Endoscopic hematoma evacuation for acute subdural hematoma with improvement of the visibility of the subdural space and postoperative management using an intracranial pressure sensor.

Background: The first choice to treat acute subdural hematoma (ASDH) is large craniotomy under general anesthesia. However, increasing age or the comorbid burden of patients may render invasive treatment strategy inappropriate. These medically frail patients with ASDH may benefit from a combination of small craniotomy and endoscopic hematoma removal, which is less invasive. We proposed covering with protective sheets to prevent brain injury due to contact with the endoscope and suction cannula and improve visualization of the subdural space. Moreover, we placed an intracranial pressure (ICP) sensor after endoscopic hematoma removal. In this article, we attempted to clarify the use of small craniotomy evacuation with endoscopy for ASDH. Methods: Between January 2015 and December 2019, nine patients with ASDH underwent hematoma evacuation with endoscopy at our hospital. ASDH was removed using a suction tube with the aid of a rigid endoscope through the small craniotomy (5-6 cm). Improvement of the clinical symptoms and procedure-related complications was evaluated. Results: No procedure-related hemorrhagic complications were observed. The outcomes of our endoscopic surgery were satisfactory without complications or rebleeding. The outcomes were not inferior to those of other reported endoscopic surgeries. Conclusion: The results suggest that small craniotomy evacuation with endoscopy and postoperative management using an ICP sensor is a safe, effective, and minimally invasive treatment approach for ASDH in appropriately selected cases.

Incidence of radiculopathy following lumboperitoneal shunt placement without fluoroscopy for normal pressure hydrocephalus.

Background: Spinal catheter insertion in lumboperitoneal shunt (LPS) surgery for normal pressure hydrocephalus (NPH) can result in radiculopathy due to mechanical irritation of the nerve roots of the cauda equina. Here, we analyzed the position of LPS shunts placed without portable fluoroscopy in 72 patients, a subset of whom developed postoperative radiculopathy. Methods: We retrospectively analyzed how frequently 72 consecutive NPH patients experienced radiculopathy following LPS catheter placement performed without intraoperative fluoroscopy. Results: The rate of incorrect catheter placement was 15.3% (11/72 cases). We observed that is, downward placement in 6.9% (5/72 cases), hyperflexion in 6.9% (5/72 cases), and subcutaneous migration in 1.4% (1/72 cases) patients. One patient with initial correct LPS placement developed radicular pain 5-day postoperatively attributed to 1-cm of catheter movement; they recovered simply by utilizing oral analgesics for 1-month duration. Conclusion: LPS insertion without fluoroscopic guidance resulted in a 15.3% risk of spinal catheter displacement. We suggest, therefore, that intraoperative imaging guidance be utilized for the placement of LPS in patients with NPH and/or for other pathology to avoid the 15.3% risk of postoperative radiculopathy.

Rapid Change in Shape of Unruptured Intracranial Aneurysm with Acute Perforating Infarction.

Acute ischemic stroke is a rare complication resulting from an unruptured intracranial aneurysm (UIA). Ischemic stroke adjacent to the aneurysms is considered the risk of rupture of aneurysms. However, there is presently no consensus on the optimal strategy for the management of UIAs with ischemic stroke. A 27-year-old woman presented with sudden onset left hemiparesis. Acute infarction of the right basal ganglia and an aneurysm of the right middle cerebral artery were discovered on brain imaging. Antiplatelet therapy was used to treat her. The diagnosis revealed ischemic stroke caused by a thrombosed aneurysm due to the change in the shape of the aneurysm on day 4. The UIA clipping procedure was performed on day 21 due to the risk of subarachnoid hemorrhage (SAH). The findings of the surgery and indocyanine green imaging revealed a partially thrombosed aneurysm and occlusion of a perforating artery. As is well known, enlargement of aneurysm size indicates increasing rupture risk. In the present case, after ischemic events developed, magnetic resonance angiography revealed enlargement of the aneurysm. The findings of the surgery revealed possible pathogenic mechanisms were perforating artery occlusion due to local extension of the luminal thrombus. Clinicians should be aware of the risk of ischemic stroke due to luminal thrombosis of the UIA and SAH and should consider urgent treatment of the UIA even immediately after ischemic stroke.

[A case of swallow syncope associated with Parkinson disease].

A 73-year-old woman with Parkinson disease (PD) was admitted to our hospital because of aspiration pneumonia. She presented with recurrent episodes of loss of consciousness with bradycardia while swallowing solid foods or fluids. Upper endoscopy revealed a normal esophagus without hiatus hernia, cancer, diverticulum, stenosis, or achalasia. Balloon inflation at the cervical esophagus induced sinus arrest and bradycardia followed by a loss of consciousness. The diagnosis of swallow syncope (SS) was confirmed. Esophageal dilatation and an increase in the esophageal pressure induced by esophageal peristaltic disturbance associated with PD can cause SS by stimulating the vagal reflex. In addition, the head-up tilt test showed that she had orthostatic hypotension, and the coefficients of variations of the R-R intervals on electrocardiograms and the total number of beat-to-beat differences greater than 50 mseconds in the RR interval during a 24 hour ambulatory electrocardiogram were normal. The cardiovascular autonomic dysfunction characterized by the presence of sympathetic inhibition and a preserved parasympathetic function might be involved in the onset of SS. Permanent pacemaker implantation improved her clinical symptoms. The recognition of SS on the examination of a PD patient with loss of consciousness while eating is important, as PD patients might develop SS due to peristaltic disturbance and autonomic dysfunction caused by PD.

Left Adrenal Tumor Disappeared Outside a Field of Vision During Laparoscopic Surgery: The True Identity Was Gastrointestinal Stromal Tumor.

Background: We report a case of gastrointestinal stromal tumor (GIST) mimicking a left adrenal tumor. Case Presentation: A 62-year-old female was referred to our hospital for the treatment of left adrenal tumor of 2.8 × 2.3 cm incidentally found during her annual checkup. The preoperative diagnosis based on upper gastroscopy and imaging complete examinations was nonfunctional left adrenal tumor possessing malignant potential. Transperitoneal laparoscopic left adrenalectomy was performed. However, the tumor was not found in the excised adrenal gland that had been completely removed during surgery. Repeat computed tomography revealed the presence of the same tumor. Finally, reoperation led us to the true diagnosis of GIST. Conclusion: Many urologists are not familiar with GIST. It is necessary to take GIST into consideration when left adrenal tumor close to the stomach is diagnosed. We discuss the traps which we fell into during the perioperative period in this case.

Modified Gas Chromatographic Method to Determine Monoacylglycerol and Diacylglycerol Contents in Edible Fats and Oils.

Monoacylglycerol (MAG) and diacylglycerol (DAG) are minor components of edible fats and oils, and they relate to the quality of these foods. The AOCS official method Cd 11b-91 has been used to determine MAG and DAG contents in fats and oils. There are, however, difficulties in the determination of MAG and DAG using this analytical procedure. Therefore, we improved this method by modifying the trimethylsilyl derivatization procedure and replacing the internal standard (IS) material. In our modified method, TMS-HT (mixture of hexamethyldisilazane and trimethylchlorosilane) was used for derivatization of MAG and DAG, which was followed by liquid-liquid extraction with water and n-hexane solution containing the IS, tricaprin. Using the modified method, we demonstrated superior repeatability in comparison with that of the AOCS method by reducing procedural difficulties. The relative standard deviation of distearin peak areas was 1.8% or 2.9% in the modified method, while it was 5.6% in the AOCS method. In addition, capillary columns, such as DB-1ht and DB-5ht could be used in this method.

Novel antioxidant capacity assay for lipophilic compounds using electron paramagnetic resonance spectroscopy.

A novel antioxidant capacity assay for lipophilic compounds was developed using electron paramagnetic resonance (EPR) spectroscopy. The assay is based on antioxidant's scavenging ability against the tert-butoxyl radical generated photolytically from di-tert-butyl peroxide in ethyl acetate, and named the tert-butoxyl-based antioxidant capacity (BAC) assay. The radical was trapped by spin trap, 5,5-dimethyl-1-pyrroline-N-oxide, and EPR signal intensity of the spin adduct was used as a quantitative marker of radical levels. Signal intensity decreased in a dose-dependent manner in the presence of an antioxidant that competitively reacts with the radical, which was utilized to evaluate BAC values. The BAC method enabled the accurate estimation of antioxidant capacity for lipophilic materials that may counteract lipid peroxidation in biological membranes. The BAC values for quercetin and caffeic acid are 0.639 ± 0.020 and 0.118 ± 0.012 trolox equivalents, respectively, which are much smaller than values obtained by other aqueous methods such as H-ORAC and ORAC-EPR. Thus, antioxidants present in a non-aqueous environment should be evaluated using a non-aqueous system. In combination with in situ ascorbate reduction, the BAC method was capable of accurately determining the antioxidant capacity of water-insoluble materials that may be reduced in living cells.

Clear cell adenocarcinoma arising from abdominal wall endometriosis mimicking urachal tumor.

A 41-year-old woman presented with severe lower abdominal pain. She had a history of 2 cesarean deliveries. Magnetic resonance imaging (MRI) revealed a 4.3 × 4.6 × 4.8-cm mass on the urinary bladder dome. Preoperative diagnosis was invasive urachal tumor. Wide resection of the tumor was performed. The histopathological diagnosis was clear cell adenocarcinoma with endometriosis. MRI revealed normal-sized ovaries and uterus. The definite diagnosis of clear cell carcinoma arising from abdominal wall endometriosis was made. Adjuvant chemotherapy with paclitaxel and carboplatin (total 6 courses) was planned. The patient has thus far received 4 courses of this treatment.

Novel pre-fractionation method of trans fatty acids by gas chromatography with silver-ion cartridge column.

We developed a novel pre-separation method of trans fatty acids (TFAs) using a silver-ion cartridge column and GC. As a preliminary study, a mixture of fatty acid methyl esters consisting of saturated, cis-unsaturated, and trans-unsaturated fatty acids was dissolved in dichloromethane and loaded onto a Bond Elut SCX ion-exchange cartridge column that was converted to the silver-ion form. The column was then eluted with dichloromethane to obtain the saturated fatty acids, dichloromethane/ethyl acetate (90/10) for the trans mono-ene, dichloromethane/ethyl acetate (65/35) for the cis mono-ene, dichloromethane/acetone (60/40) for the trans di-ene, and acetone/acetonitrile (80/20) for the others. Satisfactory separation of the cis/trans isomers was confirmed by GC analysis. To generalize this technique, the elution conditions of the ready-to-use Discovery Ag-ION SPE cartridge column were also optimized. Both cartridge columns had good separation, recovery, and repeatability. Peer laboratory verification was carried out between two laboratories using different production lots of the ready-to-use cartridge column, and the robustness of the product and reproducibility of the method were found to be satisfactory. This technique is therefore a powerful tool not only for routine analyses of TFAs in oils, fats, and foods but also for detailed analyses of TFAs in various research fields.

Preoperative diagnosis of congenital segmental giant megaureter presenting as a fetal abdominal mass.

We describe a case of congenital segmental giant megaureter in a boy that presented as a fetal abdominal mass. He also had bilateral undescended testes, bilateral vesicoureteral reflux, and segmental aniridia. He presented with hypoglycemia in the neonatal period that resolved. Postnatal magnetic resonance imaging, voiding cystourethrography and radionuclide imaging established the diagnosis, and a ureteroureterostomy was performed at 12 months.

Orally tolerized T cells can form conjugates with APCs but are defective in immunological synapse formation.

Oral tolerance is systemic immune hyporesponsiveness induced by the oral administration of soluble Ags. Hyporesponsiveness of Ag-specific CD4 T cells is responsible for this phenomenon. However, the molecular mechanisms underlying the hyporesponsive state of these T cells are not fully understood. In the present study, we investigated the ability of orally tolerized T cells to form conjugates with Ag-bearing APCs and to translocate TCR, protein kinase C-theta (PKC-theta), and lipid rafts into the interface between T cells and APCs. Orally tolerized T cells were prepared from the spleens of OVA-fed DO11.10 mice. Interestingly, the orally tolerized T cells did not show any impairment in the formation of conjugates with APCs. The conjugates were formed in a LFA-1-dependent manner. Upon antigenic stimulation, the tolerized T cells could indeed activate Rap1, which is critical for LFA-1 activation and thus cell adhesion. However, orally tolerized T cells showed defects in the translocation of TCR, PKC-theta, and lipid rafts into the interface between T cells and APCs. Translocation of TCR and PKC-theta to lipid raft fractions upon antigenic stimulation was also impaired in the tolerized T cells. Ag-induced activation of Vav, Rac1, and cdc42, which are essential for immunological synapse and raft aggregation, were down-regulated in orally tolerized T cells. These results demonstrate that orally tolerized T cells can respond to specific Ags in terms of conjugate formation but not with appropriate immunological synapse formation. This may account for the hyporesponsive state of orally tolerized T cells.

Selective adsorption of human CD4 T cells.

The pathogenesis of most autoimmune diseases directly involves CD4(+) helper T cells. To remove CD4(+) T cells selectively from the circulation, we designed a new column in which an anti-CD4 monoclonal antibody was immobilized on the activated substance. Nearly 90% of CD4(+) T cells were selectively adsorbed from whole blood with a single passage through the column in vitro, resulting in depletion of the antigen-specific T cell responses. We conclude that this new column would be potentially useful for treatment of T cell-mediated autoimmune diseases.

Cytapheresis with a filter for selective removal of CD4+ T cells in experimental autoimmune encephalomyelitis.

Experimental autoimmune encephalomyelitis (EAE) is a major animal model of human multiple sclerosis (MS). CD4+ T cells are thought to play a pivotal role in the pathogenesis of EAE and MS. In order to investigate the depletion of CD4+ T cells from the systemic circulation as an effective strategy for the treatment of MS, we performed extracorporeal CD4+ T cell adsorption, using a filter to which anti-CD4+ antibody is immobilized as a ligand, in adoptively transferred EAE. Rats treated with CD4+ T cell removal filter (CD4RF) exhibited milder clinical signs of EAE and earlier recovery than those receiving sham treatment. Moreover, the thymic cells from EAE rats treated with CD4RF exhibited a suppressed proliferative response and IFN-gamma production to myelin basic protein. These results suggest that depletion of CD4+ T cells from the systemic circulation by extracorporeal treatment is a potentially useful strategy for treatment of acute phase and relapsing MS.

X-linked motor and sensory neuropathy with pyramidal signs and cerebral white matter lesions.

We report two brothers with hereditary motor and sensory neuropathies and pyramidal signs. Electrophysiological evaluation revealed polyneuropathy and involvement of the central motor, somatosensory, and auditory pathways. Brain magnetic resonance imaging studies showed diffuse white matter lesions, and sural nerve biopsy identified a reduction in the large myelinated nerve fibers. The patients' mother and sister exhibited similar, but milder neurologic findings suggesting that the genetic defect may be X-linked; however, a point mutation in the connexin 32 gene was negative.