Endoscopic hematoma evacuation for acute subdural hematoma with improvement of the visibility of the subdural space and postoperative management using an intracranial pressure sensor.

Background: The first choice to treat acute subdural hematoma (ASDH) is large craniotomy under general anesthesia. However, increasing age or the comorbid burden of patients may render invasive treatment strategy inappropriate. These medically frail patients with ASDH may benefit from a combination of small craniotomy and endoscopic hematoma removal, which is less invasive. We proposed covering with protective sheets to prevent brain injury due to contact with the endoscope and suction cannula and improve visualization of the subdural space. Moreover, we placed an intracranial pressure (ICP) sensor after endoscopic hematoma removal. In this article, we attempted to clarify the use of small craniotomy evacuation with endoscopy for ASDH. Methods: Between January 2015 and December 2019, nine patients with ASDH underwent hematoma evacuation with endoscopy at our hospital. ASDH was removed using a suction tube with the aid of a rigid endoscope through the small craniotomy (5-6 cm). Improvement of the clinical symptoms and procedure-related complications was evaluated. Results: No procedure-related hemorrhagic complications were observed. The outcomes of our endoscopic surgery were satisfactory without complications or rebleeding. The outcomes were not inferior to those of other reported endoscopic surgeries. Conclusion: The results suggest that small craniotomy evacuation with endoscopy and postoperative management using an ICP sensor is a safe, effective, and minimally invasive treatment approach for ASDH in appropriately selected cases.

Incidence of radiculopathy following lumboperitoneal shunt placement without fluoroscopy for normal pressure hydrocephalus.

Background: Spinal catheter insertion in lumboperitoneal shunt (LPS) surgery for normal pressure hydrocephalus (NPH) can result in radiculopathy due to mechanical irritation of the nerve roots of the cauda equina. Here, we analyzed the position of LPS shunts placed without portable fluoroscopy in 72 patients, a subset of whom developed postoperative radiculopathy. Methods: We retrospectively analyzed how frequently 72 consecutive NPH patients experienced radiculopathy following LPS catheter placement performed without intraoperative fluoroscopy. Results: The rate of incorrect catheter placement was 15.3% (11/72 cases). We observed that is, downward placement in 6.9% (5/72 cases), hyperflexion in 6.9% (5/72 cases), and subcutaneous migration in 1.4% (1/72 cases) patients. One patient with initial correct LPS placement developed radicular pain 5-day postoperatively attributed to 1-cm of catheter movement; they recovered simply by utilizing oral analgesics for 1-month duration. Conclusion: LPS insertion without fluoroscopic guidance resulted in a 15.3% risk of spinal catheter displacement. We suggest, therefore, that intraoperative imaging guidance be utilized for the placement of LPS in patients with NPH and/or for other pathology to avoid the 15.3% risk of postoperative radiculopathy.

Creating of "fascial sheath" around subcutaneous lumboperitoneal shunt catheters largely prevents postoperative subcutaneous shunt catheter migration.

Background: Spinal catheter migration into the subcutaneous tissue is common after lumboperitoneal shunt (LPS) placement. This study proposed a new method (i.e., wrapping fascia around the catheter like a sheath) to prevent LPS spinal catheter migration. Methods: After a LPS spinal catheter was inserted under routine fluoroscopic guidance, and the paravertebral muscle fascia was closed, the fascia was sutured to wrap the catheter like a sheath using intermittent sutures. Results: Before the introduction of this technique, the rate of LPS spinal catheter subcutaneous migration was 4.6%. In this study, following LPS shunt placement in 18 consecutive patients with normal pressure hydrocephalus, no further spinal catheter migrations were observed. Conclusion: This novel method of "wrapping the LPS catheter with intermittent suture like a sheath" was found to be safe and effective for preventing further spinal catheter subcutaneous migration.

Rapid Change in Shape of Unruptured Intracranial Aneurysm with Acute Perforating Infarction.

Acute ischemic stroke is a rare complication resulting from an unruptured intracranial aneurysm (UIA). Ischemic stroke adjacent to the aneurysms is considered the risk of rupture of aneurysms. However, there is presently no consensus on the optimal strategy for the management of UIAs with ischemic stroke. A 27-year-old woman presented with sudden onset left hemiparesis. Acute infarction of the right basal ganglia and an aneurysm of the right middle cerebral artery were discovered on brain imaging. Antiplatelet therapy was used to treat her. The diagnosis revealed ischemic stroke caused by a thrombosed aneurysm due to the change in the shape of the aneurysm on day 4. The UIA clipping procedure was performed on day 21 due to the risk of subarachnoid hemorrhage (SAH). The findings of the surgery and indocyanine green imaging revealed a partially thrombosed aneurysm and occlusion of a perforating artery. As is well known, enlargement of aneurysm size indicates increasing rupture risk. In the present case, after ischemic events developed, magnetic resonance angiography revealed enlargement of the aneurysm. The findings of the surgery revealed possible pathogenic mechanisms were perforating artery occlusion due to local extension of the luminal thrombus. Clinicians should be aware of the risk of ischemic stroke due to luminal thrombosis of the UIA and SAH and should consider urgent treatment of the UIA even immediately after ischemic stroke.

[A case of swallow syncope associated with Parkinson disease].

A 73-year-old woman with Parkinson disease (PD) was admitted to our hospital because of aspiration pneumonia. She presented with recurrent episodes of loss of consciousness with bradycardia while swallowing solid foods or fluids. Upper endoscopy revealed a normal esophagus without hiatus hernia, cancer, diverticulum, stenosis, or achalasia. Balloon inflation at the cervical esophagus induced sinus arrest and bradycardia followed by a loss of consciousness. The diagnosis of swallow syncope (SS) was confirmed. Esophageal dilatation and an increase in the esophageal pressure induced by esophageal peristaltic disturbance associated with PD can cause SS by stimulating the vagal reflex. In addition, the head-up tilt test showed that she had orthostatic hypotension, and the coefficients of variations of the R-R intervals on electrocardiograms and the total number of beat-to-beat differences greater than 50 mseconds in the RR interval during a 24 hour ambulatory electrocardiogram were normal. The cardiovascular autonomic dysfunction characterized by the presence of sympathetic inhibition and a preserved parasympathetic function might be involved in the onset of SS. Permanent pacemaker implantation improved her clinical symptoms. The recognition of SS on the examination of a PD patient with loss of consciousness while eating is important, as PD patients might develop SS due to peristaltic disturbance and autonomic dysfunction caused by PD.

[Non-cirrhotic Portal-systemic Encephalopathy with Total Aphasia and Right Hemiplegia Following Transient Right Hemiparesis: A Case Report].

A 77-year-old right-handed woman without any liver diseases was admitted to our hospital because of transient right hemiparesis. She developed total aphasia with right hemiplegia on the third hospital day. We suspected that she had a cerebral infarction following a transient ischemic attack. However, brain diffusion-weighted images revealed no abnormal-intensity lesions, and cerebral angiography showed patent arteries. Additionally, her serum ammonia level was elevated. Theta waves without triphasic waves were detected by electroencephalogram. T1-weighted magnetic resonance brain images revealed high-intensity signals in the bilateral globus pallidus. Enhanced abdominal computed tomography showed a portal-systemic shunt from the splenic and inferior mesenteric veins into the left renal vein via the left ovarian vein. The administration of branched-chain amino acids and lactulose improved her clinical symptoms. We confirmed the diagnosis of non-cirrhotic portal-systemic encephalopathy (NCPSE), therefore balloon-occluded retrograde transvenous obliteration of the shunt vessel was performed. The recognition of NCPSE on the examination of a suspected stroke patient is important, as patients with NCPSE can present as stroke mimics. (Received June 26, 2017; Accepted August 22, 2017; Published February 1, 2018).

Left Adrenal Tumor Disappeared Outside a Field of Vision During Laparoscopic Surgery: The True Identity Was Gastrointestinal Stromal Tumor.

Background: We report a case of gastrointestinal stromal tumor (GIST) mimicking a left adrenal tumor. Case Presentation: A 62-year-old female was referred to our hospital for the treatment of left adrenal tumor of 2.8 × 2.3 cm incidentally found during her annual checkup. The preoperative diagnosis based on upper gastroscopy and imaging complete examinations was nonfunctional left adrenal tumor possessing malignant potential. Transperitoneal laparoscopic left adrenalectomy was performed. However, the tumor was not found in the excised adrenal gland that had been completely removed during surgery. Repeat computed tomography revealed the presence of the same tumor. Finally, reoperation led us to the true diagnosis of GIST. Conclusion: Many urologists are not familiar with GIST. It is necessary to take GIST into consideration when left adrenal tumor close to the stomach is diagnosed. We discuss the traps which we fell into during the perioperative period in this case.

Modified Gas Chromatographic Method to Determine Monoacylglycerol and Diacylglycerol Contents in Edible Fats and Oils.

Monoacylglycerol (MAG) and diacylglycerol (DAG) are minor components of edible fats and oils, and they relate to the quality of these foods. The AOCS official method Cd 11b-91 has been used to determine MAG and DAG contents in fats and oils. There are, however, difficulties in the determination of MAG and DAG using this analytical procedure. Therefore, we improved this method by modifying the trimethylsilyl derivatization procedure and replacing the internal standard (IS) material. In our modified method, TMS-HT (mixture of hexamethyldisilazane and trimethylchlorosilane) was used for derivatization of MAG and DAG, which was followed by liquid-liquid extraction with water and n-hexane solution containing the IS, tricaprin. Using the modified method, we demonstrated superior repeatability in comparison with that of the AOCS method by reducing procedural difficulties. The relative standard deviation of distearin peak areas was 1.8% or 2.9% in the modified method, while it was 5.6% in the AOCS method. In addition, capillary columns, such as DB-1ht and DB-5ht could be used in this method.

Novel antioxidant capacity assay for lipophilic compounds using electron paramagnetic resonance spectroscopy.

A novel antioxidant capacity assay for lipophilic compounds was developed using electron paramagnetic resonance (EPR) spectroscopy. The assay is based on antioxidant's scavenging ability against the tert-butoxyl radical generated photolytically from di-tert-butyl peroxide in ethyl acetate, and named the tert-butoxyl-based antioxidant capacity (BAC) assay. The radical was trapped by spin trap, 5,5-dimethyl-1-pyrroline-N-oxide, and EPR signal intensity of the spin adduct was used as a quantitative marker of radical levels. Signal intensity decreased in a dose-dependent manner in the presence of an antioxidant that competitively reacts with the radical, which was utilized to evaluate BAC values. The BAC method enabled the accurate estimation of antioxidant capacity for lipophilic materials that may counteract lipid peroxidation in biological membranes. The BAC values for quercetin and caffeic acid are 0.639 ± 0.020 and 0.118 ± 0.012 trolox equivalents, respectively, which are much smaller than values obtained by other aqueous methods such as H-ORAC and ORAC-EPR. Thus, antioxidants present in a non-aqueous environment should be evaluated using a non-aqueous system. In combination with in situ ascorbate reduction, the BAC method was capable of accurately determining the antioxidant capacity of water-insoluble materials that may be reduced in living cells.

Determination of sphingoid bases from hydrolyzed glucosylceramide in rice and wheat by online post-column high-performance liquid chromatography with O-phthalaldehyde derivatization.

We developed a determination method for sphingoid bases using online post-column high-performance liquid chromatography (HPLC) with O-phthalaldehyde (OPA) derivatization. Good separation was achieved using a reversed-phase column and eluting with 50% acetonitrile containing formic acid and heptafluorobutyric acid. Using these conditions, an excellent linearity (R² > 0.999) was achieved using standard solutions of sphinganine (d18:0), sphingosine (d18:1(4t)), 4-hydroxy-sphinganine (t18:0), glucosylsphingosine (glc-d18:1(4t)), and galactosylsphingosine (gal-d18:1(4t)). Plant glucosylceramides were hydrolyzed with 1 M aqueous HCl in methanol for 18 h at 90°C, followed by extraction of sphingoid bases with diethyl ether in preparation for analysis using the proposed HPLC conditions. The glc-d18:1(4t) standard was also hydrolyzed and analyzed by HPLC using the same procedure, and the d18:1(4t) peak obtained from the hydrolyzed glc-d18:1(4t) standard was used as a reference for calculation. We also confirmed the applicability of this method to the analysis of sphingoid bases in rice and wheat, obtaining relative standard deviations of 8.0% for rice and 4.6% for wheat. The recoveries of spiked rice and wheat samples were 104% and 106%, respectively. Our proposed method enables the straightforward determination of sphingoid bases without expensive facilities, employing fluorescence detection of OPA derivatives.

Clear cell adenocarcinoma arising from abdominal wall endometriosis mimicking urachal tumor.

A 41-year-old woman presented with severe lower abdominal pain. She had a history of 2 cesarean deliveries. Magnetic resonance imaging (MRI) revealed a 4.3 × 4.6 × 4.8-cm mass on the urinary bladder dome. Preoperative diagnosis was invasive urachal tumor. Wide resection of the tumor was performed. The histopathological diagnosis was clear cell adenocarcinoma with endometriosis. MRI revealed normal-sized ovaries and uterus. The definite diagnosis of clear cell carcinoma arising from abdominal wall endometriosis was made. Adjuvant chemotherapy with paclitaxel and carboplatin (total 6 courses) was planned. The patient has thus far received 4 courses of this treatment.

Novel pre-fractionation method of trans fatty acids by gas chromatography with silver-ion cartridge column.

We developed a novel pre-separation method of trans fatty acids (TFAs) using a silver-ion cartridge column and GC. As a preliminary study, a mixture of fatty acid methyl esters consisting of saturated, cis-unsaturated, and trans-unsaturated fatty acids was dissolved in dichloromethane and loaded onto a Bond Elut SCX ion-exchange cartridge column that was converted to the silver-ion form. The column was then eluted with dichloromethane to obtain the saturated fatty acids, dichloromethane/ethyl acetate (90/10) for the trans mono-ene, dichloromethane/ethyl acetate (65/35) for the cis mono-ene, dichloromethane/acetone (60/40) for the trans di-ene, and acetone/acetonitrile (80/20) for the others. Satisfactory separation of the cis/trans isomers was confirmed by GC analysis. To generalize this technique, the elution conditions of the ready-to-use Discovery Ag-ION SPE cartridge column were also optimized. Both cartridge columns had good separation, recovery, and repeatability. Peer laboratory verification was carried out between two laboratories using different production lots of the ready-to-use cartridge column, and the robustness of the product and reproducibility of the method were found to be satisfactory. This technique is therefore a powerful tool not only for routine analyses of TFAs in oils, fats, and foods but also for detailed analyses of TFAs in various research fields.

Increased T-cell immunity against aquaporin-4 and proteolipid protein in neuromyelitis optica.

In neuromyelitis optica (NMO), B-cell autoimmunity to aquaporin-4 (AQP4) has been shown to be essential. However, the role of T cells remains ambiguous. Here, we first showed an increase in CD69+ activated T cells in PBMCs during NMO relapses. Next, T-cell responses to AQP4 and myelin peptides were studied in 12 NM0 patients, 10 multiple sclerosis (MS) patients and 10 healthy subjects (HS). Four hours after adding 1 of 28 overlapping AQP4 peptides, a mixture of AQP4 peptides (AQP4-M) or one of six distinct myelin peptides to 2-day cultured PBMC, CD69 expression on CD4+ T cells was examined. Data were analyzed by paired t-test, frequency of samples with 3-fold increase of CD69 on CD4+ cells (fSI3) and mean stimulation index (mSI). The T-cell response to AQP4-M was significantly increased in NMO (fSI3 = 10/12, mSI = 5.50), with AQP4 (11-30) and AQP4 (91-110) representing the two major epitopes (AQP4 (11-30), fSI3 = 11/12, mSI = 16.0 and AQP4 (91-110), fSI3 = 11/12, mSI = 13.0). Significant but less extensive responses to these two epitopes were also observed in MS and HS. Significant reactivities against AQP4 (21-40), AQP4 (61-80), AQP4 (101-120), AQP4 (171-190) and AQP4 (211-230) were exclusively found in NMO. In addition, responses to AQP4 (81-100) were higher and more frequently detected in NMO, without reaching statistical significance. Interestingly, among the six myelin peptides studied, proteolipid protein (95-116) induced a significant T-cell response in NMO (fSI3 = 7/12, mSI = 4.60). Our study suggests that cellular as well as humoral responses to AQP4 are necessary for NMO development and that the immune response to myelin protein may contribute to disease pathogenesis.