Intracranial aneurysm with systemic lupus erythematosus treated by endovascular intervention.

Systemic lupus erythematosus (SLE) is a chronic disease with multiple pathologies that can affect every organ system of the body including central nervous system. Intracerebral aneurysms and subarachnoid hemorrhage (SAH) are one of comparatively rarer manifestations of central nervous system SLE. Here we present a case of known SLE complicated by the rupture of intra cerebral aneurysm at basilar artery tip which was successfully treated with endovascular coiling.

The pharmacokinetics and pharmacodynamics of meropenem in the cerebrospinal fluid of neurosurgical patients.

This study examined the pharmacokinetics and pharmacodynamics of meropenem in cerebrospinal fluid (CSF). Meropenem (0.5 g every 8 h) was administered by 0.5-h infusion to six neurosurgical patients. Lumbar CSF and venous blood samples were obtained at 0.5-16 h after the start of the first infusion. Drug concentrations in the CSF and plasma were analyzed pharmacokinetically and used for a Monte Carlo simulation with the minimum inhibitory concentration (MIC) data of clinical isolates in Japan. Meropenem penetrated into the CSF with the area under the drug concentration-time curve ratio of 0.10 +/- 0.03 (mean +/- SD) and the repeated infusions caused the drug concentration in the CSF to accumulate slightly. Against Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae, and Escherichia coli isolates, 0.5 g q8h achieved a >90% probability of pharmacodynamic target (50% of the time above MIC) attainment, and 1 g q8h was needed for a >90% probability of target (100% of the time above MIC) attainment. However, against Pseudomonas aeruginosa, 2 g q8h achieved a lower probability of target attainment. These results should help us to better elucidate the pharmacokinetics of meropenem in the cerebrospinal space while also helping us to choose the appropriate drug dosages for the management of bacterial meningitis.

Transfemoral transvenous embolization of dural arteriovenous fistulas involving the isolated transverse-sigmoid sinus.

SUMMARY: Dural arteriovenous fistulas involving the transverse-sigmoid sinus (T-S dAVFs) are sometimes isolated because this affected sinus is often thrombosed. It is difficult to perform to microcatheter cannulation to the isolated sinus through the thrombosed portion. We are now treating these T-S dAVFs by transfemoral transvenous embolization via the ipsilateral side even if the affected sinus is thrombosed and isolated or not. We use a triaxial system (6Fr. guiding catheter / 4Fr. diagnostic catheter / microcatheter) to emphasize the pushability and handling of the microcatheter. And we insert 4Fr. Catheter into the affected sinus. So we can perform microcatheter cannulation into the isolated and affected sinus for treatment by coil embolization with various detachable coils.

Subtracted 3D CT angiography for evaluation of internal carotid artery aneurysms: comparison with conventional digital subtraction angiography.

BACKGROUND AND PURPOSE: 3D computed tomographic angiography (3DCTA) has been used recently for the evaluation of intracerebral aneurysms, but it is difficult to use this technique to visualize aneurysms near the base of the skull because of the presence of bone. Subtracted 3DCTA could replace digital subtraction angiography (DSA) for evaluation of aneurysms near the base of the skull if the 2 methods were to give similar results. The aim of this study was to compare the evaluation of aneurysms of the internal carotid artery (ICA) near the base of the skull by subtracted 3DCTA and DSA. METHODS: CTA and DSA were obtained in 25 patients with unruptured aneurysms of the ICA. To create subtracted 3DCTA images, we used a volume subtraction (VS) method, wherein nonenhanced volume data are subtracted from enhanced volume data. CTA and DSA were reviewed by 2 neuroradiologists who performed the detection and characterization of aneurysms of the ICA by using 2D multiplanar reformatted (MPR) and VS- and nonsubtracted (NS)-3DCTA images with volume rendering techniques. RESULTS: DSA detected 29 aneurysms in the 25 patients. VS-3DCTA detected all 29 aneurysms in the 25 patients and was equivalent to DSA for evaluating their characteristics (location, size, and direction). NS-3DCTA detected 19 (1 cavernous, 4 ophthalmic, 1 superior hypophyseal, 7 posterior communicating, and 6 anterior choroidal artery) of these 29 aneurysms, but it could not characterize ophthalmic and superior hypophyseal artery aneurysms because they were only partly visible on NS-3DCTA because of bony structures. 2D-MPR images detected all but the small aneurysms (24 of 29 detected). VS-3DCTA and 2D-MPR could visualize all branching arteries (ophthalmic, posterior communicating, and anterior choroidal) detected by DSA, but NS-3DCTA could not visualize ophthalmic arteries because of the presence of bony structures. CONCLUSION: VS-3DCTA can be used as an alternative to DSA for preoperative examination of aneurysms near the skull base, where it provides equivalent identification and characterization.

CT perfusion imaging for childhood moyamoya disease before and after surgical revascularization.

Moyamoya disease is a progressive occlusive disease of the circle of Willis with prominent collateral arterial formation. We report on a 12-year-old girl with moyamoya disease presenting with transient ischemic attacks (TIAs). Surgical indirect revascularization was performed. The patient did not suffer further TIAs at 12 month follow-up. Pre and postoperative cerebral perfusion were studied in quantitative single photon emission computerized tomography (SPECT) and CT perfusion imaging. CT perfusion imaging demonstrated postoperatively increased cerebral blood flow as well as SPECT before and after revascularization. Furthermore, the area of decreased vascular reserve in SPECT with acetazolamide corresponded to areas of increased cerebral blood volume in CT perfusion imaging. CT perfusion imaging was equivalent to SPECT in accuracy, and superior in spatial resolution. CT perfusion imaging is likely to become more widely available as an easy-to-perform technique for assessing cerebral perfusion in a patients with moyamoya disease.

Characteristics of aneurysms of the internal carotid artery bifurcation.

BACKGROUND: Arterial bifurcations are sites of maximal hemodynamic stress, where cerebral aneurysms commonly develop. However, in our experience with endovascular treatment for aneurysms of the internal carotid artery (ICA) bifurcation, we often experienced that the aneurysmal neck did not necessarily exist only at the ICA bifurcation (ICBi). In this study, we have retrospectively evaluated characteristics of aneurysms at the ICBi. METHODS: Ten ICBi aneurysms in 10 consecutive patients were studied retrospectively. The size of the aneurysms, the angles formed between the ICA and the anterior cerebral artery (ACA) and middle cerebral artery (MCA), and the diameter of the ICA, ACA and MCA were measured. Furthermore, to study the relationship between the location of the aneurysmal neck and the bifurcation of the ICA, the distance between the midline of the aneurysmal neck and of the ICA was measured. RESULTS: The average aneurysm size was 6.3+/-3.2 mm and the average neck was 3.1+/-1.2 mm. The average ICA-ACA angle was 57.3+/-16.5 degrees, and the average ICA-MCA angle was 128.9+/-24.1 degrees. The average diameters of the ICA, ACA and MCA were 2.9+/-0.5 mm, 1.9+/-0.4 mm and 2.5+/-0.4 mm, respectively. The average distance between the midline of the aneurysmal neck and the ICA was 1.6+/-0.6 mm, and all aneurysmal necks of the ICBi arose from the side of the ACA. CONCLUSION: ICBi aneurysms were deviated to the side of the A1 segment of the ACA, where the artery might suffer higher hemodynamic stress.

Endovascular treatment of basilar tip aneurysms associated with moyamoya disease.

We report the efficacy and safety of endovascular treatment of basilar tip aneurysms (BTA) in five patients with moyamoya disease. The patients underwent intra-aneurysmal embolisation with detachable platinum coils. Three BTA presented with subarachnoid haemorrhage (SAH); the other two were asymptomatic. In four cases, one embolisation procedure produced >95% angiographic obliteration of the aneurysm. In the other patient, 80-90% obliteration was achieved initially, but due to growth of the residual aneurysm, the procedure was repeated 7 months later. Two patients experienced transient oculomotor paresis as a procedure-related complication. Mean follow-up was 43.6+/-34.0 months (range 8-92 months). One patient died of putaminal haemorrhage unrelated to the aneurysm 15 months after embolisation. The other four had no subsequent SAH and survived without sequelae. Endovascular embolisation using detachable platinum coils proved to be a safe and efficient treatment modality for BTA associated with moyamoya disease.

A small asymptomatic intracranial aneurysm in an elderly woman that ruptured soon after discovery.

A 78-year-old woman underwent magnetic resonance (MR) imaging to assess the deterioration of her right hemiparesis initially caused by putaminal hemorrhage that occurred 5 years prior to referral. MR imaging detected an anterior communicating artery aneurysm but no new lesion was seen that might have caused the deterioration was observed. Hemiparesis improved within several days and she was referred for endovascular treatment of the aneurysm. Digital subtraction angiography demonstrated a 4.4 mm long aneurysm at the A1-A2 junction of her left anterior cerebral artery. Information on the risk associated with treatment caused her to hesitate. Three days after discharge and 40 days after the discovery of the aneurysm it ruptured, causing severe subarachnoid hemorrhage. The patient died on the following day.

Experimental study on slow-speed elongation injury of the peripheral nerve: electrophysiological and histological changes.

Slow-speed elongation of the sciatic nerves was induced in 41 rabbits by lengthening the osteotomized femur by 2.1 mm/day with an external fixator. Time courses were monitored. About 2 weeks after elongation began, the amplitude of the compound nerve action potentials decreased, and delayed latency began. Histological observations showed that the wavy structure of the nerve fibers was lost during the stage at which reduction in the amplitude of action potentials occurred. In some nerve fibers, narrowing of the axons was observed. Further elongation caused delay in the percent latency. Histologically, collagen fibers were noted in the nerve fascicles, as well as narrowing in all the nerve fibers. When elongation ceased at the stage at which a reduction in the amplitude of action potential was noted, recovery from nerve damage followed. When elongation did not cease until the stage at which latency was delayed, however, recovery was not apparent, either histologically or electrophysiologically. The critical level of percent amplitude for recovery was at 82.4% of the original level (the critical rate for bone lengthening was 20.5%).

Primary intracerebral and aneurysmal subarachnoid hemorrhage in Izumo City, Japan. Part II: management and surgical outcome.

OBJECT: The purpose of this study was to assess the overall management and surgical outcome of primary intracerebral hemorrhage (ICH) and aneurysmal subarachnoid hemorrhage (SAH) among the 85,000 residents of Izumo City, Japan. METHODS: During 1991 through 1996, 267 patients with ICH and 123 with SAH were treated in Izumo. Of the 267 patients with ICH, 25 underwent hematoma removal by open craniotomy or suboccipital craniectomy and 34 underwent stereotactic evacuation of the hematoma, whereas aneurysm clipping was performed in 71 of the 123 patients with SAH; operability rates were thus 22% for ICH and 58% for SAH (p < 0.0001). The overall 30-day survival rates were 86% for ICH and 66% for SAH (p < 0.0001) and the 2-year survival rates were 73% and 62% (p = 0.0207), respectively. In patients who underwent surgery, 30-day and 2-year survival rates were 93% for ICH and 100% for SAH (p = 0.0262), and 75% for ICH and 97% for SAH (p = 0.0002), respectively. In patients with ICH, the most important predictors of 30-day case-fatality rates were the volume of the hematoma, the Glasgow Coma Scale (GCS) score, rebleeding, and midline shifting, whereas those for 2-year survival were the GCS score, age, rebleeding, and hematoma volume. In patients with SAH, the most important determinants of 30-day case-fatality rates were the GCS score and age, whereas only the GCS score had a significant impact on 2-year survival. CONCLUSIONS: The overall survival rates for patients with ICH or SAH in Izumo were more favorable than those in previously published epidemiological studies. However, despite improved surgical results, the overall management of ICH and SAH still produced an unsatisfactory outcome, mainly because of primary brain damage.

[A case of multiple cerebral arteriovenous malformations treated by gamma knife radiosurgery].

We reported a case of multiple cerebral arteriovenous malformations (AVMs) treated by gamma knife radiosurgery. A 6-year-old girl was admitted because of systemic tonic convulsion. At the first admission, we performed only vertebral angiography, which showed a 15 mm cerebral AVM. It was fed by the right posterior cerebral artery and drained into the great vein of Galen. Seven years after the first admission, the patient returned again with severe headache. Four-vessel cerebral angiograms showed another 7 mm AVM fed by the left frontopolar artery. We treated both cerebral AVMs bv gamma knife radiosurgery. Follow-up angiograms performed 2 years after radiosurgery confirmed the disappearance of both AVMs. We then discuss treatment of multiple cerebral AVMs.

[A case of cranial metastasis of hepatocellular carcinoma].

A case of cranial metastasis of hepatocellular carcinoma is reported. A 77-year-old woman with an elastic hard tumor in the right temporal region was referred to our department on April 30, 1992. On admission, the patient had slight weakness of the left upper limb. Plain skull X-ray and computed tomography (CT) showed bone destruction in the right temporal region. Magnetic resonance images (MRI) showed that the tumor was hypo-intense with T1-sequences and hyper-intense with T2-sequences, and included hyper-intense spots on both T1- and T2-images. Right carotid angiography showed that the tumor was fed by the middle meningeal and accessory meningeal arteries. The patient became disoriented, and the left hemiparesis worsened on May 4, 1992. CT scan revealed an irregular high-density area in the tumor because of intratumoral hemorrhage. After embolization of the arteries feeding the tumor, surgery was performed on May 8, 1992, and the tumor was totally removed. Histological examination of the tumor specimen revealed that it was a metastatic hepatocellular carcinoma. The patient died 8 months after initial diagnosis because of hepatocellular carcinoma.

[A case of meningioma associated with intracerebral hemorrhage and acute deterioration].

We report a case of convexity meningioma associated with sudden onset of intracerebral hemorrhage followed by acute deterioration. A 76-year-old previously healthy male suddenly collapsed into coma and was admitted to our department. On admission, he was deeply comatose. Computerized tomography (CT) scan revealed intracerebral hemorrhage in the right frontal lobe, together with an isodense mass lesion of about 5 cm in diameter. The density on the fronto-medial side of the mass increased after administration of contrast medium, probably due to extravasation. However, there was no enhancement of the mass lesion. Cerebral angiography revealed marked prolongation in circulation time and extravasation via the right middle internal frontal artery. The right middle meningeal artery was dilated and elongated, but no tumor stain was found. The patient died on the following day. Autopsy disclosed massive hemorrhage in the right frontal lobe together with a convexity meningioma. Histological examination showed that the tumor was a fibroblastic meningioma. We review previously reported cases of convexity meningioma associated with intracranial hemorrhage, and discuss mainly the mechanism of bleeding.

Synthesis of omega-(methoxycarbonyl)alkyl and 9-(methoxycarbonyl)-3,6-dioxanonyl glycopyranosides for the preparation of carbohydrate-protein conjugates.

omega-(Methoxycarbonyl)alkyl glycopyranosides of D-mannose having C4, C7, C9, C12, and C15 carbon chains, L-fucose and 2-acetamido-2-deoxy-D-mannose having C7 and C9 carbon chains, D-xylose and 2-acetamido-2-deoxy-L-fucose having a C9 carbon chain, and 9-(methoxycarbonyl)-3,6-dioxanonyl glycopyranosides of D-mannose, 2-acetamido-2-deoxy-D-mannose, and L-fucose were synthesized as intermediates for coupling to human serum albumin in order to examine the effect of chain length and hydrophobicity of the spacer arm on the binding specificity of lectins. 8-(Methoxycarbonyl)octyl glycosides of beta-D-Man-(1----2)-alpha-D-Man, alpha-D-Man-(1----2)-alpha-D-Man, alpha-D-ManNAc-(1----2)-alpha-D-Man, beta-D-GlcNAc-(1----2)-alpha-D-Man, and their 6-O-positional isomers, beta-D-Man-(1----6)-alpha-D-Man, alpha-D-Man-(1----6)-alpha-D-Man, alpha-D-ManNAc-(1----6)-alpha-D-Man, and beta-D-GlcNAc-(1----6)-alpha-D-Man, were also synthesized.

Absorption and metabolic characteristics of p-aminobenzoic acid and its isomer, m-aminobenzoic acid, from the rat small intestine.

Absorption and metabolic characteristics of p-aminobenzoic acid (PABA) and m-aminobenzoic acid (MABA) from the rat small intestine were examined by means of in situ recirculation and in vitro everted sac experiments. p-Aminobenzoic acid was extremely rapidly absorbed from the rat small intestine, whereas the absorption of MABA, the m-isomer of PABA, was comparably slower. This finding was partly explained by the result that PABA is more lipophilic than MABA. The metabolite percentage of PABA was considerably greater than that of MABA in mucosal fluid, tissue, and serosal fluid. On the other hand, a concentration-dependent and a directional difference in the transfer rate of these drugs were observed in everted and noneverted sacs of rat small intestine. Furthermore, mucosal uptake of PABA or MABA was inhibited by 1 mM 2,4-dinitrophenol, 10 mM sodium azide, and pretreatment with HgCl2 (10 mM). These results indicate that MABA, as well as PABA, is transported through the intestine by a carrier-mediated transport system, and that the molecular structure of these drugs is important for their absorption and metabolic characteristics.

Production of N4-succinyl-1-beta-D-arabinofuranosylcytosine, a novel metabolite of N4-behenoyl-1-beta-D-arabinofuranosylcytosine, in mice and its biological significance.

A novel metabolite was found in the urine and bile of mice given i.v. injections of N4-behenoyl-1-beta-D-arabinofuranosylcytosine (behenoyl-ara-C). Acid and alkaline hydrolysis of this metabolite resulted in the production of 1-beta-D-arabinofuranosylcytosine and succinic acid, as determined by thin-layer chromatography and high-performance liquid chromatography. Mass spectrometry identified this metabolite as N4-succinyl-1-beta-D-arabinofuranosylcytosine (succinyl-ara-C). This conclusion was supported by thin-layer chromatography and by the ultraviolet spectrum, upon which the characteristics of this metabolite agreed with those of succinyl-ara-C. Only a very small amount, if any, of this metabolite was found in the urine and bile of mice given injections of N4-stearoyl- or N4-palmitoyl-1-beta-D-arabinofuranosylcytosine, suggesting that behenoyl-ara-C was metabolized differently from the other two analogs. Comparison of the metabolites of behenoyl-ara-C, radiolabeled at different positions of the behenoyl-residue, suggested that behenoyl-ara-C was degraded by omega-oxidation and then by beta-oxidation, resulting in the production of succinyl-ara-C. This metabolite was more potent than behenoyl-ara-C in suppressing the in vitro proliferation of murine L1210 cells. The high therapeutic potency of behenoyl-ara-C in L1210-bearing mice may be ascribable to the contribution of succinyl-ara-C to the efficacy of behenoyl-ara-C, either by suppressing the proliferation of L1210 cells or by protecting 1-beta-D-arabinofuranosylcytosine, the possible eventual metabolite, from inactivation by deaminase.

Development apparatus for thin-layer gel chromatography in organic solvent systems.

An apparatus is devised for development of thin-layer gel chromatograms, which is easy to handle and gives reproducible results even with volatile organic solvent systems. The print technique with a silicone-treated paper can facilitate detection of the samples chromatographed.