Hiroshi Kashimura

Serum inflammatory adhesion molecules and high-sensitivity C-reactive protein correlates with delayed ischemic neurologic deficits after subarachnoid hemorrhage

BACKGROUND The purpose of the present study was to investigate the relationship between serum concentrations of the immunoglobulin-like superfamily, selectins, hsCRP, and the development of DIND in patients with aneurysmal SAH. METHODS Serum ICAM-1, VCAM-1, E-selectin, P-selectin, L-selectin, and hsCRP were measured in 33 patients with SAH who underwent aneurysmal clipping within 48 hours of the onset of symptoms. Serum samples were obtained during the early period (day 0) and the late period (day 7). RESULTS The serum concentrations of ICAM-1 (P = .009), VCAM-1 (P = .0383) and hsCRP (P = .0014) during the early period were significantly higher in patients with SAH than in control patients. Further, serum hsCRP concentration during the late period was significantly higher in patients with SAH than in control patients (P = 0033). Finally, serum concentrations of ICAM-1, VCAM-1, and hsCRP during the early (P = .0055, P = .0266, and P = .0266) and late (P = .0423, P = .0041, and P = .0004) period were significantly higher in patients with DIND than in patients without DIND. CONCLUSIONS Serum levels of ICAM-1, VCAM-1 and hsCRP during the early and late period following SAH correlate with DIND.

Prediction of meningioma consistency using fractional anisotropy value measured by magnetic resonance imaging

OBJECT Preoperative planning for meningiomas requires information about tumor consistency as well as location and size. In the present study the authors aimed to determine whether the fractional anisotropy (FA) value calculated on the basis of preoperative magnetic resonance (MR) diffusion tensor (DT) imaging could predict meningioma consistency. METHODS In 29 patients with intracranial meningiomas, MR DT imaging was performed preoperatively, and the FA values of the tumors were calculated. Tumor consistency was intraoperatively determined as hard or soft, and the histological diagnosis of the tumor was established. RESULTS Of the 29 tumors, 11 were classified as hard and 18 as soft. The FA values of fibroblastic meningiomas were significantly higher than those of meningothelial meningiomas (p = 0.002). The FA values of hard tumors were significantly higher than those of soft tumors (p = 0.0003). Logistic regression analysis demonstrated that the FA value was a significant independent predictor of tumor consistency (p = 0.007). CONCLUSIONS The FA value calculated from preoperative MR DT imaging predicts meningioma consistency.

Diffusion tensor imaging for differentiation of recurrent brain tumor and radiation necrosis after radiotherapy—Three case reports

Fractional anisotropy (FA) is influenced by histological data such as cellularity, vascularity and/or fiber structure in astrocytic tumors. We describe two patients with tumor recurrence and one patient with radiation necrosis who were diagnosed using assessment of FA value. The assessment of FA value in enhanced lesions after radiotherapy may be able to differentiate radiation necrosis from tumor recurrence.

Cognitive function and anxiety before and after surgery for asymptomatic unruptured intracranial aneurysms in elderly patients.

BACKGROUND The prevalence of patients with asymptomatic unruptured intracranial aneurysms (UIAs) will likely increase as the general population ages. The goal of the present study was to prospectively assess cognitive function and anxiety before and after surgical repair of asymptomatic UIAs in patients ≥ 70 years. METHODS A total of 28 patients ≥ 70 years with UIAs underwent cognitive testing using the Wechsler Adult Intelligence Scale-Revised, Wechsler Memory Scale (WMS), and the Rey-Osterrieth Complex Figure test (ROCF) 1 month before and 1 month after surgery. All patients also underwent anxiety testing at these time points using the State-Trait Anxiety Inventory. RESULTS Group-rate analysis demonstrated that the performance intelligence quotient (IQ) and ROCF recall trial scores were significantly increased postoperatively, whereas there were no postoperative differences in verbal IQ, WMS, and ROCF copy trial scores. State anxiety scores were significantly decreased postoperatively, but there was no change in trait anxiety scores. Furthermore, a significant negative correlation was observed between changes in state anxiety scores and preoperative verbal IQ, performance IQ, and WMS. None of the patients developed postoperative cognitive functional impairments as demonstrated by event-rate analysis. CONCLUSIONS Surgical treatment of UIAs does not impair cognitive function and results in improvement in state anxiety in elderly patients.

Female sex as a risk factor for the growth of asymptomatic unruptured cerebral saccular aneurysms in elderly patients

OBJECT The prevalence of patients with asymptomatic unruptured intracranial aneurysms (UIAs) increases with the advancing age of the general population. The goal of the present study was to identify risk factors for the growth of UIAs detected with serial MR angiography (MRA) in patients 70 years of age or older. METHODS This prospective study enrolled 79 patients (age range 70-84 years) with 98 UIAs. Patients were followed up every 4 months, including an assessment of the aneurysm diameter and morphological changes on MRA, neurological status, and other medical conditions. Aneurysm growth was categorized into two different patterns on the basis of the MRA findings: 1) maximum increase in aneurysm diameter of 2 mm or more; and 2) obvious morphological change, such as the appearance of a bleb. RESULTS The mean duration of follow-up was 38.5 months (250.2 patient-years). Aneurysm rupture did not occur, but aneurysm growth was observed in 8 aneurysms (8 patients) during the study period. Univariate analysis showed that female sex, patient age ≥ 75 years, and an aneurysm location in the internal carotid artery (ICA) or middle cerebral artery (MCA) were associated with aneurysm growth (p = 0.04, p = 0.04, and p < 0.001, respectively). Multivariate analysis demonstrated that female sex was the only independent predictor of aneurysm growth (p = 0.0313, OR 2.3, 95% CI 1.3-30.2). CONCLUSIONS Female sex is an independent risk factor for the growth of UIAs in elderly patients. In addition, an age ≥ 75 years and aneurysm location in the ICA or MCA are characteristics that may warrant additional attention during follow-up imaging.

Cerebrospinal fluid adrenomedullin concentration correlates with hyponatremia and delayed ischemic neurological deficits after subarachnoid hemorrhage.

Background: Adrenomedullin (AM), a vasorelaxant peptide, is secreted into the cerebrospinal fluid (CSF) from the choroid plexus and can exert natriuretic effects in the kidney. CSF AM concentration is elevated 7–10 days after the onset of aneurysmal subarachnoid hemorrhage (SAH). The aim of the present study was to determine whether CSF AM concentrations correlate with hyponatremia and delayed ischemic neurological deficits (DIND) after SAH. Methods: CSF and plasma concentrations of AM, brain natriuretic peptide, and atrial natriuretic peptide concentrations were measured in 32 patients with SAH who underwent aneurysmal clipping within 48 h of onset. CSF and blood samples were obtained from these patients during the early period (days 1–3, day 0 being regarded as the day of SAH onset) and the late period (days 8–10). Results: In all patients, AM concentration during the early and late periods was significantly higher in the CSF than in the plasma (p = 0.0028 and p < 0.0001). In addition, CSF AM concentration was significantly higher during the late period than during the early period (p < 0.0001). Hyponatremia (plasma sodium <135 mmol/l) was present in 11 patients (34.4%) during the late period, and DIND developed in 6 patients (19%) between day 5 and day 13. Logistic regression analysis demonstrated that late-period CSF AM concentration correlated with hyponatremia and DIND (95% CI: 1.003–1.069, p = 0.0074 and 95% CI: 1.003–1.052, p = 0.0108). Conclusions: The present study demonstrated that CSF AM during the late period following SAH correlates with hyponatremia and DIND.

Comparison of postoperative cognitive function in patients undergoing surgery for ruptured and unruptured intracranial aneurysm

BACKGROUND Patients with SAH often experience cognitive decline. Previous studies used normal volunteers, published normal test values, and orthopedic patients as controls to identify factors for postoperative cognitive decline. The present study excluded the effects of surgery by comparing cognitive function after surgical repair in patients with aneurysmal SAH and patients with unruptured intracranial aneurysm. METHODS This study recruited 117 patients with SAH due to ruptured aneurysm and 39 patients with incidentally found unruptured intracranial aneurysms. The cognitive test battery consisted of the Japanese translation of the WAIS-R, the Japanese translation of the WMS, and the recall trial of the ROCF. Postoperative neuropsychological test scores for the patients with SAH and control subjects were compared using group-rate and event-rate analysis. The relationship between clinical variable and postoperative cognitive decline in the patients with SAH was evaluated by univariate analysis using the Mann-Whitney U test or chi(2) test. RESULTS Group-rate analysis showed that the WAIS-R and ROCF scores were significantly lower in the SAH group than in the control group. Event-rate analysis demonstrated that the incidence of cognitive decline in the patients with SAH (73 [62.4%] of the 117 patients) was significantly higher than that in the control subjects (12 [30.8%] of 39 patients). The Hunt and Hess grade was significantly higher in patients with postoperative cognitive decline. CONCLUSION The cognitive function after SAH was significantly correlated with Hunt and Hess grade on admission when using patients with postoperative unruptured intracranial aneurysm as the control group.

Pontine Cavernous Angioma Resected Using the Subtemporal,Anterior Transpetrosal Approach Determined Using Three-Dimensional Anisotropy Contrast Imaging:Technical Case Report

OBJECTIVE AND IMPORTANCE: We describe a case of brainstem cavernous angioma resected by the subtemporal, anterior transpetrosal approach, selected on the basis of three-dimensional anisotropy contrast (3-DAC) imaging. CLINICAL PRESENTATION: A 64-year-old woman presented with sudden headache and gait disturbance. Anatomic magnetic resonance imaging showed a mass lesion in the left anterolateral part of the pons. On 3-DAC imaging, posteromedial compression of the left corticospinal and corticopontine tracts by the mass lesion was demonstrated. INTERVENTION: The lesion was resected through the anterolateral side of the pons via the subtemporal, anterior transpetrosal approach. Neurological symptoms improved postoperatively, and postoperative 3-DAC imaging demonstrated preservation of the corticospinal and corticopontine tracts. CONCLUSION: The technique of 3-DAC imaging may provide important information regarding neural tracts for the planning of brainstem surgery.

Symptomatic occlusion at the origin of the vertebral artery treated using external carotid artery–cervical vertebral artery bypass with interposed saphenous vein graft

BACKGROUND Symptomatic atherosclerotic steno-occlusive diseases of the vertebrobasilar artery portend a poor prognosis and high risk of stroke recurrence despite medical therapy. We describe 5 medically refractory patients with occlusion at the origin of the VA and the distal portion of the cervical VA perfused via muscular collateral vessels who underwent ECA-cervical VA (V(2) segment) bypass with interposed SVG. METHODS The ECA was isolated through a linear incision along the anterior portion of the sternocleidomastoid muscles. The ECA was either laterally or medially retracted, the longus colli muscle was dissected, and the anterior wall of the foramen transversarium was partially removed, which exposed the cervical VA. Each end of the SVG was anastomosed to both the VA and the ECA in a side-to-end fashion. RESULTS Surgery proceeded smoothly in all patients without any new neurologic postoperative deficits. Postoperative cerebral angiography demonstrated that the anastomosis was patent. None of the patients developed further brain ischemic events during follow-up periods ranging from 13 to 114 months (mean, 62 months) after surgery. CONCLUSION The ECA-cervical VA bypass with interposed SVG is useful when the VA is occluded at the origin and when the distal portion of the cervical VA is perfused via muscular collateral vessels of patients with medically refractory ischemic events in the vertebrobasilar territory.

Acute Intracranial Hypertension due to Occlusion of the Brachiocephalic Vein in a Patient Undergoing Hemodialysis

Introduction Stenoses and occlusions of central veins may occur after repeated or prolonged catheterization for hemodialysis access [1–3] . If the draining vein of a functioning shunt is obstructed, extreme venous hypertension can develop and result in pain, incapacitating swelling, and venous stasis ulcers of the arm, chest, neck and face on the ipsilateral side [4, 5] . A few reports have suggested that intracranial venous hypertension may also occur in the context of peripheral venous obstruction [6, 7] . We report a case of acute intracranial hypertension due to occlusion of the brachiocephalic vein in a patient undergoing hemodialysis. Case Report A 62-year-old woman, who had undergone ongoing hemodialysis for 9 years via a left arm arteriovenous fi stula, presented with dyspnea and was admitted to a local hospital. Physical and radiological examinations demonstrated pulmonary edema due to volume overload, presumably related to underdialysis. Venography was performed via the left arteriovenous fi stula from the left subclavian artery and showed stenosis of the left brachiocephalic vein. The patient underwent percutaneous angioplasty and stenting through the right femoral vein without diffi culty. On the day following percutaneous angioplasty and stenting for stenosis of the left brachiocephalic vein, the patient underwent hemodialysis uneventfully. Blood chemistries before hemodialysis showed elevations in urea nitrogen (64.0 mg/dl) and creatinine (6.8 mg/dl). Following dialysis, these values decreased to the normal range (urea nitrogen of 10.2 mg/dl and creatinine of 0.4 mg/dl). Serum sodium and calcium were within normal limits both before and after hemodialysis. Hypotension did not occur during the procedure. However, on the second postoperative day, the patient experienced abrupt onset of headache and generalized seizures. Systemic blood pressure measured at this time was 200/105 mm Hg. The patient was transferred to our Department for further evaluation and care. On admission, the patient was confused. Systemic blood pressure was 180/100 mm Hg, and physical examination was notable for the absence of dilated veins on the chest, neck or face. Blood chemistry revealed a slightly elevated serum creatinine of 1.2 mg/dl. Computed tomography and magnetic resonance imaging showed no abnormal fi nding. Venography of the left arteriovenous fi stula via the left subclavian artery demonstrated occlusion of the left brachiocephalic vein and refl ux of the left brachial