Hidetaka Sato

Implications of Excessive Fibrinolysis and α2-Plasmin Inhibitor Deficiency in Patients with Severe Head Injury

OBJECTIVETo evaluate the involvement of the fibrinolytic system, especially focused on &agr;2-plasmin inhibitor, in patients with head injury. METHODSThis study consisted of 47 patients with isolated blunt head trauma in whom blood sampling could be initiated within 3 hours after injury. Patients were divided into two groups according to Glasgow Outcome Scale score status at 3 months after injury. In Group 1 patients (n = 26), the outcome was characterized as good recovery or moderate disability; in Group 2 patients (n = 21), the outcome was characterized as severe disability, vegetative state, or death. RESULTSConcentrations of thrombin-antithrombin III complex were greater than 100 &mgr;g/L in 39 of 47 patients, and concentrations in Group 2 patients were elevated significantly beyond the concentrations in Group 1 patients. Activities of &agr;2-plasmin inhibitor in Group 2 were significantly lower than in Group 1 (P < 0.0001). In Group 1 patients, &agr;2-plasmin inhibitor activity was greater than 60%, while in all but four Group 2 patients, the inhibitor was reduced to less than 60% of normal activity within 3 hours of injury. All patients with &agr;2-plasmin inhibitor activity less than 60% showed a marked bleeding tendency and/or severe brain edema. Using sandwich enzyme-linked immunosorbent assay, fibrinogen degradation product and fibrin degradation product were measured separately. A significant correlation was apparent between thrombin-antithrombin III complex and fibrinogen degradation product, as well as between the complex and fibrin degradation product. Marked decreases in &agr;2-plasmin inhibitor were noted only in patients with thrombin-antithrombin III complex concentrations exceeding 500 &mgr;g/L. CONCLUSIONFibrinolysis and fibrinogenolysis may be involved according to the degree of coagulation activation in the pathophysiology of severe head injury. Decreased activity of &agr;2-plasmin inhibitor indicated poor prognosis and may be an exacerbating factor in the acute phase of head trauma.

Measurements of cortical cellular pH by intracranial tonometer in severe head injury.

ObjectiveTo evaluate the cortical cellular damage in acute severe head injury, we measured the cortical cellular pH by using an intracranial tonometer made in our institution. DesignProspective, 3.5-yr data collection. SettingUniversity hospital trauma intensive care unit. PatientsSeverely head-injured patients (n = 29) with Glasgow Coma Scale score <8. InterventionRoutine emergency neurologic procedure. Measurements and Main ResultsWe made 98 measurements of cortical cellular pH by intracranial tonometer in 29 severely head-injured patients in the acute phase. Each patient’s intracranial pressure was recorded, and in 16 patients, the saturation of jugular venous oxygen was monitored. The outcome at 6 months after injury was significantly better in patients having a cortical cellular pH of >7.2 than those with <7.2. The cerebral perfusion pressure and cortical cellular pH correlated significantly (p < .0001). ConclusionsOur study suggests the usefulness of measurement of cortical cellular pH by intracranial tonometer for evaluating the severity of focal anaerobic cerebral metabolism and predicting patient prognosis.

Time Course of Coagulation and Fibrinolytic Parameters in Patients with Traumatic Brain Injury

Traumatic brain injury (TBI) has long been associated with coagulopathy; however, the time course of coagulation/fibrinolytic parameters in the acute phase of TBI remains unclear. The purpose of the study was to analyze the time course of coagulation/fibrinolytic parameters in the acute phase of TBI and to elucidate parameter relationships to prognosis. We retrospectively evaluated 234 patients with severe isolated TBI with initial blood samples obtained no more than 1 h after injury. Platelet count, prothrombin time, activated partial thromboplastin time (aPTT), plasma levels of fibrinogen, and D-dimer were measured on arrival in the emergency department and 3, 6, and 12 h after injury. Multivariate logistic regression analysis was performed to identify risk factors for poor prognosis at each time point. From hospital admission to 12 h after injury, an elevated D-dimer level was a significant negative prognostic indicator (admission: p < 0.0001; 3 h after injury: p = 0.0005; 6 h after injury: p = 0.005; 12 h after injury: p = 0.0009). An upward trend of aPTT on admission and 3 h after injury was also a significant negative prognostic indicator (admission: p = 0.0011; 3 h after injury: p = 0.013). On multivariate logistic regression analysis, which included all initial variables, independent risk factors for poor prognosis included older age (p = 0.0005), low Glasgow Coma Scale score (p < 0.0001), high Abbreviated Injury Score (p = 0.015), aPTT >30.2 sec (p = 0.019), and elevated D-dimer level (p = 0.0005). We concluded that D-dimer is the best coagulation/fibrinolytic parameter to monitor for prediction of outcome.

A left ventricular lipoma diagnosed on three-dimensional electrocardiogram-gated cardiac computed tomography

Cardiac lipomas are extremely rare primary benign cardiac tumors. We describe a patient with a chief complaint of ventricular tachycardia associated with a lipoma arising in the left ventricular myocardium. The cardiac lipoma was qualitatively evaluated and its location was accurately determined noninvasively with the use of three-dimensional images reconstructed from data acquired by electrocardiogram-gated cardiac computed tomography (CT). Our experience suggests that high-resolution three-dimensional CT imaging may facilitate the determination of strategies for surgical treatment.

Anomalous internal carotid anastomosis to contralateral anterior cerebral artery.

BACKGROUND Many anomalies and variants in vascular anatomy have been reported in relation to the anterior cerebral artery (ACA). PATIENTS AND METHODS We encountered an apparently novel anomaly in a 30-year-old man admitted for disturbance of consciousness following a traffic accident. Computed tomography revealed an acute subdural hematoma and subarachnoid hemorrhage. RESULTS AND CONCLUSIONS No vascular abnormalities related to the hemorrhage were detected by conventional angiography, so we concluded that the bleeding was of traumatic origin. Anomalous origin of the ACA was disclosed incidentally, with both A1 segments arising from the right internal carotid artery; no normal A1 segment of the left ACA was visualized. We discuss possible bases for this anomalous origin.

Erratum to: Evaluation of primary prostate cancer using 11C-methionine-PET/CT and 18F-FDG-PET/CT

Erratum to: Ann Nucl MedDOI 10.1007/s12149-011-0551-6The fifth coauthor’s name was incorrectly given as NaohisaYoshihara. It should be Hisashi Yoshihara. In the affiliationline, it should be shown as H. Yoshihara, not N. Yoshihara.Also, the title and the contents of Table 2 were incor-rect. They should be given as shown below.

Validation of fast-RAMLA in clinical PET

ObjectiveImages using the fast row action maximum likelihood algorithm (fast-RAMLA), which employs half-interpolated sinograms of conventional 3DRAMLA, are immediately generated following positron emission tomography (PET) scanning and are invariably produced in the process of line-of-response RAMLA (LOR-RAMLA) reconstruction. We quantitatively and visually compared the clinical validity of dual time point [18F]-FDG imaging with fast-RAMLA and LOR-RAMLA.MethodsAn International Electrotechnical Commission (IEC) phantom was established in which the ratio of the activities in the hot sphere was set up and a background of 3.8:1 was scanned and reconstructed using both algorithms. The contrast recovery coefficient was then calculated. The clinical study retrospectively analyzed 35 patients (25 men and 10 women; age range 30–84 years; mean age 63.9 years) with confirmed specific pathological lesions or clinical follow-up; 21 of the patients had 51 malignant lesions and 15 had 23 benign lesions. The maximum standard uptake value (SUVmax) was measured in all lesions using LOR-RAMLA. The maximal counts of all lesions determined manually were divided by the average count of bilateral ventricles and the aortic arch for standardization on fast-RAMLA, and the values were compared with the SUVmax of LORRAMLA. Inter-observer variation in detection was determined among three radiologists who blindly reviewed and scored 70 maximum intensity projection images from 35 patients reconstructed using LORRAMLA and fast-RAMLA.ResultsWe identified a quantitative correlation and determined the visual quality of lesion detection between fast-RAMLA and LOR-RAMLA and indicated usefulness and improvement point on fast-RAMLA.ConclusionsFast-RAMLA can improve the strategy for using dual time point [18F] fluorodeoxyglucose positron emission tomography ([18F]-FDG-PET) and increase the efficiency of the [18F]-FDG-PET scanner.

Survival After Subarachnoid Hemorrhage Using Brain Hypothermia After Recovery of Spontaneous Circulation from Cardiopulmonary Arrest: A Case Report

A 55-year-old woman was admitted to our intensive care unit with cardiopulmonary arrest (CPA). On admission, a brain computed tomography scan which was carried out after recovery of spontaneous circulation (ROSC) revealed a subarachnoid hemorrhage (SAH; Fisher group 3) and brain swelling. After admission, the elevated intracerebral pressure (ICP) was controlled by moderate hypothermia (34°C). On the day after admission, the light reflex appeared and electroencephalography showed burst and suppression. Cerebral angiography indicated a ruptured anterior communicating artery aneurysm and an unruptured aneurysm located at the basilar tip. Neck clipping of the aneurysms was performed under moderate hypothermia (32°C). During the surgical procedure, the degree of brain swelling was sufficiently moderate to allow clipping of the aneurysms. After the operation, the patient was gradually rewarmed. Now with severe disability, she was moved to another hospital. Aneurysmal SAH is one of the most common causes of CPA, but survival of SAH patients after CPA is rare. In this case, ICP was controlled under moderate hypothermia and clipping of the aneurysms was performed. Moderate hypothermia is considered an attractive treatment strategy for ruptured aneurysms.

Causes and Treatment of Desaturation in SjO2 Monitoring

To minimize secondary brain damage, which greatly influences prognosis during brain damage, it is necessary to avoid the state of ischemia as much as possible because ischemia is an important factor in secondary brain damage. On the other hand, because ischemia has various causes, gaining an understanding of its pathology and deciding on a course of treatment is certainly not easy. In an attempt to resolve this problem, continuous monitoring of jugular bulb venous oxygen saturation (SjO2) has recently attracted considerable attention. SjO2 reflects the status of total brain oxygen metabolism because its value is determined by the ratio between cerebral blood flow and brain oxygen metabolism.