Cardiopulmonary arrest induced by atlantoaxial dislocation with subarachnoid hemorrhage: a case report and review of the literature.

Introduction: Spinal cord injury (SCI) with atlantoaxial dislocation (AAD) is often fatal. We present the case of a resuscitated patient with AAD and traumatic subarachnoid hemorrhage (SAH) at the craniovertebral junction (CVJ). Case presentation: We present the case of an 84-year-old man who suffered an observed cardiopulmonary arrest. Cardiopulmonary resuscitation was initiated and spontaneous circulation returned. In the emergency room, the patient's Glasgow Coma Scale was 3 (E1V1M1). No spontaneous respiration was noted. Neuroimaging revealed SAH at the CVJ. Contrast-enhanced computed tomography (CT) revealed a vessel running through the left C2/3 intervertebral foramen into the spinal canal. The ventral space of spinal cord revealed contrast enhancement. Angiography revealed extravasation from the spinal branch of the left vertebral artery, without venous filling. It did not appear to be a vascular malformation with an arteriovenous shunt, but rather a traumatic laceration of the artery. Plain CT and CT angiography suggested AAD. Magnetic resonance imaging revealed injury to the medulla oblongata and upper cervical spinal cord, with AAD and retrodental subligamentous hemorrhage. We embolized the branch of the left vertebral artery and performed a C1 laminectomy. The patient moved his extremities postoperatively. Discussion: This was a case of injury to the medulla oblongata and upper cervical spinal cord due to AAD with SAH. This is the first report of resuscitated case of traumatic AAD with SAH in the CVJ. Traumatic AAD should be included in the differential diagnosis in case of SAH in CVJ, which may be misdiagnosed as intrinsic SAH.

Effectiveness of 7-day versus weekday-only rehabilitation for stroke patients in an acute-care hospital: a retrospective cohort study.

PURPOSE: Early rehabilitation is widely recommended for acute-stroke patients. We tested the hypothesis that the functional prognosis of stroke patients receiving daily early rehabilitation in a clinical practice setting is generally better than that of patients receiving rehabilitation only on weekdays. MATERIALS AND METHODS: We analyzed hospitalized patients who experienced either cerebral infarctions or cerebral hemorrhages and subsequently underwent rehabilitation at our hospital between October 2010 and September 2014. We examined the association between training frequency and activities of daily living improvements, as indicated by the Barthel Index (BI) effectiveness. RESULTS: In total, 661 patients with cerebral infarctions and 245 with intracerebral hemorrhages (ICHs) were analyzed. The BI effectiveness was highest for patients receiving high-frequency therapy following cerebral infarction. In addition, multiple linear regression analysis indicated that BI effectiveness was significantly and positively correlated with high-frequency therapy (coefficient, 0.072; 95% confidence interval, 0.019-0.126; p < 0.01) in patients with cerebral infarctions. There was no significant difference in BI effectiveness between therapeutic protocols for patients with ICHs. CONCLUSION: This retrospective cohort study demonstrated that extensive therapy can result in functional recovery in patients with cerebral infarctions. Implications for Rehabilitation Early intervention with intensive rehabilitation therapy is important for improving the functional recovery of patients during acute-care hospitalization. Few acute hospitals provide more than 2 h of daily rehabilitation for patients with acute stroke. In a daily clinical practice setting, this clinical study demonstrates a direct relationship between early intervention with intensive rehabilitation therapy and good functional recovery of stroke patients in an acute ward.

[Association of Lower limb Neuropathy with Lumboperitoneal Shunt Transection:A Case Report].

A 49-year-old woman suffered hydrocephalus after subarachnoid hemorrhage, and underwent a lumboperitoneal(LP)shunt operation. X-ray imaging revealed that a spinal catheter inserted into the cranial side from L2/3 turned caudally at the Th12 level. Postoperative numbness and pain of the left buttocks and posterior femoral region persisted. The spinal catheter was pulled about 5 cm to improve flexure, and was reconnected 10 months after the shunt procedure. Symptoms improved, but a similar symptom developed one and a half years later. The spinal catheter was torn at the connection to the shunt valve. The catheter curved to the left side of the spinal cord and the catheter tip was located around the right Th12/L1 intervertebral foramen. We continued observations with analgesics, but symptoms did not subside. The shunt was removed 16 months after symptom relapse, and symptoms disappeared immediately. Bent insertion of the lumbar catheter is a potential cause of lower limb neuropathy after LP shunt operation. Attention must also be paid to the continuity of the catheter in follow-up after shunt procedures.

Emergency Superficial Temporal Artery to Middle Cerebral Artery Bypass After Intravenous Administration of Tissue Plasminogen Activator for Stroke.

Intravenous tissue plasminogen activator (IVtPA) is effective for the treatment of acute stroke. Although IVtPA is easily administered and is effective in many cases, the clinical condition of some patients can worsen after the initiation of thrombolytic therapy due to sustained cerebrovascular insufficiency. In such cases, several additional treatment options to re-establish cerebral perfusion are available, including superficial temporal artery to middle cerebral artery bypass. However, it is recommended that invasive procedures should be avoided soon after IVtPA administration because tPA is believed to exert prolonged fibrinolytic effects may continue for more than 24 hours. We described three cases of emergency superficial temporal artery to middle cerebral artery bypass performed within 24 hours of IVtPA administration, and discussed the safety of such procedures. We believe that superficial temporal artery to middle cerebral artery bypass can be safely performed even within 24 hours after IVtPA administration.

Feasibility of the combination of 3D CTA and 2D CT imaging guidance for clipping microsurgery of anterior communicating artery aneurysm.

OBJECTIVE: We report the technique of three-dimensional computed tomography angiography (3D CTA)+two-dimensional computed tomographic (2D CT) imaging as an adjunct in early surgery for a ruptured anterior communicating artery (ACoA) aneurysm by adopting an anterior interhemispheric approach. These combined imaging modalities provide accurate intraoperative anatomical information. METHODS: To produce images for an anterior interhemispheric approach, 3D CTA+2D coronal CT images, which are perpendicular to the direction of the surgical approach at three levels (brain surface, genu of the corpus callosum and aneurysm neck), were constructed. We also produced two 3D CTA+2D CT images of the lamina terminalis, with a horizontal 10-degree difference, to clarify the vascular architecture around the aneurysm stereotactically, as well as the dissection point and direction to open the lamina terminalis. Furthermore, we produced a 3D CTA+2D sagittal CT image at the midline, which allowed us to understand the anatomical architecture of the aneurysm, planum sphenoidale and tuberculum sellae. In addition, four different 3D CTA aneurysm images were produced for deciding the clip size preoperatively. RESULTS: The imaging findings in 28 patients with 28 ACoA aneurysms facilitated early clipping. Based on these 3D CTA+2D CT images, we conducted aneurysm surgery, and successfully performed neck clipping via an anterior interhemispheric approach. CONCLUSION: The combination of 3D CTA and 2D CT images is a feasible and useful method of image guidance for ACoA aneurysm microsurgery.

[CT and histological findings and treatment outcomes after carotid endarterectomy for symptomatic cervical carotid artery stenosis in octogenarians].

Symptomatic cervical carotid artery stenosis is one of the common causes of ischemic stroke in octogenarians. The records for 90 consecutive patients with symptomatic cervical carotid artery stenosis treated by carotid endarterectomy(CEA)were analyzed retrospectively. The patients were divided into two groups:21 patients aged 80 years or over and 69 patients aged less than 80 years. CT angiography revealed that ulcer formation was significantly more common and the length of carotid artery stenosis was significantly greater in the octogenarians. Histological examination of the plaque revealed no significant difference between the two groups in terms of ulcer formation, lipid content, and intraplaque hemorrhage. However, all three of these pathological findings were present in a significantly higher number of octogenarians. No significant difference was observed for new ischemic lesions on diffusion-weighted MR imaging, neurological complications, or cardiac and pulmonary complications. However, treatment with an albumin preparation and loop diuretics was significantly more common in octogenarians after CEA. The present study suggests that with careful postoperative management CEA can be safely performed in symptomatic patients aged 80 years or over with almost the same risk as that for patients aged less than 80 years.

Effects of intravenous infusion of hydrogen-rich fluid combined with intra-cisternal infusion of magnesium sulfate in severe aneurysmal subarachnoid hemorrhage: study protocol for a randomized controlled trial.

BACKGROUND: The failures of recent studies intended to prevent cerebral vasospasm have moved the focus of research into delayed cerebral ischemia away from cerebral artery constriction towards other mechanisms. Recent accumulating evidence has suggested that early brain injury is also involved in the development of delayed cerebral ischemia, and that hydrogen can prevent early brain injury. Therefore, we have established a combination therapy of intravenous hydrogen infusion and intra-cisternal magnesium sulfate infusion for the treatment of both early brain injury and cerebral vasospasm. The present randomized controlled clinical trial is designed to investigate the effects of this novel therapeutic strategy on the occurrence of cerebral vasospasm, delayed cerebral ischemia, and clinical outcomes after high-grade subarachnoid hemorrhage. METHODS: This study is a randomized, double-blind, placebo-controlled design to be conducted in two hospitals. A total of 450 patients with high-grade subarachnoid hemorrhage will be randomized to one of three arms: (i) Mg + H2 group, (ii) Mg group, and (iii) control group. Patients who are assigned to the Mg + H2 group will receive intra-cisternal magnesium sulfate infusion (2.5 mmol/L) at 20 mL/h for 14 days and intravenous hydrogen-rich fluid infusion (200 mL) twice a day for 14 days. Patients who are assigned to the Mg group will receive intra-cisternal magnesium sulfate infusion (2.5 mmol/L) at 20 mL/h for 14 days and intravenous normal glucose-electrolyte solution (200 mL) without added hydrogen twice a day for 14 days. Patients who are assigned to the control group will receive intra-cisternal Ringer solution without magnesium sulfate at 20 mL/h for 14 days and intravenous normal glucose-electrolyte solution (200 mL) without added hydrogen twice a day for 14 days. Primary outcome measures will be occurrence of delayed cerebral ischemia and cerebral vasospasm. Secondary outcome measures will be modified Rankin scale score at 3, 6, and 12 months and biochemical markers. DISCUSSION: The present protocol for a randomized, placebo-controlled study of intravenous hydrogen therapy with intra-cisternal magnesium infusion is expected to establish the efficacy and safety of this therapeutic strategy. TRIAL REGISTRATION UMIN-CTR: UMIN000014696.

Decompressive craniectomy after intravenous tissue plasminogen activator administration for stroke.

OBJECTIVE: Intravenous tissue plasminogen activator (IV tPA) is an approved treatment for acute ischemic stroke. However, the effects of decompressive craniectomy (DC) after IV tPA administration for ischemic stroke are still largely unknown. The aim of this study was to investigate the safety and outcomes of DC after IV tPA administration. METHODS: We retrospectively reviewed patients who underwent DC for malignant hemispheric infarction. We compared 20 patients who underwent DC after IV tPA administration with another 20 patients who underwent DC without prior IV tPA administration. RESULTS: The patient characteristics did not differ between the DC patients with and without prior IV tPA administration. New intracranial bleeding or worsening of pre-existing ICH occurred in two patients (10%) in each group. Furthermore, the rates of an mRS score of 4-6, 5 or 6, and 6 did not differ significantly between the two groups. CONCLUSION: DC may be a safe and useful surgical procedure for space-occupying edema after IV tPA administration for acute stroke.

[Correlation between increased platelet ADP aggregability and silent brain infarcts].

The purpose of this study was to investigate the correlation between platelet aggregability and silent brain infarcts. The study subjects were 445 people (264 men, 181 women; mean age, 53 ± 14 years) with no neurologic signs, history of brain tumor, trauma, cerebrovascular disease, or antiplatelet medications. Adenosine diphosphate (ADP)-induced platelet aggregation was measured by the aggregation-size analytic method. Platelet aggregability was classified into 9 classes. The presence of headache/vertigo, hypertension, diabetes mellitus, hyperlipidemia, or smoking was elicited by questioning or blood sampling. A head MRI scan was performed, and if marked atherosclerosis or obvious stenosis in the intracranial vessels was detected, it was defined as a positive MRA finding. Silent brain infarcts were detected in 26.3% of subjects. Hyperaggregability defined as that above class 6, 7, and 8 was present in 43.8%, 30.8%, and 15.7% of subjects, respectively. The risk factors for silent brain infarcts by multiple logistic regression analysis were aging, hypertension, positive MRA findings, and hyperaggregability. Platelet ADP hyperaggregability might be a risk factor for silent brain infarcts.

Usefulness of an ultrasonic scalpel to harvest and skeletonize the superficial temporal artery for extracranial-intracranial bypass surgery.

OBJECTIVE: A new method to harvest and skeletonize the superficial temporal artery (STA) using an ultrasonic scalpel is presented. The technique is simple and safe, and reduces bleeding. We also investigated histopathological changes in donor vessels and whether it is possible to shorten the time needed for STA harvesting using the ultrasonic scalpel. METHODS: Between January 1, 2005, and December 31, 2007, 31 consecutive patients underwent STA and middle cerebral artery anastomosis surgery in our hospital. All patients underwent harvesting of both the frontal and parietal branches of the STA. STA harvesting using an ultrasonic scalpel was performed in 18 of the 31 patients. We compared the time needed for STA harvesting by dividing patients into 2 groups: a non-ultrasonic scalpel group and an ultrasonic scalpel group. We also examined the histopathological changes by application of ultrasonic waves on the STA in the 6 most recent patients. RESULTS: The mean time needed for STA harvesting was 84.2 +/- 14.1 minutes for the non-ultrasonic scalpel group and 55.1 +/- 15.2 minutes for the ultrasonic scalpel group. The ultrasonic scalpel group showed a significantly shorter harvesting time than the non-ultrasonic scalpel group (P < 0.01). No histopathological change was observed in any layers of the STA. CONCLUSION: Our data suggest that STA harvesting with the ultrasonic scalpel may be useful for STA-middle cerebral artery anastomosis surgery.

Usefulness of preoperative three-dimensional computed tomographic angiography with two-dimensional computed tomographic imaging for rupture point detection of middle cerebral artery aneurysms.

OBJECTIVE: We report the technique of three-dimensional computed tomographic (CT) angiography with a two-dimensional CT image aiding in the early operation of ruptured middle cerebral artery aneurysms. This combined image allows the prediction of the rupture point in the aneurysm and may reduce the risk of rupture during early clipping surgery. METHODS: The findings for 14 patients with 14 middle cerebral artery ruptured aneurysms who underwent subsequent early clipping were analyzed. The average aneurysm size was 8.5 mm, and there were two large and one giant aneurysms. CT examinations were performed by means of a multidetector CT scanner (Aquilion M16; Toshiba Medical Systems, Tokyo, Japan) and reconstructed with a workstation (ZIO M900 QUADRA; Amin Co., Ltd., Tokyo, Japan). We constructed an operating view through three-dimensional CT angiography for a lateral transsylvian approach with a two-dimensional CT image (nonshaded volume-rendering image), which was perpendicular to the direction of the surgical approach. Using this combined image, we predicted the rupture point of the aneurysm and successfully performed clipping surgery through a lateral transsylvian approach. Rupture points were confirmed at the time of surgery. Rupture points of 13 out of 14 aneurysms appeared as we expected, but one differed; all aneurysms were successfully clipped. Thirteen of the 14 patients could be clipped without rupture at surgery, but the remaining patient experienced rupture just after craniotomy. CONCLUSION: The combination of three-dimensional CT angiography and two-dimensional CT images may help improve the surgical outcome by indicating aneurysmal rupture points, leading to the prevention of rupture.

Multicentric involvement of non-Hodgkin's lymphoma in the central nervous system and testis--case report.

A 73-year-old male presented with diffuse mixed B cell lymphoma with involvement of the central nervous system (CNS) and testis manifesting as mild disorientation and aphasia. A left frontal cerebral mass and a right testicular tumor were found, and both lesions were surgically resected. Histological examination revealed diffuse mixed B cell type malignant lymphoma in the CNS and testis. The patient received irradiation to the head, and his initial symptoms improved. Pelvic computed tomography revealed enlargement of the contralateral testis and prostate. Needle biopsy confirmed lymphoma. The patient died 5 months after the initial diagnosis of septic shock. Autopsy examination revealed lymphoma cell invasion of the lung, bone marrow, prostate gland, and thalamus, but without involvement of the systemic lymph nodes. In a patient with an intracranial lymphoma, it is important to determine if the lesion is primary or metastatic and to plan medical treatment including systemic chemotherapy as soon as possible. Improvement of the prognosis of systemic non-Hodgkin's lymphoma with CNS involvement requires the detection and effective treatment of systemic lesions as well as the control of the CNS lesions.

[Wallerian degeneration demonstrated by MRI and functional outcome in patients suffering from supratentorial cerebrovascular disease].

An early diagnosis of the outcome of patients with cerebrovascular disease is important for selecting the optimal treatment strategy. The purpose of this study was to estimate the prognosis of Wallerian degeneration on MRI in stroke patients with hemiparesis. The subjects consisted of 87 stroke patients, 50 hemorrhagic patients and 37 ischemic patients, who were evaluated by MRI at 1 to 6,275 days after stroke onset. Among the 36 patients who were evaluated by consecutive MRI, 161 films were obtained and analyzed. Wallerian degeneration was diagnosed when a small prolonged T 2 lesion was seen in the corticospinal tract of the brainstem on at least two contiguous slices. The atrophic rate of the midbrain was calculated as: (the area of the unaffected side of the midbrain--the area of the affected side of the midbrain)/2 x (the area of the unaffected side of the midbrain). The patients' ability to perform the activities of daily living was scored by the Barthel index (BI). Wallerian degeneration in the ipsilateral brainstem was seen for two to three months in 32 cases (37%) and in 58 films (36%) and disappeared about 3 years after the onset of stroke. Wallerian degeneration correlated with the BI scores from 2 to 6 months after stroke (p < 0.05), although no relationship was observed at 7 months or later. From 2 to 6 months after stroke, the shrinkage of the midbrain on MRI correlated with the BI scores (p < 0.001), although no relationship was observed at 7 months or later. It was therefore both Wallerian degeneration and a shrunken midbrain observed on MRIs, evaluated from 2 to 6 months after stroke were thus suggested to indicate a poor outcome in such patients.