Shodo Fujioka

Improvement of quality of life in patients surgically treated for asymptomatic unruptured intracranial aneurysms

Objective: To compare the preoperative and postoperative health-related quality of life (QOL) and psychological state of patients with asymptomatic unruptured intracranial aneurysms (ICAs) who underwent elective surgery. Methods: Out of 67 patients who underwent neck clipping of ICAs, we assessed the QOL of 61 patients using Short Form-36 (SF-36); their psychological state was rated on the Hospital Anxiety and Depression Scale (HADS) before, 3 months, and 1 and 3 years after treatment. Results: The preoperative mean scores for each of the eight SF-36 domains except bodily pain were significantly lower in the study population than in the reference population. 14 (20.9%) patients experienced surgical complications defined as neurological deterioration and/or abnormal CT findings within 30 days of the operation. Despite some complications, the QOL of all operated patients returned to the mean level of the reference population 3 years after treatment. At 3 months after surgery, the scores for psychosocial activities and general health perception were transiently below the preoperative levels. According to the HADS, the patients experienced mild anxiety before the operation; it disappeared by the third postoperative month. Conclusions: Preoperatively, patients with unruptured ICAs reported a significantly decreased QOL. It further declined transiently after elective surgery, but it returned to the mean level recorded for the reference population within 3 years. Our findings suggest that these patients derived significant QOL benefits from their surgery. Hence subjective QOL issues should be considered in deciding whether treatment-related risks and their natural history, such as their potential rupture, warrant surgery of asymptomatic unruptured ICAs.

Significance of Elevated Thrombin-Antithrombin III Complex and Plasmin-α2-Plasmin Inhibitor Complex in the Acute Stage of Nontraumatic Subarachnoid Hemorrhage

Thrombin-antithrombin III complex (TAT) and plasmin-alpha 2-plasmin inhibitor complex (PIC) were examined in the acute stage in 51 patients with nontraumatic subarachnoid hemorrhage. TAT and PIC values were correlated with severity at the time of onset and with outcome. In the patients whose TAT levels were 25 ng/ml or more and PIC levels were 3.0 micrograms/ml or more (n = 16), only 25% had a good or fair outcome. In the patients with TAT levels less than 25 ng/ml or PIC levels less than 3.0 micrograms/ml (n = 35), on the other hand, 82.9% had a good or fair outcome. There were no significant differences in TAT and PIC levels between patients who experienced arterial spasm and those who did not. These results indicate that TAT and PIC values may reflect the severity of the brain damage induced by subarachnoid hemorrhage. It is speculated that marked coagulation and fibrinolytic disorders occur in the acute stage of subarachnoid hemorrhage.

Hyperacute Diffusion-Weighted Imaging Abnormalities in Transient Ischemic Attack Patients Signify Irreversible Ischemic Infarction

Background: To characterize the frequency and clinical features of diffusion-weighted imaging (DWI) abnormalities in the hyperacute phase of transient ischemic attacks (TIAs). Methods: We performed DWI in 21 consecutive patients with TIA (mean age 64 years; 17 men and 4 women) during both the hyperacute phase (within 6 h after onset) and subacute phase (within 2–9 days after onset). Results: DWI abnormalities were present in the hyperacute phase in 11 patients (positive group) and absent in the other 10 patients (negative group). These groups could not be differentiated based on the clinical characteristics. In the subacute phase, all 11 patients from the positive group had abnormalities on MRI including T2-weighted and fluid attenuation inversion recovery images as well as DWI, with lesions being located in regions similar to those observed in the hyperacute phase. Of the 10 patients in the negative group, new DWI abnormalities were noted in 2 during the subacute phase. Conclusions: Approximately half of TIA patients in whom MRI was performed in the hyperacute phase had DWI abnormalities, all of which persisted in the subacute phase. The findings suggest that essentially all hyperacute DWI abnormalities in TIA patients may indicate irreversibility and signify the presence of brain infarction.

Surgery and long-term outcome for ruptured anterior circulation aneurysms in patients in their ninth decade of life

BACKGROUND The present pilot study was undertaken to analyze the long-term results of surgery for ruptured anterior circulation aneurysms in patients in their 9th decade of life. METHODS Between 1992 and 1997, we treated 10 consecutive patients with ruptured anterior circulation aneurysms who were 80 years or older on admission and judged eligible for surgery based on stringent criteria. The outcomes at discharge and the latest outcomes (obtained at a median of 41.6 months) were assessed using the Glasgow Outcome Scale and the Barthel Score, respectively. RESULTS Upon discharge, six of the 10 patients showed good recovery, two patients were moderately disabled, and two patients who suffered symptomatic vasospasm were severely disabled. As for the latest outcomes, assessed using Barthel Score, four patients had the maximum score of 100, two a score of 90, one a score of 35, two a score of 10, and one patient died. Of four patients who were in poor condition, two experienced deterioration attributable to unrelated causes 18 and 32 months after the ictus. CONCLUSION Advanced age alone does not preclude successful surgery for ruptured anterior circulation aneurysms. Carefully selected patients over 80 years should also be considered for surgical treatment.

Rotational vertigo associated with parietal cortical infarction

A 65-year-old woman experienced sudden positional vertigo with rightward, horizontal nystagmus that resolved within days. MRI revealed a left parietal lobe infarction involving the supramarginal gyrus. The patient experienced a transient recurrence of vertigo after 7 days but MRI failed to reveal the presence of any new lesions; furthermore, the patients EEG was normal. We suggest that this patients vertigo was due to her parietal cortical infarction.

Ruptured distal accessory anterior cerebral artery aneurysm: case report.

OBJECTIVE AND IMPORTANCE Accessory anterior cerebral artery (ACA), which is a type of median artery of anomalous triplicate ACA, is not rare, but aneurysmal formation is extremely rare. We report a rare case with ruptured aneurysm arising from a distal accessory ACA. We discuss the characteristics and causes of this type of aneurysm and classification of this anomaly. CLINICAL PRESENTATION A 63-year-old man suddenly developed severe headache and then loss of consciousness and paraplegia. Computed tomography disclosed thick and diffuse subarachnoid hemorrhage and interhemispheric hematoma. Subsequent bleeding occurred 2 hours after the first hemorrhage. Cerebral angiography disclosed a saccular aneurysm arising from the distal accessory ACA. INTERVENTION Neck clipping of the aneurysm was performed 22 hours after the second episode, using an interhemispheric approach. CONCLUSION Although transient paraplegia occurred 8 days after onset, the patient recovered well after surgery without neurological deficit. The characteristics of the aneurysm arising from distal accessory ACA are considered similar to those of distal ACA aneurysm. There is, however, some confusion regarding the terminology of the anterior communicating artery complex anomalies, which we discuss.

Cavernous malformation of the optic chiasm: case report

We report a 14-year-old boy with cavernous malformation of the optic chiasm. He had a 2-year history of gradually worsening visual disturbance. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a suprasellar mass, findings compatible with craniopharyngioma. The mass was biopsied and histological examination confirmed cavernous malformation. On the second day after the biopsy, he suffered chiasmal apoplexy due to intratumoural haemorrhage, lost visual acuity and developed a field cut. Cavernous malformations arising from the optic nerve and chiasm are extremely rare; only 29 cases have been reported to date. Most patients manifested acute visual acuity and visual field disturbances. Although MRI findings of cavernous malformations in the brain parenchyma have been reported, MRI findings on the optic nerve and chiasm may not be completely diagnostic. Of the 29 documented patients, 16 underwent total resection of the lesion without exacerbation of their preoperative symptoms; in some cases, resection was complicated by risk of damage to the surrounding neural tissue. As patients may suffer intratumoural haemorrhage after biopsy or partial removal of the lesion, the advisability of surgical treatment of cavernous malformations of the optic nerve and chiasm must be considered carefully.

Clinical Characteristics of Subarachnoid Hemorrhage With or Without Headache

OBJECTIVE Some patients report the absence of a typical headache at the onset of subarachnoid hemorrhage (SAH). We investigated the clinical backgrounds and characteristics of patients with SAH without headache and compared the findings with those of patients with SAH and headache. METHODS We examined 224 patients retrospectively who underwent intracranial aneurysmal clipping. Patients characteristics, Fishers computed tomography grade, situation at onset, site of ruptured aneurysm, and symptoms were compared. Subjects were categorized into two groups: headache group and nonheadache group. RESULTS Eighteen patients (8.0%) did not present with headache. There were no significant differences in terms of age, sex, Fishers computed tomography grade, onset time, or site of ruptured aneurysm. CONCLUSIONS The patients without headache have no specific clinical characteristics over patients with common SAH.

Clinical Investigation of Lumbar Epidural Pressure

To evaluate the usefulness of measuring lumbar intraspinal epidural pressure (ISEDP) measurements for the estimation of intracranial pressure, we studied the relationship between ISEDP and intracranial epidural pressure (ICEDP) in 12 patients with high intracranial pressure after neurosurgical procedures. ISEDP was measured with a Gaeltec catheter-tip pressure transducer placed percutaneously in the lumbar epidural space with a Touhy needle. ICEDP was determined by the conventional method. During the measurement, some manipulations were carried out. ISEDP and ICEDP measurements exhibited a linear correlation. In all but one patient with normal cerebrospinal fluid, ISEDP was 84 to 100% of ICEDP. In patients with mild subarachnoid hemorrhage, ISEDP was 82 to 86% of ICEDP. In patients with severe subarachnoid hemorrhage, ISEDP was 45 to 57% of ICEDP and always fluctuated in parallel with ICEDP. ISEDP accurately reflected ICEDP in response to manipulations such as breath holding, neck compression, compression at the cranial defect, mannitol administration, and coughing. These data suggest that ISEDP measurement is useful in monitoring intracranial pressure in patients with intracranial hypertension. In addition, the measurements can be obtained easily and safely.

Significance of Eosinophilic Infiltration in Chronic Subdural Hematoma Membrane

Remarkable eosinophilic infiltration of the hematoma membrane, observed not infrequently around sinusoidal vessels, has not been well documented. Histological analysis of the membrane obtained from 57 patients was performed and the findings were classified into 5 groups according to histological maturity and clinical stage. Eosinophils were most conspicuous in membrane which had attained a certain thickness and had completed the sinusoidal pattern of the vessels. It was considered that eosinophils were closely related to the membranes histological maturity, indicating healing. Eosinophilic infiltration was found in 30% of male patients, whereas all of the female patients showed marked eosinophilic infiltration of the membrane. Significantly, the number of female patients was much smaller. In male patients, the degree of eosinophilic infiltration was related to the estrogen level. An experimental work was undertaken to produce hematoma membrane in the subcutaneous tissue of the guinea pig, and eosinophilic infiltration of the membrane was examined in relation to estrogen administration and the animals sex. The results suggested a significant relationship between the membrane eosinophilia and estrogen level, as well as to the sex. It was postulated that eosinophilic infiltration of the chronic subdural hematoma membrane was a manifestation of healing, as in chronic inflammatory granulation, and that it was closely related to the estrogen level as evidenced by the predominate occurence of chronic subdural hematoma in males.