Cilostazol improves outcome after subarachnoid hemorrhage: a preliminary report.

BACKGROUND: Cerebral vasospasm (VS) is the most common cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage (SAH). Reversal of VS by intra-arterial infusion of cyclic adenosine monophosphate (cAMP)-elevating agents has been reported; however, the preventive role in the development of VS is not fully understood. This study is designed to evaluate the possible efficacy of using cilostazol, a selective inhibitor of phosphodiesterase type 3 and a cAMP-elevating agent, in patients with SAH. METHODS: In this prospective randomized study, we enrolled 100 SAH patients who met the following criteria: neck clipping within 72 h after onset, Hunt and Hess (HH) score ≤4, modified Rankin scale (mRS) score ≤2 prior to ictus, and no serious cardiovascular complications. Patients were divided into control and cilostazol groups; we focused on the effects of cilostazol on the decrease in the incidence of symptomatic VS, cerebral infarction, and the mRS score at discharge. RESULT: Patients' age, male/female ratio, mRS score prior to ictus, HH grade, Fisher group, site of the aneurysm, drugs prescribed during the observation period, and length of hospital stay were not different between the groups. Cilostazol did not significantly decrease the incidence of symptomatic VS (37.3% in the control vs. 22.4% in the cilostazol group, p = 0.183) and cerebral infarction (27.5% in control vs. 10.2% in the cilostazol, p = 0.091). However, mRS score was significantly improved at discharge (2.6 in controls vs. 1.5 in the cilostazol group, p = 0.041). Patients' age being ≤65 years (OR = 8.47, 95% CI = 2.45-29.32, p = 0.0007), Fisher group ≤3 (OR = 4.64, 95% CI = 1.00-21.45, p = 0.049), HH grade ≤2 (OR = 4.31, 95% CI = 1.27-14.59, p = 0.019), no hydrocephalus (OR = 8.55, 95% CI = 1.72-19.23, p = 0.0046), and cilostazol use (OR = 5.52, 95% CI = 1.61-18.90, p = 0.0065) were independent predictors of good outcomes (mRS score ≤2). CONCLUSION: Cilostazol may improve outcomes after SAH, but further double-blind, placebo-controlled studies are required for a definitive conclusion.

[Intravascular lymphoma confirmed by brain biopsy, quickly treated by chemotherapy: a case report].

A 60-year-old female with intravascular lymphoma (IVL) presented with the complaint of urinary dysfunction and gait disturbance. T2 weighted MR imaging of the thoracic spinal cord showed a hyperintense lesion, and brain MR imaging indicated hyperintense lesions in the deep white matter. Multiple sclerosis was assumed, so steroid pulse therapy was administered. However, her level of consciousness decreased and her paraplegia progressed. Laboratory data showed that anemia and thrombocytopenia had worsened with high serum LDH and soluble IL-2 receptor levels. Biopsy of bone marrow indicated hypercellularity associated with hemophagocytic histiocytes, although no atypical lymphocytes were detected. Brain MR imaging indicated a new subcortical lesion in the left parietal lobe. One and a half months after admission, an open brain biopsy of the left parietal cortex was performed. Histopathological diagnosis was IVL, large B cell type. Immediately, she underwent CHOP therapy containing rituximab (R-CHOP therapy). After chemotherapy, spinal and brain MR images showed no new abnormal lesions. Clinically, it is difficult to make a diagnosis of IVL in life as it has no characteristic symptoms or radiological findings. Therefore, if a patient is suspected of having IVL, a biopsy of different organs, including brain, is necessary for making an early diagnosis and initiating chemotherapy.

Cerebrospinal fluid leakage in intracranial hypotension syndrome: usefulness of indirect findings in radionuclide cisternography for detection and treatment monitoring.

PURPOSE: To evaluate indirect findings of cerebrospinal fluid (CSF) leakage on radionuclide cisternography and their changes after treatment. MATERIALS AND METHODS: This study was approved by the hospital's institutional review board and informed consent was obtained before each examination. A total of 67 patients who were clinically suspected of spontaneous intracranial hypotension (SIH) syndrome underwent radionuclide cisternography, and 27 patients who had direct findings of CSF leakage on radionuclide cisternography were selected for this evaluation. They were 16 males and 11 females, aged between 26 and 58 years. Sequential images of radionuclide cisternography were acquired at 1, 3, 5, and 24 hours after injection. We assessed the presence or absence of 4 indirect findings; early visualization of bladder activity, no visualization of activity over the brain convexities, rapid disappearance of spinal activity, and abnormal visualization of the root sleeves. Changes of the direct and indirect findings after treatment were also evaluated in 14 patients who underwent epidural blood patch treatment. RESULTS: Early visualization of bladder activity was found in all 27 patients. Seven of 27 (25.9%) patients showed no activity over the brain convexities. Rapid disappearance of spinal activity and abnormal root sleeve visualization were present in 2 (7.4%) and 5 (18.5%) patients, respectively. After epidural blood patch, both direct CSF leakage findings and indirect findings of early visualization of bladder activity had disappeared or improved in 12 of 14 patients (85.7%). The other indirect findings also disappeared after treatment in all cases. CONCLUSION: Indirect findings of radionuclide cisternography, especially early visualization of bladder activity, may be useful in the diagnosis and posttreatment follow-up of CSF leakage.

[Idiopathic Intracranial Hypotension].

Idiopathic intracranial hypotension (hypovolemia) is almost exclusively provoked by cerebrospinal fluid (CSF) leakage through spontaneously rent dural sac. An initial clinical feature of a severe headache with or without nausea/vomiting should be differentiated from a life-threatening stroke. An early diagnosis and proper therapy may guarantee a good outcome, while delays may promote complicated manifestations and irreversible poor outcome in a few patients. In this article, neuro-imaging studies of some demonstrable cases are presented and the outlets of the spinal CSF and spinal CSF pathways are shown with immunohistological staining.

Impact of low coagulation factor XIII activity in patients with chronic subdural hematoma associated with cerebrospinal fluid hypovolemia: A retrospective study.

BACKGROUND: Cerebrospinal fluid hypovolemia (CSFH) is sometimes associated with chronic subdural hematomas (CSHs). Affected patients often develop enlargement and recurrence of the CSH, even if appropriate treatments such as epidural blood patch (EBP) and/or burr-hole surgery for the CSH are performed. This situation may lead to subclinical coagulopathy, including low coagulation factor XIII (CFXIII) activity. We retrospectively analyzed whether CFXIII activity was involved in the development of CSHs and post-treatment exacerbation of CSHs in patients with CSFH. METHODS: We diagnosed CSFH by radioisotope (RI), magnetic resonance imaging (MRI) and computed tomography (CT) findings, and CSH by CT and/or MRI findings. The plasma CFXIII activity was assessed on admission. All patients with CSFH initially received conservative treatments. When these treatments were ineffective, the patients underwent EBP and/or CSH surgery according to previously reported therapeutic strategies. RESULTS: Among 206 patients with CSFH, 19 developed CSHs. Fourteen patients with a thin hematoma underwent EBP and three with a thick hematoma underwent CSH surgery immediately after EBP on the same day. We were unable to diagnose two patients with CSFH at the time of admission, and one of these two patients underwent repeated CSH surgery before obtaining the correct diagnosis. Seven patients (36.8%) developed CSH exacerbation after the treatment. The CFXIII activity was significantly lower in patients with than without a CSH (42.1% vs. 12.8%, respectively; P = 0.003). The CFXIII activity was significantly lower in patients with than without post-treatment CSH exacerbation (P = 0.046). All five patients with low CFXIII activity who developed CSH exacerbation received intravenous injection of CFXIII and had no recurrence of CSH after the additional treatment. CONCLUSION: In patients with CSFH, low CFXIII activity is one of the risk factors for both the development of a CSH and the post-treatment exacerbation CSH.

[Case of central nervous system lymphoma metastasized to breast after remission by methotrexate chemotherapy].

We report a case of primary central nervous system lymphoma (PCNSL) who responded well to initial systemic chemotherapy, but subsequently developed breast metastasis with local recurrence in the brain 27 months after complete remission. The 53-year-old female suddenly felt weakness in her left extremity. She was transferred to the emergency ward in our hospital. Neurological examination on admission showed disorientated state and mild hemiparesis. Brain MRI showed a well enhanced round lesion in the right basal ganglia with perifocal edema. A stereotactic biopsy of the tumor made a diagnosis of classic diffuse non-Hodgkin's B-cell type lymphoma. She received chemotherapy with a high-dose methotrexate under a condition of 20% of Karnofsky Performance Status (KPS). She enjoyed a useful life for about 5 years (KPS; 60-70%). Both recurrent and metastatic lesions responded poorly to various aggressive multiagent regimens of chemotherapy. An intensive initial treatment for the primary lesion and closely monitoring of the whole body at regular intervals are necessary for ensuring a long useful life.

Reversible non-thrombotic occlusion of the superior sagittal sinus caused by metastatic malignant lymphoma--case report.

A 57-year-old female presented with intracranial hypertension secondary to non-thrombotic superior sagittal sinus occlusion manifesting as acute onset of headache, vomiting, and disorientation. She had a history of intrapelvic malignant lymphoma. Neuroimaging and tumor biopsy revealed that both the superior sagittal sinus and the straight sinus were occluded by metastatic deposits of malignant lymphoma. Her clinical symptoms were remarkably improved by irradiation and chemotherapy, and the affected sinuses were angiographically recanalized.

Symptomatic spinal extramedullary mass lesion secondary to chronic overdrainage of ventricular fluid--case report.

A 69-year-old man presented with progressive nuchal pain and spastic gait 2 years after undergoing ventriculoperitoneal (VP) shunting for a pineal astrocytoma with obstructive hydrocephalus. The neurological manifestations were compatible with radiculomyelopathy caused by an upper cervical lesion. Magnetic resonance imaging showed an enhanced extramedullary mass lesion tightly constricting the upper cervical spinal cord. The pressure of the shunt system was 150 mmH2O, and lumbar puncture revealed normal cerebrospinal fluid (CSF) pressure of 170 mmH2O. After removal of the shunt system, the clinical symptoms and neuroradiological findings markedly improved. This symptomatic spinal mass lesion was thought to be formed secondary to chronic depletion of ventricular CSF through the VP shunt.