Background: The feasibility of transcranial color flow imaging (TC-CFI) for evaluation of in-stent flow after flow diverter stenting has not been clarified.
Case: A 59-year-old man was admitted due to headache and was diagnosed as having a dissecting aneurysm of the right vertebral artery (RVA) by magnetic resonance angiography (MRA) and cerebral angiography. Although he was discharged after conservative therapy, he was readmitted due to worsening of his headache 2 months later. Since brain MRA showed enlargement of the dissecting aneurysm, he was treated with flow diverter stenting on day 14 after admission. A 4.5 × 18 mm Pipeline Flex embolization device with Shield technology was placed in the RVA across the dissecting aneurysm. Mild stenosis at the distal part of the Pipeline remained even after percutaneous transluminal angiography. MRA on postoperative day 1 showed decreased signals in the RVA inside the Pipeline. For evaluation of in-stent stenosis, TC-CFI by the foramen magnum approach was performed. The Pipeline was slightly visible on two-dimensional images. TC-CFI at the RVA inside the Pipeline was performed uneventfully and demonstrated normal flow findings, suggesting the absence of in-stent stenosis.
Conclusions: TC-CFI can be used to evaluate in-stent flow after flow diverter stenting.

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A 40-year-old man referred to our hospital due to pain and numbness in the left thumb. Neurological findings revealed decreased tactile, temperature and pain sensations only in the left thumb. The strength of the left finger was almost normal, but the muscles associated with the thumb had a similar degree of mild weakness as pain was induced. A painful trigger point at the base of the left thumb suggested impairment of the nerve associated with thumb sensation. Nerve ultrasound was performed targeting the small nerves running from the left palm to the fingers, and local swelling was observed in the common palmar digital nerve to the left thumb. Sensory nerve conduction studies of the median nerve with thumb stimulation and wrist recording revealed decreased amplitude on the left side. Additional medical history revealed that the patient held the smartphone in his left hand and operated it with his left thumb, spending more than eight hours playing smartphone games every day. We concluded that the patient’s left thumb pain and numbness was due to common palmar digital nerve injury to the left thumb, which was caused by habitual smartphone focal nerve compression, and nerve ultrasound was helpful in its diagnosis.

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Langerhans cell histiocytosis (LCH) is a neoplastic disease characterized by the idiopathic proliferation of Langerhans cells. X-ray, computed tomography (CT), and magnetic resonance imaging (MRI) are often performed, and pathology should be identified for a definitive diagnosis. Single-system single-site lesions can be treated by surgical excision, but multi-system and single-system multi-site lesions are challenging to treat by surgical excision alone; therefore, chemotherapy is used after definitive diagnosis through biopsy. We report a single-system multi-site LCH of the skull that was safely biopsied using preoperative ultrasound evaluation. A 2-year-old girl was referred to our hospital with suspected LCH on CT to evaluate a head contusion. A biopsy was conducted for a definite diagnosis, and chemotherapy was administered because of multi-site lesions. To ensure a safe biopsy, preoperative ultrasonography was performed to evaluate the relationship between tumors and the dura mater, venous sinus, and blood flow inside tumors. The pathology was divided into bone lesion, the part of temporalis muscle in contact with the bone lesion, muscle belly of temporalis muscle directly above the bone lesion, and capsular tendon membrane. Langerhans cells were present only in bone lesions. Preoperative sonographic diagnosis is helpful for Langerhans cell histiocytosis. Additionally, a biopsy should be performed on the tumor, not the surrounding tissue.

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Transoral carotid ultrasonography (TOCU) is a useful method for evaluating the distal internal carotid artery, which cannot be examined by a linear probe. An endocavity probe is typically used only to perform TOCU, and the application of an endocavity probe to carotid ultrasonography other than TOCU has not been reported. This case series presents the unique use of the endocavity probe for carotid ultrasonography. Carotid ultrasonography with an endocavity probe (CUEP) is useful for evaluating the middle to distal segments of the internal carotid artery. CUEP is less invasive than TOCU and can sometimes be an alternative to TOCU, although TOCU is more useful than CUEP for close examination of the distal segment of the internal carotid artery. Furthermore, because the endocavity probe has a small head and a wide range of views, CUEP is useful when the presence of other medical devices or inadequate space limit the field of view of a linear probe or its necessary contact with the body surface. Thus, CUEP can be applied in various situations to overcome the limitations of linear probes.

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