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A 48-year-old woman with no previous neurological diseases was transferred to our hospital because of sudden-onset unconsciousness. On arrival, she showed consciousness disturbance (E1V1M3 on the Glasgow Coma Scale), tetraplegia, right conjugate deviation and bilateral pathological reflexes. These symptoms resulted in a NIH stroke scale score of 32. Brain diffusion-weighted MR imaging (DWI) showed multiple hyper-intense lesions, and MR angiography revealed occlusions of the basilar artery (BA) and superior branch of the right middle cerebral artery (MCA). Transthoracic echocardiography disclosed a 51 × 24 mm myxoma in the left atrium. These findings led to diagnosis of acute ischemic stroke due to embolization from cardiac myxoma. Thrombolytic therapy with intravenous tissue plasminogen activator (IV tPA) was started 120 min after onset because there were no contraindications for this treatment. However, the symptoms did not resolve, and thus endovascular therapy was performed immediately after IV tPA. Angiography of the left vertebral artery initially showed BA occlusion, but a repeated angiogram resulted in spontaneous recanalization of the BA. However, the left posterior cerebral artery remained occluded by a residual embolus. Subsequently, occlusion found in the superior branch of the right MCA was treated by intra-arterial local thrombolysis using urokinase and thrombectomy with a foreign body retrieval device, but the MCA remained occluded. DWI after endovascular therapy showed new hyper-intense lesions in the bilateral medial thalamus and left occipital cortex. Clinically, neurological status did not improve, with a score of 5 on the modified Rankin Scale. IV tPA can be used for stroke due to cardiac myxoma, but development of brain aneurysms and metastases caused by myxoma is a concern. Given the difficulty of predicting an embolus composite from a thrombus or tumor particle, aspiration thrombectomy may be safer and more effective for stroke due to cardiac myxoma to avoid delayed formation of brain aneurysms and metastases.

Magnetic resonance angiography (MRA) is widely used in screening for unruptured intracranial aneurysm (UIA) in the prevention of onset of subarachnoid hemorrhage (SAH) in Japan. However, the clinical efficacy of mass screening of UIA using MRA has not been established. This study aims to establish the clinical efficacy of mass screening of UIA using MRA by decision-making. The decision tree is constructed simulating a flow of population (100,000 persons, aged 50-59) starting from the MRA screening until the final outcomes of quality adjusted life or death in ten years. In order to estimate the numerical values various parameters were used as follows, prevalence rate: 1%; sensitivity of MRA: 74%; specificity of MRA: 76%; death rate by intracranial angiography: 0.1%; rupture rate of UIA: 2%/year; death rate of SAH: 57%; and death rate for surgery for UIA: 0.0%. The following results were obtained: 1. The number of lives saved by the MRA screening was 760, while the number saved without MRA was 79. 2. The number of deaths in those receiving the MRA screening was 52, while the number of deaths without MRA was 104. 3. The level of quality adjusted life with the MRA screening was higher than that without MRA in all cases. In conclusion, mass screening of UIA using MRA appears to be effective.

Recently we experienced two cases of multiple cerebral aneurysms for the aneurysmal neck clipping operation. In these cases, as these aneurysms can not be clipped primarily, the patient may still be susceptible to the rupture of remaining aneurysm after operation. Frequent bucking and hypertension occurring during extubation and emergence from anesthesia, can lead to intracranial hemorrhage and increases of intracranial pressure. To reduce this hemodynamic responses, several studies have been reported, but techniques in those papers are not sufficient to prevent the bucking perfectly, and the anesthesiologist has to hold the face mask forcefully for a long time after operation. The laryngeal mask airway (LM) seemed preferable for prevention of bucking and attenuation of cardiovascular response. Therefore, we tried to use LM at the emergence from anesthesia. After surgery, tracheal tube was removed at the deep level of anesthesia, and LM was inserted. After muscle relaxant was reversed, oxygen, nitrous oxide, and 0.3-0.5% sevoflurane were administered until spontaneous breathing became adequate. When sufficient breathing volume was confirmed, all anesthetic agents were terminated, and LM was removed after ascertaining swallowing motion. No bucking and serious hypertension were seen during the procedures, and the patient recovered uneventfully.

The incidence of rerupture during the period of delayed ischemic neurological deficit (DIND) was studied in patients with aneurysmal subarachnoid hemorrhage (SAH) before surgical aneurysmal obliteration, and optimal management of DIND for preventing rerupture is discussed. At Tokai University Hospital, 511 patients with SAH were admitted during the 5-year period from 1988 to 1992. Of these, 247 had not undergone obliteration of the aneurysm neck within 3 days after SAH. In this group, 31% (77 patients) developed DIND. Of these 77 patients, 40 were managed with induced hypertension and/or hypervolemic therapy for DIND (25 with both (group 1), 15 with normotensive hypervolemic therapy (group 2)), and 37 did not receive either kind of therapy (group 3). The incidences of rerupture were as follows: all SAH patients: 11.5%; group 1: 48%; group 2: 7%; group 3: 11%. The incidence of rerupture in group 1 was significantly higher than that in the other groups. On the other hand, the favorable outcome rate (excellent and good) was as follows: group 1: 40%; group 2: 73%; group 3: 22%. This rate was significantly higher in patients who received normotensive hypervolemic therapy, than in other groups. This study suggests that, to avoid rerupture and unfavorable outcome, normotensive hypervolemic therapy is the optimal management approach in patients with DIND after SAH who have not undergone obliteration of the aneurysmal neck.

The purpose is to study the potentiality of Elastase in preventing the development of experimentally induced aneurysms in rats. 64 Sprague-Dawly male rats of 5 months age were used. Unilateral common carotid artery ligation was done to effect hemodynamic changes in intracranial vessels. Posterior renal artery was ligated to induce hypertension which was further augmented by feeding with 1% saline and 0.1% BAPN, separately and in combination. The rats were divided into two equal groups of 32 and 32. The second group was in addition treated with intra-muscular injection of Elastase at a dose of 10 mg/kg/day for 6 days in a week. The rats were sacrificed at the end of 18 weeks to study the development of intracranial aneurysm and the effect of Elastase. There were 5 aneurysms in the first group comparing with 2 aneurysms in second group. The histopathology showed thickening of the intima and breakdown of elastic lamina at the site of the aneurysm. The effect of Elastase on these pathological changes is discussed.