[Associations between Skeletal Muscle Mass, Physical Function, and Quality of Life at Diagnosis in Patients with Hematological Malignancies].

INTRODUCTION: Skeletal muscle mass is considered a prognostic factor for survival in patients with cancer. In this study, we investigated the associations between skeletal muscle mass, physical function, fatigue, and quality of life(QOL)at diagnosis in patients with hematological malignancies. METHODS: In this study, we included 27 untreated patients with newly diagnosed hematological malignancies who visited our hospital. The patients were assessed during the period from diagnosis to the start of chemotherapy. Data regarding age, white blood cell count, hemoglobin level, platelet count, and body mass index(BMI)were obtained from the patients' medical records. In addition, skeletal muscle mass index(SMI), phase angle (PhA), grip strength, knee extension strength, and short physical performance battery, brief fatigue inventory, EuroQol 5 dimensions 5-levels, and mini nutritional assessment short-form scores were calculated. RESULTS: The mean SMI value was 6.6±1.3 kg/m2(7.4±1.2 kg/m2 in men and 5.7±0.6 kg/m2 in women). SMI showed significant correlations with platelet count(r=-0.42, p=0.03), BMI(r=0.61, p≤0.01), PhA(r=0.54, p≤0.01), grip strength(r=0.81, p≤0.01), and knee extension strength(r=0.49, p=0.01). Multiple regression analysis, conducted using SMI as the dependent variable, revealed that BMI and grip strength were significant variables(p≤0.01). DISCUSSION: In untreated patients with newly diagnosed hematological malignancies, SMI was associated with BMI and grip strength but not with fatigue or QOL. Assessment of BMI and grip strength at diagnosis may help predict skeletal muscle mass.

Jugular Venous Pressure and Kussmaul's Sign as Predictors of Outcome in Heart Failure.

Simplifying the estimation of internal jugular venous pressure (JVP) as visible or not visible above the right clavicle in the sitting position has attracted attention for risk assessment in patients with heart failure (HF). It remains unclear whether this simple assessment, combined with its inspiration response known as Kussmaul's sign, is useful in patients with HF who vary in features such as HF with reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF).This study consisted of 246 patients who were admitted for the management of HF. JVP was assessed before discharge and considered high if visible at rest. The inspiration response was also examined. The primary outcome was a composite of all-cause death and hospitalization for worsening HF.One year after discharge, primary outcome events occurred in 91 patients (37%). The incidence of primary outcome was higher in patients with a high JVP at rest (odds ratio, 5.06; 95% confidence interval, 2.31-11.1; P = 0.0001) or with inspiration (odds ratio, 5.93; 95% confidence interval, 2.14-16.4; P < 0.01) than in patients without high JVP conditions. These findings were similarly observed among patients with HFrEF and HFpEF (odds ratios, 3.53 and 6.76; 95% confidence intervals, 1.68-8.68 and 2.19-15.5; P = 0.01 and < 0.01, respectively) and in subgroup analysis stratified by baseline characteristics of the patients.A high JVP at rest and with inspiration as assessed by this simple, practical method may be useful for risk assessment in patients with HF, independent of baseline characteristics.

[Research of Cognitive Impairment in Lung Cancer Patients Undergoing Chemotherapy].

Nineteen non-small cell lung cancer patients admitted for chemotherapy were investigated for cognitive dysfunction and factors affecting cognitive function. The results showed that the patients experienced some decline in cognitive function, and fatigue affected cognitive function and quality of life. Cognitive function in cancer patients affects their treatment choices, employment, and social life. We need to be aware of the cognitive dysfunction of cancer patients, and at the same time, we need to intervene with consideration for cognitive function, as fatigue can easily lead to a sense of cognitive decline.

Physical Therapy for a Multiple Myeloma Patient with COVID-19: A Case Report.

Background: This case report describes the successful management of rehabilitation therapy for a hematological malignancy patient who was receiving chemotherapy and had coronavirus disease 2019 (COVID-19). Case: A 76-year-old man receiving chemotherapy for relapsed refractory multiple myeloma (MM) presented to our hospital with fever and dyspnea and was hospitalized with a diagnosis of COVID-19. Physical therapy (20 min/day, 5 days/week) was started on day 6 of hospitalization while the patient was receiving oxygen therapy. Conditioning exercises and movement exercises were performed in an isolation room, and blood counts, fracture susceptibility, and respiratory status were monitored. The patient was severely immunocompromised and required 34 days of isolation due to persistent severe acute respiratory syndrome coronavirus 2 virus (SARS-CoV-2) infection. Physical function was assessed by manual muscle testing of the lower extremities and by the extent of lower extremity fatigue and dyspnea on exertion, as assessed using the Borg scale. Motor capacity was assessed using the de Morton Mobility Index (DEMMI) score and the Barthel Index (BI). Muscle weakness and severe dyspnea developed 4 days after physical therapy was started. However, physical therapy led to improvements in DEMMI score and BI. The patient was discharged home on day 43 with home medical care. Discussion: Careful management of MM and COVID-19 facilitated safe treatment with physical therapy. The patient's physical function improved with a carefully planned physical therapy program. Moreover, the patient required prolonged isolation due to persistent viral shedding; however, as a result of the treatment, which was coordinated between physicians and nurses, the patient could be discharged home.

Effect of Exercise Instructions With Ambulatory Accelerometer in Japanese Patients With Type 2 Diabetes: a Randomized Control Trial.

This study aimed to investigate the effects of physical therapists' exercise instructions in Japanese patients with type 2 diabetes. Thirty-six participants were recruited from the outpatient clinic at Matsushita Memorial Hospital, Osaka, Japan from June 2020 to September 2020 and were randomly assigned to either the non-intervention or intervention group. The intervention group received exercise instructions from physical therapists for 30 min at baseline (week 0) and at week 4 by referring to ambulatory accelerometer records. Laboratory parameters, physical activity, body composition, motor skill, and transtheoretical model were assessed in both the groups at baseline (week 0) and week 8. In week 8, patients in the intervention group had a statistically significant reduction in HbA1c levels compared with those in the non-intervention group (7.3% [6.8-%-7.9%] vs. 7.4% [7.3%-7.7%], P = 0.04). The number of steps per day (P = 0.001), energy expenditure (P = 0.01), lower extremity muscle strength (P = 0.002), and 6-min walk test results (P = 0.04) were significantly increased in the intervention group compared with those in the non-intervention group in week 8. The transtheoretical model varied between baseline (week 0) and week 8 only in the intervention group (P < 0.001). Thus, outpatient exercise instructions from physical therapists could improve glycemic control owing to physical activity by improving motor skills and changing the transtheoretical model in Japanese patients with type 2 diabetes.

Quality of life of patients with hematological malignancies and factors affecting health state utility values.

PURPOSE: It is well studied that physical function and social background affect the quality of life (QoL) of cancer patients. However, differences in QoL by age and factors affecting health state utility values (HSUV) of patients with hematological malignancies have not yet been sufficiently investigated. Our aim is to investigate the factors that affect QoL and HSUV in such patients. METHODS: A total of 32 patients with hematological malignancies on outpatient chemotherapy were included. QoL and HSUV were evaluated using the EuroQol-5 Dimension 5-level (EQ-5D-5L). Physical function was assessed using grip strength, knee extension strength, 6-min walking distance, and Short Physical Performance Battery (SPPB). Fatigue was assessed using Brief Fatigue Inventory (BFI), and nutritional status was assessed using Mini Nutritional Assessment-Short Form (MNA-SF). RESULTS: In the EQ-5D-5L, a high percentage of the patients were aware of mobility problems and pain/discomfort, and mobility problems were more common in the older-aged group (≥ 65 years old, n = 16) than in the middle-aged group (< 65 years old, n = 16). In addition, the older-aged group showed lower HSUV and physical function. SPPB (ß = 0.38, p < 0.01), BFI (ß = - 0.58, p < 0.01), and MNA-SF (ß = 0.29, p = 0.02) were independent factors affecting HSUV (adjusted R2 = 0.65, p < 0.01). BFI was correlated with HSUV in both older and middle-aged groups. CONCLUSION: Comprehensive supports, to improve lower extremity function, fatigue, and nutritional status, are required to augment QoL and HSUV in patients with hematological malignancies.

Clinicopathologic Factors Associated with Tumor Necrosis after Preoperative Embolization of Meningiomas.

Objective: Preoperative embolization of meningiomas induces necrosis prior to surgery and facilitates resection. Lack of contrast enhancement on postembolization MRI correlates with pathological findings of necrosis and can be used to assess embolization efficacy. This study aimed to examine clinicopathologic factors associated with tumor necrosis after embolization. Methods: A total of 119 patients with intracranial meningioma who underwent 145 surgical resections between 2010 and 2019 at our institute were reviewed. Inclusion criteria for the study were preoperative embolization with trisacryl gelatin microspheres (Embosphere) or absorbable gelatine sponge (Gelfoam). Postembolization Gd-enhanced T1-weighted and angiographic imaging, and histopathologic examination results were reviewed to evaluate the effectiveness of embolization. Results: In all, 66 patients satisfied the inclusion criteria. In total, 36 patients were embolized with Embosphere and 30 patients were embolized with Gelfoam. Patients embolized with Embosphere had a significantly higher necrosis rate (NR) than patients with Gelfoam (21% vs. 7.1%, P <0.01). The 36 Embosphere patients were analyzed regarding clinicopathologic factors associated with NR. Tumors in 12 patients were located in the parasagittal/falx region; these patients had a significantly lower NR compared with tumors in other locations (10.6% vs. 26.2%, P = 0.016). In all, 13 patients had feeders arising from only the middle meningeal artery (MMA), which was associated with a significantly higher NR (29.3% vs. 14.4%, P = 0.015). In total, 11 patients had meningeal feeders arising from internal carotid artery (ICA), which was associated with a significantly lower NR (9.0% vs. 26.3%, P <0.01). Conclusion: This study showed embolization agent, tumor location, and blood supply were important factors predicting necrosis after preoperative embolization.

Response of Jugular Venous Pressure to Exercise in Patients With Heart Failure and Its Prognostic Usefulness.

Jugular venous pressure (JVP) has been established for the assessment of central venous pressure in patients with heart failure (HF), but data are limited regarding the response of JVP to exercise because of its complicated methods. Simplifying the estimation of JVP may be applied in such situations. JVP was assessed before and after the 6-minute walk test (6MWT) in 81 patients with HF using a simple method by which the JVP was considered high when the internal jugular venous pulsation on the right side was visually identified above the right clavicle in the sitting position. The primary outcome was a composite of cardiovascular death and hospitalization for worsening HF. None of the patients exhibited high JVP before the 6MWT and 11 patients (14%) had a high JVP after. The 6MWT distances were lower in patients with a high JVP after the 6MWT (338 ± 114 m) than those in patients without a high JVP (417 ± 78 m, p = 0.04). During a follow-up period of 13.4 ± 6.9 months, 11 patients died and 8 patients were hospitalized for worsening HF. The incidence of adverse cardiac events was higher in patients with a high JVP after the 6MWT (64%) than in patients without a high JVP after (64% vs 17%; hazard ratio, 7.52; 95% confidence interval, 2.69 to 20.83; p <0.001). In conclusion, high JVP after exercise was associated with exercise intolerance and poor prognosis. The response of JVP to exercise using this simple technique of physical examination may be a new approach for patients with HF for risk assessment.

A Rare Case of Postoperative Symptomatic Cyst Formation After Resection of a Large Convexity Meningioma.

BACKGROUND: Symptomatic cyst formation after brain tumor resection is a rare complication of the early postoperative phase. We describe a complicated case of postoperative symptomatic cyst formation after gross total removal of a convexity meningioma. CASE DESCRIPTION: A 59-year-old woman presented with recent onset motor aphasia. Magnetic resonance imaging revealed a left convexity tumor. We performed gross total resection of the tumor, which was pathologically diagnosed as an atypical meningioma. Tumor resection and decompression of the normal cerebral hemisphere improved aphasia. However, 3 days after surgery, her motor aphasia worsened. Computed tomography scan confirmed that the frontal lobe was being compressed by an enlargement of the postoperative tumor cavity. Conservative therapy did not shrink the cavity, and her motor aphasia persisted. Therefore, 21 days after surgery, a drainage tube was inserted into the enlarged cavity using a neuroendoscope, which promoted shrinkage of the cavity and improved her motor aphasia. We suspected that the enlargement of the postoperative cavity was because of the presence of a valve-like structure. CONCLUSIONS: Even though formation of symptomatic cystic lesions after brain tumor resection is rare, neurosurgeons should be aware of such early postoperative complications and their management strategies.

Association between dexmedetomidine use and neurological outcomes in aneurysmal subarachnoid hemorrhage patients: A retrospective observational study.

PURPOSE: Recent studies in animal subarachnoid hemorrhage (SAH) models have reported that dexmedetomidine (DEX) use demonstrates significantly better neurological outcomes. This study aimed to evaluate whether DEX use is associated with favorable neurological outcomes (FO) in SAH patients. MATERIALS AND METHODS: We retrospectively reviewed all SAH patients between 2009 and 2017. We calculated the total dosage of DEX administered for the first 24h after admission. All patients were classified into no use, low dosage, and standard dosage group. Multivariate analysis was performed to clarify the association between DEX use and FO (modified Ranking Scale score of 0-2 at hospital discharge). RESULTS: There were 161 patients with 55.3% of FO. On univariate analysis, there were significant differences with regard to age, Hunt and Kosnik (H&K) grade, and DEX use. Multivariate analysis showed that age, H&K grade, and low dosage DEX (rather than no use) (odds ratio (OR) 3.17; 95% confidence interval (CI), 1.24-8.53; p=0.02) were significantly associated with FO. However, standard dosage DEX was not a significant factor (OR, 0.75; 95% CI, 0.25-2.16; p=0.59). CONCLUSIONS: Low dosage DEX during the first 24h after admission was associated with FO in SAH patients.

Blood Glucose Variability: A Strong Independent Predictor of Neurological Outcomes in Aneurysmal Subarachnoid Hemorrhage.

PURPOSE: In patients with aneurysmal subarachnoid hemorrhage (SAH), increased glucose variability (GV) is associated with increased mortality and cerebral infarction; however, there are no reports demonstrating an association between GV and neurological outcome. This study investigated whether GV had an independent effect on neurological outcomes in patients with SAH in the intensive care unit. MATERIALS AND METHODS: Consecutive adult patients hospitalized with SAH between January 1, 2009, and May 31, 2015 (N = 122) were retrospectively reviewed. Univariate/multivariate analyses were performed to identify independent predictors of poor neurological outcome. Patients were divided according to the mean glucose level (80-139 vs 140-200 mg/dL) and further subdivided using quartiles (Q) of the standard deviation (SD, representing variability) of the glucose level (Q1, Q2 + 3, and Q4). RESULTS: Unfavorable neurological outcomes occurred in 44.2% of the patients. On multiple regression analysis, age, Hunt and Kosnik grade, SD of glucose (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.02-1.17; P < .01), and minimum blood glucose level (OR, 0.95; 95% CI, 0.91-0.99; P < .01) were significantly associated with unfavorable neurological outcomes. Both groups (mean glucose levels: 80-139 and 140-200 mg/dL groups) had increasing unfavorable neurological outcomes with increasing SD of glucose (Q1, 15.0%; Q2 + 3, 40.0%; Q4, 52.4% and Q1, 44.4%; Q2 + 3, 50%; Q4, 88.9% in the 80-139 and 140-200 mg/dL groups, respectively). Patients with minimum glucose of <90 mg/dL comprised >50% of unfavorable neurological outcome. CONCLUSION: Increased GV was an independent predictor of unfavorable neurological outcomes in patients with SAH.

Cavernous sinus dural arteriovenous fistula treated by facial vein direct puncture: Case report and review of the literature.

Introduction In case of cavernous sinus dural arteriovenous fistula (CSDAVF), transvenous embolization (TVE) of the cavernous sinus (CS) via the inferior petrosal sinus (IPS) is generally performed. However, various approach routes have been reported when the accessibility of the IPS is challenging. We herein report a case of CSDAVF treated by TVE with direct puncture of the facial vein. Case report A 70-year-old woman who suffered from tinnitus, chemosis, diplopia and bruit was referred to our hospital. Digital subtraction angiography (DSA) demonstrated CSDAVF. We initially attempted to perform TVE via the IPS route; however, we could not guide a catheter to the CS because of an anatomical difficulty. Then, we performed percutaneous direct puncture of the dilated facial vein, and successfully treated the patient. Conclusion When navigating microcatheter to the CS is difficult because of an anatomical difficulty of the IPS, direct puncture of the facial vein is a feasible route.

Serial blood lactate measurements and its prognostic significance in intensive care unit management of aneurysmal subarachnoid hemorrhage patients.

PURPOSE: This study assesses the behavior of serial blood lactate measurements during intensive care unit (ICU) stay to identify prognostic factors of unfavorable neurological outcomes (UO) in patients with aneurysmal subarachnoid hemorrhage (SAH). METHODS: We retrospectively reviewed all patients who were consecutively hospitalized with SAH between 2009 and 2016. Arterial blood lactate levels were routinely obtained on admission and every 6h in the ICU. Univariate/multivariate analyses were performed to identify independent predictors of UO (modified Rankin scale of 3-6 upon hospital discharge). RESULTS: There were 145 patients with 46% of UO. Initially, increased lactate levels reached maximum levels during the first 24h and then decreased to within the normal range. Then, the levels slightly increased again to within the normal range for the next 24h, especially in UO. On multiple regression analysis, lactate levels measured at 24h, and 48h after admission were strong predictors of UO. Lactate level measured at 48h after admission demonstrated the greatest accuracy and the highest specificity (area under the curve, 0.716; sensitivity, 40%; specificity, 92.1%). CONCLUSIONS: The lactate level at 48h after admission was the most accurate predictor of UO with a high specificity in SAH patients.

Target Serum Sodium Levels During Intensive Care Unit Management of Aneurysmal Subarachnoid Hemorrhage.

INTRODUCTION: Dysnatremia commonly occur in the intensive care unit (ICU) management of patients with aneurysmal subarachnoid hemorrhage (SAH). However, detailed management strategies have not been provided even by current guidelines. The purposes of this study were to examine the association of abnormal serum sodium levels with unfavorable neurologic outcomes and to identify the target range of serum sodium in patients with SAH. METHODS: We retrospectively reviewed all patients who were consecutively hospitalized with a confirmed diagnosis of SAH between January 2009 and December 2015. Univariate/multivariate analyses were performed to identify the independent predictors of an unfavorable neurologic outcome (modified Rankin scale of 3-6 upon hospital discharge). RESULTS: There were 131 patients included in this study. Unfavorable neurologic outcomes occurred in 45% of patients. On multiple regression analysis, age, Hunt and Kosnik grade, and serum sodium levels in the ICU at the maximum [odds ratio (OR), 1.18; 95% CI, 1.05-1.35; P < 0.01] and minimum (OR, 0.88; 95% CI, 0.77-0.99; P = 0.048) values were significantly associated with unfavorable neurologic outcomes. The receiver operating characteristic curve analysis showed that the cut-off serum sodium levels were 145 mmol/L for maximum value and 132 mmol/L for minimum value. Patients with hyponatremia and hypernatremia during the first 2 weeks in the ICU accounted for 88.2% of patients with an unfavorable neurologic outcome; whereas, those with normal sodium levels accounted for only 15.6%. CONCLUSIONS: In patients with SAH, both hyponatremia and hypernatremia during ICU management were significantly associated with unfavorable neurologic outcomes.

Association Between Comorbidities, Nutritional Status, and Anticlotting Drugs and Neurologic Outcomes in Geriatric Patients with Traumatic Brain Injury.

BACKGROUND: Several studies using trauma data banks and registers showed that age, Glasgow Coma Scale (GCS), Injury Severity Score, and intraventricular hemorrhage were independent factors for neurologic outcomes in geriatric patients with traumatic brain injury (TBI). However, these analyses did not comprehensively evaluate factors particularly associated with geriatric patients. We aimed to identify factors particularly associated with geriatric patients that affect neurologic outcomes in TBI. METHODS: Patients aged ≥65 years who were hospitalized consecutively in Kagawa University Hospital with severe TBI between 1 January 2008 and 31 October 2015 were retrospectively reviewed. We evaluated background factors particularly associated with geriatric patients, including comorbidities (Charlson Comorbidity Index [CCI]), nutritional status (serum albumin level), and presence/absence of antiplatelet and anticoagulant drugs, in addition to baseline characteristics. Multivariate analyses were performed to identify independent predictors of unfavorable neurologic outcomes (UO), as defined as a Glasgow Outcome Scale score of 1-3 at discharge from hospital. The association between CCI and UO was evaluated in a subgroup analysis. RESULTS: UO occurred in 65.0% of 140 patients. Multivariate analyses showed that the CCI (odds ratio, 1.91; 95% confidence interval, 1.21-3.29; P = 0.011), age, and GCS were independent predictors of UO. In subgroup analyses of patients with an initial GCS score of 13-15, the rate of UO significantly increased with CCI score (CCI 0, 35.5%; CCI 1 or 2, 39.4%; CCI >2, 83.3%; P < 0.01). CONCLUSIONS: CCI was an independent predictor of UO in geriatric patients with severe TBI.

Impact of neurointensivist-managed intensive care unit implementation on patient outcomes after aneurysmal subarachnoid hemorrhage.

PURPOSE: The purpose of the study is to evaluate the impact of neurointensivist-managed intensive care unit (NIM-ICU) implementation for patients admitted with aneurysmal subarachnoid hemorrhage (SAH). METHODS: This study retrospectively evaluated 234 patients (mean age, 61.7 years; male, 67) admitted with SAH between January 1, 2001, and March 31, 2014. Neurologic outcomes between patients admitted from January 2001 to December 2006 (intensivist-managed intensive care unit group) and January 2007 to March 2014 (NIM-ICU group) were compared. The primary outcome was the incidence of a good neurologic outcome at discharge (GO; the modified Ranking Scale score: GO, 0-2; poor neurological outcome, 3-6) at discharge. RESULTS: Neurointensivist-managed intensive care unit was initiated for 151 (64.5%) of 234 patients. Univariate analysis demonstrated significantly better outcomes for NIM-ICU group vs intensivist-managed intensive care unit group (GOs, 58.3% vs 41.0%, respectively, P = .01). Multivariate logistic regression was used to evaluate NIM-ICU efficacy for SAH patients, but NIM-ICU was not significantly associated with GOs (P = .054). Subgroup analysis of patient grading by Hunt and Kosnik grades I to II showed that NIM-ICU implementation was an independent predictor of GOs (odds ratio, 4.54; 95% confidence interval, 1.08-22.17; P = .04). CONCLUSION: Neurointensivist-managed intensive care unit may improve neurologic outcomes in SAH patients with Hunt and Kosnik grades I to II.

[Intrapituitary adenoma metastasis from lung cancer with progressive cranial nerve palsies: a case report and literature review].

We report a rare case of metastasis to a preexisting pituitary adenoma. An 80-year-old man with a history of pituitary adenoma and lung cancer presented with recent onset of bilateral visual impairment, oculomotor nerve palsies, and severe headache. A CT scan revealed a pituitary tumor expanding into the suprasellar region and infiltrating the bilateral cavernous sinuses. We performed transsphenoidal surgery and diagnosed the tumor as lung cancer metastasis to the pituitary adenoma. After the surgery, visual impairment and severe headache were resolved, and the patient underwent radiation therapy for the residual tumor. To the best of our knowledge, 20 cases of metastases to pituitary adenomas have been reported in the literature. Clinical features of metastasis to a pituitary adenoma are different from those of metastasis to normal pituitary gland. In the case of a pituitary lesion with acute aggravation, one should be aware of the possibility of metastasis to preexisting pituitary adenomas.

Treatment of acute cerebral artery occlusion using the Penumbra system: our early experience.

Intravenous recombinant tissue-type plasminogen activator (rt-PA) therapy is highly recommended to patients who are diagnosed with ischemic stroke within 4.5 hours after the onset while mechanical clot retrieval can be attempted in patients who are not indicated for or cannot effectively receive intravenous rt-PA therapy. In this article, we report early treatment outcomes and discuss the usefulness of mechanical clot retrieval using the Penumbra system (Penumbra Inc., Alameda, California, USA), especially in terms of technical cautions during the procedure and adaptability to elderly and high National Institutes of Health Stroke Scale (NIHSS) patients. We included 7 patients with thromboembolic occlusion. Pretreatment NIHSS score ranged from 11 to 36 (mean: 24.9). All patients achieved good recanalization [thrombolysis in cerebral infarction (TICI) grade 2a or greater] without complications. The NIHSS score at 30 days after the treatment ranged between 0 and 28 (mean: 12.4), and improved more than 10 points in 4 of the 7 patients (57.1%). To obtain good recanalization without complications, selection of suitable reperfusion catheter and careful manipulation of separator prefiguring the occluded distal vessels are essential. The improved NIHSS score at 30 days after the treatment may have led to favorable results, such as an increased participation in available rehabilitation programs and the alleviation of the burden of care. Our findings suggest that the Penumbra system might be effective for treatment in elderly patients or patients with high NIHSS score wherein rt-PA therapy is inadvisable or ineffective in ischemic stroke secondary to large vessel occlusion. Recanalization can improve their quality of life on condition that the procedure is performed successfully without serious complications.

Cerebral blood flow and oxygen metabolism measurements using positron emission tomography on the first day after carotid artery stenting.

BACKGROUND: The aim of the present study is the characterization of hemodynamics to predict hyperperfusion syndrome (HPS) after carotid artery stenting (CAS) with positron emission tomography (PET) obtained before and on the first day after the treatment. METHODS: Cerebral perfusion and oxygen metabolism were evaluated by (15)O-gas PET in 18 patients with symptomatic internal carotid artery (ICA) stenosis before and on the first day after CAS. Regional cerebral blood flow (CBF), oxygen extraction fraction (OEF), cerebral metabolic rate of oxygen (CMRO2), and cerebral blood volume (CBV) were measured in the ipsilateral and contralateral middle cerebral artery territories and compared between before and after CAS. RESULTS: CBF increased in 16 of 18 patients on the first day after CAS and postoperative CBF was significantly higher than preoperative CBF bilaterally. OEF decreased in 15 of 18 patients on the first day after CAS and postoperative OEF was significantly lower than preoperative OEF in the ipsilateral hemisphere. CMRO2 and CBV did not change significantly. None of the patients showed HPS after CAS. All patients who had preoperative OEF of 53% or more (misery perfusion) in the ipsilateral hemisphere showed 50% or more increase in CBF postoperatively. The preoperative OEF value significantly correlated with the rate of postoperative increase in CBF bilaterally. CONCLUSIONS: CAS increases cerebral perfusion and improves hemodynamic compromise in patients with symptomatic ICA stenosis. Although we could not clarify the usefulness of PET before and on the first day after CAS in predicting HPS, a high preoperative OEF is related to postoperative marked CBF increase and might be used as a predictor of HPS. Patients with greater hemodynamic compromise with a high preoperative OEF should be managed carefully to prevent HPS, but they have a greater chance of CBF increase after CAS.

Usefulness of L-[methyl-11c]methionine positron emission tomography in the treatment of idiopathic hypertrophic cranial pachymeningitis--case report.

A 53-year-old man suffered from pulsating headache for 2 months. Magnetic resonance imaging with gadolinium revealed a linear or nodular mass along the left fronto-parietal convexity. Positron emission tomography (PET) with L-[methyl-11C]methionine (11C-MET) demonstrated increased uptake in the enhanced lesion. Biopsy, obtained by craniotomy, demonstrated granulation with lymphocyte and plasma cell infiltration, suggesting inflammatory changes, and a diagnosis of idiopathic hypertrophic cranial pachymeningitis (IHCP) was made. Steroid therapy resulted in improvement of the clinical symptoms and shrinkage of the enhanced lesion in a week. Follow-up 11C-MET PET study, after 18 months of steroid therapy, demonstrated significantly decreased uptake in the lesion, so the steroid therapy was discontinued. Neither clinical nor radiological recurrence was observed one year after discontinuation of the steroid therapy. This case of IHCP with increased 11C-MET uptake, which then decreased after steroid therapy suggests that 11C-MET PET is a useful monitoring modality for therapeutic efficacy against IHCP, and can indicate the appropriate timing of therapy discontinuation.