Kenji Sugiu

Assessment of the difference in posterior circulation involvement between pediatric and adult patients with moyamoya disease

OBJECTnThere is no description of the change in the posterior cerebral artery (PCA) in the diagnostic criteria of moyamoya disease (MMD). However, PCAs are often involved in the clinical setting, and an understanding of the significance of PCA lesions is therefore of great importance when evaluating the disease progression and predicting prognosis. The aim of this study was to assess the difference in posterior circulation involvement in pediatric and adult patients with MMD.nnnMETHODSnThe records of 120 consecutive patients with MMD were reviewed. The clinical manifestations at diagnosis were evaluated on the basis of symptoms and CT and MRI findings. The degree of steno-occlusive internal carotid artery (ICA) lesions and the existence of steno-occlusive PCA lesions were evaluated by observing a total of 240 ICAs and PCAs on angiography. Angiographic correlation between anterior and posterior circulation was assessed in pediatric and adult patients with MMD.nnnRESULTSnSeventeen (26%) of 66 pediatric patients and 18 (33%) of 54 adult patients exhibited steno-occlusive PCA lesions. There was no significant difference in the prevalence of PCA lesions between pediatric and adult patients with MMD (p = 0.36). The prevalence of infarction in pediatric and adult patients with PCA involvement was significantly higher than that in pediatric and adult patients without PCA involvement (p = 0.0003 and p = 0.003, respectively). There was no significant difference in the distribution of infarction areas between pediatric and adult patients with PCA involvement (p = 0.62). On the basis of the staging system used, steno-occlusive lesions in ICAs ipsilateral to PCAs with lesions were in significantly advanced stages compared with lesions in ICAs ipsilateral to PCAs without lesions in both pediatric and adult cases (p < 0.0001 and p = 0.0008, respectively). Pediatric patients had less advanced steno-occlusive lesions in ICAs ipsilateral to PCAs with lesions compared with adults (p < 0.05).nnnCONCLUSIONSnThe clinical significance of posterior circulation involvement in MMD was similar between pediatric and adult patients. The only significant difference was that less advanced ICA lesions could complicate posterior circulation involvement in pediatric patients.

Mannitol enhances therapeutic effects of intra-arterial transplantation of mesenchymal stem cells into the brain after traumatic brain injury

Traumatic brain injury (TBI) sustained in a traffic accident or a fall is a major cause of death that affects a broad range of ages. The aim of this study was to investigate the therapeutic effects of intra-arterial transplantation of mesenchymal stem cells (MSCs) combined with hypertonic glycerol (25%) or mannitol (25%) in a TBI model of rats. TBI models were produced with a fluid percussion device. At 24h after TBI, MSCs (1×10(6)cells/100μl) with glycerol or mannitol were administered via the right internal carotid artery. Rats were evaluated behaviorally and immunohistochemically, and hyperpermeability of the blood-brain barrier (BBB) induced by hypertonic solutions was explored. Compared to PBS or glycerol, the administration of mannitol resulted in increased BBB disruption. The mannitol-treated rats showed significant improvement in motor function. Intra-arterial transplantation of MSCs caused no thromboembolic ischemia. Immunohistochemically, more MSCs were observed in the injured brain tissues of mannitol-treated rats than in glycerol or PBS-treated rats at 24h after transplantation. Intra-arterial transplantation of MSCs combined with mannitol is an effective treatment in a TBI model of rats. This technique might be used for patients with diseases of the central nervous system including TBI.

Recent trends in neuroendovascular therapy in Japan: analysis of a nationwide survey--Japanese Registry of Neuroendovascular Therapy (JR-NET) 1 and 2.

The present study retrospectively analyzed the database of the Japanese Registry of Neuroendovascular Therapy 1 and 2 (JR-NET1&2) to determine annual trends, including adverse events and clinical outcomes at 30 days after undergoing neuroendovascular therapy. JR-NET1&2 are surveys that targeted all patients in Japan who underwent neuroendovascular therapy delivered by physicians certified by the Japanese Society of Neuroendovascular Therapy (JSNET) between 2005 and 2009. Medical information about the patients was anonymized and retrospectively registered via a website. Data from 32,608 patients were analyzed. The number of treated patients constantly increased from 5,040 in 2005 to 7,406 in 2009 and the rate of octogenarians increased from 7.0% in 2005 to 10.4% in 2009. The proportion of procedures remained relatively constant, but ratios of angioplasty slightly increased from 32.8% in 2005 to 33.7% in 2009. Procedural complications were associated more frequently with acute stroke (9.6%), ruptured aneurysms (7.4%), intracranial artery disease (ICAD) (5.4%), and arteriovenous malformation (AVM, 5.2%). The number of patients requiring neuroendovascular treatment in Japan is increasing and the outcomes of such therapy are clinically acceptable. Details of each type of treatment will be investigated in sub-analyses of the database.

Anti-high mobility group box-1 (HMGB1) antibody attenuates delayed cerebral vasospasm and brain injury after subarachnoid hemorrhage in rats

Although delayed cerebral vasospasm (DCV) following subarachnoid hemorrhage (SAH) is closely related to the progression of brain damage, little is known about the molecular mechanism underlying its development. High mobility group box-1 (HMGB1) plays an important role as an initial inflammatory mediator in SAH. In this study, an SAH rat model was employed to evaluate the effects of anti-HMGB1 monoclonal antibody (mAb) on DCV after SAH. A vasoconstriction of the basilar artery (BA) associated with a reduction of nuclear HMGB1 and its translocation in vascular smooth muscle cells were observed in SAH rats, and anti-HMGB1 mAb administration significantly suppressed these effects. Up-regulations of inflammation-related molecules and vasoconstriction-mediating receptors in the BA of SAH rats were inhibited by anti-HMGB1 mAb treatment. Anti-HMGB1 mAb attenuated the enhanced vasocontractile response to thrombin of the isolated BA from SAH rats and prevented activation of cerebrocortical microglia. Moreover, locomotor activity and weight loss recovery were also enhanced by anti-HMGB1 mAb administration. The vasocontractile response of the BA under SAH may be induced by events that are downstream of responses to HMGB1-induced inflammation and inhibited by anti-HMGB1 mAb. Anti-HMGB1 mAb treatment may provide a novel therapeutic strategy for DCV and early brain injury after SAH.

Clinical and radiographic features of moyamoya disease in patients with both cerebral ischaemia and haemorrhage.

Abstract Objectives. Patients with moyamoya disease (MMD) very rarely develop both cerebral ischaemia and haemorrhage. The aim of this study was to clarify the clinical and radiographic features of MMD in patients who presented with both ischaemia and haemorrhage, compared with MMD patients who presented with one or the other. Materials and methods. The records of 92 consecutive patients with MMD were reviewed. These patients were divided into three groups, according to the type of presentation: ischaemic presentation (Group I); haemorrhagic presentation (Group H); and haemorrhagic-ischaemic presentation (Group H-I). The patient characteristics, areas of infarction, and angiographic findings were evaluated. Results. Seventy-six (82%) of the 92 patients were categorised as Group I, 7 (8%) as Group H, and 9 (10%) as Group H-I. Median follow-up periods for Group H-I was 55 months (IQR, 36–116 months). There were eight females in Group H-I, in which the median age was 30 years. Of the nine cases in Group H-I, six presented with cerebral haemorrhage as the precedent event and three had complications during the acute phase. In Group H-I, the prevalence of posterior cerebral artery (PCA) lesions was high (42%) and infarctions were most frequently found in PCA-related areas. Conclusions. The presence of steno-occlusive PCA lesions may be of pathogenic importance in MMD patients who develop both cerebral ischaemia and haemorrhage. The prevalence of this type of stroke in MMD patients is higher than expected, and further investigation in clinical settings is thus warranted.

Long-term outcomes in adult patients with ischemic-type moyamoya disease involving posterior circulation

BackgroundThe object of this study was to compare the long-term outcomes in adult patients with moyamoya disease (MMD) with posterior circulation involvement (PCi) treated through surgical revascularization with those in adult patients without PCi.MethodsThe records of 32 consecutive adult patients with ischemic-type MMD who were treated with revascularization were reviewed. Twelve of these patients (38xa0%) had PCi at initial onset. Clinical characteristics of the patients with PCi were compared to those without PCi. Neurological outcomes were assessed using the modified Rankin Scale (mRS) in the preoperative and postoperative follow-up periods. A five-year Kaplan-Meier stroke risk was calculated.ResultsThe frequency of presenting with infarction was significantly higher among patients with PCi than among those without PCi (pu2009=u20090.006). mRS scores in the preoperative period were significantly higher in patients with PCi than in patients without PCi (pu2009=u20090.0004). There were no significant differences in mRS scores between the preoperative and postoperative follow-up period in patients with PCi (pu2009=u20090.3), nor were there any between the preoperative and postoperative follow-up periods in patients without PCi (pu2009=u20090.2). The five-year Kaplan-Meier risk of surgical morbidity and ipsilateral stroke was 14.3xa0% in surgically treated hemispheres with PCi versus 14.9xa0% in surgically treated hemispheres without PCi (pu2009=u20090.96).ConclusionsPCi at initial onset was significantly correlated with poor outcome. Revascularization for the middle cerebral artery territory in patients with PCi was effective at preventing recurrent ischemic stroke.

Successful embolization of a spinal perimedullary arteriovenous fistula with cellulose acetate polymer solution: Technical case report

OBJECTIVE AND IMPORTANCE Spinal perimedullary arteriovenous fistulae are rarely reported in the literature and can be treated via both endovascular and direct surgical approaches. Coils, glues, and balloons have all been used to embolize these fistulae. Cellulose acetate polymer (CAP) solution is a liquid embolic material that was originally developed for thrombosis of cerebral aneurysms. This is the first report of CAP solution being used to treat a spinal perimedullary arteriovenous fistula, with changes in the viscosity of the solution. CLINICAL PRESENTATION A 15-year-old boy experienced spinal subarachnoid hemorrhage without any neurological deficits. A radiological examination revealed a spinal perimedullary arteriovenous fistula (Type 2) at the L1 level. INTERVENTIONTransarterial embolization was performed with local anesthesia. The microcatheter was navigated through the anterior spinal artery to a site just proximal to the fistula. After provocative testing demonstrated negative results, CAP solution was injected and the fistula was completely closed, without complications. The patient experienced an uneventful postoperative course. CONCLUSIONWe describe the usefulness of CAP solution in the treatment of a spinal perimedullary arteriovenous fistula. This procedure must be performed for a larger series of patients for assessment of its long-term results.

Nationwide survey of the nature and risk factors of complications in embolization of meningiomas and other intracranial tumors: Japanese Registry of NeuroEndovascular Therapy 2 (JR-NET2).

IntroductionEmbolization of intracranial tumor is widely performed in Japan, mainly before neurosurgical resection. A retrospective, multicenter, observational study in Japan was conducted to clarify the nature, frequency, and risk factors of complications in intracranial tumor embolization.MethodsPatients were derived from the Japanese Registry of NeuroEndovascular Therapy 2 (JR-NET2). A total of 20,854 patients were enrolled in JR-NET2, of which 1,018 patients (4.88xa0%) with intracranial tumors underwent embolization. The primary end point was the proportion of patients with a modified Rankin scale (mRS) score of 0–2 (independency) at 30xa0days. The secondary end point was the occurrence of complications related to the procedures. The risk factors of the occurrence of complications were studied.ResultsThe proportion of patients with mRS scores ≤2 at 30xa0days after procedure was 91.3xa0%. Complications occurred in 15 of the 1,012 patients (1.48xa0%). Multivariate analysis showed that embolization for tumors other than meningioma (OR, 4.626; 95xa0% CI, 1.347–14.59; pu2009=u20090.0105) was significantly associated with the development of complications.ConclusionThe frequency of complications after intracranial tumor embolization was relatively low in this large Japanese cohort. Embolization for tumors other than meningioma was the only significant risk factor for the occurrence of complications.

[Cervical spinal dural arteriovenous fistula with rapidly progressive brainstem dysfunction due to venous congestion: a case report].

Spinal dural arteriovenous fistulas(S-dAVFs)are rare vascular malformations of the spine. We experienced a case that presented with rapidly progressive brainstem dysfunction due to venous congestion of cervical dAVFs. A 56-year-old man diagnosed with cervical dAVF four years prior presented with gait disturbance and abnormal thermal nociception on his right side. In addition to the high-intensity lesion from the lower pons to the medulla oblongata on T2-weighted magnetic resonance imaging, diffusion-weighted imaging demonstrated cerebral infarction of the left ventrolateral medulla oblongata. Left vertebral angiography revealed that a feeding artery supplied by the radicular artery at the C4 level formed a fistula with the dilated ascending anterior perimedullary vein. We made a diagnosis of venous congestion due to cervical dAVFs. Numbness on the left upper limb occurred five days after the first symptom. Subsequently, hemiparesis on the left upper limb and swallowing disturbance occurred two weeks after the first symptom. The patient underwent surgical ligation of the dilated abnormal vein, with gradual improvement of his symptoms. Myelopathy due to venous congestion of S-dAVFs usually progresses slowly for several years. However, this case report warns about the possibility that some cases of S-dAVF with rapidly exacerbated symptoms may require prompt therapy.

Combined Transarterial and Transvenous Approach for Curative Obliteration of Klippel-Trenaunay-Weber Syndrome-Associated Spinal Perimedullary Arteriovenous Fistulas.

flow AVF (double arrows in Fig. 2a and b), which drained into the descending perimedullary vein and exited the intrathecal space at the left L4/5 intervertebral foramen (white arrowhead in Fig. 2b), before joining the right iliac vein (black arrowhead in Fig. 2b). Angiograms of the left L-4 segmental artery disclosed three ascending feeder branches. The anterior and posterior branches formed a circle with the descending feeder from the left T-11 artery and fed the above mentioned large AVF (double arrows in Fig. 2c and d). The middle branch supplied blood to another smaller AVF at a different fistulous point (white arrows in Fig. 2c and d) that drained into a smaller perimedullary vein with a venous pouch (black arrows in Fig. 2c and d), which was compatible with the source of the intramedullary hematoma. Urgent treatment for flow reduction was performed to prevent further progression of the symptoms. An Excelsior® SL-10TM microcatheter (Stryker Neurovascular, Fremont, CA) was navigated from the left L-4 artery into the smaller AVF through the middle feeder branch, and five detachable platinum coils and 0.1 ml 30 % n-butyl cyanoacrylate (NBCA) were delivered. Then, another SL-10 microcatheter was advanced from the left L-4 artery into the larger AVF through the ascending posterior branch. Four detachable coils were delivered just proximal to the shunt. Control angiograms demonstrated that the smaller AVF had disappeared and that the flow through the larger AVF had slowed. The patient’s clinical symptoms gradually ameliorated. However, a residual AVF was demonstrated on MR images 2 weeks later. Left T-11 angiograms disclosed a small branch that fed both the residual larger AVF and the anterior and posterior spinal arteries (small arrows in Fig. 3a). The fistula was also supplied by the anterior feeding branch of the left L-4 artery (arrow in Fig. 3b). We aimed at complete obliteration of the fistula, but it seemed difficult using TAE alone Introduction