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OBJECTIVE: There are few reports on the relationship between carotid artery stenting (CAS) and frailty. In this study, medium-term outcome after CAS in patients with asymptomatic carotid artery stenosis was examined to see the effect of frailty itself. METHODS: A retrospective study was performed in 71 consecutive patients who were treated with CAS for asymptomatic lesions from January 2007 to June 2014. In this study, only patients without neurologic symptoms before treatment were included. Frailty was defined on the basis of the presence of ≥2 of the 5 items on the Cardiovascular Health Study (CHS) Index. The relationship of frailty with a composite endpoint of the incidence of stroke, disease requiring hospital admission, and death for 3 years after CAS was examined. RESULTS: There were 23 cases (average age 73.9 years, median CHS index 3) with frailty and 48 (average age 70.9 years, median CHS index 0) without frailty. There were no differences in comorbidities or CAS perioperative complications between these groups. However, there was a significantly higher incidence of the composite endpoint in patients with frailty (13/23 vs. 4/48, P < 0.001), and in multivariate analysis, frailty was strongly associated with this endpoint (odds ratio 28.24, 95% confidence interval 4.62-172.71). CONCLUSIONS: In CAS conducted for asymptomatic lesions, perioperative complications had no relationship with frailty. However, frailty is likely to be associated with lower activity of daily life in the medium term after CAS, and consideration of underlying diseases is required in patients with frailty.
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Arteria Carótida Común/cirugía , Estenosis Carotídea/epidemiología , Endarterectomía Carotidea , Stents/efectos adversos , Anciano , Angioplastia/efectos adversos , Estenosis Carotídea/cirugía , Endarterectomía Carotidea/métodos , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: We conducted a phase III trial of personalized peptide vaccination (PPV) for human leukocyte antigen (HLA)-A24+ recurrent glioblastoma to develop a new treatment modality. METHODS: We randomly assigned 88 recurrent glioblastoma patients to receive PPV (n = 58) or the placebo (n = 30) at a 2-to-1 ratio. Four of 12 warehouse peptides selected based on preexisting peptide-specific immunoglobulin G levels or the corresponding placebos were injected 1×/week for 12 weeks. RESULTS: Our trial met neither the primary (overall survival [OS]) nor secondary endpoints. Unfavorable factors for OS of 58 PPV patients compared with 30 placebo patients were SART2-93 peptide selection (n = 13 vs 8, hazard ratio [HR]: 15.9), ≥70 years old (4 vs 4, 7.87), >70 kg body weight (10 vs 7, 4.11), and performance status (PS)3 (8 vs 2, 2.82), respectively. Consequently, the median OS for PPV patients without SART2-93 selection plus one of these 3 favorable factors (<70 y old, ≤70 kg, or PS0-2) was significantly longer than that for the corresponding placebo patients (HR: 0.49, 0.44, and 0.51), respectively. Preexisting immunity against both all 12 warehouse peptides besides SART2-93 and the other cytotoxic T lymphocyte epitope peptides was significantly depressed in the patients with SART2-93 selection (n = 21) compared with that of the patients without SART2-93 selection (n = 67). Biomarkers correlative for favorable OS of the PPV patients were a lower percentage of CD11b+CD14+HLA-DRlow immunosuppressive monocytes and a higher percentage of CD4+CD45RA- activated T cells, the intermediate levels of chemokine C-C ligand 2 (CCL2), vascular endothelial growth factor, interleukin (IL)-6, IL-17, or haptoglobin, respectively. CONCLUSION: This phase III trial met neither the primary nor secondary endpoints.
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Antígenos de Neoplasias/inmunología , Neoplasias Encefálicas/tratamiento farmacológico , Vacunas contra el Cáncer/uso terapéutico , Glioblastoma/tratamiento farmacológico , Recurrencia Local de Neoplasia/tratamiento farmacológico , Vacunas de Subunidad/uso terapéutico , Adulto , Factores de Edad , Anciano , Neoplasias Encefálicas/inmunología , Neoplasias Encefálicas/metabolismo , Proteínas de Unión al ADN/inmunología , Femenino , Glioblastoma/inmunología , Glioblastoma/metabolismo , Antígeno HLA-A24/metabolismo , Humanos , Estado de Ejecución de Karnofsky , Masculino , Persona de Mediana Edad , Proteínas de Neoplasias/inmunología , Recurrencia Local de Neoplasia/inmunología , Recurrencia Local de Neoplasia/metabolismo , Medicina de Precisión , Pronóstico , Modelos de Riesgos Proporcionales , Tasa de Supervivencia , Resultado del Tratamiento , Adulto JovenRESUMEN
OBJECTIVE To avoid ischemic complications, it is important to consider the arteries in resection planning for lesions such as a vascular intraparenchymal tumor and arteriovenous malformation. Here, the clinical application of laser speckle flow imaging (LSFI) as a complementary method for the management of mass lesion-related arteries during surgery was evaluated. METHODS LSFI was performed in 12 patients with mass lesion-related arteries and brain tumor or arteriovenous malformation. The portable LSFI device was centered over the surgical field, and the relative cerebral blood flow (CBF) before and after the temporary interruption of the arteries was measured through continuous recording. CBF fluctuations permitted the classification of 3 kinds of artery-a feeding artery (FA), a "passing through" artery (PA), and a combined FA and PA (FA+PA)-based on decreased relative CBF in the inner resection area and unchanged CBF in the surrounding area (FA), unchanged CBF in the inner area and decreased CBF in the surrounding area (PA), or decreased CBF in both areas (FA+PA). This information allowed the appropriate management of these arteries and avoidance of postoperative ischemic complications. RESULTS Good visualization of CBF in the surgical field and relative CBF measurements in the regions of interest were achieved in real time with excellent spatiotemporal resolution. In 11 patients (92%) and 20 regions of interest, a decline in CBF was observed after temporary interruption of the FA (n = 8), PA (n = 2), and FA+PA (n = 2) types. There was a significant average reduction in CBF of 15.3% ± 29.0%. There were no ischemic complications, and only 1 patient had a postoperative ischemic lesion caused by resection through an artery that could not be viewed by LSFI due to a positional problem. CONCLUSIONS LSFI permits noninvasive and rapid intraoperative real-time recognition of mass lesion-related vasculature. This information can be used to avoid ischemic complications as a procedure complementary to neurophysiological monitoring.
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Isquemia Encefálica/prevención & control , Neoplasias Encefálicas/diagnóstico por imagen , Neoplasias Encefálicas/cirugía , Angiografía Cerebral , Imagen Óptica , Complicaciones Posoperatorias/prevención & control , Adulto , Anciano , Arterias/diagnóstico por imagen , Encéfalo/irrigación sanguínea , Encéfalo/diagnóstico por imagen , Encéfalo/cirugía , Isquemia Encefálica/diagnóstico por imagen , Neoplasias Encefálicas/irrigación sanguínea , Angiografía Cerebral/métodos , Circulación Cerebrovascular , Niño , Preescolar , Femenino , Humanos , Rayos Láser , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/diagnóstico por imagenRESUMEN
BACKGROUND: The importance of acute-phase brain temperature management is widely accepted for prevention of exacerbation of brain damage by a high body temperature. METHODS: In this study, we investigated the influence of body temperature in the early postoperative period on the outcomes of 62 patients with subarachnoid hemorrhage who were admitted to our department. Body temperature was measured from day 4 to day 14 after onset. The patients were divided into those treated with surgical clipping (clip group) and coil embolization (coil group), those graded I-III (mild) and IV-V (severe) based on the Hunt & Hess classification on admission, those with and without development of delayed cerebral ischemia (DCI), and those with favorable and poor outcomes. Body temperatures throughout the hospital stay were compared in each group. RESULTS: There was no significant difference in body temperature between the clip and coil groups or between the mild and severe groups, but body temperature was significantly higher in patients with DCI compared to those without DCI, and in patients with a poor outcome compared to those with a favorable outcome. CONCLUSIONS: Fever in the early postoperative period of subarachnoid hemorrhage is associated with development of DCI and a poor outcome.
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Regulación de la Temperatura Corporal , Isquemia Encefálica/prevención & control , Embolización Terapéutica/efectos adversos , Fiebre/terapia , Hipotermia Inducida , Procedimientos Neuroquirúrgicos/efectos adversos , Cuidados Posoperatorios/métodos , Hemorragia Subaracnoidea/terapia , Anciano , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/etiología , Isquemia Encefálica/fisiopatología , Femenino , Fiebre/diagnóstico , Fiebre/etiología , Fiebre/fisiopatología , Humanos , Hipotermia Inducida/efectos adversos , Masculino , Persona de Mediana Edad , Factores de Riesgo , Índice de Severidad de la Enfermedad , Hemorragia Subaracnoidea/diagnóstico , Hemorragia Subaracnoidea/fisiopatología , Factores de Tiempo , Resultado del TratamientoRESUMEN
The authors report a case of intracranial epidural hemorrhage (ICEH) during spinal surgery. We could not find ICEH, though we recorded transcranial electrical stimulation motor evoked potentials (TcMEPs). A 35-year-old man was referred for left anterior thigh pain and low back pain that hindered sleep. Sagittal T2-weighted magnetic resonance imaging revealed an intradural tumor at L3-L4 vertebral level. We performed osteoplastic laminectomy and en bloc tumor resection. TcMEPs were intraoperatively recorded at the bilateral abductor digiti minimi (ADM), quadriceps, tibialis anterior and abductor hallucis. When we closed a surgical incision, we were able to record normal TcMEPs in all muscles. The patient did not fully wake up from the anesthesia. He had right-sided unilateral positive ankle clonus 15 min after surgery in spite of bilateral negative of ankle clonus preoperatively. Emergent brain computed tomography scans revealed left epidural hemorrhage. The hematoma was evacuated immediately via a partial craniotomy. There was no restriction of the patient's daily activities 22 months postoperatively. We should pay attention to clinical signs such as headache and neurological findgings such as DTR and ankle clonus for patients with durotomy and cerebrospinal fluid (CSF) leakage. Spine surgeons should know that it was difficult to detect ICEH by monitoring with TcMEPs.
RESUMEN
BACKGROUND: The aims of this study were to reveal the strategies and pitfalls of motor-evoked potential (MEP) monitoring methods during supratentorial aneurysm surgery, and to discuss the drawbacks and advantages of each method by reviewing our experiences. METHODS: Intraoperative MEP monitoring was performed in 250 patients. Results from 4 monitoring techniques using combinations of 2 stimulation sites and 2 recording sites were analyzed retrospectively. RESULTS: MEP was recorded successfully in 243 patients (97.2%). Direct cortical stimulation (DCS)-spinal recorded MEP (sMEP) was used in 134 patients, DCS-muscle recorded MEP (mMEP) in 97, transcranial electrical stimulation (TES)-mMEP in 11 and TES-sMEP in 1. TES-mMEP during closure of the skull was used in 21 patients. DCS-mMEP was able to detect waveforms from upper and/or lower limb muscles. Alternatively, DCS-sMEP (direct [D]-wave) could accurately estimate amplitude changes. A novel "early warning sign" indicating ischemia was found in 21 patients, which started with a transiently increased amplitude of D-wave and then decreased after proximal interruption of major arteries. False-negative findings in MEP monitoring in 2 patients were caused by a blood insufficiency in the lenticulostriate artery and by a TES-sMEP recording, respectively. CONCLUSIONS: The results of this study suggest that to perform accurate MEP monitoring, DCS-mMEP or DCS-sMEP recording should be used as the situation demands, with combined use of TES-mMEP recording during closure of the skull. DCS-sMEP is recommended for accurate analysis of waveforms. We also propose a novel "early warning sign" of blood insufficiency in the D-wave.
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Potenciales Evocados Motores/fisiología , Aneurisma Intracraneal/cirugía , Monitoreo Intraoperatorio/métodos , Corteza Motora/fisiopatología , Adulto , Anciano , Anciano de 80 o más Años , Estimulación Eléctrica , Femenino , Humanos , Aneurisma Intracraneal/fisiopatología , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
OBJECT: Endoscopic surgery plays a significant role in the treatment of intracerebral hemorrhage. However, the residual hematoma cannot be measured intraoperatively from the endoscopic view, and it is difficult to determine the precise location of the endoscope within the hematoma cavity. The authors attempted to develop real-time ultrasound-guided endoscopic surgery using a bur-hole-type probe. METHODS: From November 2012 to March 2014, patients with hypertensive putaminal hemorrhage who underwent endoscopic hematoma removal were enrolled in this study. Real-time ultrasound guidance was performed with a bur-hole-type probe that was advanced via a second bur hole, which was placed in the temporal region. Ultrasound was used to guide insertion of the endoscope sheath as well as to provide information regarding the location of the hematoma during surgical evacuation. Finally, the cavity was irrigated with artificial cerebrospinal fluid and was observed as a low-echoic space, which facilitated detection of residual hematoma. RESULTS: Ten patients with putaminal hemorrhage>30 cm3 were included in this study. Their mean age (±SD) was 60.9±8.6 years, and the mean preoperative hematoma volume was 65.2±37.1 cm3. The mean percentage of hematoma that was evacuated was 96%±3%. None of the patients exhibited rebleeding after surgery. CONCLUSIONS: This navigation method was effective in demonstrating both the real-time location of the endoscope and real-time viewing of the residual hematoma. Use of ultrasound guidance minimized the occurrence of brain injury due to hematoma evacuation.
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Endoscopía/métodos , Procedimientos Neuroquirúrgicos/métodos , Hemorragia Putaminal/cirugía , Cirugía Asistida por Computador/métodos , Ultrasonografía Intervencional/métodos , Adulto , Anciano , Sistemas de Computación , Femenino , Humanos , Hemorragia Intracraneal Hipertensiva/patología , Hemorragia Intracraneal Hipertensiva/cirugía , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Hemorragia Putaminal/patología , Lóbulo Temporal/diagnóstico por imagen , Lóbulo Temporal/cirugía , Irrigación Terapéutica , Resultado del TratamientoRESUMEN
Magnetic resonance imaging (MRI) is an important diagnostic tool for glioblastoma, with almost all cases showing characteristic imaging findings such as a heterogeneous-ring enhanced pattern associated with significant edema. However, MRI findings for early-stage glioblastoma are less clear. In this study, a retrospective review of MRI findings in five patients showed slight T2WI signal changes on initial scans that developed into typical imaging findings of a ring-like or heterogeneously enhanced bulky tumor within 6 months. The diagnoses based on initial MRI were low grade glioma in three cases, venous thrombosis in one case, and uncertain in one case. Four cases were treated with gross total resection, while one case underwent biopsy. Immunohistochemical examinations showed that two cases were p53-positive, and that all cases were IDH1 R132H-negative and had overexpression of EGFR. FISH analysis showed that all cases were 1p19q LOH-negative. De novo glioblastoma was the final diagnosis in all cases. Our results show that initial MRI findings in early-stage glioblastoma of small ill-defined T2WI hyperintense lesions with poor contrast develop to bulky mass lesions with typical findings for glioblastoma in as short a period as 2.5 months. The early MRI findings are difficult to distinguish from those for non-neoplastic conditions, including ischemic, degenerative or demyelinating processes. Thus, there is a need for proactive diagnosis of glioblastoma using short-interval MRI scans over several weeks, other imaging modalities, and biopsy or resection, particularly given the extremely poor prognosis of this disease.
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Biomarcadores de Tumor/análisis , Neoplasias Encefálicas/patología , Glioblastoma/patología , Imagen por Resonancia Magnética/métodos , Anciano , Anciano de 80 o más Años , Neoplasias Encefálicas/metabolismo , Neoplasias Encefálicas/mortalidad , Femenino , Estudios de Seguimiento , Glioblastoma/metabolismo , Glioblastoma/mortalidad , Humanos , Técnicas para Inmunoenzimas , Hibridación Fluorescente in Situ , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Pronóstico , Estudios Retrospectivos , Tasa de SupervivenciaRESUMEN
BACKGROUND: Indications of clipping (Clip) or coil embolization (Coil) for unruptured cerebral aneurysms (uAN) was not elaborated because prediction of rupture and risk of treatment are difficult. This study aims to determine the risk-benefit analysis of treating uAN by a comprehensive and retrospective investigation of the adverse events and sequelae in patients treated by our Clip/Coil combined units. METHODS: Clip and Coil were performed in 141 and 80 patients, respectively; Clip for middle cerebral artery AN and Coil for paraclinoid or basilar apex AN. Worsening of modified Rankin scale or mini-mental state examination was defined as major morbidity. Minor morbidity or transient morbidity was defined as other neurologic deficits. Mortality and these morbidities were considered as serious adverse events. Convulsion or events outside the brain were defined as mild adverse events. RESULTS: Total mortality and major morbidity were low. Incidence of serious adverse events was not significantly different between the Clip and Coil (17 patients [12.1%] and 6 patients [7.5%]), but the number of total adverse events was significantly different (32 patients [22.7%] in Clip vs. 8 patients [10.0%] in Coil). Because mild morbidities were significantly more frequent in the Clip (20 patients [14.2%]) compared with the Coil (2 patients [2.5%]). Convulsion occurred in 11 (7.8%) patients in the Clip but none in the Coil. CONCLUSIONS: Our combined unit decreased the occurrence of mortality/major morbidity; however, minor adverse effects were common, especially in the Clip group because of many intrinsic problems of Clip itself. This result suggests further consideration for the treatment modality for uAN.
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Embolización Terapéutica/efectos adversos , Aneurisma Intracraneal/terapia , Adulto , Anciano , Anciano de 80 o más Años , Arteria Cerebral Anterior/patología , Enfermedades de las Arterias Carótidas/patología , Infarto Cerebral/etiología , Infarto Cerebral/patología , Trastornos Cerebrovasculares/etiología , Trastornos Cerebrovasculares/patología , Embolización Terapéutica/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Calidad de Vida , Medición de Riesgo , Factores de Riesgo , Instrumentos Quirúrgicos , Vasoespasmo Intracraneal/etiología , Vasoespasmo Intracraneal/patologíaRESUMEN
We report a case of a 62-year-old woman with multiple ischemic strokes caused by nonbacterial thrombotic endocarditis (NBTE) because of gallbladder cancer. Transesophageal echocardiography showed NBTE on the mitral valve. The NBTE disappeared with anticoagulation treatment for 2 weeks. Abdominal computed tomography showed a gallbladder tumor that was surgically resected. Histopathologic studies showed poorly differentiated tumor cells and the production of mucin. Trousseau syndrome with gallbladder cancer is very rare. We suggest that the development of NBTE is related to the production of mucin.
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Isquemia Encefálica/etiología , Endocarditis/complicaciones , Neoplasias de la Vesícula Biliar/complicaciones , Accidente Cerebrovascular/etiología , Femenino , Humanos , Persona de Mediana EdadRESUMEN
BACKGROUND: After cardioembolic stroke (CES), left atrial thrombus (LAT) is detected by transesophageal echocardiography (TEE) in some cases but not in others. We propose that there are 2 types of embolization in CES: fragmental and massive embolization. METHODS: Consecutive patients with nonvalvular atrial fibrillation (AF) of acute CES or transient ischemic attack (TIA) were prospectively enrolled in the study between May 2009 and July 2011. TEE was performed within 7 days of admission. The patients were classified into 2 groups: those with occlusion of the main trunk (internal carotid artery, M1, and basilar artery; group M) and those with occlusion of other distal arteries (group D). Clinical features were compared between patients who did and did not have a thrombus on TEE. RESULTS: Of the 41 patients in the study, 21 were in group M and 20 were in group D. Age, sex, and treatment with tissue plasminogen activator did not differ significantly between the 2 groups. The rate of detection of LAT was significantly higher in group D (14% v 65%; P < .001). CONCLUSIONS: Patients with distal artery occlusion had a significantly higher rate of LAT compared to those with main trunk occlusion. Distal artery occlusion in CES therefore tends to result from fragmental embolization and is associated with a remnant LAT, with which there may be a concern of a risk of early recurrence.
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Fibrilación Atrial/complicaciones , Embolia Intracraneal/etiología , Accidente Cerebrovascular/complicaciones , Accidente Cerebrovascular/etiología , Anciano , Trombosis de las Arterias Carótidas/complicaciones , Angiografía Cerebral , Ecocardiografía Transesofágica , Femenino , Humanos , Angiografía por Resonancia Magnética , Imagen por Resonancia Magnética , Masculino , Análisis Multivariante , Estudios Prospectivos , Resultado del TratamientoRESUMEN
We report the case of a 37-year-old male with Cowden disease that caused a gradual neurological deficit because of rupture of a brain stem cavernous hemangioma. Removal of the hemangioma and hematoma was performed with an infrafacial triangle approach. Nine months after the operation, magnetic resonance imaging showed abnormal vessels on the cerebellar surface. Digital subtraction angiography showed a dural arteriovenous fistula (dAVF) from part of the meningeal artery to the ectatic inferior vermian vein with cortical reflux. After embolization, surgical obliteration of the dAVF was performed. Surgical findings showed neovascularization in the thickened dura, in which dural vessels shunted to cerebellar vessels through adhesion between the dura mater and cerebellar surface. Therefore, the thickened dura was removed with the cerebellar surface. This case suggests that postoperative angiogenesis may cause arteriovenous fistula in patients with Cowden disease.
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Neoplasias del Tronco Encefálico/cirugía , Malformaciones Vasculares del Sistema Nervioso Central/etiología , Duramadre/irrigación sanguínea , Síndrome de Hamartoma Múltiple/complicaciones , Hemangioma Cavernoso del Sistema Nervioso Central/cirugía , Hematoma/cirugía , Procedimientos Neuroquirúrgicos/efectos adversos , Adulto , Angiografía de Substracción Digital , Biopsia , Neoplasias del Tronco Encefálico/complicaciones , Neoplasias del Tronco Encefálico/diagnóstico , Neoplasias del Tronco Encefálico/genética , Malformaciones Vasculares del Sistema Nervioso Central/diagnóstico , Malformaciones Vasculares del Sistema Nervioso Central/terapia , Angiografía Cerebral/métodos , Embolización Terapéutica , Síndrome de Hamartoma Múltiple/diagnóstico , Síndrome de Hamartoma Múltiple/genética , Hemangioma Cavernoso del Sistema Nervioso Central/complicaciones , Hemangioma Cavernoso del Sistema Nervioso Central/diagnóstico , Hemangioma Cavernoso del Sistema Nervioso Central/genética , Hematoma/diagnóstico , Hematoma/etiología , Humanos , Imagen por Resonancia Magnética , Masculino , Mutación , Neovascularización Patológica , Fosfohidrolasa PTEN/genética , Reoperación , Rotura Espontánea , Resultado del TratamientoRESUMEN
We report the case of a 67-year-old man with repeating cerebral embolism caused by a dolichoectatic right common carotid artery. The patient had a history of hypertension, hypercholesterolemia, cigarette smoking, and a postoperative abdominal aortic aneurysm. He presented with a sudden onset of weakness of the left arm and leg. Magnetic resonance imaging revealed old and fresh infarction in the right cerebral hemisphere. Carotid duplex ultrasonography showed a dolichoectatic right common carotid artery with a maximum diameter of 39 mm with thick plaque and strong spontaneous echo contrast. The flow velocity was considerably reduced, which caused thrombus formation, and strong antithrombotic therapy was required. This case provides a rare example of ischemic stroke caused by extracranial carotid artery dolichoectasia.
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Isquemia Encefálica/etiología , Isquemia Encefálica/patología , Arterias Carótidas/patología , Enfermedades de las Arterias Carótidas/complicaciones , Enfermedades de las Arterias Carótidas/patología , Imagen por Resonancia Magnética/métodos , Anciano , Diagnóstico Diferencial , Dilatación Patológica/complicaciones , Dilatación Patológica/patología , Humanos , Masculino , RecurrenciaRESUMEN
We report a case of intracranial yolk sac tumor in a 17-year-old girl with Down syndrome who presented with left slowly progressive hemiparesis. Initial magnetic resonance imaging (MRI) showed a small area of ill-defined abnormal signal intensity without a mass in the bilateral basal ganglia. These findings progressed very slowly for 2 years, but then the lesion rapidly progressed to a huge mass on MRI 4 months after the previous scan. The patient subsequently underwent a blood examination and endoscopic biopsy, and was finally diagnosed with yolk sac tumor. Standard platinum-based chemotherapy and radiotherapy were performed as soon as practicable. The frequency of solid cancer in patients with Down syndrome is generally lower than that in individuals without this disorder. Brain tumor is also rare in Down syndrome, but half of these cases are germ cell tumors. Moreover, slowly progressive non-tumor-like lesions in the basal ganglia may also be germ cell tumors. Therefore, MRI signal abnormalities in the basal ganglia in patients with Down syndrome require careful and frequent follow-up scans based on the possibility of a germ cell tumor that may exhibit rapid growth.
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Ganglios Basales , Neoplasias Encefálicas/diagnóstico , Neoplasias Encefálicas/terapia , Síndrome de Down/complicaciones , Tumor del Seno Endodérmico/diagnóstico , Tumor del Seno Endodérmico/terapia , Adolescente , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Neoplasias Encefálicas/patología , Quimioradioterapia , Cisplatino/administración & dosificación , Progresión de la Enfermedad , Tumor del Seno Endodérmico/patología , Etopósido/administración & dosificación , Femenino , Humanos , Ifosfamida/administración & dosificación , Imagen por Resonancia Magnética , Paresia/etiología , Resultado del TratamientoRESUMEN
A 31-year-old healthy male presented with a rare case of cerebral arteriovenous malformation (AVM) manifesting as repeated ischemic attacks and cerebral infarction causing left sensori-motor disturbance. Neuroimaging revealed cerebral infarction in the right thalamus as well as right occipital AVM without bleeding. The AVM was mainly fed by the right angular artery, and the right posterior cerebral artery (PCA) showed mild stenosis and segmental dilation at the P(2)-P(3) portion. After referral to our hospital, transient ischemic attacks causing left homonymous hemianopsia, and left arm and leg numbness were frequently recognized. Additional imaging revealed a new ischemic lesion in the occipital lobe, and repeated cerebral angiography showed right PCA occlusion at the P(2)-P(3) segment. Cerebral AVM presenting with cerebral infarction due to occlusion of feeding arteries is rare. In our case, intimal injury due to increased blood flow or spontaneous dissection of the artery were possible causes. We should monitor any changes in the architecture and rheology of the feeding vessels during the clinical course to prevent ischemic complications.
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Infarto de la Arteria Cerebral Posterior/diagnóstico , Malformaciones Arteriovenosas Intracraneales/diagnóstico , Ataque Isquémico Transitorio/diagnóstico , Lóbulo Occipital/irrigación sanguínea , Adulto , Angiografía Cerebral , Dominancia Cerebral/fisiología , Humanos , Imagen por Resonancia Magnética , Masculino , Examen Neurológico , Tálamo/irrigación sanguínea , Tomografía Computarizada por Rayos XRESUMEN
OBJECTIVE: Motor-evoked potentials (MEPs) are commonly recorded from upper-extremity muscles, whereas lower-extremity MEP (LE-MEP) monitoring has not been adequately established. The goal of the study was to develop a MEP monitoring method using direct cortical stimulation (DCS) for predicting motor deficits of lower extremities. METHODS: Intra-operative LE-MEP monitoring was performed in 22 patients. After craniotomy, a subdural electrode was placed on the cortex so that the optimal contact was positioned 2 cm lateral from the midline on the motor cortex. The electrodes for stimulation consisted of a cathode at Fpz and an anode at the optimal contact site on the motor cortex. After stimulation was performed with short trains of five stimuli, LE-MEPs were recorded from the lower-limb muscles. RESULTS: LE-MEPs were consistently recorded in all patients. Disappearance or amplitude reduction of MEP waveforms was observed in five patients, but the MEP waveforms had recovered and remained at the control level by dural closure, and no permanent motor deficit was observed in any patient. CONCLUSIONS: We accomplished LE-MEP recording during supratentorial surgery using monopolar DCS with a subdural electrode placed on the convex side of the motor cortex. SIGNIFICANCE: A useful method of intra-operative LE-MEP recording was described.
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Potenciales Evocados Motores/fisiología , Extremidad Inferior/fisiología , Monitoreo Intraoperatorio/métodos , Corteza Motora/fisiología , Músculo Esquelético/fisiología , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Aneurisma Intracraneal/fisiopatología , Aneurisma Intracraneal/cirugía , Masculino , Persona de Mediana EdadRESUMEN
UNLABELLED: In surgical treatment of cervical radiculopathy, localization of the responsible lesions by various imaging modalities is essential. Among them, MRI is non-invasive and plays a primary role in the assessment of spinal radicular symptoms. However, demonstration of nerve root compression is sometimes difficult by the conventional methods of MRI, such as T1 weighted (T1W) and T2 weighted (T2W) sagittal or axial images. We have applied a new technique of curved coronal multiplanar reconstruction (MPR) imaging for the diagnosis of cervical radiculopathy. METHODS: Ten patients (4 male, 6 female) with ages between 31 and 79 year-old, who had clinical diagnosis of cervical radiculopathy, were included in this study. Seven patients underwent anterior key-hole foraminotomy to decompress the nerve root with successful results. All the patients had 3D MRI studies, such as true fast imaging with steady-state precession (FISP), 3DT2W sampling perfection with application optimized contrasts using different fillip angle evolution (SPACE), and 3D multi-echo data image combination (MEDIC) imagings in addition to the routine MRI (1.5 T Avanto, Siemens, Germany) with a phased array coil. The curved coronal MPR images were produced from these MRI data using a workstation. RESULTS: The nerve root compression was diagnosed by curved coronal MPR images in all the patients. The compression sites were compatible with those of the operative findings in 7 patients, who underwent surgical treatment. The MEDIC imagings were the most demonstrable to visualize the nerve root, while the 3D-space imagings were the next. CONCLUSION: The curved coronal MPR imaging is useful for the diagnosis of accurate localization of the compressing lesions in patients with cervical radiculopathy.
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Imagen por Resonancia Magnética/métodos , Radiculopatía/diagnóstico , Adulto , Anciano , Femenino , Humanos , Imagenología Tridimensional , Masculino , Persona de Mediana Edad , Radiculopatía/cirugíaRESUMEN
PURPOSE: Spinal canal stenosis (CS) occurs in patients with hydrocephalus who are treated with cerebrospinal fluid (CSF) shunting. The pathophysiology of CS comprises CSF overdrainage. We analyzed the incidence of CS and the factors causing it. METHODS: Thirty-three patients who underwent ventriculoperitoneal shunt during childhood visited the Outpatient Department in Yamaguchi University Hospital in 2006. Diameters of spinal canal at C(4) were measured. Treatment procedure, age, and type of hydrocephalus in the patients with CS were compared with those without CS. RESULTS: Of the 33 patients, 10 (30.3%) presented CS, and two (6.1%) were symptomatic. A low-pressure valve caused CS with a significantly higher incidence than a medium- or high-pressure valve (60.0% vs. 17.4%, P < 0.05). Although the difference was not significant, the average age of shunt insertion for a patient with CS was slightly less (0.87 +/- 0.99) than for a patient without CS (1.63 +/- 1.58). No differences in the CS incidence were observed between obstructive and communicating hydrocephalus. CONCLUSION: In order to prevent CS, the hydrocephalus should be appropriately controlled by using a medium- or high-pressure valve until the diameter of the spinal canal reaches the required level. Adjustment of the programmable valve with the patient's growth should be ideal.
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Derivaciones del Líquido Cefalorraquídeo/efectos adversos , Hidrocefalia/complicaciones , Hidrocefalia/cirugía , Estenosis Espinal/epidemiología , Adolescente , Factores de Edad , Quistes Aracnoideos/complicaciones , Quistes Aracnoideos/cirugía , Ventrículos Cerebrales/anomalías , Ventrículos Cerebrales/lesiones , Niño , Preescolar , Fosa Craneal Posterior/cirugía , Diseño de Equipo , Falla de Equipo , Femenino , Humanos , Hidrocefalia/epidemiología , Lactante , Recién Nacido , Imagen por Resonancia Magnética , Masculino , Estenosis Espinal/patología , Estenosis Espinal/cirugía , Columna Vertebral/patología , Columna Vertebral/cirugíaRESUMEN
Thrombolytic therapy with intravenous and intra-arterial recombinant tissue-type plasminogen activator (rtPA) has been established for the treatment of acute ischemic stroke. However, tPA has also been suggested to have neurotoxic effects. The purpose of this study was to examine direct neurotoxicity of rtPA in vivo. The animals (Wistar rats) were divided to the following three groups: low-dose (15 micromol/L) rtPA group (n = 6); high-dose (30 micromol/L) rtPA group (n = 6); and control (physiological saline) group (n = 6). The rtPA solution was perfused into the cortex via a microdialysis probe. The volume of the lesion was quantified histologically by image analysis of the lesions. Blood-brain barrier (BBB) disruption was evaluated by intravenous injection of Evans blue, and injury to the basal lamina was evaluated by immunohistochemistry using an anti-laminin antibody. In the rtPA-perfused animals, a pale lesion was produced around the probe, and microscopically, neurons showed necrotic changes. The volume of the lesions increased significantly as the concentration of perfused rtPA was increased. Marked extravasation of Evans blue was observed, and laminin immunoreactivity of blood vessels in the rtPA-induced lesions was lost. These results suggest that rtPA promotes acute direct neurotoxicity and participates in disruption of the microvascular basal lamina to cause BBB disruption, thereby increasing edema formation.
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Encéfalo/patología , Síndromes de Neurotoxicidad/patología , Activador de Tejido Plasminógeno/toxicidad , Animales , Análisis de los Gases de la Sangre , Presión Sanguínea/fisiología , Barrera Hematoencefálica/efectos de los fármacos , Temperatura Corporal/fisiología , Edema Encefálico/patología , Muerte Celular/fisiología , Colorantes , Azul de Evans , Espacio Extracelular/fisiología , Concentración de Iones de Hidrógeno , Inmunohistoquímica , Laminina/metabolismo , Masculino , Ratas , Ratas Wistar , Proteínas Recombinantes/toxicidadRESUMEN
It has been well documented that memory difficulties in patients with anterior skull base meningioma may improve after tumour resection. However, there have been few reports on studies where precise testing of cognitive function has been conducted before and after surgery. Here we report 2 cases of anterior skull base meningioma where 2 tests of cognitive function, the Wechsler adult intelligence scale-revised (WAIS-R) and the Wechsler memory scale-revised (WMS-R), were performed by the patient before and after surgical treatment. After the operation there was a dramatic increase in the performance IQ as measured by the WAIS-R. In addition, the scores for both the "Attention/Concentration" and the "Delayed Recall" subsets of the WMS-R scale improved. There were differences between the 2 patients in the length of time required for functional recovery and this was thought to be due to the tumour size and the age of the patient. The use of these scales would enable physicians who are treating patients with anterior skull base meningioma to assess the recovery time that is likely to be needed before full return of cognitive function after surgery.