[Quality Control of Medical Instruments and Cleaning Water].

PURPOSE: Herein we aimed to investigate the degradation of surgical instruments in our hospital and how water quality affects the rate of metal corrosion. MATERIALS AND METHODS: We observed 279 stainless steel instruments, and determined the presence of damage like metal corrosion or scale formation. We also measured the concentrations of chloride(Cl-)and silicate(SiO44-)ions in the water used for cleaning in our operating rooms, including tap water from the city water supply and reverse-osmosis(RO)filtered water. RESULT: Pitting corrosion was observed on 71% of the instruments we investigated. The concentration of Cl- was 0.7mg/L in tap water and 0.1mg/L in RO water, while the concentration of SiO44- was 0.3mg/L in both the tap and RO water. DISCUSSION: Of the dissolved ions Cl- and SiO44-, Cl- is more of a concern, as it causes pitting corrosion over time, while SiO44- causes scale formation. Considering the typical water quality in the operating-room environment, degradation must be monitored for the general maintenance of metal surgical instruments.

[A Patient with Sinking Skin Flap Syndrome who Underwent Perfusion MRI before and after Cranioplasty].

Background:Sinking skin flap syndrome(SSFS)manifests as subjective symptoms, such as headache, dizziness, and undue fatigability, in addition to neurologic symptoms, such as hemiplegia, aphasia, and perceived failure, when the skin over a bone defect sinks in the weeks or months following a decompressive craniectomy. Indeed, these symptoms can improve after a cranioplasty. Case presentation:A 58-year-old woman presented with a disturbance of consciousness. She was found to have a subarachnoid hemorrhage due to a ruptured right middle cerebral artery aneurysm. She underwent a craniotomy with clipping of the affected artery and a decompressive craniectomy on the same day. Post-operatively, the disturbance of consciousness improved, but the left-sided paralysis persisted. She complained of intractable headaches, was disoriented, and a lack of spontaneity emerged as the skin over the bone defect sank. She underwent cranioplasty on the 43rd day after admission, and the symptoms resolved promptly after surgery. Rehabilitation was canceled at the onset of symptoms, but resumed after the symptoms improved. Based on perfusion MRI, the cerebral blood flow(CBF):cerebral blood volume(CBV)ratio of the affected side increased before and after surgery compared with the healthy side. A lumboperitoneal shunt was placed on the 52nd day after admission to manage the hydrocephalus. She was discharged from the hospital with higher brain dysfunction and a mild state of paralysis. Conclusion:The timing of cranioplasty in patients with SSFS has not yet been established, but surgery should be performed before symptoms appear because SSFS impairs rehabilitative efforts.

Quality assurance monitoring of a citywide transportation protocol improves clinical indicators of intravenous tissue plasminogen activator therapy: a community-based, longitudinal study.

BACKGROUND: Stroke-bypass transportation to the stroke center by paramedics is important to maximize the efficiency of intravenous tissue plasminogen activator (iv-tPA) therapy. To improve access to stroke thrombolysis, a citywide protocol was launched on January 2007 in Kawasaki City (population 1.4 million) using the Maria Prehospital Stroke Scale (MPSS), and quality assurance monitoring has been performed every 6 months. The aim was to identify whether the citywide quality assurance monitoring improves the process and outcome of iv-tPA therapy. METHODS: All of the MPSS-based transportation data prospectively recorded by the Kawasaki City Fire Department and the associated clinical data in the 11 hospitals that accept stroke-bypass transfers were merged every 6 months for the quality assurance monitoring. Clinical indicators such as ambulance call-to-door time, onset-to-needle time, door-to-needle time, frequency of thrombolytic use, and outcome of thrombolytic therapy were analyzed. These clinical indicators were also compared between patients transferred on weekdays and on weekends. RESULTS: A total of 2049 patients was registered from April 2009 to March 2013. Their mean age was 70.4 ± 13.2 (range, 24-98) years, and 64.3% were male. Ambulance call-to-door time decreased gradually from 37.5 ± 12.5 minutes to 33.9 ± 11.7 minutes over 4 years (P = .000, analysis of variance with the post hoc Dunnett test). Onset-to-needle time and door-to-needle time were similar over the 4 years. Good outcome (modified Rankin Scale score <2) after iv-tPA therapy increased from 24.1% to 35.3% (P = .045, 2010 vs. 2012). No deleterious effect of weekend admission was observed based on these clinical indicators. CONCLUSIONS: A citywide MPSS-based transportation protocol significantly decreased the delay in the ambulance call-to-door time. The implementation of standardized cross-institutional quality assurance programs for acute stroke therapy may improve the process and outcome of iv-tPA therapy in the community.

Evaluation in vitro of the efficacy of colistin methanesulfonate against biofilm-forming multidrug-resistant Pseudomonas aeruginosa (MDRP).

The aim of this study was to evaluate in vitro the efficacy of clinically using colistin methanesulfonate against biofilm-forming multidrug-resistant Pseudomonas aeruginosa (MDRP), with minimum inhibitory concentrations (MICs) of ciprofloxacin, imipenem, and amikacin showing ≥4, 16, and 32 µg/ml, respectively, by disk diffusion susceptibility testing (CLSI document M100-S21). The minimum eradication biofilm concentration (MBEC) of colistin methanesulfonate for strain MDRP-YMD isolated from a patient's urine, which formed a biofilm on plastic pegs attached to a microplate lid, was compared with that of P. aeruginosa ATCC27853 for quality control testing with MICs of ciprofloxacin, imipenem, and amikacin showing ≤1, 4, and 16 µg/ml, respectively. In an uneven biofilm approximately 10 µm thick, as determined with confocal laser scanning microscopy (CLSM), ratios of MBEC to MIC of colistin methanesulfonate against strains MDRP-YMD and ATCC27853 were 10.5 and 8.0, whereas those of minimum bactericidal concentration (MBC) to MIC in planktonic cells were 1.0 and 2.0 µg/ml, respectively. Morphological examination using scanning electron microscopy and CLSM verified that embedded cells in biofilm matrices of the two strains were disrupted and died under the MBEC. Therefore, bactericidal effects of colistin methanesulfonate on biofilm-forming cells of strain MDRP-YMD as well as strain ATCC27853 were significantly decreased compared with those on the planktonic cells.

A case of meningitis due to Neisseria subflava after ventriculostomy.

Surgical site infection (SSI) is an emerging problem in all fields of surgery, as well as in neurosurgery, with numerous strategies against SSI initiated in many countries. In this report, we describe a case of SSI caused by Neisseria subflava a month after ventriculostomy placement for acute hydrocephalus. A 53-year old man was referred to our hospital, and was diagnosed with a thalamic hemorrhage with ventricular rupture. Bilateral ventriculostomies were performed on the day of presentation. After intensive care for the acute stage, an SSI at the left ventriculostomy site was recognized on the 39th hospital day. The installed reservoir and ventricular tube was removed on the 40th hospital day. The CSF cell count was 2064/3, and N. subflava was recovered from the CSF culture. N. subflava is a common inhabitant found in the human upper respiratory tract, and is reported to be a rare cause of meningitis. There is one case report of meningitis caused by N. subflava transmitted during myelography from medical staff who did not wear facemasks during the procedure. Meningitis caused by N. subflava is rare, and transmission via a medical procedure is extremely rare. Although reported to be only rarely pathogenic, we must recognize that N. subflava can indeed be pathogenic, and can in rare cases be the cause of postoperative meningitis.

[A case of post-operative cerebral abscess caused by multidrug-resistant Acinetobacter baumannii-possibly originating abroad, and poorly susceptible to colistin].

We report a case of post-neurosurgical meningitis, subdural empyema, and cerebral abscess caused by multidrug-resistant Acinetobacter baumannii (MRAB) poorly susceptible to colistin. A 49-year-old man was transferred to our hospital after surgical treatment for putaminal hemorrhage in a foreign country hospital. Several examinations revealed surgical site infection (SSI). From cerebro-spinal fluid examination via ventricular drainage, MRAB was recovered. The minimum inhibitory concentration (MIC) of colistin was 2 µg/mL. Intravenous administration of colistin with ceftazidime and rifampicin was started, with intrathecal colistin administration, based on the results of a Break-point Checkerboard examination, and resulted in effective infection control. Nosocomial infection by MRAB has become an emergent problem in many countries. In Japan, several outbreak accidents caused by MRAB have been reported so far. In this case, genetic analysis revealed that the pathogen had originated from a foreign country, and the prevalence of colistin-resistant pathogens has also increased in these countries. Besides adequate isolation precautions, strategies for post-neurosurgical SSI management and establishment of effective treatments are necessary against neurosurgical SSIs caused by colistin-resistant MRAB.

[Annual incidence of human group A rotavirus G-serotypes detected in a Japanese University Hospital between 2003 and 2007].

Group A rotavirus G-serotyping by polymerase chain reaction (PCR) using university hospital subject samples in September 2003 to August 2004, September 2004 to August 2005, September 2005 to August 2006, and September 2006 to August 2007 showed the most common serotypes G1 and G3, detected in 27 and 33 subjects, compared to 4 subjects in whom serotype G4 was detected. Between 2003 and 2004, serotypes G1 accounted for 50% and G3 for 38%, contrasting with serotype G3 at 79% between 2004 and 2005, serotype G1 at 91% between 2005 and 2006, and serotype G1 and G3 at 37% and 63% between 2006 and 2007, respectively. Serotypes G2 and G9 were not detected at all during any of our time periods. No correlation was seen between subject age and G serotype, although subjects younger than two years old accounted for 73% of subjects. This infection caused combined fever, diarrhea, and vomiting in 48% of subjects but showed no correlation with G serotype. These findings under-score the importance of G-serotyping in understanding rotavirus infection epidemiology at different times and in different locales.

[Efficacy of preoperative radiation therapy in hyper-vascular solitary fibrous tumor].

The hyper-vascular form of solitary fibrous tumors (SFTs) is rare and there have been few therapeutic evaluations of this entity. We encountered a hyper-vascular SFT and had difficulty removing it surgically. Following radiotherapy, both tumor size and feeder vessels were reduced and we could proceed with gross total removal. A 29-year-old woman was admitted with a 1-year history of decreasing visual acuity on the right side. Magnetic resonance imaging with gadolinium enhancement showed a homogenous enhancing mass (6x5x5 cm) which expanded the superior and inferior tentorium cerebelli. The tumor was fed by the left posterior cerebral artery, bilateral middle meningeal arteries and the right occipital artery. The first operation employed an occipital transtentorial approach and a highly vascular tumor was found. Tumor resection was limited due to severe bleeding. Histologically, the tumor showed focal hypercellularity with spindle cells and numerous capillaries. Immunohistochemically, the tumor was diffusely positive for CD34 and a diagnosis of SFT, hyper-vascular subtype, was made. After the first operation, local irradiation of a total of 40 Gy was performed. Both the tumor size and vascularity decreased dramatically. At the second operation, gross total removal was able to be performed. Radiotherapy appears effective in reducing the hyper-vascular subtype of SFT and would be one possible therapy to deal with these tumors, given their propensity of excessive bleeding during initial surgery.

[The influence on the images of computed tomography caused by the use of artificial cranial reconstructive materials].

Various materials have been used for cranioplasty; however, these materials frequently produce artifacts that appear when examined with conventional radiography. Computed tomography (CT), in particular, detects high density artifacts near artificial bones, which is manipulated by increased noise, and limits diagnostic performance. The purpose of this study was to evaluate the extent and shape of the artifacts due to artificial cranial bones and to consider CT imaging parameters necessary for accurate recognition of structures under the materials. Four different artificial bone materials were evaluated in this study: hydroxyapatite with 1) 40% or 2) 50% porosity, 3) titanium plate, and 4) hydroxyapatite-polymethylmethacrylate composite (HA-PMMA). CT scanning was performed with standard clinical settings. Sample specimens were placed on the right side, under the artificial bones, and CT was performed to evaluate specimen visibility. We compared the artifacts created by the four bone types listed above, and measured the CT values of those materials. With ordinary scan settings, all the artificial bones revealed high-density artifact surrounding the materials, including the inability to accurately measure specimen thickness. The upper part of the specimen in contact with the artificial bones could not be distinguished from the artifact. The CT value in the medial aspect of the artificial bones increased more than the actual CT values. Of the four artificial bone materials studied, HA-PMMA produced the fewest artifacts. Description of the structures under the artificial bones can be improved by extending the window width to approximately twice that of normal settings.

[Spontaneous closure of dural arteriovenous fistula after performing diagnostic angiography].

The pathogenesis and clinical treatment of dural arteriovenous fistulas (DAVF) has been well established. However, only 15 cases of spontaneous closure of DAVFs have been reported. We describe a case of spontaneous closure of a DAVF. A 60-year-old male presented with pulsatile tinnitus. Selective cerebral angiography revealed a left posterior DAVF fed by the left occipital artery and the middle meningeal artery, which drained into the left transverse sinus and sigmoid sinus. Following the initial angiography, the patient exhibited vomiting with transient disorientation and amnesia. These symptoms, along with the tinnitus, disappeared by the following day. Seven days after the initial angiography, a second angiography was performed that revealed the complete disappearance of the DAVF. Previous reports have described a long period of closure for DAVFs following initial diagnosis. Possible mechanisms for spontaneous closure of DAVFs include the development of scar tissue or a sinus thrombosis that leads to occlusion of the DAVF In this case, the DAVF closure may have been due to a sinus thrombosis induced by sinus stenosis, since occlusion of the draining sinuses coincided with the spontaneous closure of the DAVF. In cases of non-traumatic DAVF without cortical venous reflex that do not present severe symptoms, a prudent course of treatment is necessary since there is a chance of spontaneous closure of the DAVF occuring.

Unexpected complications immediately after cranioplasty.

Case: An 84-year-old man with subarachnoid hemorrhage underwent craniotomy and clipping with external decompression. Perfusion magnetic resonance imaging showed subclinical sinking skin flap syndrome, and he underwent cranioplasty on postoperative day 58. No problems occurred during the operation, but cerebral edema and hemorrhage were recognized on immediate postoperative computed tomography. Edema continued to progress, but edema and bleeding eventually improved without additional surgery. Outcome: Neurological symptoms improved to presurgical baseline and stabilized. Conclusion: Causes of cerebral edema and hemorrhage immediately after cranioplasty include reperfusion, reduction of automatic adjustment function, sinking skin flap syndrome, negative pressure due to s.c. drain, venous stasis, vascular damage following restoration of midline shift, and allergic reaction. Although cranioplasty itself is a relatively minor surgery, the fatality rate for this complication is high. Most complications are due to infection, convulsions, or epidural hematoma, but brain edema and hemorrhage also occur. It is necessary to elucidate the etiology before corrective surgery.

Prehospital triage for endovascular clot removal in acute stroke patients.

Aim: To establish prehospital triage in accordance with the new guidelines for endovascular therapy, we retrospectively analyzed the monitoring data of the city-wide transportation system using the Maria Prehospital Stroke Scale (MPSS), a novel prehospital stroke scale for emergency medical technicians (EMTs) to predict the likelihood of thrombolytic therapy after transportation. Methods: Kawasaki City, Japan, has six comprehensive stroke centers (CSCs) and six primary stroke centers (PSCs). In CSCs, endovascular therapy can be carried out 24 h a day, 7 days a week, but not in PSCs. There is no "drip and ship" protocol for further endovascular therapy from PSCs to CSCs. We determined the predictive value of MPSS scoring by the EMTs for the performance of endovascular therapy after transportation. Results: There were 2031 patients (mean age, 71.1 ± 13.3 years) registered from April 2012 to March 2015. Multivariate logistic regression analysis indicated that the MPSS score and type of stroke center were independent predictors for performance of endovascular therapy. In particular, the odds ratio (OR) for endovascular therapy was significant for MPSS score 3 (OR, 2.914; 95% confidence interval (CI), 1.152-7.372; P = 0.024), MPSS score 4 (OR, 5.474; 95%CI, 2.300-13.029; P = 0.000), and MPSS score 5 (OR, 11.459; 95%CI, 4.334-30.296; P = 0.000) when MPSS score 1 was set as a reference. The diagnostic accuracy of the MPSS score evaluated by EMTs was 0.689 (95%CI, 0.627-0.751). Conclusions: Prehospital triage using MPSS scores evaluated by EMTs can predict the likelihood of performance of endovascular therapy after transportation, and may become a tool offering a flexible solution for designing a new transportation protocol.

Dural invasion of meningioma: a histological and immunohistochemical study.

Meningioma usually grows and expands into the brain, but invasion into the brain parenchyma is relatively rare. Meningioma arises from arachnoid cap cells, and infiltration into dura mater is the main growth pattern of meningiomas. However, little is known about the mechanism of meningioma invasion into the dura mater. In this study, seven specimens, including dural attachments, from seven cases of meningioma were used for immunohistochemical analysis. Matrix metalloproteinase (MMP)-1, -2, -9, urokinase-type plasminogen activator (uPA), vascular endothelial growth factors (VEGF), flt-1, E-cadherin, estrogen receptor (EgR), progesterone receptor (PgR), and aquaporin (AQP)-1, -4 were used as primary antibodies. There were several patterns of meningioma invasion into the dura mater: papillary-shaped invasion with destruction of dural structure, infiltration along the fibers of the dura mater, and invasion of several tumor cell units with fibroblast infiltration. Strong immunostaining was obtained with MMP-1, followed by AQP-1 and uPA, within the invading tumor cells. Neovasculature and extravasated erythrocytes, which stained with AQP-1, were also occasionally observed around the invading tumor cells. Simpson grade II removal of meningiomas results in high recurrence rates, and the inhibition of meningioma growth via dural invasion will facilitate improved remission in many cases with meningioma. In this study, MMP-1, AQP-1, and uPA are considered to have some role in the dural infiltration of meningioma cells. The fact that AQP-1 was highly expressed at the dural attachment and invading front of meningioma may indicate that dural invasion of the meningioma may be facilitated by AQP-1-induced water flow and neovascularization.

[Evaluation of cerebral blood perfusion with IVR-CT/angio system during interventional procedures].

An interventional-radiology computed-tomography (IVR-CT)/angio system is a combination of an angiographic unit and a CT scanner. This system allows patient's movement in and out of the two imaging units, on the same table. Since June 2003, we have applied our conventional protocol for evaluation of cerebral blood perfusion during interventional radiology (IVR) procedures. We reviewed our experience using the IVR-CT/angio system and investigated the efficacy and limitations of this technique. No complications relating to radiation exposure, contrast medium use, or IVR procedures were observed. CT perfusion was useful for detecting cerebral perfusion impairment during IVR procedures. This was helpful in deciding the postoperative management. Because patients do not need to be transported to another radiographic suite to evaluate cerebral blood perfusion, the IVR-CT/angio system is ideal for safely and simply detecting cerebral perfusion defects during IVR procedures. However, it is important to consider whether there is sufficient indication for the procedure, because radiation exposure and the amount of contrast medium use are increased if the IVR procedures become difficult.

A case of multiple radiation-induced gliomas 24 years after radiation therapy against pituitary adenoma.

We treated a case in which multiple astrocytomas of varying grades developed in the irradiation field 24 years after radiation therapy. Differentiation from radiation necrosis based on presurgical diagnostic imaging was difficult; therefore, we feel it is essential to aggressively pursue histological diagnoses to select the optimal treatment method.

A case of organized arachnoid cyst with repeated hemorrhage.

Hemorrhage sometimes occurs within arachnoid cysts, however, organized arachnoid cysts has not been reported. We speculate the previous invasive stress or some kind of infection may have triggered the formation of the organized membrane, which may have formed via a similar mechanism to that for organized chronic subdural hematomas.

Cerebral and Intra-ventricular Abscess Caused by Bisphosphonate-related Osteonecrosis of the Jaw (BRONJ).

Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is one of the major complications caused by prolonged bisphosphonate administration. We treated a case of BRONJ-related cerebral and intraventricular abscess. An 80-year-old woman was referred to our hospital for osteonecrosis of the maxilla. Removal of a decayed tooth followed by several oral antimicrobial administrations was performed, but the inflammation spread gradually into the orbit. Twenty-seven months after the initial treatment, she was referred to our hospital. A computed tomography (CT) scan revealed formation of an intraventricular abscess secondary to destruction of the maxillary and sphenoid sinuses. Reports of BRONJ associated with intracranial infection are rare. With prolonged life expectancy, BRONJ cases will increase with many comorbid diseases. Co-operation among physicians, dentists, and pharmacologists will be needed to treat these conditions appropriately.

Transcranial echo-guided transsphenoidal surgical approach for the removal of large macroadenomas.

OBJECT: Transsphenoidal surgery for the removal of macroadenomas has some disadvantages, including the risk of performing procedures without adequate visualization, difficulties in estimating the amount of residual tumor, and the risk of injuring major vessels. To overcome these disadvantages, the authors have developed transcranial echo-guided transsphenoidal surgery. METHODS: Three patients with large macroadenomas and two patients with irregularly shaped macroadenomas were selected for this operation. In addition to standard preparations for transsphenoidal surgery, in each case the right frontal bone was trephined and an echo probe was inserted transdurally through the trephination hole. During tumor removal, brightness-mode echo images and Doppler color flow images were obtained. The echo images allowed for real-time visualization of the tumor and surrounding brain structures including major arteries and the cisterns; histological heterogeneities of the tumor could also be appreciated. The tumors were removed safely and maximal tumor removal was achieved. CONCLUSIONS: Transcranial echo-guided transsphenoidal surgery provides real-time visualization of tumor removal. The method enhances the safety of this surgery, maximizes the removal of the tumor, and is inexpensive.

A case of prolactin-secreting pituitary carcinoma and its histological findings.

Pituitary carcinomas are very rare. The diagnosis of pituitary carcinoma is defined by evidence of craniospinal and/or systemic metastasis, rather than by histological malignancies. We report a case of prolactin-secreting pituitary macroadenoma invading the cavernous sinuses at the time of initial treatment, which later metastasized to the cerebellum, medulla oblongata, and spinal axis. The patient survived approximately nine years following the initial diagnosis of a pituitary tumor and two years following the diagnosis of metastatic disease. Histological examination of the metastatic cerebellar tumor showed an adenoma with high cellularity and hyperchromasia, but no mitoses.

Immunohistochemical analysis of reactive astrocytes around glioblastoma: an immunohistochemical study of postmortem glioblastoma cases.

To investigate the mechanisms of proteolysis within the glioma, and tissue reactions against glioblastoma, immunohistochemical detection both outside and inside of the tumor was performed using seven brains with glioblastoma that were obtained from autopsies. Immunohistochemistry was performed to detect vascular endothelial growth factor (VEGF), matrix metalloproteinases (MMP)-1,-2,-9, membrane-type matrix metalloproteinase (MT-MMP), interleukin (IL)1-beta, and IL-6. The data were translated into color graphics and the localization of these proteins was analyzed. In glial cells around the tumor, GFAP, VEGF, MMP-2, and MT-MMP were strongly expressed. Moreover, IL1-beta was also expressed strongly in the glial cells at the periphery of the tumor. IL-6 was recognized outside of the tumor, but was expressed only in the swollen astrocytes and normal pyramidal cells. These data suggest that in the periphery of the tumor, tissue reconstruction processes take place with concomitant degradation of the matrix by MMP-2 and MT-MMP, as well as vascular remodeling promoted by VEGF. The fact that IL1-beta, but not IL-6, was expressed strongly in the glial cells around the tumor, may indicate that these proteins expressed outside of the tumor are not utilized for tumor growth, but may be used to guard the tumor against invasions, such as immune response.