Vertebral artery V3 portion-radial artery-distal common carotid artery (V3-RA-dCCA) bypass for large basilar trunk aneurysm with bilateral proximal common carotid artery occlusion-technical note.

BACKGROUND: Large basilar trunk aneurysm caused by bilateral occlusion of the proximal common carotid artery is rare. We treated one case with vertebral V3 portion-radial artery-distal common carotid artery (V3-RA-dCCA) bypass. CASE DESCRIPTION: Basilar trunk aneurysm and bilateral occlusion of the proximal CCA were found incidentally in a 70-year-old woman. During the next 5 years, the aneurysm gradually enlarged to 12 mm, and blood flow of the anterior circulation was supplied through the posterior communicating artery. V3-RA-dCCA bypass was performed to reduce the stress of blood flow and prevent aneurysm growth and rupture. After exposing the neck portion, forearm of RA, and V3 portion of the vertebral artery, we created a space just below the sternocleidomastoid muscle to bypass the RA. We flushed the RA with albumin to stiffen the artery and temporarily clamped the bilateral sides of the RA to prevent twisting. We anastomosed the V3 and RA with a 9-0 thread and temporarily clamped the V3. After flushing the RA with albumin to prevent twisting, we clamped the external and internal carotid arteries, opened the dCCA with a vascular punch to prevent arterial dissection, and anastomosed the RA to the dCCA. The patency of the bypass was confirmed with Doppler and indocyanine green video angiography. The postoperative course was uneventful, bypass patency was good, and the aneurysm did not expand further. CONCLUSION: V3-RA-dCCA bypass may be an effective and low-risk treatment for large basilar trunk aneurysms with bilateral occlusion of the proximal common carotid artery.

Open surgical embolectomy for cardiogenic cerebral embolism: Technical note and its advantages.

BACKGROUND AND IMPORTANCE: In cardiogenic cerebral embolism, early recanalization is the most important factor for good prognosis. However, endovascular thrombectomy often fails to achieve recanalization. We present an open surgical embolectomy technique and discuss its advantages. CLINICAL PRESENTATION: A 79-year-old woman developed right hemiparesis and severe aphasia. Magnetic resonance imaging revealed an acute cerebral infarction caused by left middle cerebral artery (MCA) occlusion. We attempted endovascular thrombectomy but failed because it was impossible to guide the catheter to the occlusion site. Hence, we converted to open surgical embolectomy. Sylvian fissure was widely opened. After confirming the range of thrombosis using indocyanine green videoangiography (ICGVAG), the proximal and distal arteries were secured, and a temporary clip was placed on the distal M2 to prevent distal thrombosis migration. MCA was cut approximately 3 mm from the bifurcation, and thrombosis was removed using micro-forceps. The proximal clip was simultaneously inserted but was not clamped because the thrombus was extruded by proximal vascular flow. Immediately after removing the thrombus, intense bleeding occurred from the proximal flow. An assistant clamped the proximal artery using the prepared clip, and the incised area of MCA was sutured using 9-0 threads. We finally confirmed blood flow after recanalization using ICGVAG. The time from skin incision to recanalization was 27 min. After the procedure, the patient developed slight aphasia but had no hemiparesis and was later transferred to a rehabilitation hospital. CONCLUSION: Open surgical embolectomy may be a secondary rescue treatment option in the case of endovascular thrombectomy failure.

Relationship between Flow-mediated Endothelial Vasodilation and the Pulse Wave Velocity, and Cervical Carotid Artery Stenosis.

Carotid artery stenosis is elicited by atherosclerosis and is the main cause of cerebral thrombosis. Flow-mediated endothelial vasodilation (FMD) can be measured noninvasively to assess vascular endothelial function related to atherosclerosis. The pulse wave velocity (PWV) is used to evaluate the vascular media involved in atherosclerosis. We investigated the relationship between these measurements in 75 consecutive patients with atherosclerotic cerebral thrombosis. They were assigned to three equal groups based on the severity of carotid artery stenosis on ultrasonograms. Group 1 had no stenosis, group 2 manifested moderate stenosis (<60%), and group 3 presented with severe stenosis (≥60%). We compared the FMD and PWV among the three groups. The PWV was significantly lower in group 1 than the other two groups. The FMD was significantly lower in group 3; it was significantly lower in group 2 than group 1. There was an inverse correlation between the FMD and the severity of carotid artery stenosis. Our findings show that for assessing the severity of carotid artery stenosis, the FMD is more useful than the PWV.

Neck and Occipital Pain Caused by Deep Cervical Intramuscular Lipoma: A Surgical Case.

A lipoma is a slow-growing, benign tumor and is usually asymptomatic; hence, surgical intervention can often be avoided in patients with these tumors in the cervical and cranial area. Lipomas arise most commonly in the subcutaneous fat, but occasionally in muscle tissue. Intramuscular lipomas in the cervico-cranial area have rarely been reported. We describe here a patient with a large intramuscular lipoma in the deep cervical tissue. The patient experienced troublesome pain in the neck and occipital area, and surgical treatment was therefore suggested. Particularly in the cervical area, intramuscular lipomas sometimes invade the surrounding muscles and tissue layers and develop into an irregular mass, despite being benign. In addition, the cervical area has one of the most complex muscle structures. Nevertheless, surgical management of intramuscular lipoma in the cervical and cranial area is sometimes indicated, for example, in patients with clinical symptoms or masses with a tendency to grow large.

[Clinical Study of Percutaneous Radiofrequency Ablation for Small Renal Tumor].

Percutaneous radiofrequency ablation (PRFA) has been applied as an option of minimally invasive treatment for small renal tumor. We retrospectively evaluated 5 patients with small renal tumor for whom PRFA was performed at our hospital. The average age was 69.6 years (range 45-86), average tumor diameter 20.0 mm (8-34), average preoperative glomerular filtration rate (eGFR) 66.8 ml/min/1.73m2 (42. 1-93.2), and follow-up period was 23.4 months (8-34). There were two minor complications (grade 1), including perirenal hematoma and pain at the probe insertion site in each patient. One patient had local recurrence 22 months after PRFA and the additional PRFA will be performed. PRFA could be a feasible, safe and effective therapy for small renal tumor.

Indwelling Drains Are Not Necessary for Patients Undergoing One-level Anterior Cervical Fixation Surgery.

BACKGROUND: Anterior cervical discectomy and fusion (ACDF) has become a common procedure for cervical spine surgeries, since it is safe and effective in most patients. However, some patients develop life-threatening problems such as respiratory obstruction arising from rare postoperative hematoma and edema, although intraoperative bleeding caused by the connective tissue splitting procedure or bleeding caused by postoperative insertion of a suction tube has rarely been reported. Investigation of the requirement for indwelling drains in patients who undergo cervical spine surgery is necessary because of the pain, anxiety, and discomfort caused despite the use of high-quality materials. METHODS: Enrolled in the study were 43 patients who underwent one-level anterior cervical fixation surgery, including 23 (randomly selected) who received an indwelling drain (group A, mean age: 57.78±14.46 years, range: 39-82 years, male/female: 13/10), and 20 who received no indwelling drain (group B, mean age: 57.00±13.99 years, range: 29-81 years, male/female: 12/8). Intraoperative bleeding amounts, lateral views of plain cervical spine radiographs, prevertebral space (PVS) changes on plain radiographs and computed tomography (CT) images, wound inspections, and pain assessments on the Numeric Rating Scale (NRS) were compared between groups. In addition, a history of risk factors for bleeding, such as hypertension, diabetes, and cerebrovascular diseases which require antiplatelet therapy, was determined. Hepatic failure was observed in none of the patients. RESULTS: Postoperative CT images obtained the day following surgery showed no densities indicating the presence of postoperative hematoma in any of the 43 patients. The maximum amount of intraoperative bleeding was 10 mL, with no significant difference between groups. No patients reported an obvious pain level on NRS, but the pain was significantly milder in group B (A: 1.326±0.911, B: 0.555±0.556, p=0.0037). The postoperative PVS increment on plain radiographs was comparable between groups (A: 1.778±0.992, B: 1.730±0.966, p=0.8728). DISCUSSION: Given the negligible intraoperative and postoperative bleeding observed in both groups, and the lack of difference in PVS increments between the groups, our results suggested that indwelling drains are not required for patients undergoing typical anterior cervical fixation surgery. However, it is important to take care of major vessels such as the superior and inferior thyroid arteries and the external jugular vein as well as the prevertebral venous plexus during surgery.

Effect of a combination of whole body vibration exercise and squat training on body balance, muscle power, and walking ability in the elderly.

A randomized controlled trial was conducted to clarify the beneficial effect of whole body vibration (WBV) exercise plus squat training on body balance, muscle power, and walking ability in the elderly with knee osteoarthritis and/or spondylosis. Of 35 ambulatory patients (14 men and 21 women) who were recruited at our outpatient clinic, 28 (80.0%, 12 men and 16 women) participated in the trial. The subjects (mean age 72.4 years) were randomly divided into two groups (n=14 in each group), ie, a WBV exercise alone group and a WBV exercise plus squat training group. A 4-minute WBV exercise (frequency 20 Hz) was performed 2 days per week in both groups; squat training (20 times per minute) was added during the 4-minute WBV training session in the WBV exercise plus squat training group. The duration of the trial was 6 months. The exercise and training program was safe and well tolerated. WBV exercise alone improved indices of body balance and walking velocity from baseline values. However, WBV exercise plus squat training was more effective for improving tandem gait step number and chair-rising time compared with WBV exercise alone. These results suggest the benefit and safety of WBV exercise plus squat training for improving physical function in terms of body balance and muscle power in the elderly.

Vernet's syndrome after carotid endarterectomy.

Unilateral paresis of cranial nerves IX to XI is defined as Vernet's syndrome. We retrospectively assessed cranial nerve symptoms from the clinical records of 143 carotid endarterectomy patients. A flexible nasolaryngoscope was used to examine vocal fold movements in 73 patients. If vocal fold paresis (VFP) was confirmed, the patient also underwent magnifying laryngoscopy (for correct diagnosis of injury to the glossopharyngeal and vagus nerves). It was found from clinical records that 8 patients (6%) were confirmed to have cranial nerve symptoms corresponding to Vernet's syndrome; 7 patients (9 %) had VFP on nasolaryngoscopy. In 2 patients, magnifying laryngoscopy confirmed ipsilateral VFP, pharyngeal paresis, pharyngeal wall hypesthesia, and ipsilateral pharyngeal wall swelling. These 2 patients also had symptoms of injury to the accessory nerve. Damage to cranial nerves IX to XI probably occurred in the parapharyngeal space, based on the existence of posterior pharyngeal wall edema or swelling after carotid endarterectomy.

Immunonegative "null cell" adenomas and gonadotropin (Gn) subunit (SUs) immunopositive adenomas share frequent expression of multiple transcription factors.

The differentiation of pituitary cells and human pituitary adenomas follow three cell lineages: GH-PRL-TSH, ACTH, and FSH/LH, which are regulated by a combination of various transcription factors and co-factors. We have used RT-PCR and immunohistochemistry to show that immunonegative, "null cell" adenomas are equipped with multiple transcription factors and co-factors. The "null cell" adenomas showed similar frequencies of transcription factors as did the gonadotropin subunit (GnSU)-positive adenomas, with the exception that there were fewer instances of SF1 in the former. We speculate, therefore, that null cell adenomas and GnSU-positive adenomas share common molecular mechanisms in functional differentiation, even though the former do not produce hormones. From the high frequency of various transcription factors, we also speculate that both null cell adenomas and GnSU-positive adenomas are derived from "committed" pituitary progenitor stem cells. The questions, why a certain proportion of these pituitary tumor groups lack hormone production and why they are molecularly more committed to Gn transcription, remain to be further investigated.

Resection of arteriovenous malformation in a patient with hemophilia type A.

A 34-year-old man with hemophilia type A presented with a huge intracerebral hematoma (ICH) in the left frontoparietal lobe due to rupture of an arteriovenous malformation (AVM). Angiography demonstrated the AVM in the frontoparietal lobe fed by the anterior cerebral arteries and the middle cerebral arteries, with a vein draining into the superior sagittal sinus. He developed signs of cerebral herniation due to the huge ICH. An emergent operation was performed to reduce intracranial pressure and to stop bleeding from the AVM under continuous administration of factor VIII. To prevent postoperative hemorrhage, aggressive blood pressure control and continuous administration of factor VIII were performed for 10 days. His neurological status improved so that he could hold a simple conversation. Continuous administration of factor VIII during surgery and intensive intra- and postoperative therapy resulted in a favorable outcome for this patient with hemophilia type A.

Expression of hypoxia-inducible factor 1alpha and cathepsin D in pituitary adenomas.

Hypoxia-inducible factor (HIF)-1alpha is a crucial transcription factor involved in the adaptive response to hypoxia, whereas cathepsin D, which regulates angiostatin in several cancer cell lines, has been reported to be upregulated by HIF-1alpha. In order to determine the involvement of angiogenesis in pituitary adenomas, we studied the expression of both HIF-1alpha and cathepsin D in tissues from 58 patients (39 women, 19 men, ranging in age from 20 to 78 yr), sorted by histological group, and assayed by double immunohistochemistry. HIF-1alpha immunoreactivity, confined to the nucleoplasm, was present in both tumor and vascular endothelial cells. There was no difference in microvascular density (p = 0.7761) by histotype. ACTH-producing adenomas showed the lowest level of HIF-1alpha, whereas prolactin (PRL)-producing adenomas and HIF-1alpha-positive microvessels showed the highest (p < 0.001). In contrast, the lowest expression of cathepsin D was observed in PRL-producing adenomas, whereas the highest expression was detected in ACTH-producing adenomas (p < 0.0001). Imaging analysis with fluorescence double immunohistochemistry showed that HIF-1alpha-negative tumor cells did not express significantly higher levels of cathepsin D. In these poorly vascularized tumors, the hypoxic marker HIF-1alpha may not downregulate cathepsin D. The mechanisms of tumor angiogenesis and cell invasion in pituitary adenomas may differ from those in other tumor cells.

Molecular pathology of the pituitary. Development and functional differentiation of pituitary adenomas.

This review article describes functional differentiation of the pituitary cells and pituitary adenomas with special emphasis on transcription factors and co-factors. Human pituitary adenomas generally follow the combination of transcription factors and co-factors, which are similar to those of physiologic anterior pituitary cells. On very rare occasions, the single pituitary adenoma produces two hormones, which belong to different cell lineage 'trans-cell lineage'. Basic mechanism for this was considered to be 'aberrant expression' of transcription factors, i.e. NeuroD1 and Pit-1. This was experimentally supported by the induction of GH (mRNA and protein) in AtT-20 cells by transfecting Pit-1 gene. Various mechanisms have been reported for the experimental pituitary oncogenesis. Among these, GHRH has been emphasized as one of oncogenic factors for both human GHomas as well as in the transgenic animals.

[Spontaneous remission of acromegaly after meningitis: a case report].

There have been several reports describing the cases of acromegaly, which show reduction in size of tumor in due to pituitary apoplexy or lymphocytic hypophysitis. We have encountered a patient of acromegaly, who developed panhypopituitarism after suffering from meningitis and showed the reduction of tumor in size. The results of imaging examination suggested the presence of pituitary apoplexy and lymphocytic hypophysitis. The patient was a 27-year-old woman, who visited a local physician with complains of headache and fever. After performing lumbar puncture, she was diagnosed as viral meningitis, and conservative therapy was initiated. The results of biochemical test of blood revealed hyponatremia. Because facial appearance of the patient was similar to that of acromegaly, endocrine dysfunction was suspected. The result of pituitary hormone tests showed high levels of growth hormone (GH) and somatomedin C (IGF-1) and low levels of the other hormones. At the same time, sign of diabetes insipidus was noted, and the patient was referred to our hospital. In the examination at the admission, GH and IGF-1 showed the trends to decrease, and the reduction in size of tumor was also detected. From the results of imaging examination, pituitary apoplexy and lymphocytic hypophysitis were suspected. Operation was performed, and pathological examination revealed inflammation of pituitary adenoma.

Fenestrated stent-graft for traumatic juxtahepatic inferior vena cava injury.

PURPOSE: To report the use of a fenestrated stent-graft to manage a traumatic rupture of the juxtahepatic inferior vena cava (IVC). CASE REPORT: A 62-year-old man was involved in a traffic accident and hospitalized for severe right leg fractures. Computed tomography also uncovered liver contusion and retroperitoneal hematoma. The next day, he became hemodynamically unstable; a huge retroperitoneal hematoma had developed from a rupture of the juxtahepatic IVC. An emergent procedure to implant a self-expanding fenestrated stent-graft was successful in repairing the IVC injury and maintaining hepatic venous return. The patient recovered and continues in good health with a patent endograft 16 months after treatment. CONCLUSIONS: This experience supports the efficacy of fenestrated endograft implantation for emergent repair of IVC injuries, although proper facilities, an experienced interventional team, and an assortment of devices must be available.