Search

Retrograde flow through the anterior spinal artery (ASA) from the cervical vertebral artery (VA) to the intracranial distal VA due to disrupted perfusion caused by bilateral VA occlusion is rare. We report two cases of hemodynamic vertebrobasilar circulatory insufficiency caused by bilateral VA occlusion. In these patients, the ASA filled in the retrograde direction, and provided collateral support to the ipsilateral posterior inferior cerebellar artery. The patients were treated with drip intravenous infusion of edaravone and/or argatroban. One patient had a good collateral supply from the posterior communicating artery and recovered almost completely within one month, but the other did not and lapsed into a coma, with generalized hyperreflexia, pin-point pupils, and ataxic respiration. Severe calcified lesions on three-dimensional computed tomography angiography at the occlusion site in the second patient indicated direct surgery including right superficial temporal artery to superior cerebellar artery anastomosis, rather than the endovascular approach. Retrograde flow through the ASA may be observed in this type of critical situation, and may be an important source of collateral supply to the posterior fossa territory.

The precise etiology of perimesencephalic nonaneurysmal subarachnoid hemorrhage (P-SAH) has not yet been determined. We decided to compare the venograms of patients with P-SAH with those of patients with aneurysmal SAH (A-SAH) to examine the relationship between P-SAH and venous drainage patterns.We retrospectively studied 18 patients with P-SAH during the past 10 years and 112 patients with ruptured A-SAH during the past 4 years by reevaluating their venograms for possible abnormalities in venous structures, particularly focusing on the basal vein of Rosenthal (BVR). Anatomical variants were classified into three types according to the drainage pathway.The location and drainage pathway of the BVR proved to be a significantly more primitive configuration in patients with P-SAH than in those with A-SAH (P0.05). On the other hand, physical action including components of the Valsalva maneuver were the cause of nine cases of P-SAH (69.2%) in this case profile. The occurrence rate was significantly higher in the P-SAH group than in the A-SAH group (14.3%) (p0.05).Our data suggest that failure of longitudinal anastomoses between the primary primitive veins as well as excessive strenuous exertion including components of the Valsalva maneuver plays an important predisposing role in the etiology of P-SAH.

The effect of cisternal drainage and intrathecal urokinase (UK) injections in preventing symptomatic vasospasm after aneurysmal subarachnoid haemorrhage was retrospectively studied in 69 patients with uniform backgrounds with regard to subarachnoid haemorrhage (SAH; WFNS grade I to IV, Fisher's group 3, undergoing surgery or coil embolization within 72 h of the onset). With regard to the selection of patients, 34 patients belonging to the control group (no UK injection group) underwent the treatment during the 3-year period from 2001 to 2003, while 35 patients belonging to the UK group underwent the treatment during the 3-year period from 2004 to 2006. The incidence of symptomatic vasospasm was 5/35 with the UK group, but 12/34 with a control group. The UK injection significantly reduced the incidence of symptomatic vasospasm (p = 0.042, Pearson chi-square test), resulting in an improvement shown by the Glasgow Outcome Scale (GOS; p = 0.030, Mann-Whitney U test; Table V). The distribution on the angiographic grading scales for cerebral vasospasm significantly shifted in a positive direction for the UK group (mild 0, moderate 5, severe 0) in comparison with the control group (mild 0, moderate 4, severe 8; p = 0.014, Mann-Whitney U test). This study suggests that combining continuous cerebrospinal drainage and intermittent intrathecal UK injection therapy is a relatively simple and effective method for symptomatic vasospasm prophylaxis in patients with aneurysmal SAH.

Patients who undergo dialysis treatment or a renal transplant have a high risk of blood-borne viral infections, including the Torque teno virus (TTV). This study identified the presence of TTV and its genome groups in blood samples from 118 patients in dialysis and 50 renal-transplant recipients. The research was conducted in a hospital in the city of Maringá, state of Paraná. The viral DNA, obtained from whole blood, was identified by using two nested Polymerase Chain Reactions (PCR). The frequencies of TTV were 17% and 36% in dialysis patients using the methodology proposed by Nishizawa et al . (1997) and Devalle and Niel (2004) , respectively, and 10% and 54% among renal-transplant patients. There was no statistically significant association between the frequency of the pathogen and the variables: gender, time in dialysis, time since transplant, blood transfusions, and the concomitant presence of hepatitis B, for either the dialysis patients or the renal-transplant recipients. Among dialysis patients and renal-transplant recipients, genogroup 5 was predominant (48% and 66% respectively), followed by genogroup 4 (37% and 48%) and genogroup 1 (23% and 25%). Genogroup 2 was present in both groups of patients. Some patients had several genogroups, but 46% of the dialysis patients and 51% of the renal-transplant recipients had only a single genogroup. This study showed a high prevalence of TTV in dialysis patients and renal-transplant recipients.

Inhibition of angiotensin II AT1 receptors protects against stroke, reducing the cerebral blood flow decrease in the periphery of the ischemic lesion. To clarify the mechanism, spontaneously hypertensive rats (SHR) and normotensive control Wistar Kyoto (WKY) rats were pretreated with the AT1 receptor antagonist candesartan (0.3 mg · kg−1 · d−1) for 28 days, a treatment identical to that which protected SHR from brain ischemia, and the authors studied middle cerebral artery (MCA) and common carotid morphology, endothelial nitric oxide synthase (eNOS) and inducible nitric oxide synthase (iNOS) messenger RNA (mRNA), and protein expression in cerebral microvessels, principal arteries of the Willis polygon, and common carotid artery. The MCA and common carotid artery of SHR exhibited inward eutrophic remodeling, with decreased lumen diameter and increased media thickness when compared with WKY rats. In addition, there was decreased eNOS and increased iNOS protein and mRNA in common carotid artery, circle of Willis, and brain microvessels of SHR when compared with WKY rats. Both remodeling and alterations in eNOS and iNOS expression in SHR were completely reversed by long-term AT1 receptor inhibition. The hemodynamic, morphologic, and biochemical alterations in hypertension associated with increased vulnerability to brain ischemia are fully reversed by AT1 receptor blockade, indicating that AT1 receptor activation is crucial for the maintenance of the pathologic alterations in cerebrovascular circulation during hypertension, and that their blockade may be of therapeutic advantage.

Pharmacological blockade of peripheral and brain Angiotensin II (Ang II) AT 1 receptors protects against brain ischemia. To clarify the protective role of brain AT 1 receptors, we examined the effects of specific antisense oligodeoxynucleotides (AS-ODN) targeted to AT 1 receptor mRNA administered intracisternally to spontaneously hypertensive rats (SHRs), 4 and 7 days before middle cerebral artery (MCA) occlusion, and we determined the infarct size and tissue swelling 24 h after surgery. A single intracisternal injection of AT 1 mRNA receptor antisense oligodeoxynucleotides reduced systemic blood pressure for 5 days and AT 1 receptor binding for at least 4 days in the area postrema and the nucleus of the solitary tract. A similar injection of scrambled oligodeoxynucleotides (SC-ODN) was without effect. Both blood pressure and AT 1 receptor binding returned to normal 7 days after antisense receptor mRNA administration. Both the infarction size and the tissue swelling after middle cerebral artery occlusion were reduced when the antisense oligodeoxynucleotide was administered 7 days, but not 4 days, before the operation. We conclude that 4 to 5 days of decrease in brain AT 1 receptor binding by a single administration of an AT 1 receptor mRNA oligodeoxynucleotide are sufficient to significantly protect the brain against ischemia resulting from total occlusion of a major cerebral vessel.

We report two instructive cases of ruptured dissecting aneurysm of the basilar artery. Although stent-assisted endovascular treatment was successful, recurrent bleeding occurred 4 h after the procedure in one patient, and the other's basilar artery occluded 6 days after the procedure. These cases suggest that the high porosity of currently available stents may be insufficient to induce intraluminal thrombosis and merely stenting may fail to prevent bleeding, while postoperative anticoagulation alone may be inadequate to prevent occlusion of the stented vessel.

A 46-year-old woman presented with a dissecting aneurysm of the right middle cerebral artery manifesting as subarachnoid hemorrhage followed by hemorrhagic infarctions. The aneurysm was clipped and wrapped. However, serial angiography showed progression of the lesion, which was probably responsible for the clinical course of this patient. Intracranial dissecting aneurysms are less common, and the natural history of these lesions is unclear. Conservative management might be preferable in this patient.

SUMMARY: We present 3 cases of extracranial head and neck schwannomas exhibiting fluid-fluid levels. In the described cases, CT and MR imaging showed predominantly cystic components, intermixed with cellular components. Histopathologic examinations of excised specimens revealed hemosiderin deposition, reflecting intratumoral hemorrhages, which was presumably a cause of fluid-fluid levels. Although fluid-fluid levels are nonspecific findings, schwannoma should be considered when radiologic images demonstrate marked cystic formation with fluid-fluid levels in extracranial head and neck tumors.

This study is designed to determine whether patients with aneurysmal subarachnoid hemorrhage have mutations in the phospholipase C-delta 1 (PLC-delta 1) gene, which was identified as a gene responsible for hypertension in spontaneously hypertensive rats. Seventy-two cases (31 male and 41 female) with intracranial saccular aneurysms were analyzed. The mean age was 60.1 +/- 11.5 years (mean +/- SD) (range 24-85 years). There were 35 patients (48.6%) with hypertension, 5 (6.9%) with diabetes mellitus, 12 (16.7%) with hyperlipidemia, 8 (11.1%) with ischemic heart disease, and 25 (34.7%) who were active smokers. The location of aneurysm was distributed as follows: 33 (33%) were at anterior cerebral artery, 23 (23%) were at middle cerebral artery, 28 (28%) were at internal carotid artery, and 16 (16%) were at vertebro-basilar artery. Six patients (8.3%) had a family history of intracranial aneurysms. There were 20 patients (27.8%) with multiple aneurysms, and 8 patients (11.1%) with a large or giant aneurysm. The four regions of PLC-delta 1 gene (bases 1099-1271, 1254-1401, 1343-1481, and 1882-2023) where genetic mutations were found in spontaneously hypertensive rats, were screened by PCR-SSCP analysis and their nucleotide sequences of all patients were determined. However, no mutations were detected in all patients. These results suggest that mutations of PLC-delta 1 gene previously implicated in hypertensive factor in rats may not be the case with human patients and therefore may be poorly related with aneurysmal subarachnoid hemorrhage.

Object. Endoglin, a transforming growth factor β—binding protein, is a glycoprotein expressed on the surface of human vascular endothelial cells. Mutations of this gene are responsible for hereditary hemorrhagic telangiectasis and are associated with sporadic intracerebral hemorrhage as a risk factor. The purpose of this study was to examine the polymorphism of this gene in patients with intracranial aneurysms.Methods. The authors identified the mutations and insertion polymorphism around exon 7 of the endoglin gene in 82 patients with intracranial saccular aneurysms (aneurysm group) and 114 control volunteers (control group).A 6-base insertion (GGGGGA) was found in intron 7 at 26 bases beyond the 3′ end of exon 7. The homozygous insertion of intron 7 of the gene was present in 20.7% of the aneurysm group compared with 6.1% of the control group (χ2 = 9.837, p = 0.0073). The insertion allele frequency was significantly higher in the aneurysm group (67 [40.8%] of 164) than that in the control group (63 [27.6%] of 228) (χ2 = 7.48, p = 0.0062). The most notable clinical characteristic of the 17 patients with homozygous insertion in the aneurysm group was the relatively high percentage of patients with hypertension and of those with multiple aneurysms.Conclusions. The data provide evidence of an association between aneurysm development and a polymorphism at a genetic variant of endoglin in patients with these lesions.

The profile of patients undergoing haemodialysis in the dialysis unit of Hospital Santa Casa de Maringa, Maringa PR Brazil, is provided. A questionnaire on social and economic data and underlying diseases prior to the Chronic Kidney Disease (CKD) identified the patients' profile. The project was approved by the Ethics Committee of the institution. Eighty-three patients, with 54.21% males, were interviewed. Age bracket ranged between 20 and 59 years in 65.06% of patients. Only 27.71% maintained jobs after the diagnosis and the start of treatment; 63.86% had an average personal income between 1 and 3 minimum wages; 63.85% did not practice any physical activity. Moreover, 53.01% belonged to the European-Brazilian white group; 20.48% to the Afro-Brazilian brown group; 19.28% to the Afro-Brazilian Negro group; 6.02% to other ethnic groups. Further, 85.54% patients reported having an underlying disease prior to the CKD, namely, 61.45% were hypertensive; 31.33% were diabetics and 20.48% had other diseases. Results show the need of a greater attention to these patients' health care to reduce the negative impacts related to the chronic disease focused.

Background Aneurysms arising from the distal portion of the SCA are relatively rare. A case is presented of an aneurysm arising from the cortical segment of the SCA. Case Description A 45-year-old woman was admitted to our institution because of severe headache. Radiological examination revealed SAH caused by rupture of the aneurysm located in the cortical segment of the SCA and was treated successfully with coil embolization. Conclusions This type of aneurysms may be difficult to treat surgically because of its inaccessibility and of the common difficulty in preserving the involved parent artery. In view of the previously reported cases, these peripheral aneurysms of the SCA often have undefinable necks, as is shown in our case, which makes a reconstructive endovascular and/or surgical technique more or less difficult. However, the overall outcome is almost always favorable, even if surgical treatment results in proximal parent artery occlusion or trapping with surgical clips. These results imply that an equivalent endovascular approach to these rare lesions can be an effective alternative method of management.

Rationale and Objectives The detection and management of asymptomatic lacunar infarcts on magnetic resonance (MR) images are important tasks for radiologists to ensure the prevention of severe cerebral infarctions. However, accurate identification of the lacunar infarcts on MR images is a difficult task for the radiologists. Therefore the purpose of this study was to develop a computer-aided diagnosis scheme for the detection of lacunar infarcts to assist radiologists’ interpretation as a “second opinion.” Materials and Methods Our database comprised 1,143 T1- and 1,143 T2-weighted images obtained from 132 patients. The locations of the lacunar infarcts were determined by experienced neuroradiologists. We first segmented the cerebral region in a T1-weighted image by using a region growing technique for restricting the search area of lacunar infarcts. For identifying the initial lacunar infarcts candidates, a top-hat transform and multiple-phase binarization were then applied to the T2-weighted image within the segmented cerebral region. For eliminating the false positives (FPs), we determined 12 features—the locations x and y, signal intensity differences in the T1- and T2-weighted images, nodular components from a scale of 1 to 4, and nodular and linear components from a scale of 1 to 4. The nodular components and the linear components were obtained using a filter bank technique. The rule-based schemes and a support vector machine with 12 features were applied to the regions of the initial candidates for distinguishing between lacunar infarcts and FPs. Results Our computerized scheme was evaluated by using a holdout method. The sensitivity of the detection of lacunar infarcts was 96.8% (90/93) with 0.76 FP per image. Conclusions Our computerized scheme would be useful in assisting radiologists for identifying lacunar infarcts in MR images.

Background Distal aneurysms of the anterior inferior cerebellar artery (AICA) are rare. Most of the reported cases have been located near the internal auditory meatus. Among these cases, only six located in the internal auditory meatus have been reported in the literature. Methods A 64-year-old female presented with sudden onset of severe headache. Computed tomography (CT) revealed moderate subarachnoid hemorrhage and Gd-DTPA enhanced magnetic resonance imaging (MRI) showed a small high-intensity mass at the right cerebellopontine angle. Although initial digital subtraction angiography (DSA) showed no vascular abnormalities, repeated DSA disclosed a saccular aneurysm at the top of the meatal loop of the right AICA. The patient underwent a suboccipital craniectomy on the 18th day after the hemorrhage. Results In this case, the aneurysm was completely buried in the internal auditory meatus. After unroofing the meatus, the aneurysm was successfully clipped. After 3 months of hospitalization, the patient was discharged with right-sided deafness, partial facial palsy, and no other complications. Conclusion We discuss some of the clinical features and pitfalls in the surgical management of intracanalicular AICA aneurysms and review previous reports of similar cases.

A 21-year-old woman with severe mitral valve regurgitation due to infectious endocarditis was transferred to our institute in a deep coma with intracerebral hemorrhage and acute subdural hematoma. She had no history of head injury. Brain computed tomography revealed left frontoparietal intracerebral hematoma and adjacent acute subdural hematoma that were evacuated on the day of admission, but the distal middle cerebral artery (MCA) aneurysm remained undetected. Follow-up cerebral angiography demonstrated the distal MCA aneurysm, which had enlarged by 25% at 2 weeks following the first operation. The aneurysm originated from a branch of the angular artery and was successfully resected on Day 22. Histological examination of the aneurysm section showed no infectious nature, but the final diagnosis was infectious intracranial aneurysm based on the presence of infectious endocarditis.

Background: Dissecting aneurysm of the posterior inferior cerebellar artery (PICA) uninvolved with the vertebral artery is rare. The exact pathohistological diagnosis might result in ‘unknown' because the underlying pathoanatomical features are, for a variety of reasons, not always identified. Case description: We report herein two cases of dissecting aneurysm harbored in different segments of the distal posterior inferior cerebellar artery. In our cases, after trapping the PICA at both just proximal and distal to the aneurysm, the abnormal portion was successfully resected with/without an end-to-end anastomosis. The first patient made a good recovery, while the other died 2 days after the surgery. Although its pathogenetic etiology was unidentified in the second case, the formation of dissecting aneurysm had resulted from a segmental mediolytic arteriopathy in the first case. Conclusion: This is the first report of a segmental mediolytic arteriopathy possibly being identified as causing an isolated dissecting aneurysm at this site.

Background and Purpose— Pretreatment with angiotensin II AT 1 receptor antagonists protects against cerebral ischemia. We studied whether modulation of cerebral blood flow (CBF) and morphometric changes in brain arteries participated in this protective mechanism. Methods— We pretreated adult spontaneously hypertensive rats with equally antihypertensive doses of candesartan (0.1 or 0.3 mg/kg per day), nicardipine (0.1 mg/kg per day), or captopril (3.0 mg/kg per day) for 3 or 28 days via subcutaneous osmotic minipumps followed by permanent left middle cerebral artery (MCA) occlusion distal to the origin of the lenticulostriate arteries. We measured CBF by autoradiography with 4-iodo-[ N -methyl- 14 C]antipyrine 3 hours after operation and the areas of infarct and tissue swelling 24 hours after operation. Morphometric changes in the MCA were studied after antihypertensive treatment. Results— Twenty-eight days of candesartan pretreatment decreased the infarct area by 31%; reduced the CBF decrease at the peripheral area of ischemia and the cortical volume of severe ischemic lesion, where CBF was Conclusions— Angiotensin II system inhibition protects against neuronal injury more effectively than calcium channel blockade. Protection after AT 1 receptor blockade is not directly correlated with blood pressure reduction but with normalization of MCA media thickness, leading to increased arterial compliance and reduced CBF decrease during ischemia at the periphery of the lesion.

The purpose of this study was to clarify the occurrence rate and characteristics of spinal injuries caused by snowboarding that were sustained at the Okumino skiing area in Gifu Prefecture, Japan, from 1988 to 2000.This study was a retrospective review of 13,490 cases of snowboard- or ski-related injury treated at Sumi Memorial Hospital over this period.A total of 7,188 patients sustained snowboard-related injuries, and 238 of these had spinal injuries caused by snowboarding (3.3%), whereas 6,302 patients sustained ski-related injuries, and 86 of these had spinal injuries caused by skiing (1.4%). Although there were no significant differences in the difficulty of slope, location of vertebral fracture, or spinal cord injury between snowboarders and skiers, the incidence of transverse process fractures was significantly higher in snowboard-related than in skiing-related injury (p0.05). In addition, there was a significantly higher incidence of spinal injury among beginner snowboarders than among beginner skiers (p = 0.04). Furthermore, intermediate or expert snowboarders were more likely to be injured because of jumping than beginners (p0.001), whereas about 70% of spinal injuries caused by skiing resulted from a simple fall.Spinal injuries sustained while snowboarding are increasing considerably in incidence and are characterized as complex injuries. We must educate young snowboarders of the risk of this sport, to prevent these serious injuries.

A 61-year-old female presented with a unique case of moyamoya disease associated with pulmonary sarcoidosis. She was admitted for sudden onset of left temporalgia with episode of numbness on face, tongue, and upper extremity on the right side. The next morning, she had symptoms of Gerstmann syndrome and her ability to speak was disturbed. Her medical history included radical resection of lung cancer on the right side. She had no symptoms of pulmonary sarcoidosis. Neuroimaging showed an infarction in the left occipital lobe. Angiography showed occlusions of the bilateral internal carotid arteries at the supraclinoid portions. Subsequently, a left superficial temporal artery-middle cerebral artery anastomosis with encephalo-myo-synangiosis was performed. Ninety-three days after admission, she suddenly developed dyspnea which resulted in death 3 hours later. Autopsy findings showed typical epithelioid granulomas of sarcoid type in the lymph nodes of the peribronchus, lung, and liver. Thrombotic emboli were found in the bilateral pulmonary arteries, and marked fibrous intimal thickening in the bilateral internal carotid arteries. Immunological reaction with inflammatory events may cause pathological changes in patients with moyamoya disease or sarcoidosis. The co-incidence in this case suggests that some common inflammatory events may be involved in the pathogenesis of these diseases.

Aim To analyse the distribution of HLA class I (A and B) and HLA class II (DRB1) alleles of chronic renal patients and the association with negative and positive PRA, based in sensitization events. Methods One hundred fifty chronic kidney patients from southern region of Brazil, were subdivided into 4 groups, according to the patients’ PRA results, regardless of the occurrence or not of one of the sensitiveness events, such as pregnancy (P), transfusion (S) or transplantation (T), characteristics grouped and identified as PST: Group 1, PRA = 0 (n = 79); Group 2, PRA > 0 (n = 71); Group 3, PRA between 0 and 50% (n = 43); Group 4, PRA > 50% (n = 28). Control group comprised 71 nonsensitized chronic kidney patients (PRA = 0), classified as positive for any of the PST events. HLA genotyping was undertaken by the RSSO-LABType methodology. PRA were obtained by LABScreen methodology. Fisher’s exact test and Odds Ratio (OR) with 95% confidence interval (CI) were used for statistical analysis. Further, p rates were significant when lower than 0.05. Results No significant differences with regard to loci HLA-A, HLA-B and HLA-DRB1 were found in Group 1 when compared to control group. No significant differences with regard to loci HLA-A and HLA-DRB1 were found in Groups 2 and 3. However, allele HLA-B ∗ 08 had a significant negative association in Group 2 (p = 0.0258; OR = 0.27; 95%IC = 0.09-0.83) and in Group 3 (p = 0.0334; OR = 0.22; 95%IC = 0.05-0.98) when compared to control group. Significant positive association in Group 4 was found for alleles HLA-A ∗ 26 (p= 0.0101; OR = 4.57; 95%IC = 1.42-14.64), HLA-B ∗ 58 (p = 0.0074; OR = 13.82; 95%IC = 1.58- 121.17) and HLA-B ∗ 13 (p = 0.0218; OR = 17.97; 95%IC= 0.91-353.64). No significant differences were found within the HLA-DRB1 alleles when compared to control group. Conclusions There are HLA alleles that influence chronic kidney patients to sensitization of HLA molecules. HLA Class I alleles seem to be more involved to susceptibility and/or resistance to the development of anti-HLA antibodies.