[Magnetic resonance vessel wall imaging reveals rupture site in subarachnoid hemorrhage with multiple cerebral aneurysms].

We report a case of subarachnoid hemorrhage(SAH)with multiple cerebral aneurysms, in which magnetic resonance vessel wall imaging(MR-VWI)revealed the rupture site. A 68-year-old woman presented with SAH. Computed tomography(CT)showed diffuse SAH(Fisher group 3). 3D-CT angiography revealed two intracranial aneurysms:a 4.2-mm anterior communicating artery aneurysm(Acom An)and a 5.8-mm basilar tip aneurysm(BAtip An). As the BAtip An was the larger of the two, it was deemed the most likely site of rupture;however, high-resolution MR-VWI with gadolinium showed thick wall enhancement in the Acom An and no enhancement in the BAtip An. Thus, we performed a craniotomy for the Acom An. Intraoperative findings confirmed the rupture site at the Acom An. We concluded that high resolution MR-VWI may be useful for identifying the rupture site in patients with spontaneous SAH and multiple cerebral aneurysms.

Bilateral carotid and vertebral rete mirabile presenting with subarachnoid hemorrhage caused by the rupture of spinal artery aneurysm.

Rete mirabile (or carotid rete) is a normal structure that plays physiological roles in the lower mammals. However, the rete does not exist in the normal carotid circulation of humans. Carotid rete mirabile (CRM) is a rare condition compensating for congenital dysplastic internal carotid artery. Arterial plexus at the cavernous region, which supplies intradural internal carotid artery instead of the aplastic cavernous portion of internal carotid artery, looks like the "rete mirabile" seen in the lower mammals, and is a characteristic angiographical finding of CRM. In addition to the CRM, existence of segmental occlusion and tortuous collaterals of vertebral artery, so-called carotid and vertebral rete mirabile (CVRM), is a very rare condition. We report a 70-year-old female patient with bilateral CVRM presenting with subarachnoid hemorrhage (SAH) caused by the rupture of a cervical spinal artery aneurysm. Our patient is the oldest, compared with the previously reported four patients with CVRM. Moreover, this is the first report of ruptured spinal artery aneurysm as a cause of SAH associated with CRM/CVRM. To avoid rebleeding in the patient, we successfully treated the patients by performing coil embolization of the remaining spinal aneurysms. In patients with CVRM, aneurysm formation of the cervical spinal artery may be a reasonable consequence because of the hemodynamic stress on the spinal artery as a collateral pathway. Detailed evaluation of the cervical spinal arteries should be performed to detect or to rule out ruptured aneurysm in patients with SAH associated with CVRM.

[A case of theophylline-associated seizures with postictal fever and postictal pleocytosis].

We report a 70-year-old man who developed theophylline-associated seizure with postictal fever and postictal pleocytosis. He was admitted to our hospital for a left hemiconvulsion lasting for two hours. The concentration of theophylline was high (21.6ng/ml), and electroencephalogram demonstrated periodic lateralized epileptiform discharges. Diffusion-weighted magnetic resonance imaging showed high signal intensity lesions in the right cingulated gyrus, insula and thalamus. Temperature above 38.0° was detected 5.5 hours after seizure and lasted for 60 hours. Cerebrospinal fluid (CSF) analysis on day 2 demonstrated pleocytosis (62/uL) with a predominance of polymorphonuclear leukocytes (90%). Temperature and CSF pleocytosis subsided after sedation. Intracranial inflammatory or infectious disease is the first consideration in epilepsy with fever and CSF pleocytosis, and then diagnosis of postictal fever and postictal pleocytosis should be made only by rigorous exclusion of that possibility.

Downregulation of Ras C-terminal processing by JNK inhibition.

After translation, Ras proteins undergo a series of modifications at their C-termini. This post-translational C-terminal processing is essential for Ras to become functional, but it remains unknown whether and how Ras C-terminal processing is regulated. Here we show that the C-terminal processing and subsequent plasma membrane localization of H-Ras as well as the activation of the downstream signaling pathways by H-Ras are prevented by JNK inhibition. Conversely, JNK activation by ultraviolet irradiation resulted in promotion of C-terminal processing of H-Ras. Furthermore, increased cell density promoted C-terminal processing of H-Ras most likely through an autocrine/paracrine mechanism, which was also blocked under JNK-inhibited condition. Ras C-terminal processing was sensitive to JNK inhibition in the case of H- and N-Ras but not K-Ras, and in a variety of cell types. Thus, our results suggest for the first time that Ras C-terminal processing is a regulated mechanism in which JNK is involved.

[Operative case of isomorphic astrocytoma].

Diffuse astrocytomas are classified as WHO Grade II tumors. Recently, a subtype presenting with better prognosis has been proposed, and it is known as "isomorphic astrocytoma." A clinical case that we encountered was believed to be categorized as this subtype; it has been presented in this report. The patient was a 20-year-old male with a chief complaint of intractable epileptic seizures. He experienced his first attack at 16 years of age in July 2001, and it was a generalized seizure. Anticonvulsants prescribed by a previous doctor had no effect on controlling the seizures. MRI performed in March 2004 showed a lesion approximately 2.0 cm in diameter in the left temporal lobe. The patient was referred to our institution for further investigation of the lesion and therapy. Electroencephalography and magnetoencephalography were used to assess the lesion at seizure focus. The tumor was resected under awake surgery. The pathological diagnosis was diffuse astrocytoma, but this tumor was considered to be the isomorphic subtype. Some parts of the tumor showed a relatively high MIB-1 labeling index (LI) of 9.2%, and additional 50-Gy radiotherapy was performed. The postoperative course was uneventful and despite decreasing the anticonvulsant dosage, he has remained seizure free. Isomorphic astrocytoma is characterized by prolonged epileptic seizures, a low MIB-1 LI, and better prognosis. In our case, since the MIB-1 LI was higher in some parts of the tumor, the appropriate therapy for WHO Grade II tumors was performed. However, this case was considered representative of isomorphic astrocytoma. No reports of this tumor subtype have been previously described in Japan. Therefore, this report is the first case of isomorphic astrocytoma reported to Japanese literature.