Case report: Late in-stent thrombosis in a patient with vertebrobasilar dolichoectasia after stent-assisted coil embolization due to the discontinuation of antiplatelet therapy

Vertebrobasilar dolichoectasia (VBD) is a rare type of cerebrovascular disorder with high rates of morbidity and mortality. Due to the distinct pathological characteristics that fragmented internal elastic lamina and multiple dissections, VBD is difficult to treat and cured. Stent-assisted coil embolization is one of the main treatment modalities for such lesions. However, the duration of healing remained questionable, and there were no effective measures for evaluating endothelial coverage. Before complete endothelial coverage, the discontinuation of antiplatelet therapy may lead to fatal in-stent thrombosis; however, continued antiplatelet therapy could also result in bleeding complications. Thus, we present an autopsy case of late in-stent thrombosis due to the discontinuation of antiplatelet therapy and systematically review the literature to provide a reference for endovascular treatment and antiplatelet regimen of VBD

Devote much attention to neuropathological study on meningeal diffuse lesions

DOI：10.3969/j.issn.1672-6731.2011.05.00

IgG4-related idiopathic hypertrophic pachymeningitis: one case report and review of the literature

Objective To study the clinical, neuroimaging and histopathological features of IgG4-related idiopathic hypertrophic pachymeningitis (IHP). Methods One case of pathologically confirmed IgG4-related IHP was reported, and related literature of the clinical, radiological and pathological characteristics of this disease was reviewed. Postoperative specimen was sent to Department of Pathology, Xuanwu Hospital. It was sliced and then stained with HE method and examined by immunohistochemistrical study (S-100, Ki-67, CD20, CD3, IgG, IgG4). Results The case was a 55-year-old male patient with IHP. The clinical manifestations of IHP were variable. The patient firstly presented seizures of epilepsy showing left limb convulsions. Brain contrast-enhanced MRI showed that the pachymenx was partly thickened with line-like or nodular enhancement. Microscopically, meningeal biopsies showed dura mater encephali was thickened and hardened. Under microscope, meningeal biopsies showed abnormal thickening of the pachymenx with fibrous connective tissue hyperplasia and infiltration of many inflammatory cells. Inflammatory cells were mainly composed of lymphocytes and plasmocytes with a small amount of eosinophils. Immunohistochemistrical study showed a large number of lymphocytes with expression of IgG, and a small part with expression of IgG4. The treatment of IgG4-related IHP with hormones and immunosuppressive agents was effective. Conclusion IHP is a class of unknown etiologic diseases, with dural fibrous inflammatory lesion, and part of the IHP patients may be suffering from IgG4-related IHP. DOI：10.3969/j.issn.1672-6731.2011.05.01

Atypical central nervous system Whipple's disease: a case report and review of the literature

Objective To report the first case of central nervous system Whipple's disease (WD) with relatively good prognosis in China and present a brief review of central nervous system WD so as to improve the understanding of the diagnosis and treatment of this rare disease. Methods The clinical data of diagnosis, treatment and prognosis of one case of 35-year-old female was analysed in detail. Results Headache, hemiplesia and dementia were the main symptoms of this case and hypercranial pressure crisis occurred. During the course of disease, the patient successively presented paroxysmal extremity convulsion, right leg weakness, urinary incontinence, overeating, body mass increase. Despite of high dose of corticosteroid, penicillin and compound sulfamethoxazole were used, no effect was seen. Along with the increasing of intracranial pressure, cerebral hernia occurred. Cerebrospinal fluid examination indicated that glucose and chloride were normal while protein was obviously increased to 1700 mg/L. Electrocardiography (EEG) showed slow wave in right frontal and temporal lobes. Serial magnetic resonance imaging (MRI) revealed mutiple long T1 and long T2 signals mainly in right cerebral hemisphere, frontal parietal temporal lobes, semioval center and basal ganglion, with edema and irregular loose contrast and extended to left cerebral. Brain biopsy showed large pieces of necrosis at right fronto-temporal lobe with massive infiltration of lymphocytes and plasmocytes at perivascular and brain tissue, and exudation of glitter cells. Positive PAS and methenamine silver staining revealed bacterial particles inglitter cells. Central nervous system tumor, demyelinating disease and inflammatory pseudotumor were excluded. Both clinical symptoms and neuroimging recovered well after regular antibiotic therapy. Conclusion Central nervous system WD is a rare disease with complicated symptoms and imaging characters challenging diagnosis and treatment. The pathological findings may only indicate a special infection of central nervous system with unknown origin. The management is difficult. The misdiagnosis rate and fatality are high. It is important for clinicians to be aware of the features of this disease and make early decision to perform brain biopsy for diagnosis. Once it is diagnosed, normalized therapy should be given. DOI：10.3969/j.issn.1672-6731.2011.05.01

Schematic associations between the evolution of diffusion indices and underlying pathology in Wallerian degeneration.

<p>Schematic associations between the evolution of diffusion indices and underlying pathology in Wallerian degeneration.</p

LFB stained histological images of cat's pons.

<p>The LFB images of normal and degenerated side of pons at 2^nd, 6^th, 10^th, 20^th, 30^th, 45^th and 60^th day after modeling were displayed. White arrow heads indicated the activated microglias that phagocytized the axonal debris (purple stained), while black arrow heads labeled the microglias with myelin debris (blue stained). Black arrows indicated the reactive astrocytes. Scale bar, 50 µm.</p

Dynamic changes of diffusion indices.

<p>The diffusion indices on the intact side of corticospinal tract (black bar) showed little changes between each time points, which however, evolved dynamically on the injury side (twill bar).</p

H&E stained histological images of cat's pons.

<p>The H&E images of normal side and the degenerated side of pons at 2^nd, 6^th, 10^th, 20^th, 30^th, 45^th and 60^th day after modeling were displayed. Black arrows indicated the activated microglias, and the black arrow heads labeled the reactive astrocytes. Microgliosis emerged at 10^th day after modeling, while marked astrocytosis started at 45^th day after modeling. Scale bar, 50 µm.</p

ROI definition of corticospinal tract.

<p>Three sections of corticospinal tract were defined on FA maps at 8^th day after modeling, including the pons (A), cerebral peduncle (B), and internal capsule (C) level, respectively. Note the decreased FA signal at the left CST.</p