[Primary Intracranial Malignant Lymphoma Associated with Acquired Immunodeficiency Syndrome(AIDS):A Case Report].

The spread of human immunodeficiency virus(HIV)infection may result in an increased likelihood of surgery in patients with HIV infection. We treated a patient with intracranial malignant lymphoma associated with acquired immunodeficiency syndrome(AIDS)caused by HIV infection. The recommendations of the countermeasure manual for AIDS were followed. Only surgical staff without finger injury or inflammation were permitted to be involved in the operation. All staff were dressed in a waterproof, full-body surgical gown, and wore double gloves, double foot covers, and an N95 mask. The surgery could be performed safely with such infection control measures. Histological examination revealed a diffuse large B-cell lymphoma. The patient was referred to the Division of Infectious Diseases and Respiratory Medicine for chemotherapy.

Canine double hemorrhage model of experimental subarachnoid hemorrhage.

Several animal subarachnoid hemorrhage (SAH) models have been proposed for the investigation of cerebral vasospasm. We describe the experimental procedures of a canine double-SAH model and also examine the model based on the canine physiological parameters and occurrence of angiographic delayed cerebral vasospasm using magnetic resonance (MR) imaging and digital subtraction angiography. Autologous blood was injected twice on days 1 and 3 in 36 beagles. All animals showed delayed angiographic vasospasm in the vertebrobasilar arteries on day 7. The degree of vasospasm was 29-42 % of the arterial caliber. MR imaging did not show any ischemic change. This animal model can produce definite delayed vasospasm without detectable cerebral infarction on MR imaging. The canine SAH model is suitable for the quantitative and chronological study of delayed angiographic vasospasm, but not for investigating early brain injury and delayed cerebral ischemia.

[Metastatic brain tumor from esophageal carcinoma:a report of three cases].

A metastatic brain tumor originating from esophageal carcinoma is very rare, accounting for only about 2% of all intracranial metastatic tumors. We review three cases of metastatic brain tumor from esophageal carcinoma and present one interesting case. A 60-year-old man was referred to our hospital with aphasia, 3 years after surgery for esophageal carcinoma. Magnetic resonance imaging demonstrated a 7-cm mass lesion with a cystic component in the left temporal lobe. Tumor resection was performed and an Ommaya reservoir system was placed. Histological analysis indicated squamous cell carcinoma, and metastatic brain tumor from esophageal carcinoma was diagnosed. After surgery, the cystic component was collapsed by drainage through the Ommaya reservoir, and cyberknife therapy was performed as an adjunctive therapy. Regrowth of the cystic component and exacerbation of cognitive dysfunction were identified 2 months later, so aspiration of cyst fluid through the Ommaya reservoir was continued. However, the cystic component regrew 5 months after the operation, and the patient died 1 month later. Metastatic brain tumors from primary esophageal carcinoma often have a cystic component, which makes treatment difficult. Control of cyst growth by aspiration using the Ommaya reservoir is effective for improvement of functional prognosis in such patients.

Effects of intravenous infusion of hydrogen-rich fluid combined with intra-cisternal infusion of magnesium sulfate in severe aneurysmal subarachnoid hemorrhage: study protocol for a randomized controlled trial.

BACKGROUND: The failures of recent studies intended to prevent cerebral vasospasm have moved the focus of research into delayed cerebral ischemia away from cerebral artery constriction towards other mechanisms. Recent accumulating evidence has suggested that early brain injury is also involved in the development of delayed cerebral ischemia, and that hydrogen can prevent early brain injury. Therefore, we have established a combination therapy of intravenous hydrogen infusion and intra-cisternal magnesium sulfate infusion for the treatment of both early brain injury and cerebral vasospasm. The present randomized controlled clinical trial is designed to investigate the effects of this novel therapeutic strategy on the occurrence of cerebral vasospasm, delayed cerebral ischemia, and clinical outcomes after high-grade subarachnoid hemorrhage. METHODS: This study is a randomized, double-blind, placebo-controlled design to be conducted in two hospitals. A total of 450 patients with high-grade subarachnoid hemorrhage will be randomized to one of three arms: (i) Mg + H2 group, (ii) Mg group, and (iii) control group. Patients who are assigned to the Mg + H2 group will receive intra-cisternal magnesium sulfate infusion (2.5 mmol/L) at 20 mL/h for 14 days and intravenous hydrogen-rich fluid infusion (200 mL) twice a day for 14 days. Patients who are assigned to the Mg group will receive intra-cisternal magnesium sulfate infusion (2.5 mmol/L) at 20 mL/h for 14 days and intravenous normal glucose-electrolyte solution (200 mL) without added hydrogen twice a day for 14 days. Patients who are assigned to the control group will receive intra-cisternal Ringer solution without magnesium sulfate at 20 mL/h for 14 days and intravenous normal glucose-electrolyte solution (200 mL) without added hydrogen twice a day for 14 days. Primary outcome measures will be occurrence of delayed cerebral ischemia and cerebral vasospasm. Secondary outcome measures will be modified Rankin scale score at 3, 6, and 12 months and biochemical markers. DISCUSSION: The present protocol for a randomized, placebo-controlled study of intravenous hydrogen therapy with intra-cisternal magnesium infusion is expected to establish the efficacy and safety of this therapeutic strategy. TRIAL REGISTRATION UMIN-CTR: UMIN000014696.

Surgical resection of developmental venous anomaly causing massive intracerebral haemorrhage: a case report.

Abstract Cerebral developmental venous anomalies (DVAs) very rarely cause massive haematoma, but should be included in the differential diagnosis of atypical massive intracerebral haematoma (ICH). We describe a case of massive ICH caused only by a DVA and successfully treated by haematoma evacuation with surgical resection of the DVA.

Sulfasalazine and temozolomide with radiation therapy for newly diagnosed glioblastoma.

BACKGROUND: A recent phase 1/2 clinical trial argued for caution for the use of sulfasalazine in progressive glioblastoma (GBM). However, the study enrolled patients with recurrent or progressive high-grade glioma indicating that patients recruited probably had severe disease. Thus, the study may not accurately reflect the effectiveness of sulfasalazine for GBM and we hypothesized that earlier sulfasalazine administration may lead to anticancer effects. AIM: The aim of this study was to investigate whether sulfasalazine can improve the outcomes of patients with newly diagnosed GBM. SUBJECTS AND METHODS: A total of 12 patients were treated with temozolomide and sulfasalazine with radiation therapy after surgery. Twelve patients with primary GBM treated with temozolomide and radiation therapy formed the control group. Progression-free survival (PFS), overall survival (OS) and seizure-free survival (SFS) curves were obtained using the Kaplan-Meier method. The survival curves were compared using the log-rank test. RESULTS: The median OS, PFS and SFS did not differ between the groups. Grade 3 or 4 adverse events occurred over the duration of the study in nine (75%) patients. The median SFS was 12 months in nine patients who received sulfasalazine administration for more than 21 days, which was strongly but not significantly longer than the 3 months observed in the control group (P = 0.078). CONCLUSIONS: Sulfasalazine treatment with temozolomide plus radiotherapy for newly diagnosed primary GBM is associated with a high rate of discontinuation due to hematologic toxic effects. This treatment may have no effect on OS or PFS, although it may improve seizure control if an adequate dose can be administered.

[Extradural temporopolar approach for surgical management of paraclinoid lesions].

OBJECTIVE: Surgical treatment of paraclinoid tumors adjacent to important anatomical structures, such as the optic nerve, optic chiasm, pituitary stalk, and internal carotid artery, should emphasize maximum resection and preservation of visual function. Thus, early localization and exposure of the optic nerve, and complete mobilization and decompression of the optic nerve and internal carotid artery, are necessary in order to prevent intraoperative neurovascular injuries. However, this technique requires wide exposure of the optic-carotid space through the interpeduncular cistern. We have developed an extradural temporopolar approach for resection of paraclinoid tumors, which can also allow early devascularization of arteries that feed the tumors. We evaluated the surgical outcomes of this approach, paying special attention to clinical and visual outcomes. PATIENTS AND METHODS: Thirteen patients(4 men, 9 women;24-78 years, mean age 54 years), underwent tumor removal using an extradural temporopolar approach between March 2000 and April 2013. We retrospectively reviewed medical charts, radiological findings, intensive care unit flow sheets, and surgical records. RESULTS: Histological diagnoses included craniopharyngioma(4 cases), pituitary adenoma(3 cases), medial sphenoid ridge meningioma(2 cases), tuberculum sellae meningioma(2 cases), trigeminal neurinoma(1 case), and malignant epidermoid(1 case). Tumors were 1.5-6.0cm in length(mean 3.2cm). Tumors were cystic in all 4 craniopharyngiomas and solid in the other 9 cases. Preoperative neurological deficits included visual disturbance in 10 patients, double vision caused by oculomotor nerve palsy in 2 patients, and vertigo in 1 patient. Additional orbitozygomatic craniotomies were performed in 8 patients. Total tumor removal was performed in 7 patients and subtotal removal performed in 6. The pituitary stalk was microscopically preserved in all patients. Postoperative complications included transient diabetes insipidus in 2 patients, chronic subdural hematoma in 1 patient, and abducens palsy in 1 patient. All complications were completely resolved. Surgical outcomes on discharge were recorded as follows:good recovery(11 patients), moderate disability(1 patient), and severe disability(1 patient, who suffered preoperative consciousness disturbance). Visual outcomes were improved in 7 patients, unchanged in 5, and worsened in 1, with recurrence. CONCLUSIONS: The present extradural temporopolar approach, which allows early decompression of the optic nerve, and early devascularization and detachment of the tumor, may lead to greater tumor resection and improved visual outcomes in patients with paraclinoid tumors.

[CT and histological findings and treatment outcomes after carotid endarterectomy for symptomatic cervical carotid artery stenosis in octogenarians].

Symptomatic cervical carotid artery stenosis is one of the common causes of ischemic stroke in octogenarians. The records for 90 consecutive patients with symptomatic cervical carotid artery stenosis treated by carotid endarterectomy(CEA)were analyzed retrospectively. The patients were divided into two groups:21 patients aged 80 years or over and 69 patients aged less than 80 years. CT angiography revealed that ulcer formation was significantly more common and the length of carotid artery stenosis was significantly greater in the octogenarians. Histological examination of the plaque revealed no significant difference between the two groups in terms of ulcer formation, lipid content, and intraplaque hemorrhage. However, all three of these pathological findings were present in a significantly higher number of octogenarians. No significant difference was observed for new ischemic lesions on diffusion-weighted MR imaging, neurological complications, or cardiac and pulmonary complications. However, treatment with an albumin preparation and loop diuretics was significantly more common in octogenarians after CEA. The present study suggests that with careful postoperative management CEA can be safely performed in symptomatic patients aged 80 years or over with almost the same risk as that for patients aged less than 80 years.

[Usefulness of extradural optic canal unroofing and decompression of the optic nerve for improvement of visual acuity in traumatic optic neuropathy].

An 81-year-old man presented with poor visual acuity of the left eye, swelling of the left eyelid, and elevation of the left intraocular pressure after contusion of the left palpebral portion. CT revealed left ocular proptosis and left intraorbital hematoma. Traumatic optic neuropathy was suspected, and emergent optic nerve decompression was performed through extradural anterior clinoidectomy followed by optic canal release. Postoperatively, his left visual acuity was markedly improved and the elevated intraocular pressure decreased. Postoperative CT demonstrated improvement of the left ocular proptosis and decompression of the optic nerve. Emergent optic canal release has been recommended in patients who have suffered visual dysfunction caused by optic canal fracture or intraorbital hematoma. The advantages of extradural anterior clinoidectomy followed by optic canal release include a shorter surgical route and easy identification of the optic nerve, resulting in fewer surgical complications. In addition, this procedure can achieve intraorbital decompression. We recommend extradural anterior clinoidectomy followed by optic canal release as a safe and reliable procedure for optic nerve decompression in patients with traumatic optic neuropathy.

[A case of primary intraosseous cavernous hemangioma extending from the orbital rim to the sphenoid wing: a case report].

A primary intraosseous cavernous hemangioma located at the sphenoid bone with extensive involvement of the orbital roof and the lateral wall of the orbit is very rare. A 48-year-old woman presented with progressive right exophthalmos and diplopia. CT showed a bony mass lesion in the right sphenoid bone extending to the orbital bone. MRI showed an abnormal lesion in the sphenoid bone, which was heterogeneously enhanced with gadolinium. All of the abnormal bone was surgically removed, and histological examination confirmed a cavernous angioma. We also present a brief clinical and radiological review of seven previously reported cases.

Simultaneous combined keyhole mini-transcranial approach and endoscopic transsphenoidal approach to remove multi-lobulated pituitary neuroendocrine tumor with suprasellar extension.

BACKGROUND: Transsphenoidal surgery (TSS) is the main method to remove pituitary neuroendocrine tumor (PitNET), but large or multi-lobulated one is still challenging. OBJECTIVE: The less invasive simultaneous combined keyhole mini-transcranial approach and standard transsphenoidal approach was used to remove multi-lobulated or hourglass-shaped non-functioning PitNET to avoid the specific complications related to extended TSS. METHODS: Twenty-one patients of large multi-lobulated or hourglass-shaped PitNET (6 patients were recurrent cases after TSS or transcranial approach) were treated by this simultaneous combined approach. The supraorbital or midline keyhole approach was performed under the operating microscope so that the fine arteries feeding optic apparatus were dissected from the tumor capsule safely and securely and the suprasellar part of the tumor was removed in the extra-capsular fashion in combination with transsphenoidal approach. RESULTS: Visual function improved after the surgery in 14 (74 %) of 19 patients with preoperative disturbance of the visual fields. Four patients (19 %) developed postoperative deterioration of pituitary endocrine functions requiring permanent hormonal replacement. One patient (4.2 %) suffered cortical laminar necrosis without permanent disorders and another patient (4.2 %) suffered cerebrospinal fluid rhinorrhea but neither was permanent. Postoperative computed tomography detected no subarachnoid hemorrhage in any patient. Gross total removal was achieved in 15 patients (71 %). Five patients (24 %) with subtotal removal and one patient (4.2 %) with partial removal had lateral tumor extension with Knosp classification 3 or 4. CONCLUSION: The combined method is an effective treatment option to remove complex PitNET safely and securely with dissecting fine arteries on the tumor capsule.

Evaluation of the stage of hemorrhage using optical diffuse reflectance spectroscopy: an in vivo study.

Intracerebral hemorrhage (ICH) is a common and often fatal subtype of stroke. Estimation of the stage of hemorrhage allows clinicians to know when the hemorrhage occurred, even in unconscious patients, enabling decisions to be made about the optimal management and treatment strategy. After ICH, oxidative denaturation of the hemoglobin progresses, and deoxyhemoglobin is gradually converted to methemoglobin. MRI has been used to estimate the stage of hemorrhage by evaluating the status of hemoglobin. However, there is currently no bedside device that can be used for the measurement of hemoglobin derivatives in patients with hematomas. The aim of the present study was to investigate the validity of using optical diffuse reflectance spectroscopy (ODRS) for bedside evaluation of the stage of hemorrhage. An ICH model was generated in adult Sprague-Dawley male rats by stereotactically injecting 50 µl of autologous blood into the right caudate nucleus. To analyze the hemoglobin derivatives in the hematomas, ODRS measurement was performed for the rats in vivo. In all rats, we found increased absorption at around 630 nm, which indicated the formation of methemoglobin. In conclusion, the results of the present study suggest that ODRS allows clinicians to more easily evaluate the stage of hemorrhage at the patient's bedside.

A better mild traumatic brain injury model in the rat.

The primary pathology associated with mild -traumatic brain injury (TBI) is selective axonal injury, which may characterize the vast majority of blast-induced TBIs. Axonal injuries in cases of mild TBI have been considered to be the main factors responsible for the long-lasting memory or attentional impairment in affected subjects. Among these axonal injuries, recent attention has been focused on the cingulum bundle (CB). Furthermore, recent studies with diffusion tensor MR imaging have shown the presence of injuries of the CB in cases of mild TBI in humans. This study aimed to provide a better laboratory model of mild TBI.Sprague-Dawley rats were subjected to mild TBI using laser-induced shock waves (LISW) (sham, 0.5 J/cm(2), or 1.0 J/cm(2); n = 4 per group). Bodian-stained brain sections 14 days after LISW at 0.5 J/cm(2) or 1.0 J/cm(2) showed a decrease in the CB axonal density compared with the sham group, whereas there were no differences in the axonal density of the corpus callosum.The present study shows that this model is capable of reproducing the histological changes associated with mild TBI.

Adiponectin and traumatic brain injury.

Adiponectin, a circulating adipose-derived hormone regulating inflammation and energy metabolism, has beneficial actions on cardiovascular disorders. Recent studies have suggested that adiponectin might be a potential molecular target for ischemic stroke therapy; however, little is known about the effects of adiponectin on traumatic brain injury. The present study examined the immunoactivity of adiponectin.Adult male Sprague-Dawley rats were subjected to lateral fluid percussion injury using the Dragonfly device. Immuno-histochemical studies showed that the adiponectin expression was increased in the cerebral cortex at 24 h after injury and in the hippocampus at 72 h after injury. Our findings suggest that adiponectin might participate in the pathophysiological process occurring after traumatic brain injury.

Cerebrospinal fluid congestion in the perioptic space.

Recent attention has been paid to the -cerebrospinal fluid (CSF) dynamics between the intracranial subarachnoid space (SAS) and the SAS around the optic nerve (ON-SAS). We experienced three patients who had an expanded ON-SAS associated with mass lesions extending into the optic canal, and studied their MRI findings after decompressive surgery. In all three patients, decompressive surgery of the optic canal resulted not only in the disappearance of the expanded ON-SAS, but also in improvement of the visual function. The present study may indicate that normalization of the ON-SAS can be considered to be the achievement of "effective" decompression. Therefore, we suggest that, in patients with an expanded ON-SAS associated with mass lesions, the state of the ON-SAS should be evaluated by pre- and postoperative MRI, in addition to the degree of tumor resection.

Surgical results after primary decompressive craniectomy in poor-grade aneurysmal subarachnoid hemorrhage.

It is well known that patients with poor-grade aneurysmal subarachnoid hemorrhage (SAH) have poor outcomes owing to significant mass effect and brain stem compression. On the other hand, decompressive craniectomy (DC) has shown efficacy in reducing morbidity and mortality in patients with intracranial hypertension. Here, we study the efficacy of DC in poor-grade SAH with attention to surgical outcome. A total of 38 consecutive patients with poor-grade SAH was treated in our hospital between 1 August 2005 and 30 July 2010. Among these 38 patients, we involved 15 patients with DC in the present study. We retrospectively reviewed medical charts and radiological findings. Glasgow Outcome Scale score on discharge showed good response in 1 (6.7 %), moderate disability in 6 (40.0 %), severe disability in 4 (28.1 %), vegetative state in 2 (1.3 %), and death in 2 (13.3 %). In particular, 3 grade IV patients (50.0 %) had a favorable outcome. Recent several experimental studies also indicated that DC significantly improves outcome owing to increased perfusion pressure or reduced intracranial pressure. We suggest that the DC provided the efficacy in reducing mortality in poor-grade SAH patients.

Is decompressive craniectomy a risk factor for ventriculomegaly?

OBJECTIVE: Decompressive craniectomy (DC) is an established therapeutic option following severe traumatic brain injury (TBI). However, several delayed complications of DC have been reported, including ventriculomegaly, which can lead to poor patient outcomes. Nevertheless, ventriculomegaly can occur after TBI even without DC. The aim of the present study was to investigate the influence of DC on ventriculomegaly. MATERIAL AND METHODS: Adult male Sprague-Dawley rats (300-400 g) were subjected to lateral fluid percussion injury using a fluid percussion device. Rats were randomly divided into four groups: sham, craniectomized without trauma (D group), traumatized without DC (FPI group), and craniectomized immediately after trauma (FPI + D group). On day 28 of recovery, ventricular volumes were measured by image analysis. RESULTS: There was no significant difference in ventricular size between the sham group and the D group animals or between the FPI group and the FPI + D group animals. CONCLUSION: These data suggest that DC may not be a risk factor for ventriculomegaly after TBI.

A suitable formula for estimating the volume gained by decompressive craniectomy in malignant hemispheric infarction.

Decompressive craniectomy (DC) improves the survivability and functional outcome in patients with malignant hemispheric infarction (MHI). The decompressive effect of DC depends on the decompressive volume (DV). The value of the formulas for estimating DV has not been reported to date. We have investigated the value of the formulas to estimate DV in patients with MHI. We analyzed the head CTs of six patients who underwent DC for MHI. We examined 1/2ABC, 1/3ABC, π/6ABC, and 2/3Sh formulas to determine the formula that gives the closest estimation of DV compared with computer-assisted volumetric analysis (gold standard). The mean volume values of the gold standard, 1/2ABC, 1/3ABC, π/6ABC, and 2/3Sh formulas were 100.2, 102.4, 68.3, 105.2, and 109.2 mL respectively. Spearman's correlation coefficient was assessed for DV obtained by each of the four different formulas relative to the gold standard. These were as follows: 1/2ABC = 0.8095 (p < 0.05), 1/3ABC = 0.8095 (p < 0.05), π/6ABC = 0.7381 (p < 0.05), and 2/3Sh = 0.4524 (p > 0.05). In conclusion, the 1/2ABC formula is the most useful and the closest estimation of DV in patients with MHI after DC.

Adiponectin receptor 1 expression is associated with carotid plaque stability.

BACKGROUND: Adiponectin is a hormone secreted exclusively by adipose tissue, and is important in the regulation of tissue inflammation and insulin sensitivity. Adiponectin exerts its effects through two cell-surface receptors: Adiponectin receptor 1 (ADR1) and ADR2. However, the relationship between ADR1/2 expression and progression of atherosclerosis or plaque vulnerability remains unclear. AIMS: To investigate the relationship between ADR1/2 expression and plaque characteristics in patients with carotid artery atherosclerosis. MATERIALS AND METHODS: Forty-three patients who underwent carotid endarterectomy for treatment of carotid artery stenosis were reviewed. Immunohistochemical staining for ADR1 and ADR2 was performed in the specimens of carotid plaque. The relationships between ADR1/2 expression and clinical characteristics were analyzed statistically. RESULTS: Plaque was stable in 7 patients and vulnerable in 36 patients. ADR1 expression was considered weak in 29 patients and strong in 14 patients. The formation of vulnerable plaques was significantly correlated with weak ADR1 expression (P < 0.003). ADR2 expression was considered weak in 14 patients and strong in 29 patients. Rates of formation of vulnerable plaque did not differ between patients with weak and strong ADR2 expression. CONCLUSIONS: Based on previous and the present results, ADR1 may be strongly related to the stabilization of established atherosclerotic plaques via inactivating macrophages. Enhancement of ADR1 expression could serve as a therapeutic target for the prevention of the formation of vulnerable plaque.

L-Leucine induces growth arrest and persistent ERK activation in glioma cells.

Glioma is the most common type of brain tumor, and has the worst prognosis in human malignancy. Experimental evidence suggests that the use of high concentrations of various amino acids may perturb neoplastic cell growth. Thus, the aim of this study was to investigate whether essential amino acids can alter the growth and proliferation of glioma cells. Studies were performed using C6 rat glioma cell lines. High concentration of L-leucine induced growth arrest of glioma cell lines. Terminal transferase uridyl nick end labeling assay and cell cycle analysis showed that the effect of L-leucine on glioma cells growth was not cytotoxic, but rather cytostatic. Additionally, the extracellular signal-regulated protein kinase was activated in L-leucine-treated glioma cells, and inhibition of mitogen-activated protein kinase/extracellular signal-regulated kinase kinase 1 (MEK) enhanced the effect of L-leucine on glioma cell growth. These data suggest that high concentration L-leucine combined with inhibition of MEK is a potential strategy for glioma cell growth arrest.