The effectiveness of palliative middle meningeal artery embolization prior to craniotomy for large acute epidural hematoma: A case report.

INTRODUCTION AND IMPORTANCE: Acute epidural hematoma is typically managed with craniotomy. However, there are a few reports on transcatheter arterial embolization (TAE) as an adjunctive therapy. CASE PRESENTATION: A 70-year-old female with no obvious history of trauma was transported to our hospital. Computed tomography scan revealed an epidural hematoma of approximately 80 ml with a midline shift of 5 mm. We decided to perform an emergency craniotomy. However, the operating room (OR) was already occupied by a scheduled surgery and it would take 30 min to an hour to prepare it. We opted to wait for our OR, considering that, even if the patient was transferred to another hospital, it would take time for the craniotomy to commence. CLINICAL DISCUSSION: We performed TAE for the middle meningeal artery (MMA) as a palliative measure to prevent hematoma enlargement. The MMA was selectively embolized with 20 % n-butyl-2-cyanoacrylate (NBCA), resulting in no hematoma enlargement or observed complications. The criteria for endovascular treatment of acute epidural hematoma are not yet well-established. This case demonstrates the potential role of endovascular treatment for large acute epidural hematomas in carefully selected patients. CONCLUSION: If there is a time gap before craniotomy, TAE could be considered a viable option for large acute epidural hematomas as a palliative intervention before craniotomy.

Artificial intelligence model substantially improves stratum corneum moisture content prediction from visible-light skin images and skin feature factors.

BACKGROUND: Appropriate skin treatment and care warrants an accurate prediction of skin moisture. However, current diagnostic tools are costly and time-consuming. Stratum corneum moisture content has been measured with moisture content meters or from a near-infrared image. OBJECTIVE: Here, we establish an artificial intelligence (AI) alternative for conventional skin moisture content measurements. METHODS: Skin feature factors positively or negatively correlated with the skin moisture content were created and selected by using the PolynomialFeatures(3) of scikit-learn. Then, an integrated AI model using, as inputs, a visible-light skin image and the skin feature factors were trained with 914 skin images, the corresponding skin feature factors, and the corresponding skin moisture contents. RESULTS: A regression-type AI model using only a visible-light skin-containing image was insufficiently implemented. To improve the accuracy of the prediction of skin moisture content, we searched for new features through feature engineering ("creation of new factors") correlated with the moisture content from various combinations of the existing skin features, and have found that factors created by combining the brown spot count, the pore count, and/or the visually assessed skin roughness give significant correlation coefficients. Then, an integrated AI deep-learning model using a visible-light skin image and these factors resulted in significantly improved skin moisture content prediction. CONCLUSION: Skin moisture content interacts with the brown spot count, the pore count, and/or the visually assessed skin roughness so that better inference of stratum corneum moisture content can be provided using a common visible-light skin photo image and skin feature factors.

Measurement of erythrocyte creatine might be useful for diagnosing latent hemolysis.

OBJECTIVES: Whereas HbA1c values are low relative to glycemia in patients with hemolytic anemia, including compensatory anemia, low HbA1c levels along with negative results for conventional hemolysis indicators have been reported in patients with latent hemolysis. Conversely, glycated albumin (GA) is a glycemic control indicator unaffected by hemolysis. Erythrocyte creatine (EC) is a hemolysis indicator that reflects the mean age of red blood cells (MRBC). We recently reported a formula for obtaining MRBC based on EC. The present study examined the usefulness of EC measurements and MRBC calculated with EC for diagnosing latent hemolysis. MATERIALS AND METHODS: Two patients with latent hemolysis and low HbA1c values relative to glycemia were investigated, while controls comprised 214 patients (including patients with hemolysis and/or type 2 diabetes mellitus). HbA1c was expressed in International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) units (iA1c). GA/iA1c ratios, reticulocyte counts, EC, and MRBC in patients with latent hemolysis were compared to non-hemolysis, compensatory hemolysis, and hemolytic anemia patients. RESULTS: Both reticulocyte counts and haptoglobin levels were within reference ranges in patients with latent hemolysis. GA/iA1c ratios and EC were higher than reference values in patients with latent hemolysis, and MRBC values were 41.6 and 48.4 days, respectively, shorter than the reference range (49.1-66.8 days). CONCLUSIONS: EC measurement and MRBC values calculated on the basis of EC might be useful for diagnosing latent hemolysis.

TYK2 Promoter Variant Is Associated with Impaired Insulin Secretion and Lower Insulin Resistance in Japanese Type 2 Diabetes Patients.

Accumulating evidence has suggested that viral infection causes type 1 diabetes due to direct ß-cell damage and the triggering of autoimmune reactivity to ß cells. Here, we elucidated that the tyrosine kinase 2 (Tyk2) gene, encoding an interferon receptor signaling molecule, is responsible for virus-induced diabetes in mice, and its promoter variant confers a risk of type 1 diabetes in humans. This study investigated the relationship between a TYK2 promoter variant (TYK2PV) and insulin secretion in type 2 diabetes patients. TYK2PV status was determined using direct DNA sequencing and its associations with fasting insulin, C-peptide, and homeostatic model assessment of insulin resistance (HOMA-IR) were evaluated in type 2 diabetes patients without sulfonylurea or insulin medication. Of the 172 patients assessed, 18 (10.5%) showed TYK2PV-positivity. Their body mass index (BMI) was significantly lower than in those without the variant (23.4 vs. 25.4 kg/m2, p = 0.025). Fasting insulin (3.9 vs. 6.2 µIU/mL, p = 0.007), C-peptide (1.37 vs. 1.76 ng/mL, p = 0.008), and HOMA-IR (1.39 vs. 2.05, p = 0.006) were lower in those with than in those without the variant. Multivariable analysis identified that TYK2PV was associated with fasting insulin ≤ 5 µIU/mL (odds ratio (OR) 3.63, p = 0.025) and C-peptide ≤ 1.0 ng/mL (OR 3.61, p = 0.028), and also lower insulin resistance (HOMA-IR ≤ 2.5; OR 8.60, p = 0.042). TYK2PV is associated with impaired insulin secretion and low insulin resistance in type 2 diabetes. Type 2 diabetes patients with TYK2PV should be carefully followed in order to receive the appropriate treatment including insulin injections.

[A case of elderly myxedema coma patient with end-stage renal failure].

CASE: 84-year-old woman had been diagnosed hypothyroidism before, but she did not take tablets of thyroid hormone prescribed. Anorexia and decreased consciousness level were discovered by workers of the facility. Her family doctor found thyroid function abnormality as a cause, and she was introduced to our hospital to treat because the whole body condition was bad. Her physical examination was observed that JCS was 3-10. Laboratory examination showed that TSH 562.81 µIU/mL, fT4 0.40 ng/mL, pH 7.33, and Na 124 mEq/L. It was not a contradictory finding with the diagnostic criteria of mucus edema coma. Blood and peritoneal dialysis is denied, although her data indicated eGFR 8-10 ml/min/1.73 m2. Her hospitalization was long-term, but exhibited finally good clinical course. After three months of hospitalization, she was discharged from the hospital. The problems were as follows. The clear guideline of myxedema coma with end-stage renal failure state and many complications was not found. She and her family did not hope dialysis under this condition.We treated a case of myxedema coma in a case of an elderly person with terminal renal failure who did not hope dialysis. In addition to myxedema coma as a rare disease, there are many basic diseases in the elderly. Although it was a difficult case, it is important to repeatedly confirm the explanation and the intention of the person and the family with regard to the selection of the treatment policy.

Estimation of the hemoglobin glycation rate constant.

In a previous study, a method of obtaining mean erythrocyte age ([Formula: see text]) from HbA1c and average plasma glucose (AG) was proposed. However, the true value of the hemoglobin glycation constant ([Formula: see text] dL/mg/day), required for this model has yet to be well characterized. Another study also proposed a method of deriving [Formula: see text] from erythrocyte creatine (EC). Utilizing these formulae, this study aimed to determine a more accurate estimate of [Formula: see text]. One hundred and seven subjects including 31 patients with hemolytic anemia and 76 subjects without anemia were included in this study. EC and HbA1c data were analyzed, and [Formula: see text] using HbA1c, AG and the newly-derived constant, [Formula: see text] were compared to [Formula: see text] using traditional [Formula: see text] in three patients whose data were taken from previous case studies. A value of [Formula: see text] dL/mg/day was determined for [Formula: see text]. [Formula: see text] using HbA1c, AG and [Formula: see text] were found to no be significantly different (paired t-test, [Formula: see text]) to [Formula: see text] using traditional [Formula: see text]. [Formula: see text] enables the estimation of [Formula: see text] from HbA1c and AG.

Comparison of Patient-Led and Physician-Led Insulin Titration in Japanese Type 2 Diabetes Mellitus Patients Based on Treatment Distress, Satisfaction, and Self-Efficacy: The COMMIT-Patient Study.

INTRODUCTION: In Japan, patient-led insulin titration is rare in type 2 diabetes mellitus (T2DM) patients. Few studies have compared the effects of patient-led versus physician-led insulin titration on patient-reported outcomes in Japanese T2DM patients. This study aimed to compare the effects of patient-led and physician-led insulin titration in Japanese insulin-naïve T2DM patients on safety, glycemic control, and patient-reported outcomes (emotional distress, treatment satisfaction, and self-efficacy). METHODS: Ultimately, 125 insulin-naïve Japanese T2DM patients were randomly assigned to either a patient-led insulin self-titration group or a physician-led insulin titration group and monitored for 24 weeks. The primary endpoint was a change in emotional distress as measured using the Problem Areas in Diabetes scale (PAID). Secondary endpoints included treatment satisfaction, as measured with the Diabetes Treatment Satisfaction Questionnaire (DTSQ), self-efficacy as measured using the Insulin Therapy Self-Efficacy Scale (ITSS), glycated hemoglobin (HbA1c) levels, fasting plasma glucose levels, body weight, insulin daily dose, and frequency of hypoglycemia. RESULTS: There was no significant difference between the groups in PAID and DTSQ scores. The results for the primary endpoint should be interpreted taking account that the sample size for the power calculation was not reached. ITSS scores were significantly higher in the patient-led self-titration group. HbA1c and fasting plasma glucose levels were significantly decreased in both groups, but the decrease was significantly larger in the patient-led self-titration group. Although the insulin daily dose was significantly higher in the patient-led self-titration group, severe hypoglycemia did not occur in either group, and the frequency of hypoglycemia was similar in both groups. CONCLUSION: Self-measurement of blood glucose and self-titration of insulin enhanced the patients' self-efficacy without compromising their emotional distress or treatment satisfaction. Also, insulin self-titration was found to be safe and effective; it resulted in better glycemic control without severe hypoglycemia. TRIAL REGISTRATION: University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR) (registration number: UMIN000020316).

Effects of intensive exercise combined with dapagliflozin on body composition in patients with type 2 diabetes: a randomized controlled trial.

This study was aimed to evaluate the effects of intensive exercise in addition to the administration of sodium-glucose cotransporter 2 inhibitor dapagliflozin (DAPA) on body composition, including fat-free mass, in type 2 diabetes. We randomly assigned 146 patients to 24 weeks of treatment with intensive exercise, including resistance training, plus 5 mg (up to 10 mg) of DAPA daily (IT group) or DAPA alone (CT group). The primary endpoint was the difference in the change in fat-free mass from baseline to 24 weeks between the groups. The skeletal muscle mass index (SMI); metabolic profile, including HbA1c; and regional fat mass were also determined. ANCOVA was used for the group comparison, with least squares mean (LSM) differences and 95% confidence interval (CI). There was no significant difference in the change in fat-free mass (LSM difference -0.1 kg (95% CI: -0.5 to 0.4) and SMI (LSM difference -0.1 kg (95% CI: -0.2 to 0.1) between the groups. In contrast, the reduction of trunk fat mass was significantly higher in the IT group than in the CT group ((LSM difference -0.5 kg [95% CI -0.9 to -0.1]). Higher adherence to the resistance training tended to be associated with changes in HbA1c and high-sensitivity CRP levels. Our study suggests that intensive exercise do not prevent the reduction of fat-free mass after administration of SGLT2 inhibitors but can increase the reduction in abdominal fat, presumably leading to further improvements of hyperglycemia and chronic inflammation than DAPA alone in type 2 diabetes patients.

Successful endovascular treatment of a ruptured bihemispheric posterior inferior cerebellar artery aneurysm: illustrative case.

BACKGROUND: Normal posterior inferior cerebellar artery (PICA) anatomy is highly variable, but bihemispheric PICA crossing the midline to supply the vascular territory of bilateral cerebellar hemisphere is rare. Herein, the authors reported a rare case of ruptured aneurysm that was associated with bihemispheric PICA and successfully treated endovascularly. OBSERVATIONS: A 46-year-old woman presented with sudden headache and loss of consciousness because of an intraventricular hemorrhage due to a ruptured aneurysm that was associated with the bihemispheric PICA. Angiography revealed that the aneurysm was located at the bifurcation between the bihemispheric PICA and the bilateral distal PICA. The ruptured aneurysm was successfully occluded using coil embolization, which preserved the parent artery with no procedural-related complication. LESSONS: To the best of the authors' knowledge, this was the first report of a ruptured aneurysm associated with bihemispheric PICA being successfully treated endovascularly. Aneurysm formation may be accelerated by hemodynamic stress and vascular fragility. For neurosurgeons and neurointerventionalists, it is important to understand the anatomical variation of PICA, especially bihemispheric PICA, which is a potential risk factor for a fatal stroke.

Efficacy of an email-based recording and reminding system for limiting daytime non-functional tooth contact in patients with temporomandibular disorders: A randomized controlled trial.

BACKGROUND: Oral parafunctional activities such as daytime non-functional tooth contact (nFTC) are considered aetiological factors for temporomandibular disorders (TMD). OBJECTIVES: To evaluate the effectiveness of an email-based recording and reminding system for limiting daytime nFTC in patients with TMDs. METHODS: Thirty patients with TMDs (mean age, 30.7 ± 8.7 years) were randomly assigned to three groups according to the intervention for limiting nFTC: cognitive behavioural therapy (CBT) with an email-based recording and reminding system for 20 days (e-CBT group, n = 10), CBT with a sticky note reminder for 20 days (s-CBT group, n = 10) and simple verbal instructions to avoid nFTC that were provided before the experimental period (control group, n = 10). The frequency of nFTC, range of pain-free unassisted mouth opening and pain intensity during painful unassisted maximum mouth opening was evaluated before and after the experimental period. RESULTS: The frequency of nFTC significantly decreased after the intervention in the e-CBT and s-CBT groups. Among the three groups, the decrease in the nFTC frequency was the maximum in the e-CBT group (P < .01). In addition, the range of pain-free unassisted mouth opening showed a significant increase in all three groups, with the maximum improvement in the e-CBT group (analysis of variance, P < .01). CONCLUSIONS: The present findings suggest that our email-based recording and reminding system may have the potential to effectively control daytime nFTC and could be an effective strategy for the management of TMDs.

HbA1c adjusted by erythrocyte creatine is a useful glycemic control indicator in patients with hemolysis.

OBJECTIVES: HbA1c shows low in patients with hemolysis, whereas glycated albumin (GA) is not affected by hemolysis. Therefore, the GA/HbA1c ratio reflects hemolysis in diabetic patients with hemolysis. Erythrocyte creatine (EC) is an indicator of hemolysis that reflects the mean erythrocyte age. The aim of this study was to examine whether HbA1c adjusted by EC accurately reflected glycemic control in patients with hemolysis. MATERIALS AND METHODS: A total of 238 individuals, consisting of 131 diabetic patients and 107 non-diabetic subjects, and consisting of 42 patients with hemolysis, and 196 subjects without hemolysis were selected for the study. HbA1c expressed in the IFCC units (iA1c) as well as in the NGSP units (A1C) were used. From the fact that EC and the GA/iA1c ratio showed a significant positive correlation, a formula for iA1c adjusted by EC (ECadj-iA1c) was created from a regression equation between EC and the GA/iA1c ratio. RESULTS: Significant correlations were observed between the GA/iA1c ratio and various hemolytic indicators but not between the GA/ECadj-iA1c ratio and those hemolytic indicators. The GA/iA1c ratio in individuals with hemolysis was significantly higher than in individuals without hemolysis, while no significant differences were observed in the GA/ECadj-iA1c ratio between the groups. Further, iA1c concentrations in non-diabetic patients with hemolysis were significantly lower than in the non-diabetic subjects without hemolysis, whereas ECadj-iA1c and GA concentrations showed no significant difference between the two groups. CONCLUSIONS: These results suggested that ECadj-iA1c accurately reflected glycemic control in patients with hemolysis.

Effects of a contingent vibratory stimulus delivered by an intra-oral device on sleep bruxism: a pilot study.

PURPOSE: Although sleep bruxism (SB) is one of the most important clinical problems in dental practice, there is no definitive method for controlling it. This pilot study evaluated the effects of contingent vibratory feedback stimuli using an occlusal splint for inhibition of sleep bruxism. METHODS: Thirteen subjects with clinically diagnosed SB participated after providing an informed consent. Portable polysomnographic recordings were conducted in the subjects' home environment to make a definitive SB diagnosis and to evaluate the effects of the vibratory stimuli on SB. A force-based bruxism detection system, which used a pressure-sensitive piezoelectric film embedded in the occlusal splint, was utilized to trigger vibration feedback stimuli, which was scheduled to be applied intermittently for 30 min, at 30-min intervals. RESULTS: The number of SB episodes (times/hour), the total SB duration (seconds/hour), the mean duration of SB episodes (seconds/episode), and the micro-arousal index (times/hour) were scored for each time period (with and without vibration). The effects of the vibration on these scores were tested (paired t test; p < 0.05). The number of SB episodes tended to decrease with the vibration stimuli, and the decrease in the total SB duration was statistically significant (14.3 ± 9.5 vs. 26.0 ± 20.0, p = 0.03). No substantial change was found in terms of the micro-arousal index. CONCLUSIONS: These study results suggested that the SB inhibitory system employing a vibratory stimulus might be able to suppress the total SB duration without disturbing sleep.

Shortened mean erythrocyte age in female patients with type 2 diabetes mellitus.

BACKGROUND: The hyperglycemic state is known to shorten the erythrocyte life span. Erythrocyte creatine (EC) reflects the mean erythrocyte age and is useful as an indicator of hemolysis. Here, we studied the relationship between EC and glycemic control indicators [HbA1c or glycated albumin (GA)] in non-diabetic subjects and diabetic patients. METHODS: This study included 119 patients with type 2 diabetes mellitus (T2DM) and 76 non-diabetic subjects matched by sex and age. We studied the relationships between EC and HbA1c or GA in patients with T2DM and non-diabetic subjects. RESULTS: Erythrocyte creatine in T2DM patients was significantly higher than that in non-diabetic subjects, and the ratio of high EC levels (>1.8 µmol/g Hb) in T2DM patients was significantly higher as well. Furthermore, female EC was significantly higher than male EC, and the ratio of high EC levels in females was significantly higher than in the males as well. While male EC had no significant correlation with HbA1c or GA, female EC had significant positive correlations with both. Male EC had no significant difference between T2DM patients and non-diabetic subjects, while the EC in female patients with T2DM was significantly higher than in female non-diabetic subjects. CONCLUSIONS: The significant positive correlations of EC with HbA1c and GA in female patients with T2DM suggested that the mean erythrocyte age decreased in female diabetic patients with poor glycemic control.

Improvement of quality of life through glycemic control by liraglutide, a GLP-1 analog, in insulin-naive patients with type 2 diabetes mellitus: the PAGE1 study.

BACKGROUND: In addition to achieving good glycemic control, diabetes care management aims to improve the quality of life (QOL) in patients. Treatment-associated difficulties and side effects frequently cause deterioration in QOL. Liraglutide, a GLP-1 receptor agonist, is a novel injection drug that promotes insulin secretion. It is a user-friendly, once-daily injection with fewer hypoglycemic events. In this study, we aimed to examine the effect of liraglutide therapy on QOL in patients. METHODS: In total, 304 insulin- and liraglutide-naïve patients with type 2 diabetes were enrolled in this observational study; they received liraglutide therapy for 12 weeks. The main outcome measure was change in QOL from baseline, which was assessed using diabetes therapy-related QOL (DTR-QOL). RESULTS: At week 12, liraglutide significantly decreased HbA1c levels (8.7 ± 1.5 vs. 7.5 ± 1.3, p < 0.001) and BMI (27.9 ± 5.3 vs. 27.3 ± 5.2, p < 0.001). According to the QOL scores, although the treatment modality had changed from non-injection to injection therapy, liraglutide improved patient satisfaction with treatment. Significant correlations were found between change in HbA1c level and satisfaction with treatment, as well as between change in body weight and burden on social and daily activities, anxiety and dissatisfaction with treatment, and hypoglycemia. CONCLUSIONS: Liraglutide significantly improved glycemic control and reduced the body weight without deteriorating QOL in obese patients with type 2 diabetes. Trial registration UMIN-CTR: UMIN000007159.

Association between patterns of jaw motor activity during sleep and clinical signs and symptoms of sleep bruxism.

The aim of this study was to investigate the association between patterns of jaw motor activity during sleep and clinical signs and symptoms of sleep bruxism. A total of 35 university students and staff members participated in this study after providing informed consent. All participants were divided into either a sleep bruxism group (n = 21) or a control group (n = 14), based on the following clinical diagnostic criteria: (1) reports of tooth-grinding sounds for at least two nights a week during the preceding 6 months by their sleep partner; (2) presence of tooth attrition with exposed dentin; (3) reports of morning masticatory muscle fatigue or tenderness; and (4) presence of masseter muscle hypertrophy. Video-polysomnography was performed in the sleep laboratory for two nights. Sleep bruxism episodes were measured using masseter electromyography, visually inspected and then categorized into phasic or tonic episodes. Phasic episodes were categorized further into episodes with or without grinding sounds as evaluated by audio signals. Sleep bruxism subjects with reported grinding sounds had a significantly higher total number of phasic episodes with grinding sounds than subjects without reported grinding sounds or controls (Kruskal-Wallis/Steel-Dwass tests; P < 0.05). Similarly, sleep bruxism subjects with tooth attrition exhibited significantly longer phasic burst durations than those without or controls (Kruskal-Wallis/Steel-Dwass tests; P < 0.05). Furthermore, sleep bruxism subjects with morning masticatory muscle fatigue or tenderness exhibited significantly longer tonic burst durations than those without or controls (Kruskal-Wallis/Steel-Dwass tests; P < 0.05). These results suggest that each clinical sign and symptom of sleep bruxism represents different aspects of jaw motor activity during sleep.

Effect of clonazepam and clonidine on primary sleep bruxism: a double-blind, crossover, placebo-controlled trial.

The aim of this study was to assess the acute effects of clonazepam and clonidine on rhythmic masticatory muscle activity in young adults with primary sleep bruxism, as well as accompanying effects on sleep architecture and cardiac activity. This study used a double-blind, crossover, placebo-controlled design. Polysomnography was performed on 19 subjects [nine men and 10 women; mean age (±SE): 25.4 ± 2.7 years] for 5 nights. The first 2 nights were used for the habituation and diagnosis of sleep bruxism. The other 3 nights were randomly assigned for clonazepam (1.0 mg), clonidine (0.15 mg) or placebo (all administered 30 min before bedtime). Sleep, oromotor activity and cardiac activity variables were assessed and compared among the three drug conditions. Clonidine significantly reduced the median percentage of time spent in the rapid eye movement sleep stage compared with placebo and clonazepam. The number of rhythmic masticatory muscle activity episodes was reduced with clonidine by >30% compared with placebo and clonazepam. The reduction of rhythmic masticatory muscle activity index by clonidine was associated with an increase of mean RR intervals (slower heart rate) during quiet sleep periods and during a 70-s period before the onset of rhythmic masticatory muscle activity episodes. However, no changes in cardiac activity variables were observed for clonazepam. In young adults with primary sleep bruxism, clonidine was significantly more effective in suppressing sleep bruxism than clonazepam. The acute effects of clonidine on rhythmic masticatory muscle activity episodes may be mediated by suppression of autonomic nervous system activity and non-rapid eye movement-rapid eye movement sleep processes.

The Usefulness of CT-Diffusion Weighted Image Mismatch in Patients with Mild to Moderate Traumatic Brain Injury.

Traumatic brain injury (TBI) has a complex and heterogeneous pathology. It is frequently difficult to predict the neurological deterioration of patients with TBI, and unpredictable change may occur even when TBI is mild to moderate. When computed tomography (CT) findings are considered to be inconsistent with the traumatic origin or with the neurological deterioration of patients observed on admission, magnetic resonance imaging (MRI) is employed based on the standards of our ethical committee. In this retrospective study, we compared CT and diffusion weighted imaging (DWI) of patients with mild to moderate TBI in the very acute phase. When the high-intensity lesions on DWI are larger than the high-density lesions on CT images, we defined the imaging finding as a 'CT-DWI mismatch'. Between January 2010 and December 2013, 92 patients were inspected using both CT and MRI at admission, and we detected a CT-DWI mismatch in 35 patients. CT-DWI mismatch was 92.6% (95% confidence interval 79.8-97.9) sensitive and 84.6% (95% confidence interval 79.3-86.3) specific for the prediction of enlargement of the hemorrhagic lesions on repeat CT. CT-DWI mismatch is considered to be useful as one of the predictors of the enlargement of hemorrhagic lesions in patients with mild to moderate TBI.

[A Case of Transorbital Penetrating Brain Injury Caused by a Steel Wire Entirely Embedded in the Brain Parenchyma].

Penetrating brain injury(PBI)is very rare in Japan. Because there is a very wide variety of pathological condition of PBI, the guideline for the treatment of PBI has not been established yet. We report the unique case of PBI caused by a steel wire piece completely embedded in the brain parenchyma. A 75-year-old man was brought to the emergency department due to ocular injury caused by a steel wire piece. Neurological examination revealed only left visual disturbance. CT scan revealed a steel wire piece located intraparenchymally between the left frontal lobe and the ventricles, but digital subtraction angiography showed no significant vascular injury in the surrounding structures. We performed an open surgery and removed the steel wire piece. Because the steel wire piece was completely embedded in the brain, we used intraoperative X-ray fluoroscopy to choose a less invasive approach for the brain. The patient suffered no additional neurological deficit and no sign of cerebral infection or seizure after surgery. He was discharged after a 4-week administration of antibiotics. In most cases of PBI caused by low velocity injury, foreign bodies are not completely embedded in the brain except for remnants after surgical removal. This is the first report of low velocity PBI caused by a foreign body completely embedded in the brain.

[A case of intracranial invasion from sinonasal small cell neuroendocrine carcinoma].

Sinonasal neuroendocrine carcinomas (NECs) are rare tumors. We present a rare case of intracranial invasion of sinonasal small-cell NEC. A 61-year-old woman with nasal obstruction and bleeding was referred to our hospital. Computed tomography showed a polyp-like tumor occupying her left nasal cavity and extending to the paranasal sinuses and anterior cranial fossa. The tumor was removed using a transfacial approach by otolaryngologists and a bifrontal cranial approach by neurosurgeons. In histopathological analyses, we found that the tumor presented with both an epithelial and neuroendocrine nature, and was diagnosed as a small-cell NEC. Post-surgery, she received localized radiation therapy and chemotherapy, and is alive, 18 months after diagnosis. In cases where it is difficult to perform a differential diagnosis of tumors arising from the frontal cranial base and extending to the nasal and cranial sides, NEC should be considered as a possibility.

[A case of intracranial primary leptomeningeal lymphoma].

Primary leptomeningeal lymphoma(PLML)is a neoplastic meningitis of lymphomatous origin without parenchymal central nervous system(CNS)disease or a systemic tumor. We report a case of PLML that presented with epileptic seizure, and review relevant literature. A 27-year-old man was brought to the emergency department with an epileptic seizure. Two months later, he was again brought to the emergency department with an epileptic seizure. MRI showed enhanced lesions on the surface of the right cerebellar hemisphere, right parietal sulci, and interhemispheric surface of the frontal lobes. We performed an open biopsy and diagnosed the patient with diffuse large B-cell lymphoma of the leptomeninges on the basis of histological findings. The patient was initially treated with chemotherapy including high-dose methotrexate(MTX). Because remission was not achieved by chemotherapy, the patient was treated with whole-brain radiation therapy. After onset, the patient survived for 2 years without recurrence. PLML is a particularly rare type of primary CNS lymphoma. The outcome of PLML, compared with general primary CNS lymphoma, is reported to be very poor because chemotherapy including MTX is ineffective.