Purpose: Bone cement enhancement by percutaneous vertebroplasty (PVP) for the treatment of osteoporotic vertebral compression fractures remains unapproved, as it has not been fully evaluated in Japan. The current multicenter study was conducted in Japan to verify the safety and efficacy of PVP in patients with painful osteoporotic vertebral fractures. Material and Methods: In this retrospective study, we referred to previous studies to evaluate the non-inferiority of PVP to balloon kyphoplasty (BKP). We reviewed consecutive patient data from April 2017 to March 2018 from four institutions based on the medical records of the intervention. We statistically investigated the adverse events due to cement leakage or other factors associated with PVP, and new vertebral compression fractures after PVP were evaluated for safety, pain relief, and gait improvement. Results: This study included 485 patients; most of whom were in the middle- to oldest- age groups (mean age, 81.4 years). No serious adverse events were reported in patients available for safety evaluation (n = 485). Cement leakage and new vertebral compression fractures occurred in 35.7% and 18.6% (26.2%-38.4% and 8.9%-20.7%) of the patients undergoing PVP, respectively, both of which were also judged to be equivalent to those of BKP. The pain score improved in those undergoing PVP, and this improvement was maintained during a one-year follow-up. Of the 206 patients who had difficulty walking at baseline, 156 had restored walking at discharge. Conclusions: PVP was shown to be a safe and effective treatment, even in elderly patients with painful osteoporotic vertebral fractures.

PURPOSE:Persistent hypoglossal artery (PHA) is the second most common anastomosis between the carotid and vertebrobasilar systems and it demonstrates some variations.METHODS:Using magnetic resonance angiography, we diagnosed a case of low origin of the PHA associated with the high carotid bifurcation, and the resulting origin close to the carotid bifurcation.RESULTS:The PHA is typically clinically silent as in our case, but it could be a potential cause of glossopharyngeal neuralgia, hypoglossal palsy, and intracranial aneurysms or technical complications in interventional procedure such as carotid stenting.CONCLUSIONS:We have described a case of low origin of the PHA associated with high carotid bifurcation. To the best of our knowledge, no similar case has been reported in the English-language literature.

Zytotoxische Balkenläsionen haben viele Ursachen. Sie müssen als das angesehen werden, was sie sind – als sekundäre Läsionen. Es ist daher wichtig, dass Ärzte mit den bekannten Ursachen zytotoxischer Balkenläsionen vertraut sind, damit diese ermittelt und angegangen werden können und nicht fälschlicherweise eine Ischämie diagnostiziert wird. Deshalb schildert dieser Artikel Mechanismen, Ursachen und Manifestationen zytotoxischer Balkenläsionen.

Neurological complications of paediatric cancers are a substantial problem. Complications can be primary from central nervous system (CNS) spread or secondary from indirect or remote effects of cancer, as well as cancer treatments such as chemotherapy and radiation therapy. In this review, we present the clinical and imaging findings of rare but important neurological complications in paediatric patients with cancer. Neurological complications are classified into three phases: pre-treatment, treatment and post-remission. Paraneoplastic neurological syndromes, hyperviscosity syndrome, haemophagocytic lymphohistiocytosis and infection are found in the pre-treatment phase, while Trousseau’s syndrome, posterior reversible encephalopathy syndrome and methotrexate neurotoxicity are found in the treatment phase; though some complications overlap between the pre-treatment and treatment phases. Hippocampal sclerosis, radiation induced tumour, radiation induced focal haemosiderin deposition and radiation-induced white matter injury are found in the post-remission phase. With increasingly long survival after treatment, CNS complications have become more common. It is critical for radiologists to recognise neurological complications related to paediatric cancer or treatment. Magnetic resonance imaging (MRI) plays a significant role in the recognition and proper management of the neurological complications of paediatric cancer.

Cytotoxic lesions of the corpus callosum (CLOCCs) are secondary lesions associated with various entities. CLOCCs have been found in association with drug therapy, malignancy, infection, subarachnoid hemorrhage, metabolic disorders, trauma, and other entities. In all of these conditions, cell-cytokine interactions lead to markedly increased levels of cytokines and extracellular glutamate. Ultimately, this cascade can lead to dysfunction of the callosal neurons and microglia. Cytotoxic edema develops as water becomes trapped in these cells. On diffusion-weighted magnetic resonance (MR) images, CLOCCs manifest as areas of low diffusion. CLOCCs lack enhancement on contrast material-enhanced images, tend to be midline, and are relatively symmetric. The involvement of the corpus callosum typically shows one of three patterns: (a) a small round or oval lesion located in the center of the splenium, (b) a lesion centered in the splenium but extending through the callosal fibers laterally into the adjacent white matter, or (c) a lesion centered posteriorly but extending into the anterior corpus callosum. CLOCCs are frequently but not invariably reversible. Their pathologic mechanisms are discussed, the typical MR imaging findings are described, and typical cases of CLOCCs are presented. Although CLOCCs are nonspecific with regard to the underlying cause, additional imaging findings and the clinical findings can aid in making a specific diagnosis. Radiologists should be familiar with the imaging appearance of CLOCCs to avoid a misdiagnosis of ischemia. When CLOCCs are found, the underlying cause of the lesion should be sought and addressed. ©RSNA, 2017 An earlier incorrect version of this article appeared online. This article was corrected on February 13, 2017.

However, our search of the literature failed to disclose any report of FMD associated with fenestration of the cervicocephalic arteries; therefore, it is presumed that the association observed in the present patient was incidental. The clinical significance of fenestration of the vertebral artery has not been determined. An aneurysm susceptible to rupture may arise in the proximal portion of the fenestration as in the basilar, internal carotid, or intracranial arteries [5-7). Fenestration without an aneurysm is probably innocuous, although fenestration may become a nidus for clot formation [2).

OBJECTIVEThe purpose of this study was to investigate the advantages of contrast-enhanced MRI (CE-MRI) for detecting intravertebral clefts over unenhanced MRI in relation to the time since onset of vertebral fracture.MATERIALS AND METHODSIn this retrospective study, a total of 115 patients (88 women, 27 men; mean age, 77.1 years) who underwent percutaneous vertebroplasty for a single-level compression fracture within 7 days of preprocedural MRI were enrolled. Two radiologists evaluated preprocedural unenhanced MRI (T1-weighted and STIR) and CE-MRI examinations for intravertebral clefts on separate days by consensus. The time from the onset of fracture to MRI was classified into three groups: early phase fractures (< 1 month), late phase fractures (1-3 months), and chronic phase fractures (≥ 3 months). The cement distribution during percutaneous vertebroplasty was used as a reference standard, and detectability of clefts was compared between unenhanced MRI and CE-MRI in relation to the time frame. An analog of the McNemar test was used for analyses.RESULTSThere were 104 patients (90.4%) with and 11 patients (9.6%) without a cleft. The sensitivities of unenhanced MRI and CE-MRI, respectively, for detecting clefts were 60.9% and 91.3% for early phase fractures (p = 0.02); 78.6% and 100% for late phase fractures (p = 0.014); and 92.5% and 94.3% for chronic phase fractures (p = 0.3). The specificities were the same for both groups (100% for each time frame).CONCLUSIONCE-MRI is more sensitive than unenhanced MRI for detecting intravertebral clefts in patents with benign compression fractures less than 3 months old.

Purpose We evaluated the relationships between pre-procedural radiological findings and short-term pain relief in patients with osteoporotic compression fractures after percutaneous vertebroplasty (PVP). Materials and methods A retrospective review of pre-procedural radiological images of 156 patients with painful osteoporotic compression fracture was performed. Pain was measured with a visual analogue scale (VAS). Complete pain relief was defined as a VAS pain score of 0 or 1 at 3 months after PVP. Statistical analyses were conducted to evaluate the relationship between the pre-procedural imaging factors and pain relief using Pearson’s chi-squared test. Multivariate logistic regression analysis was also performed. Results Complete pain relief was obtained in 45.5% of patients. An intravertebral cleft larger than half the height of the fractured vertebral body (FVB) was a significant key factor in the complete pain relief group after 3 months. Further, ≥40% of the spinal canal occupied by bony fragments of the FVB was related to incomplete pain relief. Conclusion A large intravertebral cleft was a favorable short-term outcome predictor in patients with osteoporotic compression fractures after PVP, while severe protrusion of the FVB causing lumbar spinal canal stenosis was not a favorable short-term outcome predictor of complete pain relief.

We report a case of spinal subdural hematoma in the lumbar spine of a 75-year-old woman. Magnetic resonance imaging showed lesions of homogeneous high intensity in the spinal canal on both T₁- and T₂-weighted images, findings closely resembling those for epidural lipomatosis. Identification of 2-layered signal intensity surrounding the cauda equina on axial images is the key for accurate diagnosis.

To maintain the patient's quality of life, palliative treatment for symptomatic bone metastases is as important as treatment of the primary lesion. Percutaneous vertebroplasty (PVP) was initially reported as a minimally invasive treatment for painful vertebral angioma, and then began to be performed for not only vertebral metastases or multiple myeloma but also osteoporotic vertebral fractures. PVP has been widely performed for relieving pain and stabilizing vertebral bodies following compression fractures of osteoporotic vertebral bodies refractory to medical therapy. Brace treatment and open surgical intervention are less desirable in this population because of the associated medical comorbidities. The indication for this procedure was subsequently extended to the treatment of vertebral compression fractures related to osteoporosis, metastases, or multiple myeloma, with the analgesic and stabilizing effects on the spine being validated by multiple studies. PVP is now widely used as standard treatment for osteoporotic fractures and metastatic tumors of the vertebral bodies in the United States and Europe. The PVP procedure is performed using a biplane angiography unit under local anesthesia and conscious sedation in a conventional manner. The patient is placed in a prone position under sterile conditions. After a small skin incision is made, a disposable 11- or 13-gauge bone biopsy needle is positioned with its tip near the center of the pedicle. Anteroposterior and lateral fluoroscopy is used to guide the advancing needle through the pedicle into the vertebral body. Bone cement is prepared by combining sterile barium and polymethylmethacrylate (PMMA). Injection of bone cement is performed either manually or with an injection device. The effectiveness of percutaneous injection of PMMA for metastatic tumors in a weight-bearing region such as vertebral bodies and pelvis has been reported. Percutaneous injection of bone cement is a promising alternative therapy for metastatic spinal tumors. The mechanism of pain relief in patients with neoplastic lesions treated by cement injection is not well known, but stabilization of the destroyed bone in addition to the analgesic effect of PMMA due to the thermal effect in itself seem to be main contributors to pain relief. PVP using PMMA is effective in relieving pain and perioperative complications related to PVP are rare; however, when these complications occur, they can be potentially devastating. Injection of cement into the paravertebral vessels can result in pulmonary emboli, while extravasation of cement posteriorly into the neural foramen or spinal canal can result in neurologic deficit. PVP offers a less invasive technique that can be performed for pain relief in patients with painful vertebral metastases or myeloma and short life expectancy whose general condition makes surgery difficult. PVP can therefore be proposed as part of the palliative care of patients in whom no further treatment options are available. (author)

OBJECTIVE:Previous studies have shown the possible efficacy of prophylactic cement injection for nonfractured vertebrae during percutaneous vertebroplasty for compression fractures. The purpose of this study was to investigate risk factors for subsequent fractures after prophylactic percutaneous vertebroplasty. MATERIALS AND METHODS:This retrospective study included 116 patients with osteoporotic compression fractures who underwent prophylactic percutaneous vertebroplasty. The patients were monitored with physical examinations and radiographs at 1 day and at 3 and 12 months after percutaneous vertebroplasty, and if back pain recurred. We analyzed the following multiple covariates to determine whether they were associated with recurrence: age, sex, steroid use, and the preoperative number of unhealed or chronic compression fractures. RESULTS:Subsequent fractures in any vertebra occurred within 3 months after the procedure at 26 vertebrae in 21 patients (18.1%), and 36 occurred in 28 patients (24.1%) within 12 months. The occurrence of subsequent fractures within 12 months depended on the preoperative number of unhealed vertebrae: the occurrence rate was 16.9% (11/65) for one vertebra, 27.0% (10/37) for two vertebrae, and 50.0% (7/14) for three or more vertebrae. The incidence of subsequent fractures was significantly higher in patients with three or more fractures than in those with one fracture (p < 0.05). There were no statistically significant differences for the other factors. CONCLUSION:Patients with three or more fractures tended to have subsequent fractures, despite undergoing prophylactic percutaneous vertebroplasty. However, there was no increased risk of subsequent fractures related to prophylactic percutaneous vertebroplasty.

We have performed percutaneous vertebroplasty (PV) using polymethylmethacrylate (PMMA) for patients with vertebral metastases since 2002. This study investigated the therapeutic effects of PV on vertebral metastases.

Carotid artery stenting (CAS) using Angioguard XP/Precise stent (AG/PS) has been widely used for treating carotid artery stenosis. However, the use of this device was considered to cause a relatively high occurrence rate of embolic complications compared with the use of other off labeled occlusion or protection devices. One of the reasons is thought to be the excessive pressing on the atheroma plaque lesion post-angioplasty after stenting. Here, we report the preliminary results of CAS with AG/PS using mild post-angioplasty (mild post-PTA) in a small number of patients at our institution. CAS was successfully performed in 12 patients (men, 11; women, one; average age 70.6 years; six patients under general anesthesia) using this technique over a 10 month period. Eight patients showed symptomatic carotid artery stenosis. The preoperative carotid artery average per cent stenosis by NASCET criteria was 73.8%. Furthermore, we discuss the postoperative carotid artery per cent stenosis, cerebral ischemic complication, other complication events, no flow/slow flow event and carotid artery restenosis rate. The postoperative carotid artery average per cent stenosis was improved to 7.5%. Moreover, good dilatation was achieved after stenting using mild post-PTA. Postoperative diffusion weighted MR images showed high intensity spotty lesions. One patient (8.3%) presented with motor speech disturbance and asymptomatic no flow event. Perioperative complication and carotid artery restenosis after stenting have not occurred so far during a short follow-up period, indicating a relatively acceptable result of CAS with AG/PS using mild post-PTA. Other procedures to achieve good stenting results using mild post-PTA are needed, as well as data from long term follow-up at our own institution.

Introduction Keeping microcatheters stable in anterior cerebral artery (ACA) or middle cerebral artery (MCA) aneurysms during coil embolization is crucial in the success of the treatment. We currently use a triple coaxial catheter system by using long 4 French or 5 French Cerulean G catheters (Medikit, Tokyo, Japan) as second guiding catheter to support microcatheters in cases of distal cerebral aneurysms. The purpose of this retrospective study is to evaluate the efficacy of the triple coaxial system in the treatment of distal cerebral aneurysms. Materials and methods We retrospectively reviewed eight cases (five men and three women; aged 47–90 years; mean 68.1 years) of ACA and MCA ruptured aneurysms treated by endovascular coil embolization by using the triple coaxial system between April 2009 and February 2010. The location of the aneurysms included the anterior communicating artery (n=6), distal ACA (n=1) and distal MCA (n=1). A 5 French guiding sheath (n=4) or 6 French guiding catheter (n=4) was used as the primary guiding catheter. A 4 French or 5 French Cerulean G catheter was introduced up to the petrous portion of the internal carotid artery as a second guiding catheter. Evaluated subjects included success of microcatheter navigation, stability of microcatheter during the procedure and other technical issues. Results In all cases, a microcatheter was navigated into the aneurysms successfully. Microcatheters were kept stable inside the aneurysms during the procedure. However, to advance preshaped SL-10 microcatheters (Boston Scientific, Natick, Massachusetts, USA) inside 4 French Cerulean G catheter in two cases was so difficult that we had to exchange the microcatheter to another one. There was no complication associated with the technique. Contrast injection through the guiding catheter during the procedure was slightly hard when 6 French guiding catheters were used as the primary guiding catheter. Conclusion Triple coaxial system for ACA and MCA aneurysms is a safe and feasible technique. However there are several technical issues that we have to take into account.

Purpose Ruptured dissecting vertebral artery aneurysms should be treated immediately because of the high risk of rebleeding. The purpose of this retrospective study is to evaluate the efficacy of endovascular internal trapping by platinum coils for ruptured dissecting vertebral artery aneurysms. Materials and methods We retrospectively reviewed 13 cases (eight men and five women; aged 50–80 years; mean 65 years) of acutely ruptured aneurysms of the vertebral artery treated by endovascular internal trapping between April 2003 and February 2010. Endovascular trapping was done by coil embolization of the dissected arterial segment, including the aneurysm. Evaluated subjects included success of the therapy, presence of rebleeding, procedural complication and other technical issues. Results In all cases, endovascular internal trapping was done successfully. There was no case of rebleeding. Three cases in which perforating arteries to brainstem originated from the dissected segment had postprocedural medullary infarction. However, the neurological symptoms diminished during the follow-up period. Conclusion Endovascular internal trapping is an effective and feasible therapy for ruptured dissecting aneurysms of the vertebral artery in terms of prevention of rebleeding. However, there is a risk of postprocedural medullary infarction in cases of perforating arteries originating from the dissected segment.

RATIONALE AND OBJECTIVES:We investigated the efficacy of prophylactic cement injection into the vertebral body adjacent to fractured vertebra to prevent new fractures after percutaneous vertebroplasty (PV). MATERIALS AND METHODS:Between February 2002 to August 2004, PV was performed for osteoporotic compression fractures in 89 consecutive patients. All patients underwent PV for only fractured vertebrae. Between September 2004 and October 2006, we performed prophylactic cement injection for 155 patients, with cement injected into the non-fractured vertebra adjacent to the fractured vertebra, immediately above the fractured vertebra in the same procedure. We evaluated the frequency of new vertebral fractures and the efficacy of prophylactic therapy. RESULTS:In the non-prophylactic group, 15 of 89 patients (16.8%) developed new fractures within 3 months and 20 of 89 patients (22.4%) developed new painful compression fractures within a year after the first PV. These fractures occurred mostly in adjacent vertebra, particularly in the vertebra immediately superior to the treated one and occurred in the lower thoracic and upper lumbar spine. In the prophylactic group, 7 of 155 patients (4.5%) developed new compression fractures within 3 months and 15 of 155 patients (9.7%) developed new compression fractures within 1 year. Statistical analysis showed that fewer new fractures developed in the prophylactic group than in the non-prophylactic group at both 3 months (P = .0020, Fisher's exact test) and 1 year (P = .0079). CONCLUSIONS:Prophylactic cement injection into non-fractured vertebrae adjacent to fractured vertebrae may prevent new compression fractures after vertebroplasty for osteoporotic patients.

We present a 33-year-old man who had hypertensive encephalopathy accompanied by obstructive hydrocephalus. The patient presented with headache subsequent to a hypertensive emergency. MR imaging revealed evidence of brainstem and bilateral cerebellar encephalopathy that resolved completely. Resolution of the cerebellar edema also led to improvement of the hydrocephalus.

BACKGROUND AND PURPOSE: The purpose of this study is to estimate the change in partial pressure of oxygen (Pao(2)) during percutaneous vertebroplasty and also to examine the factors related to the change in Pao(2).MATERIALS AND METHODS: We retrospectively reviewed preprocedural and postprocedural Pao(2) of 59 consecutive patients who underwent percutaneous vertebroplasty between November 2003 and April 2005 (11 men and 48 women; age range, 50-93; mean age, 75 years). Fifty-four patients were treated for osteoporosis-related fractures and 5 had malignant disease. Percutaneous vertebroplasty was performed in a conventional manner under local anesthetics and conscious sedation. Preprocedural and postprocedural blood drawing was performed 5 days to 30 minutes before percutaneous vertebroplasty and also at 30 minutes after the injection of bone cement. The difference between preprocedural and postprocedural data of Pao(2) was correlated with patients' age, number of treated vertebral bodies, presence of cement leakage, and presence of malignant neoplasm for each patient.RESULTS: Mean pre-Pao(2) and post-Pao(2) were 80.9 +/- 1.4 and 70.6 +/- 1.3 mm Hg (mean +/- SE) respectively (P = .0001). Using analysis of variance, there was a significant difference according to the number of vertebral bodies. There was a positive trend of decrease in Pao(2) according to the number of vertebral bodies during percutaneous vertebroplasty. Using multiple linear regression and after adjusting by preprocedural Pao(2) and other variables, the number of vertebral bodies was still highly significant.CONCLUSION: Pao(2) decreases during percutaneous vertebroplasty, and there is a correlation between the number of treated vertebral bodies and decrease in Pao(2).

PURPOSE:The success of percutaneous vertebroplasty (PVP) depends greatly on preprocedural evaluation of the patients. The purpose of this study was to evaluate the efficacy of preprocedural magnetic resonance imaging (MRI) for the indications of PVP.MATERIALS AND METHODS:A retrospective review of 122 osteoporotic compression fractures in 63 patients who underwent preprocedural gadolinium-enhanced MRI and PVP was performed. Based on the extent of contrast enhancement on preprocedural MRI, each case was classified into one of two groups: group 1, which represented more than 50% of the vertebral body enhanced; and group 2, which represented less than 50% of the vertebral body enhanced. The most enhancing level was evaluated in multilevel PVP sessions. We evaluated the difference of pre- and postprocedural pain scales between groups 1 and 2 using Mann-Whitney's U-test.RESULTS:There was a trend toward higher preoperative pain score in group 1, but it was not statistically significant (P = 0.0537). In addition, the postoperative pain score in group 2 was significantly higher than that in group 1 (P = 0.0007). The difference between the pre- and postoperative pain scores was significantly higher in group 1 than in group 2 (P = 0.0001).CONCLUSION:Contrast enhancement on MRI indicates a painful lesion and extensive contrast enhancement predicts better pain relief after PVP.