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Retropharyngeal cellulitis/abscesses are deep neck infections that may become life-threatening if airway compromise occurs. This condition is more common in children than in adults, and associated intracranial vessel narrowing has been reported. We report an adult patient with extensive retropharyngeal cellulitis and intracranial vasospasm. The patient was a 62-year-old woman who presented with fever, sore throat, and neck pain. She also had uncontrolled type 2 diabetes mellitus. Leukocytosis, prolonged erythrocyte sedimentation rate, elevated C-reactive protein, and hyperglycemia were present on admission. Computed tomography and contrast-enhanced magnetic resonance imaging revealed severe swelling in the nasopharyngeal, retropharyngeal, prevertebral, and bilateral carotid spaces. Gadolinium enhancement extended to the middle cranial fossa and visceral space. Multiple stenoses in several intracranial vessels was also identified. Intravenous antibiotic therapy was initiated, the patient's symptoms resolved, and repeat imaging confirmed improvement. Intracranial vasospasm should be considered in patients with retropharyngeal cellulitis.

Intravenous lipoma of the inferior vena cava is an incidental finding on contrast-enhanced computed tomography in 0.5% of individuals. We report a case of multiple intravenous lipomas discovered during diagnosis of cholangitis in a 39-year-old woman. Imaging revealed three fatty masses that appeared connected by cordlike structures: one in the left renal vein with wide mural attachment and two in the inferior vena cava, the higher of which was mobile. We hypothesize that these originated as a single lipoma that subsequently divided into three distinct masses. Because mobile masses may cause pulmonary thromboembolism, surgery is recommended in these cases.

PurposePulmonary hypertension (PH) is a severe vascular disorder that may affect 50% of patients with heart failure. Currently, right-sided heart catheterization is required to definitively diagnose PH. However, this method is invasive and thus may not be appropriate for repeated, long-term monitoring of PH patients. This retrospective study’s aim was to evaluate whether 4D flow magnetic resonance imaging (MRI) can be used to quantitively measure flow parameters to identify patients with PH. MethodsThe study cohort included 97 patients recruited from a single institution and divided into three groups based on echocardiographic estimate of pulmonary artery systolic pressure (PASP): normal group with PASP50mmHg. 4D flow MRI was used to quantitively assess blood flow and velocity, regurgitation, wall shear stress (WSS) and kinetic energy in the pulmonary artery trunk, right main pulmonary artery, and left pulmonary artery. Two experienced radiologists independently analyzed the MR images, blinded to clinical details. ResultsWe found a significant difference in WSS in the pulmonary artery trunk, right main pulmonary artery and left main pulmonary artery among the three patient groups. We also found significant differences in the kinetic energy and average through velocity in the pulmonary artery trunk and right main pulmonary artery, and significant differences in the flow rate in the right main pulmonary artery. ConclusionsThese data suggest that 4D flow MRI can quantitate pulmonary artery flow parameters and distinguish between patients with and without PH.

Purpose: Identifying plaque components such as intraplaque hemorrhage, lipid rich necrosis, and calcification is important to evaluate vulnerability of carotid atherosclerotic plaque; however, conventional vessel wall MR imaging may fail to discriminate plaque components. We aimed to evaluate the components of plaques using quantitative susceptibility mapping (QSM), a newly developed post-processing technique to provide voxel-based quantitative susceptibilities. Methods: Seven patients scheduled for carotid endarterectomy were enrolled. Magnitude and phase images of five-echo 3D fast low angle shot (FLASH) were obtained using a 3T MRI, and QSM was calculated from the phase images. Conventional carotid vessel wall images (black-blood T1-weighted images [T1WI], T2-weighted images [T2WI], proton-density weighted images [PDWI], and time-of-flight images [TOF]) were also obtained. Pathological findings including intraplaque hemorrhage, calcification, and lipid rich necrosis at the thickest plaque section were correlated with relative susceptibility values with respect to the sternocleidomastoid muscle on QSM. On conventional vessel wall images, the contrast–noise ratio (CNR) between the three components and sternocleidomastoid muscle was measured respectively. Wilcoxon signed-rank test analyses were performed to assess the relative susceptibility values and CNR. Results: Pathologically, lipid rich necrosis was proved in all of seven cases, and intraplaque hemorrhage in five of seven cases. Mean relative susceptibility value of hemorrhage was higher than lipid rich necrosis unexceptionally (P = 0.0313). There were no significant differences between CNR of hemorrhage and lipid rich necrosis on all sequences. In all six cases with plaque calcification, susceptibility value of calcification was significantly lower than lipid rich necrosis unexceptionally (P = 0.0156). There were significant differences between CNRs of lipid rich necrosis and calcification on T1WI, PDWI, TOF (P < 0.05). Conclusion: QSM of carotid plaque would provide a novel quantitative MRI contrast that enables reliable differentiation among intraplaque hemorrhage, lipid rich necrosis, and calcification, and be useful to identify vulnerable plaques.

Purpose: We aimed to investigate the clinical significance of the low signal in the intracranial vertebral artery wall observed on susceptibility-weighted angiography. Materials and Methods: We retrospectively reviewed susceptibility-weighted angiographies from 200 consecutive patients with acute ischemic stroke in the posterior circulation territory. The presence of eccentric or concentric low signals in the vertebral artery wall was examined and evaluated. The etiology of the low signal was also investigated as much as possible by referring to computed tomography and T1-weighted imaging (T1WI). We also compared its frequency in each stroke subtype. Results: A low signal was observed in 128/200 patients (64%). The low signals (58%) corresponded to vessel wall calcification in 74 of 128 patients and to vessel wall thickening showing intermediate to low (n = 8) or high (n = 16) signals on T1WI in 24 (19%) patients. The low signal did not have vessel wall thickening or calcification in 1 patient, and the cause of the low signal could not be verified in 29 patients. According to stroke subtypes, a low signal was observed in 14/14 (100%) vertebral artery dissections, all of which corresponded to intramural hematoma. A low signal was observed in 51/65 (78%) atherothromboses, which were significantly more frequent than cardioembolism (34/66; 52%) and small-artery disease (18/39; 46%) (p < 0.01). In atherothrombosis, calcification was the most common cause of low signal (n = 32; 63%). Conclusion: Low signals on susceptibility-weighted angiography were frequently observed in vertebral artery dissection and atherothrombosis, reflecting intramural hematoma in all of the former and predominantly calcification in the latter.

Background Diagnosis of hemangioblastoma by magnetic resonance imaging (MRI) can sometimes be difficult when the tumor is a solid mass in the posterior fossa. We therefore evaluated perfusion images and diffusion-weighted images as brain function images to diagnose hemangioblastoma in order to obtain the most useful quantitative features. Methods Forty-five posterior fossa tumors whose pathological diagnosis was confirmed by surgery were included in groups A (18 hemangioblastomas) and B (non-hemangioblastoma 27 cases: metastatic brain tumor 8 cases, pilocytic astrocytoma 6 cases, and other 13 cases). All cases were imaged by 3.0-Tesla MRI, with arterial spin labeling (ASL) as the relative value from the CBF map to the region of interest (ROI) in the contralateral hemisphere as perfusion image. Among 45 cases, 27 cases were evaluated with both ASL and dynamic susceptibility contrast (DSC) as rCBF, rCBV, corrected CBV, and K2. The ROI was set to match the contrast-enhanced part, and the two groups were compared and examined. Results The relative ASL value of group A and the corrected CBV in DSC were significantly higher than group B (p < 0.001). In contrast, the ADC showed no marked difference between the two groups. In the distinction between the two groups, the receiver operating characteristic (ROC) analysis showed that the area under the curve (AUC) of the relative ASL value was significantly higher than the other parameters (AUC 0.995, cut-off value 2.34, sensitivity 100%, specificity 99.5%). Conclusions The non-contrast ASL method was extremely useful for diagnosing hemangioblastoma in posterior fossa tumors. Non contrast ASL can be used instead of contrast-enhanced DSC in diagnosing posterior fossa hemangioblastoma.

BACKGROUND Aggressive fibromatosis is a rare histologically benign but locally infiltrative myofibroblastic tumor. Primary intracranial aggressive fibromatosis (IAF) can exhibit a clinically malignant course. OBSERVATIONS A 22-year-old otherwise healthy woman presented with left painful ophthalmoplegia. Magnetic resonance imaging (MRI) revealed a left sellar tumor with cavernous sinus invasion. Endoscopic transsphenoidal surgery was performed. The lesion could not be totally resected. An inflammatory myofibroblastic tumor was suspected, so steroid pulse therapy was introduced, but it was ineffective. The tumor recurred after a few months, and she complained of visual acuity loss, abducens nerve palsy, trigeminal neuralgia, and panhypopituitarism. The lesion was diagnosed as primary IAF by a pathological review. Gamma Knife radiosurgery was performed, and chemotherapies were introduced but ineffective. Her consciousness was disturbed, and MRI showed hypothalamic invasion of the tumor, occlusion and stenosis of carotid arteries, and cerebral stroke. Palliative care was introduced, and she died 32 months after the onset. The autopsy revealed tumor invasion to the cavernous sinus, optic nerve, hypothalamus, pituitary, and tonsillar herniation due to massive cerebral stroke. LESSONS Radical resection can be impossible in patients with IAF. Radiotherapy and chemotherapy are not always effective for residual lesions. Adjuvant therapy for IAF remains to be explored.

The genetic causes of combined pituitary hormone deficiency remain elusive in most patients. Recently, incompletely penetrant heterozygous mutations in ROBO1 have been described in patients with pituitary stalk interruption syndrome. Herein, we identified a novel homozygous slice site mutation in ROBO1(c.1342+1G>A) using a trio whole-exome sequencing strategy in a 5-year-old Japanese boy who had combined pituitary hormone deficiency, psychomotor developmental delay, severe intellectual disability,sensorineural hearing loss, strabismus, and characteristic facial features, including a broad forehead, micrognathia, and arched eyebrows. Magnetic resonance imaging delineated anterior pituitary hypoplasia, ectopic posterior pituitary, invisible pituitary stalk, thinning of the corpus callosum, and hypoplasia of the pons and midbrain. The phenotypically normal parents (first cousins) were heterozygous for the mutation. The results provide further evidence of ROBO1 being involved in the development of the pituitary gland.A recessive mutation of ROBO1 is a potential novel cause of a syndromic disorder associated with combined pituitary hormone deficiency., Journal of Human Genetics, 64, pp.341?346; 2019

Background and Objectives: Determining the occlusion site and collateral blood flow is important in acute ischemic stroke. The purpose of the current study was to test whether arterial spin labeling (ASL) magnetic resonance imaging (MRI) could be used to identify the occlusion site and collateral perfusion, using digital subtraction angiography (DSA) as a gold standard. Method: Data from 521 consecutive patients who presented with acute ischemic stroke at our institution from January 2012 to September 2014 were retrospectively reviewed. Image data were included in this study if: (1) the patient presented symptoms of acute ischemic stroke; (2) MRI was performed within 24 h of symptom onset; and (3) DSA following MRI was performed (n = 32 patients). We defined proximal intra-arterial sign (IAS) on ASL as enlarged circular or linear bright hyperintense signal within the occluded artery and distal IAS as enlarged circular or linear bright hyperintense signals within arteries inside or surrounding the affected region. The presence or absence of the proximal IAS and distal IAS were assessed, along with their inter-rater agreement and consistency with the presence of occlusion site and collateral flow on DSA images. Results: The sensitivity and specificity for identifying occlusion site with ASL were 82.8 and 100%, respectively. Those for identifying collateral flow with ASL were 96.7 and 50%, respectively. The inter-rater reliability was excellent for proximal IAS (κ = 0.92; 95% CI 0.76–1.00) and substantial for distal IAS detection (κ = 0.78; 95% CI 0.38–1.00). Conclusions: Proximal IAS and distal IAS on ASL imaging can provide important diagnostic clues for the detection of arterial occlusion sites and collateral perfusion in patients with acute ischemic stroke.

Vestibular schwannomas are the most common tumor at the common cerebellopontine angle, followed by meningiomas. Differentiation of these tumors is critical because of the different surgical approaches required for treatment. Recent studies have demonstrated the utility of amide proton transfer (APT)-chemical exchange saturation transfer (CEST) imaging in evaluating malignant brain tumors. However, APT imaging has not been applied in benign tumors. Here, we explored the potential of APT in differentiating between schwannomas and meningiomas at the cerebellopontine angle. We retrospectively evaluated nine patients with schwannoma and nine patients with meningioma who underwent APT-CEST MRI from November 2020 to April 2022 pre-operation. All 18 tumors were histologically diagnosed. There was a significant difference in magnetization transfer ratio asymmetry (MTRasym) values (0.033 ± 0.012 vs. 0.021 ± 0.004; p = 0.007) between the schwannoma and meningioma groups. Receiver operative curve analysis showed that MTRasym values clearly differentiated between the schwannoma and meningioma groups. At an MTRasym value threshold of 0.024, the diagnostic sensitivity, specificity, positive predictive value, and negative predictive values for MTRasym were 88.9%, 77.8%, 80.0%, and 87.5%, respectively. Our results demonstrated the ability of MTRasym values on APT-CEST imaging to discriminate patients with schwannomas from patients with meningiomas., International journal of molecular sciences, 23(17), art. no. 10187; 2022

Purpose: It is sometimes challenging to diagnose hemangioblastoma by MRI when the tumor is a solid mass in the posterior fossa. We therefore evaluated perfusion images and diffusion-weighted images to diagnose hemangioblastoma in order to obtain the most useful quantitative features. Methods: Thirty-one posterior fossa tumors whose pathological diagnosis was confirmed by surgery were included in groups A (12 hemangioblastomas) and B (non-hemangioblastoma 19 cases: metastatic tumor 6 cases, pilocytic astrocytoma 3 cases, malignant lymphoma 3 cases, glioblastoma 2 cases, medulloblastoma 2 cases, and other 3 cases). All cases were imaged by 3.0-Tesla MRI, with the apparent diffusion coefficient (ADC) on diffusion-weighted imaging as the parameter, arterial spin labeling (ASL) as the relative value from the CBF map to the region of interest (ROI) in the contralateral hemisphere as perfusion image, dynamic susceptibility contrast (DSC) as rCBF, rCBV, corrected CBV, and K2. The ROI was set to match the contrast-enhanced part, and the two groups were compared and examined. Results: The relative ASL value of group A and the corrected CBV in DSC were significantly higher than group B (p

BACKGROUND Pituitary apoplexy associated with aneurysmal rupture is extremely rare and may be misdiagnosed as primary pituitary adenoma apoplexy. The authors present a case of a patient with pituitary apoplexy caused by rupture of an anterior cerebral artery aneurysm embedded within a giant pituitary adenoma, and they review the relevant literature. OBSERVATIONS A 78-year-old man experienced sudden headache with progressive vision loss. Magnetic resonance imaging (MRI) revealed a giant pituitary tumor with abnormal signal intensity. Magnetic resonance angiography immediately before surgery showed a right A1 segment aneurysm, suggesting coexisting pituitary apoplexy and ruptured aneurysm. The patient underwent urgent transsphenoidal surgery for pituitary apoplexy. The tumor was partially removed, but the perianeurysmal component was left behind. Subsequent cerebral angiography showed a 5-mm right A1 aneurysm with a bleb that was successfully embolized with coils. Retrospective review of preoperative dynamic MRI showed extravasation of contrast medium from the ruptured aneurysm into the pituitary adenoma. Histopathologic examination showed gonadotroph adenoma with hemorrhagic necrosis. Postoperatively, the patient’s visual function improved. LESSONS MRI identification of pituitary apoplexy caused by aneurysmal rupture has not been reported previously. Aneurysmal rupture should be considered in the differential diagnosis of pituitary apoplexy. When a ruptured aneurysm is encountered, the authors recommend treating it before addressing pituitary apoplexy.

This study examined whether using an artificial neural network (ANN) helps beginners in diagnostic cardiac imaging to achieve similar results to experts when interpreting stress myocardial perfusion imaging (MPI). One hundred and thirty-eight patients underwent stress MPI with Tc-labeled agents. An expert and a beginner interpreted stress/rest MPI with or without the ANN and the results were compared. The myocardium was divided into 5 regions (the apex; septum; anterior; lateral, and inferior regions), and the defect score of myocardial blood flow was evaluated from 0 to 4, and SSS, SRS, and SDS were calculated. The ANN effect, defined as the difference in each of these scores between with and without the ANN, was calculated to investigate the influence of ANN on the interpreters' performance. We classified 2 groups (insignificant perfusion group and significant perfusion group) and compared them. In the same way, classified 2 groups (insignificant ischemia group and significant ischemia group) and compared them. Besides, we classified 2 groups (normal vessels group and multi-vessels group) and compared them. The ANN effect was smaller for the expert than for the beginner. Besides, the ANN effect for insignificant perfusion group, insignificant ischemia group and multi-vessels group were smaller for the expert than for the beginner. On the other hand, the ANN effect for significant perfusion group, significant ischemia group and normal vessels group were no significant. When interpreting MPI, beginners may achieve similar results to experts by using an ANN. Thus, interpreting MPI with ANN may be useful for beginners. Furthermore, when beginners interpret insignificant perfusion group, insignificant ischemia group and multi-vessel group, beginners may achieve similar results to experts by using an ANN.

A male patient underwent conventional transcatheter chemoembolization for advanced recurrent hepatocellular carcinoma (HCC). Even after the injection of 7 mL of lipiodol followed by gelatin sponge particles, the flow of feeding arteries did not slow down. A repeat angiography revealed a newly developed vascular lake draining into systemic veins; however, embolization was continued without taking noticing of the vascular lake. The patient's level of consciousness deteriorated immediately after the procedure, and non-contrast computed tomography revealed pulmonary and cerebral lipiodol embolisms. The patient's level of consciousness gradually improved after 8 wk in intensive care. In this case, a vascular lake emerged during chemoembolization and drained into systemic veins, offering a pathway carrying lipiodol to pulmonary vessels, the most likely cause of this serious complication. We should be aware that vascular lakes in HCC may drain into systemic veins and can cause intratumoral arteriovenous shunts.

A dural arteriovenous fistula (DAVF) with spinal perimedullary venous drainage can cause progressive myelopathy, and it is sometimes incorrectly diagnosed as another spinal cord disease. Here we report the cases of three individuals with a DAVF (one craniocervical junction DAVF and two tentorial DAVFs) with progressive myelopathy showing unique magnetic resonance (MR) imaging findings. MR T2*WI or susceptibility-weighted imaging (SWI) demonstrated symmetrical dark signal intensity lesions predominantly in the dorsal aspect of medulla and the central gray matter of cervical spinal cord that showed the "black butterfly" silhouette. Cerebral angiography revealed DAVFs draining into anterior and posterior spinal veins. Dark signals on T2*WI and SWI were presumed to be hemorrhages, which were probably caused by prolonged venous congestion. Identifying this "black butterfly" sign can facilitate the diagnosis of DAVF, differentiating DAVF from other spinal cord diseases such as demyelinating lesions and neoplasms.

We report a unique case of middle cerebral artery fenestration with M2 fusion detected during an aneurysm clipping. A 72-year-old woman was diagnosed with an unruptured aneurysm of the right middle cerebral artery, and middle cerebral artery fenestration with M2 fusion was detected during the aneurysm clipping surgery. It was difficult to identify this unusual vascular anomaly before the surgery. Therefore, neurosurgeons should be cautious of such hidden vascular anomalies and be prepared for the possible complications during surgery.

Although many studies have evaluated the retrieved thrombus to assess the cause of stroke after mechanical thrombectomy for acute large vessel occlusion, the results remain controversial. We investigated the hypothesis that histology of the retrieved thrombus is enhanced by mechanical thrombectomy devices.Thrombi were collected from consecutive patients who had undergone endovascular mechanical recanalization for large intracranial vessel occlusion. The mechanical thrombectomy device used was either an aspiration catheter or a stent retriever. The hematoxylin and eosin-stained specimens were quantitatively analyzed with respect to the relative fractions of the main constituents (erythrocytes and fibrin). Clinical and radiologic findings were also evaluated.Of 65 patients, an aspiration catheter was used in 27, and a stent retriever was used in 38. The presence of a preoperative susceptibility vessel sign on magnetic resonance imaging was not correlated with the percentage of erythrocytes. Thrombus cross-sectional area was larger in the aspiration group than in the stent group (P0.01). Conversely, the percentage of the fibrin component was higher in the stent group (P0.001). Preoperative intravenous administration of recombinant tissue plasminogen activator reduced thrombus cross-sectional area with a trend of increased percentage of fibrin and reduced percentage of erythrocyte in the stent group.Histologic differences in retrieved thrombi are enhanced by mechanical thrombectomy devices. Stent retrievers may crush the thrombus, which may have a synergistic effect with recombinant tissue plasminogen activator. Histology of the retrieved thrombi might be different from histology of the original thrombi.

BACKGROUND: Vacuolar encephalomyelopathy, a disregarded diagnosis lately, was a major neurological disease in the terminal stages of human immunodeficiency virus (HIV)-1 infection in the pre-antiretroviral therapy (ART) era. Granulomatous-lymphocytic interstitial lung disease (GLILD) was classically identified as a non-infectious complication of common variable immunodeficiency; however, it is now being recognized in other immunodeficiency disorders. Here, we report the first case of GLILD accompanied by vacuolar encephalomyelopathy in a newly diagnosed HIV-infected man. CASE PRESENTATION: A 40-year-old Japanese man presented with chronic dry cough and progressing paraplegia. Radiological examination revealed diffuse pulmonary abnormalities in bilateral lungs, focal demyelinating lesions of the spinal cord, and white matter lesions in the brain. He was diagnosed with GLILD based on marked lymphocytosis detecting in bronchoalveolar lavage, and transbronchial-biopsy proven T-cellular interstitial lung disease with granulomas. Microbiological examinations did not reveal an etiologic agent. The patient was also diagnosed with HIV-associated vacuolar encephalomyelopathy on the basis of an elevated HIV viral load in cerebrospinal fluid. After initiating ART, the brain lesions and paraplegia improved significantly, and interstitial abnormalities of the lungs and cough disappeared. CONCLUSION: This report highlights that even in the post-ART era in developed countries with advanced healthcare services, HIV-associated vacuolar encephalomyelopathy should be considered in the differential diagnosis of a progressive neurological disorder during the first visit. Furthermore, GLILD may represent an HIV-associated pulmonary manifestation that can be treated by ART., AIDS research and therapy, 17(1), art.no.38; 2020

To clarify the possible pathological conditions of cartilaginous portion of the Eustachian tube (ET) and its surrounding tissues.Retrospective review.Twenty-five normal subjects (control group) and 25 patients with patulous ET (patulous group).We reconstructed cross-sectional 3 Tesla magnetic resonance (MR) images using the multiplanar reconstruction (MPR) technique. Cross-section area widths that were measured included the following: 1) inferior head of lateral pterygoid muscle (PM); 2) pterygoid venous plexus (PVP); 3) medial soft tissues of ET, including ET cartilage; and 4) maximum cross-sectional area of high intensity surrounding the medial ET lumen.A statistically significant difference was found in the thickness of the inferior head of the lateral PM between male and female; it was thicker in the male participants. Ostmann's fatty tissue (OF) was significantly smaller in the patulous ET group.Smaller size of the surrounding tissues of the ET, viz., the OF, may contribute to the pathogenesis of patulous ET.

OBJECTIVERegional ischemic vulnerability of the brain reportedly differs between the cortex and basal ganglia and has been poorly assessed in the setting of endovascular mechanical thrombectomy. This study was conducted to determine the fate of an ischemic basal ganglia and its contribution to the clinical outcome after successful endovascular recanalization for acute ischemic stroke with large vessel occlusion involving the lenticulostriate arteries.METHODSClinical and radiological findings were retrospectively analyzed in consecutive patients with acute ischemic stroke characterized by large vessel occlusion involving the lenticulostriate arteries. Mechanical thrombectomy was performed in all patients using a stent retriever. The fate of ischemic basal ganglia based on location (lentiform nucleus, caudate nucleus, and internal capsule) and insular cortex was assessed according to the Alberta Stroke Programme Early CT Score (ASPECTS).RESULTSOf 170 patients with large intracranial vessel occlusion who achieved successful endovascular recanalization, defined as a thrombolysis in cerebral infarction grade of ≥ 2B, involvement of the lenticulostriate arteries was seen in 55 patients (internal carotid artery, n = 35; proximal middle cerebral artery, n = 20). Preoperative infarction was detected in the lentiform nucleus (66.7%), internal capsule (11.1%), and caudate nucleus (33.3%), all of which showed secondary advancement despite successful recanalization (85.4%, 27.3%, and 54.5%, respectively; p < 0.05). Lenticulostriate arteries with a lateral proximal and/or medial proximal origin significantly affected the development of mature infarction in the lentiform nucleus. Postoperative hemorrhagic transformation was detected in 25 of 55 patients, mostly in the lentiform nucleus. Involvement of insular ribbon infarction was significantly high in patients with hemorrhagic transformation in the basal ganglia. Age, initial National Institutes of Health Stroke Scale (NIHSS) score, initial ASPECTS, postoperative ASPECTS, postoperative infarction in the insular ribbon, and lesions in the middle cerebral artery area (M1–M6) were significantly different between patients with good and poor modified Rankin Scale scores. Interestingly, no differences were detected in postoperative infarction or hemorrhagic transformation in the basal ganglia. Multivariate analysis showed that only age (p = 0.02, OR 0.88) and the initial NIHSS score (p = 0.01, OR 0.86) independently affected favorable clinical outcomes.CONCLUSIONSThe basal ganglia are vulnerable and readily develop secondary infarction and hemorrhagic transformation despite successful recanalization. However, this does not have a significant impact on the clinical outcome of acute ischemic stroke with large vessel occlusion involving the lenticulostriate arteries.

OBJECT Recent studies have demonstrated that plaque morphology can contribute to identification of patients at high risk of carotid artery atherosclerosis as well as the degree of stenosis in those with carotid atherosclerosis. Neovascularization of carotid plaques is associated with plaque vulnerability. However, the mechanism of neovascularization in intraplaque hemorrhage (IPH) and its clinical contribution remain undetermined. In this study, the authors aimed to clarify the characteristics of neovessel appearance with a focus on inwardly projecting neovessels, which are reportedly important in plaque advancement. METHODS Consecutive patients with moderate to severe carotid atherosclerosis who underwent carotid endarterectomy were prospectively analyzed from 2010 to 2014. The neovessel appearance was categorized into 3 groups based on intraoperative indocyanine green (ICG) videoangiography: early appearance of neovessels from the endothelium (NVe), late appearance of neovessels from the vasa vasorum (NVv), and no appearance of vessels. Each neovessel pattern was evaluated with respect to clinical, radiological, and pathological findings including IPH, neovascularization, hemosiderin spots, and inflammation. RESULTS Of 57 patients, 13 exhibited NVe, 33 exhibited NVv, and 11 exhibited no neovessels. Overall, the interobserver and intraobserver reproducibilities of neovessel appearance were substantial for ICG videoangiography (κ = 0.76) and at 7 days postoperatively (κ = 0.76). There were no significant differences in baseline characteristics among the 3 groups, with the exception of a higher percentage of symptomatic presentations in patients with NVe (artery-to-artery embolic infarction in 61.5% and transient ischemic attack in 23.1%). Moreover, patients with NVe exhibited larger infarctions than did those with NVv (9675.0 ± 5601.9 mm3 vs 2306.6 ± 856.9 mm3, respectively; p = 0.04). Pathologically, patients with NVe had more severe IPH (47.2 ± 8.3 mm2 vs 19.8 ± 5.2 mm2, respectively; p < 0.01), hemosiderin spots (0.5 ± 0.2 mm2 vs 0.2 ± 0.1 mm2, respectively; p = 0.04), neovessels (0.4 ± 0.7 mm2 vs 0.1 ± 0.4 mm2, respectively; p = 0.11), and inflammation (1.0 ± 1.1 mm2 vs 0.6 ± 0.9 mm2, respectively; p = 0.26) around the endothelium than did patients with NVv, and all of these parameters were correlated with hyperintensity on time-of-flight MRI. However, the neovessel and inflammation differences were nonsignificant. Interestingly, inflammation was significantly correlated with neovessel formation (r = 0.43, p = 0.0008), hemosiderin spots (r = 0.62, p < 0.0001), and IPH (r = 0.349, p = 0.0097), suggesting that inflammation may be a key factor in plaque vulnerability. CONCLUSIONS Communication of inwardly projecting neovessels with the lumen and inflammation synergistically contribute to IPH and symptomatic presentations in patients with carotid stenosis and are more specific than the vasa vasorum. This condition could be a new therapeutic target, and regression of luminal neovessel sprouting and inflammation may help to prevent IPH development and a symptomatic presentation.

Background: Although transvenous embolization (TVE) is an effective method for treating dural arteriovenous fistula (AVF), directing the catheter to the lesion site is difficult. Objective: We report on the utility of a quadruple coaxial catheter system for TVE. Materials and methods: The quadruple catheter system comprised a 6 Fr guiding sheath, 6 Fr guiding catheter, 4 Fr intermediate catheter, and a regular microcatheter. The system was utilized in 27 consecutive dural AVF cases treated with TVE. In this study, we reviewed our experience with this system, including the theory, method of use, and complications. Results: Stenosis or obstruction of the vascular access was identified in 12 cases. The catheter could not reach to the lesion in three cases of cavernous sinus (7.4%); therefore, transarterial embolization was employed. Angiographic results revealed that the cases consist of total occlusion (n = 16, 59.5%), subtotal (n = 10, 37.0%), and partial occlusion (n = 1, 3.7%). Complete resolution or improvement of symptoms was observed in 23 patients (85.2%), no improvement of symptoms was observed in three patients (7.4%), and deterioration of symptoms was observed in one patient (3.7%). Venous perforation occurred in one patient without any neurological deficit. The catheter system provided access to the lesion and provided stability during the mechanically demanding process navigating the catheter and placing the coils. Conclusion: We determined that the quadruple coaxial system was safe and efficient for TVE for dural AVF., Neurological Research, 37(4), pp.328-331; 2015

The authors present an extremely rare case of a 48-year-old female who developed repeated perianeurysmal edema at 2, 9, and 16 weeks after endovascular coil embolization for the ruptured intracranial aneurysm. Interestingly, the mechanism for this edema could be different at each time point in this case; acute thrombosis formation, chemical inflammation, and aneurysm recanalization. We have to be aware of this potential complication in the long term after endovascular coil embolization for the intracranial aneurysm, especially with large size or buried into the brain parenchyma. The clinical implications of this case are discussed with a review of the literature.

Background Because infective endocarditis (IE) carries a high risk of morbidity and mortality, rapid diagnosis and effective treatment are essential to achieving a good patient outcome. However, the diagnosis of IE is often difficult in patients presenting with nonspecific clinical manifestations. An association between IE and hypointense signal spots on brain T2*-weighted magnetic resonance imaging (MRI) has been reported, but the clinical significance remains unclear.Methods and Results:To assess the clinical importance of silent lesions in the brains of IE patients, hypointense signal spots detected on their brain T2*-weighted MRI scans were investigated in a retrospective review of 44 consecutive patients with definite or suspected IE evaluated by MRI between June 2006 and January 2014. Hypointense signal spots on T2*-weighted MRI were detected in 37 (84%) patients; of these, 21 (46%) had ischemic lesions, 10 (22%) had subarachnoid hemorrhage, 4 (9%) had intraparenchymal hemorrhage, and 4 (9%) had infectious aneurysm. The hypointense signal spots on T2*-weighted images were preferentially distributed in cortical areas. Conclusions T2*-weighted hypointense signal spots are highly frequent in patients with IE and their presence may be informative in the monitoring of IE-associated brain lesions, even those that are neurologically asymptomatic. The strong association between IE and T2*-weighted hypointense signal spots supports the need to consider additional criteria in the diagnosis of IE.

Moyamoya disease is a unique occlusive disease of the internal carotid artery(ICA)with moyamoya vessels that can lead to transient ischemic attacks and hemorrhagic stroke. When other inherited or acquired disorders and conditions occur in conjunction with moyamoya disease, the syndrome is known as quasi-moyamoya disease. We report the case of a 34-year-old woman with a past history of SAPHO(Synovitis-Acne-Pustulosis-Hyperostosis-Osteomyelitis)syndrome, who presented with arm weakness and headache. Magnetic resonance angiography revealed severe terminal stenosis of the left ICA with moyamoya vessels, and she was diagnosed as moyamoya disease associated with SAPHO syndrome. She underwent superficial temporal artery-middle cerebral artery anastomosis and her arm weakness improved postoperatively. Postoperative course was uneventful, although she showed transient right paresthesia, which improved with conservative therapy. Autoimmune response could contribute to the development of this moyamoya disease, and we discuss its mechanism with a literature review.

Background and Purpose: Endovascular thrombectomy is of benefit to most patients with acute ischemic stroke caused by major intracranial vessel occlusion. Reperfusion injury is, however, one of the critical complications after successful recanalization, which has not been fully evaluated. The aim of this prospective study was to assess the impact of hyper-intensity signal on postoperative arterial spin labeling (ASL) MR imaging on hemorrhagic complications and clinical outcome after endovascular treatment. Methods: Consecutive patients showing acute stroke with major intracranial vessel occlusion were prospectively analyzed. All the patients underwent endovascular thrombectomy, and MR imaging including ASL was performed at pre-, postoperative day 1 and day 7. Clinical and radiological outcomes were evaluated especially focusing on arterial spin labeling findings. Results: Of 81 patients, 21/81 (25.9%) showed hyper-intensity signal on ASL (ASL+) at postoperative day 1. There were no significant differences in baseline characteristics between the groups with and without ASL+, including preoperative NIH stroke scale, door to puncture time, occlusion vessel and TICI score. Interestingly, 15/21 (71.4%) patients developed minor bleeding or hemorrhagic changes in ASL+ group, which was detected only in 3/60 (5.0%) in ASL- group. Modified Rankin Scale was not different between the groups at postoperative day 90 under strict control of blood pressure. Multivariate regression analysis showed that ASL+ is significantly related to postoperative hemorrhagic complications (Adjusted OR: 21.68, P=0.004). Conclusions: Postoperative hyper-intensity signal on ASL MRI indicates vasoparalysis and luxury perfusion even successful recanalization after endovascular thrombectomy, which has a risk for hemorrhagic complications.

Background and Purpose: Thrombus composition has been suggested to have a decisive impact on the outcome of patients treated by mechanical thrombectomy because of embolic stroke. The aim of this prospective study was to assess the impact of a mechanical thrombectomy device (Penumbra aspiration catheter vs. Stent retriever) on thrombus composition, which could affect flow impairment after reperfusion. Methods: Thrombi of consecutive stroke patients with large vessel occlusion were collected during intracranial mechanical recanalization. Mechanical thrombectomy device was used either Penumbra aspiration catheter or Stent retriever. The hematoxylin and eosin-stained specimens were quantitatively analyzed in terms of the relative fractions of the main constituents (red blood cells and fibrin/platelets). Results: Of 65 cardio-embolic patients, Penumbra aspiration catheter was used in 27 patients, and Stent retriever was used in 38 patients. There was no significance in age, sex, occlusion vessel, NIH stroke scale, and onset to reperfusion time. The volume of thrombi was significantly larger in Penumbra group compared with that in Stent group (3.68 cm3 vs. 0.95 cm3, P Conclusions: Stent retriever could crush thrombus and reduce its size, which induce distal migration of the red blood cell component. However, it did not affect the final infarct lesion and outcome.

Background and purpose: T2 star weighted MR angiography (SWAN) can detect hemodynamic insufficiency as hypointensity areas in the medullary or cortical veins. In this study, we investigate whether SWAN in 1.5T MRI can help to detect ischemic penumbra-like lesions in acute ischemic stroke (AIS) patients. Materials and methods: Patients showing acute major vessel occlusion (ICA and MCA) within 4.5 hours from onset were consecutively analyzed with MRI including SWAN, DWI, and MRA. To evaluate ischemic area in SWAN and DWI, modified ASPECT (mASPECTS) were used. SWAN- and DWI- based mASPECTS was calculated, and correlation between DWI-SWAN mismatch and final infarct lesion or outcome was evaluated. Results: Thirty-five patients were included in this study. Of the 35 patients (mean age: 73.5 ± 13.5 years), cardioembolic stroke was confirmed in 26 patients, atherothrombotic stroke was in 4 patients, and the others had unknown etiology. Overall, recanalization was achieved in 23 patients (65%), showing higher mASPECTS in follow up DWI and lower mRS at 90 days than patients with no recanalization ( P =0.037 and P P =0.016 and P =0.042). Of 12 patients showing no recanalization, DWI-SWAN mismatch was significantly correlated with infarct growth (R 2 =0.6160, P =0.0025). On the other hand, there was no such correlation for patients showing recanalization. Interestingly, initial SWAN-based mASPECTS was significantly correlated with mRS at 90 days (R=-0.38, P =0.037) regardless of recanalization. Conclusions: DWI-SWAN mismatch in 1.5T MRI could show penumbra-like lesions in AIS patients with major vessel occlusion. Low mASPECTS in initial SWAN might predict unfavorable outcome. Assessment of ischemic penumbra from venous side using SWAN can visualize a lesion’s viable tissue and is quite useful without contrast media.

Objective: Carotid artery stenting (CAS) is a well-accepted treatment for atherosclerotic stenosis of carotid arteries. Since the occurrence of distal embolization with CAS is still a major concern embolus protection devices (EPD) are usually employed during the procedure. We examined two types of embolus protection filters (Angioguard XP (AG); Filterwire EZ (FW)) and evaluated the function. Thus, the filter was examined postoperatively and the cause of intraoperative flow impairment was evaluated. Materials and methods: CAS was performed for 54 patients with carotid artery stenosis (55 lesions: 25 AG; 27 FW; 3 others). After completing CAS the filter membrane was stained with hematoxylin-eosin (HE) solution and removed from the filter strut. Once mounted on a glass slide the filter was evaluated under a microscope. The area occupied with debris was measured and the relationship to intraoperative flow impairment was evaluated. Furthermore, the relationship between perioperative ischemic complications and intraoperative flow impairment was statistically analyzed. Results: Microscopic observation of the slide revealed the pore density of the FW was 1.5 times higher than that of the AG and the filter area of the FW was 2.5 times wider than than the AG. HE staining facilitated characterization of the debris composition. The area occupied with debris was significantly more in the AG (0.241 ±0.13 cm2) than in the FW (0.129 ±0.093 cm2). Thus, fibrin was significantly more precipitated in the AG. Flow impairment occurred in 6 AG cases (24.0 %) and 4 FW cases (14.8 %). It was induced by filter obstruction in the AG and by vasospasms in the FW. Three cases treated with AG (12.0 %) were complicated with cerebral infarction and all of them were related to flow impairment. One FW case (3.7 %) was complicated with cerebral infarction in presence of preserved flow throughout the intervention. Conclusion: Filter function is different according to each design. The cause of flow impairment was attributable to filter obstruction in the AG group and to vasospasms in the FW group. Filter obstruction tends to result in cerebral infarction., Acta Neurochirurgica, 156(9), pp.1721-1728; 2014

C-stopper coil (CSC) which are available for 0.018-inch inner diameter microcenter have been used for neurointervention such as transarterial embolization (TAE) of feeding artery. Although various shapes of pushable microcoils have been developed, microcoils are usually short to embolize the lesion and require lots of coils. The most specific feature of CSC is the extended length of 18 cm. To evaluate the usefulness of CSC, we reviewed our experience of CSC. Neurointervention using CSC was performed for 28 patients (31 treatments). Intervention procedures were TAE for dural arteriovenous fistula (AVF) (n = 15), transvenous embolization for dural AVF (n = 4), parent artery occlusion for cerebral aneurysm, dissection and carotidcavernous fistula (n = 8), TAE for epistaxis (n = 2), and preoperative embolization for tumor (n = 2). CSCs were deployed with push technique through microcatheter. CSCs were successfully placed into the lesion namely feeding artery, venous sinus, parent artery of aneurysm, or dissection. There were no major technical complications resulting in morbidity. Postoperative course was uneventful. No recanalization of the occluded vessel occurred during follow-up. Use of CSCs was safe and feasible for embolization of cerebrovascular lesion., Neurologia medico-chirurgica, 54(6), pp.450-456; 2014

Endovascular coil embolization for intracranial aneurysms, arteriovenous malformations (AVMs), dural arteriovenous fistulas (AVFs), and hypervascular tumors are recognized as an effective adjunctive or curative treatment. In this setting, it is sometimes difficult to navigate a coil delivery microcatheter to the target point of a tiny, tortuous vessel. We herein present a case series of a novel method that enabled super-selective coil embolization using an extremely soft bare, electrodetachable coil (ED extrasoft(®) coil) through a liquid embolic delivery microcatheter (Marathon(®)). The Marathon(®) catheter was successfully placed at the target point of the tiny, tortuous vessel, and coil embolization was achieved in all 16 patients with 9 AVMs, 2 distal aneurysms, 2 AVFs, and 3 meningiomas. The primary ED extrasoft(®) coil and delivery wire have a very small radius, and the coil is rapidly detachable with an alarm notice from the generator even under Marathon(®) with one marker. We believe that this technique can provide safe and efficient embolization for selected patients.

Purpose: We evaluated the rim patterns of intracranial meningiomas on nonenhanced(NE) and contrast-enhanced (CE) 3-dimensional fluid-attenuated inversion recovery (3DFLAIR) imaging on 3-tesla magnetic resonance (MR) imaging to clarify the associatedimaging and pathologicalfindings and the value of the rims in predicting tumor cleavability.Methods: Thirty-two patients with meningioma underwent tumor excision. We classifiedthe rim patterns on 3D FLAIR, subdivided into“rim-NE,” a rim with relatively low signalintensity on NE 3D FLAIR and“rim-CE,” a rim with relatively high signal intensity on CE3D FLAIR, into 4 grades by their extent from 0(no rim visible) to 3 (rim visible over mostof the tumor-brain interface)and correlated them with tumor size, grade of peritumoralbrain edema, presence/absence of pial supply, grade of tumor-brain adhesion, and histo-logical findings.Results: On NE 3D FLAIR,“rim-NE” wasgraded0in5patients,onein5,2in6,and3in 16. On CE 3D FLAIR,“rim-CE” wasgraded0inonepatient,onein13,2in4,and3in14. The grade of“rim-NE” correlated negatively with the grade of brain edema (P = 0.023)and positively with surgical tumor-brain cleavability (P < 0.001). It also correlated withthe amount of connective tissue at the tumor-brain interface histologically (P = 0.041).Furthermore, a lower grade of“rim-NE” was more often seen in atypical than benign men-ingioma (P = 0.003). Although“rim-CE” was more prominent in tumors with pial supplyon digital subtraction angiography (DSA) (P = 0.002), it was not useful in predicting tu-mor-brain adhesion or histological tumor grading.Conclusion: The rim pattern of meningioma on NE 3D FLAIR can predict surgicalcleavability and histological tumor grading. A higher grade of rim pattern on CE 3DFLAIR suggests prominent pial supply to the tumor but has no added value in predictingtumor-brain adhesion and histological tumor grading.Keywords: DSA, meningioma, MRI, tumor-brain adhesion, 3D FLAIR

Remote cerebellar hemorrhage is reported as a possible complication after supratentorial surgery and spinal surgery, and there is no previous report after lumbar puncture. A 44-year-old man was diagnosed with Herpes simplex virus (HSV) encephalitis, which was complicated with cerebellar hemorrhage remote from the active encephalitis lesion. The hematoma in the cerebellar hemisphere, shown as low a intensity lesion in a T2 star weighted angiography, image was diagnosed as a remote cerebellar hemorrhage caused by lumbar puncture. Physicians must be aware of this streaky, zebra-pattern radiographic image of remote cerebellar hemorrhage.

Background: We aimed to evaluate the validity of duplex ultrasonography (DUS) using a microconvex array transducer (MAT) with enhanced flow imaging (EFI) for visualization of the distal, internal carotid artery (ICA) and the accurate assessment of ICA stenosis. Methods: Patients who underwent both DUS and digital subtraction angiography (DSA) were registered for this study. DUS was performed by using a linear array transducer (LAT) and an MAT with EFI. The visibility of the ICA was compared between the 2 transducers. ICA stenosis was evaluated by the North American Symptomatic Carotid Endarterectomy Trial (NASCET) method on DUS, and the peak systolic flow velocity (PSV) was evaluated by using an MAT. These results were compared with DSA. Results: In 238 internal carotid arteries, the average length of visualized ICA was longer for DUS using an MAT than an LAT (38.7 ± 11.7 mm versus 25.8 ± 9.8 mm, P, Journal of Stroke and Cerebrovascular Diseases, 22(8), pp.e360-e365; 2013

The aim of this study was to identify whether subacute diffusion-weighted imaging (DWI) lesion volume could predict long-term outcome in patients who had undergone intravenous thrombolysis.Patients underwent DWI at baseline and 7days after thrombolysis. Outcomes included complete independence (modified Rankin scale [mRS] score 0 to 1), unfavorable outcome (mRS score 4 to 6) at 90days, and mortality within 90days. Multivariate logistic regression analysis was used to identify outcome predictors.Of 164 patients, 72 patients (43%) achieved complete independence. Poor outcomes were observed in 45 patients (27%) with an unfavorable outcome and 10 patients (6%) who died. Subacute DWI lesion volume was 3.4mL (interquartile range, 1.1-11.6) in patients with complete independence, 90.1mL (23.8-180.2) in patients with unfavorable outcome and 155.5mL (78.4-377.5) in patients who died. In multivariate logistic regression analysis, subacute DWI lesion volume was an independent predictor of complete independence (odds ratio [OR], 0.939; 95% confidence interval [CI], 0.914-0.965; p0.001), unfavorable outcome (OR, 1.023; 95% CI, 1.014-1.033; p0.001), and mortality (OR, 1.016; 95% CI, 1.005-1.028; p=0.005).Subacute DWI lesion volume is a critical determinant of 90-day functional outcome and mortality after thrombolysis.

Parent artery occlusion for intractable aneurysms or sinus packing for dural arteriovenous fistulas (DAVFs) is sometimes difficult and requires many expensive coils to accomplish complete occlusion. To help solve these problems, we reviewed our experience using 0.035-inch coil (0.035 coil; Boston Scientific, San Leandro, CA, USA), which has been used in cardiovascular and abdominal lesions. These 0.035 coils were preferably used in addition to the detachable and fibered coils for patients with intractable aneurysms, traumatic vessel blowout, and DAVF. Our strategy was as follows: (1) detachable coils were deployed first for the ideal anchoring of the coils; (2) small fibered coils were additionally deployed to stabilize the coil mass; (3) 0.035 coils were deployed to complete the occlusion. From January 2012 to December 2013, seven consecutive patients were treated by endovascular embolization with 0.035 coils. Reasons for intervention were parent artery occlusion for carotid blowout (n = 1), internal carotid artery aneurysm (n = 2), traumatic vertebral artery injury (n = 2), vertebral AVF (n = 1), and transverse sinus-sigmoid sinus DAVF (n = 1). In our cases, a mean of 20.1 ± 8.5 coils per vessel were placed, and mean total coil length was 258.4 ± 91.5 cm per vessel. All procedures were safely performed and complete occlusions achieved. From our initial experience and treatment results, we believe endovascular parent artery occlusion or sinus packing with 0.035 coils to be useful in terms of reducing the number and expense of coils and also accomplishing immediate occlusion.

Background and Purpose: The ivy sign on fluid-attenuated inversion recovery (FLAIR) magnetic resonance imaging (MRI) is a specific finding in moyamoya disease (MMD). This sign indicates decreased cerebral perfusion, dilated pial vasculature, and slow leptomeningeal collateral flow. This study aimed to clarify the characteristics of perioperative changes in the ivy sign in relation to cerebral hyperperfusion (HP), which frequently occurs in MMD of unknown etiology. Methods: This prospective study included patients with MMD who underwent superior temporal artery-middle cerebral artery single bypass. FLAIR MRI was performed to evaluate the appearance of the ivy sign in the ipsilateral hemisphere preoperatively and on postoperative days 2 and 30. The ivy sign was assessed in combination with perioperative symptoms and cerebral hemodynamics using single-photon emission computed tomography (SPECT). Results: Of 42 consecutive patients (55 sides) who underwent bypass surgery, 32 (58.2%) showed an increase in the ivy sign (de novo ivy sign) on postoperative day 2; this had disappeared by day 30. Interestingly, these 32 patients had a significantly higher incidence of HP on SPECT and HP syndrome, and there was no correlation between the de novo ivy sign and a preoperative ivy sign or the preoperative cerebral hemodynamics. In multivariate analysis, a de novo ivy sign was significantly correlated with postoperative HP. Conclusions: In MMD, a de novo ivy sign could indicate postoperative HP after bypass, which is not always correlated with preoperative hemodynamic impairment. Additional factors other than preoperative cerebral hemodynamics might be involved in postoperative HP in MMD.