Late-onset aqueductal membranous occlusion treated neuroendoscopic procedure and consideration of its pathological findings: A case report.

Background: Aqueduct of Sylvius stenosis/obstruction interferes with cerebrospinal fluid (CSF) flow and leads to the non-communicating hydrocephalus. Acquired non-neoplastic causes of aqueduct of Sylvius stenosis/ obstruction include simple stenosis, gliosis, slit-like stenosis, and septal formation, but the detailed mechanisms are not clear. In the present study, we experienced a case of late-onset aqueductal membranous occlusion (LAMO) successfully treated by neuroendoscopic procedure, which allowed us to examine the pathology of the membranous structures of the aqueduct of Sylvius occlusion. Case Description: A 66-year-old woman presented with gradually progressive gait disturbance, cognitive dysfunction, and urinary incontinenc. Brain magnetic resonance imaging (MRI) showed enlargement of the bilateral lateral ventricles and the third ventricle without dilatation of fourth ventricle, and heavily T2-weighted images showed an enlarged aqueduct of Sylvius and a membranous structure at its caudal end. Gadolinium contrast-enhanced T1-weighted images showed no neoplastic lesions. We diagnosed this case that the hydrocephalus due to late-onset idiopathic aqueductal stenosis or LAMO and the patient underwent endoscopic third ventriculostomy and endoscopic aqueduct oplasty. Membranous tissue specimens were obtained from the occluded aqueduct of Sylvius at the time of treatment. Histopathological examination revealed gliosis, and inside the gliosis, there were cell clusters that appeared to be ependymal cells and were corpora amylacea. We confirmed CSF flow at the site of obstruction of the aqueduct of Sylvius and the stoma of the third ventricle floor by MRI images. Her symptoms were improved immediately. Conclusion: We experienced a case of LAMO successfully treated by neuroendoscopic procedure, which allowed us to examine the pathology of the membranous structure of the aqueduct of Sylvius. The pathological study of LAMO is rare, and we report it, including a review of the literature.

Postpartum reversible cerebral vasoconstriction with cortical subarachnoid hemorrhage and posterior reversible encephalopathy syndrome concomitant with vertebral artery dissection diagnosed by MRI MSDE method: A case report and review of literature.

Headache is one of the most common symptoms encountered during the postpartum period. The cause may be unknown, or the following illnesses are possible: cervical artery dissection (CAD), reversible posterior cerebral encephalopathy syndrome (PRES), and reversible cerebral vasoconstrictor syndrome (RCVS). It is suggested that they are interrelated and share a similar mechanism such as small vessel endothelial dysfunction, deficiencies in self-regulation, and decreased sympathetic innervation of the posterior circulation. However, there are few reports of neuroradiological findings. We experienced a rare case of multiple postpartum vascular disease occurring at the same time. A 38-year-old woman suddenly developed thunderclap headache after giving birth. She was clear and had no neuropathy. Computed tomography revealed subarachnoid hemorrhage, including the cortical surface of the frontal lobe. Magnetic resonance image fluid-attenuated inversion recovery revealed high-intensity area in the bilateral basal ganglia and right occipital cortex. Angiography showed "string sausage" and extracranial left vertebral artery stenosis, but no aneurysm. Based on the clinical course and neuroradiological findings, we diagnosed her as postpartum vascular disease including CAD, PRES, RCVS, and cortical subarachnoid hemorrhage (SAH). Three-dimensional black blood T1-weighted images using a motion-sensitized driven equilibrium three-dimensional turbo spin echo (MSDE) sequencing method revealed an intramural hematoma consistent with the extracranial vertebral artery. After 3 months, MSDE lost its abnormal signal. Our case was rare in that multiple phenomena of postpartum vascular disease occurred at the same time. In particular, we could reveal that this speculation was reversible in the MRI MSDE sequencing.

Ingenuity using 3D-MRI fusion image in evaluation before and after microvascular decompression for hemifacial spasm.

Background: Hemifacial spasm (HFS) is most often caused by blood vessels touching a facial nerve. In particular, responsible vessels compress the root exit zone (REZ) of the facial nerve. Although we recognize these causes of HFS, it is difficult to evaluate the findings of precise lesion in radiological imaging when vessels compress REZ. Hence, we tried to obtain precise images of pre- and postoperative neuroradiological findings of HFS by creating a fusion image of MR angiography and the REZ of facial nerve extracted by magnetic resonance imaging (MRI) diffusion tensor image (DTI). Case Description: A 52-year-old woman had a 2-year history of HFS on the left side of her face. It was confirmed that the left vertebral artery and anterior inferior cerebellar artery were presented near the facial nerve on MRI. REZ of the facial nerve was visualized using DTI and fusion image was created with vascular components, making it possible to recognize the relationship between compression vessels and REZ of the facial nerve in detail. She underwent microvascular decompression and her HFS completely disappeared. We confirmed that the REZ of the facial nerve was decompressed by MRI imaging, in the same way as before surgery. Conclusion: We describe that the REZ of facial nerve and compressive vessels was delineated in detail on MRI and this technique is useful for pre- and postoperative evaluation of HFS.

Endovascular Treatment of Hemifacial Spasm Associated with a Tentorial DAVF Using Transarterial Onyx Embolization: A Case Report.

Objective: We describe a patient treated with transarterial Onyx embolization for a tentorial dural arteriovenous fistula (DAVF) who presented with hemifacial spasm (HFS). Case Presentation: A 56-year-old man suffered from right blepharospasm for 4 years, and the symptom gradually spread to the right side of his face with oculo-oral synkinesis. MRI of the brain revealed abnormal multiple flow voids at the surface of brainstem and cerebellar hemisphere. MRA (time of flight) and spoiled gradient recalled echo-revealed abnormal vessels at the posterior fossa indicated arteriovenous shunting. 3D-MRI fusion images showed that a dilated vein was in contact with the root exit zone (REZ) of the right facial nerve. The right carotid angiography displayed a complex tentorial DAVF on the right side. There were multiple feeding vessels drained to the tentorial sinus at the point where the inferior cerebellar vermian vein met, and severe venous congestion was noted. We diagnosed a tentorial DAVF and thought that this was responsible for the right HFS. We used neuroendovascular treatment for this lesion. After transarterial Onyx embolization, his right HFS diminished. MRI after treatment showed that the vein in contact with the REZ of the right facial nerve had shrank. Conclusion: We experienced a rare case of HFS associated with a DAVF. Our case supports that transarterial Onyx embolization can treat HFS associated with a tentorial DAVF. It is the first description of successful treatment that could be confirmed through postoperative MRI.

Bioresorbable plate fracture after cranioplasty caused by head injury: a pediatric case.

BACKGROUND: Recently, bone fixation materials have been developed as surgical materials. Bioabsorbable materials offer several advantages over other materials and are widely used. We report a rare case of the fracture of bioresorbable plates caused by head injury and describe some considerations. CASE DESCRIPTION: A 6-year-old boy suffered from consciousness disturbance. He was admitted to our hospital and diagnosed with left frontal subcortical hemorrhage due to ruptured arteriovenous malformation (AVM). He received the surgery of removal of the AVM with decompressive craniectomy. He was discharged without any neurologic deficit and underwent the cranioplasty 4 months after the initial surgery. Two months after the last treatment, he was fallen and hit his left frontal head. The next day, he noticed an abnormal bulge in the injured area. We diagnosed the bulging as cerebrospinal fluid leakage because of the dural tear. The repairment of dural tear was performed. We found that two bioresorbable plates used by cranioplasty were both cracked, and the dura mater beneath them was torn. We repaired the damaged dura with an artificial dura mater. After surgery, cerebrospinal fluid leakage did not occur. CONCLUSION: It has been reported that the durability of bioresorbable plates is no less than that of titanium plates. We experienced a relatively rare case in which bioabsorbable plate used for bone fixation was damaged due to head trauma. After craniotomy or cranioplasty using bioresorbable plates, special attention should be paid to head trauma that involves bone flap sinking force and side bending stress.

Association of Diaphragm Movement During Cough, as Assessed by Ultrasonography, With Extubation Outcome.

BACKGROUND: A cough peak flow (CPF) of < 60 L/min was associated with increased risk of extubation failure after a successful spontaneous breathing trial (SBT). Passive cephalic excursion of the diaphragm (PCED), measured by ultrasonography during cough expiration, was reported to predict CPF in healthy adults. We hypothesized that PCED, diaphragm peak velocity, or both during cough, as measured by ultrasonography, might predict CPF and extubation outcomes in mechanically ventilated patients. This study attempted to identify associations of diaphragm movement during cough, as assessed by ultrasonography with simultaneously measured CPF, and to determine predictive values of ultrasonographic indices for extubation outcomes after a successful SBT. METHODS: In the study, 252 mechanically ventilated subjects with a successful SBT were enrolled in a prospective cohort study. Right hemidiaphragm passive cephalic excursion and peak velocity were measured by ultrasonography during voluntary cough expiration with maximum effort. CPF was measured simultaneously by ultrasonography. RESULTS: A multiple regression model adjusted for age and sex showed a significant association between PCED and CPF (P < .001, adjusted ß coefficient 11.4, 95% CI 8.88-14.0, adjusted R2 = 0.287) and between diaphragm peak velocity and CPF (P < .001, adjusted ß coefficient 1.71, 95% CI 1.91-2.24, adjusted R2 = 0.235). The areas under the curves of PCED, diaphragm peak velocity, and CPF for extubation failure were 0.791 (95% Cl 0.668-0.914), 0.587 (95% Cl 0.426-0.748), and 0.765 (95% Cl 0.609-0.922), respectively. CONCLUSIONS: PCED on ultrasonography was significantly associated with CPF and extubation failure after a successful SBT. Future studies should investigate if this method is applicable for determination of tracheostomy decannulation in stable patients in general wards.

Coil embolization of subarachnoid hemorrhage with ruptured persistent primitive olfactory artery aneurysm.

BACKGROUND: Persistent primitive olfactory artery (PPOA) is a rare anomaly of the anterior cerebral artery. We experienced a rare case of subarachnoid hemorrhage caused by a ruptured saccular aneurysm of PPOA. CASE DESCRIPTION: A 72-year-old man was transported to our hospital with sudden headache. On examination, World Federation of Neurological Surgeons scale was Grade I, and computed tomography of the head showed subarachnoid hemorrhage in Fisher Group 3. Cerebral angiography showed left PPOA and a 4-mm saccular aneurysm at the hairpin turn. No other abnormalities causing bleeding were observed. Based on these findings, subarachnoid hemorrhage due to a ruptured PPOA aneurysm was diagnosed. As the patient had a ventilatory defect due to emphysema, direct approach to the lesion would have been difficult and an endovascular surgery was performed. Three coils were inserted into the aneurysm, and complete occlusion was achieved. Cerebral vasospasm was not observed, and the patient was discharged 1 month after surgery without any neurologic deficit. CONCLUSION: Most aneurysms of the PPOA are formed at the hairpin turn, as observed in our patient; therefore, a hemodynamic mechanism may be involved in the etiology. To the best of our knowledge, there is no report on treatment using intra-aneurysmal coil embolization, indicating that ours was the first case. As the long-term outcome of intra-aneurysmal coil embolization for PPOA aneurysm is unknown, careful follow-up will be necessary in the future.

Incidence and management of metabolic acidosis with sodium bicarbonate in the ICU: An international observational study.

BACKGROUND: Metabolic acidosis is a major complication of critical illness. However, its current epidemiology and its treatment with sodium bicarbonate given to correct metabolic acidosis in the ICU are poorly understood. METHOD: This was an international retrospective observational study in 18 ICUs in Australia, Japan, and Taiwan. Adult patients were consecutively screened, and those with early metabolic acidosis (pH < 7.3 and a Base Excess < -4 mEq/L, within 24-h of ICU admission) were included. Screening continued until 10 patients who received and 10 patients who did not receive sodium bicarbonate in the first 24 h (early bicarbonate therapy) were included at each site. The primary outcome was ICU mortality, and the association between sodium bicarbonate and the clinical outcomes were assessed using regression analysis with generalized linear mixed model. RESULTS: We screened 9437 patients. Of these, 1292 had early metabolic acidosis (14.0%). Early sodium bicarbonate was given to 18.0% (233/1292) of these patients. Dosing, physiological, and clinical outcome data were assessed in 360 patients. The median dose of sodium bicarbonate in the first 24 h was 110 mmol, which was not correlated with bodyweight or the severity of metabolic acidosis. Patients who received early sodium bicarbonate had higher APACHE III scores, lower pH, lower base excess, lower PaCO2, and a higher lactate and received higher doses of vasopressors. After adjusting for confounders, the early administration of sodium bicarbonate was associated with an adjusted odds ratio (aOR) of 0.85 (95% CI, 0.44 to 1.62) for ICU mortality. In patients with vasopressor dependency, early sodium bicarbonate was associated with higher mean arterial pressure at 6 h and an aOR of 0.52 (95% CI, 0.22 to 1.19) for ICU mortality. CONCLUSIONS: Early metabolic acidosis is common in critically ill patients. Early sodium bicarbonate is administered by clinicians to more severely ill patients but without correction for weight or acidosis severity. Bicarbonate therapy in acidotic vasopressor-dependent patients may be beneficial and warrants further investigation.

Trigeminal Neuralgia Due to Compression of Primitive Trigeminal Artery Variant: Usefulness of Fusion Images of Constructive Interference in Steady-State Magnetic Resonance Imaging and Computed Tomography Angiography.

BACKGROUND: Trigeminal neuralgia (TN) is one of the neuropathic pain syndromes, most commonly caused by vascular compression in the root entry zone of the trigeminal nerve in the cerebellopontine angle. It was rare as offending artery that primitive trigeminal artery and primitive trigeminal artery variant (PTAv) as an anomaly that occurs carotid-basilar anastomosis. We report a case of TN caused by the PTAv, and usefulness of fusion images of magnetic resonance imaging (MRI) and computed tomography angiography (CTA). CASE DESCRIPTION: A 65-year-old man presented with a 2-year history of left paroxysmal facial pain in the second division of the trigeminal nerve. We diagnosed left TN due to PTAv using constructive interference in steady state magnetic resonance imaging (CISS MRI) and CTA. Microvascular decompression surgery disclosed trigeminal nerve compressed by PTAv consisted with findings from preoperative neuroimaging. We report a case of TN caused by PTAv, and usefulness of fusion images of CISS MRI and CTA to understand the neurovascular and bony structure during the perioperative period. CONCLUSIONS: The fusion image created by CISS MRI and 3-dimensional CTA was useful to identify the offending vessel and to clearly understand the neurovascular structure preoperatively.

Effect of low-dose atrial natriuretic peptide in critically ill patients with acute kidney injury: a retrospective, single-center study with propensity-score matching.

BACKGROUND: Acute kidney injury (AKI) is a major comorbidity in critically ill patients. Low-dose atrial natriuretic peptide (ANP) has been shown to effectively prevent acute kidney injury (AKI), especially in cardiovascular surgery patients. However, its treatment effects for AKI in critically ill patients are unclear. METHODS: This single-center, retrospective, observational study included patients with AKI diagnosed within 7 days after intensive care unit (ICU) admission during the period January 2010 to December 2017. We conducted a propensity-matched analysis to estimate the treatment effect of low-dose carperitide (a recombinant human ANP) on the clinical outcomes. The primary outcome was a composite of death, renal replacement therapy dependence, or no recovery from AKI (defined as an increase of the serum creatinine level to ≥200% of baseline) at hospital discharge. RESULTS: During the study period, 4479 adult patients were admitted to the ICU. We identified 1374 eligible patients with AKI diagnosed within 7 days after ICU admission. Among these patients, 346 (25.2%) were treated with low-dose carperitide, with an average dose of 0.019 µg kg- 1 min- 1. The primary outcome occurred more often in the treatment group than in the control group (29.7% versus 23.4%, respectively; p = 0.022). After propensity score matching, characteristics of 314 patients from each group were well- balanced. Significant difference of the primary outcome, as seen with the full cohort, was no longer obtained; no benefit of carperitide was detected in the matched cohort (29.0% versus 25.2%; p = 0.281). CONCLUSIONS: Low-dose ANP showed no treatment effect in general critically ill patients who developed AKI.

Delayed acute subdural hematoma treated with endoscopic procedure: A case report.

Background: Delayed acute subdural hematoma (DASDH) is defined as late onset ASDH with the absence of any abnormal radiological and clinical findings at initial examination. Moreover, this entity is very rare in traumatic brain injury and its mechanism is still unclear. Recently, endoscopic surgery for ASDH has also been performed. In this case, we describe some considerations of the mechanism of DASDH and review previous literature and usefulness of endoscopic surgical procedure for ASDH. Case Description: A 73-year-old man fell at night, and visited a former medical institution by himself. No abnormal neurological finding was detected. Head computed tomography (CT) detected no abnormal finding. He was diagnosed minor head injury and was hospitalized at midnight and discharged after brain magnetic resonance image (MRI) next day. Brain MRI also detected no abnormal findings. Three days later, he visited our hospital himself, because of the severe headache. Neurologically, he had a mild consciousness disturbance and head CT revealed left ASDH. We performed endoscopic evacuation of hematoma under local anesthesia. Then, the clot was evacuated under the endoscopic procedure through dilated burr hole and pulsatile bleeding from the cortical artery was observed, which was considered to be the source of the ASDH. The patient's consciousness disturbance was improved immediately after surgery and he discharged without neurological deficit. Conclusion: We revealed the source of bleeding of DASDH under endoscopic procedure and described hypothesis and speculation of its cause in our case. DASDH is rare entity, so we need further experiences and more considerations.

Prosthesis Used in Microvascular Decompressions: A Multicenter Survey in Japan Focusing on Adverse Events.

OBJECTIVE: To investigate the characteristics of materials used as prostheses for microvascular decompression surgery (MVDs) in Japan and their possible adverse events (AEs) to determine preferable materials for MVDs. METHODS: A questionnaire was sent to all members of the Japanese Society for MVDs, and answers were obtained from 59 institutions. RESULTS: Among a total of 2789 MVDs, 1088 operations for trigeminal neuralgia, 1670 for hemifacial spasm, and 31 others, including 117 reoperations, were performed between April 2011 and March 2014. Nonabsorbable material was used in 96.5% of MVDs, including polytetrafluoroethylene (PTFE) (80.5%), polyurethane (11.9%), expanded PTFE (2.1%), and silk thread (1.47%). The use of absorbable materials, including fibrin glue (87.5%), cellulose (13.5%), gelatin (4,77%), and collagen (1.76%), was reported. The major combinations were PTFE with fibrin glue (58.7%) followed by PTFE alone (7.60%). Eighty-eight AEs in 85 (3.2%) cases were reported among 2672 first operations. AEs included 51 central nervous system dysfunctions, 15 wound infections/dehiscence, and 10 others, which were presumed to be related to the intraoperative procedure. Among relatively high-, moderate-, and low-volume centers, there were no significant differences in the frequency of AEs (P = 0.077). Tissue-prosthesis adhesion and/or granuloma formation were reported in 13 cases of 117 reoperations. The incidence of adhesion-related recurrence was 11.1% of all reoperations. CONCLUSIONS: The number of AEs was quite low in this survey, and intradural use of any prosthesis reported in this paper might be justified; however, further development of easily handled and less-adhesive prosthesis materials is awaited.

Ultrasonographic Assessment of Passive Cephalic Excursion of Diaphragm During Cough Expiration Predicts Cough Peak Flow in Healthy Adults.

BACKGROUND: Evaluation of cough strength is clinically important, especially for patients with neuromuscular disorders and before extubation of mechanically ventilated patients. The pressure gradient between the airway and thoracoabdominal cavities during the cough expiratory phase generates cough flow and passive cephalic movement of the diaphragm. We hypothesized that passive diaphragmatic cephalic excursion, peak velocity, or both during cough expiration might predict cough peak flow (CPF). This physiologic study investigated associations of CPF with simultaneously measured ultrasonographic indices in healthy adults during the cough expiratory phase. METHODS: 56 healthy adults participated in this study. Right hemidiaphragm excursion and peak velocity were measured with ultrasonography during voluntary cough expiration with maximum effort. CPF was simultaneously measured for all coughs along with the ultrasonographic measurements. A linear regression model was used to determine whether ultrasonographic indices predicted CPF. RESULTS: Simple regression analysis showed significant associations between excursion and CPF in men and women (P < .001, beta coefficient 37.8, 95% CI 10.9-64.7, adjusted R2 = 0.195 for men; P < .001, beta coefficient 46.1, 95% CI 22.3-69.9, adjusted R2 = 0.386 for women). A multiple regression model adjusted for age, height, and sex showed a significant association between CPF and excursion (P < .001, adjusted beta coefficient 38.32, 95% CI 21.20-55.44, adjusted R2 = 0.643). Simple regression analysis showed a significant association between diaphragmatic peak velocity and CPF only in women (P = .004, beta coefficient 5.07, 95% CI 1.81-8.33, adjusted R2 = 0.280 for women). CONCLUSIONS: Passive cephalic excursion of the diaphragm during the cough expiratory phase significantly predicted CPF with maximum cough effort in healthy adults. Future studies should investigate the relationship between CPF and excursion in persons with respiratory and neuromuscular disorders.

Novel Burr Hole Dilator for Endoscopic Surgery for Intracranial Hemorrhagic Lesion: Technical Note.

OBJECTIVE: When performing burr hole endoscopic neurosurgery, it is necessary to get enough surgical corridor. We have used various instruments to extend burr hole size, but it was cumbersome to use so many tools. METHODS: In this report, we describe a novel instrument-a dilator attachment with a cordless handle to make it simple and safe to extend a burr hole. We developed this burr hole dilator attachment with blades on the side and an arc form on the bottom to prevent dural damage. It can be used to drill safely and efficiently. We describe some experiences of using this device. RESULTS: It is important to balance the maximization of the operation range and surgical invasiveness for endoscopic neurosurgery. This new dilator for extending a burr hole is a safe, useful device to get enough surgical view and easily perform a surgical procedure in endoscopic surgery. CONCLUSIONS: Our dilator for expanding a burr hole improves the work of endoscopic surgery on intracranial hemorrhagic lesions.

The Treatment Intensity of Anticoagulant Therapy for Patients With Sepsis-Induced Disseminated Intravascular Coagulation and Outcomes: A Multicenter Cohort Study.

We examined the institutional variations in anticoagulation therapy for sepsis-induced disseminated intravascular coagulation (DIC) and their effects on patient outcomes. This post hoc analysis of a cohort study included 3195 patients with severe sepsis across 42 intensive care units. To evaluate differences in the intensity of anticoagulation therapy, the proportion of patients receiving anticoagulation therapy and the total number of patients with sepsis-induced DIC were compared. Predicted in-hospital mortality for each patient was calculated using logistic regression analysis. To evaluate survival outcomes, the actual/mean predicted in-hospital mortality ratio in each institution was calculated. Thirty-eight institutions with 2897 patients were included. Twenty-five institutions treated 60% to 100% (high-intensity institutions), while the rest treated 0% to 50% (low-intensity institutions) of patients with sepsis-induced DIC having anticoagulant therapy. Every 10-unit increase in the intensity of anticoagulant therapy was associated with lower in-hospital mortality (odds ratio: 0.904). A higher number of high-intensity institutions (compared to low-intensity institutions) had lower in-hospital mortality and fewer bleeding events than predicted. In conclusion, institutional variations existed in the use of anticoagulation therapy in patients with sepsis-induced DIC. High-intensity anticoagulation therapy was associated with better outcomes.

Large Volume Fluid Resuscitation for Severe Acute Pancreatitis is Associated With Reduced Mortality: A Multicenter Retrospective Study.

BACKGROUND AND AIMS: Although fluid resuscitation is critical in acute pancreatitis, the optimal fluid volume is unknown. The aim of this study is to evaluate the association between the volume of fluid administered and clinical outcomes in patients with severe acute pancreatitis (SAP). METHODS: We conducted a multicenter retrospective study at 44 institutions in Japan. Inclusion criteria were age 18 years or older, and diagnosed with SAP from 2009 to 2013. Patients were stratified into 2 groups: administered fluid volume <6000 and ≥6000 mL in the first 24 hours. We evaluated the association between the 2 groups and clinical outcomes using multivariable logistic regression analysis. The primary outcome was in-hospital mortality. Secondary outcomes included the incidence of pancreatic infection and the need for surgical intervention. RESULTS: We analyzed 1097 patients, and the mean fluid volume administered was 5618±3018 mL (mean±SD), with 708 and 389 patients stratified into the fluid <6000 mL and fluid ≥6000 mL groups, respectively. Overall in-hospital mortality was 12.3%. The fluid ≥6000 mL group had significantly higher mortality than the fluid <6000 mL group (univariable analysis, 15.9% vs. 10.3%; P<0.05). In multivariable logistic regression analysis, administration of ≥6000 mL of fluid within the first 24 hours was significantly associated with reduced mortality (odds ratio, 0.58; P<0.05). No significant association was found between the administered fluid volume and pancreatic infection, or between the volume administered and the need for surgical intervention. CONCLUSIONS: In patients with SAP, administration of a large fluid volume within the first 24 hours is associated with decreased mortality.

Epidemiology of disseminated intravascular coagulation in sepsis and validation of scoring systems.

PURPOSE: We investigated the epidemiology and outcome of disseminated intravascular coagulation (DIC) in patients with sepsis. MATERIALS AND METHODS: We analyzed data from a multicenter observational study (Japan Septic Disseminated Intravascular Coagulation [JSEPTIC-DIC] study) conducted in 42 intensive care units in Japan. DIC scores were calculated using two scoring systems: the International Society on Thrombosis and Haemostasis (ISTH) and Japanese Association for Acute Medicine (JAAM) criteria. We compared demographics and clinical characteristics of patients with and without DIC, and performed multivariable logistic regression analyses to assess the association of diagnosis and scores for DIC with in-hospital mortality. RESULTS: Of 1895 eligible patients, 1162 (61%) and 554 patients (29%) were diagnosed as having DIC by the JAAM and ISTH criteria, respectively. Patients with DIC had higher in-hospital mortality compared with those without DIC (33% vs. 20% in JAAM and 38% vs. 24% in ISTH). However, in multivariable analysis, the JAAM score (odds ratio 1.026, 95% confidence interval 0.958-1.097; p = 0.465) and the ISTH score (odds ratio 1.049, 95% confidence interval 0.969-1.135; p = 0.238) did not have an independent association with in-hospital mortality. CONCLUSIONS: Patients with sepsis and DIC have high mortality. However, the DIC are not independently associated with in-hospital mortality.

[Magnetic Resonance Vessel Wall Imaging Reveals a Ruptured Blood Blister-like Aneurysm:A Case Report].

Recent advances in digital subtraction angiography(DSA)and 3D-CT angiography(3D-CTA)have enabled the identification of tiny intracranial aneurysms. However, the imaging of blood blister-like aneurysms(BBAs)in the internal carotid artery(ICA)is still challenging. We report the case of a subarachnoid hemorrhage(SAH)with a ruptured BBA in the ICA that was revealed by magnetic resonance vessel wall imaging(MR-VWI). A 68-year-old woman presented with SAH. CT showed diffuse SAH(Fisher group 3). 3D-CTA and DSA showed a small bulge in the right ICA. MR-VWI with gadolinium showed thick wall enhancement in the supraclinoid portion of the right ICA; hence, we diagnosed SAH because of the ruptured BBA of the right ICA. Trapping combined with high-flow bypass was performed for the ruptured BBA. We concluded that MR-VWI may be useful for diagnosing ruptured BBAs under strict blood pressure management.

Nationwide registry of sepsis patients in Japan focused on disseminated intravascular coagulation 2011-2013.

Sepsis is a syndrome with physiologic, pathologic, and biochemical abnormalities induced by infection. Sepsis can induce the dysregulation of systemic coagulation and fibrinolytic systems, resulting in disseminated intravascular coagulation (DIC), which is associated with a high mortality rate. Although there is no international consensus on available treatments for sepsis-induced DIC, DIC diagnosis and treatment are commonly performed in Japanese clinical settings. Therefore, clinical data related to sepsis-induced DIC diagnosis and treatment can be obtained from Japanese clinical settings. We performed a retrospective nationwide observational study (Japan Septic Disseminated Intravascular Coagulation [J-SEPTIC DIC] study) to collect data regarding characteristics of sepsis patients in Japan, with a focus on coagulofibrinolytic dysregulation and DIC treatment received by each patient. The J-SEPTIC DIC study collected information for a total of 3,195 patients with severe sepsis and septic shock and is the largest data set in Japan on DIC diagnosis and treatment in clinical settings.