Verification of a Three-day Hospitalization Protocol for Chronic Subdural Hematoma Surgery.

Chronic subdural hematoma (CSH) is predominantly a disease of the elderly. Aging societies in advanced countries are seeing the number of CSH cases increasing. We applied a three-day hospitalization protocol for CSH surgery to reduce healthcare costs and more efficiently manage hospital beds. We investigated the clinical factors that influenced prolonged hospitalization. From January 2015 to December 2020, we performed irrigation, evacuation, and drainage of CSH cases in 221 consecutive patients. The χ2 test and logistic regression analysis were conducted to detect clinical factors influencing prolonged hospitalization. A p-value below 0.05 was considered statistically significant. Applying a three-day hospitalization protocol showed no adverse outcomes. Fifty-two (24%) of 221 patients experienced prolonged hospitalization. The χ2 test showed that female gender, atrial fibrillation, alcohol abuse, preoperative consciousness level, verbal function disturbance, and perioperative activities of daily living were significantly related to prolonged hospitalization. Female gender, atrial fibrillation, and alcohol abuse were significant factors in the logistic regression analysis. A three-day hospitalization protocol for CSH is suitable for patient care; however, particular attention needs to be focused on the female gender, atrial fibrillation, and alcohol abuse, all three of which prolong hospitalization.

Effect of Surgical Arachnoid Plasty on Functional Outcome in Aneurysmal Subarachnoid Hemorrhage.

OBJECTIVE: Various techniques have been performed to reduce subarachnoid clotting during aneurysmal neck clipping surgery. We considered that maintaining the physiologic cerebrospinal fluid circulation by performing arachnoid plasty after clipping during surgery would lead to the accelerated clearance of the subarachnoid clot. METHODS: Patients in a prospectively maintained aneurysmal subarachnoid hemorrhage (aSAH) database at our institution and with aSAH that fulfilled the criteria were selected for this study. The incidence of delayed cerebral ischemia, angiographic vasospasm, 3-month functional outcome, and the amount of subarachnoid clot on computed tomography were compared between the 2 groups after matching. RESULTS: From 2006 through 2016, 228 clipping cases met the inclusion criteria. Using propensity score matching, 89 cases of clipping without arachnoid plasty were matched to 89 cases of clipping with arachnoid plasty. Univariate analyses showed that arachnoid plasty significantly reduced the occurrence of hydrocephalus and incidence of poor outcome. Arachnoid plasty statistically significantly reduces the occurrence of hydrocephalus (odds ratio 0.267, 95% confidence interval 0.074-0.963, P < 0.05). Multivariate analysis also showed that arachnoid plasty was the factor reducing poor outcome at 3 months after aSAH (odds ratio 0.222, 95% confidence interval 0.075-0.661, P < 0.01). CONCLUSIONS: The present study suggests that good hematoma clearance due to arachnoid formation reduced brain damage, cerebral vasospasm, and hydrocephalus, resulting in significantly fewer cases with poor functional prognosis. It therefore follows that procedures such as arachnoid plasty should be taken into consideration in order to improve outcome in surgical clipping.

The Effect of Goreisan on the Prevention of Chronic Subdural Hematoma Recurrence: Multi-Center Randomized Controlled Study.

The relatively high rate of post-operative recurrence in the treatment of chronic subdural hematoma (CSDH) is a significant problem. Goreisan is an herbal medicine that exhibits a hydragogue effect by inhibiting the expression of aquaporins, and its efficacy in preventing post-operative CSDH recurrence has been suggested by several case trials. This multi-center prospective randomized controlled trial was performed to investigate the preventative effect of goreisan on post-operative CSDH recurrence. Patients with symptomatic CSDH over 60 years old undergoing burr hole surgery were enrolled in this study. The patients were randomly allocated to the control group or the goreisan group, in which oral administration of goreisan (7.5 g daily) was continued for 12 weeks. The primary end-point was the post-operative recurrence rate at 12 weeks and the secondary end-point was hematoma volume reduction rates on computed tomography scan at 12 weeks. The analyses were performed not only on patients of all ages older than 60 years, but also on patients divided into those over or under 75 years old. One hundred and eighty patients were followed and analyzed (the control group, n = 88; the goreisan group, n = 92). The recurrence rates considering patients of all ages and patients under 75 years old were relatively low in the goreisan group but without a significant difference. The hematoma volume reduction rates showed no significant difference. Based on the results of the present study, a larger-scale study including more cases is necessary in future to confirm the efficacy of goreisan.

Intra-arterial oxidative stress correlates negatively with cognitive function and positively with postoperative ischemic lesions in carotid artery stenosis stenting.

BACKGROUND AND PURPOSE: Carotid plaque contains biologically active substances released into the blood during carotid artery stenting (CAS). The main purpose of this prospective study was to analyse sequential changes in oxidative stress during CAS and their relationship to clinical factors. METHODS: Twenty-two consecutive CAS procedures were performed between May 2014 and April 2016. Arterial blood was collected four times: (1) after the sheath insertion without edaravone; (2) pre-angioplasty with edaravone from the carotid artery; (3) after post-stenting angioplasty from an occluded carotid artery; and (4) before sheath removal. Derivatives of reactive oxygen metabolites (d-ROMs) and biological antioxidant potential (BAP) were measured photometrically. The relationship between d-ROMs or BAP and preoperatively investigated biochemical parameters, cognitive function, and number of diffusion-weighted image (DWI) high spot lesions was analysed using one-way ANOVA and the Tukey-Kramer HSD test. RESULTS: The d-ROM values for CAS were 355±58.8 Carratelli Units at sheath insertion, 315±57.2 after edaravone infusion, 328±56.8 after post-stenting angioplasty, and 315±53.0 just before sheath removal. The d-ROM values were reduced significantly after edaravone infusion (P<0.05). The BAP at sheath insertion was reduced significantly according to age (P<0.05). The d-ROMs at sheath insertion correlated negatively with the dementia scale and positively with the post-CAS DWI high spots (1.00±1.07; P<0.05). Other biochemical parameters did not correlate with the d-ROM values or BAP. CONCLUSION: Oxidative stress is correlated negatively with cognitive function and positively with postoperative ischemic lesions. Antioxidant potential decreases with ageing.

Regression of atherosclerosis with apple procyanidins by activating the ATP-binding cassette subfamily A member 1 in a rabbit model.

BACKGROUND AND AIMS: Apple polyphenol contains abundant procyanidins, which have been associated with an anti-atherosclerosis and cholesterol-lowering effect. The aim of this study was to investigate whether apple procyanidins (APCs) feature therapeutic efficacy in terms of regressing atherosclerosis and whether this efficacy is due to mechanisms other than a cholesterol-lowering effect. METHODS: After eight weeks on an atherogenic diet, rabbits were given a normal diet for another eight weeks to normalize the increased serum lipids level. The rabbits in the baseline group were sacrificed at this stage. The control group was subsequently fed a normal diet for eight weeks, while the APCs group was administrated 50 mg/kg/day of APCs in addition to the normal diet. Serum lipids and aortic intimal-medial thickness (IMT) were serially examined, and the resected aorta was examined histologically and through molecular biology. RESULTS: Aortic IMT on ultrasonography and the lipid accumulation area examined using Sudan IV staining were significantly reduced in the APCs group as compared to the control group. Serum lipid profiles were not different between the groups. Immunohistochemistry showed significantly decreased staining of an oxidative stress marker and significantly increased staining of ATP-binding cassette subfamily A member 1 (ABCA1) in the APCs group. Western blotting and RT-PCR also showed increased expression of ABCA1 mRNA and its protein in the APCs group. CONCLUSIONS: This study revealed that APCs administration causes a regression of atherosclerosis. APCs might hold promise as an anti-atherosclerotic agent.

Stem Cell Therapies for Intracerebral Hemorrhages.

BACKGROUND: An insult due to intracerebral hemorrhage (ICH) is critical to patients. So, breakthroughs in ICH treatment are very important. OBJECTIVE: Advances in the stem cell treatment of stroke have been remarkable. And stem cell experimentation on ischemic stroke, however, preceded such work on ICH and did not emphasized ICH therapy. METHOD: We review recent stem cell treatments for ICH, an experimental model of ICH, the medical care of ICH, and several stem cell therapies for ICH along with future prospects. RESULTS: Stem cell therapy for ICH is effective in rodent or animal models. For humans, only a small number of clinical trials have been done, and significant functional recovery was recorded. CONCLUSION: We need to reveal the mechanism of stem cell therapy and develop a reliable, definitive treatment strategy for treatment of ICH. In the future, several types of stem cells will be available for the treatment of ICH.

Neuro-regeneration therapy using human Muse cells is highly effective in a mouse intracerebral hemorrhage model.

A novel type of non-tumorigenic pluripotent stem cell, the Muse cell (multi-lineage, differentiating stress enduring cell), resides in the connective tissue and in cultured mesenchymal stem cells (MSCs) and is reported to differentiate into multiple cell types according to the microenvironment to repair tissue damage. We examined the efficiency of Muse cells in a mouse intracerebral hemorrhage (ICH) model. Seventy µl of cardiac blood was stereotactically injected into the left putamen of immunodeficient mice. Five days later, 2 × 105 of human bone marrow MSC-derived Muse cells (n = 6) or cells other than Muse cells in MSCs (non-Muse, n = 6) or the same volume of PBS (n = 11) was injected into the ICH cavity. Water maze and motor function tests were implemented for 68 days, and immunohistochemistry for NeuN, MAP2 and GFAP was done. The Muse group showed impressive recovery: Recovery was seen in the water maze after day 19, and motor functions after 5 days was compared with the other two groups, with a significant statistical difference (p < 0.05). The survival rate of the engrafted cells in the Muse group was significantly higher than in the non-Muse group (p < 0.05) at day 69, and those cells showed positivity for NeuN (~57%) and MAP-2 (~41.6%). Muse cells could remain in the ICH brain, differentiate into neural-lineage cells and restore functions without inducing them into neuronal cells by gene introduction and cytokine treatment prior to transplantation. A simple collection of Muse cells and their supply to the brain in naïve state facilitates regenerative therapy in ICH.

[Epidemiological Investigation of Patients in Persistent Vegetative States in Aomori, Japan].

The actual number and condition of Japanese patients in persistent vegetative states have not yet been fully understood. The aim of this study is to investigate the epidemiology of patients in persistent vegetative states in the Aomori prefecture. We sent questionnaires regarding gender, age, cause of persistent vegetative state, and residence of patient to all medical institutions in the Aomori prefecture (n=682). Two hundreds and seventeen institutions (31.8%) replied to the questionnaire, and eleven hundred ninety-eight patients(Male/Female=381/817) were included. Patients over 80 years-old were the most common (63.4%), and cerebrovascular stroke was the major cause (64.4%) of persistent vegetative state. Nursing homes (48.1%) and hospitals (34.6%) were the main care institutions. Population based analysis revealed that 869 persistent vegetative state patients per million were cared for in the Aomori prefecture. This result was twice as many as was previously reported in Miyagi prefecture. The number of patients in persistent vegetative states will increase in the future, due to an increasing elderly population and a high incidence of stroke in this demographic. We therefore predict that increased medical and administrative support will be required in the future.

Safety of preprocedural antiplatelet medication in coil embolization of ruptured cerebral aneurysms at the acute stage.

Preoperative antiplatelet medication for aneurysm coil embolization during acute subarachnoid hemorrhage (SAH) is not common. However, recent advances in neurointerventional devices make antiplatelet medication necessary for SAH surgery. We tested the hypothesis that preprocedural antiplatelet therapy in the acute stage of SAH prevents complications due to ischemia or induced bleeding. We retrospectively reviewed 35 consecutive ruptured cerebral saccular aneurysms that underwent coiling at our institute. Two hundred milligrams of aspirin and 150 mg of clopidogrel were administered to the patients at least two hours before coiling. Systemic heparinization was given after sheath insertion. Procedure-related thrombus formation on digital subtraction angiography, and clinical evidence of ischemia and procedure-related stroke on CT were reviewed. The median patient age was 69 years. Five males and 30 females were included. Seventy-seven percent of patients were Hunt-Hess grades 1 to 3. Assist techniques were used in 20 cases (57%). We inserted one extracranial internal carotid artery stent, but no intracranial stent. Intraoperative thrombosis occurred in one case (2.9%), with no clinical symptoms. Postoperative cerebrospinal fluid drainage was done in three cases, but we experienced no bleeding complications. Preoperative antiplatelet therapy leads to a low rate of thromboembolic events in coiling during acute stage SAH, and this strategy had no adverse influence on bleeding complications.

Role of oxidized LDL and lectin-like oxidized LDL receptor-1 in cerebral vasospasm after subarachnoid hemorrhage.

OBJECT: Cerebral vasospasm after subarachnoid hemorrhage (SAH) is a serious complication. Free radicals derived from subarachnoid clotting are recognized to play an important role. Oxidized low-density lipoprotein (ox-LDL) and lectin-like oxidized LDL receptor-1 (LOX-1) have been shown to be related to the pathogenesis of atherosclerosis and may increase in cerebral arteries after SAH, due to the action of free radicals derived from a subarachnoid clot. These molecules may also affect the pathogenesis of vasospasm, generating intracellular reactive oxygen species and downregulating the expression of endothelial NO synthase (eNOS). If so, apple polyphenol might be effective in the prevention of vasospasm due to an abundant content of procyanidins, which exhibit strong radical scavenging effects, and the ability to suppress ox-LDL and LOX-1. The purposes of this study were to investigate changes in levels of ox-LDL and LOX-1 after SAH and whether administering apple polyphenol can modify cerebral vasospasm. METHODS: Forty Japanese white rabbits were assigned randomly to 4 groups: an SAH group (n = 10); a shamoperation group (n = 10), which underwent intracisternal saline injection; a low-dose polyphenol group (n = 10) with SAH and oral administration of apple polyphenol at 10 mg/kg per day from Day 0 to Day 3; and a high-dose polyphenol group (n = 10) with SAH and oral administration of apple polyphenol at 50 mg/kg per day. At Day 4, the basilar artery and brain was excised from each rabbit. The degree of cerebral vasospasm was evaluated by measuring the cross-sectional area of each basilar artery, and the expression of ox-LDL, LOX-1, and eNOS was examined for each basilar artery by immunohistochemical staining and reverse transcriptase polymerase chain reaction. In addition, neuronal apoptosis in the cerebral cortex was evaluated by TUNEL. RESULTS: Compared with the sham group, the expression of ox-LDL and LOX-1 in the basilar arterial wall was significantly increased in the SAH group, the expression of eNOS was significantly decreased, and the cross-sectional area of basilar artery was significantly decreased. Compared with the SAH group, the cross-sectional area of basilar artery was increased in the polyphenol groups, together with the decreased expression of ox-LDL and LOX-1 and the increased expression of eNOS. In the high-dose polyphenol group, those changes were statistically significant compared with the SAH group. In the low-dose polyphenol group, those changes were smaller than in the high-dose polyphenol group. No apoptosis and no changes were seen in the cerebral cortex in all groups. CONCLUSIONS: This is the first study suggesting that ox-LDL and LOX-1 increase due to SAH and that they may play a role in the pathogenesis of vasospasm. It is assumed that procyanidins in apple polyphenol may inhibit a vicious cycle of ox-LDL, LOX-1, and ROS in a dose-dependent manner. Apple polyphenol is a candidate for preventive treatment of cerebral vasospasm.

Long-term tumor-free survival case of congenital embryonal tumor with various pathological components.

PURPOSE: Treatment strategy of malignant congenital brain tumor is controversial. We report a congenital embryonal tumor case with various pathological components. METHODS: A normally delivered male infant had an enlarged head circumference at 1 month after birth. The abnormality of the right side of the head was also noted during the routine 4-month health check. The head circumference was 45.1 cm (+2.25, SD); neurological status, however, was normal, with a pediatric GCS of 9 and body weight of 6,370 g (-0.85, SD). Magnetic resonance imaging (MRI) revealed right brain tumor whose size was 99 × 91 × 86 mm. The tumor was enhanced homogeneously with central necrosis, and the margin of the tumor was well circumscribed. RESULTS: We performed a subtotal removal of the tumor. The pathological diagnosis was meningioma (MIB-1 index was 2 %). The residual tumor gradually shrank, and we performed monthly MRI follow-up. The tumor abruptly recurred 7 months after the operation. The level of patient consciousness deteriorated, and emergency removal surgery was performed. The histological examination showed various types of embryonal components without meningioma-like parts. The pathological diagnosis was an embryonal tumor. The MIB-1 index was 48 %. One month after the second operation, dissemination of the tumor occurred at the right temporal lobe, cerebellum, and in subcutaneous tissue. Chemotherapy (vincristine, cisplatin, cyclophosphamide, and etoposide) was initiated following radiation therapy (3 Gy/day, 8×). Adjuvant therapies were effective, and no tumor recurrence was detected during 34 months follow-up. CONCLUSION: Treatment strategies for malignant indefinite diagnosed tumor need to be discussed.

[Chronic subdural hematoma (CSH) complicated by bilateral occipital lobe infarction: two case reports].

Chronic subdural hematoma (CSH) is a common disease that is treated with burr hole drainage by neurosurgeons. The outcome of CSH is mostly favorable. We treated 2 cases with bilateral occipital lobe infarction due to CSH. A 57-year-old woman was ambulatory when she visited a clinic for evaluation of headache. One hour after the CT was taken, she developed acute impairment of consciousness, so that she was referred to our hospital. The second patient was a 73-year-old woman with a history of depression who was involved in a traffic accident 5 weeks before admission to our hospital. She was at first admitted to a psychiatric hospital for evaluation of gait disturbance. Three weeks after she was admitted to the psychiatric hospital, she fell into a coma. She was referred to our hospital. Their brain CT on admission revealed compressed ambient and interpeduncular cistern and bilateral CSH. Although burr hole drainage surgery was performed, the 2 patients developed severe sequelae due to occipital lobe infarction caused by central transtentorial herniation.

Case of pleomorphic xanthoastrocytoma with anaplastic features in the pineal gland.

BACKGROUND AND IMPORTANCE: Different types of tumor have been reported in the pineal gland, but pleomorphic xanthoastrocytoma (PXA) in this region is extremely rare. CLINICAL PRESENTATIONS: A 61-year-old man had gait disturbance and dementia for 1 month. Radiological examination revealed a 22 × 26 × 22-mm-diameter mass in the pineal gland and remarkable hydrocephalus. Biopsy of the tumor was performed and histological examination confirmed diagnosis of PXA with anaplastic features. Radiation therapy with concomitant temozolomide was performed, and tumor reduction was achieved. CONCLUSION: We report the first case of PXA with anaplastic features in the pineal gland. This case indicates that temozolomide and radiation therapy are effective for treating PXA with anaplastic features.

Dilation of the Internal Carotid Artery at the Entrance to the Carotid Canal following Carotid Artery Stenting Predicts Postprocedural Hyperperfusion.

OBJECTIVE: Ischemic stroke and hyperperfusion (HP) are the most frequent and important complications in carotid artery stenosis surgery. Carotid artery stenting (CAS) has replaced carotid endarterectomy in high medical risk patients. Prior to CAS, initial angiographic findings disclose a small caliber internal carotid artery (IC) due to stenosis, but after the stenosis is relieved, the diameter of the IC becomes enlarged. We investigated whether a change in the IC diameter was related to ischemic complication and HP using cerebral blood flow single photon emission computed tomography (SPECT). METHODS: From February 2008 to December 2009 we consecutively performed 39 CAS on 35 patients. We retrospectively analyzed the relationship between changes at the level before the entry to the petrous bone canal of the IC and stenosis of the etiological artery, improvement in stenosis, HP and postintervention diffusion-weighted image high-intensity lesions. Statistical analyses comprised Wilcoxon/Kruskal-Wallis analysis, analysis of variance and a multivariate logistic analysis. RESULTS: A total of 9 cases showed HP in SPECT. Severity of IC stenosis and change in the IC at the level before the entry to the petrous bone canal were related with statistical significance to HP. Other factors did not correlate with HP. CONCLUSION: Procedure-related dilation of the IC at the level before the entry to the petrous bone canal occurred due to release of the etiological stenosis. This finding can also support the prediction of HP.

Decompressive hemi-craniectomy is not necessary to rescue supratentorial hypertensive intracerebral hemorrhage patients: consecutive single-center experience.

OBJECTIVE: A consensus on decompressive surgery for hypertensive intracranial hemorrhage (ICH) has not been reached. We retrospectively analyzed our single-center experience with ICH. MATERIAL AND METHODS: From January 2004 to August 2009, 65 consecutive supratentorial ICH patients underwent surgery in our institute. Supratentorial ICHs that exhibited a hematoma volume of over 50 mL according to the xyz/2 method were included in this study. We compared a hematoma removal plus decompressive craniectomy group (DC) and a hematoma removal group (HR) with regard to GCS, preoperative hematoma volume, shift from the midline, time from the ictus to surgery, post-surgical hematoma volume, brain swelling, hospitalization periods, and m-RS after 3 months. Statistical analysis was done using the t-test or χ2 test, and the odds ratio was calculated. RESULTS: Twenty-five patients participated in this study. The DC group included 5 male patients, and the HR group 20 patients (F/M=8/12). Mean DC group age was 44.2 years, and 56.8 years for the HR group (p<0.05). GCS, preoperative hematoma volume, shift from the midline, time from the ictus to surgery, and postoperative hematoma volume were similar between both groups. Brain swelling on post-operative [corrected] CT was demonstrated to be mild and delimited within the cranium in the DC group, similar to the HR group. Hospitalization periods increased in the DC group (p<0.05). The m-RS after 3 months was similar for both groups. The factors relevant for m-RS were age, postoperative hematoma volume, and GCS at 24 h after surgery. CONCLUSION: Decompressive craniectomy is not necessary for rescue in ICH if the hematoma can be removed completely.

Irrigation with thrombin solution reduces recurrence of chronic subdural hematoma in high-risk patients: preliminary report.

Abstract Chronic subdural hematoma (CSH) is a disease frequently seen in the neurosurgical department. CSH also has a high rate of recurrence. Our hypothesis is that thrombin solution irrigation reduces recurrence in high-risk CSH patients. We define high risk as follows: use of anti-platelets, use of anticoagulants, recurrent CSH, renal failure, liver cirrhosis, and hematological disease. From January 1, 1998, to March 31, 2008, we compared a saline solution irrigation group (43 patients) and a thrombin solution (100 unit/ml) irrigation group (36 patients) prospectively and randomly. Surgical procedures were the same: one burr hole craniostomy, drainage of hematoma, irrigation of cavity, frontal insertion of silicon tube, replacement of air with solution, and removal of tube at 24 h after surgery. We define recurrence as an additional drainage operation due to neurological deficit within six months of surgery. Recurrences of CSH arose in two patients (5.5%) with thrombin irrigation and in 11 patients (25.6%) with saline irrigation (p < 0.05). Saline irrigation patients with anti-platelet medication experienced recurrence in five of 19 patients, although no thrombin-irrigated side recurred with the same drug. No complication occurred in relation to thrombin irrigation. Irrigation of CSH with thrombin solution is an effective treatment option for high-risk cases of CSH without complication.

[Role of coil embolization and arterial injection in elderly subarachnoid hemorrhage patients: preliminary report].

With the recent advanced aging seen in society, the number of elderly patients with aneurismal subarachnoid hemorrhage (SAH) is increasing. We focused on current management of SAH in patients who were over 75 years old. From January 1st, 2004 to the end of June, 2007, we had treated 170 SAH patients including 39 who were over 75 years old. We divided the patients into three groups : Coiling Group, Clipping Group, and conservative treatment group (Conservative Group). We analyzed the Hunt-Kosnik grade (H-K), the rate of symptomatic vasospasm, the rate of shunting operation, the Glasgow Outcome Scale (GOS) at 30 days after the onset of SAH, bed rest periods and rate of shunt operation retrospectively. The Conservative Group included many H-K poor grade cases. Symptomatic vasospasm occurred significantly less in the Coiling Group. Rates of shunting operation did not have any significant change. GOS of the Coiling Group and Clipping Group had no significant change, due to the effectiveness of arterial injection for vasospasm. Patients in the Coiling Group started walking significantly earlier than members of other groups. Twenty-five percent of the Clipping Group needed a shunt operation but no patients of the Coiling Group needed a shunt. For elderly SAH patients, we recommend doing coil embolization or clipping and maintaining the patients' activity in daily life. Interventional treatment is necessary to improve results for elderly SAH patients.