Neuro-endoscopic management of hemorrhagic moyamoya disease in the acute stage: single institute experience.

Background: Management of hemorrhagic moyamoya disease (MMD) is one of the most challenging issues in neurosurgical practice. Recently, surgical revascularization by superficial temporal artery-middle cerebral artery anastomosis was reported to significantly reduce the risk of re-bleeding in hemorrhagic-onset MMD patients in the chronic state, but the optimal treatment strategy in the acute phase of hemorrhagic MMD is undetermined. Thus, we retrospectively analyzed our surgical results for hemorrhagic MMD in the acute stage, focusing on the efficacy of neuro-endoscopic management for hematoma removal. Materials and methods: Among 26 consecutive hemorrhagic MMD patients who were managed at our institution in the acute stage, 8 patients with intracerebral hemorrhage underwent surgical evacuation of the hematoma. All patients were diagnosed with MMD before surgery by magnetic resonance angiography and/or catheter angiography. Results: The initial surgical procedure was neuro-endoscopic hematoma removal in seven patients and microsurgical hematoma removal by craniotomy in one patient. One patient treated by the neuro-endoscopic procedure required subsequent small craniotomy due to difficulty in hemostasis. Satisfactory hematoma evacuation was achieved in all eight patients, as demonstrated by post-operative computed tomography, although one patient who was deeply comatose before surgery died in the early post-operative period. Conclusion: Neuro-endoscopic hematoma removal may be the optimal management method for hemorrhagic MMD in the acute stage in terms of the maximum preservation of pre-existing collateral anastomosis without affecting the potential donor vessels used for future revascularization surgery. Abbreviations: MMD: Moyamoya disease; STA: Superficial temporal artery; MCA: Middle cerebral artery; JAM: Japan Adult Moyamoya; ICH: Intracerebral hemorrhage; IVH: Intraventricular hemorrhage; SAH: Subarachnoid hemorrhage; CT: Computed tomography; TE: Total evacuation; PE: Partial evacuation; SMR: Light mass reduction; MR: Magnetic resonance; mRS: Modified Rankin scale; GCS: Glasgow Coma Scale; ICP: Intracranial pressure.

[Neuro-endoscopic Management of Intraparenchymal Arachnoid Cyst in Adults:Three Case Reports].

We report 3 cases of symptomatic intraparenchymal arachnoid cysts in adults, including 2 in elderly patients. Case 1:An 81-year-old woman developed right-sided hemiparesis and hemianopsia due to the enlargement of left occipital arachnoid cyst, which had been incidentally diagnosed 3 years ago. Under the guidance of neuronavigation, we inserted a rigid endoscope into the cyst and perforated the cyst wall toward the posterior horn of the lateral ventricle, making a good communication between the cyst and the ventricle for cerebrospinal fluid. Her symptoms improved within 3 days after the surgery, and the cyst mass reduced. Case 2:A 57-year-old woman was incidentally found to have a right frontal arachnoid cyst. She had a 3-month long history of low mood and loss of interest in work. We perforated the transparent septum via the cyst wall toword the left lateral ventricle in a neuro-endoscopic procedure. After the surgery, she regained interest in work, and her symptom was considered to be indicative of depression due to arachnoid cyst. Case 3:A 94-year-old woman in a geriatric facility developed left-sided hemiparesis due to the enlargement of a right temporal arachnoid cyst, which had been detected 10 years ago. Neuro-endoscopic perforation of the cyst wall toward the lateral ventricle remarkably improved her symptoms. Arachnoid cysts can become symptomatic in the long term, not only in the young but also in the elderly. Neuro-endoscopic fenestration is an effective treatment for symptomatic intraparenchymal cysts, especially in elderly patients. The neuronavigation system was useful in the planning of the trajectory and in the detection of the target point of fenestration.

Application of neuro-endoscopic target aspiration of the necrotic core for cerebral contusion with delayed progression: technical note.

BACKGROUND: The optimal management strategy for cerebral contusion remains controversial, especially when standard craniotomy could not be used. We performed neuro-endoscopic target lesionectomy for the delayed progression of cerebral contusion in order to aspirate the necrotic core, which is the primal source of contusional edema. METHODS: The present study included 10 consecutive patients (2 women and 8 men, with a mean age of 67 years old) with traumatic brain injury presenting with delayed deterioration of cerebral contusion where standard craniotomy could not be used. Neuro-endoscopic aspiration of the necrotic core was prospectively performed for all patients. We assessed the computed tomography findings after surgery to evaluate the efficacy of this procedure. RESULTS: Endoscopic surgery was performed promptly after neurological deterioration, with a mean interval between trauma and surgery of 7 days, ranging from 2 to 16 days. During the operation, the centers of contusions comprised serous liquid components in all 10 patients and were easily aspirated by endoscopy. Contusional edemas were markedly decreased in all within 3 days after surgery. CONCLUSIONS: Progression of contusional edema can be caused by the accumulation of water into the necrotic core due to the rapid increase in osmolality. In light of the highly liquefied demarcated characteristics of the necrotic core, neuro-endoscopic aspiration could be an optional treatment strategy for cerebral contusion with delayed progression in a minimally invasive manner.

Spontaneous Development of Encapsulated Subdural Hematoma in the Posterior Cranial Fossa after Cardiac Surgery: A Case Report.

We report a case of an encapsulated subdural hematoma in the posterior cranial fossa, showing spontaneous development and rapid increase in size after cardiac surgery. An 86-year-old woman underwent aortic valve replacement for aortic valve stenosis, followed by anticoagulant therapy with heparin. Three days after the cardiac surgery, she complained of headache. Computed tomography revealed development of a subdural hematoma in the posterior cranial fossa. The hematoma rapidly increased in size within 7 days. Eleven days after cardiac surgery, she underwent removal of the subdural hematoma by craniotomy. Intraoperatively, the subdural hematoma was covered by a thick granulomatous capsule, with histopathological findings similar to those of a chronic subdural hematoma. She was discharged 2 weeks after the craniotomy without any neurological deficits. Encapsulated subdural hematoma in the posterior cranial fossa is rare and its etiology is unknown. In this case, postoperative anticoagulant therapy can promote the rapid growth of thick hematoma capsule. It is possible that previously reported cases of "posterior fossa chronic subdural hematoma" contain similar lesions to that in our patient.

[Coil Embolization of Vertebral Artery Aneurysm Using Direct Percutaneous Puncture of Vertebral Artery:A Technical Report].

Although direct puncture of the cervical vertebral artery(VA)is not commonly performed in neuroendovascular therapy, it is sometimes inevitable for procedural or technical reasons. We report a case of a ruptured VA aneurysm that required direct cervical VA puncture for treatment. A 79-year-old man was transferred to our hospital with the diagnosis of subarachnoid hemorrhage. Cerebral angiography revealed a right VA-posterior inferior cerebellar artery aneurysm. The aneurysm showed downward projection due to retrograde flow of the right VA caused by chronic occlusion of the right subclavian artery. For endovascular treatment, the approach through the VA union via the left VA was thought to be most appropriate;however, the left VA was very tortuous and the microcatheter could not cross the VA union. We performed percutaneous direct puncture of the left cervical VA. An 18-G intravenous catheter needle(Surflo®)was advanced and set into the C5/6 segment of the VA under biplane fluoroscopic road-mapping guidance. The microcatheter reached the aneurysm and coil embolization was successfully performed. The patient was kept intubated under general anesthesia overnight, to monitor for cervical subcutaneous hematoma. Several procedures for direct VA puncture have been reported. The major problem is the difficulty with hemostasis and maintenance of the airway is important. Although the indication is limited due to the difficulty of adjunctive techniques and postoperative antithrombotic therapy, direct VA puncture under biplane fluoroscopic guidance was useful in this case.

Transient forebrain ischemia induces impairment in cognitive performance prior to extensive neuronal cell death in Mongolian gerbil (Meriones unguiculatus).

In Mongolian gerbils, bilateral common carotid artery occlusion (BCCAO) for several minutes induces ischemia, due to an incomplete circle of Willis, resulting in delayed neuronal cell death in the Cornet d'Ammon 1 (CA1) region of the hippocampus. Neuronal cell death in the hippocampus and changes in behavior were examined after BCCAO was performed for 5 min in the gerbils. One day after BCCAO, the pyramidal neurons of the CA1 region of the hippocampus showed degenerative changes (clumped chromatin in nuclei). At 5 and 10 days after BCCAO, extensive neuronal cell death was observed in the hippocampal CA1 region. Cognitive performance was evaluated by using the radial maze and passive avoidance tests. In the radial maze test, which examines win-stay performance, the number of errors was significantly higher in ischemic gerbils than in sham-operated gerbils on days 1 and 2 post-operation. In the passive avoidance test, the latency and freezing times were significantly shorter in ischemic gerbils than in sham-operated gerbils on the days 1, 2, and 4-6 post-operation. These results indicate that transient forebrain ischemia impairs cognitive performance, even immediately after the ischemic insult when there are only subtle signs of neuronal cell death.

Maternal protein restriction that does not have an influence on the birthweight of the offspring induces morphological changes in kidneys reminiscent of phenotypes exhibited by intrauterine growth retardation rats.

Severe restriction of maternal protein intake to 6-8% protein diet results in intrauterine growth retardation (IUGR), low birthweight and high risk of metabolic syndrome in the adult life of the offspring. However, little information is available on the effects of maternal protein restriction on offspring under the conditions that does not have an influence on their birthweight of the offspring,. In the present study, pregnant rats were kept on a diet consisting of either 9% (low-protein, Lp rats) or 18% (normal-protein, Np rats) protein by weight/volume/etc. After birth, both Lp and Np rats were kept on a diet containing 18% protein. Neonatal body weight was significantly lower in Lp rats compared to Np rats from 4 days to 5 weeks after birth. While glomerular number per unit volume (1 mm(3) ) of the kidney (Nv) was comparable between Lp and Np rats 4 weeks after birth, the Nv was significantly decreased in Lp rats at 20 weeks after birth. Four and 20 weeks after birth, glomerular sclerosis index, interstitial fibrosis score, and ratio of ED1-positive cell ratio were all significantly higher in Lp compared to Np rats. Transforming growth factor-ß1-positive cells were observed in the distal tubules in the kidney of 4- and 20-week-old Lp rats kidneys, but not in those of age-matched Np rats. Altogether, these findings revealed that maternal protein restriction that does not have an influence on the birthweight of the offspring, induces similar changes as those seen in the kidneys of IUGR neonates.

Outcomes of Oculomotor Nerve Palsy Caused by Internal Carotid Artery Aneurysm: Comparison between Microsurgical Clipping and Endovascular Coiling.

The purpose of this study was to compare the clinical outcomes of microsurgical clipping and endovascular coiling in patients with oculomotor nerve palsy (ONP) caused by internal carotid artery (ICA) aneurysm. Among 17 patients with ICA aneurysms presented with ONP, 9 (52.9%) underwent microsurgical clipping and 8 (47.1%) underwent endovascular coiling. Outcomes of functional recovery of ONP were investigated and compared between surgical group and endovascular group. Mean intervals between the onset and treatment were significantly longer in microsurgical group (18.2 days) than in endovascular group (3.5 days). In microsurgical group, complete resolution (CR) of ONP was obtained in 7 of 9 patients (77.8%) and partial resolution (PR) was seen in 2 patients (22.2%). In endovascular group, CR was obtained in 5 of 8 patients (62.5%) and PR was seen in 3 patients (37.5%). The optimal treatment of aneurysm-induced ONP remains controversial; however, present study suggests both procedures are beneficial for achieving functional recovery of ONP. The treatment strategy should be decided primarily considering the general risks of the two procedures, and presence of ONP is not a disadvantageous factor for either procedure.

Effects of maternal subtotal nephrectomy on the development of the fetal kidney: A morphometric study.

The present study was designed to explore if maternal subtotal (5/6) nephrectomy affects the development of fetal rat kidneys using morphometric methods and examining whether there are any apoptotic changes in the fetal kidney. To generate 5/6 nephrectomized model rats, animals underwent 2/3 left nephrectomy on gestation day (GD) 5 and total right nephrectomy on GD 12. The fetal kidneys were examined on GDs 16 and 22. A significant decrease in fetal body weight resulting from maternal 5/6 nephrectomy was observed on GD 16, and a significant decrease in fetal renal weight and fetal body weight caused by maternal nephrectomy was observed on GD 22. Maternal 5/6 nephrectomy induced a significant increase in glomerular number, proximal tubular length, and total proximal tubular volume of fetuses on GD 22. Maternal 5/6 nephrectomy resulted in an increase in the number of apoptotic cells in the metanephric mesenchyme of the kidney on GD 16, and in the collecting tubules on GD 22. These findings suggest that maternal 5/6 nephrectomy stimulates the development of the fetal kidney while suppressing fetal growth.

[Clinical features of intracerebral hemorrhage under antithrombotic therapy in the warfarin era].

We investigated the clinical characteristics and prognosis of intracerebral hemorrhage(ICH)under antithrombotic therapy. We retrospectively reviewed the medical records of 463 patients admitted to our hospital due to ICH during 3-year periiod between January 2010 and December 2012. The ICH patients were classified into 4 groups: patients with anticoagulant therapy(AC, n=36), antiplatelet therapy(AP, n=65), anticoagulant and antiplatelet therapies(AC+AP, n=18), and no antiplatelet or anticoagulant therapy(NT, n=344). There were no significant differences between the groups in terms of gender, hematoma location, and initial hematoma size. Age and previous history of ischemic cerebral disease or ischemic coronary disease were significantly higher in the AC, AP, and AC+AP groups than in the NT group. The number of patients who had received previous treatment for hypertension was higher in the AC, AP, and AC+AP groups, and systolic blood pressure at admission was lower in the AC and AC+AP groups than in the NT group. Hematoma enlargement occurred more frequently in the AC and AC+AP groups. The AC, AP and AC+AP groups showed worse prognosis and higher mortality than the NT group. Anticoagulant therapy can be a risk factor for hematoma enlargement, and anticoagulant and/or antiplatelet therapy can be a risk factor of poor outcome.

Expression of transforming growth factor ß and fibroblast growth factor 2 in the lens epithelium of Morioka cataract mice.

In the Morioka cataract (MCT) mice, lens opacity appears at 6 to 8 weeks of age, and swollen lens fiber is electron-microscopically observed at 3 weeks after birth. The present study was designed to characterize the expression of transforming growth factor ß (TGFß) and fibroblast growth factor 2 (FGF2) in the lens epithelium of the MCT mice. Immunohistochemical analysis showed that the expression of TGFß in the lens epithelium of the MCT mice was stronger than that of the wild-type ddY mice at 2 and 4 weeks after birth. The expression of TGFß receptors (TGFßRI and TGFßRII) and FGF2 in the lens epithelium of the MCT mice was stronger than that of the wild-type ddY mice at 4 weeks and weaker than that of the wild-type ddY mice at 15 weeks after birth. Using real time polymerase chain reaction (PCR), quantitative RT-PCR analysis showed that expression of TGFß1 and TGFß2 mRNA in the lens of 2-week-old MCT mice was significantly higher compared to age-matched wild-type ddY mice. These findings indicate that the lens epithelium of MCT mice has increased expression of TGFß before cataract affection and that changes in the expression of FGF2 as well as TGFß may contribute to the progression of the cataract in the mice.

Arachnoid cyst in the middle cranial fossa presenting with pulsatile exophthalmos: case report and literature review.

A 20-year-old woman suffered gradual progression of right pulsatile exophthalmos and slight headache. Computed tomography (CT) demonstrated outward and downward displacement of the right globe and an arachnoid cyst in the right middle cranial fossa associated with thinned and anterior protrusion of a bony orbit. Microscopic cystocisternotomy was performed and the cerebrospinal fluid (CSF) inside of the cyst communicated into the carotid cistern and cistern in the posterior cranial fossa. Pulsatile exophthalmos improved immediately after surgery. Arachnoid cyst in the middle cranial fossa presenting with exophthalmos is rare. Microscopic cystocisternotomy might successfully improve CSF flow and relieve exophthalmos.

Effects of transient forebrain ischemia on the hippocampus of the Mongolian gerbil (Meriones unguiculatus): an immunohistochemical study.

In the Mongolian gerbil, bilateral common carotid artery occlusion (BCCAO) for several minutes induces ischemia and delayed neuronal cell death in the CA1 region of the hippocampus due to their incomplete Circle of Willis. In the present study, the expression of fibroblast growth factor 2 (FGF2), its receptors (FGFR1 and FGFR2), glial fibrillary acidic protein (GFAP), and isolectin B4 (ISLB4) was investigated by immunohistochemical and lectin-binding methods after BCCAO was performed for 5 min in gerbils. One day after BCCAO, the pyramidal cells of the CA1 region of the hippocampus showed degenerative changes and lowered expression of FGF2, FGFR1, and FGFR2. Three days after BCCAO, there was an increase in GFAP-positive astrocytes and ISLB4-positive microglial cells. From five to 10 days after BCCAO, intense neuronal cell death in the stria pyramidale of the hippocampal CA1 region was observed, as well as an increase in GFAP-positive astrocytes and decrease in ISLB4-positive microglial cells. These results indicate that transient forebrain ischemia induces neuronal cell death with lowered expression of FGF2 and its receptors, and that the activation of glial cells may not directly lead to neuronal cell death.

Simultaneous presentation of two cerebral aneurysms.

A 48-year-old woman experienced sudden onset of severe headache. Computed tomography showed subarachnoid hemorrhage (SAH) and intracerebral hematoma in the right frontal lobe. Digital subtraction angiography revealed three aneurysms in the anterior communicating artery (AcomA), the right posterior communicating artery (PcomA), and the right middle cerebral artery. The AcomA aneurysm was treated with endovascular coiling. However, her oculomotor nerve palsy was aggravated after the procedure. Embolization of the right PcomA aneurysm was conducted immediately and her oculomotor nerve palsy recovered completely 3 months later. Simultaneous presentation of multiple aneurysms with separate symptoms is rare. We speculate that the progressive oculomotor nerve palsy was caused by tiny enlargement or morphological change of the aneurysm caused by elevated blood pressure and pulsatile effect after SAH.

Endovascular repair of ruptured aneurysm arising from fenestration of the horizontal segment of the anterior cerebral artery: case report.

A 50-year-old man presented with an aneurysm arising from a fenestration of horizontal portion (A(1)) of the anterior cerebral artery manifesting as subarachnoid hemorrhage. Coil embolization was conducted and the aneurysm was occluded easily. Most reported cases of these types of aneurysms underwent direct surgery. Aneurysm arising from the A(1) fenestration is rare, but the present case shows that coil embolization can be an effective treatment modality. Three-dimensional rotational angiography and aneurysmography were helpful to characterize this complicated vascular structure.

[Brain metastasis from papillary thyroid carcinoma with acute intracerebral hemorrhage: a surgical case report].

We report a rare case of brain metastasis from papillary thyroid carcinoma with intracerebral hemorrhage. A 79-year-old woman presented with sudden headache and monoplegia of the right upper limb 10 years after diagnosis of thyroid papillary adenocarcinoma. Despite the known metastatic lesions in the cervical lymph nodes and lungs, she had been well for 10 years since thyroidectomy, focal irradiation and internal radiation of 131I. CT demonstrated intracerebral hemorrhage in the left temporal lobe. Magnetic resonance imaging showed marked signal heterogeneity. She underwent radical surgery on the day of the onset and the histological diagnosis was metastatic brain tumor of thyroid papillary carcinoma. Postoperative course was uneventful, and the monoplegia was improved. Papillary thyroid carcinoma has a relatively benign course, and surgical removal of the brain metastasis is able to contribute to longer survival times for patients.

Acute occlusion and recanalization of vertebral artery dissection after subarachnoid hemorrhage: usefulness of bilateral simultaneous vertebral angiography and basiparallel anatomic scanning-magnetic resonance imaging. Case report.

A 41-year-old man presented with subarachnoid hemorrhage. Initial digital subtraction angiography showed occlusion of the right vertebral artery (VA), which recanalized immediately, and dissecting aneurysm on the distal part of the right VA. Basiparallel anatomic scanning (BPAS)-magnetic resonance (MR) imaging showed the morphology of the aneurysm clearly. Coil embolization of the entire affected artery was performed using bilateral vertebral angiography road mapping. Although acute occlusion of ruptured VA dissection may have the potential for natural healing, spontaneous recanalization seems to be hazardous because of rebleeding. In cases with acute occlusion of parent artery, BPAS-MR imaging and bilateral simultaneous vertebral angiography may give useful information.

An increase in apoptosis and reduction in αB-crystallin expression levels in the lens underlie the cataractogenesis of Morioka cataract (MCT) mice.

We examined the morphological changes in fibers, localization of apoptotic cells, and protein expression of αB-crystallin in the lens of Morioka cataract (MCT) mice, a novel cataract model. Using a scanning electron microscope, swollen lens fibers and enlarged spaces between lens fibers were observed in the lens of 3-week-old MCT mice. At 2 weeks of age (before cataract), the single-strand DNA (ssDNA)-positive (indicating apoptosis) cell ratio of the lens epithelium was significantly higher in MCT than in wild-type ddY mice. At 2 and 4 weeks of age, αB-crystallin protein expression of the lens in MCT mice was significantly lower than that in wild-type ddY mice. These findings suggest that increase in apoptosis and reduction in αBcrystallin level are involved in the cataractogenesis of MCT mice.