Effectiveness of hinge craniotomy as an alternative to decompressive craniectomy for acute subdural hematoma.

BACKGROUND: Acute subdural hematoma (ASDH) is a life-threatening condition, and hematoma removal is necessary as a lifesaving procedure when the intracranial pressure is highly elevated. However, whether decompressive craniectomy (DC) or conventional craniotomy (CC) is adequate remains unclear. Hinge craniotomy (HC) is a technique that provides expansion potential for decompression while retaining the bone flap. At our institution, HC is the first-line operation instead of DC for traumatic ASDH, and we present the surgical outcomes. METHODS: From January 1, 2017, to December 31, 2022, 372 patients with traumatic ASDH were admitted to our institution, among whom 48 underwent hematoma evacuation during the acute phase. HC was performed in cases where brain swelling was observed intraoperatively. If brain swelling was not observed, CC was selected. DC was performed only when the brain was too swollen to allow replacement of the bone flap. We conducted a retrospective analysis of patient demographics, prognosis, and subsequent cranial procedures for each technique. RESULTS: Of the 48 patients, 2 underwent DC, 23 underwent HC, and 23 underwent CC. The overall mortality rate was 20.8% (10/48) at discharge and 30.0% (12/40) at 6 months. The in-hospital mortality rates for DC, HC, and CC were 100% (2/2), 21.7% (5/23), and 13.0% (3/23), respectively. Primary brain injury was the cause of death in five patients whose brainstem function was lost immediately after surgery. No fatalities were attributed to the progression of postoperative brain herniation. In only one case, the cerebral contusion worsened after the initial surgery, leading to brain herniation and necessitating secondary DC. CONCLUSIONS: The strategy of performing HC as the first-line operation for ASDH did not increase the mortality rate compared with past surgical reports and required secondary DC in only one case.

[Preoperative Metallic Stent Placement and Neoadjuvant Chemotherapy for Locally Advanced Sigmoid Colon Cancer with Obstruction and Invasion of the Psoas Muscle-A Case Report].

A 77-year-old man was diagnosed with obstructive sigmoid colon cancer invading the psoas major and iliac muscles. To avoid the postoperative paralysis of the lower limb, a self-expandable metallic stent(SEMS)was placed, and systemic chemotherapy was administered subsequently. After 4 courses of SOX, Hartmann's procedure was performed. The patient did not develop lower limb paralysis and is alive without recurrence 2 years and 3 months postoperatively. This case suggests that preoperative metallic SEMS placement and neoadjuvant chemotherapy could be an effective treatment for locally advanced colon cancer with obstruction and invasion of the adjacent tissues.

Ruptured Aneurysm Originating from a Posterior Inferior Cerebellar Artery Communicating Artery: A Case Report and Review of the Literature.

This report presents a rare case of such an aneurysm arising from such a communicating artery. A 66-year-old woman presented with a subarachnoid hemorrhage located predominantly in the cisterna magna with intraventricular hemorrhage. Angiography showed hypoplasia of the right posterior inferior cerebellar artery. Its vermian territory was supplied by the communicating artery from the posterior medullary segments of the left posterior inferior cerebellar artery. An aneurysm was on that communicating artery itself at a nonbranching site. The aneurysm was trapped the next day. Postoperative computed tomography showed no infarct in the right posterior inferior cerebellar artery territory. Trapping is applicable when other collateral vessels supply the contralateral posterior inferior cerebellar artery territory. J. Med. Invest. 67 : 197-199, February, 2020.

[A Case Report of Basilar Artery Thromboembolism from Severe Stenosis of the Vertebral Artery Ostium].

We report a case of basilar artery embolism from the large thrombus of the right vertebral artery with severe stenosis of the vertebral artery ostium. Intravenous recombinant tissue plasminogen activator treatment and thrombectomy by catheter with reverse blood flow using a proximal subclavian artery blocking balloon(intentional subclavian artery steal phenomenon)were performed. A large thrombus along with other small thrombi were removed by an aspiration catheter. Additional stent placement was performed for residual vertebral artery stenosis, at ten days after the thrombectomy. Finally, the patient was discharged without any neurological deficits.

Postoperative urinary incontinence exacerbates nocturia-specific quality of life after robot-assisted radical prostatectomy.

OBJECTIVES: To elucidate the effect of postoperative urinary incontinence on nocturia-related quality of life after robot-assisted radical prostatectomy. METHODS: A total of 100 consecutive patients who underwent robot-assisted radical prostatectomy completed a nocturia quality of life questionnaire score and a frequency-volume chart before and after surgery. These patients were divided into two groups by continence status (continent and incontinent) according to the number of pad exchanges per day and the 1-h pad test after surgery. Assessment was carried out before surgery, and then at 3 and 12 months after surgery. RESULTS: The Nocturia Quality of Life questionnaire total score and the Bother/Concern subscore were significantly lower in incontinent patients at 3 and 12 months after surgery (Nocturia Quality of Life questionnaire total score: Bother/Concern subscores P = 0.006: P = 0.04 at 3 months after surgery; and P = 0.04: P = 0.02 at 12 months). Both nocturnal maximum voided volume and nocturnal frequency were not significantly different between continent and incontinent patients. On multivariate analysis, nocturnal urinary frequency (P = 0.01) and urinary incontinence (P = 0.005) were significantly associated with nocturia-specific quality of life. CONCLUSIONS: Although the number of nocturia episodes was not significantly different between the continent and incontinent patients after surgery, the Nocturia Quality of Life questionnaire score was significantly worse in incontinent patients. In these patients, other than the number of nocturia episodes, psychological stress might worsen the Nocturia Quality of Life questionnaire score. Therefore, prevention of post-prostatectomy incontinence might be important to avoid aggravating the Nocturia Quality of Life questionnaire score.

Molecular classification of benign prostatic hyperplasia: A gene expression profiling study in a rat model.

OBJECTIVES: To characterize the molecular features of benign prostatic hyperplasia by carrying out a gene expression profiling analysis in a rat model. METHODS: Fetal urogenital sinus isolated from 20-day-old male rat embryo was implanted into a pubertal male rat ventral prostate. The implanted urogenital sinus grew time-dependently, and the pathological findings at 3 weeks after implantation showed epithelial hyperplasia as well as stromal hyperplasia. Whole-genome oligonucleotide microarray analysis utilizing approximately 30 000 oligonucleotide probes was carried out using prostate specimens during the prostate growth process (3 weeks after implantation). RESULTS: Microarray analyses showed 926 upregulated (>2-fold change, P < 0.01) and 3217 downregulated genes (<0.5-fold change, P < 0.01) in benign prostatic hyperplasia specimens compared with normal prostate. Gene ontology analyses of upregulated genes showed predominant genetic themes of involvement in development (162 genes, P = 2.01 × 10(-4) ), response to stimulus (163 genes, P = 7.37 × 10(-13) ) and growth (32 genes, P = 1.93 × 10(-5) ). When we used both normal prostate and non-transplanted urogenital sinuses as controls to identify benign prostatic hyperplasia-specific genes, 507 and 406 genes were upregulated and downregulated, respectively. Functional network and pathway analyses showed that genes associated with apoptosis modulation by heat shock protein 70, interleukin-1, interleukin-2 and interleukin-5 signaling pathways, KIT signaling pathway, and secretin-like G-protein-coupled receptors, class B, were relatively activated during the growth process in the benign prostatic hyperplasia specimens. In contrast, genes associated with cholesterol biosynthesis were relatively inactivated. CONCLUSION: Our microarray analyses of the benign prostatic hyperplasia model rat might aid in clarifying the molecular mechanism of benign prostatic hyperplasia progression, and identifying molecular targets for benign prostatic hyperplasia treatment.

Sunitinib for refractory malignant pheochromocytoma: two case reports.

Sunitinib, a molecular-targeted therapy, is a potential new treatment strategy for malignant pheochromocytoma. However, because of the rarity of malignant pheochromocytoma and the consequent limited number of patients available for clinical study, there is no good evidence of the efficacy of sunitinib for malignant pheochromocytoma. The present report describes our experience with sunitinib for refractory malignant pheochromocytoma. Two patients were treated with sunitinib at a standard dose (50 mg daily; 4 weeks on, 2 weeks off) after cyclophosphamide/vinblastine/dacarbazine chemotherapy, because vascular endothelial growth factor (VEGF)-positive cells were partly observed by immunohistochemical staining. Both patients were assessed as having stable disease according to the Response Evaluation Criteria in Solid Tumors 1.1. The duration of overall survival from the time sunitinib was initiated was 13 and 8 months, respectively, and the progression-free survival was 5 and 4 months, respectively. Adverse events were evaluated according to the Common Terminology Criteria for adverse events of the US Department of Health and Human Services version 4.0. One patient experienced hypothyroidism (Grade 2) and thrombocytopenia (Grade 2). The other patient experienced anorexia (Grade 3) and general malaise (Grade 3). In conclusion, sunitinib was effective in the treatment of malignant pheochromocytoma when VEGF-positive cells were observed in the tumor specimens.

High prevalence of gastroesophageal reflux disease in Parkinson's disease: a questionnaire-based study.

The aim of this study is to investigate the frequency and clinical features of gastroesophageal reflex disease (GERD) in Parkinson's disease (PD). Consecutively recruited PD patients and controls were questioned about heartburn and GERD with a questionnaire. In PD patients, disease duration and severity, quality of life, and nonmotor symptoms were also examined and then the clinical features of GERD were analyzed. A total of 102 patients and 49 controls were enrolled and 21 patients and 4 controls had heartburn, significantly frequent in PD. The prevalence rate of GERD was 26.5% in PD and the odds ratio was 4.05. Heartburn, bent forward flexion, and wearing-off phenomenon were frequent, and scores of UPDRS, total and part II, PD questionnaire-39, and nonmotor symptom scale were significantly higher in PD patients with GERD than without GERD. Multiple logistic regression analysis revealed statistical significance in UPDRS part II and nonmotor symptom scale. This study suggests that GERD is prevalent in PD. Deterioration of daily living activities and other nonmotor symptoms can imply the presence of GERD. Because clinical symptoms of GERD are usually treatable, the management can improve the patient's quality of life. Increased attention should be given to detect GERD in PD.

Cerebrovascular lesions in elderly Japanese patients with Alzheimer's disease.

OBJECTIVE: Cerebrovascular lesions (CVLs) are known to play important roles in the pathophysiology underlying Alzheimer's disease (AD), especially in elderly AD cases. The present study was conducted to elucidate the relationship between the CVLs and vascular risk factors (VRFs) in elderly Japanese patients with AD. SUBJECTS AND METHODS: The CVLs such as lacunar infarcts, old microbleeds (OMBs), white matter lesions (WMLs), and occlusive vascular lesions on MRI were analyzed in relation to the risk factors in 120 Japanese patients with probable AD. Their mean age was 75.6 years. The subjects were divided into two age groups: young-old group (YOG) consisting of 55 cases being younger than 75 years and old-old group (OOG) consisting of 65 cases being 75 years or older. RESULTS: In overall analysis, 10 cases (8.3%) showed brain atrophy without CVLs on MRI, 46 cases (38.3%) showed WMLs in addition to the brain atrophy, 61 cases (50.8%) showed lacunar lesions, and 3 cases (2.5%) were diagnosed as having a superficial siderosis. Lacunar infarcts and OMBs were more frequently observed in OOG than in YOG, and were also more frequently observed in those with 2 or more VRFs than those with less than 2 VRFs (p<0.05). The WMLs were more pronounced in OOG, and in those with more VRFs. CONCLUSION: The CVLs including lacunes, WMLs, and OMBs were present more than 90% of elderly Japanese patients with AD. As the severity of CVLs was associated with VRFs and age, VRFs may modify clinical presentation of elderly AD patients.

Clinical diagnosis of vascular dementia.

Vascular dementia (VaD) is a heterogeneous clinical entity based on various vascular pathophysiological processes underlying the subtypes of cerebrovascular disease (CVD). Several diagnostic criteria are currently being used for the clinical diagnosis of VaD, but they are mostly more than 10 years old and need to be renovated including the use of functional brain imaging methods such as single photon emission computerized tomography (SPECT). There is a limitation in the diagnosis based on the strict dichotomy between AD and VaD, and the concept of "AD with CVD" or "mixed dementia" should be included in the clinical diagnosis of VaD.

Hemodynamic aspects of Alzheimer's disease.

Neuroradiological functional imaging techniques demonstrate the patterns of hypoperfusion and hypometabolism that are thought to be useful in the differential diagnosis of Alzheimer's disease (AD) from other dementing disorders. Besides the distribution patterns of perfusion or energy metabolism, vascular transit time (VTT), vascular reactivity (VR), and oxygen extraction fraction (OEF), which can be measured with positron emission tomography (PET), provide hemodynamic aspects of brain pathophysiology. In order to evaluate the hemodynamic features of AD, PET studies were carried out in 20 patients with probable AD and 20 patients with vascular dementia (VaD). The PET findings were not included in their diagnostic process of AD. Using oxygen-15-labeled compounds, cerebral blood flow (CBF), cerebral metabolic rate of oxygen (CMRO(2)), OEF, cerebral blood volume, and VTT were measured quantitatively during resting state. To evaluate VR, CBF was also measured during CO(2) inhalation. There was a significant increase in OEF in and around the parietotemporal cortices, but both VTT and VR were well preserved in patients with AD. By contrast, VR was markedly depressed and VTT was mildly prolonged in patients with VaD. Thus, from the hemodynamic point of view, the preservation of vascular reserve may be a distinct difference between AD and VaD. Furthermore, this indicates a hemodynamic integrity of the vasculature in the level of arterioles in AD.