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Ethanol sclerotherapy has shown favorable short-term efficacy in managing head and neck arteriovenous malformation (AVM) which is well known for high recurrence rate after treatment. The purpose of this study was to report immediate treatment results and long-term follow-up results of ethanol sclerotherapy in patients with head and neck AVMs.We performed a retrospective review of 45 patients with head and neck AVMs treated between April 1997 and December 2013 by using ethanol sclerotherapy with or without adjunctive surgery. The degree of AVM eradication was analyzed, and complications per treatment session were recorded. Long-term treatment effectiveness was assessed with clinical and imaging follow-up.In total, 132 sclerotherapies were performed in the 45 patients, with a total angiographic eradication rate of 17.8% (n = 8). Partial resolution was achieved in 34 patients, and three patients showed no response. Mean follow-up period was 56.6 months (range, 13-144 months). The long-term recurrence rate was 11.1% (5/45), and all recurrences occurred more than 3 years after the treatment with interval disease-controlled period. The major complication rate was 3.8% (5/132), and 34 minor complications (25.8%) occurred.Ethanol sclerotherapy is effective for achieving long-term durable cure of head and neck AVMs. In patients with non-curable disease, it is also effective for symptom palliation and long-term disease control. However, given recurrence after interval disease-controlled period, long-term follow-up should be required to detect recurrence in patients with any residual lesion after treatment.

Some cerebral cavernous malformations (CCMs) may be associated with vascular malformations that occur on the capillary-venous side of the cerebral circulation. The association between CCMs and dural arteriovenous shunts (DAVSs) is not well known. The purpose of this study is to investigate the relationship between CCMs and DAVSs. We retrospectively analyzed 179 patients diagnosed as intracranial DAVSs and performed with digital subtraction angiography (DSA). The DSA images were investigated for the location, cortical venous reflux (CVR), multiplicity, and treatment method/result of DAVS. MR images were investigated for the location, number, and size of CCMs and correlated with the DSA images. Six of the 179 patients with DAVSs presented with coexistent CCMs (3.4 %; M/F = 3:3; mean age, 38 ± 22 years). Five of the six DAVS patients with CCMs were associated with CVR (83 %). The total number of CCMs associated with DAVS was 20. Multiple CCMs (range, 2–7) were seen in four (66 %) of six patients. Eighteen (90 %) of the 20 CCMs were located on the ipsilateral hemisphere of the CVR (n = 10) or adjacent to the deep venous reflux (n = 8). Five de novo CCMs were detected in two patients. All de novo CCMs were located on the ipsilateral hemisphere of the DAVS with CVR or juxtapositioned to abnormally dilated deep vein. CCMs may develop in association to DAVSs. The relationship between CCMs and DAVSs suggests the venous pathogenic origin of CCMs and the role of venous hypertension in the de novo development of CCMs.

Ostium of vertebral artery (VA) is a common site of pseudostenosis on contrast-enhanced MR angiography (CE-MRA). The purpose of this study was to determine the diagnostic accuracy of CE-MRA at 3 T in the evaluation of ostial stenosis of VA and to find associated coincidental stenoses using logistic regression analysis. One hundred and thirty-five VA ostial regions from 72 patients who received CE-MRA of neck vessels, intracranial time of flight (TOF) MRA, and digital subtraction angiography (DSA) were retrospectively reviewed. The sensitivity and specificity of the CE-MRA in detection of ostial stenosis were calculated with reference standard of DSA. Ostial stenosis on MRA was correlated with coincidental lesions in intracranial and cervical arteries by logistic regression analysis. The sensitivity and specificity of the CE-MRA were 100% and 80.4% for detection of significant stenosis. In case of significant stenoses, CE-MRA showed a tendency of overestimation with a false-positive rate of 52.5%. Logistic regression analysis showed that the stenoses of middle cerebral artery (MCA) on TOF MRA was associated with significant stenoses of VA ostia (OR = 5.84, 95% confidence intervals 1.41–24.17). CE-MRA is sensitive in detection of VA ostial stenosis although it has high false-positive rate. True positive ostial stenosis should be considered in cases of coincidental stenoses of MCA on TOF MRA.

We describe our experience in which a retrievable Enterprise stent was used as a temporary recanalization and embolectomy device in an acute middle cerebral artery (MCA) occlusion after urgent stenting for ipsilateral carotid artery stenosis.

We retrospectively evaluated the ischemic complications related to the anterior choroidal artery (AChA) and clinical outcome after coiling of AChA aneurysms. We included 37 patients (27 with subarachnoid hemorrhage, 10 without) harboring 38 AChA aneurysms (23 ruptured, 15 unruptured) who were treated by coiling at four institutions. Ischemic complications related to the AChA and clinical outcomes were retrospectively evaluated. Intraprocedural transient AChA occlusion occurred in five aneurysms, all of which had AChA incorporated into the aneurysm neck. Two of the five patients suffered postprocedural transient contralateral hemiparesis, but recovered completely. The remaining three patients had no postprocedural symptoms. Incidence of transient AChA occlusion was significantly higher in those aneurysms in which the AChA was incorporated into aneurysm neck (group 2) than in those in which the AChA was not incorporated (group 1). Of the 37 patients, 31 (83.8%) had good recoveries (modified Rankin scale score 0–2). Two patients died from the consequences of subarachnoid hemorrhage. During follow-up for a mean of 27 months (range 4–72 months), none of the 35 living patients re-bled. A total of 29 aneurysms in 28 patients were followed-up angiographically. Recurrences were found in 5 of the 29 aneurysms during follow-up (mean 18 months, range 6–45 months). Re-embolization achieved near complete occlusion of two recurrent aneurysms, both of which were still stable at the time of the next two follow-up angiographies. The other three recurrent aneurysms were not retreated due to the small size of the recurrences. Coiling of AChA aneurysms resulted in good outcomes without AChA-related permanent ischemic complications. Transient AChA occlusion, potentially associated with ischemic complications, was significantly more frequent in the aneurysm in which the AChA was incorporated into the aneurysm neck.

The outcome of patients who show no early response to intravenous (i.v.) tissue plasminogen activator (tPA) therapy is poor. The objective of this study was to evaluate the feasibility of rescue localized intra-arterial thrombolysis (LIT) therapy for acute ischemic stroke patients after an early non-responsive i.v. tPA therapy. Patients with proximal MCA occlusions who were treated by LIT (n = 10) after failure of early response [no improvement or improvement of National Institute of Health Stroke Scale (NIHSS) scores ofor = 3] to i.v. tPA therapy (0.9 mg/kg-10% bolus and 90% i.v. infusion over 60 min) were selected. The recanalization rates, incidence of post-thrombolysis hemorrhage and clinical outcomes [baseline and discharge NIHSS scores, mortality, 3 months Barthel index (BI) and modified Rankin score (mRS)] were evaluated. Rescue LIT therapy was performed on ten MCA occlusion patients (male:female = 3:7, mean age 71 years). The mean time between the initiation of i.v. tPA therapy and the initiation of intra-arterial urokinase (i.a. UK) was 117+/-25.0 min [time to i.v. tPA 137+/-32 min; time to digital subtraction angiography (DSA) 221+/-42 min; time to i.a. UK 260+/-46 min]. The baseline NIHSS scores showed significant improvement at discharge (median from 18 to 6). Symptomatic hemorrhage and, consequent, mortality were noted in 2/10 (20%) patients. Three months good outcome was noted in 4/10 (40%, mRS 0-2) and 3/10 (30%, BIor = 95). In conclusion, rescue LIT therapy can be considered as a treatment option for patients not showing early response to full dose i.v. tPA therapy. Larger scale studies for further validation of this protocol may be necessary.

Using a transorbital approach we induced the temporal occlusion and reperfusion model in 18 cats. A vascular clamp was placed on the main trunk of the left middle cerebral artery (MCA) for 1 h. Diffusion- and perfusion-weighted MR images were obtained at 1, 3, 6 and 24 h after the clip was released. The cats were killed 24 h after reperfusion, and triphenyl tetrazolium chloride (TTC) staining was performed. After the relative cerebral blood volume (rCBV), time to peak enhancement (TTP) and apparent diffusion coefficient (ADC) maps had been acquired, ROIs were drawn on (1) the area of the infarct produced, (2) the area of high signal intensity on initial diffusion-weighted magnetic resonance imaging (DWI) but normal on TTC staining, e.g., salvaged parenchyma. The ratios of these areas to the normal contralateral cortex were calculated and compared with those of the areas of the final infarct and the salvaged parenchyma. Areas of final infarct showed a temporal increase of rCBV on 3 and 6-h imaging and a final depletion on 24-h imaging. A persistent decrease of ADC value and delayed TTP were observed. Salvaged parenchyma also showed increased rCBV after reperfusion until the last imaging comparing it to the final area of infarct (P

The aim of this study is to assess the relationship between the venous angioarchitectural features and the clinical course of intracranial dural arteriovenous shunt (DAVS) with cortical venous reflux (CVR). With institutional review board approval, 41 patients (M:F = 24:17; median age, 52 years (range, 1–72 years), median follow-up; 1.5 years; partial treatment, n = 36) with persistent CVR were included. We evaluated the initial presentation and the incidence of annual morbidity (hemorrhage or new/worsened nonhemorrhagic neurological deficit (NHND)) according to the venous angiographic patterns—isolated venous sinus, occlusion of the draining sinus, direct pial venous drainage, pseudophlebitic pattern, venous ectasia, brisk venous drainage, and length of pial vein reflux—on digital subtraction angiography. Cox regression was performed to identify independent factors for clinical course. During 111.9 patient-years of follow-up, the overall annual morbidity rate was 11.6 % (mortality; n = 3, rate; 2.6 %/year). Hemorrhage occurred in five patients (12.2 %, rate; 4.5 %/year) and new/worsened NHND occurred in eight patients (19.5 %, rate; 7.2 %/year). Patients with isolated venous sinus, direct pial venous drainage, and pseudophlebitic pattern were associated with initial aggressive presentation. Venous ectasia was associated with initial hemorrhagic presentation. Brisk venous drainage was associated with initial benign presentation. Patients with isolated venous sinus showed a poor clinical course with a higher annual incidence of hemorrhage or new/worsened NHND (91.2 %/year vs 9.2 %/year; hazard ratio, 6.681; p = 0.027). Venous angioarchitectural features may be predictive of the clinical course of DAVSs. DAVS patients with isolated venous sinus may be especially at high risk for future aggressive clinical course.

Dural arteriovenous fistulas involving marginal sinus are relatively rare. Transvenous embolization is a curative treatment of choice for them. Regional anatomy surrounding the marginal sinus comprises complex craniocervical bony structures and abundant venous interconnections. Therefore, dural arteriovenous fistulas involving marginal sinus may have various routes for a transvenous approach. The purpose of this article was to analyze endovascular treatment of marginal sinus dural arteriovenous fistulas with emphasis on the routes of transvenous embolization.Five patients with dural arteriovenous fistulas (DAVFs) involving the marginal sinus who were treated with transvenous embolization were retrospectively analyzed in terms of endovascular treatment: angiographic architecture, routes of venous approach, and treatment results case by case.There were no significant complications except for headache, ocular pain, and facial flushing after transvenous embolization. Immediate angiographic outcomes were complete in four patients and partial in one patient. Clinical outcomes during follow-up were complete recovery in four patients and intermittent tinnitus in one patient. Three different transvenous approaches were used for transvenous coil embolization: ipsilateral internal jugular vein in three patients, contralateral internal jugular vein in one patient, and vertebral venous plexus in one patient.Transvenous coil embolization in treating marginal sinus DAVF is a safe and effective method. In case of failure of an internal jugular venous approach, alternative routes of embolization should be considered. Understanding the regional venous anatomy of the craniocervical junction is important for targeting fistulous sites and selecting routes for transvenous embolization.

The endovascular treatment of cerebral aneurysms with coils poses significant technical challenges, particularly with respect to wide-necked aneurysms. We present the results of our initial experiences in using a stent for endovascular treatment of aneurysms, with an emphasis on potential applications, technical aspects, and associated complications. Twenty-three wide-necked aneurysms from 22 patients were treated during the 13-month study period. Seven patients presented with subarachnoid hemorrhage. Aneurysms were located at the internal carotid artery (n=14), the vertebral artery (n=3), the basilar artery (n=5), and the middle cerebral artery (n=1). A Neuroform stent2 was used for stent-assisted procedures. Premedication with antithrombotic agents was available for unruptured cases. Postprocedural antithrombotic medication was prescribed for all patients. Nineteen aneurysms were primarily stented, followed by coil placement. For five of these aneurysms, stenting was performed subsequent to failure of an attempt to frame with an initial coil. Stenting for the remaining four aneurysms was performed as a rescue procedure to prevent the migration of previously placed coils. Complete occlusion was obtained in ten aneurysms, nearly complete occlusion (95% or more occluded) in 11 aneurysms, and partial occlusion (less than 95% occluded) in one aneurysm. In one aneurysm, we failed to navigate the microcatheter into the aneurysmal sac through the interstices of the stent. Stent thrombosis was noted during the procedure in one patient. Hemorrhagic complication on the 25th day after the procedure was noted in one patient. No procedure-related complications were observed during the procedure or during follow-up in the remaining 20 patients, including seven patients who did not receive antithrombotic agents prior to endovascular treatment owing to recent subarachnoid hemorrhage. To overcome the technical limitation in the coiling of wide-necked aneurysms, stent-assisted coil embolization may be a technically feasible and relatively safe method, even though longer periods of follow-up are required.

We aimed in this study to assess the clinical usefulness of fractional anisotropy (FA) maps in the evaluation of lacunar infarctions in striatum, internal capsule and thalamus. We retrospectively reviewed 28 patients (18 men, 10 women; mean age 63 years) who had acute lacunar infarction in striatum, internal capsule and thalamus on diffusion weighted MR imaging (DWI). Fractional anisotropy (FA) maps were generated in addition to conventional T2 weighted images (T2WI) and trace maps of DWI. Two radiologists reviewed the location of infarcts in combination with and without FA maps. Exact location of infarction was determined by FA maps, i.e. on the white band of internal capsule or outside the internal capsule. Accuracy and inter-observer agreement on determination of the location of infarction was evaluated. Accuracy of infarct localization by T2WI-DWI only was varied from 72 to 91% according to the observers. Inter-observer agreement value was moderate (Kappa=0.446), when images were interpreted by T2WI-DWI only. Clinical manifestation of each lesions were varied, but sensory motor stroke was mainly observed in thalamic lesion (50%), while pure motor hemiparesis was predominant in the case of infarct involving internal capsule, corona radiata (91%) and basal ganglia (83%). The FA map is useful in the evaluation of lacunar lesions in striatum, internal capsule and thalamus. Clinical presentation varies according to the exact location of lacunar infarctions, and more accurate diagnosis can be made by FA maps as well as conventional T2-weighted image and DWI.

We reviewed the MRI findings of germinomas originating from the basal ganglia, thalamus or deep white matter in 13 patients with 14 germinomas, excluding those in the suprasellar or pineal regions. Ten cases were confirmed as germinomas by stereotaxic biopsy, three by partial and one by total removal of the tumour. Analysis was focussed on the location and the signal characteristic of the tumour, haemorrhage, cysts within the tumour and any other associated findings. Thirteen of the tumours were in the basal ganglia and one in the thalamus. Haemorrhage was observed in seven patients, while twelve showed multiple cysts. Associated ipsilateral cerebral hemiatrophy was seen in three patients. The signal intensity of the parenchymal germinomas was heterogeneous on T1- and T2-weighted images due to haemorrhage, cysts and solid portions. We also report the MRI findings of germinomas in an early stage in two patients.

The pterygopalatine fossa is an important space because it communicates with the middle cranial fossa, orbit, nasal cavity, oral cavity, pharynx, foramen lacerum, and the infratemporal fossa via eight foramina and canals. We studied the pterygopalatine fossa, foramen rotundum, inferior orbital fissure, sphenopalatine foramen, pterygoid canal, greater and lesser palatine foramen, palatinovaginal canal, and the pterygomaxillary fissure with high-resolution CT to characterise the anatomy and variants of these structures. These structures were evaluated using axial and coronal planes. In the morphometric study, the distance between the foramina rotunda did not show statistically significant differences between the anterior and posterior segments. The pterygoid canal was slightly narrower in the anterior segment (23.9 mm) than in the posterior segment (25.2 mm). The pterygoid canal narrowed in the anterior (1.8 mm) to posterior (1.2 mm) direction (P < 0.01). The distance between the pterygoid canal and the lower wall of the sphenoid sinus was 2.2 mm anteriorly and 2.8 mm posteriorly (P < 0.01). The pterygoid canal showed various relationships with the sphenoid and ethmoid sinuses. In addition, a previously unreported situation, where the foramen rotundum was surrounded by the spheroid sinus, was observed.