Cerebral amyloid angiopathy associated with hemorrhage: immunohistochemical study of 41 biopsy cases.

The relationship between cerebral amyloid angiopathy and hemorrhage was investigated by an immunohistochemical study of biopsy cases to characterize the involvement of amyloid beta-protein, apolipoprotein E, and cystatin C in cerebral amyloid angiopathy associated with hemorrhage. The amyloid-laden vessels were examined in biopsy specimens from 41 surgical cases of sporadic cerebral amyloid angiopathy (36 cases with hemorrhage and 5 cases without hemorrhage), using immunohistochemical staining with antibodies against amyloid beta-protein, apolipoprotein E, cystatin C, and alpha-smooth muscle actin. The relationship between the occurrence, recurrence, and enlargement of the hemorrhage, and the semiquantitative estimation of the cerebrovascular amyloid-related protein deposition was analyzed using Fisher's exact test. Severe amyloid beta-protein (p < 0.013) and apolipoprotein E (p < 0.013) immunoreactivity were risk factors for the occurrence of the hemorrhage. Severe cystatin C immunoreactivity was a risk factor for the occurrence (p < 0.002) and enlargement (p < 0.014) of the hemorrhage, and tended to induce recurrent hemorrhage (p < 0.103). In addition, loss of the vascular smooth muscle was observed in the intensely amyloid-laden vascular walls that showed cystatin C-immunoreactivity. The present study indicates that intense amyloid beta-protein deposition with cystatin C deposition weakens the cerebrovascular walls, and that cystatin C deposition is a strong predictor of hemorrhage in cerebral amyloid angiopathy.

Postoperative outcome of 37 patients with lobar intracerebral hemorrhage related to cerebral amyloid angiopathy.

BACKGROUND AND PURPOSE: Several recent studies have suggested that neurosurgical procedures are not contraindicated in patients with cerebral amyloid angiopathy (CAA). The purpose of this study was to elucidate the clinical factors influencing the outcome of patients with CAA-related intracerebral hemorrhage (ICH) treated surgically. METHODS: A total of 50 neurosurgical procedures (42 intracerebral hematoma evacuations, 4 ventriculoperitoneal shunts, 3 ventricular drainages, and 1 brain biopsy) were performed in 37 patients with CAA-related ICH. To ascertain the clinical factors that may influence their postoperative outcome, their clinical data (demographics, medical history, recurrent lobar hemorrhage, radiographic characteristics, multiple lobar hemorrhage, surgical details, and postoperative hemorrhage) were examined retrospectively and subjected to multivariate analysis. RESULTS: Twenty patients (54%) had a good outcome, and only 4 (11%) died. Parietal hematomas, advanced age (>/=75 years), and intraventricular hemorrhages had significant adverse influence on the postoperative outcome. Clinically significant postoperative hemorrhage requiring evacuation occurred after 2 (5%) of 42 intracerebral hematoma evacuations. Postoperative hemorrhage did not have significant adverse influence on the outcome. CONCLUSIONS: Neurosurgery can be performed relatively safely in patients with CAA-related ICH, and their postoperative outcome is better than that reported previously. Surgical treatment should be considered for such patients aged <75 years without a parietal hematoma and intraventricular hemorrhage.

Pathological significance of elevated soluble CD14 production in rheumatoid arthritis: in the presence of soluble CD14, lipopolysaccharides at low concentrations activate RA synovial fibroblasts.

In order to establish what contributes to elevated levels of soluble CD14 (sCD14) in rheumatoid arthritis (RA) plasma, levels of sCD14 were compared in RA-paired plasma and synovial fluids and, further, in the culture supernatants of monocyte-rich fractions from patients with RA and healthy donors, and macrophage-rich fractions from RA synovial tissues. The results showed elevated sCD14 in RA synovial fluid in 9 of 16 paired samples and in RA macrophage-rich fractions, suggesting that elevated sCD14 in RA plasma might be due to the sCD14 production by RA synovial macrophages. From the molecular analysis of elevated sCD14, the proteolytic cleavage of membranous CD14 (mCD14) was important in accelerated sCD14 production. Lipopolysaccharides (LPS) at low concentrations and sCD14 increased the ICAM-1 expression on RA synovial fibroblasts. This result implies that in vivo RA synovial fibroblasts may be sensitive to LPS in the presence of sCD14 and LPS-binding protein (LBP).

[Natural course of non-operative cases of acute subdural hematoma: sequential computed tomographic study in the acute and subacute stages].

We have studied 20 non-operative cases of traumatic acute subdural hematoma in the acute and subacute stages by sequential computed tomography (CT). 20 patients were divided into three groups as is shown below; 8 patients with rapid complete resolution within 24 hours (rapid resolution group), 10 patients with slow resolution beyond 24 hours, mainly in the subacute stage (slow resolution group), and 2 patients worsening clinically due to the increase of subdural fluid collection in the subacute stage (subacute worsening group, what is called, "subacute subdural hematoma"). In the rapid resolution group, CT showed mixed density thin subdural hematoma in 6 patients; delayed subdural effusion in 3 patients; cerebral contusion in 2 patients; and diffuse brain swelling in 2 patients. We reviewed 8 of our cases and 13 reported cases. As a result, we consider that the main pathological mechanisms of rapid resolution types were, in the elderly, the washout of the hematoma by the leakage of cerebrospinal fluid (CSF) and, in the young, the compression of the hematoma by brain swelling. In the subacute worsening group, CT showed, in the acute stage, mixed density thick subdural hematoma with brain atrophy and no intraaxial lesions and, in the subacute stage, the increase of low density subdural fluid collection with marked mass effect. We reviewed 2 of our cases and 19 reported cases. As a result, we related the increase of subdural fluid collection in the subacute stage with the CSF leakage into the subdural space due to the tearing of arachnoid membrane. However, massive CSF leakage into the subdural space, producing marked mass effect, may be joined by other factors such as osmotic pressure gradient or oozing from the outer membrane of the hematoma.

Transient hydrocephalus due to movement of a clot plugging the aqueduct.

A rare case of transient hydrocephalus is reported. A 64-year-old woman presented with headache. Computerized tomography (CT) scan revealed hydrocephalus with tiny blood clots in the left foramen of Monro and in the aqueduct. Six hours after the onset, the signs and symptoms disappeared spontaneously. The second CT showed improvement of the hydrocephalus with migration of the clot into the i.v. ventricle. Aqueductal trapping and releasing of the clot formed by bleeding from the choroid plexus located in the left foramen of Monro was suspected for the origin of the transient hydrocephalus.

CT findings of extravasation of contrast medium from a ruptured aneurysm during cerebral angiography--a case report and six others from the literature.

We present a case of ruptured aneurysm in which extravasation of contrast medium was suspected during cerebral angiography and confirmed by computed tomography. In cases of ruptured aneurysm, post-angiographic computed tomography before operation (measurement of the Hounsfield unit numbers and grading by them) is necessary for establishing the diagnosis of extravasation of contrast medium and for grasping its degree and extent.

[Subacute subdural hematoma: report of 3 cases].

Three surgical cases of subacute subdural hematomas are reported considering the pathophysiology. All patients had head traumas and complained the worsenings of the headaches 7-14 days after the head traumas. Serial computed tomography scan (CT) revealed the expansions of the subdural hematomas with the change of the density from high to mixed. The surgical findings of the hematomas showed blood clots and liquid covered with thin membranes. Morinaga et al. suggested the etiology of the subacute subdural hematoma that the influx of cerebrospinal fluid (CSF) to the hematoma cavity through the teared arachnoid. Our macroscopic findings of the hematomas which had the CSFlike liquid supported this estimation. We suggest that subacute subdural hematoma should be differed from chronic subdural hematoma because it may have the proper mechanisms of the development. Mild acute subdural hematomas should be observed carefully because they may develop to be subacute subdural hematomas between 1 and 3 weeks after the onset.

Brain temperature before and after brain death.

Although there has been renewed interest in human brain temperature, very little information is available on the association between brain temperature and cerebral perfusion pressure. In this study, we measured brain, tympanic, and rectal temperatures, arterial blood pressure and intracranial pressure in a case of massive hemorrhage deteriorating to brain death, and showed for the first time that when cerebral perfusion pressure began to decrease markedly brain temperature fell rapidly. Rectal and tympanic temperatures were higher than brain temperatures during the period of very low cerebral perfusion pressure. Circadian change in temperature (high at day, low at night) was preserved during the period of brain death.

Pineal and suprasellar metastasis of lung cancer: case report and review of the literature.

A very rare case of simultaneous pineal and suprasellar metastasis of lung cancer in a 46-year-old man is reported. Simultaneous mass lesions in these regions are usually diagnosed as primary germ cell tumors in the central nervous system. The clinical features and differential diagnosis are discussed.

Early, evolving Wallerian degeneration of the pyramidal tract in cerebrovascular diseases: MR study.

OBJECTIVE: The purpose of this study was to demonstrate the early features of the Wallerian degenerative process and their relationship with the severity of motor deficit. MATERIALS AND METHODS: Fourteen patients with infarction or hemorrhage of the basal ganglia were studied by MRI of the same coronal slice along the pyramidal line. RESULTS: The earliest sign of abnormal signal intensity was detected 0.7 month after the initial insult. On proton-density (PD) imaging, low signal intensity was observed on 11 (73.3%) of 15 occasions from 0.7 to 2.0 months, and abnormal signal intensity was not detected 5 (83.3%) of 6 times from 2.1 to 3.7 months. High signal intensity was revealed on 11 (78.6%) of 14 occasions after 3.8 months. The widest extent of the low-intensity signal band on PD imaging was closely related to the severity of motor deficits at > 4 months. CONCLUSION: The development of the Wallerian degenerative process was divided into four stages by MRI. We conclude that the extent of Wallerian degeneration is related to the severity of motor deficit.

Distal posterior cerebral artery aneurysms--three case reports.

One case of an aneurysm in the P3 segment and two cases of aneurysms in the P4 segment of the posterior cerebral artery are described. The P3 aneurysm in a 60-year-old female and a P4 aneurysm in a 63-year-old male were clipped or coated via the occipital interhemispheric approach. The other P4 aneurysm in a 73-year-old female was clipped via a hematoma cavity. The occipital interhemispheric approach should be selected for small or large P3 aneurysms and for P4 aneurysms associated with slack brain, as brain retraction is minimal and the approach to the aneurysm is straightforward.

[Shunting operation with the medos programmable valve shunt system].

We reviewed 13 patients with hydrocephalus of varied etiology and two patients with arachnoid cyst who underwent shunting operations using Medos programmable valve shunt system. This shunt system allows 18 pressure settings, ranging from 30 to 200mmH2O in 10mmH2O differentials, percutaneously. Following the shunting operation, the size of the ventricle or arachnoid cyst was reduced in all cases and the clinical symptoms improved in 14 cases. The valve pressure was reset during the postoperative course in all cases. In five cases, resetting was performed because of management of complications. In the others, it was performed to find the most appropriate valve pressure for each patient. Complications were subdural effusion (2 cases), chronic subdural hematoma (2 cases) and slit ventricle syndrome (1 case). Subdural effusion and slit ventricle syndrome were improved easily by resetting the valve pressure, but both cases of chronic subdural hematoma finally required surgical treatment. Artifacts in MR imaging and movement of the valve pressure by MR imaging were small and created no clinical problem. In cases 1 and 2, clinical symptoms and CT finding were improved by a change of 30mmH2O. In case 2, hydrocephalus with slight subdural effusion followed a good course with frequent change of the valve pressure. Accordingly, we consider the Medos system to be useful for a more thorough treatment of hydrocephalus and arachnoid cyst after shunting operations.

Pyramidal tract Wallerian degeneration and correlated symptoms in stroke.

In order to reveal the precise degree of injury in the pyramidal tract after stroke, we studied 35 patients with motor deficit associated with cerebrovascular disease of the internal capsule using the T2-weighted coronal image along the 'pyramidal line'. According to the severity of the motor deficit, the patients were divided into three groups. The Wallerian index was calculated as: (area of Wallerian degeneration in the pons divided by area of the ipsilateral half of the pons) x 100. There were significant differences between the three groups. It is concluded that the area of Wallerian degeneration is related to the severity of motor deficit.

[Ruptured aneurysm at the peripheral branch of the posterior cerebral artery with systemic lupus erythematosus].

We report a 73-year-old woman with systemic lupus erythematosus (SLE) in whom intracerebral and intraventricular hemorrhage developed secondary to a ruptured aneurysm on the peripheral branch of the posterior cerebral artery. We reviewed data on 22 patients (43 aneurysms) in previous reports of ruptured cerebral aneurysms associated with SLE, including our case. Of these aneurysms, 34 (79.1%) were located on the major artery, and 9 (20.9%) were located on the peripheral small artery. Fusiform aneurysms accounted for 27.9% of the total. The prognosis was poor, and 14 patients (63.6%) died. Direct aneurysmal surgery was performed in 11 patients (50%), but 4 patients died of other diseases associated with SLE.

Coronal MR imaging for visualization of wallerian degeneration of the pyramidal tract.

A coronal image taken along a straight line between the front edge of the medulla and the deepest point of the interpeduncular cistern clearly displayed wallerian degeneration of the segment of the pyramidal tract between the internal capsule and the pons, the medulla, or the decussation. This visualization was verified in 21 patients with moderate or severe hemiparesis following a stroke episode.

[Quantification of wallerian degeneration of the pyramidal tract in the capsular region by magnetic resonance imaging].

Using magnetic resonance imaging, we studied 23 patients with motor deficit associated with cerebrovascular disease of the internal capsule. According to the severity of the motor deficits, 23 patients were divided into three groups (severe group...9, moderately severe group...8, mild group...6). A coronal T2-weighted image was obtained along a straight line between the front edge of the medulla and the deepest point of the interpeduncular cistern in a midsagittal T1-weighted image. It was revealed that wallerian degeneration extended continuously from part of the internal capsule down to the pons or medulla or the decussation in all patients. The area of wallerian degeneration in the pons and the area of half the pons were calculated from the coronal T2-weighted image. Moreover, the wallerian index was calculated as: (area of wallerian degeneration in pons divided by area of half the pons) X 100. Values of the wallerian index +/- SD were 26.4 +/- 5.1 in the severe group, 19.2 +/- 5.6 in the moderately severe group, and 10.0 +/- 5.4 in the mild group. There were significant differences among the three groups. We concluded that the area of wallerian degeneration was related to the severity of motor deficits.