Aneurysmal subarachnoid hemorrhage occurring during sleep: Clinical characteristics and risk factors.

BACKGROUND: Aneurysmal subarachnoid hemorrhage (aSAH) is known to be triggered by several specific human activities. Sleep, by contrast, has not been considered a triggering activity for aSAH, and clinical characteristics of patients who sustain aSAH during sleep have rarely been reported in the literature. METHODS: This is a retrospective analysis on the data acquired through a multicenter aSAH registry. Between January 2019 and December 2021, a total of 732 aSAH patients had been registered into our database. After excluding 109 patients whose activities at aSAH onset had been unidentifiable, the remaining 623 aSAH patients were dichotomized to 59 patients who sustained aSAH during sleep (Sleep group) and 564 patients who sustained aSAH during daytime activities (Awake group). Two-group comparison of demographic variables and multivariate logistic regression analysis were performed to clarify their clinical characteristics and identify potential risk factors. RESULTS: The Sleep group exhibited significantly higher frequencies of diabetes (15.5 % vs. 6.4 %, p = 0.01) and antiplatelet use (13.8 % vs. 4.6 %, p=0.004) than the Awake group. Furthermore, multivariate logistic regression analysis showed that diabetes (OR, 3.051; 95 % CI, 1.281-7.268; p = 0.012) and antiplatelet use (OR, 3.640; 95 % CI, 1.422-9.316; p = 0.007) were correlated with aSAH occurring during sleep. There were no significant inter-group differences in the patient outcomes evaluated at discharge. CONCLUSION: The current results indicate that risk factors may exist for aSAH occurring during sleep. Further investigations on how comorbidities such as diabetes, antiplatelet use and sleep apnea affect human hemodynamic and hemostatic parameters during sleep is warranted to better understand those relationships.

Spontaneous Intracranial Hypotension Occurring after Craniotomy for Brain Tumor Biopsy Mimicking Postoperative Bleeding.

In this study, we report on a previously healthy 44-year-old man who underwent an open biopsy under general anesthesia for a tumorous lesion found in his left frontal lobe via a small supratentorial craniotomy. While both postoperative course and brain computed tomography (CT) scans had been considered unremarkable, the patient became stuporous on postoperative day (POD) 4. A brain CT obtained on that day showed a subdural hematoma with marked brain shift which we thought might have been due to postoperative bleeding; he was immediately brought to an operating theater for hematoma removal. However, no bleeding source was found, and the brain remained depressed after hematoma evacuation. Furthermore, the brain shift remained unchanged on postoperative CT. While spontaneous intracranial hypotension (SIH) was considered, imaging studies to search for possible cerebrospinal fluid (CSF) leakage in the spinal column were not performed as the patient's condition has improved. However, he became stuporous again on POD 8, which urged us to perform CT myelogram. The CT myelogram showed a massive CSF leakage at the L1-L2 level. Subsequent autologous blood patch has successfully terminated the CSF leakage, and he became fully oriented shortly after the blood patch therapy. Thus, it should be noted that SIH may occur during postoperative period of intracranial surgery, and it may manifest radiographically as a subdural hematoma indistinguishable from postoperative bleeding. SIH should also be included in a differential diagnosis of postoperative headache, regardless of its characteristics, because headache associated with SIH may not always be orthostatic.

A rare case of sacral epidural arteriovenous fistula with concomitant occult multiple lumbar epidural arteriovenous fistulas.

We describe a rare case of sacral epidural arteriovenous fistulas (edAVFs) with atypical clinical course of treatment. A 78-year-old man with a history of spinal surgery presented progressive gait disturbance and urinary incontinence. Spinal angiography demonstrated a sacral spinal AVF fed by bilateral lateral sacral arteries, draining to the venous pouch with subdural drainage. The first treatment by direct interruption of a subdural drainer was incompletely finished. Postoperative reassessment by 3D imaging analysis led to the diagnosis of sacral edAVF and 3D understanding of its angioarchitecture. The second treatment by transarterial embolization (TAE) resulted in complete occlusion of a sacral edAVF. However, spinal venous congestion didn't improve, because the recruitment of occult edAVFs at the multiple lumbar levels and complex-shaped sacral ventral epidural venous plexus (VEP) were involved in the remnant of prior subdural drainage. The third treatment was performed by TAE for three occult edAVFs and the VEP compartment connecting between a patent edAVF and subdural drainage, which resulted in complete disappearance of spinal cord edema. Endovascular embolization of VEP compartment connecting to subdural drainage in addition to fistulous occlusion may be one of the treatment options for several edAVFs at the multiple spinal levels.

Changes in Short-Term Outcomes After Discharge in Patients with Aneurysmal Subarachnoid Hemorrhage: A Multicenter, Prospective, Observational Study.

OBJECTIVE: The objective of the study was to clarify the prevalence of and factors associated with changes in patients' outcomes between discharge and 3 months after the onset of aneurysmal subarachnoid hemorrhage (aSAH). Additionally, the World Federation of Neurosurgical Societies (WFNS) and modified WFNS (mWFNS) scales were compared. METHODS: The data of curatively treated patients with aSAH, collected prospectively in the mWFNS scale study between January 2010 and December 2012, were analyzed retrospectively. The improvement or decline in the modified Rankin Scale (mRS) scores between discharge and 3 months after onset was determined. A multivariable logistic regression analysis was performed to identify factors, such as age and WFNS and mWFNS grades, associated with changes in the outcome. RESULTS: The mRS scores improved in 28.3% and declined in 2.5% of the patients. WFNS and mWFNS grades Ⅱ-V on admission were significantly associated with improved mRS scores at 3 months after onset. Older age (age: 65-74 years vs. age <65 years, odds ratio: 6.59, 95% confidence interval: 1.28-34.01; age ≥75 years vs. age <65 years, odds ratio: 17.67, 95% confidence interval: 2.11-148.26) and WFNS grade III were significantly associated with a decline in mRS scores at 3 months after onset. CONCLUSIONS: The optimal timing for postdischarge assessment of outcomes may be at 3 months after onset, especially in older patients with aSAH. The mWFNS scale is presumed to more accurately assess the outcomes of patients with aSAH than the WFNS scale, as demonstrated in this study.

[Real-time 3D reconstruction CT-jejunography guided direct percutaneous endoscopic jejunostomy for levodopa-carbidopa intestinal gel treatment in a patient with prior gastrojejunostomy].

A 68-year-old woman with Parkinson's disease, who had previously undergone Roux-en-Y gastrojejunostomy for early gastric cancer, complained of wearing-off and troublesome dyskinesia that had progressed over 7-years. After the introduction of levodopa-carbidopa intestinal gel therapy (LCIG) by nasojejunal tube, she had a good clinical response. Percutaneous endoscopic gastrostomy with a jejunal extension tube was difficult in this case, due to lack of gastrostomy site and fibrous postoperative adhesion. We introduced LCIG by direct percutaneous endoscopic jejunostomy (D-PEJ) which offers a less invasive procedure to operative tube placement. The factors affecting the success of D-PEJ could interfere with transillumination, abdominal thickness and the location of other organs. We determined the optimum site of catheter insertion with the assistance of real-time 3D reconstruction CT-jejunography. She was discharged home on postoperative day 14 without any procedure-related complications. Real-time 3D reconstructive CT-jejunography guided D-PEJ is a useful method for a patient who benefit from LCIG with prior gastrojejunostomy.

Role of Endovascular Approach as Diagnostic Technique and First-Line Therapy for the Patients with Micro-Arteriovenous Malformations: A Case Report and Literature Review.

Objective: We describe a rare case report of micro-arteriovenous malformation (micro-AVM) treated by the endovascular approach in addition with literature review. Case Presentation: A 12-year-old boy presenting with a spontaneous intracerebral hematoma in the left occipital lobe underwent conventional diagnostic workups. The results of initial catheter angiography were considered to be equivocal as the AVM. Superselective angiography (SA) demonstrated a micro or small AVM (single feeder and single drainer type) with an aneurysmal dilatation. Immediate transarterial embolization (TAE) might fail to occlude the whole of nidus area completely, and subsequently, we switched to the surgical exploration of AVM lesion. Intraoperative findings demonstrated that the whole of AVM lesion had already been occluded completely, indicating the complete occlusion by TAE only. Pathological findings of the surgical specimen showed an aneurysmal dilatation was a venous aneurysm with vulnerable vascular wall structure, which was certainly the source of bleeding. Based on the above results, the retrospective revaluation of superselective angiogram permitted us to understand that the nidus of AVM was micro nidus type and TAE had resulted in the complete nidus occlusion. Conclusion: SA is the most useful diagnostic modality to clarify the angioarchitecture of micro-AVM and AVM-related aneurysms. If SA is successfully performed and relatively safe TAE is expected to be possible, the subsequent attempt to do curative embolization as a first-line treatment may be worthy of consideration. However, the surgical procedure should be fully reserved for the possible incomplete obliteration and hemorrhagic complications.

Factors Associated with Prolonged Impairment of Consciousness in Adult Patients Admitted for Seizures: A Comprehensive Single-center Study.

Seizures are common neurological emergencies that occasionally cause prolonged impairment of consciousness. The aim of this retrospective single-center study is to clarify factors associated with prolonged impairment of consciousness for admitted adult patients investigating patient backgrounds, blood tests, electroencephalographic patterns, and MRI findings. The patients who were admitted to the hospital due to epileptic seizures were classified into two groups: (1) early recovery group, in which patients recovered their consciousness within 6 hr, and (2) delayed recovery group, in which patients showed impairment of consciousness more than 6 hr. Factors associated with prolonged impairment of consciousness were compared between these groups. In this study, 42 cases (33 patients), with a mean age of 67.8 years, were included. Fifteen cases (13 patients) and 27 cases (20 patients) were classified into the early and delayed recovery groups, respectively. The populations of older patients and patients from a nursing home were significantly higher in the delayed recovery group. With regard to radiological analyses, a high grade of periventricular hyperintensity (PVH), high Evans index score, and enlarged bilateral atrial widths were significantly associated with prolonged impairment of consciousness. Multivariable analyses showed that a high grade of PVH was significantly associated with delayed recovery of consciousness independent of age and status epilepticus. In conclusion, we proposed that diffuse white matter degeneration around the lateral ventricles contributes to prolonged impairment of consciousness.

Myoinositol to Total Choline Ratio in Glioblastomas as a Potential Prognostic Factor in Preoperative Magnetic Resonance Spectroscopy.

Isocitrate dehydrogenase (IDH) wild-type diffuse astrocytic tumors tend to be pathologically diagnosed as glioblastomas (GBMs). We previously reported that myoinositol to total choline (Ins/Cho) ratio in GBMs on magnetic resonance (MR) spectroscopy was significantly lower than that in IDH-mutant gliomas. We then hypothesized that a low Ins/Cho ratio is a poor prognosis factor in patients with GBMs, IDH-wild-type. In the present study, we calculated the Ins/Cho ratios of patients with GBMs and investigated their progression-free survival (PFS) and overall survival (OS) to determine their utility as prognostic marker. We classified patients with GBMs harboring wild-type IDH (n = 27) into two groups based on the Ins/Cho ratio, and compared patient backgrounds, pathological findings, PFS, OS, and copy number aberrations between the high and low Ins/Cho groups. Patients with GBMs in the low Ins/Cho ratio group indicated shorter PFS (P = 0.021) and OS (P = 0.048) than those in the high Ins/Cho group. Multivariate analysis demonstrated that the Ins/Cho ratio was significantly correlated with PFS (hazard ratio 0.24, P = 0.028). In conclusion, the preoperative Ins/Cho ratio can be used as a novel potential prognostic factor for GBM, IDH-wild-type.

Association of preoperative seizures with tumor metabolites quantified by magnetic resonance spectroscopy in gliomas.

Seizures are common in patients with gliomas; however, the mechanisms of epileptogenesis in gliomas have not been fully understood. This study hypothesized that analyzing quantified metabolites using magnetic resonance spectroscopy (MRS) might provide novel insights to better understand the epileptogenesis in gliomas, and specific metabolites might be indicators of preoperative seizures in gliomas. We retrospectively investigated patient information (gender, age at diagnosis of tumor, their survival time) and tumor information (location, histology, genetic features, and metabolites according to MRS) in patients with gliomas. The data were correlated with the incidence of seizure and analyzed statistically. Of 146 adult supratentorial gliomas, isocitrate dehydrogenase (IDH) mutant tumors significantly indicated higher incidence of preoperative seizures than IDH wild-type gliomas. However, MRS study indicated that glutamate concentration in IDH wild-type gliomas was higher than that in IDH mutant gliomas. Glutamate was not associated with high frequency of preoperative seizures in patients with gliomas. Instead, increased total N-acetyl-L-aspartate (tNAA) was significantly associated with them. Moreover, multivariable analysis indicated that increased level of tNAA was an independent predictor of preoperative seizures. According to MRS analysis, tNAA, rather than glutamate, might be a useful to detect preoperative seizures in patient with supratentorial gliomas.

Traumatic brain injury among two-wheeled motor vehicle riders in Utsunomiya, Japan: a comparison between mopeds and motorcycles.

PURPOSE: Two-wheeled motor vehicles are dichotomized into mopeds and motorcycles (MCs) based on their engine capacity. While efforts have been made, mostly by European researchers, to evaluate the possible difference in the frequency/severity of riders' traumatic brain injury (TBI) between the two categories, the results have been inconsistent. METHODS: To evaluate whether such differences exist in Japan, a single-center, retrospective observational study was conducted on two-wheeled motor vehicle riders wearing a helmet during high-energy road traffic accident (RTA). Between January 2011 and December 2017, 127 moped and 128 MC helmeted riders involved in RTAs had been treated in our institution. RESULTS: Moped riders were significantly older than MC riders (50.7 ± 25.0 years vs. 35.1 ± 18.6 years, p = 0.04). The frequency of TBI was significantly higher in moped riders than in MC riders (21.3% vs. 10.9%; p = 0.03). However, the frequency of other bodily injuries did not differ significantly. Among the riders with TBI, neither injury severity nor outcomes differed significantly. Multivariate regression analysis showed that the presence of altered mental status was predictive of TBI (OR 23.398; 95% CI 9.187-59.586; p < 0.001). Moped riders trended to have a higher likelihood of sustaining TBI (OR 2.122; 95% CI 0.870-5.178; p = 0.098). CONCLUSIONS: Mopeds are frequently utilized by elderly in Japan, which may have been causally associated with the higher frequency of TBI in moped riders, while other causes, including the difference in helmet type, may also be involved. This study is limited by its small sample size and retrospective design, and multi-center prospective studies are warranted.

Comparative in vitro biomechanical evaluation of two soft tissue defect products.

A soft tissue defect is often an unavoidable consequence of various surgical procedures or a result of trauma. Recently, intraoperative use of xenograft as a patch to the soft tissue defect has become popular with various products available in the market. In this study, mechanical properties of the OrthADAPT™ Bioimplants (Pegasus Biologics, Irvine, CA), new xenograft products composed of collagen from equine pericardium, were evaluated individually and against an existing bioimplant product. The OrthADAPT™ Bioimplants have three subtypes which differ in the degree of crosslinking of collagen strands. The three products are named as FX, PX, and MX in the order of the degree of collagen crosslinking and likely durability in vivo, with FX most dense in crosslinking and hence most durable. The three subtypes underwent three destructive mechanical tests: tensile strength, suture pull-out strength, and burst strength test. In tensile strength and suture pull-out strength tests, the three products were compared with CuffPatch™, a similar collagen-based xenograft product from a competing manufacturer. In the burst strength test, the three products were compared with untreated equine pericardium tissue. In tensile strength and suture pull-out strength tests, the products FX and MX were shown to have mechanical properties that were comparable with CuffPatch, while the mechanical strength of PX was significantly inferior to FX and CuffPatch in tensile strength test. In burst strength test, there were no differences in mechanical properties among the three OrthADAPT Bioimplants. This study demonstrates the biomechanical equivalence of OrthADAPT with CuffPatch. © 2007 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 2007.

Clinical Characteristics of Driving-related Stroke Occurring as a Recurrent Stroke.

BACKGROUND: Although the number of seemingly healthy subjects who suffer a minor stroke increases, there are no data on how frequently they sustain another stroke while driving. METHODS: A single-center, retrospective study was conducted to clarify the clinical characteristics of driving-related stroke occurring as a recurrent stroke by analyzing data prospectively acquired between January 2009 and June 2019 on 3452 acute stroke patients. RESULTS: One hundred-thirty five patients (85 ischemic stroke [IS] and 50 hemorrhagic stroke [HS]) had suffered a driving-related stroke. Of them, 22 (16%) had suffered a prior stroke (recurrent stroke group), while 113 had never suffered a stroke before (first-time stroke group). While the use of anti-thrombotics was significantly more common in the RS group, other variables including the frequency of road traffic accidents, did not differ significantly. The first stroke-recurrent stroke interval ranged from 0.2 to 18 years. The stroke type at the time of recurrence was IS in the majority of patients with prior IS. When compared to 432 patients with recurrent IS unrelated to driving, patients with recurrent IS related to driving (n = 16) had significantly higher frequency of lacunar strokes (56% vs 27%, P = .02) and lower frequency of cardioembolic strokes (6% vs 29%, P = .04). CONCLUSION: The current finding that 16% of patients who presented with driving-related stroke had previously suffered a stroke indicates that drivers with a prior stroke may be at increased risk for recurrent stroke while driving, and prolonged follow-up be necessary for minor stroke patients who resume driving.

[Wilson's disease presenting as Asperger syndrome].

A 24-year-old man, who had been treated for 3 years as Asperger syndrome in adolescence due to behavioral disturbances, lack of social awareness and inability to socialize, was referred to our hospital shortly after tremors developed. On the basis of clinical features, laboratory findings and the brain MRI, a diagnosis of Wilson's disease (WD) was made. WD was further confirmed by genetic testing (the mutation of ATP7B gene). He was started with trientine hydrochloride 500 mg/day, and after 1 year of follow-up, his psychiatric symptoms have improved. Since psychiatric symptoms may precede the neurological symptoms, the possibility of WD should be always considered in the differential diagnosis of psychiatric disorders in young adults.

Cerebrospinal Fluid Leakage at the Lumbar Spine: A Unique Cause of Delayed Neurologic Deterioration in a Traumatic Acute Subdural Hematoma Patient.

We present a rare case of traumatic acute subdural hematoma (SDH) in which intracranial hypotension (IC) secondary to cerebrospinal fluid (CSF) leakage at the lumbar spine caused delayed neurological deterioration. A 70-year-old male sustained a head injury after ground-level fall and was brought to our institution. A brain computed tomography (CT) showed a thin acute SDH with mild brain shift, and conservative management was initiated. He exhibited neurological deterioration on the 9th hospital day, however, and a brain CT showed a change in CT density and marked an increase in hematoma volume and brain shift. It was thought that conversion from acute to subacute SDH was associated with the deterioration, and emergency hematoma evacuation was performed. Despite the surgery, neither clinical nor radiographical improvement occurred. The lack of improvement pointed to the presence of underlying IC, and a CT myelography revealed the dural sleeve of the right L2 nerve root as the source of the CSF leakage. An epidural blood patch therapy was performed on the 12th hospital day to seal the CSF leakage. The postprocedural course was uneventful, and the patient was discharged free of symptoms on the 20th hospital day. Spinal CSF leakage should be considered as a cause of delayed neurological deterioration in patients with traumatic acute SDH which exhibits conversion to subacute SDH.

Seizures occurring while driving in patients with and without diagnosis of epilepsy: Frequency and association with automobile accidents.

Seizure may occur during any human activity, including driving. The objectives of this study were to report the frequency of seizure occurring while driving, clarify patient characteristics and analyze the behavioral patterns of drivers afflicted by seizure. A single-center, retrospective study was conducted using prospectively acquired data. Data of 658 adult seizure patients who visited our emergency department between January 2011 and December 2016 were used for analysis, focusing on daily activities immediately before seizure. Nineteen of the 658 patients (2.9%) sustained seizure while driving. The 658 patients were dichotomized on the basis of whether he or she had been diagnosed with epileptic seizure (ES). Seven of the 307 patients with ES vs. 12 of the 351 patients without ES sustained seizure while driving. The frequencies did not differ significantly between the two groups (2.3% vs. 3.4%, p = 0.49). Structural lesions on brain imaging studies were found in 6 of the 12 patients without ES (50%). Sixteen of the 19 patients (84%) caused automobile accidents after seizure. Among the 7 patients with ES, antiepileptic drugs had not been prescribed in 3 (43%). Although seizures occurring while driving have been studied extensively, most researchers focused on patients with ES. This study was unique because it focused on patients without ES, and the current findings that seizures in patients without ES outnumbered seizures in those with ES may be informative to clinical neuroscientists and emergency physicians. Prospective studies are expected to identify individuals at risk for first seizure occurring while driving.

Difference in severity and distribution of bodily injuries following collision between drivers of K-cars and standard vehicles.

BACKGROUND: Although K-cars, small four-wheeled vehicles with an engine capacity of <660 cc, have been used almost exclusively in Japan, they have recently become increasingly popular in other countries. Therefore, reporting the characteristics of bodily injuries sustained by K-car drivers after road traffic accidents (RTAs) may be important not only for health professionals but also for car manufacturers. METHODS: A single-center, retrospective observational study was conducted using prospectively acquired data. Between January 2010 and December 2017, 494 restrained drivers (331 men/163 women with a mean age of 45.1 years) whose vehicles had been severely damaged in RTAs underwent whole-body computed tomography prospectively. They were subsequently dichotomized into 221 K-car drivers and 273 standard vehicle drivers and compared for severity and distribution of bodily injuries. RESULTS: K-car drivers tended to be older and were significantly more likely to be female than standard vehicle drivers. The frequency of subjects with severe bodily injuries significantly higher among K-car drivers than among standard vehicle drivers (21.7% vs. 14.3%; p = 0.04), and the frequency of bowel/mesentery injuries tended to be higher in the former (9.0% vs. 4.4%; p = 0.06). However, the frequency of abdominal solid viscus injuries did not differ significantly between the two groups. Multivariable regression analysis showed that age [odds ratio (OR): 1.022; 95% confidence interval (CI): 0.998-1.047; p = 0.07] and K-cars (OR: 3.708; 95% CI: 0.984-6.236; p = 0.05) tended to be associated with bowel/mesentery injuries in restrained drivers. The frequency of pelvic/hip fractures also tended to be higher in K-car drivers than in standard vehicle drivers (5.9% vs. 2.6%; p = 0.10). By contrast, the severity and frequency of the upper torso injuries were similar between the two groups. CONCLUSIONS: Compared to standard vehicle drivers, K-car drivers seem to experience more severe bodily injuries after severe RTAs. Despite there being no answer for the increased frequency of only hollow viscus injuries but not solid viscus injuries among restrained K-car drivers, advanced age may, at least in part, be responsible. Given the limitations inherent to this study's single-center, retrospective design, multi-center prospective studies are warranted to verify our findings.

Clinical Characteristics of Cerebellar Infarction Due to Arterial Dissection.

OBJECTIVES AND BACKGROUND: Arterial dissection (AD) of the vertebral artery (VA) or its branches may cause ischemic stroke of the posterior circulation. However, clinical and radiological characteristics of patients with AD-related cerebellar infarction (CI) have rarely been reported. METHODS: Forty-nine patients with CI admitted to our department from April 2008 to March 2015 were identified from our database. After dichotomization into the AD and non-AD group, their demographics and presenting symptoms were compared. Subsequently, a multivariate regression analysis was performed to identify variables that correlated with AD. RESULTS: During the 7-year period, 14 and 35 patients were identified in the AD and non-AD group, respectively. The AD group was significantly younger than the non-AD group (55.0 ± 16.3 vs. 69.7 ± 10.7 years, P = 0.001) and was also more likely to experience acute pain at onset (86% vs. 17%, P < 0.001). Using a multivariate regression analysis, these two variables and the male sex were found to correlate with AD. AD was located in extracranial VA (n = 3); intracranial VA (n = 8); posterior inferior cerebellar artery (PICA) (n = 3); and superior cerebellar artery (n = 1). Identification of AD was delayed in one patient with an extracranial VA and one patient with a PICA dissection. CONCLUSIONS: AD was responsible for approximately 30% of CI in our cohort. Pain at onset may be a useful symptom to identify patients with AD-related CI. While intracranial VA was the most common location of AD, physicians should be aware of the possibility of extracranial VA or PICA dissection in patients with seemingly unremarkable radiological findings.