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An 84-year-old woman with a history of hypertension and a brain infarction presented with a rare distal anterior choroidal artery (AChoA) aneurysm not associated with moyamoya disease manifesting as sudden onset of headache caused by intraventricular hemorrhage. Digital subtraction angiography revealed a peripheral aneurysm in the left AChoA located distal to the plexal point and steno-occlusive changes of the proximal left middle cerebral artery (MCA) and the left posterior cerebral artery (PCA). Collateral arterial channels to the left MCA and left PCA territories were observed along the left AChoA. No neuroimaging findings were compatible with moyamoya disease. Since the aneurysm did not shrink at 2 months after the onset, endovascular treatment was indicated. Under local anesthesia, a microcatheter was placed into the AChoA proximal to the aneurysm with the aid of a 0.008-inch microguidewire. After a provocation test, three detachable platinum coils were delivered into the aneurysm and the parent artery. Complete obliteration of the aneurysm was achieved without additional neurological sequelae. Successful treatment of a ruptured distal AChoA aneurysm associated with atherosclerotic changes of the intracranial arteries was achieved using a meticulous endovascular technique.

Background: The benefits of intravenous thrombolysis for acute ischemic stroke are still limited., Objective: To evaluate the safety and efficacy of double-lumen balloon catheter-based reperfusion therapy with or without intra-arterial thrombolysis for acute occlusion of intracranial arteries., Methods: Fifty-nine patients with acute occlusion of intracranial arteries were enrolled. A Gateway balloon catheter was used to disrupt clots or dilate atheromatous plaques in every patient. The technical details, technique-related complications, recanalization rates, and clinical outcomes were analyzed., Results: The occlusion sites were internal carotid arteries in 17 patients, M1 segments in 32 patients, the M2 segment in 1 patient, a vertebral artery in 1 patient, and basilar arteries in 8 patients. Twenty-four patients (41%) were treated with thrombolysis first, and 20 patients (34%) were treated with percutaneous transluminal angioplasty (PTA) followed by thrombolysis. PTA alone was performed in 15 patients (25%). The mean dose of urokinase was 205 x 10 U. The extent of recanalization was complete (Thrombolysis in Myocardial Infarction [TIMI] score of 3) in 17 patients (29%), and partial (TIMI 1/2) in 28 patients (47%). Functional independence at discharge was preserved in 76%, 25%, and 7% of patients with TIMI 3, TIMI 1/2, and TIMI 0, respectively. A combination of PTA and thrombolysis resulted in a significantly higher recanalization rate than PTA only. Seven patients (12%) experienced hemorrhagic events after treatment. Severe parenchymal hemorrhage with neurologic deterioration was observed in 2 patients (4%), and vessel rupture was encountered in 1 atherosclerotic case., Conclusions: Mechanical angioplasty using a Gateway catheter combined with a low-dose thrombolytic agent is a safe and effective treatment for acute intracranial embolic and atherosclerotic occlusion with a low risk of hemorrhagic complications.

Vascular endothelial growth factor (VEGF) administration has recently been assessed as a therapeutic strategy for ischemic diseases including brain ischemia because of its angiogenic effect. However, VEGF also causes detrimental adverse effects by increasing vascular permeability. This study examined whether plasmid human VEGF (phVEGF) administration induced angiogenic effects in the rat brain ischemia model caused by permanent ligation of both common carotid arteries, and investigated the occurrence of adverse effects. Administration of various doses (0-200 microg) of phVEGF in the temporal muscle was followed by encephalo-myo-synangiosis. Thirty days after treatment, the numbers and areas of capillaries per field in the extracted brains were analyzed with the National Institutes of Health Image software program. The maximal angiogenic effect occurred with a 100 microg dose of phVEGF in the numbers and areas of capillaries in the VEGF-treated brains. Histological examination showed no apparent adverse effects in the brain parenchyma even at the highest administration dose (200 microg) of phVEGF. The maximal angiogenic effect at the optimal dose of phVEGF can be considered under the threshold to cause serious adverse effects in the rat brain.

To investigate the effect of a high-protein diet on corpus atrophic gastritis in Helicobacter pylori-infected Mongolian gerbils, H. pylori was administered orally to 5-wk-old Mongolian gerbils; and the animals were then fed a control diet (Group C); a high-fat diet (Group F: 40% fat); a high-protein diet (Group P: 32% protein); or a high-fat, high-protein diet (Group FP: 40% fat, 32% protein) for 50 wk beginning at 7 wk of age. In uninfected animals, the mucosal thickness of the corpus was significantly greater in Group P and Group FP than in Group C (P < 0.05). In infected animals, the serum gastrin level was significantly decreased in Group FP and marginally significantly decreased in Group P (P = 0.057) in comparison to Group C. The mucosal thickness of the corpus was significantly greater in Group P and Group FP than in Group C (P < 0.05). Mean inflammation and atrophy scores in the corpus were significantly lower in the high-protein groups (Groups P and FP) than in the control groups (Groups C and F; both inflammation and atrophy: P < 0.05). In conclusion, long-term administration of a high-protein diet suppresses corpus atrophic gastritis in H. pylori-infected Mongolian gerbils.

Annual retrospective surveys of 20 to 31 medical centers performing endovascular treatment of cerebral aneurysms in Japan from 1997 to 2008 were performed to analyze technical and clinical outcomes of endovascular treatment for ruptured cerebral aneurysm. Patients treated with dome embolization using bare platinum coils within 14 days after onset were retrospectively selected, and clinical features, and technical and clinical outcomes at discharge were studied. Retrospective Endovascular Subarachnoid Aneurysm Treatment (RESAT) 1 covers patients treated from 1997, when the Guglielmi detachable coil was introduced, to 2002, just after International Subarachnoid Aneurysm Trial was reported. RESAT 2 to RESAT 7 were conducted annually between 2003 and 2008. Among 5,624 patients with ruptured aneurysms treated within 14 days after onset, 4,782 patients were treated by dome embolization using platinum detachable coils. The patients in this large retrospective survey included 35.8% aged over 70 years, 36.6% with posterior circulation aneurysms, and 29.3% with poor grades (Hunt and Kosnik grades IV and V). The proportion of patients aged over 70 years tended to increase each year from 33.4% in RESAT 1 to 39.8% in RESAT 7, and the proportion of those with posterior circulation aneurysms decreased from 44.2% in RESAT 1 to 23.8% in RESAT 7 (p<0.001). Overall technical success was obtained in 4,666 patients (97.6%), and favorable clinical outcome (good recovery and moderate disability) at discharge was obtained in 88.0% of grade I-III cases and 73.6% of grade I-V cases. Procedure-related morbidity was 2.9% and mortality was 0.8%. Despite this survey involving high proportions of aged, posterior circulation, and poor-grade patients, the technical success rate and immediate clinical results were relatively favorable. The patient prognosis and aneurysm changes must be investigated over a longer period, together with the effects of the introduction of new endovascular devices for cerebral aneurysms.

A 67-year-old woman suffered rebleeding from a ruptured vertebral artery dissecting aneurysm after endovascular internal trapping. The dissecting aneurysm was initially successfully occluded with the affected vertebral artery using detachable coils. However, rebleeding from the aneurysm occurred on the next day. The rebleeding may have resulted from the thrombolytic effect of urokinase, which was injected intrathecally 3 hours before rebleeding occurred, or the relatively loose coil packing of the aneurysm. This case indicates the potential risk of intrathecal use of thrombolytic agents and the importance of complete tight coil packing of the whole dissected site in the treatment of ruptured vertebral artery dissecting aneurysms.

Objective: Carotid endarterectomy with a patch graft (Patch CEA) has been our standard treatment for patients with carotid artery stenosis, but carotid artery stenting (CAS) has emerged as an alternative. The purpose of this study was to compare the postoperative changes in the configurations and the flow velocities of carotid arteries after CAS or Patch CEA., Methods: Thirty-one patients undergoing CAS or Patch CEA were included. The pre- and postoperative shapes of the carotid arteries were evaluated by angiography and ultrasonography. Doppler waveforms were recorded in the middle portion of the common carotid artery and in the internal carotid artery bulb to measure flow velocities, including peak systolic, mean, and end-diastolic velocities., Results: Eighteen patients were treated by CAS, and Patch CEA was performed for 13 patients. Preoperatively, there were no differences in the degrees of stenosis or the flow velocities between the 2 groups. The averages of the diameters of the postoperative internal carotid artery bulbs were 4.5 mm in the CAS group and 7.0 mm in the Patch CEA group (P < 0.01). The averages of peak systolic, mean, and end-diastolic velocities measured in the internal carotid artery were 80, 42, and 25 cm/s, respectively, in the CAS group, and were significantly greater than those (53, 28, and 16 cm/s, respectively) in the Patch CEA group (P < 0.01)., Conclusion: Significant differences in postoperative morphological and hemodynamic conditions between CAS and Patch CEA were observed. The impact of these differences will be determined by further studies.

Introduction: Bow hunter's syndrome is a unique clinical entity caused by mechanical occlusion of the vertebral artery on head rotation. Although it is usually treated by direct surgical intervention, we report successful treatment using endovascular stent placement for contralateral vertebral artery stenosis., Case Description: A 56-year-old man presented with repeated vertigo and loss of consciousness caused by turning his head to the left. Right vertebral angiogram showed no abnormalities with the head in the neutral position. However, with the head rotated 60 degrees to the left, the right vertebral artery was completely occluded at the C1-2 level. A three-dimensional angiogram with bone window clearly demonstrated vertebral artery compression at the C1-2 level by the bony structure. The left subclavian angiogram revealed severe stenosis at the origin of the left vertebral artery. Left vertebral artery angioplasty followed by stent placement was successfully performed under local anesthesia. The patient showed an uneventful postoperative course and his preoperative symptoms disappeared. At 6 months postoperatively, a left subclavian angiogram showed good patency of the stented left vertebral artery and the patient showed no recurrent symptoms., Conclusion: Vertebral artery stenting is a useful and less invasive option in the treatment of bow hunter's syndrome in the setting of contralateral vertebral artery stenosis., (Georg Thieme Verlag KG Stuttgart * New York.)

The authors reported a case of a dural arteriovenous fistula (DAVF) in the left transverse-sigmoid sinus, in which 3-dimensional computed tomography (CT) angiograms (3D-CTAs) by a 64-section multidetector row CT scanner were useful for its diagnosis and treatment. The DAVF in the left transverse-sigmoid sinus appeared on the digital subtraction angiogram. 3D-CTAs were obtained by a 64-section multidetector row CT scanner before an endovascular treatment. The feeders and draining veins of the DAVF were clearly demonstrated on the 3D-CTAs, which clarified the relationship between the normal dural sinuses and DAVF. The DAVF was successfully treated with endovascular surgery, a transvenous embolization through the mastoid emissary vein, which was easily detected by using the 3D-CTA, showing both the subcutaneous vein and calvalium. 3D-CTAs by a 64-section multidetector row CT scanner are useful for both diagnosis and treatment of DAVFs.

Many studies have shown that a motif of 11 consecutive arginines (11R) is one of the most effective protein transduction domains (PTD) for introducing proteins into the cell membrane. By conjugating this "11R", all sorts of proteins can effectively and harmlessly be transferred into any kind of cell. We therefore examined the transduction efficiency of 11R in cerebral arteries and obtained results showing that 11R fused enhanced green fluorescent protein (11R-EGFP) immediately and effectively penetrated all layers of the rat basilar artery (BA), especially the tunica media. This method provides a revolutionary approach to cerebral arteries and ours is the first study to demonstrate the successful transductionof a PTD fused protein into the cerebral arteries. In this review, we present an outline of our studies and other key studies related to cerebral vasospasm and 11R, problems to be overcome, and predictions regarding future use of the 11R protein transduction method for cerebral vasospasm (CV).

Background: We present the pathological findings at orbital exenteration in a patient with Wyburn-Mason syndrome who underwent transarterial embolization., Case: A 31-year-old man with a 10-year history of gradual exacerbation of left exophthalmos and left cheek swelling was found to have facial and orbital arteriovenous malformations on the left side. There was no vascular malformation in the brain. The feeding arteries derived from the left internal maxillary artery, facial artery, and ophthalmic artery. He underwent several courses of transarterial embolization of the feeding arteries from the left internal maxillary artery and then from the facial artery, resulting in no reduction of the arteriovenous malformation. He finally elected to undergo ophthalmic artery embolization in the expectation of a reduction and with the understanding that he would lose sight in his left eye. Two years later, he requested lid-sparing orbital exenteration and reconstruction with cutaneous flap transfer and prosthesis for cosmetic reasons., Observations: Pathologically, orbital vascular channels of varying sizes were filled with embolizing glue and had degenerating vascular wall cells surrounded by inflammatory cell infiltration. The central retinal artery in the optic nerve was also filled with the embolizing glue, and the retina lost the ganglion cell layer and inner nuclear layer but maintained the outer nuclear layer and outer segments., Conclusions: Marked anastomoses and hence incomplete embolization among the feeding arteries of facial and orbital vascular malformations in Wyburn-Mason syndrome do not respond well to attempts at feeding vessel embolization, which result in unsuccessful closure of the malformation.

A 42-year-old woman presented with a rare case of fenestration of the supraclinoid internal carotid artery (ICA) with associated aneurysm manifesting as headache. Computed tomography (CT) found no abnormalities. Three-dimensional CT angiography showed fenestration of the left ICA with an associated aneurysm. Direct surgery was performed for the aneurysm, and the patient's postoperative course was uneventful. The present case of ICA fenestration associated with aneurysm indicates that surgical treatment should be considered for even small unruptured aneurysms arising from this location, because of the high risk of rupture.

Objective: Hypoxia-inducible factor (HIF)-1 is a transcription factor that regulates the expression of various neuroprotective genes. The goal of this study was to clarify the relationship between HIF-1 expression and subarachnoid hemorrhage (SAH) and to characterize the effects of deferoxamine (DFO)-induced increases in HIF-1 protein levels on the brainstem and the basilar artery (BA) after experimental SAH., Methods: Rat single- and double-hemorrhage models (injected on Days 0 and 2) of SAH were used. We assessed the time courses for HIF-1 protein levels in the brainstems and the BA diameters within 10 minutes and 6 hours on Days 1 and 2 in the single-SAH model, and also on Day 7 in the double-SAH model. After induction of double hemorrhage in rats, DFO was injected intraperitoneally. We then evaluated HIF-1 protein expression and brainstem activity, BA diameter, and brainstem blood flow., Results: After the rats experienced SAH, HIF-1 protein expression was significantly greater at 10 minutes in the single-injection model and at 7 days in the double-injection model than at similar time points in the control group, and these increases correlated with degrees of cerebral vasospasm. DFO injection resulted in significant increases in HIF-1 protein expression and activity in the brainstems of rats with SAH, compared with the rats with SAH that were given placebos, and the rats without SAH in the double-hemorrhage model. Cerebral vasospasm and reduction of brainstem blood flow were significantly attenuated in the rats that were administered DFO., Conclusion: These results show that a DFO-induced increase in HIF-1 protein level and activity exerts significant attenuation of BA vasospasm and reduction of brainstem blood flow in the rat model of SAH. DFO may be a promising agent for treating clinical SAH.

Objective: Dural arteriovenous fistulae involving the transverse-sigmoid sinus, which is occluded at its proximal and distal ends (i.e., an isolated sinus), carry a high risk of intracranial hemorrhage or progressive neurological deficits. Although transvenous coil embolization is a useful and safe treatment for such lesions, it is often difficult to reach into the isolated sinus through the occluded sinus using the percutaneous catheter approach., Methods: We report the successful treatment of two patients with transverse-sigmoid dural arteriovenous fistulae with isolated sinus using the percutaneous transvenous triple-catheter technique. A 6-French guiding catheter was placed at the internal jugular vein followed by a second 4-French catheter positioned at the end of the occluded sinus. A third microcatheter was then navigated into the isolated sinus with support of the second catheter., Results: Although initial attempts to reach into the isolated sinus without the second catheter failed, insertion of the second catheter resulted in successful navigation of the third microcatheter into the affected sinus in both cases. Complete cure was obtained in both cases by coil packing of the affected sinus., Conclusion: Although careful maneuvering is required, this triple-catheter technique is useful for treatment of dural arteriovenous fistulae with isolated sinus.

A 35-year-old male experienced a sudden onset of severe headache. A CT scan revealed subarachnoid hemorrhage. By cerebral angiography, he was diagnosed as having a ruptured right vertebral artery dissecting aneurysm (VADA). It was successfully treated by endovascular occlusion of the affected site, including the aneurysm and parent artery, by using detachable coils. A follow-up angiography obtained seven months after the first treatment revealed the recanalization of the right vertebral artery and dissected aneurysm in an antegrade fashion. A skull X-ray image was useful for detecting the change in appearance of the coils. The second embolization was successfully performed in the same manner. Based on this rare case, the authors emphasize that a careful angiographic analysis and complete internal trapping of the dissecting site are important in the treatment of the ruptured VADA.

Object: Inflammation in the subarachnoid space and apoptosis of arterial endothelial cells have been implicated in the development of delayed cerebral vasospasm after subarachnoid hemorrhage (SAH). The authors investigated mechanisms of possible antivasospastic effects of N-benzyl-oxycarbonyl-Val-Ala-Asp-fluoromethylketone (Z-VAD-FMK), a caspase inhibitor that can inhibit both inflammatory and apoptotic systems, in animal models of SAH., Methods: Rabbits were assigned to three groups of eight animals each and were subjected to SAH by injection of blood into the cisterna magna. The experiments were performed in the following groups: SA only, SAH + vehicle, and SAH + Z-VAD-FMK. The Z-VAD-FMK (1 mg) or vehicle (5% dimethyl sulfoxide) was intrathecally administered before SAH induction. Diameters of the basilar artery (BA) were measured on angiograms obtained before and 2 days after SAH. The BA diameter on Day 2 was expressed as a percentage of that before SAH. Interleukin (IL)-1 in the cerebrospinal fluid (CSF) was examined using Western blotting, and brains were immunohistochemically examined for caspase-1 and IL-1beta. In a separate experiment, 20 rats were subjected to SAH and their brains were immunohistochemically assessed for caspase-1, IL-1beta, and macrophages. RESULTS. In rabbits, Z-VAD-FMK significantly attenuated cerebral vasospasm (the BA diameter on Day 2 in SAH-only, SAH + vehicle, and SAH + Z-VAD-FMK groups was 66.6 +/- 3.2%, 66.3 +/- 3.7%, and 82.6 +/- 4.9% of baseline, respectively), and suppressed IL-1beta release into the CSF and also suppressed immunoreactivities of caspase-1 and IL-1P in macrophages infiltrating into the subarachnoid space. Immunoreactivities for caspase-1 and IL-1P were observed in immunohistochemically proven infiltrating macrophages in rats., Conclusions: These results indicate that caspase activation may be involved in the development of SAH-induced vasospasm through inflammatory reaction.

The authors report a case of adult pial arteriovenous fistula successfully treated by endovascular glue embolization. A 65-year-old man presented with left hemiparesis and was admitted to the local hospital. Computed tomography scan showed a cerebral hematoma. Cerebral angiography revealed pial single-channel arteriovenous fistula at the right angular artery. An emergent craniotomy was performed and hematoma was successfully evacuated on the next day. Since the post-operative angiography revealed a persisting arteriovenous fistula, the patient was referred to our institute for additional treatment. With the patient under local anesthesia, endovascular treatment was performed through the trans-femoral artery approach A flow-guided microcatheter was successfully navigated just proximal to the fistula site; Histoacryl was then injected, and complete obliteration of the fistula was obtained. The subsequent course was uneventful and the patient returned to his daily life with only very mild left hemiparesis. Endovascular glue embolization plays an important role in the treatment of pial arteriovenous fistula.

After endovascular coil embolization of cerebral aneurysms, coil compaction and late aneurysm recanalization have been ever observed. The HydroCoil Embolic System (HES) was developed to improve the packing efficacy of endovascular treatment of cerebral aneurysms. In this study, we evaluate the packing efficacy of HES using a silicone model of ruptured cerebral aneurysm. This silicone model was connected to a pulsatile flow pump and embolized with the initial framing coils followed by hydro coils (n = 3) or bare platinum coils (n = 3). The coils used in the two groups were identical to each other in size and length. In the hydro coil group, continuous outflow from ruptured aneurysm ceased in two out of three cases. On the other hand, in the bare platinum coil group, outflow from the ruptured point slightly decreased but did not stop in all cases. The hydro coil could result in a higher initial occlusion rate of silicone model. In addition, expanded hydrogel possibly sealed the ruptured point directly. Changes in the size of aneurysms were not detected, from which the risk of over-expansion seemed extremely low. The hydro Coil is a safe and feasible device for improving the packing efficacy in endovascular coil embolization.

A 57-year-old female presented with a left petroclival meningioma fed by the meningohypophyseal trunk of the internal carotid artery (ICA). The enlarged tentorial marginal artery and inferior hypophyseal artery were successfully embolized with the TruFill DCS Detachable Coil System through a 0.019-inch inner diameter microcatheter. Superselective catheterization into the dorsal meningeal artery could not be achieved with the same microcatheter, because the catheter tip was too large to pass into the vessel. Subsequently the feeding artery was successfully embolized with a Guglielmi detachable coil (GDC) through a 0.016-inch inner diameter microcatheter. The patient underwent surgery without blood loss on the day after embolization. Our subjective impression was that the TruFill DCS was softer and had less resistance during insertion, whereas the GDC could be delivered through a smaller caliber system for smaller vessels. Appropriate use of the TruFill DCS and GDCs can allow efficient embolization of the feeding branches of the ICA.

The preoperative assessment of microvascular decompression (MVD) for hemifacial spasm has been performed with MRI, but assessment of the compressive status by 2D imaging has a number of limitations. We used a fusion image of the 3D MR cisternogram and co-registered 3D MR angiogram, reconstructed from MR cisternogram, obtained by 3D fast spin-echo sequence, and MR angiography, 3D time-of-flight and spoiled-gradient recalled sequences, for the preoperative assessment of the offending artery in 10 patients with hemifacial spasm. The anatomical relationship of the nerve-vessel complex was assessed on the simulated images, and compared with the intraoperative findings. The fusion image of the 3D MR cisternogram/angiogram depicted contours of the brain, nerves, and vessels clearly, and that allowed precise assessment of the pathogenic compression of the facial nerve by the offending vessels, comparative to the operative findings. The fusion imaging of the 3D MR cisternogram/angiogram may provide useful information in the surgical planning of MVD for hemifacial spasm.

The internal carotid aneurysm (ICA) arising from the paraclinoid region is associated with the origins of the superior hypophyseal artery and the ophthalmic artery. Recently, other aneurysms which can arise in this region without imvolvement of the arterial branches has been reported. Among those aneurysms, there are very rare type of aneurysms located on the anterolateral aspect of the internal carotid artery. In this report, we described our experience with direct surgery for five cases of the unruptuted paraclinoid aneurysm arising from the anterolateral aspect of the ICA. Firstly, the common carotid artery was exposed to carry out proximal flow control. We used the pterional approach. The anterior clinoid process was deleted after having confirmed aneurysm and the dural ring was incised. Extreme care had to be taken during this step. All patients underwent successful neck clipping. In recent two cases we employed the neuroendoscope (EndoArm) to observe the unrecognized area of surgical microscope and untrasonic bone curette (SONOPET) to perform the safe removal of the anterior clinoid process. This procedure is very useful for carrying out the neck clipping for aneurysms which are located on the anterolateral aspect of the internal carotid artery.

Fusion imaging of 3D MR cisternography/angiography was used for the assessment of the vascular bulging finding detected by MR angiography from the viewpoint of the outer wall configuration of the corresponding internal carotid artery depicted by MR cisternography. With a fusion image, useful information was obtained to distinguish an infundibular dilation and enlarged origin of the normal posterior communicating artery from an aneurysm. This imaging technique can be a feasible addition to a noninvasive screening of cerebrovascular lesions with MR angiography alone.

We documented an interesting case of adult "unilateral (probable)" moyamoya disease displaying familial occurrence in two "definite" cases. A 55-year-old female presented with motor aphasia, involuntary movement of the right hand and right homonymous hemianopia due to cerebral infarction. Cerebral angiography revealed typical angiographic findings on the left side and normal findings on the right side; consequently, the patient was diagnosed with probable moyamoya disease. Previously, her mother and nephew had been diagnosed with definite moyamoya disease with bilateral involvement. The patient continued to exhibit unilateral involvement on angiography for more than 4 years. Clinical features such as absence of familial occurrence suggest that most cases of probable moyamoya disease are distinct from definite cases, especially in adults. To the best of our knowledge, this report appears to be the first involving an adult probable case characterized by familial occurrence. The literature pertaining to adult probable moyamoya disease was reviewed and the etiology of this disease was discussed.

Background/aims: Anti-parietal cell antibody (APCA) is used for diagnosis of pernicious anemia and type A gastritis. APCA is present in patients with Helicobacter pylori (H. pylori)-positive gastritis and is related to atrophic gastritis and gastric carcinoma. The aim of the study was to determine whether an enzyme-linked immunosorbent assay (ELISA) can be used to detect APCA., Methodology: Study subjects were 134 patients (74 men, 60 women; mean age, 63 years; range, 18-88 years) with gastric carcinoma, gastric ulcer, duodenal ulcer, gastritis, type A gastritis or pernicious anemia and H. pylori-negative normal mucosa subjects in the stomach. APCA was measured in all subjects by our ELISA method. Results of ELISA were compared with results of indirect immunofluorescence (IIF)., Results: The percentage of samples that were APCA-positives by IIF at a 1/20 or greater serum dilutions was similar to that by ELISA (86.9%). Agreement between ELISA and IIF for presence of APCA was 78.3% in patients with gastric carcinoma, 80.1% (gastric ulcer), 59.1% (duodenal ulcer), 51.7% (gastritis), 75.0% (type A gastritis), 100% (pernicious anemia) and 80.0% (normal)., Conclusions: ELISA is a useful method for detection of APCA for diagnosis of PA and type A gastritis.

Background and Aim: Many studies have shown that Helicobacter pylori infection is associated with chronic gastritis, peptic ulcers and gastric carcinoma in adults. However, little is known about these associations in the younger population. The aim of this study was to clarify endoscopic and histological findings in H. pylori-positive young adults., Methods: Two hundred consecutive outpatients younger than 29 years old undergoing esophago-gastroduodenal endoscopy at four hospitals between 2001 and 2002 were eligible for this study. At endoscopy, three biopsy specimens were obtained from the mid-antrum, the angulus and the mid-corpus. Endoscopic and histological interpretations were based on the updated Sydney System. H. pylori infection was determined by histology and serology., Results: The rates of H. pylori infection were 1.2% (1/86) in normal, 95.8% (46/48) in gastritis, 97.8% (45/46) in duodenal ulcers, 100% (17/17) in gastric ulcers, and 100% (3/3) in gastric carcinomas. Endoscopic findings in 112 H. pylori-positive patients were 25 normal (22.3%), 38 atrophy (33.9%), 18 erosion (16.1%), and 31 nodularity (27.7%). Histological findings of H. pylori-positive patients in the anturm revealed mononuclear cell and neutrophil infiltration in 100%, and atrophy in 27.7%. Histological findings of H. pylori-positive patients in the corpus revealed mononuclear cell infiltration in 75%, neutrophil infiltration in 60.7%, and atrophy in 28.6%., Conclusions: The study shows that H. pylori infection is strongly associated with chronic gastritis and peptic ulcers, and that histological corpus gastritis was found with high frequency in Japanese young adults.

Background and Aim: Helicobacter pylori infection and non-steroidal anti-inflammatory drugs (NSAIDs) are deeply involved in the etiology of gastric ulcers. The aim of our study was to clarify the endoscopic characteristics and H. pylori infection status of NSAID-associated gastric ulcers., Methods: The study group comprised 50 patients (23 men, 27 women; mean age 66.5 years) with NSAID-associated gastric ulcers and 100 sex- and age-matched patients with gastric ulcer associated with other factors (control group). Ulcer morphology, size and number of lesions, onset site and incidence of hemorrhagic ulcers were investigated endoscopically in both groups. H. pylori infection was diagnosed by serology, histology and (13)C-urea breath test., Results: Multiple lesions (68% vs 20%, P<0.001), occurrence in the antrum (56% vs 6%, P<0.001), and hemorrhagic ulcer (34% vs 4%, P<0.001) were significantly more prevalent in patients with NSAID-associated gastric ulcers than in patients with non-NSAID-associated gastric ulcer. The H. pylori infection rate was significantly lower in NSAID-associated gastric ulcer patients than in non-NSAID-associated gastric ulcer patients (48% vs 96%, P<0.001). In the NSAID-associated gastric ulcer group, the prevalence of H. pylori infection was significantly lower in patients with ulcers in the antrum than in those with ulcers in the angulus or corpus (25% vs 77.3%, P<0.001)., Conclusions: In contrast to non-NSAID-associated gastric ulcers, NSAID-associated gastric ulcers frequently occur in the antrum with bleeding. The rate of H. pylori infection in NSAID-associated gastric ulcers is significantly lower than that in non-NSAID-associated gastric ulcers.

Object: Vascular endothelial growth factor (VEGF) is a secreted mitogen associated with angiogenesis. The conceptual basis for therapeutic angiogenesis after plasmid human VEGF gene (phVEGF) transfer has been established in patients presenting with limb ischemia and myocardial infarction. The authors hypothesized that overexpression of VEGF using a gene transfer method combined with indirect vasoreconstruction might induce effective brain angiogenesis in chronic cerebral hypoperfusion, leading to prevention of ischemic attacks., Methods: A chronic cerebral hypoperfusion model induced by permanent ligation of both common carotid arteries in rats was used in this investigation. Seven days after induction of cerebral hypoperfusion, encephalomyosynangiosis (EMS) and phVEGF administration in the temporal muscle were performed. Fourteen days after treatment, the VEGF gene therapy group displayed numbers and areas of capillary vessels in temporal muscles that were 2.2 and 2.5 times greater, respectively, in comparison with the control group. In the brain, the number and area of capillary vessels in the group treated with the VEGF gene were 1.5 and 1.8 times greater, respectively, relative to the control group., Conclusions: In rat models of chronic cerebral hypoperfusion, administration of phVEGF combined with indirect vasoreconstructive surgery significantly increased capillary density in the brain. The authors' results indicate that administration of phVEGF may be an effective therapy in patients with chronic cerebral hypoperfusion, such as those with moyamoya disease.

Background: Intracranial dural arteriovenous fistulas (AVFs) with spinal perimedullary venous drainage are rarely reported, but most of the patients initially have presented with myelopathy or subarachnoid hemorrhage. This is the first report of the intracranial dural AVF patient who presented with brain stem infarction., Case Description: A 38-year-old woman experienced nausea and vomiting with an acute onset, followed by vertigo. Magnetic resonance imaging showed ischemic lesion in the medulla oblongata, and she was then sent to our hospital. On admission, she had nystagmus, swallowing difficulties, Homer syndrome, and right hemiparesis and hemisensory disturbance. Cerebral angiography revealed dural AVF draining into spinal perimedullary veins at the left transverse-sigmoid sinus. The patient was treated by transvenous embolization under local anesthesia. A microcatheter proceeded to the left sigmoid sinus via the internal jugular vein, and embolization of the sinus was performed using coils without complications. The patient's swallowing difficulties improved over a few days after the embolization, and one month later, there remained only a slight mild hemiparesis and hemisensory disturbance. Six months after the onset, there was no ischemic lesion in the brain stem on magnetic resonance imaging., Conclusions: In this case, we showed the possibility of brain stem infarction, caused by the intracranial dural AVF.

Background and Purpose: Surface irregularity and bleb formation are anatomical factors that are associated with aneurysm rupture. The perianeurysmal environment has been proposed as one factor that may influence aneurysm morphology. We have developed a fusion imaging technique of 3D MR cisternography and angiography that allows clear visualization of an aneurysm and its environment. This technique may prove useful in further understanding of the natural history of intracranial aneurysms., Methods: Fusion images of 3D MR cisternography and angiography were reconstructed by a perspective volume-rendering algorithm from the volume datasets of MR cisternography, obtained by a T2-weighted 3D fast spin-echo sequence, and coordinated MR angiography, by a 3D time-of-flight sequence. On the fusion images, the anatomic relationship of an aneurysm to the perianeurysmal structures was assessed, and the influence of perianeurysmal environment on the deformation and bleb formation of the aneurysm was investigated., Results: Marked and minor deformation and bleb formation of the aneurysmal dome were found at the areas confronted or adjacent to a certain contact with perianeurysmal structures, including cranial nerves, brain parenchyma, cranial base bones, petroclinoidal dural folds, and dura mater., Conclusion: Fusion images of 3D MR cisternography and angiography can depict the contact of an aneurysm with its perianeurysmal environment; this may provide an additional parameter in consideration for the natural history of cerebral aneurysms.

Barrett's esophagus is a premalignant condition of reflux esophagitis and the prevalence is increasing in western countries. Although pathogenesis of Barrett's esophagus is still unknown, several studies have indicated that Barrett's esophagus is related to increased acid reflux through decreased lower esophageal sphincter tone and reduced esophageal contractions. In this article recent studies of Barrett's esophagus on pathophysiology of esophageal motility is reviewed.

Recent technological development has allowed expanding applications of radiofrequency ablation (RFA) for malignant tumor therapy. We report a case with a spinal metastatic tumor treated with combination of percutaneous vertebroplasty (PVP) that provides pain relief and spinal stabilization and RFA. A 68-year-old male who had undergone resection of left ureteric carcinoma was referred to our hospital with lower back pain due to the fifth lumbar (L5) vertebral metastatic tumor. Conventional radiation therapy was discontinued because of pneumonia. One year later, the patient was admitted again with weakness of the right knee and foot and severe pain of the back and the right lower extremity. Radiographs demonstrated a compressive fracture of the L5 vertebra predominantly on the right side. CT and MRI showed a tumor of the L5 body invading the right pedicle, the intervertebral foramen, and the retroperitoneal space. RFA was performed in the ventral part of the L5 body, and then around the right L5/the first sacral intervertebral foramen. Temperature and time for ablation ranged from 74 degrees C to 95 degrees C and from 11 min. to 30 min., respectively. Next, PVP was performed by the right transpedicular approach. Bone cement was injected into the L5 body and the pedicle by an amount of 3.0 ml in total without technical complications. Postoperatively, visual analogue scale demonstrated decreased pain degree from 10 cm to 5.4 cm. Combined treatment with RFA and PVP is a feasible and promising procedure for spinal metastatic tumors. Further evaluation is necessary to confirm its long-term efficacy.

The authors report a case of local intraarterial fibrinolysis (LIF) in central retinal artery occlusion (CRAO). A 79-year-old man with stenosis of the left internal carotid artery (ICA) suffered sudden loss of vision in his left eye. LIF was carried out using a microcatheter in the origin of the ophthalmic artery on the side of the CRAO. Treatment was performed with 120,000 IU of urokinase. After LIF, marked improvement of vision was established. No complication occurred during LIF. One month later, carotid artery stenting was performed for the left ICA stenosis. We consider LIF in CRAO is effective treatment.

The anatomical relationship of an unruptured internal carotid-posterior communicating artery aneurysm and the perianeurysmal environment was investigated by using three-dimensional (3D) magnetic resonance cisternography (MRC), angiography (MRA) and newly developed fusion images of 3D MRC and 3D MRA. Contact of an aneurysm with the adjacent intra- and pericisternal structures was observed in cases with the aneurysm developing and extending beyond the capacity of the surrounding subarachnoid space. Deformation and bleb formation of the aneurysmal dome was depicted at the dome in contact with the perianeurysmal environment, including the tentorial edge, the anterior petroclinoid dural fold, the oculomotor nerve, the posterior clinoid process, the dorsum sellae and the cranial base bone. By using the fusion imaging technique of 3D MRC and 3D MRA, assessment of the contact of an unruptured cerebral aneurysm with its perianeurysmal environment can be made. Such contact gives ride to risk of deformation and bleb formation of the aneurysmal dome; and may result in cranial nerve symptoms and accelerate rupture from an unruptured cerebral aneurysm.

To evaluate the interaction between the MR signal intensity distribution pattern and bleb formation/ deformation of the aneurysmal dome, fifty cases of the unruptured cerebral aneurysms were investigated with the color-coded 3D MR angiography. Patterns were categorized into central-type, neck-type and peripheral-type according to the distribution of MR signals with low-, moderate- and high signal intensity areas. Imaging analysis revealed the significant relationship (P < 0.02) of the peripheral-type aneurysms to the bleb formation and deformation of the dome, compared with those of central- and neck-type. Additionally, peripheral-type signal intensity distribution pattern was shown with aneurysms harboring relatively large dome size and lateral-type growth including internal carotid aneurysms. Prospective analysis of intraaneurysmal flow pattern with the color-coded 3D MR angiography may provide patient-specific analysis of intraaneurysmal flow status in relation to the morphological change of the corresponding aneurysmal dome in the management of unruptured cerebral aneurysms.

We have developed conventional and transparent 3D MR cisternography to investigate the spatial relationship between the contours of aneurysmal complex and the perianeurysmal structures including the cranial nerves, dural fold, cranial base bone, and brain parenchyma. Volume data obtained by a T2-weighted 3D fast spin-echo sequence were reconstructed by using a perspective volume-rendering algorithm with a transluminal imaging technique. 3D MR cisternograms provide useful anatomic information in the therapeutic and follow-up management of unruptured cerebral aneurysms.

Intracerebral hemorrhage occurred in this 61-year-old woman with preexisting diplopia and proptosis. Results of angiography demonstrated a persistent primitive trigeminal artery (PPTA)-cavernous sinus fistula with cortical venous reflux. Two microcatheters were introduced transarterially through the PPTA into the two draining pathways in the cavernous sinus. Coils were delivered in both pathways simultaneously to prevent further venous overload on either path. The fistula was successfully occluded without complication while the PPTA was preserved. The authors describe this double-catheter technique for coil embolization of a fistula and review the literature concerning PPTA-cavernous sinus fistulas.

The authors report a case of convulsion during intra-arterial selective infusion of fasudil hydrochloride (FSD) for treatment of vasospasm following subarachnoid hemorrhage (SAH). A 47-year-old man (Hunt and Kosnik grade I) presented with sudden onset of headache and was diagnosed with SAH on CT, and admitted to our hospital. Digital subtraction angiography (DSA) performed on admission revealed an anterior communicating artery aneurysm. Neck clipping of the aneurysm was performed on the same day and no neurological deficits were noted postoperatively. Motor aphasia appeared on day 11 after the operation, and emergency DSA revealed vasospasm of the left middle cerebral artery and its branches. Emergency percutaneous transluminal angioplasty was performed with successful dilation of the left M1 artery, and 25 milligrams of FSD was injected into the left M1 artery selectively. During this injection, right hemifacial convulsion appeared, and three minutes later disappeared. No treatment was needed for the seizure. Additional injection of 30 milligrams of FSD into the left internal carotid artery resulted in vasodilatation of the left M1 artery and its branches, improvement of their blood flow on angiography, and recovery from motor aphasia. The patient was discharged 1 month later with no neurological deficits. Intra-arterial selective infusion of FSD plays an important role in treatment for vasospasm following SAH, however, we must be aware of risks of complications such as convulsion.

The combined use of Guglielmi detachable coils (GDCs) and newly developed mechanically detachable platinum coils (Detach Coil System: DCS) was evaluated for the endovascular treatment of 10 patients with cerebral aneurysms. The number and total length of detachable coils placed into the aneurysms, the detaching time for each coil, and any technical problems were recorded and evaluated. Sixty GDCs and 60 DCSs were used. The detachment time for the DCS (mean 21 seconds) was faster than that for the GDC (mean 2 minutes 35 seconds). One DCS moved inside the aneurysm during the mechanical detachment maneuver, but was successfully placed. Neither detachment system influenced the behavior of the other system during coil implantation. The DCS includes a useful J-shape coil, whereas the GDC can be detached safely in fragile aneurysms. The DCS is also cheaper. The coil systems complemented one another and the combination optimized cost and operating time.

Background: A stent-assisted coil embolization has been applied as a novel choice of treatment for vertebral artery dissecting aneurysms (VADAs)., Clinical Presentation: A 45-year-old man suffered from subarachnoid hemorrhage three times within 2 hours. The left vertebral angiogram showed a VADA at the distal origin of the posterior inferior cerebellar artery. The right vertebral artery was hypoplastic, and collateral circulation to the posterior fossa was poor., Intervention: Stent-assisted coil embolization was performed under general anesthesia. The aneurysm was excluded from the circulation with good patency of the vertebral artery, although the fourth coil caused rebleeding from the aneurysmal dome during the procedure., Conclusion: This is the first case report that demonstrates rebleeding from VADA during stent-assisted coil embolization in the acute stage of its rupture. We have to be aware of the risks and be ready to prevent fatal complications with this novel technique.

We describe a case of Pseudoxanthoma elasticum (PXE) in a 14-year-old girl. This case is especially rare because of its association with carotid rete mirabile (CRM). Only three cases have been reported previously in the literature. Although the relation between P. elasticum and carotid rete mirabile is unclear, both disorders are believed to be major risk factors for cerebrovascular disease.

To evaluate the anatomical relationship between cerebral aneurysm and the perianeurysmal environment within a cisternal space, the contours of an unruptured cerebral aneurysm and pericisternal structures were depicted on a three-dimensional (3D) MR cisternogram. By using perspective volume-rendering algorithm, the 3D MR cisternograms were reconstructed from the source axial volume data set obtained by the T2-weighted 3D fast spin-echo sequence. Those images were shown together with the coordinated 3D MR angiograms through similar visual projections, and then compared with the intraoperative findings. The outer wall configurations of cerebral aneurysms within the cisternal space were shown in conjunction with the accompanying surface veins, adjacent cranial nerves, dura mater and tentorial edge, cranial base bone, and surrounding pericisternal brain surfaces. With application of 3D MR cisternograms in the management of unruptured cerebral aneurysm, the anatomical relationship between the aneurysmal contours and the perianeurysmal environment could be evaluated the within the cisternal space. This might provide another clinical factor when considering the potential risk of growth, rupture, and symptomatic cranial nerve signs of an unruptured cerebral aneurysm.

Background: Treating a ruptured cerebral aneurysm during symptomatic vasospasm is very difficult. We describe the successful endovascular treatment of such a case and discuss its efficacy., Case Presentation: A 34-year-old man had a sudden onset of severe headache. One week later, he was referred to our institute with gradually progressing right hemiparesis and global aphasia. Cerebral angiography demonstrated severe vasospasm of the left internal carotid artery system and an anterior communicating artery aneurysm. With the patient under general anesthesia, 90% occlusion of the aneurysm was achieved with detachable coils after successful dilatation of the spastic vessels. The patient had an uneventful postoperative course and his neurologic symptoms were improved. Seven months after the endovascular treatment, the enlarged neck remnant of the aneurysm was successfully clipped without difficulty., Conclusion: The simultaneous treatment of a ruptured aneurysm and vasospasm with percutaneous transluminal angioplasty and coils can produce a better outcome for the patient.

A 58-year-old woman complaining of a mild headache was admitted to our hospital. MRI 3 months before admission revealed a round lesion at the right quadrigeminal cistern. Cerebral angiograms demonstrated a fusiform aneurysm arising from the parietooccipital artery, which is the distal branch of the right posterior cerebral artery. Repeated MRI and cerebral angiograms performed on admission demonstrated complete thrombosis of an aneurysm and the parent artery without any clinical symptoms. This is the first case of complete spontaneous thrombosis of an aneurysm of the distal posterior cerebral artery. The mechanism of its development and spontaneous thrombosis in a fusiform aneurysm is discussed.

Artificial models of cerebral aneurysms for medical training and testing of medical devices were constructed from corrosion casts of the main cerebral arteries of a human specimen. Three aneurysms with a variety of shapes were simulated at typical locations. Rigid and soft models were made of silicone using the "lost wax" technique. The transparent silicone models were anatomically accurate and reproducible copies of human vascular casts. These models could be connected in a closed circuit that used an electric pump to simulate pulsatile flow. Endovascular procedures and surgical clip application were performed under fluoroscopic or direct visual control. Surgical clipping, endoluminal coil manipulation, and consecutive hemodynamic changes were visualized by digital subtraction angiography and direct observation. The model provides trainee surgeons with an understanding of clinical conditions. New medical devices, such as platinum coils, would be experimentally implanted in the model under stable conditions. These anatomically accurate and reproducible models of cerebral vasculature and aneurysms are valuable for medical testing, training, and research.

The majority of dural arteriovenous fistulas are considered to have a benign clinical course, but some behave more aggressively, causing progressive neurological symptoms and/or intracranial hemorrhage. Several classifications of angiographic findings have been reported to predict what findings might result in catastrophic presentation. Cortical venous drainage has been described as one of the major risk factors of hemorrhage. We reviewed the records of 50 patients with dural arteriovenous fistulas admitted to our institution from 1991 to 2001 and analyzed their venous drainage patterns with reference to Cognard's classification. Six patients had hemorrhagic episodes caused by dural arteriovenous fistula and all of them had retrograde drainage through cerebral veins. The frequency of hemorrhage in Type I and IIa was 0%, in Type IIb it was 33.3%, in Type IIa + b it was 9.1%, in Type III and Type IV it was 50%, and in Type V it was 100%. These results agreed with those of Cognard reported in 1994, and we reconfirmed the usefulness of Cognard's classification. In order to adapt a firm strategy and treat them promptly and aggressively, it is important to be able to recognize what type of dural arteriovenous fistulas are perilous.