Hiroyuki Aburano

Bronchial Artery Aneurysm Embolization with NBCA

We present a case of asymptomatic bronchial artery aneurysm that formed a fistula with part of the pulmonary artery (there was no definite fistula with the pulmonary vein). We were able to catheterize the feeding vessel but could not reach the aneurysm. We therefore injected a mixture of N-butyl-2-cyanoacrylate (NBCA; Histoacryl, B. Braun, Melsungen, Germany) and iodized oil (Lipiodol; Guerbet, Aulnay-sous-Bois, France) from the feeding vessel. The fistula, aneurysm, and feeding vessel were almost totally occluded. After embolization, the patient coughed a little; there were no other definite side effects or complications. One and 3 months later, on chest CT, the aneurysm was almost completely occupied with hyperattenuating NBCA-Lipiodol embolization. NBCA is a liquid embolization material whose time to coagulation after injection can be controlled by diluting it with Lipiodol. It is therefore possible to embolize an aneurysm, feeding vessels, and efferent vessels (in our case, it was a fistula) by using an NBCA-Lipiodol mixture of an appropriate concentration, regardless of whether the catheter can reach the aneurysm or not.

Common hepatic artery aneurysm treated with an endovascular stent-graft: a case report

We present the case of a common hepatic artery aneurysm successfully treated with an endovascular stent-graft. Although the long-term usefulness of stent-graft placement is not confirmed, the favorable mid-term course in our patient suggests that stent-graft placement may be considered as the treatment of choice in selected cases with hepatic artery aneurysm.

Acute Cholecystitis Caused by Malignant Cystic Duct Obstruction: Treatment with Metallic Stent Placement

We report the successful management of acute cholecystitis using cystic duct stent placement in 3 patients with inoperable malignant cystic duct obstruction (2 cholangiocarcinoma and 1 pancreatic carcinoma). All patients underwent stent placement in the bile duct, using an uncovered stent in 2 and a covered stent in 1, to relieve jaundice occurring 8–184 days (mean 120 days) before the development of acute cholecystitis. The occluded cystic duct was traversed by a microcatheter and a stent was implanted 4–17 days (mean 12 days) after cholecystostomy. Acute cholecystitis was improved after the procedure in all patients. Two patients died 3 and 10 months later, while 1 has survived without cholecystitis for 22 months after the procedure to date.

Creation of a Cleft in an Angiography Catheter to Facilitate Catheterization of Branches of the Aorta Arising at an Acute Angle

The authors report on the use of a catheter with a cleft for catheterization of a branch artery arising from the aorta with an acute angle. The cleft was created on either the right or cephalad portion at the tip of a seated 4-F shepherd hook catheter in the artery origin, depending on vessel angulation during chemoembolization procedures. This catheter was used in eight arteries-seven inferior phrenic arteries and one right subcostal artery-that could not be catheterized with a conventional coaxial technique. The microcatheter was successfully introduced into all eight vessels through the cleft without complications.

MR Spectroscopy to Distinguish between Supratentorial Intraventricular Subependymoma and Central Neurocytoma

Purpose: The purpose of this study was to discriminate supratentorial intraventricular subependymoma (SIS) from central neurocytoma (CNC) using magnetic resonance spectroscopy (MRS). Methods: Single-voxel proton MRS using a 1.5T or 3T MR scanner from five SISs, five CNCs, and normal controls were evaluated. They were examined using a point-resolved spectroscopy. Automatically calculated ratios comparing choline (Cho), N-acetylaspartate (NAA), myoinositol (MI), and/or glycine (Gly) to creatine (Cr) were determined. Evaluation of Cr to unsuppressed water (USW) was also performed. Mann-Whitney U test was carried out to test the significance of differences in the metabolite ratios. Detectability of lactate (Lac) and alanine (Ala) was evaluated. Results: Although a statistically significant difference (P < 0.0001) was observed in Cho/Cr among SIS, control spectra, and CNC, no statistical difference was noted between SIS and control spectra (P = 0.11). Statistically significant differences were observed in NAA/Cr between SIS and CNC (P = 0.04) or control spectra (P < 0.0001). A statistically significant difference was observed in MI and/or Gly to Cr between SIS and control spectra (P = 0.03), and CNC and control spectra (P < 0.0006). There were no statistical differences between SIS and CNC for MI and/or Gly to Cr (P = 0.32). Significant statistical differences were found between SIS and control spectra (P < 0.0053), control spectra and CNC (P < 0.0016), and SIS and CNC (P < 0.0083) for Cr to USW. Lac inverted doublets were confirmed in two SISs. Triplets of Lac and Ala were detected in four spectra of CNC. Conclusion: The present study showed that MRS can be useful in discriminating SIS from CNC.

Splenial and White Matter Lesions Showing Transiently-reduced Diffusion in Mild Encephalopathy Monitored with MR Spectroscopy and Imaging

We report the time course of magnetic resonance imaging and spectroscopy of a case with lesions of the splenium and white matter with transiently reduced diffusion in clinically reversible encephalopathy. Initially normal spectroscopy showed slightly elevated choline. Signal abnormality in T2-weighted and fluid-attenuated inversion recovery images persisted for 90 days. Lesions of the splenium and white matter with transiently reduced diffusion in clinically reversible encephalopathy are not always reversible and may reflect heightened glial cell-membrane turnover without neuronal damage.

Long-term predictive factors of the morphology based outcome in bare platinum coiled intracranial aneurysms: Evaluation by pre- and post-contrast 3D time-of-flight MR angiography

PURPOSE Our aim was to identify long-term predictive factors of the morphology-based outcome (MBO) of bare platinum coiled intracranial aneurysms. MATERIALS AND METHODS A retrospective analysis of 96 bare platinum coiled intracranial aneurysms followed up from 1997 to 2016 using pre- and post-contrast 3D time-of-flight MR angiography (MRA) was performed. Logistic regression analysis was used to identify factors associated with a positive history of surrounding coil mass enhancement (SCME) and poor MBO. Spearmans rank correlation test was used to analyze the relationship between the initial angiographic result (IAR) class, sequential change of the SCME category, and MBO grade. RESULTS Factors independently associated with poor MBO were incomplete IAR (OR=14.94, 95%CI: 2.46, 289.21, P=0.002) and a history of SCME (OR=4.13, 95% CI: 1.05, 18.65, P=0.043). The MBO grade strongly correlated with the IAR class (correlation coefficient [r]=0.84, P<0.0001). MBO grade correlated with sequential change of the SCME category (r=0.56, P<0.0001). The sequential change of the SCME category correlated with IAR class (r=0.53, P<0.0001). CONCLUSION Although IAR and its class were strong long-term predictive factors of MBO, a history of SCME and upgrading of sequential change of SCME category were also long-term predictive factors of the MBO of bare platinum coiled intracranial aneurysms.

Cranial Pachymeningeal Involvement in POEMS Syndrome: Evaluation by Pre- and Post-contrast FLAIR and T1-weighted Imaging

Purpose: To evaluate the cranial pachymeningeal involvement of polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, skin changes (POEMS) syndrome using pre- and post-contrast fluid-attenuated inversion recovery (FLAIR) and T1-weighted imaging (T1WI). Methods: The appearance of pachymeningeal involvement in nine cases of POEMS syndrome was evaluated using pre- and post-contrast FLAIR and T1WI. The degree of pachymeningeal thickening was graded as normal or abnormal using pre-contrast FLAIR. The degrees of contrast enhancement effect were evaluated based on pre- and post-contrast images, and recorded in each of three separate anatomical areas, i.e., the falx cerebri, cerebral convexity, and tentorium cerebelli. The degrees of contrast enhancement of pachymeninges were graded as not detected (ND), positive, or prominent on post-contrast FLAIR, and normal range (NR), positive, and prominent on post-contrast T1WI. Results: Pre-contrast FLAIR demonstrated 41% of pachymeningeal anatomical regions as areas of thickening. Post-contrast FLAIR did not detect any contrast enhancement on 26% of the regions but showed positive enhancement on 30% and prominent enhancement on 44%. Post-contrast T1WI showed normal range enhancement on 48%, positive enhancement on 11%, and prominent enhancement on 41% of the regions. Post-contrast FLAIR showed the highest percentage for detection of pachymeningeal abnormalities (74%). Conclusion: Post-contrast FLAIR may contribute to objective judgment in the evaluation of pachymeningeal involvement in POEMS syndrome.

Striatal hemihypoplasia: An early embryonic variant of cerebral hemiatrophy

We present a case of hemihypoplasia of the striatum with ipsilateral cerebral hemispheric atrophy. The head of the caudate nucleus and putamen were hypoplastic, and gray matter cell bridges between them located in the anterior limb of the internal capsule were sparse. Cerebral atrophy was accompanied by ipsilateral mesial temporal sclerosis without thalamic atrophy. The anterior limb of the internal capsule showed no signal abnormalities or volume loss. These imaging findings and the hyperintensity at the fundus striati suggest an early embryonic insult of lateral striatal elevation.

Balloon angioplasty for traumatic popliteal artery disruption: sustained patency at 9 years.

The prompt management of patients presenting with limb-threatening ischemia owing to traumatic arterial injury is critical. In many cases, endovascular treatment of blunt vascular trauma plays an important role in avoiding surgical intervention or amputation. Among these techniques, balloon angioplasty has been applied to treat intimal injuries by pushing the intimal flap against the vascular wall to restore arterial flow. In the presence of complete limb ischemia, time is critical to prevent limb loss. To salvage the limb, total ischemic time should be ,4 hours. Hutto and Reed recently reported successful treatment of blunt popliteal artery trauma in an acutely ischemic extremity. Nine years ago, we encountered a similar situation. A 50-year-old woman fell from the third floor during demolition work. She suffered multiple fractures; notably, the left limb had an open burst fracture. Arteriography showed an intimal flap injury of the left popliteal artery, but arterial flow was maintained (Figure, A). The patient was transferred to the operating room for fixation of the fractures. Three hours after surgery, the leg became acutely ischemic; emergent angiography demonstrated disruption of the left popliteal artery at the intimal injury site (Figure, B and C). A 3-mm32-cm balloon catheter (Slalom Thrill; Cordis Europe, Roden, The Netherlands) was advanced into the disrupted portion and inflated 3 times for 60 seconds at 12 atmospheres. Arteriography documented no contrast extravasation, expansion of the disrupted portion, and good flow (Figure, D). Her left limb was salvaged, and she was ambulatory when discharged. The patient has continued to do well without major problems 9 years after intraluminal repair of the disrupted popliteal artery. Balloon angioplasty is a simple technique that can be completed relatively quickly under local anesthesia without special equipment. The durability of this approach to traumatic popliteal artery disruption is evident in this case.