Objectives: To evaluate the cerebrospinal fluid (CSF) dynamics in secondary normal pressure hydrocephalus (sNPH), we compared the three-dimensional velocities and volumes of reciprocating CSF movements and several shear stress parameters, measured by four-dimensional (4D) flow magnetic resonance imaging (MRI) among sNPH, hemorrhagic stroke, and control groups.

Methods: In this study, 4D flow MRI in the seven patients with sNPH, eight patients with acute hemorrhagic stroke who did not develop sNPH, and nine age-matched healthy controls were analyzed. The CSF stroke volumes and reversed flow rate at the 10 regions from the bilateral foramina of Monro to the foramen magnum were measured by using the 4D flow application on SYNAPSE VINCENT (FUJIFILM, Tokyo). In addition, oscillatory shear stress (OSS) and oscillatory shear index (OSI) at the dorsal and ventral sides of the cerebral aqueduct were calculated. The mean values of CSF stroke volumes, reversed flow rate, OSS amplitude, maximum and minimum values of OSS, and OSI were compared among the three groups.

Results: The sNPH group had significantly larger stroke volumes and higher reversed flow rates at the foramen of Magendie and lower end of the cerebral aqueduct, and larger stroke volumes at the upper end of the cerebral aqueduct and foramina of Monro than in the non-sNPH hemorrhagic stroke group and age-matched healthy controls. The amplitude and maximum value of OSS at the cerebral aqueduct were significantly higher in the hemorrhagic stroke group than in the controls.

Discussion: In the acute phase of hemorrhagic stroke, the CSF stroke volume at the cerebral aqueduct increases because of the decrease in brain compliance due to the increased intracranial pressure. We suggest that the increase in the OSS amplitude due to the increased CSF stroke volume promotes the dilation of ventricular walls.

Conclusions: Patients with acute hemorrhagic stroke had larger amplitudes and maximum values of OSS at the cerebral aqueduct than age-matched healthy controls. Furthermore, patients with sNPH had larger CSF stroke volumes at the bilateral foramina of Monro, upper and lower ends of the cerebral aqueduct, and foramen of Magendie, than did those with hemorrhagic stroke. Visualization of CSF movements and quantification of shear stress parameters on 4D flow MRI may help predict the development of sNPH.

A surgical method of treating vertebral artery (VA) dissection intended to prevent medullary infarctions coupled with trapping of the lesion as much as possible is described in seven consecutive patients [4 with subarachnoid hemorrhage (SAH), 3 without SAH (non-SAH)] at our hospital. Patients are first placed in the semi-prone position, then rotated to prone during lateral suboccipital craniotomy and C1 laminectomy for safety and ease of the procedure. Patients are repositioned to the semi-prone position for the micro-neurosurgery. The trans-cerebellomedullary fissure approach is used for distal VA and medullary perforating artery manipulation in the upward surgical view; thereafter, pinpoint trapping of the lesion is performed. For dissections involving the posterior inferior cerebellar artery (PICA), the PICA is reimplanted and closed in a pin-point manner, just proximal to the origin of the medullary perforating artery, which arises from the first segment of the PICA. Further improvement in the surgical method for VA dissection is needed for safer and more secure occlusion of the lesion.

Background: Poor-grade subarachnoid hemorrhage (SAH) accounts for approximately 20% of SAH cases. Generally, patients with poor-grade SAH are considered to have a poor prognosis, and the treatment indication for such patients remains controversial. This study aimed to investigate the independent risk factors affecting clinical outcomes to improve the prognosis of patients with poorgrade SAH.

Methods: We selected 95 patients with poor-grade SAH were treated at our institution from January 2008 to September 2017. Poor-grade SAH was defined as having Hunt and Kosnik Grades IV and V on admission. Clinical outcomes were assessed according to the modified Rankin Scale on discharge and stratified into favorable (modified Rankin Scale [mRS] scores 0–3) and unfavorable (mRS score 4–6). Clinical data including patient characteristics on admission and during treatment course, treatment modality, aneurysm location, and radiologic features were collected. Risk factors affecting clinical outcomes were assessed using univariate and multivariate analyses. Subgroup analyses of operative cases and Grades IV and V cases were also performed.

Results: Of the 95 patients, 32 had favorable outcomes whereas 63 had unfavorable outcomes. In the multivariate analysis, conservative treatment, Hunt and Kosnik grade V on admission, and seizure were identified as significant predictors of unfavorable outcomes in patients with poor-grade SAH. In the operative cases, no significant predictors of unfavorable outcomes were identified. In the Grade IV cases, conservative treatment was identified as a significant predictor of unfavorable outcomes. In the Grade V cases, the patients with favorable outcomes had a high frequency of pupil reactivity.

Conclusion: To improve the prognosis of patients with poor-grade SAH, those with Grade IV should be treated promptly for aneurysm. Patients with grade Vshould immediately receive treatment for aneurysm when brainstem dysfunction is judged as reversible.

A carotid web (CW) is a shelf-like projection into the lumen of the carotid artery bulb. Here, we report a case of symptomatic CW diagnosed by computed tomography angiography (CTA) that was successfully treated by carotid endarterectomy (CEA). A 40-year-old man with no significant medical or family history was admitted in the emergency ward after experiencing weakness and paresthesia in his left upper extremity. Magnetic resonance imaging (MRI) revealed acute embolic cerebral infarction of the right opercular part of the inferior frontal gyrus, confirming an embolic stroke of undetermined source (ESUS). Subsequently, he was treated with anticoagulant and antiplatelet therapy, and no further abnormalities were detected on carotid ultrasound (US) performed on the first day, except for a small plaque at the carotid artery bifurcation. However, the CTA performed on the fourth day demonstrated a CW at the origin of the right internal carotid artery, which was treated by CEA. No recurrence has been observed since the past 14 months.

This case highlights the probability of overlooking a CW during the assessment of ESUS by US alone, and that CTA is an essential diagnostic tool for CW.

A 51-year-old man presented with a subarachnoid hemorrhage (SAH). Initial computed tomography angiography revealed a ruptured right vertebral artery dissecting aneurysm (VADA) 1 h post-SAH, which was spontaneously occluded as revealed by cerebral angiography 2 hours post-SAH. On day 3 when recanalization of the VADA was diagnosed, internal trapping of the VADA and parent artery was performed. The postoperative course was uneventful, leading to good outcomes. When a ruptured VADA is spontaneously occluded and conservatively treated in the acute stage of SAH, careful imaging follow-up is necessary while considering early recanalization.

We describe a very rare case of subarachnoid hemorrhage (SAH) due to a right internal carotid-posterior communicating artery (IC-PC) aneurysm simultaneously associated with a left temporal intracerebral hemorrhage (ICH).

A 73-year-old woman suffered from sudden-onset headache and vomiting, and subsequently her consciousness gradually deteriorated. On admission, she presented with severe disturbances of consciousness and anisocoria (right 6 mm ＞ left 3 mm). Computed tomography (CT) on admission revealed a diffuse SAH and massive ICH in the left temporal lobe, including the left choroidal fissure. Three-dimensional computed tomography angiography (3D-CTA) revealed a small aneurysm at the right IC-PC and an irregularly shaped left internal carotid artery. First, we performed a left fronto-temporal craniotomy and observed the left carotid artery using the distal transsylvian approach; however, we could not detect a ruptured aneurysm at the left carotid artery. Therefore, after removal of the left temporal hematoma, we performed a right craniotomy, found a ruptured right IC-PC aneurysm, and then performed clipping of the aneurysm. Because CT findings strongly suggested the existence of a ruptured left carotid artery aneurysm, we first performed a left-side craniotomy despite the absence of an obvious aneurysm at the left carotid artery. However, ICH was not associated with aneurysm rupture. Therefore, a right-sided craniotomy was performed.

The simultaneous occurrence of aneurysmal SAH and remote ICH has been reported in only eight cases. We reviewed the literature on these eight patients, focusing on mechanism of simultaneous occurrence of aneurysmal SAH and remote hematoma mechanism.

We present a case of a cavernous sinus dural arteriovenous fistula (CS−dAVF) with concomitant multiple brain metastases (MBM) that showed hemodynamic alteration of the shunt after irradiation of the MBM. A 78-year-old woman with a history of breast cancer (cT2N1M1 Stage IV) presented to the clinic for further evaluation and treatment of multiple brain lesions identified on magnetic resonance imaging (MRI). She was diagnosed with breast cancer (cT2N1M1 Stage IV) one year before presenting to our clinic. The patient underwent surgery and adjuvant chemotherapy. Although the visceral malignancy remained dormant, the patient’s condition was complicated by MBM. Proptosis and ophthalmoplegia occurred, and head MRI indicated CS-dAVF. Radiotherapy targeting the metastatic brain tumors was performed. Cerebral angiography at 40 days post-irradiation showed CS-dAVF draining into the external jugular vein via the facial vein (FV), superior orbital vein (SOV), and superficial temporal vein (STV). On the 77th day after radiotherapy, transvenous coil embolization was planned for the CS-dAVF. Preoperative angiography showed decreased flow in both feeders and drainers. Although the angiographic changes were demonstrated, her ophthalmoplegia had progressed, which we concluded was a typical “paradoxical worsening.” Due to hemodynamic alteration, we were obliged to access the CS via the obstructed inferior petrosal sinus. Coil embolization was performed as planned, and the symptoms gradually improved without recurrence within 18 months. The drastic change in hemodynamics that we observed in this case may be explained by the radiotherapy performed in advance against MBM. Although rare, possible changes in hemodynamic flow should be considered during treatment planning when MBM is comorbid with CS-dAVF.

Objectives: It is rare that unilateral midbrain stroke causes only conjugate upward gaze palsy. There is no reports about the symptoms caused by cerebral endovascular treatments.

Case presentation: A 44-years-old female presenting with basilar tip aneurysm received coil embolization. She rapidly developed postoperative narrowing of right palpebral fissure, skew deviation and conjugate upward gaze palsy. Other neurologic symptoms were not seen. Diffusion weighted magnetic resonance revealed small infarction in unilateral midbrain. The symptoms improved two weeks after the procedure.

Conclusion: A case of conjugate upward gaze palsy due to unilateral midbrain infarction was observed post coil embolization of the basilar artery aneurysm. As this is a rare complication of endovascular therapy, involvement of an unknown mechanism for conjugate upward gaze is suggested.

A 65-year-old male presented with impaired consciousness and was evaluated at 1.5 h after onset. The National Institutes of Health Stroke Scale (NIHSS) score was found to be 36 while the posterior circulation Alberta Stroke Program Early CT score (ASPECTS) was observed to be 8. Further, magnetic resonance angiography (MRA) showed basilar artery occlusion. Therefore, tissue plasminogen activator was administered, and thrombectomy was performed. The basilar artery was recanalized although right vertebral artery stenosis persisted. Medical treatment was initiated, and rehabilitation was performed. Unfortunately, the patient's state of consciousness deteriorated and right hemiparesis was observed on Day 5 post-thrombectomy. As angiography displayed reocclusion of the right vertebral artery, emergent angioplasty was performed. The patient recovered his consciousness, and a stent was inserted in the right vertebral artery one day after surgery. The treatment strategy for a tandem lesion in the posterior circulation is unclear regarding whether anterograde or retrograde approach is better. In some cases of posterior circulation, collateral flow is poor. The retrograde approach and vertebral artery stenting are an effective option for basilar occlusion due to a tandem lesion.

A 65-year-old female complaining of a sudden onset of severe back pain was admitted to our hospital. Plain computed tomography (CT) showed subarachnoid hemorrhage (SAH) in the spinal canal, and contrast-enhanced CT detected a 3 mm vascular anomaly at the left Th5. Spinal angiography revealed an isolated spinal aneurysm (ISA) of the radiculopial artery. The back pain improved after oral pregabalin administration. However, the enhanced lesion remained unchanged on follow-up CT. Therefore, surgical resection was performed 17 days after the onset. The postoperative course was uneventful and the patient was discharged without any symptoms. The natural history of isolated spinal aneurysms remains unknown. Therefore, isolated spinal aneurysms, which are associated with spontaneous regression and death, have no unified treatment policy. Surgical intervention can be considered for a ruptured ISA in the radiculopial artery at the thoracic spinal level if there is no improvement on conservative treatment.

The anomalous origin and perfusion area of the anterior choroidal artery (AchoA) vary. Herein, we report a rare case of a ruptured cerebral aneurysm related to both the anomalous origin and perfusion area of the AchoA. An 80-year-old woman presenting with deep coma was brought to our hospital by ambulance, and she was diagnosed with subarachnoid hemorrhage. Computed tomography angiography revealed no bleeding source except a 3 mm-dilated proximal segment of the posterior communicating artery (Pcom). Catheter angiography demonstrated that an artery of unknown origin and the Pcom arose from a common trunk of the internal carotid artery, in addition to a small aneurysm projecting from the proximal segment of the Pcom. Imaging analysis using three-dimensional rotational angiography revealed that the artery of unknown origin was an anomalous hyperplastic AchoA with an anterior temporal artery which generally originates from the posterior cerebral artery (PCA). We successfully performed balloon-assisted coil embolization, preserving both the Pcom and AchoA. A ruptured aneurysm related to the anomalous origin and perfusion area of the AchoA has rarely been reported. Treating stroke related to such AchoA anomalies based on the understanding of vascular relations and anatomy of the AchoA and Pcom–PCA distributions is essential in order to avoid surgical complications.

We experienced two cases of surgical clipping of intracerebral unruptured aneurysms, in which compression of the penetrating branch by the clip head caused an ischemic change. Perforator branch compression by the clip head may occur after clipping of an aneurysm and it worsens the prognosis if left untreated. In Case 1, motor evoked potential (MEP) monitoring was effective during surgery, and in Case 2, the confirmation of neurological findings was helpful after surgery. Early detection and retreatment may improve prognosis, and based on this case, we will report on how to deal with this problem.

Abstract: We report a case where a dural arteriovenous fistula (DAVF) was treated successfully with single-stage surgically assisted transcranial transvenous embolization. For this purpose, direct puncture of the transverse sinus was made with the patient in the prone position.

Case Presentation: A 78-year-old female presented with pulsatile tinnitus and ataxia. Cerebral angiography confirmed the presence of a left transverse-sigmoid sinus DAVF with retrograde cortical venous reflux. As transvenous approach via the femoral vein was not possible, transcranial approach with direct puncture of transverse sinus was used for embolization of the fistula in the prone position with Prone View. Angiography demonstrated complete occlusion.

Conclusion: Direct puncture of transverse sinus with Prone View may be considered a safe and effective approach when other approaches are not feasible.