Masaru Hirohata

Determinants of Poor Outcome After Aneurysmal Subarachnoid Hemorrhage when both Clipping and Coiling Are Available: Prospective Registry of Subarachnoid Aneurysms Treatment (PRESAT) in Japan

OBJECTIVE To examine current determinants of poor outcome after aneurysmal subarachnoid hemorrhage (SAH) when ruptured aneurysms are treated with either microsurgery (clipping) or endovascular treatment (coiling) depending on each patients characteristics. METHODS Between March 2006 and February 2007, 534 patients with SAH were enrolled in the Prospective Registry of Subarachnoid Aneurysms Treatment (PRESAT) project. Patients were treated according to the preference of investigators who were experienced in performing both clipping and coiling. Factors influencing poor outcome (12-month modified Rankin Scale [mRS], 3-6) were determined using multivariate logistic regression analyses. RESULTS In this cohort, 32.4% of patients were World Federation of Neurosurgical Societies (WFNS) grade IV-V, and 28.1% had a poor outcome. Clipping was preferably performed for small aneurysms with a wide neck and for middle cerebral artery (MCA) aneurysms, whereas coiling was preferred for larger, internal carotid artery (ICA) and posterior circulation aneurysms. In addition to increasing age, admission WFNS grade IV-V, preadmission aneurysmal rerupture, vasospasm-induced cerebral infarct, pneumonia, sepsis, shunt-dependent hydrocephalus and seizure, postclipping hemorrhagic complications (odds ratio 4.8, 95% confidence interval 1.5-15.3, P < 0.01), and postcoiling ischemic complications (odds ratio 4.4, 95% confidence interval 1.3-15.2, P < 0.05) significantly caused poor outcomes, although the complications did not affect mortality. Type of treatment modality and size and location of aneurysms did not influence outcome. CONCLUSIONS Introducing an endovascular treatment option has made aneurysm characteristics less important to outcome, but procedural complications are problematic and should be reduced to improve outcome.

Leakage Sign for Primary Intracerebral Hemorrhage A Novel Predictor of Hematoma Growth

Background and Purpose— Recent studies of intracerebral hemorrhage treatments have highlighted the need to identify reliable predictors of hematoma expansion. Several studies have suggested that the spot sign on computed tomographic angiography (CTA) is a sensitive radiological predictor of hematoma expansion in the acute phase. However, the spot sign has low sensitivity for hematoma expansion. In this study, we evaluated the usefulness of a novel predictive method, called the leakage sign. Methods— We performed CTA for 80 consecutive patients presenting with spontaneous intracerebral hemorrhage. Two scans were completed: CTA phase and delayed phase (5 minutes after the CTA phase). By comparing the CTA phase images, we set a region of interest with a 10-mm diameter and calculated the Hounsfield units. We defined a positive leakage sign as a >10% increase in Hounsfield units in the region of interest. Additionally, hematoma expansion was determined on plain computed tomography at 24 hours in patients who did not undergo emergent surgery. Results— Positive spot signs and leakage signs were present in 18 (22%) patients and 35 (43%) patients, respectively. The leakage sign had higher sensitivity (93.3%) and specificity (88.9%) for hematoma expansion than the spot sign. The leakage sign, but not the spot sign, was significantly related with poor outcomes (severely disabled, vegetative state, and death) in all of the patients (P=0.03) and in patients with a hemorrhage in the putamen (P=0.0016). Conclusions— The results indicate that the leakage sign is a useful and sensitive method to predict hematoma expansion.

Factors contributing to blood-brain barrier disruption following intracarotid injection of nonionic iodinated contrast medium for cerebral angiography : experimental study in rabbits

PurposeThis study was performed to investigate the role of injection methods and conditions under a fixed dose of radiographic contrast medium (CM) in respect to promoting blood–brain barrier (BBB) disruption.Materials and methodsA total of 44 white rabbits (average body weight 2.7 ± 0.4 kg) were used, and their carotid injection was performed with nonionic CM. The variables assessed for the carotid injections included the following: iodine content (300 or 150 mg I/ml), liquid temperature (37° or 24°C), and the injection time duration (1 or 30 s). The rabbits were divided into five groups. To evaluate BBB disruption, pre- and post-contrast-enhanced magnetic resonance (MR) studies were performed.ResultsAbnormal enhancement of the brain parenchyma in MRI was noted in only one group, which consisted of high-iodine concentration CM injected at a low temperature over a short injection interval. Statistically significant increased values for the percentage of relative enhancement (RE%) were demonstrated (P < 0.05) in comparison with the saline-injected control group.ConclusionThis result suggests variables that may need to be carefully considered to prevent BBB injury induced by nonionic CM for cerebral angiography, especially in the setting of a neurointerventional procedure.

Posttraumatic Edema in the Corpus Callosum Shown by MRI

MRI was performed on 120 patients who sustained closed head injury of varying severity. Patients ranged in age from 4 to 87 years (average, 32 years). All patients had an initial MRI within 28 days (median 12 days) of injury. MRI disclosed areas of abnormal signals in the corpus callosum of 21 (18%) of the 120 patients; 1 (2%) of the 44 patients who sustained mild injuries (GCS > or = 13), 3 (10%) of the 31 moderate injuries (GCS 9-12), and 17 (38%) of the 45 severe injuries (GCS < or = 8) (p < 0.0001). All but 2 of the 21 patients with corpus callosum lesions had other parenchymal lesions that were visualized by MRI. Of these 21 patients, MRI was repeated in 19. In 13 of the 19 patients, repeat MRI scans at 25 to 42 days after injury showed the disappearance of lesions that had on the first MRI shown a high signal on T2-weighted and FLAIR images and a normal signal on T1-weighted images. The MRI findings and time source of the disappearance of the corpus callosum lesions mirrored those of paracontusional edema in the subcortical white matter. Patients in whom the corpus callosum lesion disappeared had a better outcome than those in whom the lesion remained (good recovery/moderate disability; 92% vs 63%). The present MRI results suggest that some lesions in the corpus callosum following closed head injury are reversible, thus resembling edema that may be produced by a relatively mild shear strain force to the corpus callosum.

Fatal hemorrhage from rupture of the intracranial internal carotid artery caused by aspergillus arteritis.

To the best of our knowledge, this is the first reported case of combined intracranial and extracranial hemorrhage due to aspergillus cerebral arteritis. Knowledge of the imaging and the importance of early diagnosis and treatment are emphasized. A 78 year old man developed progressive right-sided visual impairment and diplopia. Magnetic resonance imaging demonstrated a mass lesion located in the right orbital apex, with extension to the cavernous sinus and the right middle cranial fossa. Cerebral angiography showed no aneurysmal dilatation. He was scheduled for transnasal biopsy. However, the patient died of massive epistaxis and intracranial hemorrhage. Postmortem examination revealed an aspergillus granuloma of the orbit and the skull base involving the intracranial and extracranial internal carotid artery. Aspergillus fumigatus was identified by culture. The characteristic feature of the fungal infection is a low-intensity signal on T2-weighted magnetic resonance images. This finding may be useful in diagnosing fungal infection.

Primary choroid plexus T-cell lymphoma and multiple aneurysms in the CNS.

Although primary central nervous system lymphoma (PCNSL) accounts for 2.3% of all primary intracranial tumors, incidence is increasing and correlates to the rising number of immunosuppressed patients [1,2]. Most PCNSLs are of B-cell origin; only 1 – 3.6% have the T-cell phenotype [3]. Because of its rarity, T-cell PCNSL has been less well-defined. We describe a patient with primary choroid plexus T-cell PCNSL and multiple aneurysms; we also provide a systemic review of the literature. A 56-year-old man presented with headaches that had progressively worsened during the 2 days. His medical history was unremarkable with no evidence of immunodeficiency. Computed tomography (CT) and axial T1-weighted magnetic resonance (MR) images without contrast showed a homogeneous mass with intraventricular hemorrhage at the inferior horn of the lateral ventricle and aneurysms as a signal-void area in the bifrontal region but no subarachnoid hemorrhage (Figure 1A); we were able to differentiate that the blood on the MR images came from the tumor and not from the aneurysms. Rim-enhanced mass was observed in the choroid plexus. (Figure 1B). Angiograms showed multiple intracranial aneurysms located at the anterior choroidal artery (AchoA), the posterior communicating artery (PcoA), the terminus of the right internal carotid artery (ICA), and the carotid terminus of the left ICA (Figure 1C and 1D). Cerebrospinal fluid (CSF) from lumber puncture contained 2676 red blood cells/ml and a protein level of 299 mg/dl. We found no evidence of viral or other infectious disease; b2-microgloblin levels in the CSF were high (4.55 mg/l). CSF cytology indicated atypical lymphocytes that appear to be small with irregular nuclear membrane. Atypical lymphoid cells were immunoreactive for T-cell lymphocyte markers but not for B-cell markers (Figure 1E). We did ophthalmologic examination, whole body CT, as well as gastroscopic, bone marrow biopsies, Ga-67 scintigraphy, and F-fluoro-deoxy-D-glucose-positron emission tomography (FDG-PET) to confirm that our patient had no systemic disease and that the choroids plexus was the primary tumor site. We performed endovascular coiling on the AchoA, the PcoA, and the left ICA aneurysms, but not the small (52 mm in diameter) aneurysm at the terminal portion of the right ICA because of its size, nonbleb shape, and location. One week after embolization, we gave two cycles of MTX chemotherapy (100 mg/kg). After the completion of chemotherapy, we administered 40 Gy of whole-brain field irradiation and 10 Gy of locally involved field irradiation to prevent tumor relapse and the spread of tumor cells. CSF samples were collected during chemotherapy and examined for residual disease. After the completion of adjuvant therapy, we found no evidence of tumor cells in the CSF and no residual neoplastic disease on MR images (Figure 1F). After 19 months of outpatient follow-up that included serial MR scans and repeated CSF cytological examinations, we found no recurrence of disease. Medline literature searches were performed for articles involving TPCNSL and ventricular PCNSL. The search encompassed the years 1970 – 2005. Articles published in languages in other than English were analyzed and reviewed if an abstract in English

Primary Intracerebral Malignant Fibrous Histiocytoma in a Child

We report herein a rare case of pediatric intracerebral malignant fibrous histiocytoma (MFH). A 2-year-old boy gradually developed mild left hemiparesis and became somnolent. Magnetic resonance imaging upon admission revealed a well-enhanced mass lesion in the right frontotemporal operculum. Subtotal removal of the tumor was successfully performed using a right transsulcal and transcortical approach. The tumor developed as an extraaxial mass with brain adhesion to the arterial wall of the branch of the middle cerebral artery rather than to cerebral tissue. Pathological examination confirmed the presence of inflammatory-type MFH. Pediatric cases of intracerebral MFH are rare, and the possible origin of the tumor is discussed based on clinicopathological findings.

Production of platelet-activating factor by neuronal cells in the rat brain with cold injury

Abstract The production and localization of platelet-activating factor (PAF) in the brain following focal brain injury were examined. Immunofluorescent staining was used to detect PAF in the rat brain with cold-induced local brain injury. After cold injury, immediate-early PAF staining was observed within the cold lesion followed later by immunoreactivity in the ipsilateral white matter. PAF immunoreactivity was also clearly seen both in cortical neurons adjacent to the cold lesion and in the ipsilateral hippocampus which showed delayed neuronal degeneration. The data suggest that PAF synthesis occurs in the neuronal cells in the perilesional area and hippocampus as well as within the cold lesion site during the early stages of cold-induced brain injury. PAF expression may contribute to the onset and progression of further brain damage, such as delayed axotomy and delayed neuronal loss. [Neurol Res 2001; 23: 605-611]

Sequential pathological changes during malignant transformation of a craniopharyngioma: A case report and review of the literature

Background: Malignant transformation of craniopharyngiomas is quite rare, and the etiology of transformation remains unclear. The prognosis of malignantly transformed craniopharyngiomas is very poor. Case Description: A 36-year-old male had five craniotomies, five transsphenoidal surgeries, and two radiation treatments until 31 years of age after diagnosis of craniopharyngioma at 12 years of age. All serial pathological findings indicated adamantinomatous craniopharyngioma including those of a surgery performed for tumor regrowth at 31 years of age. However, when the tumor recurred approximately 5 years later, the pathological findings showed squamous metaplasia. The patient received CyberKnife surgery, but the tumor rapidly regrew within 4 months. The tumor was resected with the cavernous sinus via a dual approach: Transcranial and transsphenoidal surgery with an extracranial-intracranial bypass using the radial artery. Pathologic examination of a surgical specimen showed that it consisted primarily of squamous cells; the lamina propria was collapsed, and the tumor cells had enlarged nuclei and clarification of the nucleolus. The tumor was ultimately diagnosed as malignant transformation of craniopharyngioma. After surgery, he received combination chemotherapy (docetaxel, cisplatin, and fluorouracil). The tumor has been well controlled for more than 12 months. Conclusion: Serial pathological changes of the craniopharyngioma and a review of the 20 cases reported in the literature suggest that radiation of the squamous epithelial cell component of the craniopharyngioma led to malignant transformation via squamous metaplasia. We recommend aggressive surgical removal of craniopharyngiomas and avoidance of radiotherapy if possible.

Effect of Platelet-Activating Factor Antagonist on Brain Injury in Rats

The ability of a platelet-activating factor (PAF) antagonist to reduce infarct size has been reported in a animal model of focal brain ischemia. The authors studied the effect of PAF antagonist (TCV-309) on cold brain injury in rats. Twenty-four hours after injury, water content was determined by both drying-weighing and specific gravimetric techniques, and ischemic brain damage was assessed with 2,3,5-triphenyltetrazolium chloride in multiple coronal sections. Pretreatment with TCV-309 (lmg/kg) significantly reduced the water content (p < 0.01) and volume of ischemic damage (p < 0.001) produced by the cold brain injury. These results indicate that PAF antagonist can ameliorate secondary brain tissue damage following brain injury.