Hiroshi Kagami

Brain abscess developing at the site of preciding intracerebral hemorrhage

Sirs: Brain abscess is a neurological emergency that requires prompt administration of highdose antibiotics and surgical drainage. Factors that precipitate abscess formation include ear infection, dental procedures, congenital cardiac diseases with right-toleft shunt, bacterial endocarditis, and diabetes mellitus [6]. We report a rare case of brain abscess that developed at the site of an intracerebral hemorrhage (ICH) after systemic infection. A 48-old-man with a medical history of diabetes mellitus and hypertension presented with suddenonset headache and left-sided hemiparesis. Brain computed tomography (CT) revealed an ICH in the right putamen (Fig. 1A). The hypertension was thought to be responsible for the hemorrhage. The patient was conservatively treated, and his neurological condition remained stable. However, on his third hospital day, the patient vomited and developed a high fever. Aspiration pneumonia was suspected as a source of fever, and minocycline 200 mg/day was administered. Enterococcus faecalis, which had intermediate sensitivity to the antibiotics, was isolated from blood cultures. Minocycline was continued for 11 days, because the fever gradually subsided and cleared by hospital day 17. The patient’s neurological signs showed gradual recovery during the period. However, on day 30, he complained of headache and nausea, and his leftsided hemiparesis worsened. CT showed a low-density, cystic mass with marked ring enhancement at the site of the ICH (Fig. 1B, C). Magnetic resonance imaging (MRI) showed a cystic mass with marked ring enhancement that was low-intensity on the T1-weighted image and high-intensity on the T2-weighted image (Fig 2A-C). A brain abscess was strongly suspected, and the abscess was evacuated by CT-guided stereotactic aspiration. Enterococcus faecalis was isolated from the purulent material. The results of susceptibility test of both blood and brain abscess material were similar and showed high susceptibility of the pathogen to penicillins [8]. Intravenous penicillin G, 24 million units/day for the six weeks, eradicated the brain abscess, and the patient’s neurological condition improved postoperatively. The patient was discharged with left hemiparesis 90 days after the initial hemorrhage. Brain abscess is a rather uncommon disease, accounting for only 1 in 10,000 hospitalizations [6]. Still, it is a neurological emergency with mortality rate of 10 % to 20 % and requires prompt treatment, including administration of high-dose antibiotics and surgical drainage [6, 11, 12]. The routes of dissemination of the organisms responsible are hematogenous, invasion from contiguous infections of the middle LETTER TO THE EDITORS

Executive dysfunction is related with decreased frontal lobe blood flow in patients with subarachnoid haemorrhage

Abstract Objective: This study evaluated executive dysfunction in patients with subarachnoid haemorrhage (SAH) using the Behavioural Assessment of the Dysexecutive Syndrome (BADS) and correlated the occurrence of executive dysfunction with cerebral blood flow (CBF) reduction in the frontal lobe as assessed by single photon emission computed tomography (SPECT). Design: Correlational study. Subjects: Twenty-two patients who underwent microsurgical clipping at least 3 months after SAH. Methods: This study evaluated the BADS and the Wechsler Adult Intelligence Scale-III (WAIS-III). In addition, it assessed activities of daily living (ADL). CBF was evaluated using SPECT. The patients were divided into the following groups according to the results of SPECT: (1) those with reduced CBF in the frontal lobe (reduced CBF group, n = 8) and (2) those with intact CBF (intact CBF group, n = 14). Results: The BADS score was significantly lower in the reduced CBF group compared with that of the intact CBF group, while there was no significant difference in the WAIS-III scores and ADL scale between the two groups. Conclusion: Although this result was conducted with a small sample size, executive dysfunction correlates with reduced CBF in the frontal lobes of SAH patients. A detailed evaluation of executive function is suggested in SAH patients, even if the patient’s intelligence test and ADL scale reveal no abnormalities.

Epidural anterior petrosectomy with subdural visualization of sphenobasal vein via the anterior transpetrosal approach—technical case report

The drainage of the superficial middle cerebral vein (SMCV) is classified into four subtypes. The sphenobasal vein (SBV) drains from the SMCV to the pterygoid venous plexus at the temporal skull base. Epidural procedures in the standard anterior transpetrosal approach (ATPA) may damage the route of the SBV. We report a case in which modified surgical procedures via the ATPA were used to preserve the SBV. A 45-year-old man complained of right facial pain. Magnetic resonance images revealed a right cerebellopontine tumor suggestive of an epidermoid cyst. Right carotid angiography revealed that the SMCV drained into the pterygoid venous plexus via the SBV. The convexity dura mater of the temporal lobe was cut and the anterior part of the temporal lobe was retracted subdurally. The SBV was visualized from the subdural side. The basal dura mater of the temporal lobe posterior to the SBV was cut and the posterior part of the temporal lobe was retracted epidurally. After dissecting the dura mater medial to the greater petrosal nerve and to the edge of the petrous apex, the petrous apex was exposed and drilled out without injuring the SBV. The superior petrous sinus and the tentorium were cut. The tumor compressed the root exit zone of the trigeminal nerve. The tumor was grossly totally removed. The modified ATPA (epidural anterior petrosectomy with subdural visualization of the SBV) is effective in preserving the SBV.

Medial (Intra-cisternal) Acoustic Neuromas

The clinical characteristics of ?medial? or ?intra-cisternal? acoustic neuroma (AN) treated in our institute were reviewed. Among 466 patients with ANs in our series during the last 20 years, 6 patients (1.3%) were considered to fill the criteria of medial AN definition. Compared with those with non-medial ANs, the patients with medial ANs show a tendency to have cerebellar and/or cranial nerve dysfunction (especially trigeminal and/or facial nerves) in addition to hearing loss at the time of initial presentation. On magnetic resonance imaging, medial AN is visualized as a multi-cystic mass lesion in the cerebello-pontine cistern without extension into the internal auditory canal in most cases. Although total removal of tumor was achieved in all cases, the results of preservation of facial nerve function were not satisfactory. Medial AN can be considered as a clinical, but not pathological, subtype in terms of the functional outcomes of the facial nerve and hearing.

A Case of Intraosseous Microcystic Meningioma Without a Mass Lesion

Both intraosseous and microcystic meningiomas are rare tumor types. We report the case of a 66-year-old woman with intraosseous microcystic meningioma without a mass lesion. She presented with a rare intraosseous microcystic meningioma manifesting as pain. Radiological examination revealed an osteolytic lesion in the right parietal bone. Magnetic resonance (MR) images showed iso- to hypointensity on T1-weighted images and hyperintensity on T2-weighted images corresponding to the lesion. T1-weighted MR imaging with gadolinium enhancement better defined the marginal area. The inner table of the skull was disrupted prominently, and both sides of the outer table were eroded. There was fluid leakage during surgery but no obvious tumor mass. Histological examination revealed microcystic meningioma in the inner part of the defective bone. A macroscopic lesion was not found, because most of the tumor comprised microcysts, and their contents leaked out during the surgical procedure. Intraosseous microcystic meningioma may be considered as one of the differential diagnoses when the intraosseous tumor in the skull has fluid leakage and does not have a mass lesion during the surgery.

A Case of Large Anterior Paraclinoid Aneurysm with Intraoperative Premature Rupture

We report here troubleshooting of intraoperative premature rupture with large anterior paraclinoid aneurysm, which was successfully clipped. A 61-year-old woman with left nasal hemianopia was referred to our institute. Preoperative three-dimensional computed tomography angiography and a left internal carotid artery angiogram showed a large left anterior clinoid aneurysm adjacent to the anterior clinoid process. Aneurysm was ruptured prematurely and tentative clipping of the dome of the aneurysm was done incidentally to stop bleeding and to reduce the volume of the aneurysm. The anterior clinoid process and superior wall of the orbit were drilled out safely, since the tentative clipping had created sufficient space between the aneurysm and the anterior clinoid process to perform the procedure. The proximal neck was observed and tandem clipping was applied to the aneurysm. Intraoperative and postoperative angiography revealed complete disappearance of the aneurysm.

Safe Burr Hole Surgery for Chronic Subdural Hematoma Using Dabigatran with Idarucizumab

BACKGROUND Chronic subdural hematoma (CSDH) is a common intracranial hematoma. The number of patients who undergo anticoagulant therapy including a direct oral anticoagulant (DOAC) is expected to increase. Recently, idarucizumab, the antidote for dabigatran, which is a DOAC, has been developed. We successfully treated CSDH with dabigatran using emergency burr hole surgery and idarucizumab. CASE DESCRIPTION A 79-year-old Japanese man severely hit his head and visited the emergency department. Computed tomography (CT) showed tiny traumatic acute subdural hematoma, for which he was admitted. At that time, atrial fibrillation was newly detected, for which dabigatran, having a specific antidote (idarucizumab), was chosen and started 2 weeks after the discharge. Two months after the trauma episode, he revisited the emergency department because of acute left upper and lower limb motor weakness. CT revealed a midline shifted CSDH. Considering rush course of motor weakness and shifted brain, we performed emergency surgery using an antidote for dabigatran, idarucizumab. He was discharged 5 days after surgery without any complications or excessive perioperative hemorrhage. CONCLUSION Dabigatran should be used for atrial fibrillation detected after head trauma. Emergency surgery can be safely performed for CSDH with dabigatran using idarucizumab.

A pilot study of peptide vaccines for VEGF receptor 1 and 2 in patients with recurrent/progressive high grade glioma

Object Early-phase clinical studies of glioma vaccines have shown feasibility and encouraging preliminary clinical activity. A vaccine that targets tumor angiogenesis factors in glioma microenvironment has not been reported. Therefore, we performed a pilot study to evaluate the safety and immunogenicity of a novel vaccination targeting tumor angiogenesis with synthetic peptides for vascular endothelial growth factor (VEGF) receptor epitopes in patients with recurrent/progressive high grade gliomas. Methods Eight patients received intranodal vaccinations weekly at a dose of 2mg/kg bodyweight 8 times. T-lymphocyte responses against VEGF receptor (VEGFR) epitopes were assessed by enzyme linked immunosorbent spot assays. Results This treatment was well-tolerated in patients. The first four vaccines induced positive immune responses against at least one of the targeted VEGFR epitopes in the peripheral blood mononuclear cells in 87.5% of patients. The median overall survival time in all patients was 15.9 months. Two achieved progression-free status lasting at least 6 months. Two patients with recurrent GBM demonstrated stable disease. Plasma IL-8 level was negatively correlated with overall survival. Conclusion These data demonstrate the safety and immunogenicity of VEGFR peptide vaccines targeting tumor vasculatures in high grade gliomas.

Thyrotropin-producing pituitary adenoma simultaneously existing with Graves’ disease: a case report

BackgroundThyrotropin-producing pituitary tumor is relatively rare. In particular, concurrent cases associated with Graves’ disease are extremely rare and only nine cases have been reported so far. We describe a case of a thyrotropin-producing pituitary adenoma concomitant with Graves’ disease, which was successfully treated.Case presentationA 40-year-old Japanese woman presented with mild signs of hyperthyroidism. She had positive anti-thyroid-stimulating hormone receptor antibody, anti-thyroglobulin antibody, and anti-thyroid peroxidase antibody. Her levels of serum thyroid-stimulating hormone, which ranged from low to normal in the presence of high levels of serum free thyroid hormones, were considered to be close to a state of syndrome of inappropriate secretion of thyroid-stimulating hormone. Magnetic resonance imaging showed a macropituitary tumor. The coexistence of thyrotropin-producing pituitary adenoma and Graves’ disease was suspected. Initial therapy included anti-thyroid medication, which was immediately discontinued due to worsening symptoms. Subsequently, surgical therapy for the pituitary tumor was conducted, and her levels of free thyroid hormones, including the thyroid-stimulating hormone, became normal. On postoperative examination, her anti-thyroid-stimulating hormone receptor antibody levels decreased, and the anti-thyroglobulin antibody became negative. The coexistence of thyrotropin-producing pituitary adenoma and Graves’ disease is rarely reported. The diagnosis of this condition is complicated, and the appropriate treatment strategy has not been clearly established.ConclusionsThis case suggests that physicians should consider the coexistence of thyrotropin-producing pituitary adenoma with Graves’ disease in cases in which thyroid-stimulating hormone values range from low to normal in the presence of thyrotoxicosis, and the surgical treatment of thyrotropin-producing pituitary adenoma could be the first-line therapy in patients with both thyrotropin-producing pituitary adenoma and Graves’ disease.

Malignant lymphoma of the cranial vault: Analysis of three cases

The clinicopathological features of three cases with a cranial vault tumor as the initial manifestation of malignant lymphoma are described. Two of them (involving a 47‐year‐old female and a 53‐year‐old female) were primary cranial vault lymphoma. Another case (a 50‐year‐old male) was revealed to have multiple tumors in the cranial vault, right iliac bone and spleen at the first admission examination. All of the cranial vault tumors, which were painless and rapidly growing, invaded the muscle and dura mater from the skull, but not the subdural space or the outside of the superficial fascia. Histological diagnosis of the three cranial vault tumors was non‐Hodgkin diffuse large lymphoma. Moreover, the expression pattern of the lymphocytic cell markers, which were examined by immunohistochemistry, was identical; LCA(+), CD20/cy(+), CD79a(+), CD45RO(−), VS38c(−) and CD30(−) indicated that the tumors were B‐cell origin without plasmacytic differentiation.