Newly Developed Aneurysm at the Anastomosis Site of a Superficial Temporal Artery to Middle Cerebral Artery Bypass Successfully Treated by Endovascular Embolization.

BACKGROUND: The superficial temporal artery (STA) to middle cerebral artery (MCA) bypass is an effective treatment procedure for steno-occlusive severe ischemic disease of the anterior circulation. The formation of an aneurysm at the anastomosis site is a rare complication, and the mechanism underlying this condition and the appropriate treatment strategy, have not yet been established. We describe a case of an unruptured anastomosis aneurysm that was treated by endovascular embolization 7 years after bypass surgery. CASE DESCRIPTION: A 62-year-old woman presented with slurred speech, with magnetic resonance imaging and angiography showing multiple infarctions in her left cerebral hemisphere and severe stenosis in the left internal carotid artery and left MCA. An STA-MCA anastomosis was performed without neurologic sequelae. Five years later, follow-up magnetic resonance imaging showed that an aneurysm had formed at the MCA side of the anastomosis site. After 2 years, the saccular aneurysm had grown and was embedded in the brain parenchyma. Because the patient had experienced repeated problems with surgical wound healing, an endovascular intervention was performed, achieving obliteration of the aneurysm by coil embolization. CONCLUSIONS: Endovascular treatment is a feasible and efficacious treatment option for an aneurysm at the anastomosis site of an STA-MCA bypass.

Acute subdural haematoma accompanied by anorexia nervosa.

We report the case of a patient with anorexia nervosa accompanied by acute subdural haematoma following a fall. A 34-year-old Japanese woman had serious medical complications and brain atrophy. After careful nutritional treatment, her laboratory test results improved and brain atrophy was reversed, and we prevented to perform surgery. However, unexpected prominent oedema of her lower legs and pleural effusion occurred. After receiving treatment for these symptoms, she eventually returned to her former occupation and started following a normal diet. Very few cases of anorexia nervosa accompanied by intracranial haemorrhage have been reported. Coagulation disorder and brain atrophy are supposed to be the primary causes of haematoma formation in the present case. Intracranial haemorrhage likely occurs in patients with anorexia nervosa despite minor head trauma. Because anorexia nervosa is not rare and the age of such patients is advancing, knowledge regarding this disorder would be useful for neurosurgeons.

Transthyretin Concentrations in Acute Stroke Patients Predict Convalescent Rehabilitation.

OBJECTIVE: For stroke patients, intensive nutritional management is an important and effective component of inpatient rehabilitation. Accordingly, acute care hospitals must detect and prevent malnutrition at an early stage. Blood transthyretin levels are widely used as a nutritional monitoring index in critically ill patients. Here, we had analyzed the relationship between the transthyretin levels during the acute phase and Functional Independence Measure in stroke patients undergoing convalescent rehabilitation. METHODS: We investigated 117 patients who were admitted to our hospital with acute ischemic or hemorrhagic stroke from February 2013 to October 2015 and subsequently transferred to convalescent hospitals after receiving acute treatment. Transthyretin concentrations were evaluated at 3 time points as follows: at admission, and 5 and 10 days after admission. After categorizing patients into 3 groups according to the minimum transthyretin level, we analyzed the association between transthyretin and Functional Independence Measure. RESULTS: In our patients, transthyretin levels decreased during the first 5 days after admission and recovered slightly during the subsequent 5 days. Notably, Functional Independence Measure efficiency was significantly associated with the decrease in transthyretin levels during the 5 days after admission. Patients with lower transthyretin levels had poorer Functional Independence Measure outcomes and tended not to be discharged to their own homes. DISCUSSION: A minimal transthyretin concentration (<10 mg/dL) is predictive of a poor outcome in stroke patients undergoing convalescent rehabilitation. In particular, an early decrease in transthyretin levels suggests restricted rehabilitation efficiency. Accordingly, transthyretin levels should be monitored in acute stroke patients to indicate mid-term rehabilitation prospects.

Differential brain cooling induced by transarterial perfusion of cooled crystalloid solution in canines.

OBJECTIVE: We investigated the possibility of differential brain cooling by an endovascular method, perfusing cooled crystalloid solution transarterially. METHODS: Fifteen healthy adult hybrid dogs were divided into three groups according to different crystalloid infusion rates: Group 1 received 1.5 ml/kg/min (n=6), Group 2 received 3.0 ml/kg/min (n=6) and Group 3 received 5.0 ml/kg/min (n=3). A four-French angiographic catheter was placed into the right common carotid artery to infuse cooled Ringer's solution. A six-French angiographic catheter was placed into the right jugular vein to withdraw hemodiluted blood. Excessive fluid was eliminated using a dialyzer in a venovenous extracorporeal circuit. Hypothermic perfusion was continued for 30 minutes. A Swan-Ganz catheter was inserted to measure cardiac output. Temperatures were monitored in the cerebral hemispheres and rectum. RESULTS: The cooling rates of the right cerebral hemisphere were 1.8 +/- 0.9 degrees C/30 min in Group 1 and 4.7 +/- 1.0 degrees C/30 min in Group 2. The cooling rates of the left cerebral hemisphere and rectum were 1.4 +/- 0.5 and 1.5 +/- 0.7 degrees C/30 min in Group 1, and 3.5 +/- 0.5 and 3.4 +/- 0.8 degrees C/30 min in Group 2, respectively. In Group 3, two dogs died after the experiment. Systemic hemodynamics was stable throughout the experiment in Group 1, while arterial blood pressure, heart rate and cardiac output changed significantly after perfusion in Group 2. CONCLUSION: Transarterial perfusion of cooled crystalloid solution achieved differential cooling between the target and other sites. However, the difference was small and further refinements are necessary to achieve beneficial effects.

Rapid induction of brain hypothermia by endovascular intra-arterial perfusion.

OBJECTIVES: Achieving rapid, brain cooling has potentially important clinical implications. To investigate potential practicalities, we induced brain hypothermia in canines by perfusing cooled crystalloid solution into the carotid artery using an extracorporeal cooling-filtration system. METHODS: Ringer's solution cooled to approximately 6.5 degrees C was infused at a rate of 3 ml/kg/min for 30 minutes into the right common carotid artery through an angiographic catheter via the right femoral artery in six adult canines (13.81 +/- 0.60 kg). Excessive fluid was ultrafiltrated through a venovenous extracorporeal circuit via the right femoral vein. Temperature was monitored in the cerebral hemispheres, the rectum and the vena cava. The extracellular lactate concentrations were measured by microdialysis in the frontal lobes. RESULTS: Right brain temperature decreased to 33.6 +/- 2.0 degrees C from 37.7 +/- 1.1 degrees C 30 minutes after initiation of perfusion, while left brain and rectal temperatures were 34.3 +/- 1.7 and 34.1 +/- 1.3 degrees C, respectively. The cooling rate of the right cerebral hemisphere was 4.2 +/- 1.1 degrees C/ 30 minutes and advanced compared with the rectum (p<0.01), the left cerebral hemisphere and the vena cava (both p<0.05). There was no significant increase in the extracellular lactate concentrations in the cerebral hemispheres. Hemoglobin, hematocrit and cardiac function significantly changed during perfusion (p<0.05). CONCLUSIONS: Brain hypothermia was rapidly and safely induced using an intra-arterial crystalloid infusion and an extracorporeal cooing-filtration system. With refinement and further assessment of metabolic and physiologic parameters, the method holds a potential for clinical utility.

Selective brain hypothermia suppresses noxious-evoked movement in canines.

Systemic hypothermia suppresses noxious-evoked movement, but its main site of action is unknown. We examined the effect of hypothermia in the brain on noxious-evoked movement by selectively cooling the brain. Sixteen beagles were randomly divided into two groups and anesthetized with isoflurane/oxygen. After being deeply anesthetized, the dogs' lungs were artificially ventilated, and several major vessels were cannulated for perfusion and monitoring. Cold lactate Ringer's solution was infused into the right vertebral artery to cool the brain while maintaining the trunk temperature relatively warmer. When the brain temperature decreased to 20 degrees C or 25 degrees C, isoflurane administration was discontinued; the trunk temperatures at this stage were approximately 34.7 degrees C and 34.6 degrees C, respectively. After the end-tidal isoflurane concentration reached 0%, the base of the tail was stimulated with an electric current through 2 25-gauge needles. None of the dogs reacted to tail stimulation when the brain temperature was at 20 degrees C, whereas 7 of 8 reacted at 25 degrees C. These results indicate that selective brain hypothermia (20 degrees C) results in suppressing noxious-evoked movement in canines.

[Combined therapy with surgery and stereotactic radiosurgery for facial schwannoma: case report].

The authors report the successful case of combined therapy using surgery and stereotactic radiosurgery for facial schwannoma in the middle cranial fossa, and discuss the surgical strategy for preservation of facial nerve function. This 27-year-old man presented with a 9-year history of right facial palsy and spasm. CT scan and MR imaging demonstrated a tumor 3 x 3 x 4 cm in size extending to the intradural middle cranial fossa from the petrous bone. After total removal of the intradural tumor, gamma knife radiosurgery was performed for residual tumor in the petrous bone. The marginal dose to the tumor was 12 Gy. Facial spasm disappeared, but facial palsy is unchanged 14 months after the radiosurgery.