Very small vestibular schwannoma as the source of fatal subarachnoid hemorrhage: a case report.

BACKGROUND: Subarachnoid hemorrhage (SAH) is commonly caused by an aneurysm, trauma, other vascular diseases, and infrequently by a metastatic tumor or glioma. SAH due to a benign intracranial tumor, such as a vestibular schwannoma (VS), is rare. We report a case in which a very small (1 mm) VS caused fatal SAH. CASE PRESENTATION: A 75-year-old woman presented with a sudden severe headache. Computed tomography showed SAH at the right of the cerebellopontine angle. On post-onset day (POD) 27, MRI revealed a 1-mm mass on the cerebellopontine angle's right side. She was discharged with House-Brackmann grade 4 right-side facial weakness and hearing disturbance. She re-presented on POD 45 with headache and loss of consciousness. Computed tomography revealed massive SAH and intracerebellar hemorrhage. She died 4 days later. Histopathological evidence indicated a highly vascular vestibular schwannoma. CONCLUSIONS: Vestibular schwannoma should therefore be considered a source of SAH, particularly in patients with facial weakness and/or hearing disturbance.

Clinico-Radiological Characteristics and Pathological Diagnosis of Cerebral Amyloid Angiopathy-Related Intracerebral Hemorrhage.

OBJECTIVE: We aim to clarify the clinico-radiological characteristics of cerebral amyloid angiopathy-related intracerebral hemorrhage and to investigate the efficacy of pathological diagnosis using biopsy specimens. METHOD: We retrospectively reviewed 253 consecutive patients with cortico-subcortical hemorrhage who had been admitted to Aizawa Hospital between January 2006 and July 2013. We had performed craniotomy and hematoma evacuation in 48 patients, as well as biopsy of the evacuated hematoma, cerebral parenchyma adjacent to the hematoma, or both, and they were classified according to the histological results (positive or negative for vascular amyloid deposition) and to the Boston criteria. We compared the clinico-radiological characteristics of cerebral amyloid angiopathy-related intracerebral hemorrhage. We also investigated the detection rate of cerebral amyloid angiopathy with respect to the origins of the specimens. RESULTS: Pathological examination revealed that 22 subjects were positive for vascular amyloid. The number of the cerebral microbleeds located in the deep or infratentorial region was significantly larger in the negative group than in the positive group (P <.05). There was no significant difference in the distribution of lobar cerebral microbleeds and in the prevalence of hypertension. In the probable cerebral amyloid angiopathy-related intracerebral hemorrhage patients, the probability of having vascular amyloid detected by biopsy of both hematoma and parenchyma was 100%. Rebleeding in the postoperative periods was observed in 2 cases (9.1%) of the positive group. CONCLUSIONS: Our results demonstrate the importance and safety of biopsy simultaneously performed with hematoma evacuation. Deep or infratentorial microbleeds are less correlated with cerebral amyloid angiopathy-related intracerebral hemorrhage than with noncerebral amyloid angiopathy-related intracerebral hemorrhage.

Analysis of clinically relevant mechanical and thermal characteristics of titanium foam spinal implants during drilling.

Although high biocompatibility promotes the use of titanium (Ti) alloy in spinal implants, this material shows high stiffness, which is an issue for removal by drilling. The recently developed, porous Ti foam implants, which have shown enhanced osteoformation, may overcome this flaw. Thus, this study aimed to compare the mechanical and thermal characteristics of Ti-foam (80 % porosity) and conventional Ti alloy (0 % porosity) implants drilled in clinically relevant conditions. Mechanical properties were analyzed by measuring axial and torque forces using a pressure sensor with a drill of 2.5-mm diameter at a rotation frequency of 20 Hz. Thermography was used to evaluate the heat generated by a diamond burr attached to a high-speed (80,000 rpm) drill. The torque and axial strengths of Ti foam (13.63 ± 1.43 and 82.60 ± 7.78 N, respectively) were significantly lower (P = 0.001) than those of Ti alloy (73.58 ± 13.60 and 850.72 ± 146.99 N, respectively). Furthermore, irrigation reduced the area of local heating for Ti foam to 56-82 % of that for Ti alloy, indicating lower thermal conductivity. These data suggest that the use of Ti foam implants may be advantageous in cases with a probability of implant drilling in the future.

A comprehensive list of genes required for the efficient conjugation of plasmid Rts1 was determined by systematic deletion analysis.

While conjugation-related genes have been identified in many plasmids by genome sequencing, functional analyses have not yet been performed in most cases, and a full set of conjugation genes has been identified for only a few plasmids. Rts1, a prototype IncT plasmid, is a conjugative plasmid that was originally isolated from Proteus vulgaris. Here, we conducted a systematic deletion analysis of Rts1 to fully understand its conjugation system. Through this analysis along with complementation assays, we identified 32 genes that are required for the efficient conjugation of Rts1 from Escherichia coli to E. coli. In addition, the functions of the 28 genes were determined or predicted; 21 were involved in mating-pair formation, three were involved in DNA transfer and replication, including a relaxase gene belonging to the MOBH12 family, one was involved in coupling, and three were involved in transcriptional regulation. Among the functionally well-analysed conjugation systems, most of the 28 genes showed the highest similarity to those of the SXT element, which is an integrative conjugative element of Vibrio cholerae. The Rts1 conjugation gene set included all 23 genes required for the SXT system. Two groups of plasmids with conjugation systems nearly identical or very similar to that of Rts1 were also identified.

Proposed imaging assessment score for aneurysmal subarachnoid hemorrhage correlated with prognosis: Shinshu Aneurysmal subarachnoid hemorrhage score.

BACKGROUND: Aneurysmal subarachnoid hemorrhage (aSAH) imaging has been shown to correlate with prognosis. However, no numerical index of bleeding severity has been established. This study aimed to propose a new simple scoring system for computed tomography imaging of aSAH and to confirm its effectiveness in retrospective and prospective studies. METHODS: We devised an image evaluation system as an objective index. This system was established by scoring six items, with a maximum total of 19 points. Using this score, named the Shinshu Aneurysmal Subarachnoid Hemorrhage Score (S-score), we performed a retrospective study of 210 patients with aSAH at a single institution to confirm its efficacy. Age and World Federation of Neurosurgical Societies grades were adopted as other verification items, and the modified Rankin Scale was used for prognostic evaluation. A multicenter prospective study was then conducted to examine the function of the score by examining 214 patients with aSAH. RESULTS: In the retrospective study, the threshold of the S-score between good and poor prognoses was 9/19 points. The area under the curve by receiver operating characteristic analysis of the S-score was 0.819, suggesting efficacy, with an odds ratio (OR) of 1.291 (1.077-1.547). In the prospective study, the judgment capability of the S-score was evaluated with a sensitivity of 0.674, specificity of 0.881, positive predictive value of 0.789, negative predictive value of 0.804, false-positive ratio of 0.119, false-negative ratio of 0.325, positive likelihood ratio of 6.072, and negative likelihood ratio of 1.369. S-score showed a significant difference in prognosis. The OR was 1.183 (1.009-1.388). CONCLUSIONS: The scoring system could contribute to patient prognosis assessment. S-score and its prognostic formulas may serve as an objective source of information in the development of clinical medicine.

G protein-coupled estrogen receptor agonist improves cerebral microvascular function after hypoxia/reoxygenation injury in male and female rats.

BACKGROUND AND PURPOSE: Reduced risk and severity of stroke in adult females are thought to depend on normal levels of endogenous estrogen, which is a known neuro- and vasoprotective agent in experimental cerebral ischemia. Recently, a novel G protein-coupled estrogen receptor (GPER, formerly GPR30) has been identified and may mediate the vasomotor and -protective effects of estrogen. However, the signaling mechanisms associated with GPER in the cerebral microcirculation remain unclear. We investigated the mechanism of GPER-mediated vasoreactivity and also its vasoprotective effect after hypoxia/reoxygenation (H/RO) injury. METHODS: Rat cerebral penetrating arterioles from both sexes were isolated, cannulated, and pressurized. Vessel diameters were recorded by computer-aided videomicroscopy. To investigate vasomotor mechanism of the GPER agonist (G-1), several inhibitors with or without endothelial impairment were tested. Ischemia/reperfusion injury was simulated using H/RO. Vasomotor responses to adenosine triphophate after H/RO were measured with or without G-1 and compared with controls. RESULTS: G-1 produced a vasodilatory response, which was partially dependent on endothelium-derived nitric oxide (NO) but not arachidonic acid cascades and endothelial hyperpolarization factor. Attenuation of G-1-vasodilation by the NO synthase inhibitor and endothelium-impairment were greater in vessels from female than male animals. G-1 treatment after H/RO injury fully restored arteriolar dilation to adenosine triphophate compared with controls. CONCLUSIONS: GPER agonist elicited dilation, which was partially caused by endothelial NO pathway and induced by direct relaxation of smooth muscle cells. Further, GPER agonist restored vessel function of arterioles after H/RO injury and may play an important role in the ability of estrogen to protect the cerebrovasculature against ischemia/reperfusion injury.

The Legionella pneumophila effector protein DrrA is a Rab1 guanine nucleotide-exchange factor.

The intracellular pathogen Legionella pneumophila avoids fusion with lysosomes and subverts membrane transport from the endoplasmic reticulum to create an organelle that supports bacterial replication. Transport of endoplasmic reticulum-derived vesicles to the Legionella-containing vacuole (LCV) requires bacterial proteins that are translocated into host cells by a type IV secretion apparatus called Dot/Icm. Recent observations have revealed recruitment of the host GTPase Rab1 to the LCV by a process requiring the Dot/Icm system. Here, a visual screen was used to identify L. pneumophila mutants with defects in Rab1 recruitment. One of the factors identified in this screen was DrrA, a new Dot/Icm substrate protein translocated into host cells. We show that DrrA is a potent and highly specific Rab1 guanine nucleotide-exchange factor (GEF). DrrA can disrupt Rab1-mediated secretory transport to the Golgi apparatus by competing with endogenous exchange factors to recruit and activate Rab1 on plasma membrane-derived organelles. These data establish that intracellular pathogens have the capacity to directly modulate the activation state of a specific member of the Rab family of GTPases and thus further our understanding of the mechanisms used by bacterial pathogens to manipulate host vesicular transport.

Transradial Mechanical Thrombectomy Using a Radial-specific Neurointerventional Guiding Sheath for Anterior Circulation Large-Vessel Occlusions: Preliminary Experience and Literature Review.

BACKGROUND: Transradial mechanical thrombectomy (MT) is increasingly used because it is associated with a low incidence of vascular access site complications. However, transradial carotid cannulation can be technically challenging to perform in patients with an unfavorable supra-aortic takeoff. In this study, the feasibility and safety of a new transradial MT system with a radial-specific neurointerventional guiding sheath-6F Simmons guiding sheath was evaluated-in patients with anterior circulation large-vessel occlusions. Additionally, a literature review was performed. METHODS: We retrospectively analyzed data from our institutional database about consecutive patients who underwent transradial MT for anterior circulation large-vessel occlusion. After the 6F Simmons guiding sheath was engaged into the target common carotid artery, a triaxial system (Simmons guiding sheath/aspiration catheter/microcatheter), was established. MT using the continuous aspiration prior to intracranial vascular embolectomy technique was performed. Then, procedural success rate, successful revascularization, and procedure-related complications were assessed. RESULTS: A total of 13 patients who had transradial MT were included in the analysis. All 13 patients underwent successful thrombectomy without catheter kinking or system instability, and 12 of them achieved successful revascularization (modified Thrombolysis in Cerebral Infarction score of ≥2b). No complications occurred. CONCLUSIONS: To the best of our knowledge, this is the first case series on transradial MT using a radial-specific neurointerventional system for anterior circulation large-vessel occlusions. This method may increase the success rate of transradial MT. Based on our initial experience, transradial MT, using this system, was feasible and safe for anterior circulation large-vessel occlusions.

Severe Anemia Caused by Gastric Antral Vascular Ectasia and Autoimmune Gastritis.

An 80-year-old man presented to our hospital with general fatigue on exertion that had gradually worsened over 6 months. His blood test revealed severe anemia, and gastroscopy revealed findings consistent with gastric antral vascular ectasia (GAVE) and autoimmune gastritis. We diagnosed the patient with severe anemia caused by GAVE and autoimmune gastritis. The present case suggested that GAVE is triggered by autoimmune gastritis, and the mechanism is likely related to hypergastrinemia. The reporting of this rare case may help elucidate the cause of GAVE, which is currently unknown.

Ruptured anterior paraclinoid aneurysms.

The purpose of this study was to evaluate cases of subarachnoid hemorrhage (SAH) from ruptured anterior (dorsal) paraclinoid aneurysms. Anterior paraclinoid aneurysms are defined as aneurysms arising from the anterolateral wall of the proximal internal carotid artery without any relationship to an arterial branch. Between 1991 and 2008, a total of 159 patients with 169 paraclinoid aneurysms were treated at the Shinshu University Hospital and its affiliated hospitals. A retrospective analysis was carried out using charts, operation records, operation videos, and neuroimagings. Twenty six patients had anterior paraclinoid aneurysm. Six patients presented with SAH. Three aneurysms were saccular and the others were blister-like aneurysms based on operative findings. Neck laceration or premature rupture frequently happened during the clipping surgery even though the aneurysm was saccular type. The treatment of a ruptured anterior paraclinoid aneurysm is quite difficult. Trapping and bypass would be recommended for such fragile aneurysms.

Urgent open embolectomy for cardioembolic cervical internal carotid artery occlusion.

Acute ischemic stroke attributable to cervical internal carotid artery (ICA) occlusion is frequently associated with severe disability or death and is usually caused by atherosclerosis. By contrast, the cardioembolic cervical ICA occlusion is rare, and feasibility of urgent recanalization remains unclear. We present the first study in the literature that focuses on urgent open embolectomy for the treatment of cardioembolic cervical ICA occlusion. A retrospective review of the charts for patients undergoing open embolectomy was performed. Between April 2006 and September 2007, 640 consecutive patients with acute ischemic stroke were treated. Of them, three patients (0.47%) with the acute complete cardioembolic cervical ICA occlusion underwent urgent open embolectomy. All patients presented with profound neurological deficits and atrial fibrillation. The urgent open embolectomy achieved complete recanalization in all patients without any complications. All emboli in three patients were very large and fibrinous in histological findings. Two of three patients showed rapid improvement in neurological functions after surgical treatments. The cardioembolic occlusion of the cervical ICA is rare, but its possibility should be considered in patients with acute ischemic stroke suffering profound neurological deficits and atrial fibrillation. Urgent open embolectomy may be a treatment option to obtain successful recanalization for cardioembolic cervical ICA occlusion and is recommended because it is technically easier and similar to carotid endarterectomy.

[Biotin deficiency in amino acid formula nutrition for an infant with milk protein allergy].

We reported a 4-month-old girl with biotin deficiency caused by amino acid formula. Two weeks after birth, she was diagnosed as having a milk protein allergy. After switching to amino acid formula from usual formula, her symptoms and laboratory findings became normal. About three weeks after the beginning of amino acid formula, she developed intractable skin erosions around the eyes, mouth, neck, and anogenital area. By measuring concentrations of some trace elements, she was diagnosed as having a biotin deficit, because of the organic aciduria and undetectable serum biotin concentration. Her serum biotinidase level was normal. Upon administration of oral biotin supplementation, all her symptoms and laboratory findings were dramatically improved. Since amino acid formula contains very few biotin, we should pay attention to biotin deficiency when infants receiving amino acid formula.

Development and Evaluation of a Blood Glucose Management System for Reducing the Delay in Measurement.

The purpose of this study was to develop and evaluate the blood glucose management (BGM) system, which supports the scheduling of blood glucose measurements for medical staff. This system enables medical staff to continually confirm the instructions of the physicians by measuring blood glucose levels using a smart device (iPod). This paper describes the difference in the delay of the measurement between the BGM system and the non-BGM system. For the iPod device in the BGM system, the desktop device, and the laptop device, the frequencies of a delay under 30 minutes were 94%, 67%, and 80%, respectively (Ryan-test, P < 0.01), and that over 30 minutes were 6%, 33%, and 20%, respectively (Ryan-test, P < 0.01). We concluded that the BGM system reduced the delay in blood glucose measurements and led to an optimization of the time of measurement.

Effects of peripheral administration of PYY3-36 on feed intake and plasma acyl-ghrelin levels in pigs.

These studies were designed to investigate the effects of i.v. administration of peptide YY(3-36) (PYY(3-36)) on feed intake, acylghrelin, and GH levels in castrated male pigs. Feed intake levels were evaluated during both ad libitum and fast-refed conditions, and plasma hormone responses were evaluated during fasting. During ad libitum feeding, i.v. injection of PYY(3-36) (30 microg/kg body weight, BW) significantly reduced feed intake levels within 3 h post-treatment. In the fast-refed condition, both single bolus injection (30 microg/kg BW) and i.v. infusion (0.25 microg/kg BW per min) of PYY(3-36) suppressed feed intake levels 1 h post-treatment. Duration of the elevation of plasma PYY levels induced by i.v. injection of porcine PYY(3-36) in ad libitum-fed pigs was longer compared with the values of fasted or fast-refed pigs. In the infusion study, the elevation of plasma PYY levels was maintained throughout the infusion period and values were reduced less than half at 15 min after termination of infusion. These results showed that the anorexigenic short-term effect of PYY(3-36) treatment corresponds to its half-life. However, i.v. PYY(3-36) injection did not influence plasma acyl-ghrelin levels. On the other hand, single bolus injection of PYY(3-36) increased plasma GH levels 30 min after treatment. Similar to previous findings in other mammalian species, the results of these studies show that PYY(3-36) can reduce feed intake levels; in particular, the effect is potent and acute in pigs. Furthermore, basal plasma PYY levels were higher in ad libitum-fed pigs than in fasted pigs suggesting that circulating PYY(3-36) levels influence satiety and contribute to the termination of feed intake in pigs.

Local structure analyses around Er(3+) in Er-doped fibers with Al co-doping.

The local structure around Er(3+) in Er-doped optical fiber (EDFs) was explored by X-ray absorption fine structure (XAFS) measurements. Using several new approaches such as a novel sample preparation, we successfully measured the XAFS. The intensities near the 8.36 keV peaks were observed for the first time using X-ray Absorption Near Edge Structure (XANES) analysis. The intensities increased in the order of Er, Er(2)O(3), and EDF samples, indicating that Er(3+) in the EDFs existed as an oxide state. Extend X-ray Absorption Fine Structure (EXAFS) analysis also showed that the oxygen coordination number of Er(3+) increased as the Al concentration increased and that the Er-O distances of EDF with Al co-doping is longer than that of EDF without Al co-doping.

[Intratumoral hemorrhage in choriocarcinoma during neuroendoscopic third ventriculostomy: case report].

The authors report a case of intratumoral hemorrhage in a pineal region choriocarcinoma during neuroendoscopic third ventriculostomy. A 12-year-old boy who presented with headache and vomiting had precocious puberty. Neuroimagings revealed a pineal region tumor with obstructive hydrocephalus and his serum HCG level was 4,280 mIU/ml. He was diagnosed as having choriocarcinoma and underwent neuroendoscopic third ventriculostomy for obstructive hydrocephalus. There were many tumor vessels observed on the tumor surface, some of which bled subcapsularly. Postoperative CT scan showed the tumor increased in size with the intratumoral hemorrhage. After irradiation and chemotherapy, the tumor disappeared with normalization of serum HCG level. His symptoms improved and no additional neurological deficit was observed in his clinical course. We might infer from this case that the intratumoral hemorrhage was induced by the intracranial pressure change during neuroendoscopic surgery. Perioperative management is very important for avoiding fetal intratumoral hemorrhage.

Mechanisms of magnesium-induced vasodilation in cerebral penetrating arterioles.

We investigated in cerebral penetrating arterioles the signaling mechanisms and dose-dependency of extracellular magnesium-induced vasodilation and also its vasodilatory effects in vessels preconstricted with agonists associated with delayed cerebral vasospasm following SAH. Male rat penetrating arterioles were cannulated. Their internal diameters were monitored. To investigate mechanisms of magnesium-induced vasodilation, inhibitors of endothelial function, potassium channels and endothelial impairment were tested. To simulate cerebral vasospasm we applied several spasmogenic agonists. Increased extracellular magnesium concentration produced concentration-dependent vasodilation, which was partially attenuated by non-specific calcium-sensitive potassium channel inhibitor tetraethylammonium, but not by other potassium channel inhibitors. Neither the nitric oxide synthase inhibitor L-NNA nor endothelial impairment induced by air embolism reduced the dilation. Although the magnesium-induced vasodilation was slightly attenuated by the spasmogen ET-1, neither application of PF2α nor TXA2 analog effect the vasodilation. Magnesium induced a concentration- and smooth muscle cell-dependent dilation in cerebral penetrating arterioles. Calcium-sensitive potassium channels of smooth muscle cells may play a key role in magnesium-induced vasodilation. Magnesium also dilated endothelium-impaired vessels as well as vessels preconstricted with spasmogenic agonists. These results provide a fundamental background for the clinical use of magnesium, especially in treatment against delayed cerebral ischemia or vasospasm following SAH.

Iatrogenic dural arteriovenous fistula after radical neck dissection for metastatic malignant disease: A case report.

BACKGROUND: A case of dural arteriovenous fistula (dAVF) developed after radical neck dissection for lymph node metastasis 2 years after oral surgery for tongue cancer. METHODS: The patient was asymptomatic during follow-up visits with no evidence of metastasis on follow-up CT scan of the neck. However, diagnostic angiography showed left internal carotid artery (ICA) stenosis and dAVF involving the posterior meningeal artery and transverse sinus at the left posterior fossa with cortical venous reflux (Cognard type III). They were treated with carotid stenting and surgery, respectively. RESULTS: The postoperative course was uneventful. Follow-up angiography revealed obliteration of the dAVF. CONCLUSION: This was a rare case of iatrogenic dAVF after surgical ligation of venous outflow during radical neck dissection. The surgical plan is presented along with a literature review regarding the development of iatrogenic dAVFs induced by direct surgical trauma.

Analysis of Rab1 recruitment to vacuoles containing Legionella pneumophila.

Legionella pneumophila is an intracellular bacterial pathogen that utilizes a type IV secretion system to subvert the function of the Rab1 GTPase. Bacterial proteins translocated into host cells mediate the accumulation of the Rab1 protein on vacuoles containing Legionella pneumophila. Assays used to investigate recruitment of Rab1 by L. pneumophila are described. These assays can be used to determine host and bacterial factors required for L. pneumophila subversion of the host secretory pathway.

Posterior Laminoplastic Laminotomy Combined with a Paraspinal Transmuscular Approach for Removing a Lumbar Dumbbell-shaped Schwannoma: A Technical Note.

The surgical strategies and methods used to treat dumbbell-shaped tumors located in the lumbar-foraminal region are controversial. Although a total facetectomy and combined intra- and extraspinal canal approach provide a wide operative field, facet fusion is required, which can be rather invasive. Here, we report a successful removal of a lumbar dumbbell-shaped schwannoma using a combined laminoplastic laminotomy with Wiltse's paraspinal surgical approach. This was performed under an operating microscope without a complete facetectomy, fusion, and posterior fixation. Briefly, we treated two patients with lumbar foraminal tumors, both dumbbell-shaped schwannomas located in the intra- and extradural portion. After a laminoplastic laminotomy, the intradural tumor was removed. The tumor located at the extracanalicular site was removed after drilling the pars interarticularis of the lamina, which was performed to enlarge the intervertebral foramen via Wiltse's paraspinal surgical approach. During surgery, facetectomy with posterior fixation was not needed to remove the intraforaminal component. There was no lumbar instability or complication after surgery. Our results suggest that a combined posterior laminoplastic laminotomy and Wiltse's paraspinal surgical approach is useful and less invasive for treating patients with lumbar foraminal tumors.