A growing aneurysm of the posterior inferior cerebellar artery complicated with cerebellar infarction: A case report.

INTRODUCTION AND IMPORTANCE: Hereby we describe an instructive patient with cerebellar infarction and a growing aneurysm at the posterior inferior cerebellar artery (PICA), which was not a true cause of infarction. CASE PRESENTATION: A 50-year-old female presented with dizziness and posterior neck pain at our hospital (Mitaka city, Tokyo, Japan). Diffusion weighted magnetic resonance (MR) images showed cerebellar infarction in the left PICA territory and MR angiography study showed an aneurysm at the origin of the left PICA, which grew in 2 weeks. Since we considered cerebellar infarction was caused by thrombosis from the aneurysm, trapping of the PICA and occipital artery-PICA bypass was performed to prevent recurrent cerebellar infarction and rupture of the aneurysm by neurosurgeons. During the operation, dissection was observed at the distal PICA, which was diagnosed to be the true cause of cerebellar infarction. By the follow-up for 12 months at an outpatient, there was no recurrence of cerebral infarction. CLINICAL DISCUSSION: A specimen of the artery showing the findings of dissection was not obtained, and the pathological diagnosis could not be made. It would be controversial whether a surgical procedure presented here was the most optimal. CONCLUSION: This is a first reported case of growing aneurysms and cerebral infarction due to arterial dissection. Even if cerebral infarction is accompanied by growing aneurysms, arterial dissection should be included in the differential diagnoses of a cause of infarction. Posterior cervical pain can be a clue for early appropriate diagnosis in such a case.

Successful endovascular recanalization of massive cerebral venous sinus thrombosis in a patient with tuberous sclerosis and protein S deficiency: a case report.

Here, we report the case of a 27-year-old woman with tuberous sclerosis complex who underwent successful endovascular intervention for cerebral venous thrombosis at the superior sagittal sinus. She had protein S deficiency and a long-term history of anemia caused by menorrhagia from uterine fibroids, possibly leading to a hypercoagulable state. Cerebral venous sinus thrombosis accounts for ~0.5-1% of all strokes. Several cases of venous thrombosis in patients with tuberous sclerosis complex and protein S or protein C deficiency have been reported, but further studies are needed to identify whether an association of this rare combination may be explained.

Detailed standardized protocol to prevent cerebrospinal fluid shunt infection.

OBJECTIVE: While cerebrospinal fluid (CSF) shunt surgery plays an essential role in the treatment of hydrocephalus, postoperative infection due to the implantation of foreign materials is still one of the most common and potentially serious complications of this procedure. Because no previously reported protocol has been proven to prevent postoperative infection after CSF shunt surgeries in adults, the authors investigated the effectiveness of a protocol introduced in their institution. METHODS: A detailed standardized surgical protocol to prevent infection in patients undergoing CSF shunt surgeries was introduced in the authors' institution in December 2011. The protocol included a series of detailed rules regarding the surgical procedure, the surgical environment to minimize contamination from air, double gloving, local injection of antibiotics, and postoperative management. The rate of CSF shunt infection during the 3 years after surgery before and after implementation of the protocol was compared in patients undergoing their first CSF shunt surgeries. The inclusion periods were from January 2006 to November 2011 for the preprotocol group and from December 2011 to December 2014 for the postprotocol group. RESULTS: The study included 124 preprotocol patients and 52 postprotocol patients. The mean patient age was 59 years in both groups, ranging from 40 days to 88 years. Comparison of patient background factors, including known risk factors for surgical site infections, showed no significant difference between the patient groups before and after implementation of the protocol. While 9 patients (7.3%) developed shunt infections before protocol implementation, no shunt infections (0%) were observed in patients who underwent surgery after protocol implementation. The difference was statistically significant (p = 0.047). CONCLUSIONS: The authors' detailed protocol for CSF shunt surgeries was effective in preventing postoperative infection regardless of patient age.

An extracellular [NiFe] hydrogenase mediating iron corrosion is encoded in a genetically unstable genomic island in Methanococcus maripaludis.

Certain methanogens deteriorate steel surfaces through a process called microbiologically influenced corrosion (MIC). However, the mechanisms of MIC, whereby methanogens oxidize zerovalent iron (Fe0), are largely unknown. In this study, Fe0-corroding Methanococcus maripaludis strain OS7 and its derivative (strain OS7mut1) defective in Fe0-corroding activity were isolated. Genomic analysis of these strains demonstrated that the strain OS7mut1 contained a 12-kb chromosomal deletion. The deleted region, termed "MIC island", encoded the genes for the large and small subunits of a [NiFe] hydrogenase, the TatA/TatC genes necessary for the secretion of the [NiFe] hydrogenase, and a gene for the hydrogenase maturation protease. Thus, the [NiFe] hydrogenase may be secreted outside the cytoplasmic membrane, where the [NiFe] hydrogenase can make direct contact with Fe0, and oxidize it, generating hydrogen gas: Fe0 + 2 H+ → Fe2+ + H2. Comparative analysis of extracellular and intracellular proteomes of strain OS7 supported this hypothesis. The identification of the MIC genes enables the development of molecular tools to monitor epidemiology, and to perform surveillance and risk assessment of MIC-inducing M. maripaludis.

[Extradural en bloc removal and in situ replacement of the anterior clinoid process].

Extradural removal of the anterior clinoid process (ACP) is useful and essential for approaching aneurysmal and tumor lesions in and around the cavernous sinus. A safe, rapid and less invasive technique is beneficial for this basic skull base surgery. We developed a new technique by sharply cutting the ACP together with the part of the sphenoid ridge bone followed by complete replacement. A series of patients with either basilar top or internal carotid artery aneurysms underwent the present technique. After frontotemporal craniotomy, the lateral frontal and anterior middle cranial fossae are exposed extradurally. The bone was cut using a cutting steel burr from the sphenoid ridge to the superior orbital fissure and to the optic canal. By sharply separating the meningo-orbital band between the dura propria and the periorbital fascia, the ACP is exposed. The cutting burr runs underneath the ACP. By leaving a very thin sheet of bone, the entire bone piece was elevated after fracturing the thin bone using a chisel. By severing the carotid ring, the internal carotid artery is freed and mobile either laterally or medially to obtain an ample basal cistern. After operation, the once removed clinoid process is replaced in situ using a titanium plate screw. Extradural en bloc removal and in situ replacement of the ACP can be safely done by this cutting procedure. This can provide a good cosmetic result without causing enophthalmos or transient oculomotor palsy.

[Transposition technique of microvascular decompression for hemifacial spasm without using a brain retractor].

A unique transposition technique in microvascular decompression for hemifacial spasm (HFS) was employed in patients with compression by either the peripheral artery or the main trunk of the vertebral artery. Complete transposition that secured free space between the offending artery and the root exit zone (REZ) was accomplished by introducing GORE-TEX tape around the artery and suturing it to the petrous dura. An adequate working space, as if operating in a shallow basin, was essential. Throughout the procedure, it was not necessary to use a brain retractor. Instead, a gentle wrapping retraction technique using a sucker was employed over the brain covered by a sheet of Gelfoam (Pfizer Japan Inc., Tokyo) and cotton. All patients showed complete cure of HFS immediately after surgery with this technique. The difficulty of transposing the vertebral artery can be overcome by well-designed surgical strategy and skillfulness.