[Massive biliary hemorrhage due to rupture of pseudoaneurysm after endoscopic biliary plastic stenting for pancreatic cancer]

A 51-year-old woman underwent endoscopic biliary drainage with a plastic stent for obstructive jaundice due to unresectable pancreatic head cancer. During chemotherapy following heavy ion therapy for the cancer, she presented with acute cholangitis and massive rectal bleeding. The massive hemorrhage was caused by rupture of the biliary duct due to a pseudoaneurysm in the right hepatic artery. The position of the aneurysm coincided with the liver-side end of the plastic stent. Sustained irritation of the arterial and bile duct walls by the stent was considered to have contributed to formation of the aneurysm.

A Clinical Scoring System for Predicting Microvascular Invasion in Patients with Hepatocellular Carcinoma Within the Milan Criteria

BACKGROUND

Microvascular invasion (MVI) is recognized as a risk factor for early recurrence of hepatocellular carcinoma (HCC) within the Milan criteria after curative treatment.

METHODS

One hundred eleven consecutive patients with HCC within the Milan criteria who underwent hepatic resection were retrospectively reviewed. Independent preoperative predictors of MVI were identified, and a scoring system was developed using significant predictors.

RESULTS

MVI was identified in 51 of 111 patients (46%). Multivariate analysis identified the following independent predictors of MVI: alpha-fetoprotein (AFP) of > 95 ng/mL (odds ratio [OR], 9.87; 95% confidence interval [95% CI], 2.24-56.8; P = 0.002), des-γ-carboxy prothrombin (DCP) of > 55 mAU/mL (OR, 5.50; 95% CI, 2.09-15.4; P < 0.001), tumor size of > 2.8 cm (OR, 6.10; 95% CI, 2.07-20.0; P < 0.001), and non-smooth tumor margin in the hepatobiliary phase of gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI) (OR, 5.34; 95% CI, 1.84-16.9; P = 0.002). A clinical scoring system was developed using these four variables. Within a total possible score of 0 to 4, the prevalence of MVI with a score of 0, 1, 2, 3, and 4 was 4.5%, 24.0%, 45.5%, 91.7%, and 100%, respectively (P < 0.001). The area under the curve of the scoring system was 0.865 based on the receiver operating characteristic curve analysis of the prediction score.

CONCLUSIONS

Our clinical scoring system, consisting of AFP, DCP, tumor size, and tumor margin in Gd-EOB-DTPA-enhanced MRI, can be valuable for predicting MVI in HCC within the Milan criteria before curative treatment.

Magnetic Resonance Imaging Compared with Computed Tomography and Angiography in Moyamoya Disease

Magnetic resonance (MR) imaging performed in 13 patients with moyamoya disease was reviewed and compared with computed tomography (CT) and angiography. The MR findings consisted of occlusion of arteries, collateral vessels and parenchymal changes. Narrowing or occlusion of the middle cerebral artery and the supraclinoid portion of the internal carotid artery were seen in all hemispheres but one. Collateral vessels, cerebral infarcts and atrophy with dilatation of the ventricles were observed on MR imaging. In general, the MR findings correlated well with angiography regarding occlusive changes and moyamoya vessels but was less sensitive in a few cases. Because of its higher sensitivity in detecting occlusive changes and collateral vessels, MR imaging was superior to CT in the diagnosis of this disease.

Transcatheter Embolization of Testicular Vein for Varicocele Testis

Percutaneous transcatheter embolization of the testicular vein was performed on 28 patients with angiographically proven varicocele testis. In 2 patients bilateral and in 26 only the left vein was embolized using 3-, 5-, or 8-mm stainless steel coils. All patients had clinically palpable varicoceles and male infertility. The grade of varicoceles improved after embolization in 23 of 28 cases (82%). Effective sperm count increased significantly from 34.5 ± 44.6 to 65.1 ± 71.0 following embolization. However, pregnancy was achieved only in one of 28 cases. Technically, the basilic vein approach was felt to be superior to the femoral vein or jugular vein approach for this procedure.

[Neurological deterioration within 30 days of ischemic stroke with spontaneous cervicocranial artery dissection]

The objective of this study was to identify the clinical features associated with neurological deterioration within 30 days of ischemic stroke patients with spontaneous cevicocranial dissection (SCCD) and clarify the effect on outcomes. We retrospectively identified 18 patients with SCCD (1.6%, 3 women, 52 ± 16 years old) among 1,112 patients with acute ischemic stroke within 7 days after onset. Of the 18 patients, 13 (72%) had vertebrobasilar arterial dissection. Neurological deterioration was present in 4 patients (22%), and 2 patients (11%) died. All of them became worse within 3 days after onset. Their initial blood pressures were high. All of them had dominant side vertebral artery or basilar artery dissection. Subarachnoid hemorrahage (SAH) were not seen although the agressive anticoagulant therapy were performed except for a case who had aneurysmal change. The patients with neurological deterioration had poor outcome, but the patients without neurological deterioration had good outcome. Recurrent ischemic event or SAH did not occurred in 3 months if they had not neurological deterioration. When we see acute stroke patients with dissection at the dominant side vertebral artery or the basilar artery, we should observe carefully for neurological deterioration especially within three days of onset.

Antegrade internal carotid artery collateral flow and cerebral blood flow in patients with common carotid artery occlusion

OBJECTIVES

To determine the incidence of antegrade internal carotid artery collateral flow in patients with common carotid artery occlusion, which artery supplies blood to the internal carotid artery, and whether the flow affects regional cerebral blood flow in the middle cerebral artery territory.

METHODS

We determined the incidence of antegrade internal carotid artery collateral flow and identified its arterial origins using carotid sonography in 10 patients with common carotid artery occlusion and evaluated middle cerebral artery territory regional cerebral blood flow by single-photon emission computed tomography in these patients and 30 age- and sex-matched patients with internal carotid artery occlusion.

RESULTS

Six (60%) of the 10 patients with common carotid artery occlusion had antegrade internal carotid artery collateral flow, which was supplied through the carotid bifurcation from retrograde flow of the external carotid artery in 5 and by a small artery directly into the internal carotid artery in 1. The regional cerebral blood flow ipsilateral to the occlusion at rest was higher in patients with common carotid artery occlusion than those with internal carotid artery occlusion (mean ± SD, 40.4 ± 8.5 versus 34.3 ± 6.2 mL/100 g/min; P = .02). The regional cerebral blood flow was significantly higher in the 6 patients with antegrade internal carotid artery flow than those with internal carotid artery occlusion at rest (42.2 ± 7.2 versus 34.3 ± 6.2 mL/100 g/min; P = .02) but not in the other 4 patients without antegrade internal carotid artery flow.

CONCLUSIONS

Antegrade collateral internal carotid artery flow was found in 60% of patients with common carotid artery occlusion and was mainly supplied by retrograde external carotid artery flow. It contributes to maintenance of middle cerebral artery territory regional cerebral blood flow.

Histopathological features with angiographic correlates of internal carotid artery pseudo-occlusion: impact of plaque compositions. Clinical article

OBJECT

This study describes clinicopathological characteristics of pseudo-occlusion of the internal carotid artery with regard to its possible mechanisms.

METHODS

The authors retrospectively reviewed 17 patients with pseudo-occlusion and 23 with high-grade stenosis (North American Symptomatic Carotid Endarterectomy Trial criteria ≥ 90%, but no collapsed distal internal carotid artery) who underwent carotid endarterectomy. Atherosclerotic risk factors, clinical presentation, angiographic findings, and histological features of plaque obtained from the carotid endarterectomy were investigated and comparisons were made between groups.

RESULTS

Plaques obtained in the pseudo-occlusion group were significantly more fibrous and less atheromatous than those in the high-grade stenosis group. Old, organized thrombi were more frequently found in pseudo-occlusion group plaques than in high-grade stenosis group plaques. Plaques acquired in the pseudo-occlusion group had 2 different histological features: the presence or absence of the original lumen. The pseudo-occlusion plaques with total occlusion and recanalization (8 patients) were composed of thrombotic total occlusion with lumen recanalization by large neovascular channels, whereas those with severe stenosis (9 patients) were fibrous or fibroatheromatous and had severe stenosis of the original lumen. In patients with pseudo-occlusion and total occlusion and recanalization, the authors observed a significantly higher incidence of transient ischemic attack and anterior communicating artery-posterior communicating artery collateral flow than those with high-grade stenosis and pseudo-occlusion with severe stenosis.

CONCLUSIONS

Plaques of the pseudo-occlusion group were more fibrous than those of the high-grade stenosis group and had 2 different histological features: pseudo-occlusion with total occlusion and recanalization or pseudoocclusion with severe stenosis. This difference in plaque histology may be related to the clinical features of pseudoocclusion, such as symptoms and collateral flow patterns.

Outcomes associated with carotid pseudo-occlusion

PURPOSE

We tested the hypothesis that patients with carotid pseudo-occlusion (PO) have a different prognosis from those with carotid artery stenosis (CS) without PO.

MATERIALS AND METHODS

500 patients were examined for CS by cerebral angiography; those with severe CS ≥ 70% (CS group) or with PO (PO group) were enrolled in this study. The primary endpoint was defined as the combined endpoint of the occurrence of stroke, myocardial infarction, or death. Patients without any events were censored at 60 months. We followed patients for the occurrence and date of primary endpoints and compared clinical characteristics and outcomes between the PO group and the CS group.

RESULTS

We enrolled 337 patients (281 men, 56 women, mean age: 70.4 years, mean follow-up period: 32.0 months), of whom 303 (89.9%) were allocated to the CS group while 34 (10.1%) were allocated to the PO group. The rate of diabetes mellitus in the PO group (55.9%) tended to be higher than in the CS group (39.9%). According to Kaplan-Meier analysis, the PO group suffered from the primary outcome more frequently than the CS group. The occurrence of the primary outcome was also associated with older age, peripheral arterial disease and a history of myocardial infarction. Multivariate analysis indicated that patients in the PO group had a significantly poorer outcome compared with those in the CS group (p = 0.013).

CONCLUSION

Patients in the PO group more frequently had neurological and cardiac events or died compared with those in the CS group.

Prognosis of medical treatment for Japanese patients with carotid stenosis

PURPOSE

This study was designed to determine whether, among Japanese patients receiving medical treatment for carotid stenosis, symptomatic carotid stenosis was more strongly associated with subsequent neurological events than asymptomatic carotid stenosis.

METHODS

We consecutively registered Japanese patients with carotid stenosis of 50% or more as evaluated by digital subtraction angiography who were treated medically. We reviewed medical records regarding previous neurological events as well as other stroke risk factors and underlying diseases at admission. We monitored the occurrence and date of stroke and death after the first evaluation. We also attempted to obtain information from patients or their family members by means of a questionnaire or telephone survey.

RESULTS

Among 67 patients with carotid stenosis of 50% or more who were treated medically, follow-up was completed in 62 subjects (56 men, 6 women; median age, 72 years; mean follow-up period, 37.3 months). The number of patients with subsequent stroke with symptomatic carotid stenosis was five, while that with asymptomatic stenosis was four. A significantly higher rate of subsequent stroke was observed in patients with symptomatic carotid stenosis compared with those with asymptomatic stenosis (p=0.012). Cox proportional hazards model indicated that symptomatic carotid stenosis was significantly correlated with future neurologic events (p=0.019).

CONCLUSION

In a Japanese population with carotid stenosis treated medically, symptomatic carotid stenosis is associated with future stroke more frequently than asymptomatic carotid stenosis.

Correlation between the degree of left subclavian artery stenosis and the left vertebral artery waveform by pulse Doppler ultrasonography

BACKGROUND

Development of retrograde blood flow may be observed in the vertebral artery and is associated with progressive ipsilateral proximal subclavian or innominate artery stenosis. The subclavian steal phenomenon is more prevalent in the left subclavian artery (LSA). The purpose of this study was to analyze the correlation between the degree of LSA stenosis and pulse Doppler waveforms of the left vertebral artery (LVA).

METHODS

A retrospective analysis of LVA waveforms was performed in 22 cases with LSA proximal stenosis before the origin of the LVA in conventional angiograms. The degree of LSA stenosis was classified into 5 groups (<50, 50-59, 60-69, 70-89, 90-100%). Pulse Doppler waveforms of the LVA were also classified into 5 subtypes depending on the depth of the mid-systolic notch representing retrograde blood flow (normal, mid-systolic notch, retrograde flow smaller than antegrade flow, retrograde flow larger than antegrade flow, retrograde flow without antegrade flow).

RESULTS

A statistically significant correlation (R(2) = 0.646, p < 0.0001) was found between the degree of LSA stenosis and the LVA waveform.

CONCLUSIONS

The pattern analysis of LVA pulse Doppler waveforms seems to be useful in determining the degree of LSA stenosis.

[Combination of percutaneous balloon angioplasty and aggressive medical intervention improves symptomatic basilar artery stenosis with a tortuous access route: case report]

The prognosis of symptomatic intracranial artery stenosis (SIAS) by medical treatment is poor. Percutaneous balloon angioplasty (PTA) or stenting is effective for SIAS. However, recently, aggressive medical intervention (AMI) has progressed and some drugs have been reported to improve stenosis or prevent the progression of stenosis. We describe a case where combination of PTA and the AMI improved symptomatic basilar artery stenosis with a tortuous access route.

CASE

A 78-year-old man was admitted to our hospital suffering from acute brain infarction due to severe basilar artery stenosis. The AMI including cilostazol, statin, and eicosapentaenoic acid failed to prevent recurrence of the brain infarction. We performed PTA and 45% of the residual stenosis remained. We continued the AMI and the stenosis improved to 30% after 3 months.

CONCLUSION

PTA with minimal risk should be considered for SIAS resistant to AMI. Even if residual stenosis remains, continuation of AMI may prevent recurrence of a brain infarction. The strategy of a combination of PTA with minimal risk and AMI may result in a better prognosis for SIAS.

[A case of parental artery occlusion for a non-ruptured giant thrombosed aneurysm at the right vertebral artery using a goose neck snare to hold a guiding catheter]

The stabilization of a guiding catheter is one of the important factors for achieving successful endovascular treatments. However, obtaining sufficient stabilization is sometimes difficult due to the tortuousity of the approach route. A goose neck snare is useful not only for the retrieval of intravascular foreign bodies but also for holding a guiding catheter. This report presents a case of parental artery occlusion for a non-ruptured giant thrombosed aneurysm occurring in the right vertebral artery using a goose neck snare to hold a guiding catheter.

Angiographic Characteristics of Radiation-Induced Carotid Arterial Stenosis

Purpose

This study aimed to clarify the angiographic characteristics of radiation-induced carotid stenosis.

Methods

We evaluated 11 carotid arteries of patients after radiotherapy (radiotherapy group) and 26 carotid arteries of age- and gender-matched patients without a history of radiotherapy (control group). All patients had carotid stenosis detected by digital subtraction angiography (DSA). We developed an original coordinate system on the DSA to determine the accurate length and location of the carotid lesion.

Results

Radiation-induced carotid lesions were significantly longer than carotid lesions caused by atherosclerosis. The maximal stenosis of radiation-induced carotid lesions tended to be at the end of the stenotic area and within a wider range than the nonradiation-induced lesions, including in the proximal common carotid artery (CCA).

Conclusions

Radiation-induced stenotic lesions seem to exist in a wide range of carotid artery, including the CCA, along the vessel, and show maximal stenosis near the end of the stenotic area.

Characteristic sonographic findings of early restenosis after carotid endarterectomy

OBJECTIVE

Restenosis of the carotid artery after carotid endarterectomy (CEA) is a major complication. The frequency, time of occurrence, and tissue characteristics of carotid restenosis were assessed with sonography.

METHODS

Two hundred sixteen patients who had CEA for carotid stenosis were studied; follow-up sonography and magnetic resonance angiography were done 2 weeks, 3 months, and then every year after CEA. On sonography, restenosis was defined as an internal carotid artery (ICA) with a peak systolic velocity of 170 cm/s or greater or a maximum area of stenosis of 90% or greater.

RESULTS

During 605 artery-years of follow-up, 18 patients (7.5%) were found to have restenosis on sonography: 4 at 3 months, 11 at 1 year, and 3 at 2 years after CEA. At the time that restenosis was detected, in all 18 ICAs the peak systolic velocity exceeded 200 cm/s and had more than doubled since the last measurement (mean +/- SD, 103 +/- 27 to 321 +/-107 cm/s), whereas the area of stenosis exceeded 90% in 6 patients, and magnetic resonance angiography revealed stenosis of 60% or greater in 8 patients. On sonography, all of the restenotic plaques were isoechoic and concentric. The restenosis was asymptomatic in 17 patients. Vascular risk factors or the severity of initial carotid stenosis before CEA were not associated with development of restenosis. Eleven patients had successful endovascular therapy, and the others received medical treatment.

CONCLUSIONS

A marked increase in the flow velocity through an operated ICA is a good indication of restenosis. The isoechogenicity and concentricity of the restenotic plaques suggest that the restenosis is primarily the result of intimal hyperplasia.

Carotid Artery Calcification on Multislice Detector-Row Computed Tomography

BACKGROUND

To determine the underlying conditions that affect the degree of calcification of carotid arterial plaques, measured quantitatively using multidetector row computed tomography (MDCT), and to study the association of carotid calcification with clinical symptomatology.

METHODS

We measured the calcification volume of stenotic lesions at the carotid bifurcation using MDCT in 84 consecutive patients who were scheduled to undergo carotid revascularization. These results were compared with the clinical and radiological characteristics of the patients.

RESULTS

On MDCT, calcification in the carotid plaques was present in 78 patients (93%). Compared to the other patients, patients in the highest quartile of calcification volume (quartile 4) had higher serum creatinine levels (p < 0.001) and tended to have fewer symptomatic ischemic events in the territory of the affected carotid artery in the preceding 6 months (29 vs. 49%, p = 0.099); in particular, there were fewer transient symptoms (5 vs. 27%, p = 0.032) and symptoms possibly occurring due to local embolism (14 vs. 37%, p = 0.045). On ultrasound, plaque ulceration was less prevalent in patients in quartile 4 than in the remaining patients (5 vs. 29%, p = 0.026), although the severity of carotid stenosis was similar among all the quartiles.

CONCLUSIONS

Renal dysfunction was associated with enhanced carotid plaque calcification. Patients with severe carotid calcification were found to have a low risk of recent ischemic stroke, presumably due, in part, to a lower prevalence of emboligenic carotid ulceration. MDCT was valuable for the quantitative evaluation of carotid calcification.

[A case of the spontaneous dissection of the bilateral internal carotid arteries diagnosed by the transoral carotid ultrasonography (TOCU)]

A 56-year-old-man was admitted to our hospital because of acute brain infarction with symptoms of consciousness disturbance and left hemiparesis. After admission, the symptoms disappeared rapidly. MRI diffusion-weighted image on day one revealed high intensity area at the right insular cortex and MRA showed stenosis of the right middle cerebral artery. MRA on the next day demonstrated that the stenotic lesion improved, but another stenosis appeared at the petrous portion of the right internal carotid artery (ICA). Brain angiography on day eight showed improvement of the stenosis of the right ICA petrous portion and stenosis of bilateral ICAs extracranial distal portion. The transoral carotid ultrasonography (TOCU) on day nine showed clearly true lumen and false lumen at the bilateral extracranial distal ICAs, which indicated spontaneous dissection of the bilateral extracranial distal ICAs. TOCU seems very useful in evaluating the extracranial carotid arterial dissection.

[Frequent attacks of amaurosis fugax due to hemodynamic mechanism based on severe stenosis of the internal carotid artery]

A 74 year-old man with prostate hypertrophy developed frequent attacks of amaurosis fugax in the left eye. Attacks only occurred in a standing position, but not when sitting or lying. He had taken tamsulosin hydrochloride for prostate hypertrophy and had orthostatic hypotension. After stopping the administration of tamsulosin hydrochloride and starting anthithorombotic theraphy, his orthostatic hypotension disappeared and the frequency of attacks decreased. Cerebral angiography demonstrated 95% stenosis and distal collapse of the left internal carotid artery (ICA), with collateral flow to the left middle cerebral artery from the right ICA through the anterior communicating artery. We thus postulated that a hemodynamic mechanism played an important role in the development of the amaurosis fugax which disappeared after carotid endarterectomy.

Bottle neck sign of the proximal portion of the internal carotid artery in moyamoya disease

OBJECTIVE

We investigated morphologic features of the extracranial internal carotid artery (ICA) by carotid ultrasonography in patients with moyamoya disease.

METHODS

We performed conventional carotid ultrasonography and transoral carotid ultrasonography on 19 ICAs in 10 patients with moyamoya disease (moyamoya group) and 28 ICAs in 14 control subjects (control group). We evaluated whether the diameter was greatly reduced at the proximal portion of the ICA above the bulbus, like a champagne bottle neck, to be less than half that of the common carotid artery and whether the diameter of the ICA was smaller than that of the external carotid artery (diameter reversal) on conventional carotid ultrasonography. We then measured the internal diameter of the extracranial distal ICA by transoral carotid ultrasonography. We compared the incidence of a "bottle neck" appearance, diameter reversal, and the ICA diameter between the 2 groups.

RESULTS

The bottle neck and diameter reversal were shown in 14 (74%) and 16 (84%) of the 19 ICAs in the moyamoya group, respectively (chi2 test, P<.0001). However, neither of them was shown in the control group. The diameter of the distal ICA in the moyamoya group was significantly smaller than that in the control group (mean+/-SD, 2.4+/-0.60 versus 4.1+/-0.52 mm; unpaired t test, P<.0001).

CONCLUSIONS

These results suggest that rapid internal diameter reduction at the proximal portion of the ICA, characterized by a bottle neck appearance or diameter reversal, is an important morphologic feature of moyamoya disease.

Antithrombotic Therapy and Predilection for Cerebellar Hemorrhage

BACKGROUND

With the recent increase in the use of antithrombotic therapy, intracerebral hemorrhage (ICH) has been found to be a common complication. We determined whether the use of oral antithrombotic therapy and the patients' preexisting comorbidities were predictive of cerebellar hemorrhage (CH; previously reported to be associated with anticoagulants) as compared to other ICH, and whether antithrombotic therapy affected the clinical severity of CH.

METHODS

A study of 327 consecutive patients hospitalized in our institute within 3 days after the onset of ICH, including 38 patients with a CH.

RESULTS

CH accounted for 12% of all ICH, 75% of which occurred in patients on warfarin therapy with an international normalized ratio (INR) for prothrombin time >2.5 (p < 0.0001), and 33% of which occurred in patients on ticlopidine therapy (p = 0.017). Warfarin therapy with an INR >2.5 and high blood glucose on admission were independently predictive of CH as compared to other ICH. In addition, previous ischemic stroke (p = 0.002) and heart diseases (p = 0.018) were more prevalent in patients with CH than in those with other ICH. The number of major arteriosclerotic comorbidities and risk factors was also independently predictive of CH risk.

CONCLUSIONS

We confirmed that warfarin therapy with an INR >2.5 is associated with CH. Patients with CH frequently had arteriosclerotic comorbidities requiring antithrombotic therapy that can complicate their acute management.

Changes in Brain Volume 2 Years after Extracranial-Intracranial Bypass Surgery: A Preliminary Subanalysis of the Japanese EC-IC Trial

BACKGROUND AND METHODS

We studied changes in brain volume on magnetic resonance imaging in 10 patients with and without extracranial-intracranial (EC-IC) bypass surgery who met the inclusion criteria for the Japanese EC-IC Bypass Trial, a multicenter, randomized, prospective study of patients with hemodynamic brain ischemia due to cerebral artery occlusive disease. We also examined the association of cerebral hemodynamics on single-photon emission computed tomography with the changes in brain volume.

RESULTS

The affected/unaffected ratio of the percent brain volume declined in patients without EC-IC bypass surgery (p < 0.02, n = 4), and the affected/unaffected percent regional cerebral blood flow ratio increased in patients with the surgery (p < 0.03, n = 6). Acetazolamide reactivity increased in the affected hemisphere of patients with surgery (p < 0.01). Two-year increase (decrease) in acetazolamide reactivity of the affected hemisphere showed a significant positive correlation with 2-year changes in the affected/unaffected percent brain volume ratio (R2 = 0.737, p = 0.0007).

CONCLUSIONS

Change in acetazolamide reactivity might be a good predictor for brain atrophy in cerebral artery occlusive disease.

Accuracy of Conventional plus Transoral Carotid Ultrasonography in Distinguishing Pseudo-Occlusion from Total Occlusion of the Internal Carotid Artery

BACKGROUND

To investigate the accuracy of conventional carotid ultrasonography (CCU) combined with transoral carotid ultrasonography (TOCU) for distinguishing pseudo-occlusion from total occlusion of the internal carotid artery (ICA).

METHODS

This study included 95 patients who were suspected of having an occlusion of the ICA on magnetic resonance angiography (MRA) and underwent both CCU and conventional digital subtraction angiography (DSA) in order to confirm the diagnosis. TOCU was also performed to observe the cervical portion of the ICA distal to the stenosis. We compared the ultrasonographic findings with the DSA findings.

RESULTS

Twelve of the 95 patients were defined as having an ICA pseudo-occlusion on DSA. On B-mode images with CCU color Doppler, slight residual flow signals in the ICA lumen were shown in 20 patients. Among them, 2 patients had a pulsed Doppler waveform of the distal ICA occlusion pattern. Among the remaining 18 patients, 4 had a pulsed Doppler waveform of the to and fro flow pattern, and 14 had a weak antegrade flow pattern in the ICA lumen. The conventional ultrasonographic method showed 100% sensitivity with 93% specificity for diagnosing an ICA pseudo-occlusion. The addition of TOCU findings increased the specificity to 98%. In 2 patients, who were overdiagnosed as having an ICA pseudo-occlusion even using TOCU, DSA revealed an occlusion of the ICA distal to the ophthalmic artery with a severe stenosis of the proximal ICA.

CONCLUSIONS

Using conventional and transoral carotid ultrasonography, an ICA pseudo-occlusion can be diagnosed with higher accuracy.

Serial evaluation of acute cerebral hyperperfusion by transcranial color-coded sonography

Using transcranial color-coded sonography (TCCS), we evaluated the acute changes in the hemodynamics of cerebral hyperperfusion in two cases. The mean flow velocity of the cerebral arteries increased at the onset of clinical symptoms, together with an increase in the regional cerebral blood flow (rCBF). In serial follow-up studies, the flow velocity gradually returned to normal in parallel with the normalization of the rCBF values. TCCS can be useful for evaluation of acute cerebral hyperperfusion.

Adenoma of the nipple: correlation of magnetic resonance imaging findings with histologic features

Adenoma of the nipple (nipple adenoma) is a rare breast tumor that can show various histologic features. We present magnetic resonance (MR) and other imaging findings of a case of nipple adenoma and correlate them with detailed histologic features of the tumor. The lesion showed early strong enhancement with rim enhancement on dynamic contrast-enhanced MR images, and internal portions of the lesion showed washout on delayed MR images. Histologically, the tumor showed expansive growth with surrounding dense collagenous tissue and large vessels. Internal portions of the lesion showed a relatively low degree of fibrosis compared with that of the surrounding area, and tiny vessels were observed. These features were clearly reflected in the MR findings.

Venous infarction secondary to septic cavernous sinus thrombosis

A 65-year-old woman with poorly controlled diabetes presented bilateral miosis, bilateral abducens nerve palsy, and left hemiparesis. On MRI, cavernous sinus thrombosis, subdural empyema and hemorrhagic infarction in the frontotemporal lobe were detected. Cerebral angiogram revealed filling defect in the cavernous sinus with venous congestion but no involvement of internal carotid artery. Postmortem examination demonstrated hemorrhagic infarction in the right frontotemporal lobe as well as hemorrhagic necrosis of the pituitary gland. It should be noted that venous congestion due to cavernous sinus thrombosis may cause these complications.

Superficial temporal artery duplex ultrasonography for improved cerebral hemodynamics after extracranial-intracranial bypass surgery

BACKGROUND

To investigate the utility of superficial temporal artery (STA) duplex ultrasonography (STDU) for evaluating the improvement of the cerebral hemodynamics after extracranial-intracranial (EC-IC) bypass.

METHODS

This study included 40 consecutive patients who underwent EC-IC bypass for occlusive disease of cerebral arteries. STDU was performed to measure the flow velocity, pulsatility index, and diameter of the operated STA before and 14 days after EC-IC bypass. Regional cerebral blood flow (rCBF) and acetazolamide (ACZ) reactivity of the ipsilateral middle cerebral artery (MCA) territory were evaluated by quantitative single-photon emission computed tomography with the ACZ challenge test. We investigated the correlation between STA flow velocity/diameter and rCBF/ACZ reactivity in the ipsilateral MCA territory.

RESULTS

Mean flow velocity (MFV; 26.3 +/- 8.8 to 55.3 +/- 16.3 cm/s, p < 0.0001) and diameter (1.57 +/- 0.24 to 2.26 +/- 0.29 mm, p < 0.0001) of the STA, and rCBF (29.1 +/- 3.1 to 35.0 +/- 6.4 ml/100 g/min, p < 0.0001) and ACZ reactivity (-0.02 +/- 0.10 to 0.28 +/- 0.21, p < 0.0001) of the MCA territory increased after EC-IC bypass compared with the baseline values. STA MFV was significantly correlated with the rCBF 14 days after EC-IC bypass (R = 0.70, p < 0.0001). A cutoff value of postsurgical STA MFV greater than 48.5 cm/s yielded the highest diagnostic accuracy (sensitivity 86%; specificity, 82%) for rCBF > or = 32 ml/100 g/min after EC-IC bypass.

CONCLUSIONS

STDU was available for evaluating postsurgical patency of the bypass flow and the rCBF of the ipsilateral MCA territory. The mean blood flow velocity of the operated STA is a highly sensitive parameter for predicting rCBF in the ipsilateral MCA territory after EC-IC bypass.

Successful high dose glucocorticoid treatment for subacute neuromyelitis optica with systemic lupus erythematosus

A 54-year-old Japanese woman with a 6-year history of systemic lupus erythematosus (SLE) was admitted to our hospital suffering from acute blindness in her right eye. Her condition recovered after steroid pulse therapy, however, 18 months later she suffered from nuchal pain for 2 weeks after which right hemiparesis with urinary incontinence developed. A spinal magnetic resonance imaging (MRI) revealed cord swelling from C2 to C7. She was diagnosed with neuromyelitis optica (NMO) and intravenous steroid administrations were immediately commenced. Her condition promptly improved. This case was unique because the steroid treatment was quite effective for this case of myelitis, which had passed the acute phase. We supposed that, because most of the lesion was not necrotic or demyelinated, but rather showed edematous change caused by vasculitis based on autoimmune pathogenesis, the symptoms progressed rather gradually and improved promptly in response to glucocorticoid treatment.

Recurrent embolic stroke originating from an internal carotid aneurysm in a young adult

An unruptured intracranial aneurysm is an uncommon but possible embolic source to the brain. We report a young patient who developed recurrent ischemic strokes occurring mainly in the left internal carotid arterial territory within a short interval; the first stroke occurred midway through a long-distance race, and the second stroke occurred immediately following a bowel movement. The angiographical contrast deficit indicated a thrombus in the left anterior cerebral artery as a result of the embolism. A saccular aneurysm of the left distal internal carotid artery was the only detectable potential embolic source. Initially anticoagulant therapy was given, and then surgical clipping of the aneurysm was performed. The patient has been free from stroke recurrence. As a cause of ischemic stroke in young adults, a carotid saccular aneurysm should be considered. Hard exercise and a Valsalva maneuver may be important triggers of thrombus detachment from the aneurysm.

Renal cholesterol embolism in patients with carotid stenosis: a severe and underdiagnosed complication following cerebrovascular procedures

Here, we report two cases with rapidly progressive renal failure, caused by cholesterol crystal embolism (CCE), after an angiography for carotid artery stenosis. The diagnosis was determined by histological examination and from clinical symptoms, including livedo reticularis and eosinophilia. Neurologists and neuroradiologists tend to underdiagnose CCE, which results from the same atherosclerotic risk factors as cerebrovascular disease. We need to understand more about CCE and identify its unique clinical symptoms to enable an early diagnosis and treatment.

Diagnostic Impact of Transcranial Color-Coded Real-Time Sonography With Echo Contrast Agents for Hyperperfusion Syndrome After Carotid Endarterectomy

Background and Purpose— The purpose of the present study was to evaluate availability of transcranial color-coded real-time sonography (TCCS) to detect hyperperfusion after carotid endarterectomy (CEA).

Methods— This prospective study included 105 consecutive patients who underwent CEA for severe carotid stenosis. TCCS with echo contrast agents was performed serially to evaluate flow velocity of the middle cerebral artery (MCA). Regional cerebral blood flow (rCBF) and vasodilatory capacity of the MCA territory were evaluated using single-photon emission computed tomography. We compared the changes in MCA flow velocity with rCBF.

Results— Using echo contrast agents, we could evaluate the MCA flow in 95 (90%) of 105 patients. Twelve patients showed hyperperfusion syndrome. Changes in the MCA mean flow velocity (MFV) before and 4 days after CEA were significantly correlated with those in rCBF ( r =0.48; P <0.0001). An increase of >50% in MCA MFV was observed within 4 days after CEA in all 12 patients with hyperperfusion syndrome. Multivariate analysis revealed that reduced vasodilatory capacity (odds ratio, 0.14; 95% CI, 0.04 to 0.46) was an independent risk factor for a 1.5-fold increase in the MFV of MCA ipsilateral to CEA.

Conclusions— Findings of a 1.5-fold increase in the MCA MFV can accurately identify those patients with high risk of developing post-CEA hyperperfusion syndrome. TCCS with echo contrast agents is available for the evaluation of hyperperfusion after CEA.

Retroperitoneal bronchogenic cyst: a rare case showing the characteristic imaging feature of milk of calcium

Bronchogenic cysts are rare congenital anomalies of the primitive foregut that are usually found above the diaphragm, and a retroperitoneal location is extremely unusual. Due to the low prevalence of these pathologies, their imaging features have seldom been described. We report a rare case of retroperitoneal bronchogenic cyst showing characteristic imaging features of milk of calcium on plain abdominal radiography and computed tomography.

Reversible posterior leukoencephalopathy syndrome in a postpartum woman without eclampsia

We report a patient who developed reversible posterior leukoencephalopathy syndrome (RPLS) in puerperium without preeclampsia-eclampsia or chronic hypertension. The woman suddenly complained of visual loss and headache 10 days after delivery caused by edematous lesions mainly distributed in the bilateral occipital lobe. Apparent diffusion coefficient map was useful for distinction of this vasogenic edema from cytotoxic edema due to brain infarction. Under the diagnosis of RPLS, we successfully treated her disease using a trinitroglycerin as an antihypertensive, a hyperosmolar agent, methylprednisolone, and a free radical scavenger. Postpartum women may have the risk of development of RPLS even without preeclampsia-eclampsia. Vascular endothelial dysfunction may trigger RPLS, in addition to acute and modest increase in systemic pressure.

[Vascular reconstruction of tandem stenoses of the internal carotid artery]

We report a case treated successfully by carotid endarterectomy combined with endovascular stenting for tandem stenoses of the internal carotid artery. A 71-year-old man had tandem stenotic lesions affecting bifurcation and the petrous portion of the left internal carotid artery. Coronary stents were placed at the petrous portion of the internal carotid artery immediately after standard carotid endarterectomy. Endvascular techniques and surgery can be complementary in the management of patients suffering from such tandem lesions.

[A case of severe stenosis of bilateral distal vertebral artery successfully treated with anastomosis operation]

A 65-year-old male complained of loss of consciousness for several minutes, transient diplopia and dizziness. He had no neurological deficits nor abnormalities in MR imaging. However, flow velocity of bilateral vertebral artery on ultrasonography indicated severe stenosis of bilateral distal vertebral artery. Brain angiography revealed severe stenosis of bilateral distal vertebral artery as well as occlusion of right middle cerebral artery (MCA). Single photon emission CT (SPECT: ECD-RVR method with acetazolamide loading) showed decreased cerebral blood flow and poor perfusion reserve in bilateral cerebellar hemisphere and right MCA territory. Superficial temporal artery-superior cerebellar artery (STA-SCA) anastomosis was performed. The patient turned out to have no episodes of unconsciousness attack, transient diplopia and dizziness after operation. Cerebral blood flow (CBF) in the posterior circulation was also improved. Evaluating quantitative CBF measurement by means of ECD-RVR method was useful for evaluating CBF. In cases who have severe stenosis of bilateral distal vertebral artery with complaints of vertebrobasilar insufficiency, STA-SCA anastomosis may be one of the most effective treatments.

Autoimmune pancreatitis: radiologic findings in three histologically proven cases

We describe the radiologic findings of autoimmune pancreatitis, a rare variant of pancreatitis. The radiologic findings of autoimmune pancreatitis are pathognomonic and very different from those of ordinary types of acute or chronic pancreatitis. This condition is a new clinical entity that is effectively treated with steroid therapy. It is important to recognize the radiologic characteristics of autoimmune pancreatitis to avoid surgical resection and start steroid therapy.

Spectrum of CT findings in nonmalignant disease of the adrenal gland

Computed tomography (CT) plays a leading role in the evaluation of nonmalignant disease of the adrenal gland. CT is highly accurate in the localization of adrenal masses in patients with diseases associated with hyperfunctioning adrenal glands such as Cushing syndrome and Cushing disease, Conn syndrome, adrenal tumors leading to virilization or feminization, and pheochromocytomas. CT permits a specific diagnosis of acute or subacute adrenal hematoma and myelolipoma. Hematomas are round to oval and have increased attenuation (50-90 HU) that decreases on follow-up CT scans. Myelolipomas typically manifest as a well-defined suprarenal mass with an attenuation of-30 to -115 HU. Adrenal cysts are usually round to oval and manifest as a hypoattenuating mass with a smooth, thin wall. CT is useful in the evaluation of patients with Addison disease, particularly the subacute form secondary to tuberculosis or disseminated histoplasmosis. Findings typically include bilateral adrenal enlargement with a central necrotic area of hypoattenuation and peripheral enhancement. Thin-section unenhanced CT permits accurate measurement of attenuation and can be used to differentiate adrenal adenoma from metastasis in a cancer patient with an indeterminate mass: Attenuation of 10 HU or less usually indicates adenoma rather than cancer. If the mass is found incidentally at contrast material-enhanced CT, delayed scans obtained as early as 5-15 minutes after intravenous administration of contrast material appear to have comparable accuracy.

[Selective intra-arterial injection of calcium for localization of insulinomas: proposed new criteria]

To elucidate whether noninvasive arterial stimulation venous sampling (ASVS) is helpful for localizing insulinomas, calcium gluconate (0.02-0.025 mEq Ca2+/kg) was injected directly into the gastroduodenal, splenic and superior mesenteric arteries of six patients with episodic hypoglycemia. In all six patients, there was a greater than 26-fold increase in serum insulin levels in blood samples obtained from the hepatic vein after the infusion of calcium into the artery supplying the tumor. However, in four of the six patients, such an injection into an artery not supplying the tumor resulted in a greater than twofold increase in insulin concentration. Accurate localization of the insulinomas was verified at surgery in all patients. We believe that these false positive results were caused mainly by the influx of calcium via branches of intrapancreatic anastomoses. In order to minimize false positive results, we have recommended the following new criteria for ASVS: maximum insulin concentrations exceeding 150 microU/ml in blood samples obtained from the hepatic vein, and greater than twofold increases in insulin concentration. We concluded that noninvasive ASVS is helpful in determining the location of insulinomas.

Management of tracheal and bronchial stenoses with the Gianturco stent

Thirty-six cancer patients with symptomatic tracheobronchial stenoses received Gianturco tracheobronchial stents over a 9-year period. Symptoms improved in 28 patients (78%). The overall median survival was 1 month 3 weeks (range, 4 days to 35 months). The median survival for patients who showed improvement after receiving stents was 3 months compared with 1 week for those who did not respond. Complications were minimal. The Gianturco stent may palliate symptoms of tracheobronchial compression in selected cancer patients.