Endovascular therapy for hemodialysis patients with atrial fibrillation and cerebral thromboembolism: A case series.

INTRODUCTION: Hemodialysis patients with atrial fibrillation are at high risk for stroke. Intravenous recombinant tissue plasminogen activator is considered for acute ischemic stroke. However, recombinant tissue plasminogen activator therapy is contraindicated for some hemodialysis patients with atrial fibrillation. These patients and those who have received recombinant tissue plasminogen activator therapy without blood flow recovery are candidates for endovascular therapy. METHODS AND RESULTS: Three hemodialysis patients with atrial fibrillation received endovascular therapy for acute cerebral infarction. Cerebrovascular incident occurred during or after hemodialysis in two of these patients. All three patients achieved successful recanalization after endovascular therapy. CONCLUSION: In this series, endovascular therapy showed good results without complications. More cases should be investigated to obtain more evidence of successful endovascular therapy for hemodialysis patients.

Endovascular reconstruction for a kinked internal carotid artery after carotid endarterectomy.

BACKGROUND: Although different surgical techniques have been reported for repairing kinked stenosis of the internal carotid artery (ICA) after carotid endarterectomy (CEA), there are no reports using endovascular reconstruction. We present the details of a case successfully treated by carotid artery stenting (CAS). CASE DESCRIPTION: A 73-year-old female was referred to our department with fugacious amaurosis and transient sensory disturbance in the left upper limb due to moderate stenosis of the right ICA that was treated by CEA 28 days after admission. However, postoperative angiography and carotid Doppler revealed a kinked ICA with a high-flow velocity that was not present intraoperatively. After 3 months, she had suffered transient ischemic attacks that were refractory to medical treatment, so we performed CAS to prevent future events. The kinked ICA was immediately resolved by stenting and there was no restenosis at a follow-up angiogram 19 months later. CONCLUSIONS: This case shows that CAS could be a potential therapeutic option for the management of symptomatic kinking stenosis of the ICA after CEA.

Successful sinus restoration for transverse-sigmoid sinus dural arteriovenous fistula complicated by multiple venous sinus occlusions: The usefulness of preoperative computed tomography venography.

BACKGROUND: Although sinus restoration for transverse-sigmoid sinus (TSS) dural arteriovenous fistula (DAVF) has rarely been reported over the past decade, its advantage and indication still remain unclear. Herein, we discuss the indications and technical aspects of this therapy with a review of the literature. CASE DESCRIPTION: A 79-year-old female was referred to our department with generalized convulsion. An angiogram revealed a DAVF at the junction of the right TSS. The right sigmoid and left transverse sinuses were occluded, which resulted in remarkable leptomeningeal venous reflux and cerebral venous congestion. A preoperative computed tomography (CT) venogram precisely revealed the occluded segment of the right sigmoid sinus, which facilitated the sinus restoration with balloon percutaneous transluminal angioplasty and stenting. CONCLUSION: Sinus restoration is preferable in patients with severe cerebral venous congestion due to multiple sinus occlusions and/or a restricted collateral venous outlet. CT venography is useful for precise evaluation of the length and configuration of the occluded segment, which thus make it possible to evaluate the feasibility of stenting.

Evaluation of the pharmacokinetics of linezolid in an obese Japanese patient.

We evaluated the pharmacokinetics of linezolid in the case of an obese Japanese patient (body weight 116 kg; body mass index 37 kg/m(2)). Linezolid was administered at a dose of 600 mg by intravenous drip infusion for 60-90 min at 12-h intervals. The results showed increased clearance of linezolid and a reduced serum concentration compared to population pharmacokinetic parameters, with trough levels below the 90% minimum inhibitory concentration. However, linezolid was effective for improving lung infection and inflammation in our patient, which may be due to its particularly effective transfer into lung tissues. Linezolid undergoes slow non-enzymatic oxidation in vivo that may be increased in obese patients, and this may account for the greater clearance. Our findings are useful for the planning of linezolid therapy in obese patients.

Pharmacokinetics and protein binding of linezolid in cerebrospinal fluid and serum in a case of post-neurosurgical bacterial meningitis.

We describe a case of bacterial meningitis in a patient administered linezolid (LZD). The ratio of free to total LZD concentrations in cerebrospinal fluid (CSF) was 1 for all measurements, and the LZD concentration in CSF measured at the trough level was almost the same as the free serum concentration.

[Treatment of unruptured saccular vertebral artery aneurysm for preservation of the parent artery for advanced age people: a case report].

A 79-year-old female was referred to our hospital presenting with occipital headache. Her unruptured aneurysm was incidentally found by magnetic resonance angiography. Three dimensional computed tomographic angiography showed a saccular aneurysm located at the junction of the left vertebral artery (VA) and posterior inferior cerebellar artery (PICA) that originated from the aneurysm itself. Firstly, surgical clipping of the left PICA just distal to the aneurysm and occipital artery (OA)-PICA bypass was carried out and, secondly, endovascular treatment was performed for preservation of the parent artery.

Primary yolk sac tumor within the lateral ventricle.

A 13-year-old girl presented with an exceedingly rare case of primary yolk sac tumor located within the lateral ventricle, manifesting as headache, nausea, and diplopia. Magnetic resonance imaging revealed a 4-cm-diameter solid enhanced mass within the left inferior horn of the lateral ventricle. The tumor was removed subtotally via left middle temporal corticotomy. The histological and immunohistochemical diagnosis was pure yolk sac tumor. The serum alpha-fetoprotein (AFP) level was elevated at 1957.2 ng/ml and the serum beta-human chorionic gonadotropin level was 4 mIU/ml after surgery. The patient underwent radiotherapy (whole brain, 30 Gy; tumor bed, 21 Gy; whole spinal axis, 30 Gy) and chemotherapy (ifosfamide, cisplatin, etoposide). After three treatment cycles, the serum AFP level had decreased to 4.5 ng/ml. However, the tumor recurred with cerebrospinal fluid dissemination after nine cycles of chemotherapy. She died 18 months after surgery. The possibility of germ cell tumor should be considered in pediatric patients with brain tumors occurring outside the pineal or suprasellar region.

Quantitative assessment of gliomas by proton magnetic resonance spectroscopy.

BACKGROUND: Advanced magnetic resonance (MR) techniques provide physiological and metabolic information that complements the anatomical information available from conventional MR imaging. The purpose of this study was to evaluate the clinical usefulness of proton MR spectroscopy (1H-MRS) in preoperative quantitative assessment of intracranial gliomas. PATIENTS AND METHODS: Eight patients with histologically verified gliomas, comprising 2 cases with glioblastoma multiforme (GBM, grade 4), 5 cases with anaplastic oligodendroglioma (AO, grade 3; high-grade glioma), and 1 case with fibrillary astrocytoma (FA, grade 2; low-grade glioma) were evaluated using the 1H-MRS protocol following conventional MR imaging, diffusion-weighted imaging (DWI), and perfusion-weighted imaging (PWI) preoperatively. RESULTS: High-grade gliomas tended to demonstrate signal hyperintensity by DWI and higher relative cerebral blood volume (rCBV) by PWI. Increased ratios of choline (Cho) to N-acetylaspartate (NAA) (Cho/NAA) and Cho to creatine (Cr) (Cho/Cr) correlated highly with tumor malignancy. The presence of lactate and lipid was predominately detected in patients with high-grade glioma. CONCLUSION: The combination of multiple MR parameters, based on DWI, PWI and 1H-MRS, appears valuable for preoperatively predicting the degree of malignancy in glioma.

[Ruptured aneurysm of distal posterior inferior cerebellar artery located at caudal loop].

We report an unusual case of subarachnoid hemorrhage (SAH) due to ruptured aneurysm originating at the caudal loop of posterior inferior cerebellar artery (PICA). The patient was a 77-year-old female presented with a sudden onset of headache and vomiting. Initial CT scan demonstrated a SAH with thick hematoma mainly in the cisterna magna. Vertebral angiogram revealed a saccular aneurysm arising from the tonsillomedullary segment of the left PICA, and communicating artery with supplying a territory of contralateral vermis as an anastmotic vessel. At surgery, no vessel branches were confirmed in the vicinity of the aneurysm, and this aneurysm was successfully clipped. In the fetus, numerous basilar and vertebral arteries are organized in plexiform formations around the brain stem. It has been suggested that the pathogenesis of such aneurysm or communicating artery could be related with a remnant of a primitive vertebrobasilar anastomosis. Based on these considerations, congenital vessel-wall weakness and hemodynamic stress associated with communicating artery may contribute to the development of distal PICA aneurysms.

[Ruptured aneurysm of distal posterior inferior cerebellar artery located at caudal loop].

We report an unusual case of subarachnoid hemorrhage (SAH) due to ruptured aneurysm originating at the caudal loop of posterior inferior cerebellar artery (PICA). The patient was a 77-year-old female presented with a sudden onset of headache and vomiting. Initial CT scan demonstrated a SAH with thick hematoma mainly in the cisterna magna. Vertebral angiogram revealed a saccular aneurysm arising from the tonsillomedullary segment of the left PICA, and communicating artery with supplying a territory of contralateral vermis as an anastmotic vessel. At surgery, no vessel branches were confirmed in the vicinity of the aneurysm, and this aneurysm was successfully clipped. In the fetus, numerous basilar and vertebral arteries are organized in plexiform formations around the brain stem. It has been suggested that the pathogenesis of such aneurysm or communicating artery could be related with a remnant of a primitive vertebrobasilar anastomosis. Based on these considerations, congenital vessel-wall weakness and hemodynamic stress associated with communicating artery may contribute to the development of distal PICA aneurysms.