A Pure Acute Subdural Hematoma Presenting with a Diploic Arteriovenous Fistula: Case Report and Literature Review.

Objective: We report a case of pure acute subdural hematoma (SDH) caused by a diploic arteriovenous fistula (AVF) and it is a first case report as far as we researched it. Case Presentation: A 19-year-old man was admitted as an emergency to our hospital with headache and nausea. CT scan on hospital admission showed a right acute SDH. Because there was no history of head trauma, MRI, MRA, and DSA were performed to identify a source of bleeding. DSA disclosed an AVF. The shunt was located between a frontotemporal branch of the middle meningeal artery (MMA) and a diploic vein, and its shunting point formed an aneurysmal sac, which was considered to have ruptured. Endovascular treatment was administered rather than surgical treatment to prevent re-bleeding because the patient was conscious and alert, CT showed a small SDH, and the left MMA near the shunting point was accessible for catheterization. A diluted mixture of 25% n-butyl-2-cyanoacrilate was injected into a left frontoparietal branch just before the shunting point and the shunt, including the aneurysmal sac, was obliterated. The patient's postoperative course was uneventful and he was discharged without neurological deficits. Conclusion: We experienced a patient with a pure acute SDH caused by diploic AVF. In patients with non-traumatic acute SDH, DSA is recommended to determine its underlying cause. Our review of published reports yielded few instances of non-traumatic pure acute SDH in young people. Possible causative factors should be investigated promptly and appropriate treatment provided immediately.

[Ruptured Dissecting Aneurysm of M2 Portion of the Middle Cerebral Artery:A Case Report].

A 71-year-old woman presented with a sudden onset of headache and vomiting. Computed tomography(CT)showed diffuse subarachnoid hemorrhage(SAH)that was more severe on the right side. Three-dimensional CT angiography and right carotid angiography(CAG)demonstrated 2-mm microaneurysms at the middle cerebral artery(MCA)bifurcation and anterior communicating artery, with slight narrowing and dilatation of the M2 inferior trunk. Each microaneurysm was smooth, making it difficult to identify the bleeding source. Thus, surgery was postponed at the acute stage, and further investigation was planned. Repeated CAG was diagnostically unsuccessful, finding no source of the bleeding. On day 45 after the onset, exploratory craniotomy was performed to confirm the cause of the SAH. During the operation, both microaneurysms were found to be unruptured. However, the distal portion of the M2 inferior trunk was dark purplish and red and enlarged in a fusiform shape, suggesting a dissecting aneurysm. Residue of the SAH observed near the enlarged vessel identified it as the bleeding source. The enlarged vessel was wrapped with Bemsheets, and the Bemsheets was clipped to secure it. A dissecting aneurysm of the distal MCA is rare, as is the onset of bleeding. Based on a review of the literature related to dissecting aneurysms of the distal MCA, we recommend exploratory craniotomy if CT demonstrates laterality of the sylvian fissure on the SAH and CAG reveals stenosis or occlusion of the distal MCA in cases of SAH for which no bleeding source is detected.

[A case of ganglioglioma extended to the lateral ventricle and associated with neurofibromatosis type 1].

We encountered a rare case of intraventricular ganglioglioma associated with neurofibromatosis type 1. A 42-year-old woman presented with a feeling of heaviness of the head and dizziness. She was diagnosed with neurofibromatosis type 1 because she had multiple subcutaneous neurofibromas and café au lait spots. On admission, she deteriorated slightly(Japan Coma Scale 1)and suffered from cognitive dysfunction and right hemiparesis. A computed tomography(CT)scan showed that she had an obstructed hydrocephalus with a long and circular mass lesion, 2cm in diameter, in the anterior horn of the left lateral ventricle. The mass showed low signal intensity(SI)on the T1-weighted image(WI), heterogeneous high SI on the T2-WI, and dense enhancement on a Gd-DTPA contrast MRI, extending from the head of the left caudate nucleus to the lateral ventricle. The patient underwent an urgent operation via an anterior transcallosal approach because of an obstructed hydrocephalus. The tumor was removed in its entirety, including its origin at the caudate head. The pathological diagnosis was a ganglioglioma grade 1 according with the classification of the World Health Organization. Here we describe this case and discuss the rare association between gangliogliomas and neurofibromatosis type 1.

High energy trauma patients treated in the department of general surgery in a secondary emergency facility in Japan.

OBJECTIVE: We clarified the characteristics of the high energy trauma patients that entered the general surgery ward of Fukuoka city hospital (FCH), a 200 bed secondary emergency hospital in Japan. PATIENTS AND METHODS: Of the 7,826 total ambulance cases treated from April 2008 to March 2012 in our emergency room, 831 trauma patients who entered our hospital were analyzed. These patients were classified into a non high energy (NHE) and high energy trauma (HE) group based on the mechanisms of injuries. RESULTS: Of the 831 trauma cases, 741 (89.2%) were in the NHE and 90 (10.8%) were in the HE group. Eleven of the 741 cases (1.5%) in the NHE group and 18 of the 90 cases (20.0%) in the HE group entered the Department of General Surgery as inpatients, with the frequency being significantly higher in the latter group (p < 0.01). 11 of the 18 cases (61.1%) of Department of General Surgery in the HE group were diagnosed to have an injury severity score (ISS) of 15 or higher, and the rate of preventable trauma deaths (PTDs) of those 11 cases was 9.1% (1/11). CONCLUSIONS: The proportion of the patients that entered the Department of General Surgery was higher in the HE group than in the NHE group. The surgical departments of secondary emergency facilities are expected to contribute to the local trauma emergency systems.

A case of choroid plexus papilloma with stromal sclerosis and indistinct papillary structures.

We present a case of choroid plexus papilloma with unusual histopathological findings. A 41-year-old Japanese man presented with dizziness. Brain magnetic resonance imaging scan showed a distinct mass in the fourth ventricle. Histopathological examination showed proliferation of cuboidal cells forming irregular trabeculae, small nests, and pseudoglandular and indistinct papillary structures, accompanied by a variable degree of stromal sclerosis. The tissue sections also showed rare mitotic activity, no hypercellularity, cellular pleomorphism, or necrosis. The immunohistochemical findings were tumor cells positive for cytokeratin 7, vimentin, S-100 protein, and transthyretin but negative for cytokeratin 20, BerEP4 and carcinoembryonic antigen. These findings were consistent with choroid plexus papilloma. The combination of these immunohistochemical markers was helpful in establishing the diagnosis, although the morphological finding of stromal sclerosis is rare for choroid plexus papilloma.

The practice of emergency medicine in Fukuoka City Hospital, a secondary emergency facility in Japan.

OBJECTIVE: The transition of emergency departments and the current situation of emergency medicine (EM) in Fukuoka City Hospital (FCH) were reviewed. METHODS: The data concerning emergency medicine, such as the transition of intra-hospital emergency systems, were obtained from annual reports published in our hospital. Additionally, the data regarding educational programs for emergency room staff, the number of patients taken to the emergency room by ambulances, the activities regarding the Fukuoka Medical Rally (FMR) and the disaster relief team (DRT) were also reviewed and analyzed. RESULTS: Departments of neurology, neurosurgery, emergency, and cardiology were opened sequentially, starting in 2003, with an establishment of facilities of an emergency room (ER), intensive care unit (ICU), stroke care unit (SCU), and coronary care unit (CCU). Regarding educational programs, lectures and demonstrations on basic and advanced life support techniques were given to all staff annually starting in 2004, and resident doctors completed rotations in the ER and the ICU for three months. FCH staff consistently obtained excellent results at the FMR. Ambulance crews attended lectures and received training on EM and intra-tracheal intubation. The numbers of patients taken by ambulance to FCH increased from 129 in 2002 to 2,316 in 2011. The DRT was dispatched to respond to disasters that occurred in Japan. CONCLUSIONS: As a secondary emergency hospital, FCH has developed a system to accept emergency patients. This project will contribute to the improvement of the EM system in the area.

Onset and duration of symptoms and timing of disease transmission of 2009 influenza A (H1N1) in an outbreak in Fukuoka, Japan, June 2009.

The first confirmed case of 2009 influenza A (H1N1) in Fukuoka, Japan was reported in early-June 2009. The disease rapidly spread through this area, mainly in schools, until there were no new cases detected 3 weeks later. We describe herein the clinical characteristics of this novel infection that came to light through the investigation of this outbreak. The patient records at hospitals and local public health centers were reviewed, and we defined laboratory-confirmed cases as those of a person who had influenza-like symptoms, such as a fever of 37C or more, cough, sore throat, rhinorrhea, or headache. From May 19 to June 31, 2009, a total of 71 cases were identified. The median age was 11 years, and all the patient took neuraminidase inhibitors and fully recovered. The fevers lasted for 1 to 5 days (median, 2). Cough lasted for 2 to 11 days (median, 7), and in 10 cases (34.5%) cough started before the fever. The incubation period was 2 to 3 days. Infectors transmitted the disease to another person on the day of or the day before fever onset. The findings regarding the onset and duration of symptoms and the timing of disease transmission of 2009 influenza A (H1N1) may be useful for future response.

Cavernous malformation of the ventral midbrain successfully removed via a transsylvian-transpeduncular approach: case report.

A 37-year-old woman presented with a rare cavernous malformation of the ventral midbrain with brainstem hemorrhage manifesting as sudden onset of headache and vomiting. The lesion was removed successfully through a transsylvian approach and a medial peduncular route. Postoperatively, her oculomotor nerve paresis worsened temporarily, but diplopia disappeared 2 months after surgery. We recommend the transsylvian-transpeduncular approach if the lesion is located in the ventral midbrain and faces the ventral surface of the brainstem, because of the effective access with minimal neurological deficits.

Ruptured aneurysm of the distal anterior cerebral artery: clinical features and surgical strategies.

Ruptured aneurysms of the distal anterior cerebral artery (ACA) are relatively rare and surgical management provides some unique technical challenges. This retrospective analysis of 20 patients with distal ACA aneurysms evaluated the clinical features and surgical strategies. The characteristic findings were small and common concurrent aneurysms, and frequent intracerebral hematoma (ICH). Aneurysms were divided by location on the genu (n = 13), infracallosal (n = 5), and supracallosal portions (n = 2). All patients except one underwent surgery via an interhemispheric route. Unilateral craniotomy was performed for aneurysms on the genu portions without massive ICH. Bilateral craniotomies were selected for aneurysm located on the infracallosal portion or combined with massive ICH. No intraoperative rupture was observed. Favorable outcomes were achieved in 15 of 20 patients, and only one patient died. The preoperative Hunt and Kosnik grade was closely correlated with the outcome.

Pseudoaneurysm of the thoracic radiculomedullary artery with subarachnoid hemorrhage. Case report.

The authors report a rare case of a patient with a left-sided T-5 radiculomedullary artery pseudoaneurysm who presented with spinal subarachnoid hemorrhage (SAH). The patient, a 71-year-old woman, was hospitalized for progressive paraplegia and sensory loss with bladder and rectal dysfunction. Computerized tomography scanning revealed an SAH at the posterior fossa. Spinal T2-weighted magnetic resonance imaging demonstrated SAH and an inhomogeneous and slightly low signal intensity mass at T4-5. Spinal angiography revealed a tiny masslike staining without arteriovenous shunting. The resected specimen, which caused the spinal SAH, was diagnosed as a pseudoaneurysm based on operative and pathological findings.

Recombinant mutant human tumor necrosis factor-alpha (TNF-SAM2) immunotherapy with ranimustine chemotherapy and concurrent radiation therapy for malignant astrocytomas.

BACKGROUND: This study assessed the safety, tolerance and preliminary efficacy of a combination chemotherapy regimen consisting of ranimustine (MCNU) and recombinant human mutant tumor necrosis factor-alpha (TNF-SAM2) for patients with newly diagnosed supratentorial malignant astrocytomas. MATERIALS AND METHODS: The initial regimens were prescribed as adjuvant therapy in conjunction with radiotherapy following standard surgical treatment. Ranimustine (MCNU) was administered intravenously at 100 mg/m2 on Day 1, i.e., at the onset of radiation therapy, and was followed by 80 x 10(4) U/m2 TNF-SAM2 intravenously from Day 3. TNF-SAM2 was prescribed weekly for up to 5 injections during the postoperative period concurrent with radiation therapy. TNF-SAM2 and MCNU were given each 8- to 12-week cycle until tumor progression was evident, or for a total of four cycles over a 1-year period. The primary end-points were safety and tolerability and the secondary end-point was overall survival. RESULTS: Twenty-six consecutive eligible patients, including 5 with anaplastic astrocytoma (3 men and 2 women) and 21 with glioblastoma (13 men and 8 women), were treated. All of the 3 evaluable patients with anaplastic astrocytoma partially responded to treatment (PR), with a time to tumor progression (TTP) of 107 weeks and an estimated median survival time of 330 weeks. Of the 15 evaluable patients with glioblastoma, 8 (53.3%) showed no change in response to the treatment (NC), while 7 (46.7%) had progressive disease (PD), with a time to tumor progression (TTP) of 36 weeks and an estimated median survival time of 69 weeks. Although this regimen appeared to be safe, there was no improvement in response or survival time compared with a historical control of patients who received chemotherapy with MCNU alone in conjunction with radiotherapy for glioblastoma. Neither neurological toxicity, severe or life-threatening hematological toxicity, nor fatal toxicity (WHO Grade 4) was experienced. CONCLUSION: These results suggest that combined chemotherapy with mutant TNF-alpha (TNF-SAM2) in this patient population seems to be safe and tolerable and may benefit those with anaplastic astrocytoma. These intriguing clinical observations warrant further evaluation to determine whether this approach can provide therapeutic benefits and improve survival.

Treatment of recurrent malignant supratentorial astrocytomas with carboplatin and etoposide combined with recombinant mutant human tumor necrosis factor-alpha.

BACKGROUND: This study assesses the safety, tolerance and preliminary efficacy of combined treatment with carboplatin, etoposide and recombinant human mutant tumor necrosis factor-alpha (TNF-SAM2) for recurrent malignant supratentorial astrocytomas at first relapse. MATERIALS AND METHODS: Carboplatin was administered intravenously at a dose of 400 mg/m2 on Day 1, while etoposide was administered intravenously at a dose of 100 mg/m2 from Day 1 to Day 3 for 3 days. From Day 7, 80x10(4) U/m2 TNF-SAM2 was given intravenously for up to 5 injections for 2 weeks. Treatment was repeated every 8 to 12 weeks. RESULTS: Ten patients previously treated with surgery, radiation therapy and chemotherapy with a nitrosourea (ranimustine: MCNU) for malignant astrocytomas received this regimen for up to four cycles. Three patients with anaplastic astrocytomas, one patient with anaplastic oligoastrocytoma and 6 patients with glioblastomas (3 men and 7 women), aged 27 to 69 years, were eligible and were evaluated for response and toxicity. Grade 2 and 3 hematological toxicities occurred in 4 (40%) and 2 patients (20%), respectively. Grade 2 hepatic toxicity was observed in two patients. Of 9 evaluable patients, three (33%), including one glioblastoma, partially responded to the treatment (PR) with time to tumor progression (TTP) of 231, 121 and 57 weeks, respectively. Two patients had stable disease (SD), while 4 glioblastomas (44%) had progressive disease (PD) with TTP values of 11, 15, 6 and 12 weeks, respectively. CONCLUSION: These results suggest that combined therapy with carboplatin, etoposide and recombinant mutant TNF-alpha in this patient population seems to be safe and acceptable and may benefit those with recurrent anaplastic astrocytomas. These intriguing clinical observations warrant a properly stratified randomized trial to determine whether this approach can provide therapeutic benefits and improve survival.