Akira Iijima

Diagnosis of Eagle syndrome with 3-dimensional angiography and near-infrared spectroscopy: case report.

BACKGROUND AND IMPORTANCE:Elongated styloid processes sometimes compress the cervical carotid artery, causing transient ischemic attacks. Most patients with Eagle syndrome who experience transient ischemic attacks have bilateral elongated styloid processes; therefore, it is necessary to determine which side is causing the Eagle syndrome to treat it. This is the first report of the usefulness of 3-dimensional angiography and near-infrared spectroscopy (NIRS) for the diagnosis of Eagle syndrome. CLINICAL PRESENTATION:A 40-year-old man experienced transient loss of consciousness when flexing his neck. On 3-dimensional computed tomography, bilateral elongated styloid processes were revealed. We were able to determine the side of concern using 3-dimensional angiography and NIRS. Three-dimensional angiography with his neck flexed showed a compressive dent in the cervical portion of the left internal carotid artery. On NIRS, during neck flexion, the concentrations of oxygenated hemoglobin and total hemoglobin decreased in his left motor area, which was resolved immediately when he returned his neck to its natural position. This led to decreased cerebral blood flow in the left hemisphere of his brain. After partial removal of left styloid process, he was symptom free, even when keeping his neck flexed. NIRS showed that the concentrations of oxygenated hemoglobin increased in the left motor area during neck flexion. CONCLUSION:We report the usefulness of 3-dimensional angiography and NIRS for diagnosing Eagle syndrome. Three-dimensional angiography and NIRS can visualize anatomic structures and provide hemodynamic information for an appropriate surgical strategy.

Clot-Clearance Rate in the Sylvian Cistern Is Associated with the Severity of Cerebral Vasospasm After Subarachnoid Hemorrhage

Rapid clot removal and clearance has been proposed as an effective tool for preventing cerebral vasospasm after subarachnoid hemorrhage (SAH). We examined the relationship between clot-clearance rate and the severity of cerebral vasospasm in 110 consecutive patients with aneurysmal SAH. We measured clot-clearance rates per day in the basal and Sylvian cisterns, and evaluated the presence of symptomatic vasospasm based on changes in clinical symptoms and the appearance of a new low-density area on a computed tomography (CT) scan. The severity of symptomatic cerebral vasospasm was associated with age and the SAH grade on admission; however, we observed no significant difference between these variables in patients with urokinase irrigation or fasudil hydrochloride treatment. The mean clot-clearance rates per day for patients with asymptomatic and permanent delayed ischemic neurological deficit were 41.9 and 41.5 %, respectively, in the basal cistern (P = 0.7358) and 37.7 and 23.9 %, respectively, in the Sylvian cistern (P = 0.0021). The reduced clot-clearance rate in the Sylvian cistern increased the risk of vasospasm-related infarction (P = 0.0093) and markedly reduced unfavorable outcomes (P = 0.0115).

Successful treatment of cerebral hemorrhage using computed tomography angiography in a patient with left-ventricular-assist device

Cerebral hemorrhage is one of the common complications associated with left-ventricular-assist device (LVAD) treatment and leads to a high mortality rate because of excessive bleeding due to frequently unknown causes. Cerebral angiography is used to diagnose cerebrovascular events and is well recognized as being very useful for this purpose. We performed a cerebral angiography for a patient with an LVAD who developed cerebral hemorrhage, and the hemorrhagic source was clearly identified. The patient underwent successful neurosurgical treatment, which was followed by heart transplantation.

Stent-assisted Coiling for Ruptured Basilar Artery Dissecting Aneurysms: An Initial Experience of Four Cases

No treatment strategy has been established for subarachnoid hemorrhages due to basilar artery (BA) trunk dissecting aneurysms. Our aim was to report our initial experience performing stent-assisted coiling (SAC) for ruptured BA dissecting aneurysms to validate the effectiveness of this treatment. We experienced four consecutive cases of ruptured dissecting BA trunk aneurysm treated with SAC between 2008 and 2014 at three institutions. Aneurysm rebleeding was prevented without causing severe brainstem ischemia in all cases. In our opinion, both the blockage of the inflow to aneurysms and the preservation of the antegrade flow of the BA can be achieved by SAC, although controversies regarding long-term stability and appropriate antiplatelet therapy remain.

Staged surgical treatment for symptomatic vertebrobasilar artery stenosis: combined treatment with endovascular angioplasty and bypass surgery.

OBJECTIVE Because the early risk of stroke recurrence in patients with posterior circulation infarctions is high, patients with vertebrobasilar events require active preventive treatment. Previous reports have described the use of balloon angioplasty and stenting or surgical revascularization to the vertebrobasilar artery area. To compensate for the disadvantages of these techniques, we combined endovascular and surgical treatments in a patient with symptomatic vertebrobasilar artery stenosis. METHODS After endovascular surgery, we continued medical therapy to stabilize the blood flow in the posterior circulation. Superficial temporal artery-superior cerebellar artery bypass was planned for the chronic stage (∼1-2 months). RESULTS Three cases (2 vertebral artery stenosis, 1 basilar artery stenosis) presented with recurrent transient ischemic attacks or deteriorating symptoms under intensive medical treatment. We conducted staged therapy using balloon angioplasty followed by superficial temporal artery-superior cerebellar artery bypass. All patients were symptom-free after treatment with the combined therapy. CONCLUSIONS Our staged therapy may be an effective treatment for symptomatic vertebrobasilar artery stenosis.

Endovascular treatment of cerebral hemorrhage in a patient with a left ventricular assist device: report of a case

Cerebral hemorrhage is a common lethal complication associated with left ventricular assist device (LVAD) management. We performed cerebral angiography on patients with LVAD who developed cerebral hemorrhage and determined that ruptured aneurysms were the cause in some cases. Endovascular management of patients with LVAD can be a therapeutically useful approach for cerebral hemorrhage caused by aneurysm rupture.

Swine model of in-stent stenosis in the iliac artery evaluating the serial time course

The aim of this study was to propose a new animal model evaluating the serial time course of in-stent stenosis by repeated carotid artery catheterization in the same animal. 16 bare-metal stents were implanted in the normal external and internal iliac artery of 8 miniature pigs. Repeated measurements were performed in the same animal every 2 weeks for 12 weeks through carotid artery catheterization. The time course and peak neointimal proliferation were evaluated by intravascular ultrasound. Health of all animals was assessed by clinical and hematological examinations. As a result, 7 times of carotid artery catheterization was performed per pig, but all animals remained healthy without both any complications and hematological inflammatory abnormalities. The time course of neointimal proliferation of each stent was observed from the stage of hyperplasia to partial regression. The peak neointimal proliferation varied from 6 to 12 weeks despite implantation of identical stents using the same deployment method. In conclusion, repeated carotid artery catheterization to the same animal is feasible without animal health deterioration. This model should be useful to evaluate the time course of neointimal proliferation after stent deployment in preclinical study.

Intracranial dural arteriovenous fistula associated with a spinal tumor: a case report

Dear Editor, We would like to present the case of a patient with a transverse-sigmoid dural arteriovenous fistula (DAVF) associated with a spinal dumbbell schwannoma. Intracranial DAVFs are characterized by an arteriovenous (AV) shunt between the dural arteries and major intracranial dural sinuses [1]. Predisposing causes have been reported to be the presence of an intracranial brain tumor [3], a past history of intracranial surgery [6], head trauma [2], and brain infarction [4]. The most frequent brain tumor in patients with DAVFs is meningioma, which commonly develops adjacent to, and invades into, the dural sinuses [3, 5, 7, 8]. To our knowledge, there have been no case reports of an intracranial DAVF associated with a spinal tumor. A 70-year-old female had become aware of a ‘floating’ gait 10 years prior to admission and later noticed bilateral pulsating tinnitus 2 years prior to admission. On admission, neurological examination revealed slight right spastic hemiparesis, sensory disturbances in the peripheries of the upper and lower extremities, and the Romberg sign. Spinal MR imaging revealed an extramedullary spinal dumbbell tumor, which significantly compressed the spinal cord at the C2 level (Fig. 1). There were many flow voids in the posterior cervical muscle layers around the tumor. Digital subtraction angiography revealed a right transverse-sigmoid DAVF without cortical venous reflux. There were multiple AV connections between the dural arteries and the transverse and sigmoid sinuses mainly at the sinus confluence; these dural branches were fed predominantly by the right vertebral artery as well as the bilateral maxillary and occipital arteries. Contrast-enhanced CT revealed that the right internal carotid vein was severely compressed at the right C2 level between the spinal tumor and anterior deep cervical muscles originating from the right styloid process. As a result, the right internal carotid vein was thrombosed, and the thrombus progressed into the right jugular foramen to the sigmoid sinus (Fig. 1d). Arterial blood flow into the DAVF drained out via the enlarged right condylar emissary vein into the deep cervical vein. We planned to treat the DAVF with endovascular embolization before open surgery because there was massive venous drainage around the tumor and severe bleeding during tumor removal was predicted. First, dural arteries were occluded with NBCA via a transarterial approach. Then, the deep cervical vein was occluded with NBCA via a transvenous approach. Finally, the right transverse and sigmoid sinuses were packed with coils, leading to the occlusion of the DAVF. In the second stage, we performed open surgery via a posterior midline approach. During surgery, bleeding was wellcontrolled because most of the deep cervical veins were occluded with NBCA. The dumbbell tumor, which was mostly located in the epidural space, was extensively removed, piece by piece, leading to successful decompression of the spinal cord. Total blood loss was 312 ml. The pathological diagnosis was schwannoma. * Keisuke Takai takai-nsu@umin.ac.jp