Successful Management of Acute Subdural Hematoma in Deep Brain Stimulation Patient: A Case Report and Literature Review.

Deep brain stimulation (DBS) has emerged as an important therapeutic option for several movement disorders; however, the management of acute complications, such as acute subdural hematoma (ASDH), remains challenging. This is the case of a 71-year-old woman with Parkinson's disease who developed ASDH 12 years after bilateral DBS placement. On admission with altered consciousness, imaging revealed significant displacement of the DBS electrodes because of the hematoma. Emergent craniotomy with endoscopic evacuation was performed with preservation of the DBS system. Postoperatively, complete evacuation of the hematoma was confirmed, and the patient experienced significant clinical improvement. ASDH causes significant electrode displacement in patients undergoing DBS. After hematoma evacuation, the electrodes were observed to return to their proper position, and the patient exhibited a favorable clinical response to stimulation. To preserve the DBS electrodes, endoscopic hematoma evacuation via a small craniotomy may be useful.

Effects of dual antiplatelet therapy (DAPT) compared to single antiplatelet therapy (SAPT) in patients with traumatic brain injury.

Japan is one of the world's most aging societies and the number of elderly patients taking antithrombotic drugs is increasing. In recent years, dual antiplatelet therapy (DAPT), in which two antiplatelet drugs are administered, has become common in anticipation of its high therapeutic efficacy. However, there are concerns about increased bleeding complications in use of DAPT. Therefore, the goal of this study was to investigate the effects of DAPT in patients with traumatic brain injury (TBI). A prospective, multicenter, observational study was conducted from December 2019 to May 2021 to examine the effects of antithrombotic drugs and reversal drugs in 721 elderly patients with TBI. In the current study, the effect of DAPT on TBI was examined in a secondary analysis. Among the registered patients, 132 patients taking antiplatelet drugs only were divided into those treated with single antiplatelet therapy (SAPT) (n=106) and those treated with DAPT (n=26) prior to TBI. Glasgow Coma Scale (GCS) on admission, pupillary findings, course during hospitalization, and outcome were compared in the two groups. A similar analysis was performed in patients with a mild GCS of 13-15 (n=95) and a moderate to severe GCS of 3-12 (n=37) on admission. The DAPT group had significantly more males (67.0 % vs. 96.2 %), a higher severity of illness on admission, and a higher frequency of brain herniation findings on head CT (21.7 % vs. 46.2 %), resulting in significantly higher mortality (12.3 % vs. 30.8 %). The only significant factor for mortality was severity on admission. The rate of DAPT was significantly higher in patients with a moderate to severe GCS on admission, and DAPT was the only significant factor related to severity on admission. These findings suggest that the severity of injury on admission influences the outcome six months after injury, and that patients with more severe TBI on admission are more likely to have been treated with DAPT compared to SAPT.

Spinal magnetic resonance imaging artifacts in lumboperitoneal shunt surgery using adjustable valve implantation on the paravertebral spinal muscles.

BACKGROUND: Adjustable shunt valves that have been developed for managing hydrocephalus rely on intrinsically magnetic components ; thus, artifacts with these valves on magnetic resonance imaging (MRI) are inevitable. No studies on valve-induced artifacts in lumboperitoneal shunt (LPS) surgery have been published. Therefore, this study aimed to evaluate valve-induced artifacts in LPS. METHODS: We retrospectively reviewed all MRIs obtained between January 2023 and June 2023 in patients with an implanted Codman CERTAS Plus adjustable shunt valve (Integra Life Sciences, Princeton, New Jersey, USA). The valve was placed <1 cm subcutaneously on the paravertebral spinal muscle of the back, with its long axis perpendicular to the body axis. The scans were performed using a Toshiba Medical Systems 1.5 Tesla scanner. The in-plane artifact sizes were assessed as the maximum distance of the artifact from the expected region of the back. RESULTS: All spinal structures or spinal cords can be recognized, even with valve-induced artifacts. The median maximum valve-induced artifact distance on T1-weighted axial imaging was 25.63 mm (mean, 25.98 mm ; range, 22.24-30.94 mm). The median maximum valve-induced artifact distance on T2-weighted axial imaging was 25.56 mm (mean, 26.27 mm ; range, 21.83-29.53 mm). CONCLUSION: LPS surgery with adjustable valve implantation on paravertebral muscles did not cause valve-induced artifacts in the spine and spinal cord. We considered that LPS could simplify the postoperative care of these patients. J. Med. Invest. 71 : 154-157, February, 2024.

Fatal convexity and interhemispheric acute subdural hematoma from a falx meningioma: A case report.

Background: Hemorrhagic meningiomas are rare. We report a rare case of nontraumatic convexity and interhemispheric acute subdural hematoma (ASDH) caused by a falx meningioma. Case Description: An 84-year-old woman with a history of atrial fibrillation and hypertension who was taking warfarin presented to our emergency department with a sudden disorder of consciousness. The patient had no traumatic events associated with her symptoms. Computed tomography (CT) revealed right convexity and interhemispheric ASDH, mass lesions in the left frontal lobes, and brain herniation. Contrast-enhanced CT revealed vascular structures within the mass lesion. CT angiography (CTA) revealed no aneurysm or arteriovenous malformation, and the venous phase revealed occlusion in the anterior portion of the superior sagittal sinus. The patient had her right convexity and interhemispheric ASDH removed endoscopically. A mass lesion located on the falx, which was easily bleeding, soft, and suctionable, was immediately detected. Histopathological examination revealed fibrous meningioma, a benign meningioma of the World Health Organization grade 1. Despite undergoing aggressive treatment, the patient's general condition deteriorated. Conclusion: Hemorrhagic meningiomas can easily be missed with plain CT, and the enhancement effect of CTA and tumor shadow on digital subtraction angiography may not be observed during the acute phase. Surgery for nontraumatic ASDH should be performed considering the possibility that a meningioma causes it.

Usefulness of non-slip element percutaneous transluminal angioplasty scoring balloons in treating severe calcified lesions of the carotid artery for carotid artery stenting: A case report.

Background: Treatment of calcified lesions with conventional angioplasty balloons can be difficult due to insufficient lumen expansion, high dissection rates, and repeated revascularization. We report a case in which a scoring balloon was used in lesions resistant to angioplasty with a semi-compliant balloon. Case Description: A 72-year-old man presented with severe stenosis and a highly calcified lesion in the right cervical internal carotid artery. Right carotid artery stenting (CAS) was planned to prevent future ischemic stroke events. Conventional semi-compliant balloon angioplasty was unsuccessful. Three inflations of a non-slip element (NSE) percutaneous transluminal angioplasty (PTA) scoring balloon (Nipro, Osaka, Japan) successfully achieved CAS without complications. Conclusion: This is the first report to describe the use of this scoring balloon in de novo carotid artery disease. NSE PTA scoring balloon catheters can be a useful option for refractory, highly calcified stenosis.

Delayed Diagnosis of Spinal Dural Arteriovenous Fistula: A Case Report and Scoping Review.

Spinal dural arteriovenous fistula (SDAVF) is among the most common arterial shunt diseases typically found in middle aged or older men. Herein, we aimed to clarify the reasons for misdiagnoses and delayed diagnoses of SDAVF, determine how these affect prognoses, and establish how they can be prevented. We conducted a PubMed/MEDLINE literature search using "spinal dural arteriovenous fistula", "delayed diagnosis", "late diagnosis", and "misdiagnosis" terms. We identified 18 articles, including 965 SDAVF cases. Patients were predominantly males (71.8-100.0%) (mean age: 53.5-71.0 years). Misdiagnoses rates varied (17.5-100.0%) and encompassed many conditions. The mean time between early manifestations and confirmed diagnosis was approximately 10-15 months and from the first radiologic image revealing dural arteriovenous fistula (DAVF) features to diagnosis was 9.2-20.7 months. Posttreatment outcomes showed a significant improvement in motor functions, gait, and micturition, particularly in patients exhibiting preoperative symptoms over a short period. SDAVF is frequently misdiagnosed or subject to delayed diagnosis, causing poor clinical outcomes. SDAVF symptoms including progressive lower-limb weakness, paresthesia, and vesicorectal dysfunction are indications for spinal magnetic resonance imaging with subsequent spinal angiography, wherein DAVF is evidenced by extensive T2 hyperintensity and flow-void abnormalities. We reported a representative case with delayed diagnosis.

Early diagnosis of thoracic spinal dural arteriovenous fistula using lumbar magnetic resonance imaging: A case report.

In middle-aged and older men, clinicians often suspect lumbar spine disease when gait is impaired with intermittent claudication, but spinal dural arteriovenous fistula (SDAVF) may be the etiology. An understanding of the key magnetic resonance imaging findings of SDAVF is necessary for early diagnosis, appropriate treatment, and minimization of complications.

Rare complication of lumboperitoneal shunt with distal catheter migration into the inguinal hernia sac in two adults: A case report.

Background: Despite the proven benefits of lumboperitoneal shunt (LPS) for idiopathic normal-pressure hydrocephalus, complications such as catheter migration remain a problem. Inguinal complications of the distal catheter are rare in adults, and their management is uncertain. Herein, we present two cases of distal catheter migration into the inguinal hernia sac after LPS in adults and recommend their management. Case Description: An 86-year-old man presented with inguinal swelling. In another 82-year-old man who did not show any improvement after LPS, shunt angiography revealed LPS dysfunction due to lumbar catheter occlusion and distal LPS catheter in the right inguinal hernia sac, and lumbar catheter reconstruction was performed. Both patients did not have any symptoms, except inguinal swelling, and were followed up. After 2 weeks and 4 days, the distal catheter moved into the peritoneal cavity. Conclusion: Inguinal complications due to the migration of the distal catheter into the inguinal hernia sac are rare in LPS because frequent movements of the distal catheter due to trunk rotation dislodge it from the inguinal hernia sac for a short period. Urgent surgery was not recommended because the catheter was moved in a short period and the patients did not wish to undergo hernia repair.

A Case of Two-stage Surgery Using Intracranial Pressure Monitoring for Hemorrhagic Infarction during Direct Oral Anticoagulant Medication.

Direct oral anticoagulants (DOACs) are considered to cause a few hemorrhagic complications, including hemorrhagic infarction; these are administered in the acute phase of cerebral infarction for secondary prevention of cerebral embolism. Hemorrhagic infarction with cerebral herniation requires urgent decompressive craniectomy and can become fatal. Perioperative management is challenging because patients are often on antithrombotic therapy. In this study, we report on a case of a 61-year-old man with left-sided hemiparesis and impaired consciousness; he suffered from a hemorrhagic infarction with cerebral herniation during oral DOAC treatment after endovascular recanalization for the middle cerebral artery occlusion. As the patient was on apixaban for <3 h, performing decompressive craniectomy was considered difficult to stop hemostasis. We then opted to perform a small craniotomy to remove the hematoma, control the intracranial pressure (ICP), and administer fresh frozen plasma. We waited for the effect of apixaban to diminish before performing decompressive craniectomy. Gradually, his level of consciousness was noted to improve. Hemorrhagic cerebral infarction while on DOAC medications can be safely treated with small craniotomy and ICP monitoring followed by decompressive craniectomy. Thus, this case highlights the value of staged surgery under ICP monitoring in the absence of an immediate administration of DOAC antagonists.

[Initial Management of Traumatic Brain Injury].

To reduce the number of preventable trauma deaths(PTD), a standardized approach has been established with various training courses and guidelines such as the Japan Advanced Trauma Evaluation and Care and Guidelines for the Diagnosis and Treatment of Traumatic Brain Injury. To prevent PTD, initial treatment, including resuscitation, is crucial in the care of traumatic brain injury(TBI). The Japan Neurotrauma Data Bank recently reported that the number of patients with TBI is increasing. Patients on antithrombotic drugs are also increasing. Although the mortality rate is decreasing, the percentage of patients with favorable outcomes is also decreasing. Therefore, to prevent secondary brain injury, rapid and systematic assessment of physiological abnormalities and resuscitation using the ABCDE approach, diagnosis and treatment of impending D, administration of tranexamic acid(an antifibrinolytic drug), and timely administration of anticoagulant neutralizers are important.

Surgical Treatment of Vertebral Compression Fracture in a Patient with Idiopathic Normal Pressure Hydrocephalus.

Idiopathic normal pressure hydrocephalus (iNPH) with gait disturbance can be effectively treated with a cerebrospinal fluid shunt. Furthermore, balloon kyphoplasty (BKP) is a successful minimally invasive treatment for osteoporotic vertebral compression fractures (VCFs). This case report presents the surgical management of an elderly patient with iNPH who presented after a VCF due to a fall. A 77-year-old woman who had been experiencing progressive gait disturbance for five years reported experiencing back pain one month after a fall. Imaging revealed a recent L1 VCF that did not compromise the spinal canal. Furthermore, the Mini-Mental State Examination results and the timed up-and-go test were 20 points and 17.96 seconds, respectively. Magnetic resonance imaging revealed ventriculomegaly with an Evans' index of 0.35. Her symptoms improved temporarily after a tap test, and she was diagnosed with probable iNPH. BKP was performed for VCFs, followed by the lumboperitoneal (LP) shunt placement for iNPH one month later. Following the operation, her symptoms improved without complications. After one month of performing BKP, an LP shunt would be placed to prevent shunt complications, such as infection and catheter-related neurological symptoms. Screening for iNPH in the elderly who present after VCFs due to a fall may identify iNPH patients who may benefit more from surgical treatments.

Chronic epidural hematoma with frontal skull-base destruction mimicking osteogenic tumor, associated with coagulopathy due to chronic hepatitis C.

Background: Intracranial epidural hematoma is generally evoked by acute coup-injury. Though rare, it has a chronic clinical course and can be a non-traumatic event. Case Description: The patient was A thirty-five-year-old man with a complaint of one-year history of hand tremor. He was suspected diagnosis of osteogenic tumor with differential diagnosis of epidural tumor, or abscess in the right frontal skull base bone, associated with chronic type C hepatitis because of his plain CT and MRI. Results: Results of examinations and surgery, the extradural mass was chronic epidural hematoma without skull fracture. We diagnosis he is the rare case of chronic epidural hematoma caused by coagulopathy due to chronic hepatitis C. Conclusion: We reported a rare case of chronic epidural hematoma caused by coagulopathy due to chronic hepatitis C. The repeated spontaneous hemorrhage in the epidural space formed the capsule and destruction of skull base bone, just mimicking skull base tumor.

Pathology of Crooke Cells in the Human Pituitaries: A Timely Review.

Crooke cell change was first found in the regressed and suppressed corticotroph (adrenocorticotropic hormone-producing) cells, and now is known to occur in pituitary tumors. The tumor cells of this type can be recognized by morphology with immunohistochemistry, and are well known to predict aggressive behavior such as invasion and rare metastases. This is one of the representative neuroendocrine tumors in the pituitary which is now considered to have malignant potential as proposed in the pancreas and gastrointestinal tracts. It is important to emphasize the pituitary tumor pathology such as Crooke cell change for prognostication and appropriate therapies. This review article describes the evolution from the Crooke cells to Crooke cell tumors which is timely along with the Fifth WHO classification 2022 published online.

Challenges in the Treatment of Severe Traumatic Brain Injury Based on Data in the Japan Neurotrauma Data Bank.

The Japan Neurotrauma Data Bank is a source of epidemiological data for patients with severe traumatic brain injury (TBI) and is sponsored by the Japan Society of Neurotraumatology. In this report, we examined the changes in the treatment of severe TBI in Japan based on data of the Japan Neurotrauma Data Bank. Controlling and decreasing intracranial pressure (ICP) are the primary objective of severe TBI treatment. Brain-oriented whole-body control or neurocritical care, including control of cerebral perfusion pressure, respiration, and infusion, are also increasingly considered important because cerebral tissues require oxygenation to improve the outcomes of patients with severe TBI. The introduction of neurocritical care in Japan was delayed compared with that in Western countries. However, the rate of ICP monitoring increased from 28.0% in 2009 to 36.7% in 2015 and is currently likely to be higher. Neurocritical care has also become more common, but the functional prognosis of patients has not significantly improved in Japan. Changes in the background of patients with severe TBI suggest the need for improvement of acute-phase treatment for elderly patients. Appropriate social rehabilitation from the subacute to chronic phases and introduction of cellular therapeutics are also needed for patients with TBI.

Sequential expression of miR-221-3p and miR-338-3p in Schwann cells as a therapeutic strategy to promote nerve regeneration and functional recovery.

The functional properties of endogenous Schwann cells (SCs) during nerve repair are dynamic. Optimizing the functional properties of SCs at different stages of nerve repair may have therapeutic benefit in improving the repair of damaged nerves. Previous studies showed that miR-221-3p promotes the proliferation and migration of SCs, and miR-338-3p promotes the myelination of SCs. In this study, we established rat models of sciatic nerve injury by bridging the transected sciatic nerve with a silicone tube. We injected a miR-221 lentiviral vector system together with a doxycycline-inducible Tet-On miR-338 lentiviral vector system into the cavity of nerve conduits of nerve stumps to sequentially regulate the biological function of endogenous SCs at different stages of nerve regeneration. We found that the biological function of SCs was sequentially regulated, the diameter and density of myelinated axons were increased, the expression levels of NF200 and myelin basic protein were increased, and the function of injured peripheral nerve was improved using this system. miRNA Target Prediction Database prediction, Nanopore whole transcriptome sequencing, quantitative PCR, and dual luciferase reporter gene assay results predicted and verified Cdkn1b and Nrp1 as target genes of miR-221-3p and miR-338-3p, respectively, and their regulatory effects on SCs were confirmed in vitro. In conclusion, here we established a new method to enhance nerve regeneration through sequential regulation of biological functions of endogenous SCs, which establishes a new concept and model for the treatment of peripheral nerve injury. The findings from this study will provide direct guiding significance for clinical treatment of sciatic nerve injury.

Fact-Finding Survey of Treatment of Traumatic Brain Injury in Japan: Standardization of Care and Collaboration Between Neurosurgery and Emergency Departments.

BACKGROUND: Standardization of seamless treatment from prehospital injury care to initial injury and specialized care through collaboration among departments have been promoted in Japan since 2000. This survey was conducted to examine the current status of the system for treatment of traumatic brain injury (TBI) in Japan. METHODS: In February 2022, questionnaires on the treatment system and TBI care were sent to 869 facilities that participated in a training program held by the Japan Neurosurgical Society. Responses were received from 480 facilities (55.2%). These responses were compared with those in a similar survey performed in 2008. RESULTS: Among the responding facilities, 39.4% had neurosurgeons in emergency departments. Initial care for TBI was the responsibility of the neurosurgery department in 42.3% of the facilities, the emergency department in 26.0%, and jointly between these departments in 29.6%; and neurocritical care was managed by the neurosurgery department in 81.9%, the emergency department in 5.2%, and jointly in 12.1%. For patients with acute-phase TBI, intracranial pressure monitoring was performed in 72.1%. Active normothermia was performed in 86.0%, and decompressive craniectomy in 99.4%, as required. There was compliance with guidelines for treatment and management of TBI in 93.3%. CONCLUSIONS: Comparison with the 2008 results suggested role-sharing between 2 departments in TBI treatment is increasing. TBI treatment compliance with the guidelines was high. In-hospital mortality of Japanese patients with TBI has decreased since 2000. This may be due to the progress with standardization of TBI treatment and collaboration among departments in compliance with guidelines.

Hands-on neuroendovascular practice for nonselective undergraduate medical students increases interest and aspirations in pursuing neurosurgery as a specialization.

Background: The number of medical students aspiring to become neurosurgeons has decreased worldwide, mainly due to poor work-life balance among neurosurgeons; therefore, recruiting students for neurosurgery is essential to ensure the availability and appropriate quality of neurosurgical treatment. This study aimed to evaluate the efficacy of hands-on neuroendovascular practice for nonselective undergraduate medical students to determine whether this increases their interest in neurosurgery and contributes to their aspirations of becoming neurosurgeons. Methods: Hands-on neuroendovascular practice for mechanical thrombectomy was performed by undergraduate 5th-year medical students during their 2-week clinical rotation in the Department of neurosurgery at our university hospital between April 2021 and March 2023. After the neurosurgery practice, a questionnaire about their understanding of neurosurgery and aspirations for this specialization before and after the practice was anonymously completed by all students. Results: Overall, 153 students completed the questionnaire. Of these, 140 (91.5 %) showed increased interest in neurosurgery after participating in the hands-on practice. Through this practice, the number of students who considered neurosurgery as their first choice or one of their specialty choices increased from 8 (5.2%) to 12 (7.8%) (P = 0.3534) and from 19 (12.4%) to 52 (34.0%) (P < 0.0001), respectively. Furthermore, the number of students with no aspiration to become neurosurgeons decreased from 95 (62.1%) to 43 (28.1%) (P < 0.0001). Conclusion: Hands-on neuroendovascular practice for nonselective undergraduate medical students effectively increased their interest in neurosurgery specialization and their desire to become neurosurgeons. Therefore, this practice can help recruit medical students for neurosurgery specialization.

Double pituitary neuroendocrine tumors in a patient with normal growth hormone level acromegaly: A case report and review of the literature.

Background: Acromegaly is a rare disease caused by growth hormone (GH) hypersecretion caused by a pituitary neuroendocrine tumor (PitNET). However, some acromegaly patients show normal GH levels, and they can be a pitfall in clinical diagnosis. Moreover, rarely, synchronous true double or multiple PitNETs are encountered. Moreover, these PitNETs increase the risk of a left lesion during surgical exploration. Case Description: The patient, who was a 73-year-old female, was referred to our hospital with a chief complaint of headache. Assessment of basal anterior pituitary function revealed a slightly high level of insulin-like growth factor-1 (IGF-1) (standard deviation, 2.4), and her physical findings exhibited mild acromegalic features. The endocrine evaluation confirmed acromegaly and magnetic resonance imaging (MRI) showed a macro PitNET with suprasellar extension. Endoscopic endonasal surgery (EES) was performed to remove the macro PitNET. Although postoperative MRI showed complete removal of the macro PitNET, endocrinological testing indicated no improvement in GH or IGF-1 excess. Pathological examination of the surgical specimen revealed a gonadotropic PitNET. Therefore, we repeated the MRI scan and found a micro PitNET in the thin left normal pituitary gland. A second EES was successfully performed to remove the micro PitNET completely, and both endocrinological and pathological examinations confirmed that the disease was cured. Conclusion: Diagnosing acromegaly with low GH levels requires close monitoring. Double PitNETs are relatively rare and can cause incomplete remission of functional PitNETs.