Venous hypertension caused by a meningioma involving the sigmoid sinus: case report.

BACKGROUND: Intracranial venous hypertension has been associated with a few cases of meningioma secondary to compression of the venous sinus. This is the rare case of small meningioma involving the sigmoid sinus leading to intracranial venous hypertension mimicking venous thrombosis. CASE PRESENTATION: A 39-year-old woman suffered visual dysfunction due to bilateral papilledema. Noncontrast head computed tomography (CT) showed no intracranial space-occupying lesions or hydrocephalus. Cerebrospinal fluid examination revealed high opening pressure. Various image inspections such as three-dimensional CT angiography, magnetic resonance imaging, and cerebral angiography demonstrated a small 2.5-cm lesion causing subtotal occlusion of the dominant right sigmoid sinus. No improvement of clinical manifestations was observed after medical treatment for 6 months, so right presigmoid craniectomy was performed. Operative findings revealed that the tumor was located predominantly involving the sigmoid sinus. The pathological diagnosis was fibrous meningioma. Postoperative fundoscopic examination showed improvement of bilateral papilledema. CONCLUSIONS: We treated a patient presenting with intracranial hypertension due to a small meningioma involving the sigmoid sinus. This unusual case suggests that early surgical strategies should be undertaken to relieve the sinus obstruction.

Extracorporeal membrane oxygenation support for postcardiotomy cardiogenic shock in adult patients: predictors of in-hospital mortality and failure to be weaned from extracorporeal membrane oxygenation.

Postcardiotomy cardiogenic shock (PCCS) is a rare clinical entity associated with substantial morbidity and mortality. It is characterized by heart failure that results in an inability to be weaned from cardiopulmonary bypass (CPB). The aim of this study was to analyze the outcomes of extracorporeal membrane oxygenation (ECMO) in patients with PCCS and to identify predictors of in-hospital mortality and failure to be weaned from ECMO. From January 2002 to August 2016, 3248 patients underwent cardiac surgery in our hospital. Of these, 29 patients (0.89%) required ECMO because of an inability to be weaned from cardiopulmonary bypass. The median duration of ECMO support was 144 h (340-52 h) (range 17-818 h). Sixteen patients (55.2%) were weaned from ECMO, and 6 (20.7%) survived to hospital discharge. The multivariate analysis revealed that reoperation [odds ratio (OR): 13.667, 95% confidence interval (CI): 0.999-187.056, p = 0.05] and ECMO support duration > 130 h (OR: 17.688, 95% CI: 1.324-236.233, p = 0.03) were independent predictors of failure to be weaned from ECMO. Temporarily being weaned from CPB > 15 min (OR: 0.027, 95% CI: 0.001-0.586, p = 0.02) was found to be a protective factor. The multivariate analysis revealed that CPB time > 270 min (OR: 12.503, 95% CI: 1.058-147.718, p = 0.05) and ECMO support duration > 60 h (OR: 12.503, 95% CI: 1.058-147.718, p = 0.05) were independent predictors of in-hospital mortality. ECMO is an acceptable technique for treating PCCS in patients undergoing cardiac surgery. Our data suggest a reevaluation of therapeutic strategies after 60 h and again after 130 h of ECMO support.

Correction to: Extracorporeal membrane oxygenation support for postcardiotomy cardiogenic shock in adult patients: predictors of in­hospital mortality and failure to be weaned from extracorporeal membrane oxygenation.

In the original publication of the article, author group affiliation was published incorrectly.

Fungal endocarditis after transcatheter aortic valve replacement (TAVR): Case report and review of literature.

The reported number of transcatheter aortic valve replacement-associated infective endocarditis (TAVR-IE) cases has been increasing worldwide, but information about the incidence and clinical features of fungal TAVR-IE is quite limited. We present a patient who acquired TAVR-IE caused by Candida parapsilosis four month after TAVR, who was successfully treated redo-aortic valve replacement and prolonged antifungal therapy.

[Frontal Lobe Signs Caused by Migration of a Burr Hole Cap into the Brain after Deep Brain Stimulation Surgery:A Case Report].

We report a rare complication in a patient with Parkinson's disease who underwent deep brain stimulation(DBS)surgery. The patient was a 60-year-old woman who presented with frontal lobe signs, including ataxic gait and memory disturbance, that were caused by the unexpected migration of a burr hole cap into the brain three to four months after surgery. The patient had no incidence of a head injury prior to development of symptoms. The patient underwent surgery to extract the migrated cap from the frontal lobe, and her symptoms improved several months after the operation. The cap serves to fix the DBS lead to the skull using an adjunctive burr hole ring. It was intraoperatively confirmed that only the cap detached from the ring, and no cap or ring defects were detected in a postoperative quality check by the manufacturer. We have previously utilized a burr hole ring and cap, which are packaged along with the DBS electrode, when employing the product made by Medtronic Inc. No previous report has described the cap packed in the official DBS kit to have migrated into the intracranial space. It seems unlikely that the cap migration into the intracranial space would occur without the cap and/or ring breaking through either traumatic injury or from manufacturing defects. It is important to consider the migration of a burr hole cap into the intracranial space in the absence of head injury as a possible device complication after DBS surgery.

The oral administration of clarithromycin prevents the progression and rupture of aortic aneurysm.

OBJECTIVE: The pathogenesis of aortic aneurysm (AA) is associated with chronic inflammation in the aortic wall with increased levels of matrix metalloproteinases (MMPs). Clarithromycin (CAM) has been reported to suppresses MMP activity. In this study, we investigated whether CAM could prevent the formation and rupture of AA. METHODS: Male apolipoprotein E-deficient mice (28-30 weeks of age) were infused with angiotensin II for 28 days. CAM (100 mg/kg/d) or saline (as a control) was administered orally to the mice every day (CAM group, n = 13; control group, n = 13). After the administration period, the aortic diameter, elastin content, macrophage infiltration, MMP levels, and levels of inflammatory cytokines, including nuclear factor κB (NF-κB), were measured. RESULTS: The aortic diameter was significantly suppressed in the CAM group (P < .001). No rupture death was observed in the CAM group in contrast to five deaths (38%) in the control group (P < .01). CAM significantly suppressed the degradation of aortic elastin (56.3% vs 16.5%; P < .001) and decreased the infiltration of inflammatory macrophages (0.05 vs 0.16; P < .01). Compared with the controls, the enzymatic activity of MMP-2 and MMP-9 was significantly reduced in the CAM group (MMP-2, 0.15 vs 0.56 [P < .01]; MMP-9, 0.12 vs 0.60 [P < .01]), and the levels of interleukin 1ß (346.6 vs 1066.0; P < .05), interleukin 6 (128.4 vs 346.2; P < .05), and phosphorylation of NF-κB were also decreased (0.3 vs 2.0; P < .01). CONCLUSIONS: CAM suppressed the progression and rupture of AA through the suppression of inflammatory macrophage infiltration, a reduction in MMP-2 and MMP-9 activity, and the inhibition of elastin degradation associated with the suppression of NF-κB phosphorylation.

Strategy of Cardiovascular Surgery for Patients With Dementia as Evaluated by Mini-Mental State Examination.

BACKGROUND: The strategy for cardiovascular surgery in dementia patients is controversial, so we aimed to investigate whether preoperative dementia and its severity might affect the outcomes of cardiovascular surgery by evaluating with the Mini-Mental State Examination (MMSE). Methods and Results: The study group comprised 490 patients undergoing cardiovascular surgery. Their preoperative cognitive status was evaluated using the MMSE, and analysis was performed to compare the patients with MMSE score <24 (dementia group, n=51) or MMSE score 24-30 (non-dementia group, n=439). Furthermore, the effect of the severity of dementia was analyzed with a cut-off MMSE score of 19/20. Risk factors for surgical outcomes were explored using multivariate logistic regression analysis. Hospital mortality was 11.8% in the dementia group and 2.1% in the non-dementia group (P=0.002). Regarding the postoperative morbidities, the incidence of cerebrovascular disorder (P=0.001), pneumonia (P=0.039), delirium (P=0.004), and infection (P=0.006) was more frequent in dementia group. Among the patients with MMSE <20, hospital mortality was as high as 25%, and the rate of delirium was 58%. Multivariate logistic regression analysis revealed that MMSE score <24 (P=0.003), lower serum albumin (P=0.023) and aortic surgery (P=0.036) were independent risk factors for hospital death. CONCLUSIONS: Preoperative dementia affects the outcomes of cardiovascular surgery with regard to hospital death and delirium. The surgical indication for patients with MMSE <20 might be difficult, but surgery with an appropriate strategy should be considered for patients with MMSE <24.

Changes of Doublecortin-Immunoreactive Cells from the Acute Phase to Chronic Phase After Transient Global Brain Ischemia in Rat Cingulate Cortex.

Doublecortin (DCX)-immunoreactive (-ir) cells play important roles in adult cortical remodeling. We previously reported that DCX-ir cells decrease after transient global brain ischemia (GBI) in the cingulate cortex (Cg) of rats. In the present study, we examined the changes of DCX-ir cells from the acute to the chronic phase after GBI in rats. Transient GBI was induced by a four-vessel occlusion model as described previously. Thirty-six rats were divided into six groups: day 7 after sham operation (Group Sham+A), day 7 after 3 min GBI (Group GBI3+A), day 7 after 10 min GBI (Group GBI10+A), day 90 after sham operation (Group Sham+C), day 90 after 3 min GBI (Group GBI3+C), and day 90 after 10 min GBI (Group GBI10+C). The numbers of DCX-ir cells per unit area (mm2) were investigated in the anterior cingulate cortex (ACC) and retrosplenial cortex (RS). A two-way factorial analysis of variance regarding the time of GBI (sham, GBI3, GBI10) or the period after GBI (day 7, day 90) was employed in each area. Regarding the time of GBI, there were significant differences in both the ACC and the RS (p < 0.001, respectively). Regarding the period after GBI, there was no significant difference in the ACC, whereas a significant difference was found in the RS (p = 0.005). In each area and in each phase, the numbers did not change in GBI3 (one-way ANOVA followed by a Tukey test) and decreased in GBI10 (p < 0.005). The numbers in the RS from the acute phase to chronic phase did not change in the sham and GBI3, and decreased in GBI10 (independent t-test, p < 0.001). However, histochemical staining with Fluoro-Jade B suggested that neuronal cell death did not occur in both the ACC and the RS in all groups. The present findings indicate that the cortical remodeling potential in the Cg decreases in the acute phase after GBI, and continues to decrease until the chronic phase.

Transcatheter heart valve for aortic valve implantation: republication of the article published in the Japanese Journal of Artificial Organs.

This review was created based on a translation of the Japanese review first reported in the Japanese Journal of Artificial Organs in 2015 (vol. 44, no. 3, pp. 136-140), with some modifications.

Bipolar dual-lead spinal cord stimulation between two electrodes on the ventral and dorsal sides of the spinal cord: consideration of putative mechanisms.

We have applied bipolar dual-lead spinal cord stimulation (SCS) between two cylinder-type electrodes placed on the ventral and dorsal sides of the spinal cord (dual-VD-SCS). A 36-year-old man suffered from burning pain from his right elbow down to his hand after brachial plexus avulsion. The areas with paresthesia induced by conventional SCS did not include the painful hand area. However, dual-VD-SCS completely induced paresthesia in the painful hand area. We speculate that dual-VD-SCS can be applied to stimulate deeper sites of the dorsal column and dorsal horn than conventional SCS and is useful for pain reduction.

Bone marrow-derived mesenchymal stromal cells regress aortic aneurysm via the NF-kB, Smad3 and Akt signaling pathways.

BACKGROUND AIMS: We have confirmed that aortic aneurysm (AA) can be regressed by the administration of bone marrow-derived mesenchymal stromal cells (BM-MSCs). We investigated the kinetics of signaling pathways in AA following treatment with BM-MSCs. METHODS: Angiotensin II-infused apolipoprotein E-deficient mice were treated by intravenous injection of 1 × 106 BM-MSCs in 0.2 mL saline (BM-MSCs group, n = 5) or 0.2 mL saline (saline group, n = 5). Mice were sacrificed 2 weeks after injection and subjected to measurements of the incidence of AA and levels of phosphorylated proteins. Levels of proteins in conditioned media of BM-MSCs were also measured. RESULTS: The incidence of AA in the BM-MSCs group was reduced (BM-MSC 40% versus saline 100%, P <0.05). Levels of pNF-kB and pSTAT1 were reduced (pNF-kB: 0.28 versus 0.45 unit/mL, P <0.05, pSTAT1: 0.16 versus 0.34, P <0.05), whereas levels of pAkt and pSmad3 were elevated (pAkt: 0.13 versus 0.07, P <0.01, pSmad3: 1.07 versus 0.47, P <0.05) in the BM-MSCs group. The levels of pNF-kB, pAkt, and pSmad3 were correlated with aortic diameters. Trophic factors including IGFPB-3, NRF, Activin A and PDGF-AA were secreted from BM-MSCs (IGFBP-3: 35.2 pg/mL, NRF: 3.1 pg/mL, Activin A: 3.1 pg/mL, PDGF-AA: 0.45 pg/mL). CONCLUSIONS: Our findings suggested that the therapeutic mechanism of BM-MSC-mediated AA regression could contribute to regulation of the NF-kB, Smad3 and Akt signaling pathways. In addition, paracrine actions by factors including NRF, IGFBP-3, Activin A and PDGF-AA might have affected these signaling pathways.

A case of symptomatic granular cell tumor of the sellar region with large calcification.

We report here a rare case of symptomatic granular cell tumor (GCT) of the sellar region with a large calcification. A 70-year-old woman presented with a sellar mass, accompanied by bitemporal hemianopia. The patient was diagnosed preoperatively as having a craniopharyngioma or a pituitary adenoma, because of the large calcification. The patient underwent surgical tumor resection via endoscopic trans-sphenoidal surgery and was diagnosed pathologically as having GCT. The patient's postoperative course was uneventful and her visual field disturbance improved soon after the operation. We briefly discuss the pathological discrimination of GCT and other sellar tumors, since there are many unclear points concerning this rare tumor.

Spinal Cord Stimulation for Vegetative State and Minimally Conscious State: Changes in Consciousness Level and Motor Function.

Twenty-one vegetative state (VS) patients and 10 minimally conscious state (MCS) patients were treated by spinal cord stimulation (SCS) following an electrophysiological evaluation 3 months or more after the onset of brain injury.A flexible four-contact cylindrical electrode was inserted into the epidural space of the cervical vertebrae, and placed at cervical levels C2-C4. Five-hertz stimulation was applied for 5 min every 30 min during the daytime at an intensity that produced muscle twitches of the upper extremities.Both the fifth wave in the auditory brainstem response (ABR) and N20 in the somatosensory evoked potential (SEP) were detected in 8 of the 21 VS patients and 9 of the 10 MCS patients. Of the 3 VS patients and 7 MCS patients who recovered following SCS therapy, all showed a preserved fifth wave in the ABR and N20 in the SEP, and all had received SCS therapy within 9 months after the onset of brain injury. Although the 3 patients who recovered from VS remained in a bedridden state, all 7 patients who recovered from MCS were able to emerge from the bedridden state within 12 months after the start of SCS.Five-hertz cervical SCS caused increased cerebral blood flow (CBF) and induced muscle twitches of the upper extremities, and MCS patients showed a remarkable recovery of consciousness and motor function in the upper extremities compared with the lower extremities. This SCS method could be a new neuromodulation and neurorehabilitation technique, and MCS patients may be good candidates for SCS therapy.

Clinical outcomes and quality of life after surgery for dilated ascending aorta at the time of aortic valve replacement; wrapping versus graft replacement.

Wrapping and graft replacement are two optional procedures for the treatment of dilated ascending aorta at the time of aortic valve replacement (AVR). Wrapping is considered less invasive. The aim of this study was to compare the short- and long-term clinical outcomes as well as the long-term quality of life in patients undergoing these two procedures.This study enrolled 40 consecutive patients with dilated ascending aorta who had undergone either wrapping (WAA group, n=20) or replacement (RAA group, n=20) of the ascending aorta at the time of AVR. Short-term outcomes, long-term deaths, and aortic events were evaluated, as was quality of life using the SF-36 Short Form. Long-term maximal proximal aortic diameter was also obtained.There were no early deaths in either group. Pump time was shorter, and transfusion (55% vs. 95%, p=0.035) and postoperative atrial fibrillation (5% vs. 30%, p=0.036) rates were lower, in the WAA than in the RAA group. At a mean follow-up of 4.9 years, the overall 5 year survival rates in the WAA and RAA groups were 78.1% and 87.5%, respectively. There were no significant between group differences in SF-36 scores in any subcategory of this survey. Long-term maximal aortic diameter remained stable in both groups. Both surgical interventions for dilated ascending aorta at the time of AVR yield favorable and comparable results in patients with suitable anatomy. Furthermore, we found no differences in quality of life between these procedures.

[Total Arch Replacement Using Manufactured Frozen Elephant Trunk after Acute Type-A Dissection Repair].

The purpose of this study is to assess the result of total arch replacement(TAR) using manufactured frozen elephant trunk(FET) for chronic aortic dissection after initial repair including the effect of aortic remodeling by the FET. Between 2003 and 2015, we performed 11 TAR using manufactured FET. Initial repairs before were 9 ascending aortic replacements and 2 Bentall operations. The entry of residual dissection was located at arch in 7 and at distal anastomosis site in 4. There was no hospital death. The operative complication included 2 surgical site infection, 1 interstitial pneumonia and 1 paraplegia with almost full recovery. Postoperative computed tomography 2.1 months after operation showed distal end of the FET was located at aortic valve level in 7 and at pulmonary bifurcation level in 4. There was no entry in thoracic aorta. Thrombosis of descending aorta was achieved in 7 patients. Significant midterm aortic remodeling (increased diameter of true lumen and decreased diameter of false lumen) was achieved, although the total diameter of aorta was increased. TAR using manufactured FET after type-A dissection repair promoted entry closure and thrombosis of false lumen. It requires long-term observation to judge the effect for aortic remodeling.

Progression from stenosis to occlusion in the proximal native coronary artery after coronary artery bypass grafting.

Coronary artery bypass grafting (CABG) is an established treatment for multivessel coronary artery disease. However, problematic situations are occasionally encountered after CABG, such as disease progression in the native coronary artery with graft occlusion, which causes difficulty in revascularization. The purpose of this study was to evaluate changes in the native coronary artery after CABG. Between 2009 and 2012 in our institution, 351 patients underwent CABG, and 768 bypass grafts were anastomosed to non-occluded coronary arteries. Of these, 489 bypass grafts had available early postoperative angiographic results (≤6 months) suitable for assessment in this study. We defined malignant graft failure after CABG to be bypass graft occlusion and de novo complete occlusion of the target native coronary artery proximal to the graft anastomosis site. In the early angiographic results, 17 grafts were occluded (17/489; 3.5 %). Two of the grafts displayed malignant graft failure (a saphenous vein graft to the right coronary artery and a saphenous vein graft to the diagonal branch) (2 of 17 occluded grafts, and 2 of 489 studied grafts). Of the patent bypass grafts, 24 involved progression to occlusion in the proximal native coronary artery (19 saphenous vein grafts, 4 left internal thoracic artery grafts, and 1 right internal thoracic artery graft). Malignant graft failure was uncommon during short-term follow-up after CABG. At the same time, disease progression in the proximal native coronary artery from stenosis to occlusion following patent bypass grafting was relatively common, especially for vein grafts.

Glioblastoma Multiforme Developed during Chronic Deep Brain Stimulation for Parkinson Disease.

BACKGROUND: In this reported case, 7 years after the start of deep brain stimulation (DBS) of the bilateral subthalamic nucleus (STN), glioblastoma multiforme (GBM) developed around the implanted DBS lead. CASE REPORT: The brain tumor formed from the subcortical white matter to the corpus callosum bilaterally around the DBS lead but did not extend in the direction of the contact points of the lead. The GBM showed a typical invasion pattern of the butterfly type. We report the first case of GBM that developed 7 years after the start of STN-DBS. CONCLUSION: Considering the low rate of GBM occurrence in association with DBS, the location of the glioma, and the pattern of tumor invasion, we speculate that GBM developed spontaneously and extended to some degree around the DBS lead. Moreover, there is a very slight possibility that continuous electrical brain stimulation itself induced the development of the brain glioma.

The long-term results and changing patterns of biological valves at the mitral position in contemporary practice in Japan.

Mitral valve surgery has changed with the wide acceptance of mitral valve repair. The aim of this study is to obtain the long-term results of patients who underwent mitral valve replacement (MVR) using a biological prosthesis in contemporary practice in Japan. From January 1990 to December 2013, 76 patients underwent MVR using a biological prosthesis with or without concomitant surgery. Data were obtained by means of a questionnaire and a telephone interview. The mean follow-up period was 4.26 years. The etiologies of the patients included dilated cardiomyopathy (DCM) (n=20 [26.3%]), ischemic mitral regurgitation (n=7 [9.2%]). There is a trend towards decreasing number of rheumatic and degenerative disease and increasing number of DCM and ischemic mitral regurgitation. Three patients (3.9%) died in the perioperative period. The 5- and 10-year overall survival rates were 69.6% and 31.7%, respectively. The 5- and 10-year freedom from valve related death were 95.6% and 80.6 %, respectively. The linearized rates of valve-related complications were as follows: thromboembolism (0.63%/patient/year), bleeding (1.25%/patient/year). One patient underwent reoperation for structural degeneration 13 years after the first operation. The present study shows the long-term results of mitral valve replacement with bioproshtesis in a contemporary case series. The practice pattern is changing. The low rate of valve-related complication justify the current patient selection.

Importance of Pharmacological Evaluation in the Treatment of Poststroke Pain by Spinal Cord Stimulation.

OBJECTIVES: Spinal cord stimulation (SCS) is not typically recommended for the treatment of central poststroke pain (CPSP). We examined whether the pharmacological evaluation of CPSP is useful for selecting the candidates for SCS. MATERIALS AND METHODS: Changes in visual analog scale (VAS) scores for pain following pharmacological evaluation using morphine, thiopental, and ketamine were compared with those following SCS in 22 CPSP patients. RESULTS: Twelve of the 22 (54.5%) patients in the ketamine test and thiopental test, and 5 (22.7%) of the 22 patients in the morphine test showed a more than 40% reduction in VAS score and were judged as "sensitive." Pain relief by SCS was estimated as excellent (≧60% VAS score reduction) in three patients, good (30-59% reduction) in nine patients, and fair (10-29% reduction) in seven patients 24 months after the start of SCS. The remaining 3 patients evaluated as having poor pain relief (<10% reduction) only underwent test SCS. VAS score reduction induced by SCS was more significant in ketamine-sensitive patients than in ketamine-resistant patients during the test SCS (p < 0.01, Mann-Whitney's U test) and 24 months after the start of chronic SCS (p < 0.05). However, there were no significant differences in results for thiopental-sensitive/thiopental-resistant or morphine-sensitive/morphine-resistant patients during the test SCS and 24 months after chronic SCS. Analysis of the rate of VAS score reduction by pharmacological evaluation and SCS showed significant correlations with the results of the ketamine test (r = 0.670, p = 0.001, Pearson's correlation coefficient test), but not with those of the thiopental (r = 0.291, p = 0.231) or morphine test (r = 0.327, p = 0.175). CONCLUSION: We speculate that the pharmacological evaluation of CPSP patients can be a useful tool for selecting candidates for SCS.

[Aortic Valve Replacement of Quadricuspid Valve with Regurgitation].

Congenital quadricuspid aortic valve is a very rare malformation. In most cases it has been found incidentally at aortic valve surgery or at autopsy. It frequently causes aortic regurgitation, which may become manifest in adulthood and require surgical treatment. We reported 4 cases of aortic regurgitation with quadricuspid aortic valve. In all cases, aortic valve replacement was preformed with prosthetic valve, and their postoperative courses were uneventful. Two were Hurwitz's classification type b, one was type a and the last patient was type c. Although quadricuspid aortic valve is a rare anomaly, its potential for severe valve failure in adulthood should be kept in mind.