吉野 義一

Extensive cerebral hemispheric infarction is a devastating condition leading to early death in nearly 80% of cases due to the rapid rise of intracranial pressure in spite of maximum medical treatment for brain edema and swelling. Recently, decompressive craniectomy has been reevaluated to prevent the brain herniation caused by extensive hemisphelic cerebral infarction. We studied the surgical results after decompressive craniectomy for extensive cerebral infarction. Between December 1997 and August 2006, 13 consecutive patients (7 males and 6 females aged from 39 to 73 with a mean age of 59 years) with massive cerebral infarction of IC (11 patients) and MCA (2 patients) territory were treated with decompressive craniectomy and dural plasty. Five patients had a left-sided stroke with severe aphasia. The cardioembolic source of stroke was seen in 5 patients. Surgery was performed at the point of neurological deterioration, anisocoria, and effacement of perimesencephalic cistern on CT findings. The mean time between stroke onset and surgery was 39.8 hr and ranged from 13 to 102 hr. GOS on discharge was MD 1, SD 8, VS 1, and D 3 (mortality rate 30.8%). Severe pneumoniae were the causes of death. All survivors underwent cranioplasty and were transferred with the aim of rehabilitation. In this study, we showed that the decompressive craniectomy reduced mortality after extensive cerebral infarction. However, the functional outcome and level of independence are poor. It seems that the early decompressive craniectomy should be aggressively performed for extensive cerebral infarction before neurological deterioration such as worsening of consciousness disturbance or pupil abnormalities. Further investigations will be needed to clarify the surgical indications, timing, and functional outcomes.

Eosinophilic granuloma is the localized form of Langerhans' cell histiocytosis. There are several reports of magnetic resonance (MR) imaging of eosinophilic granuloma of the skull, however there are few reports about dural enhancement. We report an operative case of eosinophilic granuloma of the skull with dural invasion. A 42-year-old man was admitted to our hospital. He was neurologically intact and there were no other osseous or soft tissue lesions. CT showed an osteolytic lesion in the left parietal bone. MR images showed the lesion as iso-intense on T1-weighted, and high intense on T2-weighted images. T1-weighted images with Gd-DTPA demonstrated the mass which was enhanced with dural surface and subgaleal tissue. The angiogram demonstrated a tumor stain fed by the left occipital artery. Bone scintigraphy demonstrated a solitary lesion showing peripheral uptake with a central defect. The patient underwent craniectomy with removal of the dura and a subgaleal lesion. Histological examination revealed characteristic eosinophilic granuloma with dural invasion. No recurrence of the lesion was demonstrated 6 months after surgery.

We would like to report a rare case of a venous angioma with a chronic encapsulated hematoma, in a 3 Her neurological examination was noted to be normal. A CT was performed which showed an isodense mass in the left cerebellar hemisphere. This finding was confirmed on MR imaging, which showed a hyperintense mass on T1-weighted imaging, and a hypo to isointense area on T2-weighted images. T1-weighted images with Gd-DTPA enhancement revealed a dilated vein and, as a result, an angiogram was obtained. The venous phase demonstrated medullary veins converging on a central vein, which is usually known as a caput medusae. Follow up T1-weighted images with Gd-DTPA enhancement showed peripheral ring enhancement and expansion of the capsulated hematoma. Total removal of the hematoma and its capsule was performed in July, 2006. The hematoma was seen both inside and outside the tough capsule. A histological examination revealed that the capsule consisted of an outer collagenous layer and an inner granulated layer with deposits of hemosiderin. The hemorrhage rate of a venous angioma has been reported as between 0.22-0.61% per year. We thought that the initial small hemorrhage from the venous angioma resulted in the development of an encapsulated hematoma, and the total hematoma had expanded not only inside due to the hemorrhage of the capsule, but also outside because of the venous angioma.

Endovascular coiling has become a standard option in addition to surgical clipping in the treatment modality for cerebral aneurysms; thus, it is important to assess the effect of these different treatment options on vasospasm after aneurismal subarachnoid haemorrhage (SAH). Although several recent studies have suggested that the incidence of vasospasm is lower in patients undergoing aneurysmal coiling as opposed to clipping, other Studies have had conflicting results. Through multivariate analysis, we have reviewed 522 patients with ruptured intracranial aneurysms, treated consecutively in our centre, to determine whether the incidence of vasospasm and clinical outcomes have differed between patients treated with clipping and coil occlusion. As a result, there was no significant difference in the occurrence of symptomatic vasospasm and overall Outcome between the two treatments. The patients with better Hunt & Kosnik (H&K) grades (OR 1.19, 95% CI 1.01-1.64), rupture of posterior circulation aneurysms (OR 0.23, 95% CI 0.07-0.75), and elderly age (OR 0.97, 95% CI 0.95-0.98) were less likely to suffer from angiographic vasospasm.

Background: Patients with poor-grade aneurysmal subarachnoid hemorrhage (SAH) presenting with large intracerebral (ICH) or sylvian hematomas (SylH) have poor outcomes due to the mass effect of significant brain stem compression following mass effect. On the other hand, decompressive craniectomy (DC) can reduce morbidity and mortality in critically ill patients with massive ischemic infarction and severe head injury. However, the role of DC in SAH patients is not fully understood. We investigated the outcome of DC in poor-grade SAH presenting with large ICH or SylH. Methods: 110 consecutive patients with poor-grade SAH (Hunt & Kosnik (H&K) grades IV and V, and Fisher group 4) were admitted to our hospital between April 1, 1993, and July 30, 2004. We treated 57 of those who presented with large ICH or SylH using DC. We retrospectively reviewed medical charts, radiological findings, operative notes, and video records. Results: Among the 57 patients (mean age 57.8, male 29, female 28), 25 were classified as H&K grade IV and 32 as grade V. Ruptured aneurysms were located on the internal carotid artery in 11 and the middle cerebral artery in 46 patients. 50 of the aneurysms were small, 5 were medium, and 2 were large. Rerupture was preoperatively confirmed in 13 (22.8%). Hypothermia was applied to 17 (29.8%). The Glasgow Outcome Scale on discharge showed good recovery, moderate recovery, severe disability, vegetative state, and death in 8 (14.0%), 13 (22.8%), 16 (28.1%), 8 (14.0%), and 12 (21.1%), respectively. The outcomes of grade IV patients were favorable and poor in 14 (56.0%) and 10 (40.0%), respectively, and 1 (4.0%) died. Conclusion: Several experimental studies have also indicated that DC significantly improves outcome due to reduced intracranial pressure or increased perfusion pressure. Urgent DC for poor-grade SAH with space-occupying hematoma can lead to survival with good recovery in some patients. Copyright (C) 2008 S. Karger AG, Basel

A 32-year-old man presented with a rare case of spontaneous intracranial hypotension (SIH) associated with dural sinus thrombosis (DST) manifesting as severe postural headache which was relieved by lying down. Initial cerebrospinal fluid pressure was low. He was treated with hydration and rest under a diagnosis of SIH. Magnetic resonance (MR) imaging after 1 month showed signs of both DST and SIH. However, the patient did not demonstrate any of the classical symptoms associated with DST. The patient underwent an epidural blood patch procedure. His headache was relieved and MR imaging showed improvement of both SIH and DST. This case suggests that epidural blood patch may be effective in some cases of SIH associated with DST.

Traumatic atlantooccipital dislocation is usually fatal. Few case reports surviving this injury appeared in the literature. We report a rare case of a retropharyngeal hematoma and an atlantooccipital dislocation with survival. A 31-year-old male fell from a motorcycle and was thrown. His neurological examination showed mild weakness (gr III) and numbness of the arms. Enlargement of retropharyngeal space on the lateral cervical radiography helped to recognize the diagnosis. The BAI-BDI method proposed by Harris et al. were useful for diagnosis. Additional imaging, including CT and MRI, was helpful. He was diagnosed atolantooccipital dislocation, retropharyngeal hematoma, cervical subdural hematoma, traumatic subarachnoid hemorrhage, and mandibular fracture. He was orally intubated and the Philadelphia cervical collar was replaced. Additionally, occipitocervical fusion with internal fixation was performed. We emphasize that the presence of retropharyngeal hematoma leads us to perform airway interventions and to suspect the presence of the upper cervical spine injury including atlantooccipital dislocation.

Introduction Controversy exists as to whether Matrix coils are an improvement over bare platinum coils in preventing aneurysm recanalization in endosaccularly coiled large aneurysms. We investigated Matrix coils in a dog model of a wide-necked large bifurcation aneurysm. Methods Six experimental aneurysms were created in dogs and these aneurysms were endosaccularly coiled with 100% Matrix coils. Angiographic and histopathological data were analyzed at 2 weeks and at 3 months. Results Average aneurysm dimensions were length 17.8 mm, width 8.3 mm, and neck 6.2 mm. Aneurysm coil filling ranged 24.1 - 41.8% by volume. At 14 days, three of six Matrix-treated aneurysms showed coil compaction and aneurysm recanalization. At 3 months, one additional Matrix-treated aneurysm showed delayed coil compaction and aneurysm recanalization. At 3 months, in three harvested aneurysms, the average measured neck neointima was 0.150 +/- 0.14 mm. However, in two of the three aneurysms harvested at 3 months, aneurysm recanalization had occurred with neointimal tissue not completely covering the aneurysm orifice. Thick connective fibrous intercoil tissue was observed. No immediate or delayed thrombus formation had occurred. Conclusion Based on limited data in an experimental bifurcation aneurysm in dogs, Matrix coils appear to induce a thicker aneurysm neck neointima tissue and intercoil granulation response but appear prone to coil compaction and aneurysm recanalization. Modifications to the Matrix coil are likely needed to improve angiographic results in large aneurysms.

We reported a 72-year-old man presented with gustatory disturbance. He lost bitter, salty, sour and sweet sensation on the left half of the tongue. No other neurologic signs were observed. Brain MRI showed the cerebral infarction in the left middle cerebellar peduncle. The lesion was suspected of affecting the gustatory tract running from the nucleus solitalius to the pontine taste area in the upper pons. The gustatory tract is generally recognized to be located medially from the medial lemniscus and the reticular formation. Our case suggests that the tract would be located laterally from the medial lemniscus and the reticular formation.

Malignant gliomas are typically angiogenic and secrete high levels of VEGF. Hypoxia has been identified as an important regulator of VEGF. However, malignant gliomas express high levels of VEGF in both hypoxic perinecrotic and vital tumor areas. In this study, we examined intracellular signaling pathways involved in the secretion of VEGF in glioma cells under normoxic conditions. Human malignant glioma cell lines, T98G, U373MG, U87MG, and A172, and human fetal lung fibroblasts (HFL) were cultured both with and without IL-1 beta under normoxic conditions. VEGF, IL-1, IL-6 and TNF-alpha were measured with ELISA. VEGF mRNA levels were estimated by RT-PCR. Inhibitors of COX-2, MAPK, and phosphatidyl inositol 3-kinase (PI3-K), and blocking antibodies to TGF-beta II and TNF-alpha, or IL-1 receptor antagonist, were used to examine their effects on VEGF secretion. Phosphorylation of MAPK was examined by immunoblotting. The basal levels of VEGF secretion were significantly higher in U87MG, U373MG, and T98G, than HFL. IL-1 beta significantly stimulated VEGF secretion in these glioma cells. Inhibitors of p38 MAPK and/or JNK significantly suppressed VEGF secretion both in the presence and absence of IL-1 beta, while inhibitors of COX-2, ERK1/2, and PI3-K. did not. Constitutive phosphorylation of p38 MAPK and JNK was observed in these glioma cells. The levels of IL-1 beta in U87MG were significantly higher than in other glioma cell lines, and IL-1 receptor antagonist suppressed basal secretion of VEGF from U87MG. In conclusion, p38 MAPK and JNK pathways play an important role in VEGF secretion from malignant glioma cells under normoxic conditions, possibly contributing to VEGF-induced angiogenesis in malignant gliomas at vital tumor areas where there is no hypoxia.

We developed an experimental canine model in which four types of aneurysm-bifurcation, side-wall, small branch-artery, and arterial-stump-were surgically created in the same animal. These experimental aneurysms are exposed to simultaneous but different hemodynamic stresses correlating to human intracranial aneurysms in different locations. Because this model allowed for the creation of four aneurysms, each with different hemodynamic features, it seems to offer advantages from ones previously described. This model may foster investigation of new and current endovascular devices.

In our experience with the canine model, sidewall aneurysms made with an oblique-cut arteriotomy were less likely to thrombose than were those made with a standard technique.

Object. The authors investigated whether HydroCoils decreased coil compaction and aneurysm recanalization in a canine model of a large, wide-necked, high-flow bifurcation aneurysm. Methods. Eleven experimental aneurysms were created. Two aneurysms were untreated (Group 1); three were treated with standard platinum coils (Guglielmi Detachable Coils; Group 2); and six were treated with platinum framing coils and filling HydroCoils (Group 3). Comparative angiographic and histopathological data were analyzed at 2 weeks and again at 3 months. At 3 months, the Group 1 aneurysms remained patent without spontaneous thrombosis. After coil placement the percentage of aneurysm filling by volume ranged from 59 to 90% (mean 75.4%) for Group 3 (HydroCoil-treated) and 34.3 to 48.9% (mean 39.6%) for Group 2 (GDC-treated) (p < 0.05). At 14 days, two of the three Group 2 aneurysms exhibited coil compaction and aneurysm recanalization at the neck; in both cases the condition worsened at 3 months. At 14 days and 3 months, five of the six Group 3 aneurysms were 100%, and one of six was 90% occluded and remained stable. At 3 months, the neointima of the aneurysm neck was significantly thicker in the Group 3 lesions, which had been treated by HydroCoils (0.329 +/- 0.191 mm), than in Group 2 lesions, which had been treated with GDCs (0.026 +/- 0.018 mm) (p < 0.001). No thrombus formation occurred in Group 2; however, in two of the six aneurysms in Group 3, thrombus formed at the coil-neck interface. Conclusions. The experimental canine bifurcation aneurysm model overcomes the limitations of side-wall aneurysm models. In this model, HydroCoils resulted in significantly denser coil packing, less follow-up coil compaction, and thicker neointimal tissue at the neck of the lesion. HydroCoils also appeared more thrombogenic at the aneurysm neck-parent artery interface.

Purpose: Tumor necrosis factor (TNF)-alpha elicits two opposing effects, the induction of apoptosis and the transcription of antiapoptotic genes. We have recently shown that cisplatin sensitizes glioma cells to TNF-induced apoptosis, but only in some cell lines. To understand the mechanism involved in the different susceptibilities, we examined both the activation of caspases and cytoprotective signaling by TNF-alpha. Experimental Design: Caspase activation was examined by estimating the cleavage of substrate peptides and by immunoblot to identify the cleavage of procaspases. Peptide inhibitors of caspases were used to reverse the cytotoxicity. The binding of TNF-alpha to the receptor was analyzed by flow cytometry. Nuclear factor (NF)-KB activation was assayed by the binding of NF-KB to oligonucleotides containing the consensus binding site. Interleukin (IL)-1beta, IL-6, IL-8, and manganous superoxide dismutase (MnSOD) were measured by enzyme-linked immunoassays. Results: T98G and U87MG underwent apoptosis on treatment with cisplatin and TNF-alpha, but U373MG and A172 were resistant. Caspases 2, 3, and 6-10, but not caspases 1, 4, and 5, were activated in sensitive cells, and none were activated in resistant cells. The binding of TNF-alpha to the receptor was the same in all four of the cell lines. In the sensitive cells, NF-KB activation and the production of IL-1beta, IL-6, IL-8, and MnSOD were significantly elevated by TNF-alpha. However, in the resistant cells, the production of IL-1beta and IL-6 were specifically impaired in response to TNF-alpha. Conclusions: Our results indicate that both apoptotic and cytoprotective pathways are impaired in glioma cells that are resistant to treatment with cisplatin and TNF-alpha.

Purpose: Malignant gliomas are typically angiogenic and express greater amounts of angiogenic factors. We examined glioma tissues for their expression of an endogenous inhibitor of angiogenesis, endostatin, a COOH-terminal fragment of collagen XVIII. Experimental Design: We examined frozen tissues from 51 patients with astrocytic tumors (grade 2, 13; grade 3, 9; and grade 4, 29). Frozen tissues were subjected to immunoblot analysis and immunohistochemistry for endostatin. Tumor vascular density was determined by calculating the percentage of tumor capillary vessel areas/tissue section area. Tissue concentrations of vascular endothelial growth factor and basic fibroblast growth factor were examined by enzyme immunoassay. Results: The levels of endostatin protein estimated by immunoblotting were significantly higher in grade 4 than lower-grade glioma tissues. The immunoreactive bands for endostatin were identified as the fragment derived from noncollagenous domain 1 of collagen XVIII, a peptide 15 residues longer than endostatin toward the NH2-terminal end, by NH2-terminal amino acid sequencing. In addition to an intense immunoreactivity for endostatin in tumor blood vessels, sections from malignant gliomas showed widely distributed immunoreactivity around tumor cells near the hyperplastic microvessels. The tumor vascular density and the levels of vascular endothelial growth factor in grade 4 glioma tissues were significantly higher than grade 2 and grade 3 gliomas, whereas the levels of basic fibroblast growth factor were the same. Conclusions: The results indicate a positive correlation between the levels of tissue endostatin and malignancy grades in gliomas. The endostatin may be released near the tumor blood vessels with hyperplasia to counteract angiogenic stimuli in malignant gliomas.

BACKGROUND This case illustrates that although percutaneous subdural tapping for patients with chronic subdural hematoma (CSDH) is successful and minimally invasive, it can be complicated by acute epidural hematoma. CASE PRESENTATION A 62-year-old woman presented with headache two months after minor head trauma. Computed tomography (CT) scanning revealed CSDH with mixed density on the right side. Prior to percutaneous subdural tapping, twist-drill craniostomy was performed at the parietal tuber. When the drill-needle reached the dura mater, the patient began to complain of headache, which was followed by altered consciousness. CT scanning disclosed acute epidural hematoma abutting the CSDH; both hematomas were evacuated by emergency craniotomy. At surgery, no definite bleeding source was identified apart from oozing on the dura mater. CONCLUSION Hemorrhagic complications after percutaneous subdural tapping are rare. The formation of acute epidural hematoma during twist-drill craniostomy has not been reported in the literature. This complication can occur when the blunt tip of the drill-needle remains on the dura mater without penetrating into the subdural hematoma cavity. (C) 2000 by Elsevier Science Inc.

A rare case of dural arteriovensus fistula (DAVF) in the superior sagittal sinus (SSS), the transverse sinus and the sigmoid sinus is reported. A 64-year-old man, who had had an episode of temporary visual disturbance after moderate fever for a week about 20 years before, was aware of loss of visual acuity and reduced field of view in the right eye. When he was introduced to our outpatient service. increased intracranial pressure (ICP) was detected by lumbar puncture, Cerebral angiograms showed bilateral DAVFs both in the posterior fossa and the SSS concomitant with thrombosis in the transverse sinus, sigmoid sinus and SSS. Afterwards, endovascular transarterial embolization through bilateral occipital, posterior auricular and left middle meningeal, superior temporal arteries was carried out. In addition, transvenous thrombolytic therapy using a catheter inserted into SSS resulted in the improvement of his visual problems. Although he was discharged at once, he was readmitted to our department with Foster Kennedy syndrome and increased ICP. Cerebral angiograms showed recurrence of both DAVF and sinus thrombosis. Transarterial embolization was performed again resulting in a significant reduction of DAVF, and his visual acuity was recovered to a moderate degree. The origin of DAVF is still controversial. Although two theories, ''congenital'' and ''acquired'', are put forward, it has been thought that both factors play important roles, In our case, the patient had stenosis in the jugular canal portions of the sigmoid sinus. In addition sinus thrombosis src-med to have occurred. It is thought that increased intrasinus pressure may have lead to communication with surrounding arteries through existing dural vessels. We applied transvenous thrombolytic therapy in this ease. Our result suggests that we should consider this therapy for some cares of DAVF.