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This study aimed to elucidate the relationships between preoperative carotid imaging results, histologic characteristics, and surgical treatment outcomes of radiation-induced carotid stenosis (RICS), using control subjects without RICS for comparison.We retrospectively reviewed records of 17 patients who underwent carotid revascularization for 22 instances of RICS, including 10 cases of carotid artery stenting (CAS), 11 cases of carotid endarterectomy (CEA), and 1 case of CEA with retrograde CAS, between July 2004 and April 2013. The controls were 475 patients with no history of radiation therapy who underwent carotid revascularization in a similar period. Preoperative magnetic resonance imaging (MRI), ultrasonography (US), and computed tomography angiography results were correlated with outcomes of histologic analysis of CEA specimens. End points included ipsilateral and contralateral stroke, myocardial infarction, restenosis, in-stent thrombosis, and target lesion revascularization.Vulnerable plaques on carotid MRI (86% vs 64.2%; P = .010) and mobile (27% vs 8.0%; P = .008) and ulcerative (50% vs 15.8%; P.001) plaques on US were more frequent in the RICS group. All revascularization procedures were successful, and no occlusion occurred. Adverse events in the CAS group, including one minor stroke and one transient ischemic attack within 30 days as well as five ipsilateral neurologic events after 30 days, including three minor strokes and two transient ischemic attacks, were significantly more frequent than in the CEA group. All three cases of late ipsilateral stroke displayed vulnerable plaque on preoperative MRI and late in-stent thrombosis or restenosis on US.Our radiologic and histologic analyses revealed that advanced RICS is often accompanied by formation of vulnerable plaque. CEA can prevent undesirable late outcomes in such cases.

We analyzed the incidence of ischemic complications after internal trapping for ruptured VA dissecting aneurysms. Between April 2001 and August 2005, nine cases of ruptured VA dissecting aneurysms, five in women, “proximal” or distal (distal type) to the origin of the PICA, were treated by internal trapping in the acute stage after SAH. There were four cases of proximal type and five of distal type. The demographics of the patients were reviewed in the medical charts and radiological findings were evaluated by neuroradiologists. The dissected site was completely obliterated and PICA was preserved in all cases. Follow-up angiography performed five to 19 days after treatment revealed complete obliteration of the aneurysm and patency of the PICA. The incidence of perioprocedural ischemic complications for the PICA-distal type (75%) was higher than that for the PICA-proximal type (20%). Here we retrospectively analyzed and discussed the incidence and mechanisms of ischemic complications.

Dissecting aneurysm of the posterior inferior cerebellar artery (PICA) is a relatively rare disease and its treatment has not been well established. The authors analyzed the clinical and anatomical features of 38 reported lesions and three of our cases to clarify the "best therapeutic modality". The average age was 45.0 years old and 27 patients were male. Left-sided predominance (26 cases) was noted. As to the mode of onset, 23 cases were subarachnoid hemorrhage, 16 were ischemia, and 6 were Wallenberg's syndrome. Anatomically, the sites of dissection were located in the proximal segment of PICA in 31 lesions (75.6%). Review of the cases show that 30 (75%) patients underwent surgical therapy, and 7 (17.5%) patients underwent endovascular treatment. Twenty six patients who took surgical therapy and 5 patients who took endovascular treatment had excellent or good outcome. The critical point in therapeutic procedure is the preservation of perforating branches arising from PICA, therefore surgical trapping with the revascularization of PICA (usually extracranial-PICA anastomosis), in which these tiny branches are secured under microscopic manipulation, has the advantage in principle.

Object The authors of this study prospectively compared periprocedural neurological morbidity and the appearance of lesions on diffusion-weighted (DW) magnetic resonance (MR) imaging in patients who had undergone carotid endarterectomy (CEA) or carotid artery stent placement (CASP) with distal balloon protection, based on a CEA risk grading scale. Methods Patients undergoing CEA (139 patients) and CASP (92 patients) were classified into Grades I to IV, based on the presence of angiographic (Grade II), medical (Grade III), and neurological (Grade IV) risks. Although not randomized, the CEA and CASP groups were well matched in terms of the graded risk factors except for a greater proportion of neurologically unstable patients in the CEA group (11 compared with 3%, p = 0.037). There were greater proportions of asymptomatic (64 compared with 34%, p = 0.006) and North American Symptomatic Carotid Endarterectomy Trial–ineligible patients (29 compared with 14%, p < 0.0001) in the CASP group. The overall rates of neurological morbidity with ischemic origin and the appearance of lesions on DW MR imaging after CEA were 2.2 and 9.3%, and those after CASP were 7.6 and 35.9% (nondisabling stroke only), respectively. The only disabling stroke was caused by an intracerebral hemorrhage attributable to hyperperfusion in one case (0.7%) of CEA. There were no deaths. There was no significant association between neurological morbidity and the risk grade in patients who had undergone CEA, although the incidence of lesions on DW imaging was significantly greater in the Grade IV risk group compared with that in the other risk groups combined (42.1 compared with 4.2%, p < 0.0001). After CASP, a higher incidence of neurological morbidity and lesions on DW imaging was noted for the Grade II and III risk groups combined as compared with that in the Grade I risk group, regardless of a symptomatic or an asymptomatic presentation (neurological morbidity: 10.5 compared with 3.1%, respectively, p = 0.41; and DW imaging lesions: 47.4 compared with 19.4%, p = 0.01). The incidence of lesions on DW imaging after CEA was significantly lower than that after CASP except for the Grade IV risk groups. Conclusions Despite a higher incidence of DW imaging–demonstrated lesions in the Grade IV risk group, there was no significant association between the risk group and neurological morbidity rates after CEA. The presence of vascular and medical risk profiles conferred higher rates of neurological morbidity and an increased incidence of lesions on DW imaging after CASP. Considering that no serious nonneurological complications were noted, CEA and CASP appear to be complementary methods of revascularization for carotid artery stenosis with various risk profiles.

In the safety stenting, it is important to get to know the characteristics of a plaque. In petrous carotid artery stenosis, it is difficult to know the characteristics of the plaque. We paid our attention to the MPRAGE (Magnetization Prepared Rapid Acquisition with Gradient Echo) method on high resolving power MRI. By the MPRAGE method, low intensity was observed in these lesions of all cases. This result suggested that the plaque in petrous portion was a fibrous plaque. This method is useful to get to know the characteristics of a plaque in petrous portion before endovascular treatment. In the petrous carotid artery stenosis, only endovascular treatment is possible for recovering an antegrade blood flow. In a case uncontrollable by medication, endovascular treatment is an important therapeutic procedure and it is thought that the role will become large from now on. It is required to grasp the characterization of a plaque beforehand in order to treat more safety CAS. Characteristic diagnosis of the plaque using this MPRAGE method did not have an attack either, it is the procedure of doing simple, it was thought that qualitative diagnosis whether a plaque is hard at least or it is soft was attained, and it was thought that it was a useful procedure. The MRI-MPRAGE method can expect the useful method for the investigation the plaque characterization of the petrous carotid artery stenosis.

Background Although cytokines are known to be pivotal in the development of atherosclerotic diseases, few data exist regarding their expressions in the established stages such as aneurysmal or occlusive lesions. Therefore, in the present study the gene expression levels of cytokine-related substances in abdominal aortic aneurysm (AAA) and carotid artery stenosis (CAS) were determined using cDNA macroarray and real-time reverse transcriptase polymerase chain reaction (RT-PCR) methods. Methods and Results Tissue samples were obtained from 31 patients with AAA and 24 with CAS. The array-specific [33P]-labeled cDNA probe mixture synthesized from 2.5 μg total RNA with gene-specific primers was hybridized with nylon membranes containing 375 cDNA clones. Densitometric analysis confirmed differences in expression (>5-fold) for 97 of the cytokine-related gene products between AAA and adjacent control tissue. Among these, simultaneous upregulation was found in the expression of interleukin (IL)-8 (9-fold) and its receptor, CXCR-2 (11-fold). Thus, the expressions of IL-8 and CXCR-2 were further quantified by real-time RT-PCR. The expression of both the genes was significantly upregulated in both AAA and CAS compared with control regions as followed: IL-8 =0.53±0.16 vs 0.11±0.04 (p

The present study assessed the safety and efficacy of embolization using Guglielmi detachable coils (GDCs) in 100 asymptomatic cerebral aneurysms classified as sidewall (70) or terminal (30) aneurysms according to the parent artery (68 small aneurysms with a small neck, 21 small aneurysms with a wide neck, and 11 large aneurysms). A balloon-assisted technique was used in 49 aneurysms. Immediate angiography revealed that 71 aneurysms were completely obliterated. Transient deficits occurred in 19 patients, permanent deficits in four patients, and one patient died. Most complications occurred during or immediately after treatment and resolved within a few minutes to a few weeks. None of the surviving patients manifested significant morbidity at 1-year follow up. Follow-up angiographic study was performed in 79 aneurysms. Rates of recanalization and progressive thrombosis (total occlusion of the residual aneurysm at follow up) were 11% and 38%, respectively, in sidewall aneurysms, and 26% and 0%, respectively, in terminal aneurysms. Treatment with GDCs was effective for patients with small aneurysms with small necks, the morbidity was acceptable, and progressive thrombosis occurred during the follow-up period. GDC treatment achieved unsatisfactory results in patients with small terminal aneurysms with wide necks and in large aneurysms, because the obliteration rate was low, and the recanalization and complication rates were high. Multivariate analysis showed that complete occlusion was associated with small-necked aneurysms, and ischemic events tended to occur in terminal aneurysms and in aneurysms treated by the balloon-assisted technique.

BACKGROUND AND PURPOSE: For intracranial aneurysms treated with Guglielmi detachable coils, long-term follow-up is mandatory because coil compaction may occur and aneurysms may recur. The purpose of this study was to establish a noninvasive technique to visualize residual flow in coiled aneurysms. METHODS: We designed a 3D time-of-flight (3D-TOF) MR angiography (MRA) technique targeted to depict coiled aneurysms that employed a very short TE (1.54–1.60 ms) and a high spatial resolution (0.3 × 0.3 × 0.3 mm(3) with zero-filling) to diminish spin dephasing. To diminish spin saturation, image volume was carefully positioned so that the neck of the targeted aneurysm was within 2 cm of the inflow portion along the stream of blood. Fifty-one MRA images of 39 coiled aneurysms in 39 patients were compared with digital subtraction angiography (DSA) images. DSA and MRA findings were interpolated retrospectively for parent and branch arteries’ patency, as well as residual flow in aneurysms. In the latest 11 MR studies, a dark-blood 3D turbo spin-echo sequence was added to MRA to negate the effect high-signal-intensity thrombus. RESULTS: MRA visualized all parent and branch arteries with DSA confirmation. MRA visualized residual flow more frequently (38 studies) than did DSA (25 studies). Residual flow space visualized with MRA was always similar to or larger than that with DSA. The dark-blood sequence completely suppressed intraluminal high signal intensity on MRA images and confirmed that the high signal intensity was not due to thrombus. CONCLUSION: TOF MRA targeted to depict coiled intracranial aneurysms is noninvasive and superior to DSA in visualization of residual flow and, hence, useful for follow-up of coiled aneurysms.

The purpose of this study was to evaluate the efficacy and safety of staged carotid stenting (CS) and carotid endarterectomy (CEA) for bilateral internal carotid artery stenosis. With this strategy, initial carotid stenting was performed for the high grade carotid stenosis to reduce the risk of subsequent CEA. Eight patients were treated with staged CS and CEA; CS for asymptomatic side followed by CEA for symptomatic side. Sufficient revascularization was obtained in all procedures but one CS procedure. Two minor stroke caused by distal embolism occurred during the perioperative period of CS. Postprocedural persistent hypotension was observed in one CS procedure. The mean interval between CS and CEA was 19.8 days. In conclusion, although our strategy has some advantages such as avoidance of bilateral cranial nerve palsy and shorter admission period over staged CEA, relatively high complication rate was noted at the first CS without any stroke morbidity post CEA. Our preliminary result showed that further reduction of periprocedural complication rate at the initial stenting is mandatory for this approach justified.

The surgical and/or endovascular treatment of four patients with infectious cerebral aneurysm associated with infective endocarditis was reported. Two patients presented with intracerebral hemorrhage. One of them, with large hematoma, was treated surgically and the other, with small hematoma, was treated by endovascular surgery. The third patient, with unruptured aneurysm of the distal anterior cerebral artery, was treated by endovascular parent-artery occlusion without neurological deterioration. The fourth patient, with unruptured aneurysm of the distal middle cerebral artery, was initially treated with antibiotics, resulting in stabilization of the aneurysm. However, three weeks after open heart surgery, the aneurysm ruptured, causing a large cerebral hematoma. Despite prompt evacuation of the hematoma and surgical resection of the aneurysm, this patient remained in a vegetative state. Management strategy of intracranial infective aneurysms is discussed.

This study examined the incidence and mechanism of restenosis after carotid endarterectomy (CEA) in Japanese patients. To determine the optimal management for carotid restenosis, we retrospectively compared re-CEA with stent placement. One hundred and twenty-six patients who had received 135 CEA with primary suture were studied with angiography or duplex ultra-sonography as a follow-up study to detect restenosis (50% diameter reduction). Data was collected regarding demographics of the patients suffering restenosis, including age, sex, other risk factors. Recurrent carotid stenosis (more than 50% stenosis) developed in 9 CEA sites (6.7%) during a mean follow-up interval of 11.0 months (4.7-46.7 months). Recurrent carotid stenosis occurred to a significantly higher degree in women (p = 0.015). There was no significant difference in other risk factors. All patients who developed carotid restenosis were asymptomatic. Re-do CEA and carotid stenting were used to treat restenosis in 3 and 5 patients, respectively. No operative procedure was performed in the remaining one patient with milder restenosis (55%). The 30-day stroke morbidity-mortality rate was 33.3% in CEA and 0% in stent placement. In only one of 4 early restenosis patients, there was a bright lesion in diffusion weighted MR images after stent placement. To treat restenosis after CEA, stent placement is indicated because of a lower risk of distal emboli and there being no need to dissect the previous wound. To prevent restenosis, through plaque removal is necessary and patch closure may be needed especially in females.

Object. The authors present a retrospective analysis of their experience in the treatment of vertebral artery (VA) dissecting aneurysms and propose a management strategy for such aneurysms, with special emphasis on the most formidable VA dissecting aneurysms, which involve the origin of the posterior inferior cerebellar artery (PICA). Methods. Since 1998, 18 patients with VA dissecting aneurysms, 11 of whom presented with subarachnoid hemorrhage (SAH), have been treated by endovascular surgery at the authors' institution. Obliteration of the entire segment of the dissected site with coils (internal trapping) was performed for aneurysms without involvement of the origin of the PICA (12 cases; among these the treatment-related morbidity rate was 16.7%). The treatment strategy applied to PICA-involved VA dissecting aneurysms presenting with SAH (three cases) included proximal occlusion of the parent artery followed by internal trapping of the aneurysm (one case), proximal occlusion of the parent artery followed by occipital artery (OA)—PICA bypass (one case), and two-staged internal trapping of the aneurysm involving double PICAs (one case). For PICA-involved VA dissecting aneurysms that were not associated with SAH at presentation (three cases), OA—PICA bypass was performed and followed by internal trapping of the aneurysm (two cases). In the remaining case in which a fetal-type posterior communicating artery was present, internal trapping was performed following successful balloon test occlusion (BTO). Overall, there was no sign of infarction in the PICA territory, despite complete occlusion of aneurysms involving the PICA. There was no recurrent bleeding or ischemic symptoms during the follow-up periods. The overall treatment-related morbidity rate for the VA dissecting aneurysms involving the PICA was 16.7%. Conclusions. Dissecting VA aneurysms that do not involve the PICA can be safely treated by internal trapping. For those lesions that do involve the PICA, a decision-making algorithm is advocated to maximize the efficacy of the treatment as well as to minimize the risks of treatment-related morbidity based on BTO.

Objective and importance Cobb syndrome is a rare clinical entity characterized by the combination of a vascular skin nevus and an angioma in the spinal canal at the same metamere. We present a case report of an infant with Cobb syndrome. Clinical presentation A 5-month-old girl presented with cutaneous hemangioma of the thoracolumbar region (T5-T12) and paraparesis. The infant was examined by magnetic resonance imaging and aortography and was diagnosed with Cobb syndrome. Intervention The patient received orally administered prednisolone therapy and underwent endovascular embolization of paravertebral and spinal angiomas with the use of n-butyl-2-cyanoacrylate. Her symptoms improved by combined treatment with liquid embolization and corticosteroid therapy. Conclusion Although Cobb syndrome has been reported in older children, it is extremely rare in infants. To our knowledge, this is the first report of an infant with Cobb syndrome treated with endovascular embolization and corticosteroid therapy. The combined treatment with corticosteroid therapy and endovascular embolization of cutaneomeningospinal angioma in Cobb syndrome seems effective in alleviating symptoms and minimizing morbidity.

✓ Polyarteritis nodosa (PAN) is a rare systemic necrotizing arteritis that involves small- and medium-sized arteries in various organs. Although aneurysm formation in visceral arteries is a typical finding in PAN, intracranial aneurysms are much less common, and only a few cases of aneurysm rupture associated with this disease have been documented. In this paper, the authors report on a ruptured PAN aneurysm of the anterior cerebral artery; the lesion was trapped and resected. On histological examination, extensive fibrinoid necrosis and an inflammatory infiltration of leukocytes were seen in the aneurysm wall. To the authors' knowledge this is the first report of subarachnoid hemorrhage from a histologically confirmed PAN aneurysm.

Background: The effectiveness of comprehensive stroke center (CSC) capabilities on stroke mortality remains uncertain. We performed a nationwide study to examine whether CSC capabilities influenced in-hospital mortality of patients with ischemic and hemorrhagic stroke. Methods and Results: Of the 1,369 certified training institutions in Japan, 749 hospitals responded to a questionnaire survey regarding CSC capabilities that queried the availability of personnel, diagnostic techniques, specific expertise, infrastructure, and educational components recommended for CSCs. Among the institutions that responded, data on patients hospitalized for stroke between April 1, 2010 and March 31, 2011 were obtained from the Japanese Diagnosis Procedure Combination database. In-hospital mortality was analyzed using hierarchical logistic regression analysis adjusted for age, sex, level of consciousness on admission, comorbidities, and the number of fulfilled CSC items in each component and in total. Data from 265 institutions and 53,170 emergency-hospitalized patients were analyzed. Mortality rates were 7.8% for patients with ischemic stroke, 16.8% for patients with intracerebral hemorrhage (ICH), and 28.1% for patients with subarachnoid hemorrhage (SAH). Mortality adjusted for age, sex, and level of consciousness was significantly correlated with personnel, infrastructural, educational, and total CSC scores in patients with ischemic stroke. Mortality was significantly correlated with diagnostic, educational, and total CSC scores in patients with ICH and with specific expertise, infrastructural, educational, and total CSC scores in patients with SAH. Conclusions: CSC capabilities were associated with reduced in-hospital mortality rates, and relevant aspects of care were found to be dependent on stroke type., PLoS ONE, 9(5), e96819; 2014

The purpose of this study was to evaluate our initial procedural success rate and angiographical outcome of stent placement for vertebral artery (VA) stenosis at the intermediate follow-up period (11.3±7.3 months). Stent placement was successfully performed in 20 procedures (19 patients), resulting in a marked reduction of stenosis from 78.7 ± 12.6 % before to 8.7% ± 10.6 after stenting. Follow-up angiography, performed after an interval of 11.3 ± 7.3 months, revealed restenosis greater than 50% in a total of 6 procedures (40%) out of 15. Although PTA with stent placement for stenosis affecting VA origin provided excellent initial success, restenosis occurred at a significant rate even during the intermediate follow-up period.

Background: Carotid artery occlusion can lead to the development of rare true posterior communicating artery (PCoA) aneurysms because of hemodynamic stress on the PCoA. Surgical treatment of these lesions is challenging. Case Description: The authors report a case of a true PCoA aneurysm that developed and ruptured 37 years after ligation of the ipsilateral common carotid artery for epistaxis. The lesion was successfully treated with clipping of the distal M1 segment of the middle cerebral artery (MCA) after the occipital artery-radial artery free graft-MCA bypass, which led to extreme reduction in collateral flow through the PCoA. A cortical branch, located just proximal to the obliteration site, functioned as a sufficient flow outlet. The aneurysm shrank, and the patient has been doing well without any symptoms for 5 years after surgery. Conclusions: M1 obliteration combined with high-flow extra-intracranial bypass might be a promising option for a true PCoA aneurysm, and therapeutic design that leaves a sufficient flow outlet on the M1 is mandatory to avoid unexpected occlusion of the M1 and its perforators.

classified as obese. Comorbid conditions included gestational diabetes (6%) and chronic hypertension (8%). Among the cohort, 12% had SSD. Women with SSD compared to those without were more likely to have prepregnancy obesity (71 vs. 31%, p 0.04) but had a similar delivery gestational age (38 1.2 weeks vs. 39 1, p 0.21), similar birthweight (3330 429 vs. 3141 491, p 0.36) and similar ponderal index (2.8 0.3 vs. 2.84 4, p 0.8). Obese women when compared to normal weight women had neonates with similar birthweight (3416 646 vs. 3251 386gm, p 0.2) but higher ponderal index (2.9 0.3 vs. 2.7 0.3, p 0.02). Neonatal birthweight was predicted by gestational age ( 0.53, p 0.001) and prepregnancy obesity ( 0.28, p 0.02) but not SSD ( .121, p n.s.) After controlling for comorbid conditions, prepregnancy obesity ( 0.32, p 0.02) but not SSD ( .117, p n.s.) was predictive of neonatal ponderal index. CONCLUSION: Obesity is associated with severe sleep disturbance. In this cohort of full term neonates, it is obesity rather than sleep disturbance that appears to affect neonatal adiposity.

For better understanding of the role of platelet-derived growth factor (PDGF) B-chain in the brain, the expression of PDGF B-chain was studied in the mature rat brain at both protein and mRNA levels, by assay of PDGF B-chain-related mitogenic activity, Northern blot, in situ hybridization and immunohistochemistry. It was shown that (1) mature rat brain contained substantial PDGF B-chain-related mitogenic activity, (2) significant amounts of two sizes of transcripts (3.5 kb, widely, and 2.6 kb, weakly and in narrower areas) were expressed in the brain, and (3) the transcripts were localized in ubiquitous neurons by in situ hybridization, with the strongest signal in hippocampal pyramidal cells, which distribution almost corresponded with that of the immunoreactive products. The abundant neuronal localization of the transcript and protein, as well as the neuronal expression of the receptor reported elsewhere, suggests the role of the growth factor in neuronal cells as a neuronal regulatory and/or trophic agent acting by autocrine loop or by neuron to neuron interaction. However, there was an apparent discrepancy in part, in the distribution between transcripts and immunoreactivity; that is, transcripts were expressed intensely in the intermediate pituitary lobe with only a scattered immunoreactivity, and the opposite situation was observed in the accessory olfactory nerve and posterior pituitary lobe. This might suggest that PDGF B-chain is transported or secreted in these foci.

Summary 1. The present study was conducted to analyse the release and production of mitogen in cultured aortic endothelial cells of stroke-prone spontaneously hypertensive rats (SHRSP), for the further understanding of the role of arterial endothelial cells in the genesis of vascular lesions in hypertension. 2. The cultured aortic endothelial cells derived from SHRSP increased released mitogens were compared with those from control Wistar-Kyoto rats (WKY) with respect to cultured vascular medial smooth muscle cells and fibroblasts. 3. Biochemical analyses determined that the major part of mitogen released from aortic endothelial cells of both SHRSP and controls was the platelet-derived growth factor B-chain. 4. Further northern analyses revealed that the transcripts of PDGF B-chain were constitutively accumulated three- to fourfold in quiescent aortic endothelial cells from SHRSP, compared with those from WKY through passages 2 to 5. 5. However, the half-lives of the transcripts after actinomy cin D treatment were 1.12 h (s.d. = 0.14, n= 4) and 1.28 h (s.d. = 0.08, n= 3), in SHRSP and in WKY, respectively, showing no significant difference. 6. These suggest that the increased accumulated transcripts of PDGF B-chain in SHRSP are due to an enhanced trans-criptional rate. These enhanced release and production of PDGF-B chain in arterial endothelial cells, which may be induced under chronic hypertensive conditions, is suggested to contribute to the genesis of vascular lesion in hypertension, through the stimulation of vascular smooth muscle cell proliferation and hypertrophy.

To elucidate the role of the platelet-derived growth factor (PDGF)–B chain in the brain, we examined its expression in rat brains with focal ischemia. Focal ischemia was induced by permanent tandem occlusion of the middle cerebral and common carotid arteries in spontaneously hypertensive rats (SHRs). Northern analysis demonstrated that ischemia transiently increased mRNA expression of the PDGF–B chain, but not the PDGF–A chain, in the injured neocortex. The larger transcript (3.5 kb) of the B chain gradually increased to threefold by 16 h, whereas the smaller transcript (2.6 kb) of the B chain markedly increased sixfold by 4 h. Immunohistochemistry revealed enhanced immunoreactivity in the neurons in the infarct and in the periinfarct area from 16 h to days 4–7, with a peak at 24 h. Furthermore, the brain macrophages that accumulated in the infarct showed intense immunostaining in their perinuclear region from days 2 to 14, with a peak at days 5–6. The present study demonstrates that ischemia induces the expression of the PDGF–B chain, first in neurons and later in brain macrophages, and suggests an important role of the PDGF–B chain in the healing process of the injured brain.

SUMMARY 1. We characterized the endothelial cell-derived growth factors of SHRSP and Wistar Kyoto rats (WKY), respectively and found that platelet-derived growth factor (PDGF)-B chain related growth factor constituted a major portion of the mitogenic activity of the conditioned media of endothelial cells from both animals. There were no remarkable qualitative differences between the endothelial cell-derived growth factors of SHRSP and WKY. 2. Northern analysis revealed that the expression of PDGF-B chain was 2–4-fold enhanced in cultured aortic endothelial cells of SHRSP. This enhanced expression of PDGF-B chain, which may be induced under chronic hypertensive conditions, is suggested to contribute to the increase in endothelial cell-derived growth factors reported in this animal.

Traumatic pseudoaneurysms of the extracranial vertebral artery rarely occur, because of its deeply protected anatomical location. Because the direct surgical approach has resulted in high morbidity and mortality rates, ligation of the vertebral artery has been adopted, but this can cause an ischemia in the vertebrobasilar system. We report the case of a 73-year-old woman with a huge pseudoaneurysm of the right vertebral artery that occurred after attempted placement of a cardiac pacemaker. The aneurysm was 7 x 7 x 5 cm in size and its neck was situated just distal to the right subclavian artery. Direct surgical repair of the injured vessel and removal of the aneurysm were successfully performed using balloon catheters placed intraoperatively in both the innominate artery and the right vertebral artery.

The authors present an extremely rare case of aspergillosis of the central nervous system (CNS) causing subarachnoid hemorrhage (SAH). A 78-year-old female developed facial pain, progressive deterioration in left visual acuity, and left total ophthalmoplegia. Computed tomography demonstrated a heterogeneously enhanced mass extending from the sphenoid sinus to the left cavernous sinus and left orbit, and angiography showed luminal narrowing and irregularity of the left internal carotid artery at its siphon. Biopsy of the left orbital and sphenoid sinus mass resulted in the diagnosis of Aspergillus granuloma. Despite combined administration of amphotericin-B and 5-FC, she became comatose from brainstem infarction and finally, suddenly died. Postmortem examination revealed massive SAH due to a ruptured mycotic aneurysm of the basilar artery. Aspergillosis of the CNS is a growing problem with the wider use of immunosuppressants and antibiotics. To the authors' knowledge, however, only 13 cases of CNS aspergillosis causing SAH have been reported. The prognosis is absolutely bad, with all patients dying from rupture of major intracranial arteries such as the internal carotid artery and basilar artery. Early diagnosis and vigorous chemotherapy are important.

A rare case of epidermoid cyst traversing the brain stem is presented. Computed tomography revealed the mass within the fourth ventricle; magnetic resonance imaging showed the dumbbell-shaped mass extending from the prepontine cistern to the fourth ventricle. Despite the high mortality and morbidity of brain stem epidermoid cysts in the literature, the tumor was successfully removed. The advantages of magnetic resonance imaging over computed tomography are described.

SUMMARY Background: Intracerebral hemorrhage (ICH) is one of the most serious complications in patients supported by a left ventricular assist device (LVAD). We evaluate the efficacy of prothrombin complex concentrate (PCC) for rapid reversal of warfarin-induced anticoagulation in this population. Methods: A total of 38 consecutive ICH events in patients supported by an LVAD between 1996 and 2007 were retrospectively reviewed. Fourteen ICH events were treated with fresh frozen plasma (FFP) (Group FFP) and 24 ICH events were treated with PCC (Group PCC). The efficacy and outcome of PCC administration versus FFP were evaluated. Results: The proportion of patients surviving after an ICH event was significantly smaller in Group FFP than Group PCC (35.7% vs. 75.0%, p < 0.05). None of the patients in Group FFP were able to undergo heart transplantation, whereas 21.4% patients in Group PCC successfully underwent heart transplantation. Conclusion: Patients on LVAD are in need for intensified anticoagulation and are at high risk of ICH; therefore, adequate use of PCC in the event of ICH could be of importance for survival and allow subsequent heart transplantation. [International Journal of Gerontology 2010; 4(3): 143–147]

ObjectivesAlthough mobile plaques in the carotid arteries detected by duplex ultrasound imaging are considered to cause unstable neurologic symptoms such as crescendo transient ischemic attack or progressive stroke, the histology of mobile plaques has not been sufficiently documented. This study examined the histopathologic features of mobile plaques of the carotid artery and compared the histopathology between mobile and nonmobile plaques.MethodsOf 228 carotid plaques assessed by preoperative carotid ultrasound imaging, 21 (9.3%) were diagnosed as mobile symptomatic plaques. Of these, 18 were intact after excision by endarterectomy and enrolled for histologic examination. From the remaining 207 nonmobile plaque specimens, 17 nonmobile but symptomatic plaque specimens were extracted for histologic comparison. An investigator blinded to the ultrasound findings assessed both plaque specimens for fibrous cap thickness, fibrous cap rupture, fibrous cap area, necrotic core size, inflammatory cells, intraplaque hemorrhage, and mural thrombus. Clinical data, including progressive ischemic symptoms after admission, were also examined.ResultsProgressive ischemic symptoms were more frequently seen in patients with mobile plaques than in those with nonmobile plaques (33.3% vs 0%, P = .02). The ratio of the cross-sectional area of the necrotic core to that of the entire plaque was significantly larger for mobile plaques than for nonmobile plaques (mean, 0.660 vs 0.417, P < .0001). Mural thrombus was more prevalent among mobile plaques (89%) than among nonmobile plaques (59%), but the difference was not significant (P = .06). The median minimum thickness of the fibrous cap was extremely small in both groups (80 μm in mobile plaques and 100 μm in nonmobile plaques, P = .33).ConclusionsThe histologic characteristics of mobile carotid plaques are different from those of nonmobile symptomatic plaques, especially in the area of the necrotic core. This histologic difference may partly explain the unstable neurologic presentations of patients with mobile carotid plaques.

Background The utility of corticospinal tract (CST)-tractography-integrated navigation was reported for brain tumors near pyramidal tracts. However, the efficacy of arcuate fasciculus (AF)-tractography-integrated navigation is unclear. Awake craniotomy is recommended to preserve language function for glioma located near the language area, although the patients' condition can limit its application. In such cases, AF-tractography-integrated navigation may help protect neurological function. Methods We performed a retrospective analysis of AF-tractography-integrated navigation. We evaluated 11 patients who underwent glioma surgery near the language area using AF-tractography-integrated navigation. Six patients received intraoperative awake language functional mapping, whereas five did not due to adverse preoperative or intraoperative conditions. Language function was evaluated using the Western Aphasia Battery or Standard Language Test of Aphasia both preoperatively and postoperatively (2–4 weeks and 2–3 months after surgery). Results Extent of resection (EOR) ranged from 59.5% to 100% (mean 82.1%). Language function at 2–3 months after surgery was improved in one patient, intact in nine, and moderately disturbed in one compared with preoperative function. Among the non-awake craniotomy group, EOR ranged from 78.7% to 100% (mean 89.82%). Language function at 2–3 months after surgery was improved in one patient, intact in three, and moderately disturbed in one, in whom tumor removal very close to the AF tract was performed following preoperative patient's intent. Conclusions AF-tractography-integrated navigation is useful for glioma surgery near the language area, especially for patients with unsuitable conditions for awake craniotomy.

Three-dimensional (3D) high-definition endoscopy is an innovative technical advancement that helps surgeons gain precise depth perception and spatial recognition during endoscopic surgery. Here, we describe a new dual optical channel 3D neuroendoscopic technique and its clinical application. We performed endoscopic endonasal surgery on 88 patients using 3D and two-dimensional (2D) endoscopes in conjunction. We evaluated the usefulness of stereoscopic images acquired by dual optical channel 3D endoscopy during endoscopic surgery and compared the image resolution between dual optical channel 3D endoscopy and 2D endoscopy. Additionally, we compared the stereoscopic images acquired by dual optical channel and Visionsense 3D endoscopy in three cases. Combination surgery using 3D and 2D endoscopy was found to be safe. Stereoscopic images were useful in several surgical steps, especially in recognition of complex bony structures, bone drilling, and suprasellar manipulation. The magnitude of binocular disparity was greater in dual optical channel 3D endoscopy than in Visionsense 3D endoscopy. Stereoscopic images acquired by dual optical channel 3D neuroendoscopy were of adequate quality and were useful for endoscopic endonasal surgery. In consideration of its lower image resolution compared to that of 2D high-definition endoscopy, dual optical channel 3D neuroendoscopy can be applied as an assistive technique in endoscopic endonasal surgery. The magnitude of binocular disparity is one of the key factors to be considered for evaluation of the clinical significance of 3D endoscopy.

Candidate gene studies have identified genetic variants associated with clinical outcomes following aneurysmal subarachnoid haemorrhage (aSAH), but no genome-wide association studies have been performed to date. Here we report the results of the discovery phase of a two-stage genome-wide meta-analysis of outcome after aSAH. We identified 157 independent loci harbouring 756 genetic variants associated with outcome after aSAH (p −4), which require validation. A single variant (rs12949158), in SPNS2, achieved genome-wide significance (p = 4.29 × 10−8) implicating sphingosine-1-phosphate signalling in outcome after aSAH. A large multicentre international effort to recruit samples for validation is required and ongoing. Validation of these findings will provide significant insight into the pathophysiology of outcomes after aSAH with potential implications for treatment.