A Case of Ruptured Carotid Traumatic Blood Blister-like Aneurysm.

Ruptured cerebral aneurysms that occur in the anterior wall of the internal carotid artery (ICA) are known as blood blister-like aneurysms (BBAs); they have been reported to account for 0.3% to 1% of all ruptured ICA aneurysms. In this report, we describe the treatment of an unusual traumatic BBA (tBBA) with high-flow bypass using a radial artery graft, which resulted in a favorable outcome. A 59-year-old female suffered from an acute epidural hematoma, traumatic subarachnoid hemorrhage, and traumatic carotid-cavernous sinus fistula (tCCF) after being involved in a motor vehicle accident. Her angiography results showed tCCF and a tBBA on the anterior wall of the right ICA. On the fourth day after injury, we found rebleeding from the tBBA and performed an emergency high-flow bypass using a radial artery graft with lesion trapping as a curative procedure for the tCCF and tBBA. Postoperatively, right abducens nerve palsy appeared, but no other neurological symptoms were noted; the patient was thereafter transferred to a rehabilitation hospital 49 days after injury. Traumatic ICA aneurysms commonly occur close to the anterior clinoid process, form within 1 to 2 weeks of injury, and often rupture around 2 weeks after trauma. This case was considered rare as the ICA was likely injured and bleeding at the time of injury, resulting in a form of tBBA; this allowed early detection and appropriate treatment that resulted in a good outcome.

Rapidly progressive cerebral atrophy following a posterior cranial fossa stroke: Assessment with semiautomatic CT volumetry.

BACKGROUND: The effect of posterior cranial fossa stroke on changes in cerebral volume is not known. We assessed cerebral volume changes in patients with acute posterior fossa stroke using CT scans, and looked for risk factors for cerebral atrophy. METHODS: Patients with cerebellar or brainstem hemorrhage/infarction admitted to the ICU, and who underwent at least two subsequent inpatient head CT scans during hospitalization were included (n = 60). The cerebral volume was estimated using an automatic segmentation method. Patients with cerebral volume reduction > 0% from the first to the last scan were defined as the "cerebral atrophy group (n = 47)," and those with ≤ 0% were defined as the "no cerebral atrophy group (n = 13)." RESULTS: The cerebral atrophy group showed a significant decrease in cerebral volume (first CT scan: 0.974 ± 0.109 L vs. last CT scan: 0.927 ± 0.104 L, P < 0.001). The mean percentage change in cerebral volume between CT scans in the cerebral atrophy group was -4.7%, equivalent to a cerebral volume of 46.8 cm3, over a median of 17 days. The proportions of cases with a history of hypertension, diabetes mellitus, and median time on mechanical ventilation were significantly higher in the cerebral atrophy group than in the no cerebral atrophy group. CONCLUSIONS: Many ICU patients with posterior cranial fossa stroke showed signs of cerebral atrophy. Those with rapidly progressive cerebral atrophy were more likely to have a history of hypertension or diabetes mellitus and required prolonged ventilation.

Neurointensive Care of Traumatic Brain Injury Patients Based on Coagulation and Fibrinolytic Parameter Monitoring.

Coagulopathy, a common complication of traumatic brain injury (TBI), is characterized by a hypercoagulable state developing immediately after injury, with hyperfibrinolysis and bleeding tendency peaking 3 h after injury, followed by fibrinolysis shutdown. Reflecting this timeframe, the coagulation factor fibrinogen is first consumed and then degraded after TBI, its concentration rapidly decreasing by 3 h post-TBI. The fibrinolytic marker D-dimer reaches its maximum concentration at the same time. Hyperfibrinolysis in the acute phase of TBI is associated with poor prognosis via hematoma expansion. In the acute phase, the coagulation and fibrinolysis parameters must be monitored to determine the treatment strategy. The combination of D-dimer plasma level at admission and the level of consciousness upon arrival at the hospital can be used to predict the patients who will "talk and deteriorate." Fibrinogen and D-dimer levels should determine case selection and the amount of fresh frozen plasma required for transfusion. Surgery around 3 h after injury, when fibrinolysis and bleeding diathesis peak, should be avoided if possible. In recent years, attempts have been made to estimate the time of injury from the time course of coagulation and fibrinolysis parameter levels, which has been particularly useful in some cases of pediatric abusive head trauma patients.

Target Coil Embolization Using the Combined Transarterial and Transvenous Balloon-assisted Technique for Traumatic Direct Carotid Cavernous Fistula.

Herein, we describe a case of traumatic direct carotid cavernous fistula (DCCF) treated with target coil embolization using the combined transarterial and transvenous balloon-assisted technique. The patient was a 59-year-old woman who had been involved in a vehicular accident. She was admitted to the hospital due to chemosis and exophthalmos. Cerebral angiography revealed a shunt from the internal carotid artery (ICA) to the cavernous sinus (CS), which indicated DCCF. Thus, target coil embolization using the combined transarterial and transvenous balloon-assisted technique was performed. Angiography was performed 1 week after surgery to confirm the disappearance of DCCF. No recurrence was observed during the 1-year follow-up after treatment. Thus, target coil embolization using the combined transarterial and transvenous balloon-assisted technique is safe and effective for the treatment of traumatic DCCF.

High HMGA2 expression without gene rearrangement in meningiomas.

High mobility group AT-hook 2 (HMGA2) is a non-histone transcriptional regulator protein. Aberrant expression of the HMGA2 gene (HMGA2) and structural rearrangement at the chromosomal region 12q14 with HMGA2 involvement have been reported in several mesenchymal tumors. We analyzed truncated and full-length HMGA2 expression in 55 cases of meningioma, the most common brain tumor of mesenchymal origin. Fluorescence in situ hybridization and 3'-rapid amplification of cDNA ends were used to investigate the possibility of gene rearrangements. Moreover, the relationship between HMGA2 expression and clinicopathological features was assessed. Compared with normal brain tissues, 95% of the meningioma tissues exhibited increased HMGA2 expression. In 14 cases, the expression of truncated HMGA2 was more than two-fold higher than that of paired full-length HMGA2. Chromosomal translocation involving the chromosomal region 12q14 was undetectable. No significant correlation was found between the Ki-67 labeling index and HMGA2 expression and between the HMGA2 expression and the clinicopathological features. The majority of the meningioma cases displayed increased HMGA2 expression, which was not attributed to the chromosomal rearrangement at the corresponding region. Similar to that in the other mesenchymal tumors, increased HMGA2 expression was not associated with tumor cell proliferation in meningiomas.

[Spontaneous Retroclival Subdural Hematoma Diagnosed Using Magnetic Resonance Imaging in an Adult Patient:A Case Report].

Spontaneous retroclival subdural hematoma is rare among adults. To the best of our knowledge, only six cases have been reported. A 73-year-old man presented with sudden severe headache, diplopia, and dysarthria, with no history of trauma. Head CT revealed a retrociliary hematoma. No obvious causes of bleeding, such as cerebral aneurysms or malformations, were detected. Conservative treatment was provided to the patient. MRI showed an intraventricular hemorrhage and a space between the basilar artery and hematoma three days after onset. The hematoma almost disappeared on day 7. MRI, particularly T2-weighted sagittal MRI, is effective in localizing hematomas and confirming intraventricular hemorrhages.

Evolutionary diversification of Japanese Stomaphis aphids (Aphididae, Lachninae) in relation to their host plant use and ant association.

Phytophagous insects are among the most diverse of the earth's organisms, and their diversification patterns and the driving forces behind these have attracted considerable research interest. Host shifting to closely related plant species is thought to play an important role in phytophagous insect diversification, but the extent to which other interactions such as mutualistic associations affect diversification is not yet known. In this study, we reconstructed the molecular phylogeny of Japanese Stomaphis aphids and determined whether host shifting or mutualistic association with different ant species could explain diversification in this aphid genus. We analyzed 12 species of Stomaphis and grouped them into ten well-supported DNA lineages. Species in each lineage used a single or a few host plant species, but were mutualistically associated with many ant species of the genus Lasius. This result suggests that Stomaphis evolutionarily diversified primarily through host plant shifts. Interestingly, the reconstructed phylogeny suggests that Stomaphis host shifts occasionally occurred between very distantly related host plant taxa (spanning up to five plant orders). The dependence of Stomaphis on long-lasting Lasius ant colonies situated in temperate deciduous forests where Lasius is the dominant ant genus may have led the aphids to shift to distantly related but spatially adjacent host tree species.

A Patient with a Ruptured Blood Blister-like Aneurysm of the Internal Carotid Artery in Whom Two LVIS Stents Were Inserted.

Objective: We report a case in which multiple overlapping low-profile visualized intraluminal support (LVIS) stents were used as monotherapy for ruptured blood blister-like aneurysm (BBA) of the internal carotid artery (ICA). Case Presentation: A 48-year-old female presented to the emergency room with acute-onset headache. She was alert without neurological deficit with subarachnoid hemorrhage (SAH) Hunt and Kosnik grade I. Emergency angiography revealed a BBA from the supraclinoid ICA. This aneurysm had a small diameter, which makes coil embolization difficult. Therefore, we planned to use multiple overlapping LVIS stents as monotherapy for the ruptured aneurysm. The postoperative course was uneventful without rebleeding. The patient exhibited no neurological deficits on the clinical follow-up at 1 year. Conclusion: Multiple overlapping LVIS stents as monotherapy is useful for ruptured BBAs of the ICA.

A Patient with an Unruptured Aneurysm in the Internal Carotid Artery-duplicated Middle Cerebral Artery on Whom Coil Embolization with Balloon Remodeling Was Performed.

Objective: Treatment of an unruptured aneurysm at the origin of duplicated middle cerebral artery (DMCA) by coil embolization using balloon remodeling has not been reported. We report a case of coil embolization using balloon remodeling for an unruptured aneurysm at the origin of DMCA. Case Presentation: A 71-year-old female was found to have an unruptured aneurysm at the origin of DMCA during an examination for headache. Coil embolization using balloon remodeling for the wide neck aneurysm to preserve both the internal carotid artery (ICA) and DMCA was successful. The perioperative course was uneventful. Conclusion: This treatment enables complete embolization, and preserves both the ICA and DMCA. Thus, it is useful for aneurysms at the origin of DMCA.

Temperature drop in thawing phase reflects sufficient ice formation and better outcome of pulmonary vein isolation using second-generation cryoballoon.

BACKGROUND: Few reports exist regarding the details of ice formation on second-generation cryoballoon (CB) surface during pulmonary vein isolation (PVI). We propose a new parameter "temperature drop" in thawing phase for predicting sufficient ice formation and CB-PVI outcome. METHODS: Consecutive 106 patients who underwent successful CB-PVI for atrial fibrillation (AF) were analyzed. We defined "temperature drop" as a temperature drop of more than 3 °C just after CB catheter bending. We compared the previously known parameters predicting durable PVI between PVs with or without temperature drop. Then, we compared the PVI outcome among three groups: group 1 with temperature drop in all PVs, group 2 with temperature drop in 1-3 PVs, and group 3 without temperature drop in any PV. RESULTS: Temperature drop was present in 206 out of 424 isolated PVs. In those, PV occlusion score was significantly higher (3.7 ± 0.5 vs. 3.5 ± 0.6, P <0.001), and thawing time was significantly longer (55 ± 20 vs. 46 ± 21 s, P < 0.001) in PVs with temperature drop than those without. With a mean follow up period of 376 ± 217 days, Kaplan-Meier survival analysis revealed that no patients in group 1 experienced AF recurrence, 14 out of 86 patients (16%) experienced AF recurrence in group 2, and 5 out of 10 (50%) patients experienced AF recurrence in group 3 (Log-Rank P = 0.003). CONCLUSION: The temperature drop in thawing phase might reflect the state of ice formation and can be used to predict clinical outcome after CB-PVI.

Glucocorticoids attenuate the sensitivity of glucocorticoid-resistant lymphoid cells to doxorubicin via reduction in OCTN2.

Glucocorticoid (GC) resistance is associated with poor response to the following chemotherapy in lymphoid malignancies, such as lymphoma and leukemia. However, it remains unclear whether GCs interfere with the cytotoxic effects of anti-cancer drugs on GC-resistant cells. In this study, we examined whether GCs affected the sensitivities to vincristine (VCR)/doxorubicin (DOX) and the expression of drug transporters in GC-resistant cells. The dexamethasone (DEX)/prednisolone (PSL)-resistant lymphoid and non-lymphoid cell lines Raji and HL60 were cultured with DEX for 7 days and then treated with VCR or DOX for 3 days. Seven days of DEX treatment increased the IC50s of both VCR and DOX in Raji cells but not in HL60 cells. The mRNA and protein expression levels of organic cation/carnitine transporter (OCTN) 2, one of the drug uptake transporters expressed in both cell lines, were decreased only in Raji cells. When Raji cells were cultured with PSL, the IC50 of DOX but not VCR increased as the expression of OCTN2 decreased. No significant increases in efflux transporter expression were induced by DEX or PSL. When siRNA against OCTN2 was introduced into Raji cells, the IC50 of DOX but not VCR increased significantly. These data suggested that both DEX and PSL decreased the sensitivity of the DEX/PSL-resistant Raji cells to DOX, a change that was at least partially due to reductions in OCTN2. Thus, the continuous usage of GCs may interfere with the effects of chemotherapy on GC-resistant lymphoid cells.

Carotid surgical cut-down technique for neuroendovascular therapy.

BACKGROUND: Neuroendovascular therapy is typically performed via the femoral artery, but there are rare cases in which a tortuous upstream angioarchitecture makes it difficult to access the intracranial circulation via this route. METHODS: In this case series, we describe six cases treated by surgical cut-down in the neck, with puncture of the carotid artery. Antiplatelet and anticoagulation agents were used in all cases. The indications for the technique were postsurgical thoracic aortic aneurysm (two cases), postsurgical abdominal aortic aneurysm (one case), major vessel tortuosity of the common carotid artery (two cases) and aortic arch anomaly (one case). RESULTS: The surgical cut-down technique permitted successful neuroendovascular therapy. Although one patient had a small cervical haematoma, he was treated without surgical evacuation. CONCLUSION: Overall, our findings indicate that the surgical cut-down technique is safe and useful for patients in whom the femoral approach is unsuitable.

Predicting factors of transmural thermal injury after cryoballoon pulmonary vein isolation.

PURPOSE: Transmural thermal injury (TTI), such as esophageal erosion/ulcer and periesophageal nerve injury leading to gastric hypomotility, is not rare complications associated with pulmonary vein isolation (PVI). However, the mechanism and predicting factors of TTI have not yet been fully elucidated with second-generation cryoballoon (CB) PVI. METHODS: One hundred ten consecutive patients, who underwent CB PVI for atrial fibrillation and received esophagogastroduodenoscopy 2 days later, were investigated. The relationships between TTI and both clinical and anatomical parameters were examined. We measured the following parameters based on the computed tomography data: the angle of the left atrial (LA) posterior wall to the descending aorta (Ao) (LA-Ao angle); the branching angle of the left inferior pulmonary vein (LIPV) to the coronal plane (LIPV angle); and the minimum distance between the LA posterior wall and descending Ao enclosing the esophagus (LA-Ao distance). RESULTS: TTIs occurred in 19 patients (esophageal erosion in 2 and gastric hypomotility in 17). The patients with TTI were significantly older than those without TTI. In the anatomical parameters, the LIPV angle was larger and the LA-Ao distance was shorter in the TTI (+) group compared to the TTI (-) group. With the multivariate logistic regression analysis, the age (odds ratio [OR] 2.148, P = 0.022) and LA-Ao distance (OR 0.430, P = 0.013) were independent predictors of TTI. CONCLUSIONS: The occurrence of TTI in CB PVI was associated with aging, suggesting compromised periesophageal circulation, and the anatomical proximities between the LA and the descending Ao, which enclose the esophagus.

Clinical impact of insulin resistance on pulmonary vein isolation outcome in patients with paroxysmal atrial fibrillation.

INTRODUCTION: The relationship between insulin resistance and atrial fibrillation (AF) recurrence after pulmonary vein isolation (PVI) remains unclear. METHODS: Drug-refractory 114 paroxysmal AF patients (89 males, 62 ± 8 years) who underwent successful PVI were enrolled. Homeostasis model assessment of insulin resistance (HOMA-IR) was calculated and a value of ≥2.5 was defined as insulin resistant. The left atrial volume index (LAVI) was measured using echocardiography before and 1 year after PVI. Tumor necrosis factor-α (TNF-α) and TGF-ß1 serum levels were measured before PVI, and the left atrium (LA) conduction velocity was calculated. The patients were divided into two groups (group 1: HOMA-IR < 2.5, n = 81; group 2: HOMA-IR ≥ 2.5, n = 33). RESULTS: The LAVI between the two groups before PVI did not significantly differ (P > 0.05), nor did TNF-α (7.7 ± 2.0 vs 7.5 ± 1.0 pg/mL; P = 0.149) or TGF-ß1 (28.4 ± 12.0 vs 27.6 ± 10.3 ng/mL; P = 0.757). LAVI before and 1 year after PVI in each group did not change. The conduction velocity of group 2 was slower than that of group 1 (0.7 ± 0.1 vs 1.1 ± 0.3 m/s, P < 0.001). Kaplan-Meier analysis showed significantly higher AF recurrence in group 2 than that in group 1 ( P = 0.019). Cox multivariable analysis revealed that insulin resistance was an independent predictor of recurrence (hazard ratio 1.287, P = 0.004). CONCLUSION: Our results suggest that insulin resistance promotes LA electrical remodeling and might be related to AF recurrence after PVI.

Generation of sub-two-cycle CEP-stable optical pulses at 3.5 µm from a KTA-based optical parametric amplifier with multiple-plate compression.

We demonstrate the generation of 21 fs (1.8 optical cycle), 45-µJ, carrier-envelope phase (CEP)-stable optical pulses with an octave-spanning spectrum from 2.2 to 4.9 µm. Multi-cycle output pulses (120 fs, 149 µJ, 3.5 µm, and 300 Hz) from a KTA-based optical parametric amplifier are compressed down to the sub-two-cycle regime using YAG and Si plates. The single-shot CEP stability of the compressed pulses is measured to be 283 mrad for 500 s. This robust and compact scheme realizes a field strength of 282 MV/cm with f/11 focusing, opening a new regime of attosecond strong-field physics in solids.

Association between Serum Uric Acid Level and Ventricular Tachyarrhythmia in Heart Failure Patients with Implantable Cardioverter-Defibrillator.

OBJECTIVES: The uric acid (UA) level is related to cardiac events and mortality, but little is known about the clinical significance of serum UA with regard to the ventricular tachyarrhythmia (VT) risk in patients with heart failure. METHODS: The present study enrolled 56 patients with ischemic and nonischemic cardiomyopathy (37 males, mean age 64.7 ± 11.1 years) who received prophylactic implantable cardioverter-defibrillator (ICD) implantation. Based on a median serum UA value, study subjects were divided into two groups: serum UA < 6.1 mg/dL (group L, n = 29) and ≥6.1 mg/dL (group H, n = 27). Echo- and electrocardiograms (QRS duration and QTc intervals) were examined in each group. RESULTS: During the follow-up period (30 ± 8 months), 22 (39%) patients had appropriate ICD therapies for sustained VT. There was no significant difference in the electro- and echocardiographic data between both groups. However, appropriate ICD therapies were significantly higher in group H than in group L (p = 0.02). In multivariate analysis, UA was an independent predictor of appropriate ICD therapies (hazard ratio 1.826, 95% confidence interval 1.248-2.671, p = 0.002). CONCLUSIONS: Serum UA levels might be a predictor of VT, providing new aspects regarding the decision to adapt ICD implantation in patients with heart failure.

Uncontrolled blood pressure affects atrial remodeling and adverse clinical outcome in paroxysmal atrial fibrillation.

BACKGROUND: To investigate the impact of uncontrolled blood pressure (BP) on left atrial (LA) remodeling and clinical outcome after pulmonary vein isolation (PVI) in paroxysmal atrial fibrillation (AF). METHODS: One hundred and one symptomatic paroxysmal AF patients (85 males, 62.2 ± 8.4-year-old) who underwent successful PVI were classified as follows: group 1 (n = 46), no hypertension (HTN); group 2 (n = 36), HTN with controlled BP; and group 3 (n = 19), HTN with uncontrolled BP. Uncontrolled BP was defined as BP > 140/90 mm Hg. LA dimension was measured by echocardiography before and 6 months after PVI. LA wall thickness along the ablation line was measured using computed tomography prior to PVI. Cox regression analysis was performed for the prediction of recurrence. RESULTS: LA wall thickness in groups 2 and 3 was greater than that of group 1, except for the anterior right superior pulmonary vein (PV) and posterior left inferior PV. Kaplan-Meier analysis revealed a significantly higher recurrence in group 3 (52.6%). LA dimension only increased in group 3 (38.2 ± 5.6 mm to 41.3 ± 6.2 mm, P = 0.022). At the second procedure, all group 3 recurrent patients showed substrate degradation (low voltage area and/or dense scar formation) and required substrate modification. Uncontrolled BP was an independent risk factor for recurrence (hazard ratio: 2.350, P = 0.033). CONCLUSIONS: HTN induced heterogeneous LA hypertrophy regardless of whether HTN was controlled. Uncontrolled BP promoted atrial remodeling, and is therefore a strong predictor for recurrence of AF after PVI.

Tricuspid and Mitral Valve Regurgitation with Bi-fascicular Block Following a Horse Kick.

A 40-year-old man was transferred to our hospital following an isolated horse kick injury to the anterior chest wall. The case showed bi-fascicular block, severe tricuspid valve regurgitation due to ruptured chordae tendineae of the anterior leaflet, moderate mitral valve regurgitation due to prolapse of mitral anterior leaflet, and hypokinetic motion of the inferior septal wall. Both tricuspid and mitral insufficiency were completely repaired by a surgical operation. Fortunately, these injuries were not fatal in this case, but the comprehensive assessment of cardiac damage and careful observation are important for managing patients with cardiac injury.