[A case of infected subdural hematoma accompanied by cerebral infarction].

Infected subdural hematoma(ISH)is a rare disease caused by hematogenous infection of a preexisting subdural hematoma. We report a rare case of ISH accompanied by cerebral infarction. A 76-year-old man who had suffered a closed head injury 3 months before presented fever, headache and left hemiparesis during the medical treatment of acute cholangitis and obstructive jaundice with pancreatic cancer at the department of surgical gastroenterology. At the consultation, computed tomography(CT)scan indicated right chronic subdural hematoma. We performed a burr hole opening surgery on the same day. Abscess and hematoma was aspirated from the subdural space, and methicillin-resistant Staphylococcus aureus(MRSA)was detected in this specimen. Thus the diagnosis of the infected subdural hematoma was confirmed. However, despite the antibiotics therapy, follow-up CT showed a low-density area close to the residual abscess, which suggested cerebral infarction. Cerebral angiography showed a vasospasm at the cortical segment of the right middle cerebral artery near the residual abscess. Eventually we carried out a small craniotomy to evacuate the abscess. Our case showed that prompt surgical treatment is required in case of ISH and the whole hematoma and abscess should be removed as soon as possible with an image diagnosis and an additional surgical operation.

[Characteristics and treatment of dural and perimedullary arteriovenous fistula at the craniocervical junction presenting with subarachnoid hemorrhage].

Dural and perimedullary arteriovenous fistula (AVF) at the craniocervical junction tend to cause subarachnoid hemorrhage (SAH). However, their natural history and clinical manifestations still remain to be elucidated. From 2003 to 2009, we encountered 5 cases of dural and perimedullary AVF presented with SAH. They were all male, ranging in age from 53 to 85 year-old (mean: 68 year-old). Rebleeding occurred in 1 patient on day 11. Outcome estimated by modified Rankin Scale did not change remarkably from 2.6 on admission to 2.4 at 3 months later on average. Cerebral angiography and 3D-CT angiography disclosed feeders originating from radicular or intracranial vertebral arteries which drained into the epidural venous plexus or spinal meningeal veins. One patient died of systemic complication during his clinical course. Thus we performed open surgery in the remaining 4 patients. Of these, we failed to occlude feeders completely in the initial surgery without intraoperative digital subtraction angiography (DSA) in 2 patients. Following this treatment we performed coil embolization and repeated open surgery with the aid of intraoperative DSA, respectively. In 1 patient out of the remaining 2 patients, we utilized intraoperative DSA to confirm complete disappearance of AVF composed of multiple feeders. These observations show that SAH caused by dural and perimedullary AVF at the craniocervical junction should be mainly treated by open surgery with the aid of intraoperative DSA in order to accomplish obliteration of the feeders because, otherwise, we might fail to confirm complete disappearance of AVF.

Bailout Technique for Coil Unraveling with a KUSABI Exchange Catheter: A Case Report.

Objective: Coil unraveling is a rare, yet dangerous complication of endovascular coiling. In this study, we report a patient in whom an intraoperatively unraveled coil was successfully retrieved using a KUSABI exchange catheter, which is used in the field of cardiovascular medicine to facilitate catheter exchange in coronary interventions. Case Presentation: The patient was a 90-year-old woman. To treat an unruptured aneurysm of the right internal carotid artery, endovascular coil embolization was performed. During the filling step, the coil started to unravel. Early attempts to retrieve the unraveled coil using a microsnare were complicated when the ensnared part broke off during the process. The broken tip of the unraveled coil was maneuvered inside the guiding catheter, after which a KUSABI catheter was inflated inside the guiding catheter to press and immobilize the unraveled coil against its inner lumen. This fragment of the unraveled coil was extricated from the patient by retracting the entire guiding catheter assembly. We guided a microsnare along the remaining unraveled coil to capture the intact part of the coil, and eventually retrieval was successful. Conclusion: To our knowledge, no study has reported retrieval with a KUSABI trapping balloon catheter for the management of coil unraveling. However, this method is considered effective. We report this case and review the literature.

Importance of the initial grade of subarachnoid hemorrhage in the patients with the age of 80 years and older from a single center analysis.

In the developed countries, especially Japan, elderly population is rapidly increasing, but outcomes of elderly patients with the age of 80 years and older suffering from subarachnoid hemorrhage (SAH) remain still unclear. We retrospectively reviewed the medical records of nontraumatic SAH patients aged 80 years and older, who were hospitalized in a single center between 1998 and 2009. There were 28 patients (80-90 years old and 75% female), representing 5.9% of all non-traumatic SAHs (n = 474). Of those, 16 patients received an intervention (ten clipping and six endovascular coiling) and the remaining 12 patients were managed conservatively. The median survival time of intervention group was 110 days and that of conservative group 49 days (p = 0.12, log rank analysis). Cox's proportional hazards model yielded two variables, the Japan Coma Scale (JCS) grade on admission ( hazard ratio: 2.93 [p = 0.009]) and conservative treatment (hazard ratio: 2.14 [p = 0.054]). In the outcome of the modified Rankin Scale between these two groups, logistic regression analysis had significant variable; the JCS grade on admission (odds ratio: 280, [p = 0.020]). In the elderly patients with good initial clinical condition, an acute intervention may have good outcome.