[Rapid Recanalization of Cerebral Venous Sinus Thrombosis Secondary to Severe Dehydration:A Case Report].

A 41-year-old healthy man presented with sudden disturbance of consciousness and convulsion during a marathon. Computed tomography revealed a lateral sinus sign in the posterior fossa, and magnetic resonance(MR)venography revealed a flow gap in the posterior part of the superior sagittal sinus and bilateral transverse sinus, although the other MR image sequences were normal. Laboratory data revealed dehydration, acute kidney failure, and rhabdomyolysis. Owing to immediate correction of dehydration, clinical symptoms and radiological abnormality improved rapidly. Cerebral venous sinus thrombosis(CVST)is a rare condition, accounting for <1% of all stroke cases. In all cases, CVST cannot cause cerebral infarction or hemorrhagic change but in any case, may present a transient ischemic attack-like event because of rapid spontaneous recanalization. Therefore, CVST may occur more frequently than expected.

[A Case of Cerebral Venous Sinus Thrombosis, Secondary to Subclinical Basedow Disease].

Cerebral venous sinus thrombosis(CVST)is a rare condition accounting for <1% of all strokes. It has been linked to a multitude of risk factors, including infections, oral contraceptive use, coronary disease, malignant disease, trauma, surgery, coagulopathy and several others. However, the association between hyperthyroidism and CVST is poorly understood. We describe here a rare case of CVST, secondary to subclinical Basedow disease. A 68-year-old woman with general fatigue, headache, speech disturbance and slow behavior was admitted to our hospital. Computed tomography(CT)and magnetic resonance imaging revealed a fresh infarction in the left temporal lobe, and CT angiography revealed filling defects of superior sagittal sinus and transverse sinus. Moreover, the patient was diagnosed with Basedow disease for the first time, by examination for tachycardia. This case suggests that it is essential to have a new awareness that hyperthyroidism is an important risk factor for CVST.

[A Case of Dural Arteriovenous Fistula in the Anterior Cranial Fossa that Developed Remote from the Craniotomy Site after Surgery].

Dural arteriovenous fistula(dAVF)is relatively rare, and its etiology remains uncertain. Generally, dAVF is thought to be acquired and has been reported to develop secondary to sinus thrombosis, head injury, infection, and surgery. We report a rare case of dAVF in the anterior cranial fossa that developed remote from the craniotomy site after surgery. A 52-year-old man underwent surgery for hypertensive intracerebral hemorrhage 4 years prior. Perioperative imaging modalities demonstrated no abnormal vascular malformation except for an un-ruptured anterior communicating artery aneurysm. Four years later, follow-up magnetic resonance angiography showed abnormal vascular malformation in the anterior cranial fossa, and cerebral angiography demonstrated dAVF. dAVF and aneurysm were successfully treated. Possible formation of a dAVF should be considered after craniotomy.

[A Very Rare Case of Diffuse Subependymal Metastases from Small Cell Lung Carcinoma].

While parenchymal metastases are common in solid systemic cancers, subependymal metastases are rare. Approximately half of the reported cases of intraventricular metastases originate from renal carcinoma. A 65-year-old man presented with general fatigue, appetite loss, nausea, and disorientation. Radiological examination revealed diffuse periventricular tumors. The patient underwent an open biopsy via right frontotemporal craniotomy. The patient was diagnosed with metastatic small cell lung carcinoma after histopathological examination. Although subependymal metastases from solid systemic cancer are very rare, this ventricular wall abnormality in the cancer patients must not be overlooked. Many small subependymal metastases might be missed on routine examination.

The Cross-Sectional Area of Paraspinal Muscles Predicts the Efficacy of Deep Drain Stimulation for Camptocormia.

BACKGROUND: Camptocormia, a disturbance of posture, is a well-described clinical feature of PD and other parkinsonian syndromes. Previous reports have shown that DBS of the subthalamic nucleus (STN) or globus pallidus internus is effective in treating camptocormia. However, the efficacy of DBS for camptocormia varies. OBJECTIVE: To determine a clinical marker for selecting an appropriate therapy for camptocormia, a disabling manifestation of Parkinson's disease (PD) that has a variable response to systemic and local therapies. METHODS: We obtained pre-operative lumbar magnetic resonance imaging of 14 consecutive PD patients with camptocormia who underwent subthalamic nucleus deep brain stimulation (STN-DBS) in this retrospective-designed study. Lumbar MRI was performed three to six months prior to the operation. We measured the cross-sectional area (CSA) and width of each participant's paraspinal muscles. RESULTS: Four (28.6%) patients were effective (EF), five (35.7%) were partially effective (PE), and five (35.7%) were non-effective (NE) to STN-DBS. The lumbar paraspinal CSA and width were significantly larger in the EF group than in the PE and NE groups. CONCLUSIONS: The CSA of paraspinal muscles and erector spinae width can be good predictive markers for improving camptocormia in patients with PD after deep brain stimulation.

[A Case of Vertebral Artery Stenosis Presenting with Progressing Stroke and Treated by Percutaneous Transluminal Angioplasty].

A 75-year-old man with a history of diabetes mellitus and hypertension was suffered from dizziness and vomiting and brought to the near-by hospital. MRI showed cerebellar infarction due to right vertebral artery stenosis. Despite best medical treatment, the infarction progressed day by day and he was transferred to our hospital five days later. Neurological examination showed mild disturbance of consciousness and right hemiparesis. Right vertebral angiography revealed high-grade stenosis accompanied with atherosclerosis at the V3-V4 portion. Percutaneous transluminal angioplasty (PTA) was performed with 2.5 mm×14 mm balloon with 6 atm dilation. Postoperative course was uneventful and no further stroke occurred after the treatment. PTA was effective for vertebral artery stenosis manifested with progressing stroke. The indication of stent placement for the cerebral artery should be prudent.

The Effectiveness of the Stereotactic Burr Hole Technique for Deep Brain Stimulation.

Deep brain stimulation (DBS) is performed by burr hole surgery. In microelectrode recording by multi-channel parallel probe, because all microelectrodes do not always fit in the burr hole, additional drilling to enlarge the hole is occasionally required, which is time consuming and more invasive. We report a stereotactic burr hole technique to avoid additional drilling, and the efficacy of this novel technique compared with the conventional procedure. Ten patients (20 burr holes) that received DBS were retrospectively analyzed (5 in the conventional burr hole group and 5 in the stereotactic burr hole group). In the stereotactic burr hole technique, the combination of the instrument stop slide of a Leksell frame and the Midas Rex perforator with a 14-mm perforator bit was attached to the instrument carrier slide of the arc in order to trephine under stereoguidance. The efficacy of this technique was assessed by the number of additional drillings. Factors associated with additional drilling were investigated including the angle and skull thickness around the entry points. Four of the 10 burr holes required additional drilling in the conventional burr hole group, whereas no additional drilling was required in the stereotactic burr hole group (p = 0.043). The thicknesses in the additional drilling group were 10.9 ± 0.9 mm compared to 9.1 ± 1.2 mm (p = 0.029) in the non-additional drilling group. There were no differences in the angles between the two groups. The stereotactic burr hole technique contributes to safe and exact DBS, particularly in patients with thick skulls.

Synthesis of a peptide that can translocate to the endoplasmic reticulum.

The accumulation of unfolded proteins in the endoplasmic reticulum (ER) leads to ER stress, which has been implicated in the development of diseases. In the present study, we synthesized a peptide that entered cells and translocated to the ER. This peptide possessed fluorescein isothiocyanate (FITC), HIV-TAT, mini-αA-crystallin, and KDEL sequences. We demonstrated that this peptide entered cells and translocated to the ER. Time course experiments revealed that this peptide existed in the ER of cos-7 cells for 16 h. Furthermore, we detected the full-length peptide in cells by fluorescent immunostaining followed by SDS-PAGE. The peptide also entered glial and neuronal cells. These results suggest that this peptide has the ability to enter cells and exert chaperone activity at the ER, and provide an insight into the development of new drugs.

Spinal cord stimulation for intractable pain evaluated by a collision study using somatosensory evoked potentials: a preliminary report.

OBJECTIVE: Appropriate stimulation of the dorsal column is required in order to achieve optimal control over pain by way of spinal cord stimulation (SCS). In this study, we objectively evaluated changes in somatosensory evoked potentials (SEPs) during a collision test in order to investigate whether paresthetic sensation or amount of pain reduction was correlated with the degree of dorsal column stimulation. MATERIALS AND METHODS: We studied 12 patients with intractable pain who underwent permanent SCS implantation. SEP collision was examined while recording the cortical SEP components elicited by posterior tibial nerve stimulation. A positive collision effect was observed when the SEP amplitude was clearly reduced by the SCS. RESULTS: Based on the SEP collision findings, the effects of SCS were classified into four patterns: positive collision with pain reduction (Type 1), positive collision without pain reduction (Type 2), negative collision with pain reduction (Type 3), and negative collision without pain reduction (Type 4). Type 1 was observed for well-known diseases in which SCS was very effective, whereas Type 2 was seen in poor candidates for dorsal column stimulation. Patients with poststroke pain exhibited various patterns including types 1, 2, and 3. One patient showed Type 4 patterning, and we recommended further SCS trials before the abandonment of SCS therapy for this patient. CONCLUSIONS: We show that SEP collision is useful for evaluating the degree of dorsal column stimulation needed as well as in considering factors related to differences between responders and nonresponders to SCS therapy.

Caffeine attenuated ER stress-induced leptin resistance in neurons.

Exposing the endoplasmic reticulum (ER) to stress causes the accumulation of unfolded proteins, and subsequently results in ER stress. ER stress may be involved in various disorders such as obesity, diabetes, and neurodegenerative diseases. Leptin is an important circulating hormone, that inhibits food intake and accelerates energy consumption, which suppresses body weight gain. Recent studies demonstrated that leptin resistance is one of the main factors involved in the development of obesity. We and other groups recently reported the role of ER stress in the development of leptin resistance. Therefore, identifying drugs that target ER stress may be a promising fundamental strategy for the treatment of obesity. In the present study, we investigated whether caffeine could affect ER stress and the subsequent development of leptin resistance. We showed that caffeine exhibited chaperone activity, which attenuated protein aggregation. Caffeine also inhibited the ER stress-induced activation of IRE1 and PERK, which suggested the attenuation of ER stress. Moreover, caffeine markedly improved ER stress-induced impairments in the leptin-induced phosphorylation of STAT3. Therefore, these results suggest caffeine may have pharmacological properties that ameliorate leptin resistance by reducing ER stress.

Flurbiprofen ameliorated obesity by attenuating leptin resistance induced by endoplasmic reticulum stress.

Endoplasmic reticulum (ER) stress, caused by the accumulation of unfolded proteins, is involved in the development of obesity. We demonstrated that flurbiprofen, a nonsteroidal anti-inflammatory drug (NSAID), exhibited chaperone activity, which reduced protein aggregation and alleviated ER stress-induced leptin resistance, characterized by insensitivity to the actions of the anti-obesity hormone leptin. This result was further supported by flurbiprofen attenuating high-fat diet-induced obesity in mice. The other NSAIDs tested did not exhibit such effects, which suggested that this anti-obesity action is mediated independent of NSAIDs. Using ferriteglycidyl methacrylate beads, we identified aldehyde dehydrogenase as the target of flurbiprofen, but not of the other NSAIDs. These results suggest that flurbiprofen may have unique pharmacological properties that reduce the accumulation of unfolded proteins and may represent a new class of drug for the fundamental treatment of obesity.

Novel approach for the efficient use of a full-scale, 3-dimensional model for cervical posterior fixation: a technical case report.

STUDY DESIGN: Case report of a patient with atlantoaxial subluxation who underwent posterior cervical fixation. OBJECTIVE: To describe a novel approach for the efficient use of a full-scale, 3-dimensional model for preoperative planning and surgery. SUMMARY OF BACKGROUND DATA: Instrumented fusion of the cervical spine with screws and rods is indicated for atlantoaxial subluxation. Fatal complications, such as vertebral artery and spinal cord injuries, may occur during screw insertion. Making appropriate connecting rods, after screw insertion, is often time consuming. Therefore, precise preoperative planning and careful intraoperative procedures are required. METHODS: A 73-year-old male with atlantoaxial subluxation presented with progressive quadriplegia and gait disturbance. Surgery involving a C1 laminectomy and posterior cervical fixation was planned; and a 3D model, allowing visualization of the vertebral artery, was developed. Bilateral C1 and C4 lateral mass screws and C2 pars screws were experimentally inserted into the model. Rods with appropriate curvature were created to obtain rigid screw fixation, and were used during the surgery. Moreover, radiography and computed tomographic images of the instrumented model were analyzed to ensure the proper orientation of the screws. RESULTS: During surgery, screw insertion was performed, under fluoroscopic guidance, and compared with the 3D model and its preoperative radiographs. According to the preoperative analysis of the model-computed tomographic images, the direction of the C1 lateral mass screws was changed laterally, and the lengths of the C2 pars screws were shortened to avoid complications. The sterile, prebent rods could be elegantly adapted to the screws without additional bending. The postoperative course was uneventful, and postoperative computed tomographic images showed proper screw positioning. CONCLUSION: Three-dimensional models that allow (1) visualization of the vertebral artery, (2) evaluation of radiological images after screw insertion, and (3) the use of prebent rods during surgery contribute to the safety of the cervical posterior fixation. LEVEL OF EVIDENCE: N/A.

Initial contact of glioblastoma cells with existing normal brain endothelial cells strengthen the barrier function via fibroblast growth factor 2 secretion: a new in vitro blood-brain barrier model.

Glioblastoma multiforme (GBM) cells invade along the existing normal capillaries in brain. Normal capillary endothelial cells function as the blood-brain barrier (BBB) that limits permeability of chemicals into the brain. To investigate whether GBM cells modulate the BBB function of normal endothelial cells, we developed a new in vitro BBB model with primary cultures of rat brain endothelial cells (RBECs), pericytes, and astrocytes. Cells were plated on a membrane with 8 µm pores, either as a monolayer or as a BBB model with triple layer culture. The BBB model consisted of RBEC on the luminal side as a bottom, and pericytes and astrocytes on the abluminal side as a top of the chamber. Human GBM cell line, LN-18 cells, or lung cancer cell line, NCI-H1299 cells, placed on either the RBEC monolayer or the BBB model increased the transendothelial electrical resistance (TEER) values against the model, which peaked within 72 h after the tumor cell application. The TEER value gradually returned to baseline with LN-18 cells, whereas the value quickly dropped to the baseline in 24 h with NCI-H1299 cells. NCI-H1299 cells invaded into the RBEC layer through the membrane, but LN-18 cells did not. Fibroblast growth factor 2 (FGF-2) strengthens the endothelial cell BBB function by increased occludin and ZO-1 expression. In our model, LN-18 and NCI-H1299 cells secreted FGF-2, and a neutralization antibody to FGF-2 inhibited LN-18 cells enhanced BBB function. These results suggest that FGF-2 would be a novel therapeutic target for GBM in the perivascular invasive front.

Ruptured intracranial aneurysms in pediatric polyarteritis nodosa: case report.

Polyarteritis nodosa (PAN) is a rare, systemic necrotizing vasculitis of small and medium size arteries that leads to aneurysms in various organs. Aneurysms associated with PAN are common in visceral arteries, however, intracranial aneurysms are rare, especially in childhood. A pediatric patient with PAN developed serial hemorrhagic strokes from a ruptured superior cerebellar artery aneurysm (subarachnoid hemorrhage) and a de novo aneurysm of the frontoorbital artery (intracerebral hemorrhage) after 9 months. Patients with PAN who present with intracranial aneurysms are candidates for intervention even if the aneurysm is unruptured and still small, and close observation is needed to detect de novo aneurysms in patients with chronic history of PAN.

Repeated delayed onset cerebellar radiation injuries after linear accelerator-based stereotactic radiosurgery for vestibular schwannoma: case report.

A 63-year-old woman presented with right hearing disturbance and vertigo. Magnetic resonance (MR) imaging revealed the presence of right vestibular schwannoma (VS). Stereotactic radiosurgery (SRS) was performed with a tumor marginal dose of 14 Gy using two isocenters. She was followed up clinically and neuroradiologically using three-dimensional spoiled gradient-echo MR imaging. She experienced temporal neurological deterioration due to peritumoral edema in her right cerebellar peduncle and pons for a few months beginning 1.5 years after SRS, when she experienced transient right facial dysesthesia and hearing deterioration. Ten years after SRS, the patient presented with sudden onset of vertigo, gait disturbance, diplopia, dysarthria, and nausea. MR imaging demonstrated a new lesion in the right cerebellar peduncle, which was diagnosed as radiation-induced stroke. The patient was followed up conservatively and her symptoms disappeared within a few months. Multiple delayed onset radiation injuries are possible sequelae of SRS for VS.

[A tentorial dural arteriovenous fistula presenting progressive myelopathy: a case report].

Abstract We report a case of a dural arteriovenous fistula (DAVF) at the tentorium cerebelli, which presented progressive myelopathy. A 68-year-old man with neurological deterioration of the cervical myelopathy visited our hospital. T2 weighted magnetic resonance (MR) imaging showed high signal area and edema from the medulla to the upper thoracic spinal cord with flow voids on the dorsal surface of the cord. Angiography showed right tentorial DAVF, which was supplied by the right meningohypophyseal trunk, the middle meningeal artery, the accessory meningeal artery, and was drained into the posterior spinal veins. The patient underwent right retrosigmoid suboccipital craniotomy, then disruption of the fistula was performed by using micro Doppler sonography following endovascular obliteration of the main feeders. Postoperative angiography showed complete obliteration of the fistula. His daily functioning gradually improved up to 6 months after the surgery. Tentorial DAVFs with clinical manifestation of myelopathy are rare. Considering its aggressive nature, early surgical treatment could be necessary. (Received: November 17, 2010, Accepted: December 18, 2010).

[Pilomyxoid astrocytoma presenting in an elderly patient: a case report].

A 77-year-old man presented with progressive visual disturbance. MR images revealed a mass lesion mainly spreading in the left basal cistern, sylvian fissure and to the left hypothalamic region, with ventricular enlargement. To obtain precise diagnosis of the mass lesion, an open biopsy was performed. The pathological diagnosis was pilomyxoid astrocytoma (PMA). The patient was discharged without adjuvant therapy. A Ventriculoperitoneal shunt procedure was performed afterwards because his hydrocephalic symptoms progressed. PMA is a rare tumor newly added to the glioma section by the WHO classification renewed in 2007, and generally develops in infancy. To our knowledge, there are only four adult cases being reported. In those cases, the symptoms of the disease developed during the second to fourth decade of life. The onset at a more advanced age as in the present case seems to be extremely rare. The treatment strategy described in infant cases is similar to that for pilocytic astrocytoma, but there are only few reports. To establish a treatment protocol for adult patients, further more cases are needed to accumulate knowledge of this rare brain tumor.

[Efficacy of antimicrobial prophylaxis in neurosurgical operations].

OBJECT: It is reported that antimicrobial prophylaxis (AMP) reduces the incidence of surgical site infection (SSI) in neurological surgery. However, a great deal of variation exists regarding the type of antibiotics, dose, timing and duration. In this study, the authors analyzed the incidence of SSI comparing two different AMP protocols. CLINICAL MATERIALS AND METHODS: Five hundred and fifty patients who had undergone neurosurgeries at our institute between April 2005 and August 2007 were reviewed retrospectively. They were divided into the protocol F (309 patients with two or more days AMP) and the protocol P (241 patients with one-day AMP). RESULTS: Baseline characteristics were not statistically different between two protocols. The overall rate of SSI was 1.5%. Although SSI showed a trend of low SSI incidence in the protocol P (0.8%), this was not statistically significant compared with that in the protocol F (1.9%). CONCLUSIONS: The one-day (< 24 hours) administration of AMP is enough to prevent SSI in neurological surgery.

[Skull metastasis of hepatocellular carcinoma successfully treated by intraoperative photodynamic diagnosis using 5-aminolevulinic acid: case report].

There have been no studies on photodynamic diagnosis (PDD) using 5-aminolevulinic acid (5-ALA) in patients with metastatic skull tumors. Here, we present a case of skull metastasis of hepatocellular carcinoma (HCC) successfully treated by intraoperative PDD using 5-ALA. A 63-year-old man with HCC presented with a subcutaneous mass in the left occipital region. CT showed a hyperdensity mass and severe osteolytic change in the left side of the occipital bone. MRI revealed an extra-axial enhanced mass that compressed the left occipital lobe and enhancement was spreading to the adjacent subcutaneous soft tissue. In order to intraoperatively evaluate the extent of tumor invasion, PDD using 5-ALA was performed. Intraoperative PDD comfirmed that the tumor itself was highly fluorescent. Surgery was completed after comfirming the absence of residual fluorescence in the surgical field. The tumor was diagnosed HCC. Histopathological analysis confirmed that PDD accurately assessed the extent of tumor invasion. The patient was discharged home at 10 days after surgery. PDD using 5-ALA is convenient and inexpensive, and because adverse reactions are minimal, it may be useful in not only malignant glioma, but also other brain tumors.