Purpose: Vertebral artery (VA) stump syndrome is described as one of the causes of posterior circulation ischemic stroke associated with VA occlusion. There are no reports of findings yielded by duplex ultrasound for diagnosing VA stump syndrome. The aim of the present study was to clarify the utility of duplex ultrasound for diagnosing VA stump syndrome. Subjects and Methods: Patients with acute posterior circulation stroke and VA proximal occlusion were diagnosed with VA stump syndrome. All patients underwent both duplex ultrasound and MRA unless contraindicated. CT angiography or conventional angiography was performed if possible. Results and Discussion: Seven patients were enrolled. On duplex ultrasound, an antegrade flow pattern was observed in four patients, although the culprit VA was occluded in the proximal portion. A to-and-fro pattern and delayed systolic upstroke flow were observed in the culprit VA in three and four patients, respectively. The collateral flow could be detected on duplex ultrasonography in four patients. Brain MRA revealed no abnormal findings in the vertebrobasilar arteries in two patients. Conclusion: Duplex ultrasound is useful for diagnosing VA stump syndrome, because duplex ultrasound can be used to evaluate flow and intravascular stasis.

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The patient was a 50-year-old female. She had received treatment for systemic lupus erythematosus (SLE) with glucocorticoid since she was 34 years old. Transthoracic echocardiography performed for screening showed a mass adjacent to the anterior leaflet of the mitral valve and protruding into the left ventricular outflow tract. Follow-up 3D transesophageal echocardiography depicted the mass, which occupied approximately two-thirds of the left ventricular outflow tract, and another small mass toward the left atrium. She had an opportunistic infection caused by glucocorticoid therapy; however, the blood cultures ordered several times were all negative. Infectious endocarditis was ruled out because the patient did not meet the Duke diagnostic criteria. The patient was suspected of having nonbacterial thrombotic endocarditis (NBTE) based on the formation of the masses, the diseased area, and her medical history of SLE. Head computed tomograms revealed an old cerebral infarction, suggesting that she should have a high risk of severe embolus determined by the scattered lesion pattern and thrombus mobility. The patient underwent sub-emergency mass removal and mitral valve replacement. The soft and multilocular masses and fibrin thrombus with mixed infiltrate (neutrophils and histiocytes) revealed that the patient had NBTE. The postoperative course was uneventful and no more embolic symptoms were found. She was discharged on the 19th postoperative day. NBTE frequently occurs when endothelial cells are damaged by the immune complexes and hypercoagulability due to malignant tumors. Here, we report the successful evaluation of NBTE using transesophageal echocardiography and the favorable prognosis without any neurological impairment.

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A case of retroperitoneal cystic lymphangioma in which cystic fluid analysis using endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) was helpful for diagnosis is reported. A 40-year-old man was referred and admitted to our department for further examination with a chief complaint of back pain, and detailed examination revealed a pancreatic cyst. Abdominal contrast-enhanced CT showed a non-enhancing, lobulated, cystic lesion surrounded by the pancreatic tail, spleen, left kidney, and stomach. Magnetic resonance cholangiopancreatography showed a multilocular cyst but no dilation of the main pancreatic duct. On duodenoscopy, no mucus excretion was observed. Pancreatography showed no translucency indicative of mucus, and the cyst was not visualized even after increasing the contrast pressure. Endoscopic ultrasound showed a multilocular cystic lesion in the pancreatic tail that was 80 mm in diameter and consisted of loculi of various sizes. No nodes were seen. Intraductal papillary mucinous neoplasm was ruled out based on the above imaging findings, and EUS-FNA was performed on the cyst for differential diagnosis between serous cystic neoplasms and pancreatic pseudocysts. The cystic fluid was yellowish, and based on the findings that CEA was within the normal range and amylase was only slightly elevated (161 IU/l), mucinous tumor and pancreatic pseudocyst were ruled out. Because the patient remained symptomatic, the cyst was removed surgically. Histopathological analysis showed that the tumor consisted of cysts of various sizes. The cyst wall was composed of a single squamous epithelial layer with no atypical cells, and smooth muscle components were also observed. The patient was diagnosed as having cystic lymphangioma.

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