Clinical features of non-hypertensive lobar intracerebral hemorrhage related to cerebral amyloid angiopathy.

BACKGROUND AND PURPOSE: The present study aims to clarify the clinical features of non-hypertensive cerebral amyloid angiopathy-related lobar intracerebral hemorrhage (CAA-L-ICH). METHODS: We investigated clinical, laboratory, and neuroimaging findings in 41 patients (30, women; 11, men) with pathologically supported CAA-L-ICH from 303 non-hypertensive Japanese patients aged >OR=55, identified via a nationwide survey as symptomatic CAA-L-ICH. RESULTS: The mean age of patients at onset of CAA-L-ICH was 73.2 +/- 7.4 years; the number of patients increased with age. The corrected female-to-male ratio for the population was 2.2, with significant female predominance. At onset, 7.3% of patients received anti-platelet therapy. In brain imaging studies, the actual frequency of CAA-L-ICHs was higher in the frontal and parietal lobes; however, after correcting for the estimated cortical volume, the parietal lobe was found to be the most frequently affected. CAA-L-ICH recurred in 31.7% of patients during the average 35.3-month follow-up period. The mean interval between intracerebral hemorrhages (ICHs) was 11.3 months. The case fatality rate was 12.2% at 1 month and 19.5% at 12 months after initial ICH. In 97.1% of patients, neurosurgical procedures were performed without uncontrollable intraoperative or post-operative hemorrhage. CONCLUSIONS: Our study revealed the clinical features of non-hypertensive CAA-L-ICH, including its parietal predilection, which will require further study with a larger number of patients with different ethnic backgrounds.

Preoperative embolization of brain tumor with pial artery or dural branch of internal carotid artery as feeding artery.

SUMMARY: This study evaluated the clinical usefulness of preoperative embolization of the pial artery or dural branch of the internal carotid artery (ICA) for brain tumor. Subjects comprised 17 patients with large hypervascular brain tumors who underwent preoperative selective embolization. Micro-catheters (2- or 1.7-F) and shapeable hydrophilic micro-guide wires were used for pial artery (branching from the posterior or anterior cerebral artery) or ICA dural branch embolization. Embolization was performed under digital subtraction fluoroscopy with Polyvinyl alcohol (PVA) particles (150-250 mm) and/or liquid coil.Tumor resection was performed immediately or the day after embolization. Digital subtraction angiography (DSA) before and after endovascular devascularization, blood loss during tumor resection, and clinical outcome were evaluated. All endovascular procedures were technically successful. Post-embolization DSA revealed either a disappearance or a marked decrease of the tumor stain in all cases. Control of intraoperative bleeding was easily accomplished, and intraoperative blood loss was low. Preoperative particle embolization of the feeding artery from the cortical artery or ICA dural branch is safe and effective as adjuvant therapy before tumor resection.

Clinical Outcomes of Coil Embolization for Acutely Ruptured Aneurysm. Comparison with Results of Neck Clipping when Coil Embolization is Considered the First Option.

SUMMARY: The purpose of this prospective study was to evaluate clinical results in patients with acutely ruptured cerebral aneurysm treated by neck clipping (NC) or coil embolization (CE) when CE was considered the first option. Between 1998 and 2003, 280 patients with acutely ruptured cerebral aneurysms excluding intracerebral hematoma were evaluated. Patients were managed prospectively according to the following protocol: primary treatment modality was CE (n=179). NC (n=101) was selected for the patients with aneurysms that were small (less than 2 mm) or an unsuitable shape for CE. Surgical complication rates were 4.5% for CE and 16.8% for NC. Symptomatic vasospasm occurred in 8.4% of CE patients and 29% of NC patients. Good recovery on the Glasgow Outcome Scale was achieved by 71% of CE patients and 50% of NC patients at discharge. Surgical complications and symptomatic vasospasm were significantly reduced in CE compared to NC. Clinical outcome at discharge was also better with CE. Although 18.3% of CE patients showed various degrees of aneurysmal recanalization and 7% of CE patients required additional treatment (re-CE or NC), aneurysmal rebleeding occurred in only one patient during followup (mean, 3.95 years).

Stability of microcatheter for cerebral aneurysm embolization after steam shaping.

SUMMARY: To compare the performance of stability after steam shaping on 4 types of microcatheters, which are commonly used for cerebral aneurysm embolization, an experimental simulation was performed. Distal portion of the microcatheters were shaped into the 90 degree with length of 5 mm with the steam under the instruction of each catheter. In the temperature kept water bath, the change of the angle of the catheter tips were recorded and measured. Several stresses were added to the tips with coaxially passing through the guiding catheter, using guidewire and Guglielmi detachable coil (GDC). The degree of straightening was prominent on braided microcatheters and on the short length of shaping. The degree of recover of the primary shaping was prominent on non-braided catheter. The most influence factor of straightening of shaped catheter tip was the stress from the manipulation of guidewire. The influence from the inserting GDC was less than the guidewire manipulation. It was shown that the decreased angle after large stress was recovered under the situation of without or with small stress. Our study shows that the nonbraided microcatheter was suitable when stability of microcatheter tip after steam shaping was requested for aneurysm coiling.

Preoperative selective internal carotid artery dural branch embolisation for petroclival meningiomas.

We assessed the clinical value of preoperative embolisation of the dural branches of the internal carotid artery (ICA) in cases of petroclival meningioma was evaluated. We carried out preoperative selective embolisation on seven consecutive patients with large petroclival meningiomas, using nonbraided 2 F steam-shaped microcatheters and shapeable hydrophilic microguide-wires to enter the dural branches of the ICA. The embolisations were performed using digital subtraction fluoroscopy with 150-250 microm polyvinyl alcohol particles. The tumours were resected a few days after embolisation. We reviewed angiographic findings before and after endovascular devascularisation, blood loss during tumour resection and clinical outcome. All endovascular procedures were technically successful, and postembolisation angiography showed disappearance of or marked decrease in tumour stain in all cases. Intraoperative bleeding was easily controlled, and intraoperative blood loss was low.

Long-term evaluation of nutritional status using dual-energy X-ray absorptiometry in chronic hemodialysis patients.

BACKGROUND: Hemodialysis patients very often suffer from malnutrition with net loss of body muscle and fat stores. Since protein-calorie malnutrition has been considered to be highly associated with increased morbidity and mortality, it is important that the nutritional status is evaluated accurately and that long-term evaluation of the nutritional status is performed to obtain good outcome. PATIENTS AND METHODS: Forty-six patients (28 men and 18 women) undergoing maintenance hemodialysis were studied. Nutritional status of the patients was examined by dual-energy X-ray absorptiometry (DXA) and anthropometry measurements after a hemodialysis session and 4 years after the initial measurement. RESULTS: Percent fat, the ratio of body fat (BF) to weight, determined by DXA correlated positively with body mass index (BMI) calculated from weight and height. There was also a significant positive correlation between lean body mass (LBM) determined by DXA and arm muscle circumference (AMC) calculated using the anthropometric method. In the study period of 4 years, LBM and bone mineral content (BMC) observed at the end point were significantly lower than those at the start. In contrast, BF and %fat at the end point were significantly higher as compared with those at the initial measurement. CONCLUSION: These results indicate that DXA is a reliable method for body composition analysis in chronic hemodialysis patients. Because the detection of early alterations in body composition may provide an early indication of the development of malnutrition, serial evaluation of body composition using DXA should be valid for assessment of the nutritional status.

Production of platelet-activating factor by neuronal cells in the rat brain with cold injury.

The production and localization of platelet-activating factor (PAF) in the brain following focal brain injury were examined. Immunofluorescent staining was used to detect PAF in the rat brain with cold-induced local brain injury. After cold injury, immediate-early PAF staining was observed within the cold lesion followed later by immunoreactivity in the ipsilateral white matter. PAF immunoreactivity was also clearly seen both in cortical neurons adjacent to the cold lesion and in the ipsilateral hippocampus which showed delayed neuronal degeneration. The data suggest that PAF synthesis occurs in the neuronal cells in the perilesional area and hippocampus as well as within the cold lesion site during the early stages of cold-induced brain injury. PAF expression may contribute to the onset and progression of further brain damage, such as delayed axotomy and delayed neuronal loss.

Coil migration, malposition, stretching and retrieval.

SUMMARY: In this educational program for complicated coil placements, we report several cases of coil malposition, migration, and retrieval. We emphasize that a decrease in the expected one-toone motion of the coil is the earliest sign of a possible imminent complication, and the over the core wire technique with a fixed-loop snare (Gooseneck microsnare) is a very effective potential solution for elongated coil retrieval.

Effect of histamine H2-receptor antagonist on the phosphorus-binding abilities of calcium carbonate and calcium lactate in hemodialysis patients.

The effect of histamine H2-receptor antagonist (famotidine) on the phosphorus-binding abilities of calcium carbonate and calcium lactate were examined in 13 chronic hemodialysis patients. In seven patients receiving calcium carbonate, famotidine (20 mg/d) was given because of gastroduodenal disorders, and calcium carbonate was replaced with calcium lactate as a phosphorus binder after 4 wk of treatment with famotidine. With the 4-wk administration of famotidine accompanied by calcium carbonate, the serum phosphorus level increased from 6.3+/-0.9 to 7.1+/-0.5 mg/dl (P<0.05). However, with the substitution of calcium lactate, the serum phosphorus level decreased significantly when compared to that before substitution (6.3+/-0.2 and 6.0+/-0.9 mg/dl after 4 and 8 wk of substitution, respectively), despite continued administration of famotidine. Serum calcium, creatinine, alkaline phosphatase, high sensitive parathyroid hormone, blood urea nitrogen, arterial blood pH, and bicarbonate were not significantly altered during the trial period. In six control patients treated with calcium carbonate alone, there were no statistical changes in serum calcium and phosphorus levels after substitution of calcium lactate for calcium carbonate. These results suggest that famotidine significantly affects the phosphorus-binding ability of calcium carbonate, but not that of calcium lactate. A careful observation of changes in the serum phosphorus level should be required in hemodialysis patients receiving calcium carbonate and histamine H2-receptor antagonists. Calcium lactate may be useful as a phosphorus binder in such hemodialysis patients.

[A case of aneurysmal neck clipping following incomplete neck clipping and coil embolization].

We report a case with radical neck clipping following incomplete embolization with coils and imperfect neck clipping. A 43-year-old woman suffered from a subarachnoid hemorrhage (Hunt & Hess Grade IV) due to the rupture of a left paraclinoid internal carotid aneurysm on 28 October, 1996. Neck clipping of the aneurysm was performed at day 1. Follow-up angiogram at 2 weeks after surgery showed however a small residual aneurysm. The second angiogram 1.5 months later showed the growth of the residual aneurysm. The residual part of the aneurysm was then treated with endovascular embolization using interlocking detachable coils (IDC), resulting in incomplete occlusion of the aneurysm. The direct surgical clipping of the residual aneurysm was performed via Dolenc approach. A fenestrated clip was applied to the partial embolized aneurysm, when the aneurysmal wall was ruptured between the occluded part of the aneurysm and the residual dome. The fenestrated clip was then reapplied successfully under temporary occlusion of the parent artery. Because of the stenosis of the parent artery, STA-MCA anastomosis was then performed. Postoperative recovery of the patient was uneventful and postoperative angiogram showed stenosis of the parent artery with patent bypass flow. The patient was discharged without complications. Technical problems in neck clipping following incomplete embolization with coils are discussed.

Peripheral arterial coil embolization for hepatic arteriovenous malformation in Osler-Weber-Rendu disease; useful for controlling high output heart failure, but harmful to the liver.

A 55-year-old Japanese housewife, who had Osler-Weber-Rendu disease, was admitted to our hospital because of frequent epistaxis and worsening exertional dyspnea. The computed tomography and hepatic arteriography revealed large hepatic arteriovenous malformation, which was considered to be the leading cause of her high output heart failure. Two series of hepatic arterial coil embolization procedures were performed to reduce hepatic shunt flow. They temporarily improved her cardiac condition, but gradually induced progressive hepatic failure due to intrahepatic cholangitis. Hepatic dysfunction restricted her quality of life and lead to a fatal clinical course one year after the second coil embolization.

Fatal hemorrhage from rupture of the intracranial internal carotid artery caused by aspergillus arteritis.

To the best of our knowledge, this is the first reported case of combined intracranial and extracranial hemorrhage due to aspergillus cerebral arteritis. Knowledge of the imaging and the importance of early diagnosis and treatment are emphasized. A 78 year old man developed progressive right-sided visual impairment and diplopia. Magnetic resonance imaging demonstrated a mass lesion located in the right orbital apex, with extension to the cavernous sinus and the right middle cranial fossa. Cerebral angiography showed no aneurysmal dilatation. He was scheduled for transnasal biopsy. However, the patient died of massive epistaxis and intracranial hemorrhage. Postmortem examination revealed an aspergillus granuloma of the orbit and the skull base involving the intracranial and extracranial internal carotid artery. Aspergillus fumigatus was identified by culture. The characteristic feature of the fungal infection is a low-intensity signal on T2-weighted magnetic resonance images. This finding may be useful in diagnosing fungal infection.

Ultrastructure of obstructive tissue in malfunctioning ventricular catheters without infection.

The obstructive tissue in eight malfunctioning ventricular catheters without infection was studied using scanning and transmission electron microscopy. Shunt obstruction was due to debris from ventricular structures such as the choroid plexus and ependymal tissue. There was a preponderance of collagen fibers, and many fibroblasts were present within these tissues. The cytoplasm of the fibroblasts contained extended endoplasmic reticulum. The tissues filled the lumen of the catheters in radially arranged layers. Peeling the silicone was seen on the surface of the ventricular catheters but was not present in normal silicone catheters. Finger-like microvilli were observed on the free surface of the tissue. Many vessels were seen in the transverse section of the tissue. Activated fibroblasts and vascularization may be important in tissue growth in ventricular catheters.

The "over the core wire" technique for detachable coil retrieval.

SUMMARY: We report four cases of malpositioned detachable coil retrieval. In all cases, the malpositioned coils were retrieved without additional neurological deficits. The stretched core wire was grasped with a fixed-loop snare (Gooseneck microsnare), and the detachable coil was retrieved using an over the core wire technique with a hydrophilic microcatheter.

Posttraumatic edema in the corpus callosum shown by MRI.

MRI was performed on 120 patients who sustained closed head injury of varying severity. Patients ranged in age from 4 to 87 years (average, 32 years). All patients had an initial MRI within 28 days (median 12 days) of injury. MRI disclosed areas of abnormal signals in the corpus callosum of 21 (18%) of the 120 patients; 1 (2%) of the 44 patients who sustained mild injuries (GCS > or = 13), 3 (10%) of the 31 moderate injuries (GCS 9-12), and 17 (38%) of the 45 severe injuries (GCS < or = 8) (p < 0.0001). All but 2 of the 21 patients with corpus callosum lesions had other parenchymal lesions that were visualized by MRI. Of these 21 patients, MRI was repeated in 19. In 13 of the 19 patients, repeat MRI scans at 25 to 42 days after injury showed the disappearance of lesions that had on the first MRI shown a high signal on T2-weighted and FLAIR images and a normal signal on T1-weighted images. The MRI findings and time source of the disappearance of the corpus callosum lesions mirrored those of paracontusional edema in the subcortical white matter. Patients in whom the corpus callosum lesion disappeared had a better outcome than those in whom the lesion remained (good recovery/moderate disability; 92% vs 63%). The present MRI results suggest that some lesions in the corpus callosum following closed head injury are reversible, thus resembling edema that may be produced by a relatively mild shear strain force to the corpus callosum.

[Effect of histamine H2-receptor antagonists on the phosphorus-binding ability of phosphate binders in hemodialysis patients].

We examined the effects of histamine H2-receptor antagonists on the phosphorus binding ability of phosphate binders. Serum calcium, phosphorus, ALP, PTH and arterial blood pH and bicarbonate were measured during treatment with histamine H2-receptor antagonists accompanied by calcium carbonate in sixteen patients undergoing maintenance hemodialysis. Seven patients receiving histamine H2-receptor antagonists without calcium carbonate were selected as controls. In the sixteen patients receiving calcium carbonate, serum calcium, ALP, PTH and arterial blood pH and bicarbonate were not significantly altered during treatment with histamine H2-receptor antagonists, but serum phosphorus levels increased significantly after four (5.6 +/- 1.1 mg/dl) and eight weeks (5.9 +/- 0.8 mg/dl) of treatment as compared with that before treatment (4.8 +/- 1.2 mg/dl). Furthermore, serum phosphorus levels decreased significantly eight weeks after the discontinuation of treatment with histamine H2-receptor antagonists. In the seven control patients there were no statistical differences in serum calcium and phosphorus levels measured before and after treatment with histamine H2-receptor antagonists. In seven other patients receiving histamine H2-receptor antagonists with calcium carbonate, calcium carbonate was replaced with calcium lactate as the phosphate binder after four weeks of treatment with histamine H2-receptor antagonists. With the 4-week administration of histamine H2-receptor antagonists accompanied by calcium carbonate, the serum phosphorus level increased, similarly to that of the first study (from 6.3 +/- 0.9 to 7.1 +/- 0.5 mg/dl). However, with the substitution of calcium lactate, the serum phosphorus level decreased significantly (6.3 +/- 0.2 and 6.0 +/- 0.9 mg/dl after four and eight weeks, respectively, despite continued administration of histamine H2-receptor antagonists). These results suggest that histamine H2-receptor antagonists significantly affect the phosphorus binding ability of calcium carbonate, but not of calcium lactate. Although the exact mechanism remains obscure, one possible explanation may be related to the rise in pH of the gastric juice. Careful observation of changes in the serum phosphorus level is required in hemodialysis patients receiving calcium carbonate and histamine H2-receptor antagonists. Calcium lactate may be useful as a phosphate binder in such hemodialysis patients.