tomography (CT) showed bilateral basal ganglia hemorrhage with intraventricular extension and acute hydrocephalus. We performed external ventricular drainage. Cerebral angiograms, on 3 days after the onset, disclosed two aneurysms on the left LSA and one aneurysm on the right LSA. Cerebral angiography after 9 weeks demonstrated complete disappearance of three aneurysms.

A rare case of traumatic dural arteriovenous fistula presenting as an acute subdural hematoma and an intracerebral hematoma is reported. A 57-year-old man was admitted to our hospital complaining of aphasia and right hemiparesis. A CT on admission demonstrated a left frontotemporal subdural hematoma and an intracerebral hematoma in the left frontal lobe. Left external carotid angiographies revealed a dural arteriovenous fistula, fed by the left middle meningeal artery and draining the middle meningeal vein. A retrograde drainage into the cortical vein was also revealed. The patient had sudden loss of consciousness after cerebral angiography and demonstrated increased subdural hematoma and severe midline shift. We performed emergency decompressive craniectomy, coagulation of the dural vessels, and evacuation of the subdural hematoma. Postoperative left external carotid angiographies revealed the disappearance of the dural arteriovenous fistula. This case suggested a dural arteriovenous fistula, between the middle meningeal artery and the middle meningeal vein close to the sinus (sphenoparietal or superior sagital sinus), and resulted in a subdural hematoma and an intracerebral hematoma, due to the retrograde venous drainage into cortical veins.

Traumatic vertebral artery injuries are frequently accompanied by cervical spine injury. Transverse process fracture from C6 to C1 has been reported as a high risk factor for vertebral artery injury. We report a rare case of vertebral artery occlusion caused by transverse process fracture of C7. A 22-year-old man was admitted to our hospital after a motor-cycle accident. Neurological examination revealed almost normal findings. Axial computed tomography (CT) at the C7 level revealed soft-tissue swelling of the neck and right transverse process fracture. Further, a bony fragment protruding in the anterolateral direction was observed. Magnetic resonance (MR) image showed normal findings. MR angiography (MRA) revealed right vertebral artery occlusion at the V1 segment. Vertebral artery angiography revealed right vertebral artery occlusion, normal basilar artery, and retrograde flow of the right vertebral artery. The patient was treated with heparin and aspirin and discharged 28 days after admission. A follow up MRA at 2 months after admission demonstrated no change in right vertebral artery occlusion, and he was still asymptomatic 3 months after admission. We conclude that the transverse process fracture of C7 complicated with soft-tissue swelling of the neck could cause vertebral artery injury, and MRA and angiography are recommended for diagnosis and treatment, respectively.

Background: Maxillofacial injuries may be associated with a variety of problems including airway obstruction and hemorrhage. We studied retrospectively the patients who underwent transcatheter arterial embolization for facial hemorrhage. Methods: We retrospectively evaluated medical charts of the 12 patients who underwent transcatheter arterial embolization for facial hemorrhage between January, 2000 and December, 2006. We decided clinical outcome using Glasgow Outcome Scale (GOS) and classified the patients into the favorable outcome group (GR: good recovery, MD: moderate disability), and poor outcome group (D: dead). We compared the two groups regarding blood pressure, pulse rate, Glasgow Coma Scale (GCS), Injury Severity Score (ISS), transufused volume, interval between injury and embolization. Results: From 12 cases reviewed, nine were males and three were females. The mean age was 42 years (20-73 years). Three patients were GR, one patient was MD, and eight patients were D. In the poor outcome group, shook signs were more common, and GCS was lower The ISS was correlated with the outcome. The mean interval between injury and embolization was 3.5 hours. Conclusion: Patients with maxillofacial injuries may be fatal. Airway and breathing maintenance are most important. When pressure and packing fail to control the hemorrhage, prompt transcatheter arterial embolization may be effective.

Isolated traumatic oculomotor nerve palsy caused by minor head trauma is extremely rare. We report a case of this condition. A 65-year-old woman was transferred to our hospital after minor head injury. Initial examination of her right eye revealed a dilated pupil. The result of computed tomography, magnetic resonance imaging, and magnetic resonance angiography of the brain were normal. An examination conducted 6 hours after the accident, examination demonstrated right ptosis, and another conducted 20 hours after the accident, she demonstrated partial limitation of adduction, supraduction, and infraduction of the right eye. Constructive interference in steady-state magnetic resonance imaging demonstrated a slightly rough-shaped oculomotor nerve near the posterior petroclinoid ligament. After 8 months of the accident, the ptosis and limited eye movement were resolved. However, the right dilation of the right pupil persisted. Our case suggests that even minor head trauma can cause isolated oculomotor palsy, and that the posterior petroclinoid ligament is a candidate structure for causing oculomotor nerve palsy without intracranial hemorrhage and skull fracture.