The Short-Term Outcome of Middle Meningeal Artery Embolization for Chronic Subdural Hematoma with Mild Symptom: Case Series.

OBJECTIVE: A few reports have demonstrated the efficacy of middle meningeal artery embolization (MMAE) alone for mildly symptomatic chronic subdural hematoma (CSDH); however, the clinical course in the early posttreatment period remains unclear. The purpose of this study was to analyze the short-term outcomes of this technique at our center. METHODS: This study was based on a retrospective analysis of a single-center consecutive case series. Patients with mildly symptomatic CSDH treated with MMAE alone between July 2020 and June 2022 were examined. Neurological examinations and head computed tomography scans were performed before treatment and 1, 7, 14, and 28 days after treatment. The clinical course of the patients was analyzed. In particular, symptom improvement within 1 week from treatment or rescue evacuation and the factors associated were evaluated. RESULTS: Fifteen patients were included in this study. No procedure-related complications occurred. Partial or complete recovery within the first week from treatment was observed in 10 cases (66.7%), and the symptoms resolved completely in a median of 26 (6.5-33.5) days. Rescue evacuation was needed in 3 cases (20.0%). The hematoma volume and midline shift gradually decreased from baseline, with a significant improvement within the first week (P = 0.030 and 0.0032, respectively). CONCLUSIONS: MMAE alone provides relatively early improvement in cases of mildly symptomatic CSDH and may be a potential alternative to surgical evacuation or medical therapy.

Distal Transradial Approach in Mechanical Thrombectomy: Technical Note.

Objective: We report a case of mechanical thrombectomy (MT) via the distal transradial approach (dTRA) and technical tips. Case Presentation: An 89-year-old woman was transferred to our hospital due to back pain after a fall and sudden-onset left hemiparesis. We performed MT because three-dimensional computed tomography angiography (3D-CTA) revealed right middle cerebral artery (MCA) occlusion. The access route was Type 3 aortic arch. The abdominal aorta and common iliac artery were tortuous and partially dissected, and she had a lumbar vertebra fracture. We selected dTRA in consideration of safety, ease of access, and less postoperative postural restriction. The first pass resulted in complete recanalization using an aspiration catheter and stent retriever. Her symptoms rapidly improved and she was discharged with a modified Rankin Scale score of 1. Conclusion: dTRA in MT may be a treatment option.

Effectiveness of 7-day versus weekday-only rehabilitation for stroke patients in an acute-care hospital: a retrospective cohort study.

PURPOSE: Early rehabilitation is widely recommended for acute-stroke patients. We tested the hypothesis that the functional prognosis of stroke patients receiving daily early rehabilitation in a clinical practice setting is generally better than that of patients receiving rehabilitation only on weekdays. MATERIALS AND METHODS: We analyzed hospitalized patients who experienced either cerebral infarctions or cerebral hemorrhages and subsequently underwent rehabilitation at our hospital between October 2010 and September 2014. We examined the association between training frequency and activities of daily living improvements, as indicated by the Barthel Index (BI) effectiveness. RESULTS: In total, 661 patients with cerebral infarctions and 245 with intracerebral hemorrhages (ICHs) were analyzed. The BI effectiveness was highest for patients receiving high-frequency therapy following cerebral infarction. In addition, multiple linear regression analysis indicated that BI effectiveness was significantly and positively correlated with high-frequency therapy (coefficient, 0.072; 95% confidence interval, 0.019-0.126; p < 0.01) in patients with cerebral infarctions. There was no significant difference in BI effectiveness between therapeutic protocols for patients with ICHs. CONCLUSION: This retrospective cohort study demonstrated that extensive therapy can result in functional recovery in patients with cerebral infarctions. Implications for Rehabilitation Early intervention with intensive rehabilitation therapy is important for improving the functional recovery of patients during acute-care hospitalization. Few acute hospitals provide more than 2 h of daily rehabilitation for patients with acute stroke. In a daily clinical practice setting, this clinical study demonstrates a direct relationship between early intervention with intensive rehabilitation therapy and good functional recovery of stroke patients in an acute ward.

[Correlation between increased platelet ADP aggregability and silent brain infarcts].

The purpose of this study was to investigate the correlation between platelet aggregability and silent brain infarcts. The study subjects were 445 people (264 men, 181 women; mean age, 53 ± 14 years) with no neurologic signs, history of brain tumor, trauma, cerebrovascular disease, or antiplatelet medications. Adenosine diphosphate (ADP)-induced platelet aggregation was measured by the aggregation-size analytic method. Platelet aggregability was classified into 9 classes. The presence of headache/vertigo, hypertension, diabetes mellitus, hyperlipidemia, or smoking was elicited by questioning or blood sampling. A head MRI scan was performed, and if marked atherosclerosis or obvious stenosis in the intracranial vessels was detected, it was defined as a positive MRA finding. Silent brain infarcts were detected in 26.3% of subjects. Hyperaggregability defined as that above class 6, 7, and 8 was present in 43.8%, 30.8%, and 15.7% of subjects, respectively. The risk factors for silent brain infarcts by multiple logistic regression analysis were aging, hypertension, positive MRA findings, and hyperaggregability. Platelet ADP hyperaggregability might be a risk factor for silent brain infarcts.

Mobile and accurate detection system for infection by the 2009 pandemic influenza A (H1N1) virus with a pocket-warmer reverse-transcriptase loop-mediated isothermal amplification.

The 2009 pandemic H1N1 influenza A virus spread quickly worldwide in 2009. Since most of the fatal cases were reported in developing countries, rapid and accurate diagnosis methods that are usable in poorly equipped laboratories are necessary. In this study, a mobile detection system for the 2009 H1N1 influenza A virus was developed using a reverse-transcriptase loop-mediated isothermal amplification (RT-LAMP) kit with a disposable pocket-warmer as a heating device (designated as pwRT-LAMP). The pwRT-LAMP can detect as few as 100 copies of the virus--which is nearly as sensitive as real-time reverse-transcription polymerase chain reaction (RT-PCR)--and does not cross-react with RNA of seasonal influenza viruses. To evaluate the usefulness of the pwRT-LAMP system, nasal swab samples were collected from 56 patients with flu-like symptoms and were tested. Real-time RT-PCR confirmed that the 2009 H1N1 influenza A virus was present in 27 of the 56 samples. Of these 27 positive samples, QuickVue Influenza A+B immunochromatography detected the virus in only 11 samples (11/27; 40.7%), whereas the pwRT-LAMP system detected the virus in 26 of the 56 samples (26/27 of the positive samples; 96.3%). These findings indicate that the mobile pwRT-LAMP system is an accurate diagnostic system for the 2009 H1N1 influenza A virus, and has great potential utility in diagnosing future influenza pandemics.

Usefulness of preoperative three-dimensional computed tomographic angiography with two-dimensional computed tomographic imaging for rupture point detection of middle cerebral artery aneurysms.

OBJECTIVE: We report the technique of three-dimensional computed tomographic (CT) angiography with a two-dimensional CT image aiding in the early operation of ruptured middle cerebral artery aneurysms. This combined image allows the prediction of the rupture point in the aneurysm and may reduce the risk of rupture during early clipping surgery. METHODS: The findings for 14 patients with 14 middle cerebral artery ruptured aneurysms who underwent subsequent early clipping were analyzed. The average aneurysm size was 8.5 mm, and there were two large and one giant aneurysms. CT examinations were performed by means of a multidetector CT scanner (Aquilion M16; Toshiba Medical Systems, Tokyo, Japan) and reconstructed with a workstation (ZIO M900 QUADRA; Amin Co., Ltd., Tokyo, Japan). We constructed an operating view through three-dimensional CT angiography for a lateral transsylvian approach with a two-dimensional CT image (nonshaded volume-rendering image), which was perpendicular to the direction of the surgical approach. Using this combined image, we predicted the rupture point of the aneurysm and successfully performed clipping surgery through a lateral transsylvian approach. Rupture points were confirmed at the time of surgery. Rupture points of 13 out of 14 aneurysms appeared as we expected, but one differed; all aneurysms were successfully clipped. Thirteen of the 14 patients could be clipped without rupture at surgery, but the remaining patient experienced rupture just after craniotomy. CONCLUSION: The combination of three-dimensional CT angiography and two-dimensional CT images may help improve the surgical outcome by indicating aneurysmal rupture points, leading to the prevention of rupture.

Indications for computed tomography in patients with mild head injury.

The factors affecting outcome were analyzed in 1,064 patients, 621 males and 443 females aged 10 to 104 years (mean 46 +/- 23 years), with mild head injury (Glasgow Coma Scale [GCS] score > or =14) but no neurological signs presenting within 6 hours after injury. Intracranial lesion was found in 4.7% (50/1,064), and 0.66% (7/1,064) required surgical treatment. The Japan Coma Scale (JCS) and GCS assessments were well correlated (r = 0.797). Multivariate analysis revealed significant correlations between computed tomography (CT) abnormality and age > or =60 years, male sex, JCS score > or =1, alcohol consumption, headache, nausea/vomiting, and transient loss of consciousness (LOC)/amnesia. Univariate analysis revealed that pedestrian in a motor vehicle accident, falling from height, and mechanisms of injuries except blows were correlated to intracranial injury. No significant correlations were found between craniofacial soft tissue injury and intracranial injury. Patients with occipital impact, nonfrontal impact, or skull fracture were more likely have intracranial lesions. Bleeding tendency was not correlated with CT abnormality. The following indications were proposed for CT: JCS score >0, presence of accessory symptoms (headache, nausea/vomiting, LOC/amnesia), and age > or =60 years. These criteria would reduce the frequency of CT by 29% (309/1,064). Applying these indications to subsequent patients with GCS scores 14-15, 114 of 168 patients required CT, and intracranial lesions were found in 13. Two refused CT. Fifty-four of the 168 patients did not need CT according to the indications, but 38 of the 54 patients actually underwent CT because of social reasons (n = 21) or patient request (n = 17). These indications for CT including JCS may be useful in the management of patients with mild head injury.

[Adult bacterial meningitis complicated by cerebral infarction: report of three cases].

Fatality rates and the number of patients suffering from the after sequelae of bacterial meningitis have still remained high despite the development of new antibiotics. Cerebrovascular complications have been reported less frequently in adult cases than in child cases. We experienced 3 consecutive cases of bacterial meningitis in adults complicated by brain infarction. Primary causative organism were the Group B Streptococci in one case and the Streptococcus pneumoniae in other two cases. MRI, especially with FLAIR method and of coronal view, disclosed abnormal intensity areas near the brain surface. Conventional angiography and MR-angiography in the two cases showed tapering and stenosis of arteries. These cases suggest that routine use of MRI/ MRA in bacterial meningitis reveal neuro-vascular complications more frequently and easily. The benefits of adjunctive steroid therapy in the treatment of bacterial meningitis might be beneficial to suppression of these neurovascular complication cased by inflammatory vasculitis.

[Cerebral circulation dynamics following fasudil intravenous infusion: a CT perfusion study].

Using CT perfusion studies we evaluated changes in the cerebral circulation before and after the intravenous administration of fasudil 60 mg in 8 patients 7 to 14 days after a subarachnoid hemorrhage. The mean duration to the peak of the time-density curve and the average peak value did not change. In areas with cerebral blood perfusion (CBP) less than 40 ml/100 g/min, the CBP increased from 34.4 +/- 4.7 ml/100 g/min to 41.0 +/- 8.2 ml/100 g/min (p < 0.01) after fasudil infusion, the cerebral blood volume (CBV) rose from 2.41 +/- 0.53 ml/100 g to 2.55 +/- 0.5 ml/100 g (p < 0.05), and the mean transit time (MTT) decreased from 5.09 +/- 1.13 s to 4.82 +/- 0.89 s (p < 0.05). In areas where the CBP was more than 41 ml/100 g/min, the CBP did not change (from 51.8 +/- 7.6 ml/100 g/min to 50.4 +/- 8.4 ml/100 g/min), the CBV decreased (from 2.75 +/- 0.62 ml/100 g to 2.67 +/- 0.55 ml/100 g, p < 0.05), and the MTT did not change (from 3.80 +/- 0.76 s to 3.77 +/- 0.72 s). These results suggest that intravenous infusion of fasudil 60 mg increases cerebral blood flow and cerebral blood volume and shortens MTT in areas with decreased blood flow due to vasospasm.

[Tooth loss and the incidence of ischemic stroke].

Chronic infectious diseases may increase the risk of stroke. We investigated whether periodontal disease was a risk factor for cerebral ischemia. A case-control study with 444 stroke patients, 194 hemorrhagic patients and 250 ischemic patients, and 164 hospital controls with nonvascular and noninflammatory neurological diseases, was performed. All subjects were evaluated by either a CT scan or MRI and their number of teeth was determined. The number of teeth in the patients with cerebral ischemia was found to be significantly fewer than for the cerebral hemorrhage group and a control group between 40 and 65 years of age. The degree of tooth loss was particularly remarkable in patients with atherothrombotic and cardioembolic brain infarction. As a result, tooth loss following severe periodontal disease may therefore be a risk factor for the onset of cerebral infarction in some patients.

[Intra-arterial administration of fasudil hydrochloride: duration of action].

Intra-arterial infusion (IA) of fasudil hydrochloride for cerebral vasospasm is performed in many institutions and is associated with few side effects. Nonetheless, as optimum dose and duration of action remain unknown, the present study aimed to clarify these variables. We performed intra-arterial injection of fasudil hydrochloride for eight patients with cerebral vasospasm 7-13 days after subarachnoid hemorrhage. Fasudil hydrochloride was administered via the internal carotid artery without selective microcatheterization, at a concentration and speed of 30 mg/20 ml/10-15 min, using a total dose of 30-60 mg. Cerebral angiography was used to measure change in blood vessel diameter at 19 points, and perfusion CT was used to detect changes in cerebral blood perfusion (CBP), cerebral blood volume (CBV), and mean transit time (MTT) at 12 hemispheres. Investigations were performed before IA, immediately after IA (post IA), and 4.5 to 6 hours later. For central vessels, (A1, M1) mean change in diameter (cm) measured pre IA, post IA, and 4.5-6 hours later was 1.2 +/- 0.68, 1.5 +/- 0.72, and 1.2 +/- 0.7, respectively. For peripheral vessels (peripheral to A1, M1, and the ophthalmic artery) change in diameter (cm) was 0.65 +/- 0.16, 0.97 +/- 0.24, and 0.71 +/- 0.24, respectively. Average CBP (m/100g/min) in the infused hemisphere at pre IA, post IA, and 4.5-6 hours later was 41.6 +/- 3.56, 46.4 +/- 5.82, 41.6 +/- 7.42, respectively. Average CBV (ml/100g) was 2.72 +/- 0.21, 2.73 +/- 0.21, 2.91 +/- 0.42, respectively and average MTT (sec) was 5.16 +/- 0.38, 4.57 +/- 0.70, 5.55 +/- 1.0, respectively. Changes in peripheral vessel diameter and in MTT were statistically significant. Therefore, when performing intra-arterial administration of fasudil hydrochloride, clinicians should be aware that vasodilator effect is less than 6 hours.

Multicentric involvement of non-Hodgkin's lymphoma in the central nervous system and testis--case report.

A 73-year-old male presented with diffuse mixed B cell lymphoma with involvement of the central nervous system (CNS) and testis manifesting as mild disorientation and aphasia. A left frontal cerebral mass and a right testicular tumor were found, and both lesions were surgically resected. Histological examination revealed diffuse mixed B cell type malignant lymphoma in the CNS and testis. The patient received irradiation to the head, and his initial symptoms improved. Pelvic computed tomography revealed enlargement of the contralateral testis and prostate. Needle biopsy confirmed lymphoma. The patient died 5 months after the initial diagnosis of septic shock. Autopsy examination revealed lymphoma cell invasion of the lung, bone marrow, prostate gland, and thalamus, but without involvement of the systemic lymph nodes. In a patient with an intracranial lymphoma, it is important to determine if the lesion is primary or metastatic and to plan medical treatment including systemic chemotherapy as soon as possible. Improvement of the prognosis of systemic non-Hodgkin's lymphoma with CNS involvement requires the detection and effective treatment of systemic lesions as well as the control of the CNS lesions.

Cerebral infarction in a 24-year-old pilot.

Ischemic stroke is a rare event in young adults. We report on a 24-yr-old pilot with cerebral infarction of undetermined etiology, temporally associated with chain smoking. The patient exhibited dysphasia, stupor (confused consciousness), and right facial-nerve palsy. Computed-tomography revealed a low-density area in the left insular cortex. Cerebroangiography showed severe stenosis in a branch of the left middle cerebral artery. After admission, the patient made a rapid and uneventful recovery within 72 h. MRI showed an area of hyperintensity on T2-weighted images 2 mo after the attack. Based on the hyperintense area on FLAIR (fluid attenuated inversion recovery sequence) images obtained in MRI performed 10 mo after the attack, we diagnosed a cerebral infarction. In the Japan Air Self-Defense Force, cerebral infarction is an aeromedically disqualifying condition. However, in the evaluation 2 mo after the attack, differentiation from reversible ischemic neurological deficit was difficult. We discuss the criteria used for diagnosis and the risk factors for cerebral infarction in young adults, as well as the aeromedical disposition of young pilots.

[Wallerian degeneration demonstrated by MRI and functional outcome in patients suffering from supratentorial cerebrovascular disease].

An early diagnosis of the outcome of patients with cerebrovascular disease is important for selecting the optimal treatment strategy. The purpose of this study was to estimate the prognosis of Wallerian degeneration on MRI in stroke patients with hemiparesis. The subjects consisted of 87 stroke patients, 50 hemorrhagic patients and 37 ischemic patients, who were evaluated by MRI at 1 to 6,275 days after stroke onset. Among the 36 patients who were evaluated by consecutive MRI, 161 films were obtained and analyzed. Wallerian degeneration was diagnosed when a small prolonged T 2 lesion was seen in the corticospinal tract of the brainstem on at least two contiguous slices. The atrophic rate of the midbrain was calculated as: (the area of the unaffected side of the midbrain--the area of the affected side of the midbrain)/2 x (the area of the unaffected side of the midbrain). The patients' ability to perform the activities of daily living was scored by the Barthel index (BI). Wallerian degeneration in the ipsilateral brainstem was seen for two to three months in 32 cases (37%) and in 58 films (36%) and disappeared about 3 years after the onset of stroke. Wallerian degeneration correlated with the BI scores from 2 to 6 months after stroke (p < 0.05), although no relationship was observed at 7 months or later. From 2 to 6 months after stroke, the shrinkage of the midbrain on MRI correlated with the BI scores (p < 0.001), although no relationship was observed at 7 months or later. It was therefore both Wallerian degeneration and a shrunken midbrain observed on MRIs, evaluated from 2 to 6 months after stroke were thus suggested to indicate a poor outcome in such patients.