Search

Background and Purpose —Rebleeding is a major cause of death and disability in aneurysmal subarachnoid hemorrhage (SAH); however, there has been no report focusing on rebleeding before hospitalization in neurosurgical or neurological institutions. The aim of this study was to clarify the incidence of prehospitalization rebleeding, its impact on the clinical course and prognosis in patients with aneurysmal SAH, and the possible factors inducing it. Methods —In 273 patients who were admitted to our institution within 24 hours after the initial SAH bleeding and whose clinical course before admission could be fully evaluated, the patients’ clinical conditions and CT findings on admission, operability, prognosis, and possible factors inducing rebleeding were comparatively evaluated between the patients with and without an episode of prehospitalization rebleeding. Results —Of the 273 patients, 37 (13.6%) patients suffered from 39 episodes of rebleeding in the ambulance or at the referring hospital before admission to our hospital. The peak time of rebleeding was within 2 hours (77%), in which the incidence was statistically significant compared with that occurring 2 to 8 hours after the initial SAH bleeding ( P 160 mm Hg was a possible risk factor of rebleeding (odds ratio 3.1, 95% CI 1.5 to 6.8). Conclusions —Rebleeding during transfer and at the referring hospital is not rare. To improve overall outcome of aneurysmal SAH, the results obtained in this study should be made available to general practitioners and the doctors devoted to emergency medicine.

Cerebral microcirculation is disturbed during cerebral vasospasm, however, its influence on cerebral blood flow (CBF) and delayed ischemic neurological deficits (DIND) has not been determined, since there has been no easy method to evaluate microcirculatory changes. Cerebral microcirculation is regulated by regional cerebral blood flow (rCBF), cerebral circulation time (CCT), and regional cerebral blood volume (rCBV). In order to evaluate microcirculatory changes, CCT was measured on digital subtraction angiography (DSA).

Chronic hydrocephalus after aneurysmal subarachnoid haemorrhage (SAH) is easily diagnosed in most cases. However, the diagnosis is sometimes difficult in borderline cases, in which (a) pathognomonic clinical deterioration due to hydrocephalus is masked by the neurological deficits caused in the acute stage of SAH and (b) ventricular enlargement is not so marked on CT scan. The purpose of this study was to investigate whether or not iodine-123 labelled N-isopropyl-p-iodoamphetamine (123I-IMP) single-photon emission tomography (SPET) is of value for the early diagnosis of borderline chronic hydrocephalus after SAH. Fifteen patients who met the criteria of borderline chronic hydrocephalus were selected for the study, and underwent a shunt operation. The patients were divided into a shunt-effective group and a shunt-ineffective group according to neurological improvement after the shunt operation. 123I-IMP SPET was performed in the acute stage of SAH, within 1 week before the shunt operation, and 2 weeks after the shunt operation. Regional cerebral blood flow was estimated by the 123I-IMP autoradiographic method. Pre-shunting periventricular low-perfusion areas showed statistically significant differences between the two groups (P

The efficacy of intracisternal methylprednisolone was examined on lipid peroxidation in a canine subarachnoid haemorrhage (SAH) model. The concentration of lipid peroxides increased significantly in the cerebrospinal fluid (CSF) supernatant on Day 4, and also in the arterial wall on Day 7. Intracisternal administration of methylprednisolone reduced markedly the products of lipid peroxidation both in CSF and in the arterial wall. The findings suggest that lipid peroxidation might play a significant role in the genesis of vasospasm after SAH, and that direct administration of methylprednisolone into the subarachnoid space might reduce lipid peroxides in the arterial wall and so influence the prevention of vasospasm.

Twelve cases of ruptured cerebral aneurysm were treated in acute stage with interlocking detachable coils (IDC, Target Therapeutics, Fremont, California) and the outcome was assessed. IDCs were placed intra-aneurysm for intra-aneurysmal occlusion, or intra-artery for proximal occlusion. Cases: age 36–84 (mean; 60) y.o., 11 females and 1male; 1, 5, 4 and 2 patients were categorised (Hunt and Hess) as grades 1, 2, 3 and 4 respectively. An intra-aneurysmal occlusion in ten cases and a proximal occlusion in two were performed on day 1–11 (mean 4). On angiograms and CT findings, the ruptured point seemed to have occluded in all cases. The occlusion rate was 100% in five cases, 95% in two, 90% in three, 80% in one, and less than 50% in one. There were two cases of technical complication, one a coil migration and the other an aneurysmal perforation with IDC. Their Glasgow Outcome Scale six months after embolisation was graded as good recovery in four cases, moderately disabled state in two, severely disabled state in one, and dead in five. Follow-up angiograms taken four to six months after embolisation showed an intra-aneurysmal coil compaction in five cases. Two of these were treated by a second embolisation or by neck clipping followed by aneurysmal resection, but another two were observed without any treatment and the last one died of rebleeding. Histological examination of the resected embolised aneurysm revealed slight organization around coils but no endothelialisation over the aneurysmal orifice. In our experience, coil embolisation with IDC for acute ruptured aneurysm is a promising means of preventing rerupture during subacute stage.

Serial changes of anti-platelet-aggregating activity in the endothelial cells after experimental subarachnoid hemorrhage were studied in 30 feline two-hemorrhage models. One hour or 2, 4, 7, or 14 days after mimic subarachnoid hemorrhage, ADP (40 mg/kg) was infused into the basilar artery via the right vertebral artery to activate circulating platelets. Immediately after ADP infusion, the basilar artery was fixed by intra-arterial perfusion with 1.5% glutaraldehyde in 0.1 mol/L phosphate buffer and was removed. The luminal surface was examined under a scanning electron microscope. One hour after subarachnoid hemorrhage, no platelets adhered or aggregated on the luminal surface. However, 4 to 7 days after subarachnoid hemorrhage, many platelets were observed adhering or aggregating on the luminal surface. These findings suggest the impairment of anti-platelet-aggregating activity of endothelial cells after subarachnoid hemorrhage. This impairment may be involved in inducing cerebral ischemia during cerebral vasospasm by causing platelet adhesion and aggregation.

症例は36歳男性で，平成13年悪性髄膜腫に対して腫瘍摘出術が施行された．平成16年4月急性膵炎を発症し，腹部CTでは膵体部に石灰化を含む腫瘤陰影がみられるも慢性膵炎変化とされ経過観察となった．半年後の腹部follow up CTで膵体部の石灰化を含む腫瘤の増大が確認されたため，平成17年8月当科紹介入院となった．入院時の腹部CTでは膵体部に内部石灰化を伴う径5cmの不整形腫瘤を認め，広範囲な門脈腫瘍塞栓も認めた．同年9月開腹生検術を施行し，病理組織学的に間葉系腫瘍細胞の増生と免疫組織学的にc-kit陽性を認め，膵原発GISTと診断された．術後よりメシル酸イマチニブを投与したが腫瘍は著明な増大傾向を示し，2006年5月腫瘍破裂で死亡した．剖検の結果，膵腫瘍はmesenchymal chondrosarcomaと診断された．これまでの病理標本を再検討した結果，初回脳腫瘍は脳硬膜原発mesenchymal chondrosarcomaであり，同腫瘍が膵転移をきたした症例であると考えられた．Mesenchymal chondrosarcomaの膵転移は非常に稀で，さらにc-kit陽性を示すmesenchymal chondrosarcomaはこれまでに報告がなく自験例が最初の報告と思われたので若干の文献的考察を加え報告する．

A 61-year-old female was referred because of headache and gait disturbance. A computed tomography (CT) scan revealed a midline isodense mass lesion. The limit of the tumor was equivocal even after administration of contrast medium. Magnetic resonance imaging (MRI) study, however, clearly showed the relationship between the tumor and the surrounding structures, such as the corpus callosum, the ventricular cavities. The tumor had originated from the region of the septum pellucidum and positioned just beneath the corpus callosum from the genu to the splenium with the roof of the third ventricle pushed downward. The tumor was totally extirpated via the interhemispheric paratranscallosal route. The tumor was typical subependymoma. The post-operative course was uneventful. Transient psychiatric disturbance and inability to retain recent memory were observed and the former subsided in several weeks. CT and MRI characteristics of subependymoma are summarized and the usefulness of MRI to locate tumors and to plan proper surgical approaches are emphasized.

BACKGROUND Friction injury of cortical surface or cerebrospinal fluid leakage are the major complications of polytetrafluoroethylene (ePTFE) duraplasty because of their strong surface tension and lesser adaptability. Autologous duraplasties are also accompanied by potential donor-site complications and are inappropriate for large defects. Acellular Dermal Graft (ADG), prepared from cadaver human skin, does not have the above-mentioned drawbacks because of its human nature. Moreover, the dermal basement membrane and supporting tissues remain intact, so the rate of cellular migration and transformation to the surrounding host tissue is supposed to be excellent. We studied ADG in canine model to observe the rate of transformation into the surrounding dura mater via collagen synthesis from the invaded fibroblasts to evaluate its usefulness as a duraplasty. METHODS Dural grafting surgery was performed on 6 adult mongrel dogs weighing from 8 to 12 kgs under general anesthesia. Three dogs were sacrificed after 1 month (acute) of surgery and the other three (chronic) were sacrificed after 3 months with overdose of pentobarbital sodium. Transcardiac perfusion-fixation with 4% paraformaldehyde was done. Hematoxylin-eosin and trichrome masson stains were performed to see the graft cellularity. Thickness of grafts was also assessed along the length of the histologic sections. RESULTS Duralization, which was microscopically characterized by infiltration with regular array of collagen fibers, was observed at a few places in every high-power field in acute group. But in chronic animals, where dermal side of ADG was facing towards cranium, duralization was excellent. CONCLUSIONS Our result suggests that ADG can be considered as a useful dural substitute.

A flexible aneurysm clip applier with a small spindle-shaped head was manufactured. It is useful for aneurysmal clipping through a narrow space and the clip can be set in various directions due to its flexibility.

脳血管攣縮における血小板機能の役割を解明するために, 脳動脈瘤破裂によるクモ膜下出血症例を対象に血小板凝集能, β-TG, TXB2の採血部位別 (内頚静脈, 末梢静脈) の経時的変動を比較検討した.採血部位別の測定値を比較すると, 末梢静脈血に比して内頚静脈血測定値は病状と良く相関し, また手術中採血した上矢状静脈洞血の測定値と近似的な値を示したことから頭蓋内環境の検索には内頚静脈からの採血が適すると思われた.内頚静脈血測定値をもとに攣縮発生の有無による経時的変動を比較すると, 非攣縮例では小さな変動で経過したのに対し, 攣縮例では攣縮発生以後に全測定項目とも何等かの亢進状態を示した.特にβ-TGの亢進程度は臨床経過, 予後と相関が認められ, 攣縮時の脳虚血症状の進展に対する血栓傾向の関与が示唆された.

It is still debatable, whether the infundibular dilatation of the posterior communicating artery (ID) is preaneurysmal or not. Since there have been reports of aneurysms having developed clinically from ID, a proper follow-up or therapy procedures must be considered. In order to know what kind of cases must be followed up and operated on, incidence of ID was investigated on angiograms of 260 patients with cerebral aneurysms over the past 9 years. A statistical analysis of incidence and morphology of ID was performed. The results were as follows: 1) ID was seen in 67 out of 398 carotid angiograms (17%). This is about twice as much as in similar past studies on general neurological cases. 2) In patients with an internal carotid-posterior communicating artery aneurysm, the incidence of ID was much higher (P

In this paper, two interesting cases are introduced, one a multiple cerebral aneurysm with an infundibular dilatation of the left posterior communicating artery and a small bleb of the left anterior cerebral artery, both of which grew to large aneurysms in 10 years; the other an aneurysm of the middle cerebral artery, which recurred 6 years after treatment by neck clipping combined with muscle wrapping. These cases have motivated to conduct a histological experimental study, using 64 intracranial arteries of mongrel dogs, to evaluate the various materials so far used for the wrapping of cerebral aneurysms. The findings obtained were: 1) Muscle, fascia, and dura began to show necrotic and absorbable changes within 1 to 2 months after the operation, suggesting their unreliability as free pieces. 2) Lyodura® adhered poorly to vascular walls and showed detectable gaps against vessels. In addition, it showed necrosis and absorption in the bent site. 3) When Aron alpha A® alone was used for coating, its adhesion was unexpectedly poor; it easily peeled off from the vascular wall as a result of mutual interaction with vascular beating. It further became fragile and easily degradable with the passage of time. 4) Bemsheet® was superior in its adhesion to vascular walls, since it contributed greatly to the construction of a reinforced wall by proliferating collagen fibers in the space of the stereo-reticular structured cotton fiber. When Bemsheet® was fixed with Aron alpha A®, the latter permeated into the space of the reticular structured cotton fiber to form a sufficiently firmly reinforced wall immediately after treatment. The cotton fiber itself remained unchanged and gave almost no inflammatory reaction even after 12 months.

The Rho/Rho-kinase pathway is considered important in the pathogenesis of sustained smooth muscle cell contraction during cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH). The aims of this study were to investigate whether combination treatment, with pitavastatin as an inhibitor of RhoA and fasudil as an inhibitor of Rho-kinase, prevents the cerebral vasospasm. SAH was simulated using the double-hemorrhage rabbit model, and pitavastatin, or fasudil, or both (combination treatment) were administrated. The basilar artery (BA) cross-sectional area only in the combination treatment group was statistically larger than in the SAH group (p

In the last 9 years, infundibular dilatation (ID) has been sought in 260 aneurysm (An) cases and 398 carotid angiogram's (CAG) to reveal its incidence and morphology. Findings were as follows: 1) The incidence was about double that so far published. 2) Small ID, usually triangular in shape, tended to become round as it grew larger (P

Numerous investigations of cerebral vasospasm (hearafter referred to as vasospasm) confirm the pathogenesis to be various and complicated. In accounting for the pathogenesis of vasospasm, it is our contention that subarachnoid focal acidosis resulting from anaerobic changes in subarachnoid clots may play a role in inducing multiple cerebral microthrombosis, which in turn induces cerebral ischemia or infarction by platelet aggregation caused by an imbalance in the synthesis of TXA2 and PGI2 (Fig. 1) [6–9]. In this paper, we tried to corroborate that contention in clinical studies focussed firstly on the pH of intracranial irrigation fluid for aneurysmal surgery during the vasospasm predilection period and, secondly, on the effectiveness of TXA2 synthetase inhibitors in the prevention of symptomatic vasospasm, and in histopathological studies of the brains of patients who died of subarachnoid hemorrhage.

A 28-year-old woman with von Recklinghausen's neurofibromatosis (NF-1) had a huge hematoma in the left posterior nuchal region. Carotid and vertebral angiograms revealed marked stenosis at the C3 portion of the left internal carotid artery, slight moyamoya staining, occlusion of the left vertebral artery at the atlas level, and a right internal carotid artery aneurysm. The radiographic, clinical, and histological features of this case are discussed together with a review of 42 similar cases found in the literature. (Neurosurgery 22:544-549, 1988)