A Ruptured Aneurysm in Aplastic or Twig-like Middle Cerebral Artery: A Case Report with Histological Investigation

Aplastic or twig-like middle cerebral artery (Ap/T-MCA) is a rare vascular anomaly that can cause a hemorrhagic or ischemic event. We report a 38-year-old man who presented with intracerebral hemorrhage from a ruptured aneurysm associated with an Ap/T-MCA. After aneurysm trapping and resection, histopathological examination revealed an internal elastic lamina (IEL) disruption and a thin aneurysmal wall. The patient recovered well after surgery and rehabilitation. No hemorrhagic or ischemic events have occurred during 2 years of follow-up. Ap/T-MCA-associated aneurysms exhibit a disrupted IEL and thin wall, which demonstrates the fragility of the “twig-like” vessels.

Endoscopic Endonasal Dural Reconstruction for a Cerebrospinal Fluid Leak in the Middle Cranial Fossa of a Patient with Gorham-stout Disease with Skull Base Defect

We report the use of endoscopic endonasal surgery for dural reconstruction following a cerebrospinal fluid leak in a 33-year-old patient with recurrent meningitis since at age of 2 years. Magnetic resonance imaging showed osteolytic changes in the left temporal and sphenoid bones, including the left pterygoid plate, a few left temporal encephaloceles, and cerebrospinal fluid-like fluid in the expanded Meckel's cave and the parapharyngeal space. After endoscopic endonasal surgery, Gorham-Stout disease was diagnosed. No recurrence of cerebrospinal fluid leakage or meningitis has been observed. Thus, endoscopic endonasal surgery might improve clinical outcomes in patients with Gorham-Stout disease and skull base defects.

Conservative Treatment of Chronic Subdural Hematoma with Gorei-san

Most asymptomatic patients with chronic subdural hematoma (CSDH) are followed conservatively but can require surgical treatment if the hematoma expands. We conducted a retrospective evaluation of the effect of Gorei-san on CSDH. This study included patients treated between April 2013 and March 2015. In total, 289 patients were diagnosed with CSDH and 110 patients received conservative management. Finally, 39 patients who met the requirements were registered. We retrospectively examined the age, gender, medical history, hematoma thickness, clarity of sulci below hematomas, and midline shift of the patients. The primary outcome was the median surgery-free interval, and the secondary results were the rate of CSDH shrinkage and surgery avoidance. A comparison of patient characteristics between the Gorei-san (G) and non-Gorei-san (NG) groups found no significant differences in the percentage of men, average ages, past history, thickness of CSDH (15.0 ± 3.1 mm vs. 15.3 ± 2.6 mm, p = 0.801), or midline shift (2.0 ± 2.7 mm vs. 4.0 ± 5.0 mm, p = 0.230). The median surgery-free interval was significantly different between the G and NG groups [n. r. vs. 41 days (95% CI: 5-79), log-rank p = 0.047]. The CSDH avoidance rate was not significantly different between the two groups (70.0% vs. 34.4%, p = 0.071). Additionally, the CSDH shrinkage rate was significantly different between the two groups (60.0% vs. 10.3%, p = 0.004). This retrospective study demonstrated that CSDH treatment with Gorei-san reduces hematoma significantly more than treatment that does not include Gorei-san.

Delayed Occlusion of the Anterior Choroidal Artery Following Flow Diverter Stent Deployment for Unruptured Aneurysm: A Case Report and Literature Review

Flow diverter stent has been a promising device for intracranial aneurysm treatment. For treating aneurysms located in the anterior circulation, critical branches may be covered by flow diverter stent. The occlusion incidence of these branches has been reported, and even if branch vessel occlusions occur, associated neurological deficits are extremely rare. We present a 55-year-old woman who had a large saccular aneurysm at the right internal carotid artery (ICA). A developed fetal-type posterior communicating artery (PCOM) originated from the sac. We administered flow diverter stent deployment with coil insertion following surgical anastomosis of the superficial temporal artery to the posterior cerebral artery (STA-PCA) with ligation of the origin of the PCOM. On the seventh morning following the intervention, ischemic complication developed due to anterior choroidal artery occlusion jailed by the flow diverter stent. The occlusion of anterior choroidal artery covered by flow diverter stent is extremely rare. However, if the branch arises from the aneurysm sac, occlusion can transpire and induce serious complication. The most probable cause of occlusion in this case was that the orifice was jailed apart from the stent strut because the branch originated from the sac rather than the neck. Furthermore, the progression rate of intra-aneurysm thrombus formation is also an important factor affecting the side branch occlusion.

Treatment Strategy Based on Plaque Vulnerability and the Treatment Risk Evaluation for Internal Carotid Artery Stenosis

Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are not appropriate treatment procedure for internal carotid artery stenosis (ICAS) in some patients. The importance of plaque vulnerability and the treatment risk evaluation has been reported. We analyzed whether treatment selection contributes to the outcome. We retrospectively examined 121 patients who underwent CEA or CAS. Treatment was selected based on plaque vulnerability and the treatment risk evaluation. We selected CAS for patients with stable plaques and CEA for patients with unstable plaques, and considered the other treatment for high-risk patients. The patients were classified as the stable plaque (Stable: n = 42), the unstable plaque and CEA low risk (Unstable/Low: n = 30), and the CEA high-risk (Unstable/High: n = 49). Frequency of perioperative stroke, myocardial infarction, death, and systemic complications was examined. CEA and CAS were performed in 35 and 86 patients, respectively. One patient (2.9%) had a stroke in CEA and five patients (5.8%) in CAS (P = 0.50). Systemic complications were observed in two patients (5.7%) in CEA and six (7.1%) in CAS (P = 0.80). There were no differences in stroke (Stable; 2.4%, Unstable/Low; 3.2%, and Unstable/High; 8.2%) and systemic complications (Stable; 9.5%, Unstable/Low; 3.3%, and Unstable/High; 6.1%) among three groups (P = 0.44 and P = 0.59, respectively). The treatment selection based on plaque vulnerability and the treatment risk evaluation could provide good treatment outcome for high-risk patients. It is ideal to select an appropriate treatment for ICAS by one neurovascular team.

Prospect of Immunotherapy for Glioblastoma: Tumor Vaccine, Immune Checkpoint Inhibitors and Combination Therapy

To date, clinical trials of various vaccine therapies using autologous tumor antigens or tumor-associated/specific antigen peptide with adjuvants have been performed to treat patients with high-grade gliomas (HGG). Furthermore, immune checkpoint pathway-targeted therapies including anti- programmed cell death 1 (PD-1) antibody have been remarkably effective in other neoplasms, and various clinical trials with anti-PD-1 antibody in patients with HGG have started to date. It is possible that up-regulation of immune checkpoint molecules in tumor tissues after vaccine therapy may be one of the mechanisms of vaccine failure. Multiple preclinical studies indicate that combination therapy with vaccination and immune checkpoint blockade is effective for the treatment of malignant tumors including HGG. Thus, immunotherapy, especially combination therapy with vaccine and immune checkpoint inhibitors, may be a promising strategy for treatment of patients with HGG.

Prospect of Immunotherapy for Glioblastoma: Tumor Vaccine, Immune Checkpoint Inhibitors and Combination Therapy

To date, clinical trials of various vaccine therapies using autologous tumor antigens or tumor-associated/specific antigen peptide with adjuvants have been performed to treat patients with high-grade gliomas (HGG). Furthermore, immune checkpoint pathway-targeted therapies including anti- programmed cell death 1 (PD-1) antibody have been remarkably effective in other neoplasms, and various clinical trials with anti-PD-1 antibody in patients with HGG have started to date. It is possible that up-regulation of immune checkpoint molecules in tumor tissues after vaccine therapy may be one of the mechanisms of vaccine failure. Multiple preclinical studies indicate that combination therapy with vaccination and immune checkpoint blockade is effective for the treatment of malignant tumors including HGG. Thus, immunotherapy, especially combination therapy with vaccine and immune checkpoint inhibitors, may be a promising strategy for treatment of patients with HGG.

Profile Analysis of Chemotherapy-induced Nausea and Vomiting in Patients Treated with Concomitant Temozolomide and Radiotherapy: Results of a Prospective Study

Temozolomide (TMZ) as a concomitant and adjuvant chemotherapy to radiotherapy following maximal surgical resection is the established standard therapy for patients with newly diagnosed high-grade glioma. However, detailed analysis of chemotherapy-induced nausea and vomiting (CINV) associated with concomitant TMZ has not been sufficiently described. We prospectively analyzed the profile of CINV associated with concomitant TMZ. Eighteen consecutive patients with newly diagnosed high-grade glioma treated with concomitant chemoradiotherapy including TMZ were enrolled. CINV was recorded using a daily diary including nausea assessment, emetic episodes, degree of appetite suppression, and antiemetic medication use. The observed incidence rates of all grade nausea, moderate/severe (CTC grade 2, 3) nausea, emetic episodes, and appetite suppression for the overall period were 89%, 39%, 39%, and 83%, respectively. Moderate/severe nausea and severe (CTC grade 3) appetite suppression were frequently observed during the delayed phase of the treatment. Emetic episodes and moderate/severe nausea were significantly correlated with female gender. Moderate/severe nausea and severe appetite suppression were significantly correlated with low lymphocyte counts before chemoradiotherapy. For CINV associated with concomitant TMZ, enhanced antiemetic therapy focused on the delayed phase of the treatment will likely be beneficial, especially in female patients with a low lymphocyte count before chemoradiotherapy.

A new mechanism of cerebrospinal fluid leakage after lumboperitoneal shunt: a theory of shunt side hole--case report

Cerebrospinal fluid (CSF) overdrainage after lumboperitoneal (LP) shunt placement for the patients with idiopathic normal pressure hydrocephalus (iNPH) is mainly caused by insufficient management of pressure settings of the shunt valve and/or siphon effect of shunt systems induced by the patient's postural changes. We here report a unique case of intracranial hypotension (IH) due to CSF leakage after LP shunt placement in which another mechanism leads to the CSF leakage. A 67-year-old man suffered from persistent headache worsening with postural change 2 months after LP shunt reconstruction for iNPH. Brain computed tomography scan showed bilateral chronic subdural hematomas (CSDH). Lumbar images including shuntography and magnetic resonance imaging showed the tip of the lumbar catheter was spontaneously pulled out close to the dura mater with expansion of the epidural space due to CSF leakage from a shunt side hole of the lumbar catheter to the epidural space. Shunt removal and subsequent irrigation of CSDH improved his headache. CSF leakage in our case differs from those in previous reports, because early and enormous CSF leakage into the epidural space can be explained only by a different mechanism through a side hole just located in the epidural space in our case. We must pay attention to the possibility of this rare cause of IH due to CSF leakage in patients suffering from postural headache after LP shunt placement.

A new mechanism of cerebrospinal fluid leakage after lumboperitoneal shunt: a theory of shunt side hole--case report

Cerebrospinal fluid (CSF) overdrainage after lumboperitoneal (LP) shunt placement for the patients with idiopathic normal pressure hydrocephalus (iNPH) is mainly caused by insufficient management of pressure settings of the shunt valve and/or siphon effect of shunt systems induced by the patient's postural changes. We here report a unique case of intracranial hypotension (IH) due to CSF leakage after LP shunt placement in which another mechanism leads to the CSF leakage. A 67-year-old man suffered from persistent headache worsening with postural change 2 months after LP shunt reconstruction for iNPH. Brain computed tomography scan showed bilateral chronic subdural hematomas (CSDH). Lumbar images including shuntography and magnetic resonance imaging showed the tip of the lumbar catheter was spontaneously pulled out close to the dura mater with expansion of the epidural space due to CSF leakage from a shunt side hole of the lumbar catheter to the epidural space. Shunt removal and subsequent irrigation of CSDH improved his headache. CSF leakage in our case differs from those in previous reports, because early and enormous CSF leakage into the epidural space can be explained only by a different mechanism through a side hole just located in the epidural space in our case. We must pay attention to the possibility of this rare cause of IH due to CSF leakage in patients suffering from postural headache after LP shunt placement.

A multicenter phase I/II study of the BCNU implant (Gliadel(®) Wafer) for Japanese patients with malignant gliomas

Carmustine (BCNU) implants (Gliadel(®) Wafer, Eisai Inc., New Jersey, USA) for the treatment of malignant gliomas (MGs) were shown to enhance overall survival in comparison to placebo in controlled clinical trials in the United States and Europe. A prospective, multicenter phase I/II study involving Japanese patients with MGs was performed to evaluate the efficacy, safety, and pharmacokinetics of BCNU implants. The study enrolled 16 patients with newly diagnosed MGs and 8 patients with recurrent MGs. After the insertion of BCNU implants (8 sheets maximum, 61.6 mg BCNU) into the removal cavity, various chemotherapies (including temozolomide) and radiotherapies were applied. After placement, overall and progression-free survival rates and whole blood BCNU levels were evaluated. In patients with newly diagnosed MGs, the overall survival rates at 12 months and 24 months were 100.0% and 68.8%, and the progression-free survival rate at 12 months was 62.5%. In patients with recurrent MGs, the progression-free survival rate at 6 months was 37.5%. There were no grade 4 or higher adverse events noted due to BCNU implants, and grade 3 events were observed in 5 of 24 patients (20.8%). Whole blood BCNU levels reached a peak of 19.4 ng/mL approximately 3 hours after insertion, which was lower than 1/600 of the peak BCNU level recorded after intravenous injections. These levels decreased to less than the detection limit (2.00 ng/mL) after 24 hours. The results of this study involving Japanese patients are comparable to those of previous studies in the United States and Europe.