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We report a case of proton magnetic resonance spectroscopy (MRS) of hemangioblastoma in a 56-yearold man with a history of hyperlipidemia who was suffering from an equilibrium disorder. Proton MRS revealed a high mobile lipids (Lip) peak between 0.9 and 1.4 ppm, which was compatible with histologically proven lipids in the tumor. No lactate peak was recognized. The creatine/phosphocreatine peak was low. Choline-containing compounds were increased. The N-acetylaspartate peak was absent, which indicated that the tumor is of nonneurogenic origin. Combined with the absence of the necrotic component on magnetic resonance imaging, this Lip peak on proton MRS could be the characteristic pattern of hemangioblastoma. These unique results of proton MRS can play an important role in the differential diagnosis of intracranial hemangioblastoma. However, further investigations are required to establish the typical characteristics of proton MRS of hemangioblastoma. [ABSTRACT FROM AUTHOR]

We herein report a rare case of a patient with a clival diploic vein arteriovenous fistula (AVF) associated with a posterior condylar canal AVF and discuss the radiological features of clival diploic vein AVF during decision-making on treatment strategies. A 69-year-old male patient with one-year history of pulsatile tinnitus was evaluated with magnetic resonance angiography, which revealed a dilated venous structure. Digital subtraction angiography revealed AVFs located in the clivus and posterior condylar canal. The clival diploic vein AVF was fed by the right internal maxillary artery and the petrous branch of middle meningeal artery and shed to the posterior condylar canal only through an intraosseous vein in the jugular tubercle. Although a catheter could not be navigated into the venous pouch in the clivus, the AVFs were successfully obliterated by transvenous embolization of the venous pouch in the posterior condylar canal.

A 21-year-old man who had a history of pneumonia twice presented with chest discomfort. Computed tomography( CT) revealed dilatation of the atretic bronchus that was not continuous with the proximal one, and surrounding hyper-lucent lung fields in the outer and mediastinal sides of the right basal segment, and the absence of B10b+c. CT also demonstrated the presence of A10b+c in the former field and the aberrant artery from the inferior phrenic artery in the latter. Right basal segmentectomy was performed under the diagnosis of congenital bronchial atresia and intralobar sequestration. Pathological diagnosis accorded with preoperative one.

We herein report a case of a ruptured vertebral artery dissecting aneurysm involving the origin of the posterior inferior cerebellar artery that was treated using the stent-jack technique. After parent artery occlusion of the distal vertebral artery, stenting of the posterior inferior cerebellar artery was performed. Further coiling was needed because distal vertebral artery recanalization occurred due to transformation of the coil mass. The stent-jack technique for a ruptured vertebral artery dissecting aneurysm involving the origin of the posterior inferior cerebellar artery is effective; however, careful attention to recanalization after stenting is needed due to transformation of the coil mass.

Purpose: Laugier's hernia is a rare clinical entity compared with a typical femoral hernia. Therefore, the clinical features, radiological findings, and appropriate treatment strategies remain largely unclear. In this study, we present 15 Laugier's hernia cases. Additionally, we review the relevant literature and discuss the clinical features, radiological findings, and appropriate treatment strategies pertaining to Laugier's hernia compared with a typical femoral hernia., Methods: Among 1260 hernia patients, we retrospectively enrolled 15 Laugier's hernia patients (1.19%) and 89 femoral hernia patients (7.06%) who underwent herniorrhaphy and compared the demographic characteristics and radiological findings between the two groups., Results: Regarding the patient characteristics, a significant difference was observed in the presence of pain (p < 0.001) and ileus symptoms (p = 0.001). Regarding the hernia characteristics, significant differences were observed in the size of the hernial sac (p = 0.001), contents of the hernial sac (p = 0.003), repositioning of the hernial sac (p < 0.001), and repair with polypropylene mesh (p < 0.001). The characteristic multi-detector computed tomography (MDCT) findings enabled the preoperative diagnosis of Laugier's hernia versus conventional femoral hernia., Conclusion: Surgeons should be alert to the possibility of atypical femoral hernias while examining femoral hernia or inguinal hernia patients. If Laugier's hernia is suspected, preoperative MDCT is recommended.

Purpose: To plan a treatment strategy for a spinal arteriovenous shunt (SAVS), identifying the artery of Adamkiewicz (AKA) and its origin is indispensable. However, detecting the AKA is very difficult in patients with an SAVS when using computed tomography angiography (CTA) by the usual method to find the hairpin curved artery because dilated drainage veins nearly always coexist with the hairpin curved AKA. We designed a method to identify the AKA by focusing on the diameter and pathway of the anterior radiculomedullary arteries (RMAs)., Material and Methods: Seven consecutive patients with an SAVS were surveyed. They underwent contrast-enhanced CTA and conventional angiography from January 2009 to December 2012. Two readers evaluated the CTA images and assumed that the AKA was the artery that ran through the anterior portion of the neural foramen and continued to pass on the ventral side of the spinal cord., Results: Among the seven patients, nine AKAs were detected with conventional angiography. When using our method, seven AKAs and six AKAs were identified on CTA by Reader 1 and Reader 2, respectively. The average sensitivity was 72.3%, and the specificity, accuracy, positive predictive value, and negative predictive value were sufficiently high (i.e. > 85%) for both readers. The kappa value for detecting the AKA was 0.98., Conclusions: Detecting the origin of the AKA with CTA is challenging in patients with an SAVS. However, focusing on the diameter and pathway of the RMAs may allow successful identification., Competing Interests: The authors report no conflict of interest., (Copyright © Polish Medical Society of Radiology 2020.)

Objective: Rathke's cleft cyst (RCC) is a benign cystic lesion with a relatively high incidence of local recurrence that occasionally requires repeat surgery. To prevent recurrence, simple cyst fenestration and drainage of the cyst contents to the sphenoid sinus is recommended, but it occasionally recurs. The authors postulated that obstruction of fenestration is a main cause of recurrence, and they developed a method, named the "mucosa coupling method (MC method)," that maintains persistent drainage. In this method, the RCC epithelium and the mucosa of the sphenoid sinus are connected, which promotes re-epithelialization between the two epithelia, maintaining persistent drainage. The outcome of this method was compared with that of conventional cyst fenestration., Methods: In a consecutive series of 40 patients with RCC, the surgical strategy was changed during the study period: from December 2009 to September 2014 (the conventional period), 24 patients were scheduled to be treated using the conventional fenestration method, whereas from September 2014 to September 2017 (the MC period), 16 patients were scheduled to be treated using the MC method. However, because of an intraoperative CSF leak, the fenestration was closed during surgery in 3 patients in the conventional period and 2 in the MC period; therefore, these 5 patients were excluded from the analysis. Twenty-one patients treated with the conventional fenestration method (conventional group) and 14 patients treated with the MC method (MC group) were analyzed. All patients regularly underwent MRI after surgery to detect reaccumulation of cyst contents. The rate of reaccumulation with and without reoperation, visual outcomes, endocrinological outcomes, and postoperative complications were compared between these two groups., Results: The median follow-up period in all 35 patients was 48.0 months (range 1-96 months), 54.0 months (range 1-96 months) in the conventional group and 35.5 months (range 12-51 months) in the MC group. No reaccumulation was detected on MRI in the 14 patients in the MC group, whereas it was noted in 9 (42.9%) of 21 patients in the conventional group, and 2 of these 9 patients required repeat surgery. There were no significant differences in visual and endocrinological outcomes and complications between these two groups., Conclusions: The MC method for RCC is effective for preventing obstruction of cyst fenestration, which contributes to preventing cyst reaccumulation. Furthermore, this method is equivalent to the conventional fenestration method in terms of visual and endocrinological outcomes and the complication rate.

A concave-shaped maximal expiratory flow-volume (MEFV) curve is a spirometric feature in chronic obstructive pulmonary disease (COPD). The MEFV curve is characterized by an increase in the Obstructive Index, which is defined as a ratio of forced vital capacity to the volume-difference between two points of half of the peak expiratory flow on the MEFV curve. We hypothesized that the Obstructive Index would reflect the severity of emphysema in patients with COPD and asthma-COPD overlap (ACO). Thus, the aim of this retrospective study was to evaluate whether the Obstructive Index on spirometry is associated with the extent of emphysema on computed tomography (CT) in patients with COPD, ACO, and asthma (N = 65, 15, and 53, respectively). The percentage of low-attenuation volume (LAV%) and wall area (WA%) were measured on CT. The Obstructive Index was higher in patients with COPD and ACO than in those with asthma. Spearman correlation showed that a greater Obstructive Index was associated with a higher LAV%, but not WA%. Multivariate analysis showed that Obstructive Index was associated with LAV% (standardized β = 0.43, P < 0.0001) independent of other spirometric indices. The Obstructive Index is a useful spirometric index that reflects the extent of emphysema.

Purpose: In radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC), it is difficult to assess the ablative margin (AM) precisely by comparing pre- and post-RFA CT images. We prospectively studied the AMs using magnetic resonance imaging (MRI) with pre-administered superparamagnetic iron oxide (SPIO). SPIO is safe for kidney disease patients., Materials and Methods: Hepatocellular carcinoma patients were treated with RFA within 8 h of SPIO administration. On T2*-weighted MRI performed 4-7 days later, AM was visualized as a hypointense rim. The ablation status was classified as AM(+) if the rim completely surrounded the tumor, AM(0) if the rim was partly discontinuous without tumor protrusion, and AM(-) if the rim was partly discontinuous with tumor protrusion. The minimal thickness of AM was measured. AM(-) tumors were re-treated consecutively., Results: In total, 85 HCCs ablated in 76 patients were evaluated. The local recurrence rate at 3 years was 2% for AM(+) tumors and 34% for AM(0) tumors (p < 0.01). In addition, no local recurrence was seen in the tumors with an AM of ≥ 2 mm., Conclusion: MRI with pre-administered SPIO is useful for determining the AM precisely, and an AM of ≥ 2 mm is recommended for curative RFA., Trial Registration Number: This study was registered with UMIN Clinical Trials Registry (UMIN 000025406).

Background: Transvenous embolization (TVE) via occluded sinus is one option for the treatment of dural arteriovenous fistulas. Understanding of the anatomical characteristics of the occluded sinus is difficult. It is often hard to reach the shunt point because of some risk of vessel perforation., Methods: We assessed usefulness of T1 Volumetric Isotropic TSE Acquisition (VISTA) Black Blood (BB) and 3D-T1 Fast Field Echo (FFE) for the evaluation and visualization of an occluded sinus. Evaluation of T1 VISTA BB and 3D-T1 FFE was performed preoperatively. TVE was performed via the occluded sinus while referring to the visualized reconstruction image., Results: Fourteen cases of TVE were performed between 2009 and 2015. The entire occluded sinus, including both thrombus and blood flow, was seen as the high-intensity region on 3D FFE T1 gadlinium (Gd). On the other hand, thrombus was seen as the iso- or high-intensity region and blood flow as the low-intensity region on T1 VISTA BB. The maximum intensity projection reconstruction image of 3D FFE T1Gd could visualize the whole occluded sinus and was useful for microcatheter maneuver. Total shunt obliteration was achieved in 13 cases (92.8%) except for one., Conclusions: Magnetic resonance imaging evaluation of the occluded sinus using both T1 VISTA BB and 3D FFE T1Gd gives us valuable information of the occluded sinus regarding the development and the course of the occluded sinus, the length of the thrombotic occlusion, and leads to safer catheter maneuvers in TVE., (Copyright © 2019. Published by Elsevier Inc.)

Background: Dural arteriovenous fistulae (dAVFs) of the anatomically complex anterior condylar confluence (ACC) are often examined by computed tomography (CT) angiography and conventional angiography before treatment. Contrasted vessels often overlap with skull bones in enhanced CT scan and make it difficult to detect the shunt point of the dAVF. Bone subtraction CT angiography (BSCTA) can overcome this limitation and allow for superior imaging of dAVFs that may help to find an alternative access for catheterization., Case Description: An 80-year-old woman suffered from right ear tinnitus, headache, and an audible bruit. Preoperative imaging showed a dAVF of the ACC. It was fed by the bilateral ascending pharyngeal artery, drained to the internal jugular vein (IJV) via the inferior petrosal sinus, and had an intraosseous shunt pouch. We therefore performed transvenous embolization (TVE) via the intercavernous sinus because the angle between the anterior condylar vein and the IJV was too sharp to catheterize vessels through the ipsilateral IJV., Conclusions: Understanding the inherently complex and individually unique venous anatomy of the ACC is crucial for treatment of dAVFs. BSCTA is an effective visualization technique for dAVFs of the ACC and allows for precise preoperative vascular structure evaluation. We suggest that in the case of the angle between the ACV and the IJV being too sharp to catheterize vessels through the ipsilateral IJV, TVE via the intercavernous sinus can be efficiently used., (Copyright © 2019 Elsevier Inc. All rights reserved.)

An 83-year-old previously self-sufficient man was referred to our hospital for a fever, severe tenderness over the lumbar spine, and elevated C-reactive protein levels. Computed tomography revealed fluid collection in the intervertebral space of L3/4. Gram-positive, short rod-shaped bacteria were isolated from two sets of blood cultures. A 16S rRNA sequence analysis of an isolate showed a similarity of 98.1% to the nearest type strain Brachybacterium squillarum JCM 16464 T . Biochemical characteristics of the presently isolated strain differed from those of the most closely related species of the genus Brachybacterium. The patient was successfully discharged on day 73 of admission with antimicrobial therapies and showed no recurrence during outpatient visits. Brachybacterium spp. have mainly been isolated from the environment, and human Brachybacterium infections have rarely been documented to date. To our knowledge, this is the first clinical isolation of Brachybacterium sp. as a causative pathogen of bloodstream infection., (Copyright © 2018. Published by Elsevier Ltd.)

Mycoplasma pneumoniae is a leading causative pathogen of pneumonia among pediatric patients, and its accurate diagnosis may aid in the selection of appropriate antimicrobial agents. We established a rapid reporting system of a polymerase chain reaction (PCR) examination for M. pneumoniae that enables physicians to obtain test results approximately 90 minutes after ordering the test. In this study, we evaluated the impact of this system on antimicrobial prescriptions for pediatric pneumonia patients after its implementation from May 2016 to April 2017. In total, we identified 375 pediatric pneumonia patients, and the results of the rapid PCR examinations for Mycoplasma pneumoniae were reported immediately in 90.7% of patients (340/375), with physicians able to use these results to decide on patients' management before the prescription of antimicrobial agents. Of the 375 pediatric pneumoniae patients, M. pneumoniae was detected in 223 (59.5%). Among the 223 M. pneumoniae-positive pneumonia cases, antimicrobial agents for atypical pathogens (macrolides, tetracyclines or quinolones) were prescribed in 97.3% (217/223) at the initial evaluation, and their prescription rates increased to 99.1% (221/223) during management. In contrast, antimicrobial agents for atypical pathogens were prescribed only in 10.5% of 152 M. pneumoniae-negative pneumonia cases at the initial evaluations, and only 1 additional case was prescribed clarithromycin for persistent symptoms during management. In conclusion, we show that molecular technology could be applicable in the field of point-of-care testing in infectious disease, and its implementation will ensure the correct antimicrobial prescription for pediatric pneumonia patients.

We report a rare case of a ruptured dissecting internal carotid aneurysm caused epistaxis without a history of trauma or infection. An 89-year-old woman experienced epistaxis and suffered from hemorrhagic shock at her previous hospital. Head computed tomography(CT)images revealed a ruptured internal carotid aneurysm protruding into the Onodi cell, the most posterior ethmoidal sinus, which extends superolaterally to the sphenoid sinus. Cerebral angiography demonstrated a multilobular-shaped dissecting aneurysm with a maximal diameter of 6.7mm at the cavernous portion of the internal carotid artery(ICA). Overlapping stenting was performed to prevent recanalization. However, a fatal subarachnoid hemorrhage occurred 2 days after the procedure due to the progression of the dissection to the intracranial ICA. The anatomical characteristics of the ethmoidal sinus could be associated with the occurrence of epistaxis. A ruptured small ICA aneurysm with an Onodi cell might cause epistaxis without a history of trauma or infection.

Background: Mycoplasma pneumoniae is a common pathogen causing pneumonia; macrolide-resistant strains are rapidly spreading across Japan. However, the clinical features of macrolide-resistant M. pneumoniae pneumonia have not been well established. Here, we evaluated the clinical characteristics and seasonal variations in the prevalence of M. pneumoniae with macrolide-resistant mutations (MRM)., Methods: The monthly prevalence of MRM in M. pneumoniae strains isolated from May 2016 to April 2017 was retrospectively analyzed, and the clinical characteristics of pneumonia cases with MRM were compared to those of cases without MRM. The M. pneumoniae isolates and point mutations at site 2063 or 2064 in domain V of 23S rRNA were evaluated by the GENECUBE system and GENECUBE Mycoplasma detection kit., Results: Mycoplasma pneumoniae infection was identified in 383 cases, including 221 cases of MRM (57.7%). The MRM prevalence was 86.3% (44/51) between May and July 2016, demonstrating an apparent decrease in September 2016, subsequently reaching 43.0% (34/79) in November 2016. Mycoplasma pneumoniae pneumonia was diagnosed in 275 cases, including 222 pediatric and 53 adult cases. Macrolide use preceding evaluation was found to be the only feature of MRM pneumonia cases both in children (odds ratio [OR] 3.86, 95% confidence interval [CI]:1.72-8.66) and in adults (OR 7.43, 95% CI: 1.67-33.1)., Conclusions: The determination rate of MRM varied widely throughout the year, and our study demonstrated the challenges in predicting M. pneumoniae with MRM based on clinical features at diagnosis. Therefore, continuous monitoring of the prevalence of MRM is warranted, which may help in selecting an effective treatment.

Background: A mediastinal air cyst is a rare computed tomography (CT) finding. Once the lesion is identified, it is difficult to diagnose and treat. Meanwhile, bronchial diverticula have been reported as a CT finding observed in certain pulmonary pathologic conditions. We encountered the case of an enlarged mediastinal air cyst accompanied with bronchial diverticula and upper lobe-dominant fibrous changes of the lung., Case Presentation: A 69-year-old man with a chronic cough who had regularly visited a chest physician for upper lobe-dominant pulmonary fibrosis was referred to our hospital for the examination of an enlarged mediastinal air cyst. Chest CT exhibited an air cyst (size, 30 mm) connected to the lumen of the left main bronchus (LMB) and multiple tiny outpouches only on the LMB. Flexible bronchoscopy showed bubbling from slits or indentations of the bronchial mucosa only in the LMB but not in the right main bronchus or lobar bronchus. For therapeutic diagnosis, we removed the air cyst. Based on clinical, surgical, and pathological findings, we diagnosed the air cyst as an enlarged bronchial diverticulum., Conclusions: This is the first case wherein bronchoscopic and surgical findings of bronchial diverticula and an enlarged bronchial diverticulum are reported. There are possible pathogenic mechanisms in cases of pulmonary disease that are attributable to enlargement of the bronchial diverticula.

Although Terson's syndrome is a well-known cause of vision loss due to intracerebral aneurysm rupture, optic nerve neuropathy can also occur because of other causes. Here, we report such a case, i.e., a ruptured anterior communicating artery aneurysm accompanied by vision loss and visual field disturbances due to a cause other than Terson's syndrome. A 47-year-old man presented with right superior altitudinal hemianopia. Computed tomography (CT) showed subarachnoid hemorrhage (SAH), and three-dimensional CT angiography revealed an anterior communicating artery aneurysm. Coil embolization was performed. Right visual acuity degenerated to blindness in the acute stage. MRI performed on day 7 post-admission revealed that the aneurysm had swollen and made contact with the right optic disk. On the basis of the patient's clinical course, we believe that the deterioration in his visual acuity could have been due to ischemic optic neuropathy (ION) resulting from SAH, and the subsequent edema and poor blood perfusion may be attributed to spasm. In cases of visual disturbance associated with SAH, as in our case, it is important to perform MRI to evaluate the damage or risk to the optic nerve as soon as possible. (Received December 26, 2016; Accepted June 9, 2017; Published October 1, 2017).

In this report, we are describing a rare case of dural arteriovenous fistula(DAVF)followed by an isolated symptom of bilateral visual acuity disturbance. The patient was a 67-year-old man suffering from progressive bilateral visual acuity disturbance. Angiography revealed a diffuse arteriovenous fistula in the left transverse-sigmoid sinus affected by severe venous congestion. Visual acuity disturbance is likely to have been caused by increased intracranial pressure(IICP). Venous congestion as well as visual acuity were gradually improved following three transarterial embolizations. It is possible that a gradual progression of the clinical condition has caused only visual acuity disturbance without any other IICP symptoms, which is similar to pseudotumor cerebri. Should an unexplained visual acuity loss occur, the case should be investigated by considering DAVF.

Purpose: To demonstrate the technical benefit of the double coaxial microcatheter technique for embolization of renal arteriovenous malformations (AVMs) with n-butyl cyanoacrylate and iodized oil (glue)., Materials and Methods: Six consecutive patients (1 man and 5 women; mean age 61 years; range 44-77 years) with renal AVMs were included. Five patients had hematuria, and one had a risk of heart failure due to a large intrarenal arteriovenous shunt. All patients underwent transarterial embolization using glue and the double coaxial microcatheter technique with outer 2.6F and inner 1.9F microcatheters. After glue injection, the inner microcatheter was retracted, while the outer microcatheter was retained. We assessed the complications and clinical outcomes of this technique., Results: Technical success was achieved in all patients. In 9 sessions, 34 feeding arteries were embolized with glue using the double coaxial microcatheter technique, 1 was embolized with glue using a single microcatheter, and 2 were embolized with coils. The double coaxial microcatheter technique was useful for selecting small tortuous feeding arteries, preventing glue reflux to the proximal arteries, and approaching multiple feeding arteries without complete retraction of the microcatheters. As a minor complication, glue migrated into the venous system in four patients without any sequelae. In all patients, favorable clinical outcomes, including hematuria cessation in five patients and improvement of the large intrarenal arteriovenous shunt in one patient, were obtained without deterioration of renal function., Conclusion: Glue embolization with the double coaxial microcatheter technique was useful for treating renal AVMs with multiple tortuous feeding arteries.

A 30-year-old man was admitted to our hospital after a bicycle accident. Proptosis, conjunctival congestion, and orbital vascular bruit appeared one month after the accident. Neuroradiological findings showed a traumatic carotid cavernous fistula(CCF). CCF is a pathologic arteriovenous shunt between the carotid artery and cavernous sinus. A detachable balloon was the standard device used for treatment of high flow direct CCF, although it is currently unavailable in Japan. Therefore, many other constructive strategies are being developed. We successfully treated this patient with single transarterial embolization using hydrogel coils. Hydrogel coils are platinum coils coated with polymeric water gels, and can be used at a prospect of delayed volume expansion. In our case, the patency of the internal carotid artery was maintained using the coils, and the symptoms improved shortly after the procedure. The use of hydrogel coils for the treatment of CCF appears to be safe and effective.

Purpose: To evaluate the clinical significance of optic chiasmal edema (OCE) observed in hydrocephalus., Materials and Methods: Twenty patients with obstructive hydrocephalus and eight patients with communicating hydrocephalus were recruited. We classified both groups into OCE-positive and negative subgroups on three-dimensional T2-weighted images. In the obstructive hydrocephalus group, the pre- and postoperative periventricular hyperintensity (PVH) grade, Evans index, and third ventricle diameter were compared between the subgroups. The visual disturbances were reviewed in the medical records., Results: Eleven obstructive hydrocephalus patients (55 %) had OCE, while none of communicating hydrocephalus patients did. OCE was improved in all patients postoperatively. Preoperative PVH grade was significantly higher in the OCE-positive subgroup (p < 0.01). There were no statistically significant differences in the other indices. Visual disturbances were observed in two OCE-negative patients alone., Conclusion: OCE is a reversible finding frequently observed in obstructive hydrocephalus and may not be associated with visual disturbances.

Background and Purpose: High-resolution 3D MR cisternography techniques such as 3D T2WI-driven equilibrium radiofrequency reset pulse (DRIVE) are used preoperatively to assess neurovascular anatomy in patients with neurovascular compression syndrome, but contrast between vessels and cranial nerves at the point of neurovascular contact is limited. The postprocessing technique subtraction of 3D T2WI-driven equilibrium radiofrequency reset pulse from contrast-enhanced 3D T1WI (sDRICE) provides both high spatial resolution and excellent contrast in depicting the neurovascular contact. We evaluated the usefulness of sDRICE compared with 3D T2WI-DRIVE., Materials and Methods: Twelve patients who underwent microvascular decompression for hemifacial spasm or trigeminal neuralgia were examined preoperatively with 3D T2WI-DRIVE and sDRICE. Two neuroradiologists retrospectively analyzed and scored lesion conspicuity, defined as the ease of discrimination between offending vessels and compressed nerves or the brain stem at the neurovascular contact. They also quantitatively analyzed the contrast and contrast-to-noise ratio at the neurovascular contact., Results: The lesion conspicuity scores of sDRICE images were significantly higher than those of 3D T2WI-DRIVE for all 12 patients (P = .006) and the 6 cases of hemifacial spasm (P = .023) but were not significantly higher in the 6 trigeminal neuralgia cases alone (P = .102). For all 12 patients, the contrast-to-noise ratio between the offending vessels and the brain stem and between the vessels and nerves on sDRICE images was significantly higher than that on 3D T2WI-DRIVE (P = .003 and P = .007, respectively). Among these structures, the contrast values were also significantly higher on the sDRICE than on the 3D T2WI-DRIVE (P < .001) images., Conclusions: The postprocessing technique sDRICE is useful to evaluate neurovascular anatomy and to improve contrast and the contrast-to-noise ratio in patients with neurovascular compression syndrome., (© 2015 by American Journal of Neuroradiology.)

A 43-year-old man was referred to our hospital for an acute-onset fever and left flank pain. He had been previously diagnosed with lymphangioma, and abdominal computed tomography showed pararenal cysts with fat stranding around the left kidney, of which infection was subsequently confirmed on magnetic resonance imaging. Gram-negative spiral bacilli were isolated from two sets of blood cultures, and Helicobacter cinaedi was identified using 16S rRNA sequencing. The patient was successfully treated with ceftriaxone therapy without recurrence. A multilocus sequence typing analysis indicated the current H. cinaedi strain differed from previous strains isolated in Japan.

The purpose of this study was to investigate the anatomical risk factors for ischemic lesions detected by diffusion-weighted imaging (DWI) associated with carotid artery stenting (CAS). DWI was performed within four days after CAS in 50 stenotic lesions between January 2008 and September 2013. We retrospectively analyzed the correlation between the anatomical factors and ischemic lesions associated with CAS. Post-procedural DWI revealed new ischemic lesions after 24 (48%) of the 50 CAS procedures. All three patients with common carotid artery tortuosity, defined as the presence of severe angulation (less than 90 degrees) in the common carotid artery, developed new ischemic lesions. However, there were no significant differences between the patients with and without tortuosity, likely due to the small number of cases. Meanwhile, seven of eight patients with internal carotid artery tortuosity, defined as the presence of severe angulation (less than 90 degrees) in the cervical segment of the internal carotid artery, developed new ischemic lesions. A multivariate analysis showed internal carotid artery tortuosity (odds ratio: 11.84, 95% confidence interval: 1.193-117.4, P= 0.035) to be an independent risk factor for the development of ischemic lesions associated with CAS. Anatomical factors, particularly severe angulation of the internal carotid artery, have an impact on the risk of CAS. The indications for CAS should be carefully evaluated in patients with these factors.

A 52-year-old Japanese woman complaining of horizontal double vision for 10 days was admitted to our hospital. Neurological examination revealed left abducent nerve palsy and muscle swelling in her thighs. Brain MRI showed obstruction in the spinal fluid space of the left Dorello's canal, which transmits a portion of the abducent nerve. In Ga-67-enhanced citrate scintigraphy, wide accumulation was seen in her bilateral thighs, lower legs, and gluteus muscles. Muscular MRI showed a star-shaped central structure on short tau inversion recovery (STIR) images, and the three stripes sign on T2-weighted images. These MRI findings indicated nodular-type muscular sarcoidosis. A muscle biopsy from the quadriceps femoris showed granulomatous epithelioid giant cells and non-necrotizing chronic lymphadenitis, which also indicate sarcoidosis. Her condition was considered to be caused by sarcoid granulomas obstructing Dorello's canal. She was treated with oral prednisolone (1 mg·kg(-1)·day(-1)) and her symptoms and MRI findings improved. This is the first known report of abducent nerve impairment in Dorello's canal, other than fetal hypoplasia. Brain MRI, muscular MRI, and muscle biopsy are useful for the diagnosis of abducent nerve palsy, and it is important to consider Dorello's canal obstruction by sarcoidosis. Complete remission can be achieved with proper treatment., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Ventriculoperitoneal shunting (VPS) is a simple procedure, but there are several potential complications. We describe the first reported case of cerebral venous thrombosis (CVT) after VPS. A 69-year-old man suffering from normal pressure hydrocephalus underwent left VPS. Two months later he developed CVT and cerebral venous hemorrhage in the left frontal lobe. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed the thrombus formation just adjacent to the shunt tube. One possible cause is compression of the cortical vein after brain shift and/or tension of the cortical vein due to intracranial hypotension. A protein C deficiency was also detected. Surgeons should be aware that cerebral venous thrombosis can occur after VPS.

A 37-year-old man was transported by ambulance to our hospital due to abrupt chest pain. The pain began when he was practicing a combative-type sport. He denied any impact or blunt trauma. A chest radiograph revealed massive left pleural effusion with a mediastinal shift. Thoracentesis revealed a hemothorax;therefore, we performed an emergency thoracotomy. The intraoperative findings revealed a rupture of a posterior mediastinal tumor itself located between the descending aorta and the thoracic vertebra. After we identified the artery of Adamkiewicz that originates away from the tumor and evaluated the degree of tumor extension into the inter-vertebral foramen, we safely performed an elective tumor resection 1 month after the initial emergency operation. In patients with a hemothorax caused by rupture of the tumor itself, an elective tumor resection after detailed investigation should be considered if hemostasis can be achieved in the emergency thoracotomy.

Purpose: To optimize imaging parameters for balanced turbo field echo (BTFE) sequence combined with motion-sensitized driven equilibrium (MSDE) preparation for endoleak detection and type classification in phantom experiments., Materials and Methods: We prepared four phantoms: a pulsatile flow generator with an aortic aneurysm model simulating no endoleak, and a type-1, type-2, and type-3 endoleak. Throughout the experiments, MSDE-BTFE images with and without flow suppression were obtained at 1.5 T and subtraction images were used for image evaluation. The no-endoleak phantom was imaged using different MSDE-BTFE sequences to optimize the k-space trajectory and evaluate the use of electrocardiogram gating. The relative contrast between flowing saline and background was calculated. Then all phantoms were imaged to determine the optimal velocity encoding (VENC) for endoleak detection and type classification. Three independent observers performed the image evaluation. Consistencies between the interpreted and true results were analyzed using kappa statistics., Results: The 3D low-high k-space trajectory with electrocardiogram gating provided the highest relative contrast. Low VENCs of 2-10 cm/s and high VENCs of 20 cm/s showed perfect consistency in endoleaks detection and type classification, respectively., Conclusion: MSDE-BTFE sequences of appropriate VENCs has potential for endoleak detection and type classification, without contrast material., (Copyright © 2013 Wiley Periodicals, Inc., a Wiley company.)

Embolic stroke is not a rare complication of cerebral angiography. The risk factors for incidental embolism after cerebral angiography were retrospectively examined using diffusion-weighted magnetic resonance imaging (DWI) in 180 patients who underwent 247 angiography procedures, consisting of 174 diagnostic angiography and 73 interventional procedures, and magnetic resonance imaging including DWI within 72 hours after angiography. The two neuroradiologists in our hospital detected embolism after cerebral angiography as high-intensity lesions (HIL) on DWI. The relationships between HIL on DWI and procedural factors were evaluated. DWI after cerebral angiography revealed HIL related to the procedure in 72 of 247 angiographies. In all procedures, age (p < 0.01), past history of cerebral infarction (p < 0.05), anti-platelet therapy (p < 0.05), neuro-intervention (p < 0.01), and total amount of contrast medium (odds ratio [OR] 2.125, 95% confidence interval [CI] 1.045-4.321) were significantly correlated with HIL. In diagnostic angiography, the performance of the procedure by a resident operator (OR 2.526, 95% CI 1.214-5.254) was significantly correlated with HIL. Age, past history of cerebral infarction, and previous anti-platelet therapy determined the risk of atherosclerotic changes in patients. The neuro-intervention and total amount of contrast medium used could predict the risk of time limitations for angiography. Resident operator is also a risk factor. This study demonstrates the importance of improving the risk of time limitations for angiography and the risk due to operator inexperience. Further training of residents may be needed to reduce the occurrence of embolic complications.

A 72-year-old man presented with a very rare case of spinal dural arteriovenous fistula (AVF) with lipomyelodysplasia manifesting as progressive paraparesis and bladder dysfunction. Magnetic resonance imaging revealed a spinal lipoma associated with tethered cord and spinal cord swelling with dilated perimedullary veins. Embolization of the spinal dural AVF was successfully performed, and is an optional treatment for coexisting spinal dural AVF and lipomyelocele in adults.

Purpose: To compare the status of uterine and ovarian arteries after uterine artery embolization (UAE) in patients with incomplete and complete fibroid infarction via unenhanced 3D time-of-flight magnetic resonance (MR) angiography., Materials and Methods: Thirty-five consecutive women (mean age 43 years; range 26-52 years) with symptomatic uterine fibroids underwent UAE and MR imaging before and within 2 months after UAE. The patients were divided into incomplete and complete fibroid infarction groups on the basis of the postprocedural gadolinium-enhanced MR imaging findings. Two independent observers reviewed unenhanced MR angiography before and after UAE to determine bilateral uterine and ovarian arterial flow scores. The total arterial flow scores were calculated by summing the scores of the 4 arteries. All scores were compared with the Mann-Whitney test., Results: Fourteen and 21 patients were assigned to the incomplete and complete fibroid infarction groups, respectively. The total arterial flow score in the incomplete fibroid infarction group was significantly greater than that in the complete fibroid infarction group (P=0.019 and P=0.038 for observers 1 and 2, respectively). In 3 patients, additional therapy was recommended for insufficient fibroid infarction. In 1 of the 3 patients, bilateral ovarian arteries were invisible before UAE but seemed enlarged after UAE., Conclusion: The total arterial flow from bilateral uterine and ovarian arteries in patients with incomplete fibroid infarction is less well reduced than in those with complete fibroid infarction. Postprocedural MR angiography provides useful information to estimate the cause of insufficient fibroid infarction in individual cases.

Intracranial hemangioblastomas (HBs) are hypervascular neoplasms mainly located in the posterior fossa of the central nervous system. Preoperative embolization of the feeding arteries is one proposal for reduction of intraoperative hemorrhage, although indications for the procedures should be evaluated carefully due to the potential complications. This retrospective study investigated clinical outcomes and complications of 15 patients with HBs in the posterior fossa to evaluate the safety and effectiveness of endovascular procedures as well as angiographical procedures. Surgical excision without presurgical embolization was performed in 8 cases, and excision with presurgical embolization was performed in 7 cases, using Guglielmi detachable coils with or without polyvinyl alcohol (GDC ± PVA) in 4 cases and only n-butyl 2-cyanoacrylate (NBCA) in 3 cases. The embolization was applied for selected cases in which feeding arteries were located in a deep site and hard to coagulate surgically. Partial embolization was achieved in 5 cases, and all feeders were successfully embolized in 2 cases. Total removal was achieved in 12 cases, and subtotal/partial removal was achieved in 3 cases. Subarachnoid hemorrhage with intratumoral hemorrhage occurred in 1 case during the angiographic procedure and in 1 case during the embolization procedures. The mean volume of intraoperative blood loss was clearly less in the NBCA group than in the GDC ± PVA group. HBs are mainly located in the posterior cranial fossa, so the risk of severe clinical complication may be high if vascular problems occur. In our series, presurgical embolization using NBCA made tumor removal safe and reduced bleeding volume in posterior fossa HBs.

Purpose: The purpose of this study was to evaluate cerebral blood flow through the bypass in operated patients with Moyamoya disease using multiphase selective arterial spin labeling (ASL) technique., Materials and Methods: Fifteen surgically treated cerebral hemispheres from 11 patients with Moyamoya disease were included. Selective ASL examinations were performed during the early postoperative period (mean, 5.5 days) on 4 hemispheres and late postoperative period (mean, 332.7 days) on 15 hemispheres. The labeling slab was positioned at the bypassed external carotid artery and 5 slices in each of the 10 sequential phases were acquired using a 3-T scanner., Results: Two of 4 early postoperative ASL examinations and all late postoperative ASL examinations demonstrated blood flow through the bypass. The remaining 2 early postoperative ASL examinations showed absence of blood flow; however, blood flow improved on follow-up examinations., Conclusion: Multiphase selective ASL technique can provide information about the dynamics of postoperative blood flow through the bypass in Moyamoya disease.