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Introduction: Embolus due to plaque rupture is a risk of cerebral infarction for carotid artery stenting (CAS). Female have been controversial as a risk factor for cardiovascular interventions in recent years. MMP-9 has been previously reported to be associated with acute ischemic stroke and to be a potential marker for arteriosclerosis.Therefore, this paper aimed to investigate the gender difference of embolic complications for CAS using MMP-9.Material and Methods: We analyzed 46 consecutive cases of CAS performed with distal balloon protection, including 34 males and 12 females. Serum levels of matrix metalloproteinase (MMP) -9 were measured before and after CAS. Embolic events were examined in Diffusion Weighted Imaging (DWI) on MRI the next day after CAS.Results: 13 cases (28.3%) had DWI-positive findings after CAS, and these results showed a significant gender difference (female 58.3% vs. male 17.6%, p < 0.05). Pre-CAS MMP-9 was significantly higher in females than in males (661.7 vs. 428.1 ng/ml, p < 0.05).Pre-CAS MMP-9 tended to be higher in DWI-positive cases than DWI-negative cases with no significant difference (676.9 vs. 415.0 ng/ml, p = 0.051).Conclusion: High serum MMP-9 in female have correlation with DWI positive findings after CAS. We suggest that high serum MMP-9 have a risk of cerebral infarction for CAS. Considering the results, CAS should be carefully performed, especially in female.

Herein, we describe a case of traumatic direct carotid cavernous fistula (DCCF) treated with target coil embolization using the combined transarterial and transvenous balloon-assisted technique. The patient was a 59-year-old woman who had been involved in a vehicular accident. She was admitted to the hospital due to chemosis and exophthalmos. Cerebral angiography revealed a shunt from the internal carotid artery (ICA) to the cavernous sinus (CS), which indicated DCCF. Thus, target coil embolization using the combined transarterial and transvenous balloon-assisted technique was performed. Angiography was performed 1 week after surgery to confirm the disappearance of DCCF. No recurrence was observed during the 1-year follow-up after treatment. Thus, target coil embolization using the combined transarterial and transvenous balloon-assisted technique is safe and effective for the treatment of traumatic DCCF.

Background Distal anterior cerebral artery (DACA) aneurysms are rare, and endovascular treatment of these aneurysms is challenging. Thromboembolic events, including silent ischemic events, are one of the most important complications of coil embolization for cerebral aneurysms. The treatment outcomes and predictors of silent ischemic events in coil embolization for unruptured DACA aneurysms were investigated, focusing on the morphological characteristics of aneurysms, especially the inflow angle (IA) and global outflow angle (GOA). Methods A total of 12 patients with 12 unruptured DACA aneurysms, treated with coil embolization at our institute, were retrospectively investigated. Predictors for silent ischemic events were evaluated by comparing diffusion-weighted imaging (DWI)-positive and DWI-negative patients. Results Silent ischemic events detected on DWI were observed in eight aneurysms (66.7%). Comparison of the morphological characteristics of aneurysms between the two groups showed a significantly smaller GOA in the DWI-positive group than in the DWI-negative group (172.6 ± 17.7° vs. 216.8 ± 16.8°, P Conclusion A small GOA was a significant predictor of silent ischemic events after coil embolization for unruptured DACA aneurysms. While some patients can be treated safely with minimally invasive coil embolization, it is necessary to consider surgical clipping in patients at high risk of thromboembolic events with coil embolization.

Extra-central nervous system metastasis of gliomas is extremely rare, and the biological mechanism underlying it remains poorly understood. Epithelial-to-mesenchymal transition (EMT) has received attention as one of the important processes of cancer metastasis. Here we describe the case of a 32-year-old man with cutaneous metastasis of high-grade glioma, together with the analysis of EMT-related molecules. Our patient presented with a high-grade glioma in the right frontal lobe. Cutaneous metastasis under the surgical scar developed 17 months after complete resection of the intracranial tumor. Histopathology of both the original and metastatic tumors revealed hypercellularity; the tumors predominantly comprised glial tumor cells with poor cellular processes. Immunohistochemical analysis demonstrated intense expression of nestin, focal expression of glial fibrillary acid protein, and absence of expression of oligodendrocyte transcription factor 2, endothelial membrane antigen, or neurofilament. Genetic analyses could not provide definitive diagnostic information of glioma subtypes. Immunohistochemical analysis for EMT-related biomarkers demonstrated increased Twist, zinc finger E-box-binding homeobox 2 (ZEB2), matrix metalloproteinase 2 (MMP2), and MMP9 expressions in tumor cells of the metastatic lesion compared with those of the primary lesion. Slug, E-cadherin, and N-cadherin expression were absent in both primary and metastatic lesions; however, ZEB1 expression was present in both. Our results suggest that Twist, ZEB2, MMP2, and MMP9 facilitate cutaneous metastasis of gliomas.

Thromboembolic complications are a relevant risk in coil embolisation of cerebral aneurysms. This retrospective study aimed to assess the treatment outcomes of unruptured middle cerebral artery (MCA) bifurcation aneurysms and the predictors for thromboembolic complications based on the aneurysm morphological characteristics. We examined the following three features: inflow angle, outflow angle (OA), and bifurcation angle, formed by the aneurysm and neighbouring blood vessels.A total of 32 MCA bifurcation aneurysms were retrospectively investigated in 32 patients treated consecutively at our institute between April 2008 and March 2019. The predictors for thromboembolic complications were analysed in two groups: patients with and without thromboembolic complications.Perioperative thromboembolic complications were detected in six patients (18.8%), including two and six intra- and post-procedural thromboembolic complications, respectively; all cases were resolved. Regarding the aneurysms' morphological characteristics, the group with thromboembolic complications showed a significantly smaller OA (55.58° ± 14.05° vs. 86.04° ± 28.58°, P = 0.01) than the group without complications. Multivariate analysis revealed that smoking habits and OA 70° were significant predictors of thromboembolic complications (smoking habits: P = 0.01, odds ratio [OR]: 6.89, 95% confidence interval [CI]: 3.78-12.62; OA 70°: P = 0.04, OR: 3.19, 95% CI: 1.52-6.56).Our findings indicate significant pre-procedural predictors of thromboembolic complications to consider for safe treatment; clipping should be preferred to coil embolisation in high-risk patients. The method of choice should be considered in each case to allow the safe treatment of unruptured MCA aneurysms.

Alterations in the BRAF gene have been reported to play a key role in the tumorigenesis of various tumors. Recent studies have shown the existence of BRAF alterations in ganglioglioma (GG), pilocytic astrocytoma (PA), pleomorphic xanthoastrocytomas (PXA), and epithelioid glioblastoma (eGBM). The focus of this review was the association between the clinical characteristics and BRAF status in these glial and glioneuronal tumors. The BRAF abnormalities, KIAA1549-BRAF fusion and BRAF mutation, were detected in approximately 50% of the analyzed tumors regardless of the tumor location, and there were site-specific BRAF abnormalities that became more remarkable on analysis by each tumor subtype. The median age of patients with KIAA1549-BRAF fusion was much lesser than that of those with BRAF mutations. Histological analysis indicates that the existence of KIAA1549-BRAF fusion is related to pilocytic morphology. The review of imaging features indicated that cyst formation is associated with the existence of KIAA1549-BRAF fusion in PA and GG and the lack of BRAF mutation in GG. Hemorrhage was significantly present in cases of GG with KIAA1549-BRAF fusion, but no relevance was shown in cases with BRAF mutations. No significant relevance was detected between the presence of calcification and BRAF alterations. Our clinical and genetic review of BRAF-related tumors indicated that the KIAA1549-BRAF fusion was strongly associated with PA, but not with other glial and glioneuronal tumors.

Background: Cribriform plate dural arteriovenous fistulas (dAVFs) are rarely encountered. Here, we report a case of cribriform plate dAVF with a rare complication after endovascular therapy. Case Description: A 60-year-old man presented with severe sudden headache. Head computed tomography showed right subdural hematoma, and magnetic resonance angiography showed dilated bilateral frontal cortical vein. Digital subtraction angiography revealed cribriform plate dAVF fed by the anterior and posterior ethmoidal branches of the bilateral ophthalmic arteries. Transarterial embolization with liquid embolic material was performed and the fistula disappeared. Although magnetic resonance imaging showed the disappearance of the cribriform plate dAVF and subdural hematoma, the patient complained of anosmia after the procedure. Conclusion: Endovascular embolization is an effective treatment option for treating cribriform plate dAVFs. However, anosmia is a possible complication, and endovascular surgeons should take care of this complication, especially in cribriform plate dAVFs supplied with blood bilaterally.

Spontaneous retroclival subdural hematoma is rare among adults. To the best of our knowledge, only six cases have been reported. A 73-year-old man presented with sudden severe headache, diplopia, and dysarthria, with no history of trauma. Head CT revealed a retrociliary hematoma. No obvious causes of bleeding, such as cerebral aneurysms or malformations, were detected. Conservative treatment was provided to the patient. MRI showed an intraventricular hemorrhage and a space between the basilar artery and hematoma three days after onset. The hematoma almost disappeared on day 7. MRI, particularly T2-weighted sagittal MRI, is effective in localizing hematomas and confirming intraventricular hemorrhages.

High mobility group AT-hook 2 (HMGA2) is a non-histone transcriptional regulator protein. Aberrant expression of the HMGA2 gene (HMGA2) and structural rearrangement at the chromosomal region 12q14 with HMGA2 involvement have been reported in several mesenchymal tumors. We analyzed truncated and full-length HMGA2 expression in 55 cases of meningioma, the most common brain tumor of mesenchymal origin. Fluorescence in situ hybridization and 3'-rapid amplification of cDNA ends were used to investigate the possibility of gene rearrangements. Moreover, the relationship between HMGA2 expression and clinicopathological features was assessed. Compared with normal brain tissues, 95% of the meningioma tissues exhibited increased HMGA2 expression. In 14 cases, the expression of truncated HMGA2 was more than two-fold higher than that of paired full-length HMGA2. Chromosomal translocation involving the chromosomal region 12q14 was undetectable. No significant correlation was found between the Ki-67 labeling index and HMGA2 expression and between the HMGA2 expression and the clinicopathological features. The majority of the meningioma cases displayed increased HMGA2 expression, which was not attributed to the chromosomal rearrangement at the corresponding region. Similar to that in the other mesenchymal tumors, increased HMGA2 expression was not associated with tumor cell proliferation in meningiomas.

Background Neuroendovascular therapy is typically performed via the femoral artery, but there are rare cases in which a tortuous upstream angioarchitecture makes it difficult to access the intracranial circulation via this route. Methods In this case series, we describe six cases treated by surgical cut-down in the neck, with puncture of the carotid artery. Antiplatelet and anticoagulation agents were used in all cases. The indications for the technique were postsurgical thoracic aortic aneurysm (two cases), postsurgical abdominal aortic aneurysm (one case), major vessel tortuosity of the common carotid artery (two cases) and aortic arch anomaly (one case). Results The surgical cut-down technique permitted successful neuroendovascular therapy. Although one patient had a small cervical haematoma, he was treated without surgical evacuation. Conclusion Overall, our findings indicate that the surgical cut-down technique is safe and useful for patients in whom the femoral approach is unsuitable.

The Pipeline embolization device (PED), a type of flow diverter, has become an appealing alternative treatment option for large or giant and wide-necked intracranial aneurysms. Carotid cavernous fistula (CCF) resulting from delayed aneurysmal rupture is a rare complication of PED placement with unknown pathophysiology. Here, we describe a case of CCF resulting from aneurysmal rupture following PED placement, and present the details of treatment by transvenous coil embolization. An 81-year-old woman was referred to our hospital for treatment of an 18.0 × 10.3 mm intracranial aneurysm located in the cavernous segment of the left internal carotid artery, noted during an examination of her diplopia. Endovascular treatment was conducted by positioning a single PED (4.75 × 25 mm) across the neck of the aneurysm. The postoperative course was uneventful, and the patient was discharged 8 days post procedure. On post-procedure day 10, her left oculomotor nerve palsy had worsened and she had developed left abducens nerve palsy, left exophthalmos, and left chemosis. Angiography demonstrated left direct CCF because of rupture of the aneurysm that had been treated with PED. Transvenous coil embolization was performed on post-procedure day 11 to treat the CCF, and complete resolution of the CCF and significant thrombus formation within the aneurysm sac were confirmed 11 days after the second procedure. Our angiographic results suggest that the aneurysmal rupture was caused by aneurysmal volume expansion associated with PED-induced thrombosis. Transvenous coil embolization for the treatment of CCF following PED placement constitutes a new challenge.

The results of preoperative embolization for skull base meningiomas were retrospectively evaluated to confirm the efficacy of this procedure. Skull base meningiomas that were treated with preoperative embolization were evaluated in 20 patients. The occluded arteries, embolic materials, treatment time, excision rate, neurologic manifestations, and complications were analyzed. The embolic material was 80% liquid, 30% coils, and 15% particles. The surgery was normally completed within 3 to 5 hours. Blood loss was normally approximately 250 mL, excluding four patients having the following conditions: malignant meningioma, a large tumor located on the medial side of the sphenoidal ridge, the petroclival tumor, and infiltrated tumor into the sigmoid sinus. The mean excision rate was 90%, achieving a Simpson grade III, but 10% were graded as Simpson grade IV. No permanent complications due to the preoperative embolization occurred. No neurologic symptoms occurred after excision. Current cerebral endovascular treatment is sophisticated, and the complication rate has markedly decreased. Although it was impossible to compare directly with or without operative embolization, preoperative embolization should be actively used as part of the treatment for this benign tumor, with better understanding of dangerous anastomosis.

Hyper-responsiveness to clopidogrel abnormally inhibits platelet aggregation and increases hemorrhagic complications. The present study investigated clinical factors related to clopidogrel hyper-responsiveness in neuro-interventional procedures.Two hundred twenty-four patients receiving clopidogrel for coil embolization to treat unruptured cerebral aneurysm or carotid artery stenting to treat carotid artery stenosis at the internal carotid artery origin were retrospectively reviewed for their P2Y12 reactivity unit (PRU) values and clinical characteristics. Hyper-responsiveness to clopidogrel was defined as a PRU of95.The mean PRU was 218.2 ± 77.8. Hyper-responsiveness to clopidogrel was observed in 12 patients (5.4%). Hyper-responsiveness was observed in younger patients, patients with a lower concentration of hemoglobin A1c, and patients with a higher low-density lipoprotein cholesterol (LDL-C) concentration compared with non-hyper-responsive patients (P = 0.01, P 0.01, P 0.01, respectively). On analysis of concomitant drugs, the patients in the hyper-responsive group were less frequently administered calcium channel blockers (CCBs) compared with the non-hyper-responsive group (P = 0.01). No significant differences in the usage of proton pump inhibitors or statins were observed. A LDL-C concentration of120 mg/dL and no usage of CCBs were significant independent predictors of hyper-responsiveness to clopidogrel with a multivariate analysis (OR; 6.16, 95% CI, 1.57-26.64, P = 0.01, OR; 0.09, 95% CI, 0.01-0.82, P = 0.03, respectively).The present study shows that a higher LDL-C concentration and no usage of CCBs are independent predictors of clopidogrel hyper-responsiveness. These results are useful to predict perioperative hemorrhagic complications. Considering dose reduction of clopidogrel or alternative drugs in high risk cases is necessary to prevent perioperative hemorrhagic complications.

Introduction Pleomorphic xanthoastrocytomas (PXA) are rare, typically benign, slow-growing tumors that commonly occur in the cerebral hemispheres. We describe two cases of clinically aggressive PXA with uncommon locations; one was in the tectal plate, and the other had simultaneous multicentric lesions. Patient concerns The both cases presented with severe headache with no significant past medical history. Diagnosis PXA World Health Organization grade II were histopathologically diagnosed from surgically resected specimens, and immunohistochemical and sequence analysis revealed a high Ki-67 proliferative index and BRAF V600E mutation in both the cases. Interventions The first case presented with multicentric lesions and underwent partial resection, whereas the second case presented with a tectal plate tumor that was managed by gross total surgical resection. Strong 5-aminolevulinic acid (5-ALA)-induced fluorescence was observed in both the lesions. Postoperative radiotherapy plus concomitant and adjuvant temozolomide was administered to both the patients. Outcomes Despite completing adjuvant chemo-radiotherapy, both the patients had local tumor recurrence at 2 and 5 months after the operation, respectively. Conclusion The progressive clinical courses in our cases suggest that additional postoperative therapy should be considered during the treatment of PXA with a high Ki67 index, and that temozolomide with radiotherapy, followed by temozolomide maintenance therapy, may not prevent recurrence in such tumors. Importantly, our experience implies that unlike other subtypes of low grade gliomas, 5-ALA fluorescence is useful for intraoperative visualization of PXA.

Background Inflow into an aneurysm sac immediately following flow diverter (FD) treatment is an assumed cause of delayed aneurysmal rupture. The significance of delayed posttreatment residual flow occurring months after FD treatment is unknown. Case Description A 76-year-old woman with a large intracranial aneurysm measuring 23.0 × 18.1 mm in the cavernous segment of the right internal carotid artery was treated with placement of a single FD (Pipeline Embolization Device, Covidien, Irvine, California, USA). Postprocedure digital subtraction angiography (DSA) demonstrated flow stagnation inside the aneurysm dome. The patient was discharged 9 days post procedure without new neurologic deficits. A 6-month follow-up DSA demonstrated delayed posttreatment residual flow into the aneurysm sac. Although she was scheduled for additional FD placement because of concern for aneurysmal rupture, the operation was not conducted due to an interim motor vehicle accident. Oral treatment with aspirin (100 mg/day) and clopidogrel (75 mg/day) was continued during her recovery. DSA performed 12 months post procedure showed that the aneurysm had completely thrombosed. Conclusions Our findings suggest that delayed post-treatment residual flow into an aneurysm may form part of the normal clinical course post FD placement and may not preclude eventual thrombosis of the aneurysm. Larger studies are needed to determine whether more frequent follow-up DSAs after FD placement are necessary and whether all patients exhibiting delayed post-treatment residual flow into an aneurysm require additional FD placement or if watchful waiting is a more suitable course.

A 12-year-old girl presented with a generalized convulsion. She had regularly consulted pediatricians for an adjustment disorder over the course of 2 years and had experienced a transient episode of unconsciousness without convulsion 5 months earlier. A mental status examination revealed depressed affect, but general physical and neurological examinations were unremarkable. Computerized tomography scans showed a cystic lesion with calcifications in the left temporal lobe (Fig. 1a). A 3.2 9 2.2 cm solid tumor nodule with a unilocular cyst involving the left middle temporal gyrus was detected by magnetic resonance imaging (MRI). The solid tumor nodule was heterogeneously hyperintense on T2-weighted, T1-weighted, and FLAIR images and isointense on diffusion-weighted images with a heterogeneous contrast enhancement (Fig. 1b– d). The patient underwent surgery because of poor seizure control with anticonvulsant drugs, and the nodule was totally resected. The thickened cyst wall was partially removed to preserve the essential language center of the brain. Intraoperative findings demonstrated a gray-pink, soft tumor nodule with a visually indistinct tumor border and yellowish cyst wall. The patient was immediately seizure free, and the mental disorders showed improvement after surgery. MRI at the 6-month postoperative follow-up demonstrated no evidence of tumor recurrence despite receiving no further therapy. Microscopically, the neoplasm was predominantly composed of packed oval or round cells with small nuclei (Fig. 2a–b). Neither mitosis nor significant nuclear atypia were identified in the predominant tumor cells. The tumor border included neurons with prominent nuclei and nucleoli and ample cytoplasm which were relatively well ordered without particular dysmorphism, suggesting entrapped pre-existing elements. The tumor lesion included increased capillaries with nuclear atypia on the endothelial cells, and the surrounding tumor cells demonstrated capillary-like tubule formation (Fig. 2c–d). These findings suggested the possibility of tumor cells converting into tumoral endothelial cells. Scattered calcifications were noted predominantly in the peritumoral region. Necrotic foci were absent. Tumor cells did not extend into the subarachnoid space. Silver staining confirmed the absence of reticulin fibers among the individual tumor cells (Fig. 2e). The tumor was devoid of Rosenthal fibers, eosinophilic granular bodies, and a biphasic compact/microcystic pattern as well as cellular polymorphism and xanthomatous changes, which are the characteristics of pilocytic astrocytoma and pleomorphic xanthoastrocytoma (PXA), respectively. Immunohistochemistry revealed intense immunopositivity for S100, Olig2, MGMT, vimentin, CD34 and nestin on the tumor cells (Fig. 2f–i). The tumor cells showed focally positive for p53, but showed negative for epithelial membrane antigen, asmooth muscle actin, neurofilament, neuronal nuclear antigen, glial fibrillary acidic protein (GFAP), and mutant IDH1 staining (Fig. 2j). Immunostaining with nestin confirmed that the tumor cells infrequently contain cytoplasmic process. The MIB-1 labeling index was 1.1 %. The relatively distinct border between the tumor region and & Masaya Nagaishi nagaishi-nsu@umin.ac.jp

Multinodular and vacuolating neuronal tumors (MVNT) have been recently referred to as a distinctive neuronal tumor entity based on histopathological findings. They are characterized by multiple tumor nodules, vacuolar alteration and widespread immunolabeling for human neuronal protein HuC/HuD. Only 13 cases have been reported in the literature to date and little is known about the histopathology of these tumors. Herein, we report a case of MVNT with additional confirmation of immunohistochemical features. A 22-year-old woman presented with a continuous headache. MRI showed a subcortical white matter lesion with multiple satellite nodules in the frontal lobe appearing as T2/fluid-attenuated inversion recovery (FLAIR) hyperintensities. Histological examination of the resected lesion revealed well-defined multiple nodules composed of predominant vacuolating tumor cells. The tumor cells exhibited consistent immunolabeling for doublecortin, as well as HuC/HuD, both representative neuronal biomarkers associated with earlier stages of neuronal development. Immunopositivity for oligodendrocyte transcription factor 2 (Olig2) and S100 was also detected in tumor cells. Additionally, significant overexpression of alpha-internexin was observed in the background neuropil limited to tumor nodules. Neuronal nuclear antigen (NeuN), synaptophysin and neurofilament, markers for mature neurons, were either negative or weakly positive. The expression profile of neuronal biomarkers can be distinguished from that of classic neuronal tumors and is the immunohistochemical hallmark of MVNT. In summary, we identified the characteristic tumoral expression of HuC/HuD and doublecortin and the presence of abundant neuropil localized in MVNT tumor nodules, which exhibited widespread alpha-internexin expression. These results supported the presumption that MVNT is a distinct histopathological entity.

OBJECTIVEThe authors sought to demonstrate that hemorrhagic transformation of ischemic lesions is the main cause of delayed intracerebral hemorrhage (ICH) after Pipeline embolization device (PED) treatment and to estimate the rate of hemorrhagic transformation of new postprocedure ischemic lesions.METHODSPatients who underwent PED placement (PED group) from November 2015 to March 2017 or stent-mediated embolization (EN group) from December 2010 to October 2015 were retrospectively analyzed. Pre- and postprocedural MR images and 6-month follow-up MR images for each patient were scored for the presence of postprocedural bland ischemic and hemorrhagic lesions using diffusion-weighted MRI (DWI) and T2*-weighted MRI (T2*WI), respectively.RESULTSThe PED group comprised 28 patients with 30 intracranial aneurysms, and the EN group comprised 24 patients with 27 intracranial aneurysms. The mean number of ischemic lesions on DWI 1 day postprocedure was higher in the PED group than in the EN group (5.2 vs 2.7, p = 0.0010). The mean number of microbleeds detected on T2*WI 6 months postprocedure was higher in the PED group than in the EN group (0.6 vs 0.15, p = 0.028). A total of 36.7% of PED-treated patients exhibited new microbleeds on T2*WI at 6 months postprocedure, with at least 77.8% of these lesions representing hemorrhagic transformations of the new ischemic lesions observed on day 1 postprocedure. The rate of adjunctive coil embolization (27.3% vs 0.0%, p = 0.016) and the mean number of ischemic lesions observed 1 day postprocedure (6.6 vs 4.3, p = 0.020) were predictors of subsequent microbleeds in the PED group.CONCLUSIONSNew microbleeds detected using T2*WI at 6 months postprocedure were more common after PED treatment than after stent-mediated embolization. Approximately three-quarters of these lesions were hemorrhagic transformations of new ischemic lesions observed on day 1 postprocedure. Prevention of intraprocedural or postprocedural infarcts is necessary to reduce the risk of hemorrhagic complications following PED placement.

Background N-butyl 2-cyanoacrylate (NBCA) remains the standard embolic agent for spinal dural arteriovenous fistula (SDAVF) treatment. Treatment of SDAVF with ethylene-vinyl alcohol copolymer (Onyx, ev3-Covidien, Irvine CA, USA) is currently not well established. Although several cases have reported the use of Onyx to embolize an intracranial dural arteriovenous fistula using a dual-lumen microballoon catheter, Onyx embolization of an SDAVF using a dual-lumen microballoon catheter has not been reported. Case description We treated a 57-year-old man with an SDAVF using a dual-lumen microballoon catheter and buddy wire technique to perform transarterial Onyx embolization via the left sixth intercostal artery. Conclusions Onyx embolization using a dual-lumen microballoon catheter was effective. Furthermore, the buddy wire technique was useful for providing rigid support of the microcatheter in a narrow and tortuous intercostal artery.

Diagnosis of low-grade diffuse gliomas based on morphology is highly subjective and, therefore, is often difficult, with significant intra- and interobserver variability. Here, we investigated WHO grade II diffuse astrocytomas, oligoastrocytomas and oligodendrogliomas for immunohistochemical expression of Olig2, measuring its labeling index (LI), and evaluated the significance of Olig2 LI in the histological and molecular classifications. The means of Olig2 LI in glioma cells were 43.7 % in diffuse astrocytomas, 59.3 % in oligoastrocytomas and 76.1 % in oligodendrogliomas. There was a statistically significant difference between all pairs of histological types. The mean of Olig2 LI of gliomas with 1p/19q loss ± IDH1/2 mutation, the majority of them being oligodendrogliomas, was significantly higher than the means of those with TP53 mutation ± IDH1/2 mutation and IDH1/2 mutation only, the majority of which were diffuse astrocytomas (70.1 vs. 47.2 and 46.5 %, respectively). When categorized according to the classification of Jiao et al., Olig2 LI of I-CF gliomas (cases with IDH and one or more of CIC, FUBP1 or combined 1p/19q loss; mean 71.0 %) was significantly higher than that of I-A gliomas (cases with IDH and ATRX alterations; mean 45.3 %). These molecular classifications were reported to correlate well with clinical outcome. However, borderlines of Olig2 LI were broad and could not clearly distinguish genotypes in the molecular classifications. In conclusion, Olig2 LI cannot be taken as a complete surrogate marker for molecular genotype, but could possibly provide some ancillary information when molecular assay is not availabe.

Epithelioid glioblastoma is among the rarest variants of glioblastoma and is not formally recognized in the World Health Organization classification; it is composed of monotonous, discohesive sheets of small, round cells with eccentric nuclei and eosinophilic cytoplasm devoid of cytoplasmic stellate processes, showing the retention of nuclear staining of INI-1 protein. Here, we report a case involving a 22-year-old man with a right occipital lobe tumor, which comprised mainly epithelioid tumor cells with a small area of diffusely infiltrating less atypical astrocytoma cells showing a lower cell density. Array comparative genomic hybridization separately performed for each histologically distinct component demonstrated eight shared copy number alterations (CNAs) and three CNAs observed only in epithelioid cells; one of the latter was a homozygous deletion of a tumor suppressor gene, LSAMP, at 3q13.31. BRAF V600E mutation was observed both in epithelioid tumor cells and in diffusely infiltrating less atypical astrocytoma cells. Our findings suggest that the regional loss of LSAMP led to the aggressive nature of epithelioid cells in the present case of epithelioid glioblastoma.

Rationale:Endodermal cysts are rare benign lesions in the central nervous system. Their common symptoms include headache and neck pain caused by mass effect or inflammatory reaction. We report the case of an elderly woman with intracranial endodermal cyst who presented with nonobstructive hy

Anaplastic ependymoma, World Health Organization grade III, is a malignant glioma with ependymal differentiation characterized by high mitotic activity often accompanied by microvascular proliferation and necrosis, where, generally, much fewer ependymal rosettes are found than in ependymoma, World Health Organization grade II. Ependymal rosettes, forming a single layer of tumor cells, differ from ependymoblastic multilayered rosettes, which are characteristic histologic features of ependymoblastoma, a variant of central nervous system primitive neuroectodermal tumor. Here, we report an autopsy case involving a 24-year-old woman with a frontal lobe tumor, which showed the aggregation of true rosettes with multilayering of tumor cells resembling the ependymoblastoma histology. Molecular and cytogenetic analyses revealed the absence of 19q13.42 amplification, a specific molecular hallmark of ependymoblastoma and embryonal tumor with abundant neuropil and true rosettes, supporting the diagnosis of anaplastic ependymoma.

In recent years, Surabaya has confronted municipal solid waste (MSW) with a partnership with Kitakyushu city for the use of the Takakura Home Composting (THC) method. A large number of Takakura bins have been distributed to households and cadres have been involved in educating local households about organic waste reduction through the method. In the past decade (2005–2013), the city has reduced organic waste through many diverse composting methods such as THC and about 3421 Mt of CO 2 equivalent emissions could be reduced annually. By adapting the THC method, Surabaya has made positive changes to its MSW management practices. This kind of city-to-city technological cooperation has facilitated larger processes in other cities in Indonesia and elsewhere. This article discusses the lessons learned pertaining to the adaptation of the THC method in Surabaya to understand how city-to-city cooperation can work to boost climate co-benefits in urban areas, particularly in the waste sector.

Various degrees of peritumoral brain edema (PTBE) are observed in patients with intracranial meningiomas. Factors affecting the occurrence of PTBE in intracranial meningioma were investigated. PTBE was investigated retrospectively for 110 patients with primary intracranial meningiomas. Predictive factors related to PTBE were analyzed, for example patient age, sex, magnetic resonance imaging features (contrast enhancement, tumor shape, tumor location, tumor volume), angiographical features (tumor stain, pial-cortical arterial supply, venous obstruction), and histopathological features (histological subtypes, mindbomb homolog 1 labeling index (MIB1-LI)). Histological subtypes were classified into World Health Organization (WHO) grade I common type (meningothelial, transitional, fibrous), grade I uncommon type, and grade II and III types. The extent of PTBE was assessed by calculation of the edema index (EI). PTBE was present in 53 cases (48 %). Male sex, heterogeneous enhancement, superficial location, tumor volume (≥10 cm(3)), remarkable tumor stain, pial supply, venous obstruction, malignant pathology, and MIB1-LI ≥4 % were correlated with PTBE in univariate analysis. Pial supply and remarkable tumor stain were correlated with PTBE in multivariate analysis. WHO grade I uncommon type had obviously higher EI than WHO grade I common type, and WHO grade II and III types (P 0.001). Seven cases with prominently high EI (EI ≥10) were all WHO grade I uncommon type, including angiomatous, microcystic, secretory, and lymphoplasmacyte-rich meningioma. Prominently extensive PTBE might indicate the presence of WHO grade I uncommon type meningioma.

Gliosarcoma is a rare variant of glioblastoma characterized by a biphasic pattern of glial and mesenchymal differentiation. It is unclear whether mesenchymal differentiation in gliosarcomas is because of extensive genomic instability and/or to a mechanism similar to epithelial-mesenchymal transition (EMT). In the present study, we assessed 40 gliosarcomas for immunoreactivity of Slug, Twist, matrix metalloproteinase-2 (MMP-2) and matrix metalloproteinase-9 (MMP-9), which are involved in EMT in epithelial tumors. Nuclear Slug expression was observed in >50% of neoplastic cells in mesenchymal tumor areas of 33 (83%) gliosarcomas, but not in glial areas (P 50% of neoplastic cells in mesenchymal tumor areas of 35 (88%) gliosarcomas, but glial tumor areas were largely negative except in four cases (P 10% neoplastic cells. Thus, expression of Slug, Twist, MMP-2 and MMP-9 was characteristic of mesenchymal tumor areas of gliosarcomas, suggesting that mechanisms involved in the EMT in epithelial neoplasms may play roles in mesenchymal differentiation in gliosarcomas.

The characteristics of intracerebral hemorrhage (ICH) accompanying chronic liver disease (CLD) were investigated in ICH patients hospitalized between 1998 and 2008 divided into the CLD group (55 ICHs in 49 patients) and the idiopathic group without CLD (668 ICHs in 648 patients). The CLD group included a subgroup with liver cirrhosis (LC). Age, sex, history of hypertension, Glasgow Coma Scale (GCS) score on admission, and hematoma locations were reviewed. Outcomes on discharge and causes of in-hospital death were also studied. Factors associated with life prognosis in CLD patients were investigated using uni- and multivariate analyses. History of hypertension and deep cerebral hemorrhage were less frequent in the LC subgroup compared to the idiopathic group. Distributions of GCS scores on admission were not significantly different, but incidence of in-hospital death was significantly higher in the CLD group than in the idiopathic group. LC was an independent prognostic factor for CLD patients, but hematoma enlargement was not. Death primarily due to ICH was less frequent in the CLD group than in the idiopathic group. In conclusion, hemostatic disorders seemed to be related to site of hemorrhage, but not to life prognosis in the CLD group. Prognosis was mainly worsened by non-neurological complications.

Pilomyxoid astrocytoma (PMA) is a newly identified variant of pilocytic astrocytoma (PA). We report three cases of PMA with comparison to seven cases of PA in terms of their clinicopathological features. The three cases occurred at the ages of 2, 36 and 6 years, and their tumors were located in the left basal ganglia, the pineal gland, and the cerebellum, respectively. They were diagnosed PMA by surgical specimens that showed a characteristic monomorphous architecture with an angiocentric growth pattern and myxoid background. One patient developed localized relapse at 6 months after the surgery, but the other patients remained alive without tumor progression more than 5 years after treatment. In analysis of the immunohistochemical association in PMA and PA, no specific staining was found to be useful for differential diagnosis of PMA from PA. The expression of biomarkers including O-6-methylguanine-DNA methyltransferase, p53, MIB-1, and EGF receptor neither distinguished PMA from PA nor correlated with outcome. But almost all PMA and PA that demonstrated prominent positivity for nestin showed a high MIB-1 labelling index (LI), and four of these five patients suffered a relapse in the early phase. These results suggest that immunohistochemical expression of nestin and MIB-1 LI may correlate with the aggressiveness of the tumor in PA and PMA.

Medulloblastoma (MB) is the most common malignant brain tumor in children. It is known that overexpression and/or amplification of the MYC oncogene is associated with poor clinical outcome, but the molecular mechanisms and the MYC downstream effectors in MB remain still elusive. Besides contributing to elucidate how progression of MB takes place, most importantly, the identification of novel MYC-target genes will suggest novel candidates for targeted therapy in MB. A group of 209 MYC-responsive genes was obtained from a complementary DNA microarray analysis of a MB-derived cell line, following MYC overexpression and silencing. Among the MYC-responsive genes, we identified the members of the bone morphogenetic protein (BMP) signaling pathway, which have a crucial role during the development of the cerebellum. In particular, the gene BMP7 was identified as a direct target of MYC. A positive correlation between MYC and BMP7 expression was documented by analyzing two distinct sets of primary MB samples. Functional studies in vitro using a small-molecule inhibitor of the BMP/SMAD signaling pathway reproduced the effect of the small interfering RNA-mediated silencing of BMP7. Both approaches led to a block of proliferation in a panel of MB cells and to inhibition of SMAD phosphorylation. Altogether, our findings indicate that high MYC levels drive BMP7 overexpression, promoting cell survival in MB cells. This observation suggests the potential relevance of targeting the BMP/SMAD pathway as a novel therapeutic approach for the treatment of childhood MB.

Multiple system atrophy (MSA) is a sporadic neurodegenerative disease that is pathologically characterized by the filamentous aggregation of α-synuclein. We report a case of MSA showing unusual neuropathological findings and review six autopsied cases of MSA. The patient progressively developed parkinsonism and ataxia for the 9 years prior to her death at the age of 72 years. Neuropathological examinations revealed neuronal loss restricted to the olivopontocerebellar and striatonigral region, which was more severe in the putamen. Staining with anti-α-synuclein antibody demonstrated widespread occurrence of glial cytoplasmic inclusions, which mainly accumulated in oligodendroglial cells and corresponded closely to the degree of disease progression. In addition, tau-positive granules were detected within the glial cytoplasm in the neurodegenerative region, which was especially prominent in the putamen and internal capsule. Tau accumulation was also clearly recognized by staining with specific antibodies against three-repeat or four-repeat tau. The glia that demonstrated deposition of tau-positive granules were distinguished from α-synuclein-positive oligodendroglia by double immunohistochemical staining. These characteristic glial accumulations of tau were also present in all six cases of MSA. These results indicate that tau-positive granules in glia are common findings in MSA and that tau aggregation might be another pathway to neurodegeneration in MSA.

An 11-year-old boy presented with pineal pure germinoma with spinal dissemination manifesting as a 1-month history of ocular motility disturbance and a history of abnormal sensations in the left leg persisting for several months. His past medical history was unremarkable. Craniospinal magnetic resonance imaging showed an enhanced tumor in the pineal gland and widespread leptomeningeal dissemination in the spinal canal. Biopsy of the pineal tumor was performed. Histological examination revealed a pure germinoma. Chemotherapy with carboplatin and etoposide in combination with radiotherapy induced complete remission of the tumors. He regained normal eye movement and sensation in his left leg during the chemotherapy period. Germinomas with dissemination are generally more malignant and refractory than solitary germinomas, but this patient showed a strong response to chemoradiotherapy.