Senshu Nonaka

Endothelial cell proliferation in swine experimental aneurysm after coil embolization.

After coil embolization, recanalization in cerebral aneurysms adversely influences long-term prognosis. Proliferation of endothelial cells on the coil surface may reduce the incidence of recanalization and further improve outcomes after coil embolization. We aimed to map the expression of proliferating tissue over the aneurysmal orifice and define the temporal profile of tissue growth in a swine experimental aneurysm model. We compared the outcomes after spontaneous thrombosis with those of coil embolization using histological and morphological techniques. In aneurysms that we not coiled, spontaneous thrombosis was observed, and weak, easily detachable proliferating tissue was evident in the aneurysmal neck. In contrast, in the coil embolization group, histological analysis showed endothelial-like cells lining the aneurysmal opening. Moreover, immunohistochemical and morphological analysis suggested that these cells were immature endothelial cells. Our results indicated the existence of endothelial cell proliferation 1 week after coil embolization and showed immature endothelial cells in septal tissue between the systemic circulation and the aneurysm. These findings suggest that endothelial cells are lead to and proliferate in the former aneurysmal orifice. This is the first examination to evaluate the temporal change of proliferating tissue in a swine experimental aneurysm model.

Radiological changes in infantile dissecting anterior communicating artery aneurysm treated endovascularly. A case report and five-year follow-up.

Intracranial aneurysms are extremely rare in infants, and to our knowledge only seven infants treated for ruptured spontaneous dissecting aneurysms have been reported. Good outcomes have been achieved with endovascular treatment of infantile aneurysm. We the endovascular treatment of a one-month-old girl for ruptured dissecting aneurysm located in the anterior communicating artery, and the unique radiological changes that were observed during the perioperative and follow-up periods. These changes suggest that blood coagulation and fibrinolytic response play a part in the repair and healing processes of dissecting aneurysms. Careful neuroradiological surveys are needed for pediatric dissecting aneurysms treated endovascularly.

Endovascular Therapy for Infectious Intracranial Aneurysm: A Report of Four Cases

BACKGROUND Infectious intracranial aneurysms (IIAs) are rare but can cause substantial morbidity and mortality. We aimed to re-evaluate the role of endovascular therapy for the treatment of IIAs. METHODS This study is a retrospective review of patients diagnosed with IIAs and treated by endovascular therapy in our institutions over the past 13 years. RESULTS Four patients were diagnosed with infectious endocarditis with a total of 5 IIAs. Three of the 4 patients had ruptured IIAs. Two presented with intracerebral hemorrhage, one with subarachnoid hemorrhage, and one with cerebral infarction. The distal middle cerebral artery (MCA) was the most common site, followed by the distal segment of the posterior cerebral artery. Three patients were treated by parent artery occlusion and one by direct aneurysm obliteration. There were no periprocedural complications. One IIA treated by direct aneurysm occlusion was recanalized within 1 year and required a second embolization. Outcomes were measured by the modified Rankin Scale on discharge: 2 patients scored 0, 1 patient scored 1, and 1 patient scored 3. CONCLUSION IIAs located deep in the brain or on the peripheral MCA can be safely treated with endovascular therapy even when they are lying in the eloquent cortex.

Treatment results of endosaccular coil embolization of asymptomatic unruptured intracranial aneurysms in elderly patients

Background and purpose We report the results of endosaccular coil embolization of asymptomatic unruptured intracranial aneurysms (UIAs) in elderly patients (≥65 years). Materials There were 375 elderly patients with 400 asymptomatic UIAs. Patients were divided into two groups: group A included patients aged 65–74 years and group B patients aged ≥75 years. Results Endovascular procedures were completed in 97.8% of patients. Immediate anatomical outcomes showed complete occlusion in 53.7%, residual neck in 18.9%, and residual aneurysm in 27.4%. Anatomical follow-ups (mean 36.3±28.1 months) were unchanged in 55.7%, improved in 22.6%, minor recurrence in 11.5%, and major recurrence in 10.2%. Procedure related complications occurred in 31 patients (8.3%). 15 patients had ischemic and 10 hemorrhagic complications. Retreatments were performed in 16 patients (4.3%). Among 366 patients technically completed, 363 (99.2%) showed a favorable clinical outcome (modified Rankin Scale (mRS) score <1) at 30 days. The remaining three patients showed a worsening of mRS >0 at 30 days. The latest clinical follow-up outcomes showed: mRS score 0 in 362 patients; mRS score 1 in one; mRS score 3 in one; mRS score 4 in one; and mRS score 5 in one patient. Permanent morbidity and mortality rates were 1.1% and 0%, respectively. There were no statistically significant differences in gender, comorbidities, aneurysm size, neck width, dome-to-neck ratio, immediate anatomical outcomes, anatomical follow-up outcomes, or procedure related complications between the groups. Conclusions Endosaccular coil embolization is safe and feasible for elderly patients with asymptomatic UIAs. Old age itself should not be a contraindication.

Scleroderma en coup de sabre with recurrent episodes of brain hemorrhage

We report a 39‐year‐old man referred to our facility with linear sclerotic lesions along the several Blaschkos lines of the scalp. A year before the referral, he had had an episode of brain hemorrhage, although there was no evidence of vascular malformation or any other risk factors of brain hemorrhage for his young age. On the diagnosis of scleroderma en coup de sabre, prednisolone intake was initiated, and the skin lesions were well controlled. However, in the course of our follow up, he had another episode of brain hemorrhage, again without any evidence of cerebral vascular abnormalities. Organic intracranial abnormalities in this disease are well‐documented, but there have been few reports on comorbid recurrent brain hemorrhages. We herein discuss the possible relationship of the skin lesions with the brain hemorrhages in our case, taking notice of the implication of developmental abnormalities behind these apparently independent phenomena inside and outside the cranium.

Osteochondroma Presenting as a Calcified Mass in the Sellar Region and Review of the Literature.

Objective Osteochondroma (OC) is the most common benign bone neoplasm. It infrequently occurs in the cranial cavity as a calcified lesion and very rarely presents in the sellar region. The present study summarizes the knowledge about OCs of the sellar region. Methods We searched the literature search for the clinical appearance of OCs and other calcified pathologies occurring in the sellar region. Results A total of 21 English‐language articles published from 1961 to 2015 documented cases of calcified lesions in the sellar region including cerebral aneurysm, chondroid chordoma, chondroma, craniopharyngioma, OC, odontome, osteoma, pituitary adenoma, pituitary stone, Rathke cleft cyst, retinoblastoma, schwannoma, and xanthogranuloma. Among them, six were OC cases: three in the parasellar region and three in the sellar‐suprasellar region. Patients with sellar‐suprasellar OCs presented with visual loss and hypopituitarism; patients with parasellar OCs did not show these symptoms. OCs appeared as irregular and multilobulated calcifications on X‐ray and computed tomography. On magnetic resonance imaging, OCs showed variable intensity on T1‐weighted sequences and consistently heterogenous intensity on T2. Four patients underwent transcranial tumor resection, and the transsphenoidal route was selected for one. Five of the six resulted in a partial resection or internal decompression with a satisfactory outcome. Conclusions Calcified tumors occurring in the sellar region may be OCs, especially if they appear as irregular multilobulated calcification.

Symptomatic Very Delayed Parent Artery Occlusion After Flow Diversion Stent Embolization

Flow diversion stents (FDSs) are constructed from high-density braided mesh, which alters intra-aneurysmal hemodynamics and leads to aneurysm occlusion by inducing thrombus formation. Although there are potential complications associated with FDS embolization, one of the serious complications is the parent artery occlusion due to the in-stent thrombosis. A 72-year-old woman with a symptomatic giant fusiform aneurysm in the cavernous segment of ICA underwent single-layer pipeline embolization device (PED) embolization. Six-month and 1-year follow-up conventional angiographies showed the residual blood flow in the aneurysm. Two-year follow-up MRI showed the aneurysm sac shrinkage and the antiplatelet therapy was discontinued. The patient suffered from symptomatic parent artery occlusion due to the in-stent thrombosis, 4 months after antiplatelet therapy discontinuation. The patient with the incompletely occluded aneurysm after PED embolization should be given long-term antiplatelet therapy because of the risk of delayed parent artery occlusion.

Three Cases of Cervicocephalic Artery Dissection in an Amusement Park

About 20 cases of cerebrovascular accidents in amusement parks have been documented. However, only a few cases of amusement park stroke (APS) after roller coaster rides have been reported. Here, we present triggers of stroke, clinical characteristics, and the angiographic appearance of 3 consecutive patients of APS. Their clinical characteristics included young age, absence of atherosclerotic risk factors, and severe injuries. Serial changes in angiographic appearance led to the diagnosis of cervicocephalic artery dissection (CAD). Patients A and B were diagnosed with isolated middle cerebral artery (MCA) dissection, and patient C was diagnosed with internal carotid artery dissection involving MCA dissection. Running excitedly toward an attraction in patient A, a go-kart ride in patient B, and riding in an enhanced motion vehicle in patient C were considered as the likely triggers for APS. We had specific cases with APS associated with CAD, which can occur under diverse contexts other than roller coaster rides at amusement parks. Our findings suggest that the variable directions of the high gravitational forces induced by vehicle riding or running excitedly might injure the MCA or internal carotid artery, and thereby cause CAD in the amusement park.

Spinal Dural Arteriovenous Fistula Assumed to be Symptomatic after Placement of Lumbar Cerebrospinal Fluid Drain

A 69-year-old man presented with severe headache. Cranial computed tomography revealed diffuse subarachnoid hemorrhage. An anterior communicating artery aneurysm was identified and successfully obliterated by open microsurgery on the same day. Following placement of a continuous lumbar cerebrospinal fluid drain on hospitalization day 7, the patient developed a severe paraplegia and sensory loss below T6. Cerebral magnetic resonance imaging did not identify a responsible lesion. Spinal magnetic resonance imaging, however, showed extensive intramedullary hyperintensity on T2-weighted sequences. Spinal angiography identified a dural arteriovenous fistula fed by the segmental artery branching with the 12th intercostal artery. It was successfully embolized and the patients sensorimotor disturbances remarkably improved. A spinal dural arteriovenous fistula may better be considered as one of the underlying etiologies when patients exhibit new neurological deficits after placement of a continuous lumbar cerebrospinal fluid drain.

Ossified extradural en-plaque meningioma of the cervical spine

A 57-year-old woman sustained gradually progressive sensorimotor disturbance in the left upper extremity for one year. Neurological examination found a diminished sensation below the left C7 dermatome and reduced strength in the left interosseous muscles. Computed tomography of the cervical spine revealed a high density mass at C7, in the left dorsal part of the spinal canal. Magnetic resonance imaging found an enhancing, en-plaque tumor at C6-T1, involving a non-enhancing part, and considerable compression of the spinal cord. The patient underwent tumor resection through hemilaminectomy of C5-C7. The tumor was located epidurally, highly fibrous including bony-hard parts, and severely adhered to the dura mater that necessitated drilling for debulking. A subtotal resection was achieved and histological diagnosis was a fibrous meningioma with metaplastic ossification. Ossification may be a pathognomonic appearance of spinal extradural meningiomas that makes resection maneuvers difficult.