Near-Infrared Spectroscopy Might Help Prevent Onset of Cerebral Hyperperfusion Syndrome.

Cerebral hyperperfusion syndrome (CHS) is a rare but fatal perioperative complication after surgical correction of carotid stenosis. Despite numerous treatment options for preventing CHS, it does occur in some patients. We developed the outlet gate technique (OGT), in which the embolic balloon was deflated gradually in accordance with the ratio of oxygen saturation measured by a brain oximeter of the ipsilateral brain region to that in the contralateral region. Between June 2017 and May 2018, 39 patients with carotid stenosis underwent endovascular carotid revascularization procedures; of these, 20 underwent the procedure with the OGT. CBO was measured five times in those 20 patients: before the procedure, with the embolic protection device (EPD) on, with the EPD off, during the procedure, and after the procedure. Preventive treatment options were used more frequently in these patients, and although their surgical status seemed more complicated, perioperative complications were not increased. There were almost significant differences between CBO values except between those during and after the procedure with the OGT. This showed that the OGT allowed for stabilization of the CBO and thus has the potential to prevent CHS.

A Child with Paradoxical Cerebral Embolism in Whom Mechanical Thrombectomy Led to a Favorable Outcome.

Objective: We report a case of paradoxical cerebral embolism caused by patent foramen ovale (PFO) that was treated by the direct aspiration first pass technique (ADAPT). Case Presentation: The case involved a 12-year-old boy who had symptoms of dizziness and vomiting the day prior to being admitted to the emergency department. The following morning, consciousness disorder, dysarthria, and right paresis were observed, and he was transferred to our hospital. Computed tomography (CT) and magnetic resonance imaging (MRI) lead to the diagnosis of acute cerebral infarction due to basilar artery (BA) occlusion. Mechanical thrombectomy was performed, and Thrombolysis in Cerebral Infarction (TICI) 3 was obtained. Postoperatively, his consciousness was improved, but echocardiography revealed PFO. Percutaneous PFO closure was performed at our department of pediatric cardiology. Conclusion: For our patient with paradoxical cerebral embolism of the BA caused by PFO more than 6 hours after onset, mechanical thrombectomy with ADAPT using a Penumbra 5MAX ACE68 resulted in a good outcome.

Midterm Follow-Up of Patients with Middle Meningeal Artery Embolization in Intractable Chronic Subdural Hematoma.

OBJECTIVE: A subset of patients with chronic subdural hematoma (CSDH) remains refractory to standard treatment with hematoma drainage by burr-hole craniotomy and irrigation. We recently reported the usefulness of middle meningeal artery (MMA) embolization for intractable CSDH in patients with multiple intractable risk factors. We present the midterm outcomes of MMA embolization in patients with intractable CSDHs. METHODS AND RESULTS: Seventeen consecutive patients (average age, 76.4 years; 12 men [71%]) underwent MMA embolization of CSDH from January 2014 to July 2017. Earlier interventions included embolization using N-butyl-2-cyanoacrylate (although trisacryl gelatin microspheres were used in recent cases), followed by burr-hole craniotomy and irrigation in all cases. None of the patients experienced perioperative complications or postoperative recurrence. The modified Rankin Scale scores, which were unfavorable at admission, improved significantly at discharge but were comparable to those at the time of hospitalization when measured during the follow-up period. Although the patients required rehospitalization at other departments for unrelated causes, none required rehospitalization in our department. CONCLUSIONS: Despite the known unfavorable outcomes of patients with intractable CSDHs, MMA embolization was not associated with recurrent CSDH or rehospitalization in our department in the current case series. MMA embolization should be considered a preferred therapeutic option for intractable CSDHs.

Comprehensive Evaluation of Diagnostic and Treatment Strategies for Idiopathic Spinal Subarachnoid Hemorrhage.

BACKGROUND: Idiopathic spinal subarachnoid hemorrhage (IS-SAH), defined as spinal SAH without apparent cause, is extremely rare. The objective of the present study was to establish a consensus on the diagnosis and management of IS-SAH. METHODS: We enrolled 5 consecutive cases of IS-SAH at our institution, and we enrolled 19 previously published cases as a literature review. The patient presentations, diagnostic test findings, treatment strategies, and outcomes were retrospectively assessed. Possible causes of spinal SAH were basically excluded by multimodalities, including brain and spinal digital subtraction angiographies. RESULTS: IS-SAH usually developed in middle-aged people around 55 years old and typically presented with acute migrating back pain. Lumbar puncture and spinal magnetic resonance imaging demonstrated xanthochromia or an abnormal intensity area around the spine in all study patients who underwent these diagnostic tests. All of the patients from our institution were discharged with 1 patient (20%) complaining of neurologic dysfunction at discharge, and 1 patient (5.3%) in the published cases died during hospitalization and 5 (26.3%) complained of neurologic dysfunction at discharge. In addition, the surgical findings in 1 case from our institution suggested that one of the mechanisms of IS-SAH is a bleeding from a microvessel around the spine, and we newly propose spinal drainage as one of the treatment options in patients with IS-SAH based on our experience. CONCLUSIONS: We summarized our experience of 5 cases of IS-SAH with a literature review. We demonstrated that spinal drainage could be one of the treatment options in patients with IS-SAH.

Endovascular Treatment for Aneurysmal Subarachnoid Hemorrhage with Neurogenic Pulmonary Edema in the Acute Stage.

AIM: Severe neurogenic pulmonary edema (NPE) can occur in a variety of brain insults, including subarachnoid hemorrhage (SAH), and severe case of NPE can cause devastating consequences. But the literature on the treatment strategy about aneurysmal SAH with NPE is very scant. We present that SAH patients with severe NPE, who were treated first by embolization of aneurysm followed by insertion of lumbar spinal drainage, had comparatively good outcome. MATERIAL AND METHODS: We present 12 consecutive cases of aneurysmal SAH with NPE in the acute stage, which were treated by endovascular treatment between April 2002 and December 2012. We classified the patients according to the Hunt and Hess grading system as follows: grade-3 (1 patient), grade-4 (4 patients), and grade-5 (7 patients). All patients needed respiratory management, with the assistance of a ventilator, and underwent endovascular treatment for the ruptured aneurysms within 72 hours from onset. For all the patients, immediately after the endovascular treatment, we performed lumbar spinal drainage. RESULTS: The pulmonary edema disappeared rapidly after respiratory management and endovascular treatment. The outcomes were as follows: good recovery (GR; 3 patients), moderate disability (MD; 4 patients), severe disability (SD; 3 patients), and death (D; 2 patients). Five patients (42%) developed pneumonia, and we postponed extubation until recovery from pneumonia. The cause for severe disability and death was symptomatic vasospasm and primary brain damage. No patients had rebleeding from ruptured aneurysms. CONCLUSION: Endovascular treatment for ruptured aneurysm and placement of lumbar spinal drainage is an excellent treatment option for severe SAH with NPE.

[Responding to Arterial Perforation during Endovascular Neurosurgery].

During endovascular neurosurgery, various devices, such as catheters, are passed through the intracranial arteries to access target vessels; the arteries can thereby be perforated. Even though such incidents are serious and should be dealt with appropriately, few case reports or standard procedures have been published. Herein, we report two cases of arterial perforation that occurred recently in our hospital. In the first case, the patient had been treated preoperatively using feeder occlusion of an arteriovenous malformation; the microcatheter perforated the feeder, which branched from the middle cerebral artery. The feeder and perforation site were occluded by injection of n-butyl 2-cyanoacrylate (NBCA) through the same microcatheter, and complete hemostasis was thereby achieved. The second case occurred during an embolization of the middle meningeal artery (MMA) to treat a refractory chronic subdural hematoma;the microcatheter perforated a branch of the MMA. Both the perforation and the artery were embolized using platinum coils and by injecting NBCA, and hemostasis was achieved. Considering the anatomical and pathological properties of the injured vessels, favorable results were achieved with appropriate intervention.

Primary pontine hemorrhage in the acute stage: clinical features and a proposed new simple scoring system.

BACKGROUND: It is important to evaluate the likelihood of fatality in patients with acute primary pontine hemorrhage (PPH) in emergency departments. We aimed to evaluate the clinical symptoms and computed tomography findings of PPH to develop a simple grading scale for predicting the mortality of PPH. METHODS: Records of 101 consecutive patients admitted to our hospital with acute PPH between June 1, 2006, and January 31, 2014, were retrospectively reviewed. Independent predictors of 30-day mortality were identified by univariate and multivariate logistic regression analyses. A simple and easy clinical score (PPH score) was developed from independent factors to predict mortality in acute PPH. The PPH score was compared with the established intracerebral hemorrhage (ICH) score, which served as the reference scoring system. RESULTS: Overall mortality rate 30 days after onset was 58.4% (59 of 101). Factors independently associated with 30-day mortality were Glasgow Coma Scale (GCS) score of 6 or less (P = .0051), absence of pupillary light reflex (P = .0003), and blood glucose of 180 mg/dL or greater (P = .0312). The PPH score was the sum of independent factors, which were assigned 1 point each. The area under the receiver operating characteristic curve for predicting 30-day mortality was .90 (95% confidence interval [CI], .84-.95) for PPH score and .86 (95% CI, .78-.93) for ICH score. CONCLUSIONS: GCS score of 6 or less, absence of pupillary light reflex, and plasma glucose of 10 mmol/L or greater are independent mortality predictors of PPH. The PPH score is a simple and reliable clinical grading scale for predicting 30-day mortality.

[Ischemic complications of anterior choroidal artery aneurysm treatment].

Ischemic stroke of the anterior choroidal artery(AChA)is the most common and serious complication after AChA aneurysm treatment. The purpose of this study was to retrospectively evaluate and compare the treatment-related ischemic complications after surgical clipping and endovascular coiling of AChA aneurysms.
Between June 2006 and March 2013, 32 patients with 34 AChA aneurysms were treated in our hospital by surgical clipping or endovascular coiling. There were 12 cases of ruptured aneurysms, seven cases of unruptured aneurysms, and 15 cases of incidentally identified unruptured aneurysms. Of the 34 aneurysms, 19 were managed with surgical clipping and 15 were managed with endovascular coiling. No rebleeding or retreatment occurred in any case during 4-84 months(median, 25 months)of follow-up, and no significant differences in clinical outcome were seen between clipping and coiling cases. Although there were four cases(11.8%;surgical clipping in three;endovascular coiling in one)of postoperative AChA infarction, we believe that we preserved the blood flow of the AChA during the procedure. The occurrence of subarachnoid hemorrhage and premature rupture during surgical clipping were significantly correlated with AChA infarction.

[Embolization of the feeding artery of a meningioma with dangerous vascular anastomosis between the middle meningeal artery and the ophthalmic artery].

Preoperative embolization of intracranial meningioma has been applied to reduce intraoperative blood loss and to facilitate microsurgical removal of a tumor. It is well known that one of the reasons of the neurological risk of embolization is due to dangerous anastomosis between the extracranial and the intracranial arteries. One of the most known and dangerous case of anastomosis is between the middle meningeal artery to the ophthalmic artery. A 48-year-old woman underwent preoperative embolization of a large right middle cranial fossa meningioma. The right external carotid angiogram showed that the tumor was fed by the right middle meningeal artery and there was no branch to the right orbital region. The right internal carotid angiogram showed that the right ophthalmic artery originated from the right internal carotid artery and there was no branch to the tumor. The selective angiogram of the anterior branch of the middle meningeal artery disclosed the anastomosis to the right ophthalmic artery. Following embolization of the anterior branch of the middle meningeal artery, the patient underwent embolization of the main feeding branch of the meningioma. She successfully underwent surgical removal of the tumor without any blood transfusion and was discharged without neurological deficit. In addition, to avoid complication in embolization of the feeding artery of a skull base meningioma, clinicians must be aware of the dangerous anastomosis between the middle meningeal artery and the ophthalmic artery, even if conventional external and internal carotid angiograms do not show any anastomosis.

[Pyoktanin blue injection for resection of cystic brain tumor: a case report].

Pyoktanin blue is an agent that is often used during STA-MCA anastomosis. In this report, we inject it into a cystic tumor for complete resection, and we report its usefulness. The patient was a 57-year-old female. She suffered from progressive cerebellar ataxia. CT and MR showed a cystic metastatic tumor at the right cerebellar hemisphere, 40mm in diameter. Craniotomy was performed, 5cm in diameter, using the right suboccipital approach. After peeling off the tumor from the surface layer of the brain, we injected diluted pyoktanin blue into the tumor to dye the inside wall. After that, the tumor was peeled off completely without exposing the dyed inside wall. We sometimes find it difficult to distinguish tumor from brain if there is tearing of the tumor wall. Tearing of the tumor can be prevented by injecting pyoktanin blue into it, and making the inside wall visible. Using this procedure, we think a tumor can be resected without residual tumor or damage to the brain. Although we have used this method only a few times, we think it is an easy and useful technique to inject pyoktanin blue into a cystic tumor during its resection.

[Harvest of the superficial temporal artery using the Lone Star Retractor System TM: technical note].

Extracranial-intracranial(EC-IC)bypass is an important method of treating ischemic stroke and intracranial disease requiring sacrifice of the parent artery. The most commonly used donor artery for EC-IC bypass surgery is the superficial temporal artery(STA). But there are few reports of details of harvest methods of the STA. We describe our harvest methods of the STA using the Lone Star Retractor SystemTM. After draping, the Lone Star Retractor SystemTM is placed on the head. Skin incision is on the parietal branch of the STA. Under the surgical microscope, the dermis is cut by a scalpel from the distal side of the STA. The incised wound was tensioned by the blunt hooks(elastic stay)of the Lone Star Retractor SystemTM. Connective tissue around the STA was dissected and cut by a high voltage bipolar coagulator from the distal to the proximal side of the STA. The advantage of using of The Lone Star Retractor SystemTM for the STA harvest is that, using a surgical microscope, it is easy to set the elastic stay on the wound.

Heterogeneous cationic liposomes modified with 3ß-{N-[(N',N'-dimethylamino)ethyl]carbamoyl}cholesterol can induce partial conformational changes in messenger RNA and regulate translation in an Escherichia coli cell-free translation system.

The effect of cationic liposomes (CLs) on messenger RNA(mRNA) conformation and translation was studied, focusing on membrane heterogeneity. CLs, composed of 1,2-dioleoyl-sn-glycerol-3-phosphocholine/1,2-dioleoyl-3-timethylammonium propane (DOPC/DOTAP) and DOPC/3ß-{N-[(N',N'-dimethylamino)ethyl]carbamoyl}cholesterol (DOPC/DC-Ch), inhibited mRNA translation in an Escherichia coli cell-free translation system. Analysis of the membrane fluidity and polarity indicated a heterogeneous DOPC/DC-Ch (70/30) membrane, while other CLs exhibited homogeneous disordered membranes. mRNA adsorbed onto DOPC/DC-Ch liposomes showed translational activity, while DOPC/DOTAP liposomes inhibited mRNA translation in proportion to its adsorption onto membranes. Dehydration of DOPC/DOTAP (70/30) and DOPC/DC-Ch (70/30) was observed in the presence of mRNA but not in the case of zwitterionic DOPC liposomes, indicating that mRNA binds in regions between the phosphate [-PO(2)(-)-] and carbonyl [-C=O-] moieties of lipids. UV resonance Raman spectroscopy suggests that adenine, cytosine, and guanine interact with DOPC/DOTAP (70/30) and DOPC/DC-Ch (70/30) but not with DOPC. Circular dichroism indicates that DOPC/DOTAP (70/30) extensively denatured the mRNA. In contrast, heterogeneous DOPC/DC-Ch (70/30) induced partial conformational changes but maintained the translational activity of mRNA.

[ASPECTS-DWI, arterial occlusion sites and subtype of acute ischemic stroke have a relation with outcome following intravenous rt-PA therapy].

PURPOSE: We evaluated the usefulness of rating diffusion weighted images (DWI) using semiquantitative scores modified from the Alberta Stroke Programme Early CT Score (ASPECTS) to predict deterioration of neurological symptoms in patients with hyperacute ischemic stroke who had undergone thrombolytic therapy with recombinant tissue plasminogen activator (rt-PA). SUBJECTS AND METHODS: We examined 84 patients with acute ischemic stroke treated with intravenous rt-PA. Ischemic changes and vascular lesions were identified using DWI, and magnetic resonance angiography. Early ischemic signs were assessed using ASPECTS-DWI (11 points). Independent outcome was defined by NIHSS at 24 hours after intravenous rt-PA therapy. RESULTS: A total of 58 patients were studied, and NIHSS 27 (46.6%) of them had improved by 4 points in 24 hours. CONCLUSION: Cases of 0≦AD≦3, cardioembolic type cases with internal carotid artery occlusion in the group of 4≦AD≦7 and branch atheromatous disease in the group of 8≦AD were poor outcome at NIHSS 24 hours after intravenous rt-PA therapy for acute ischemic stroke patients.

[Transarterial embolization for cranial vault dural arteriovenous fistula: a case report].

A 70-year-old man presented with a rare case of a dural arteriovenous fistula (dAVF) at the cranial vault manifesting as headache. Cerebral angiography disclosed that multiple feeding arteries were immediately draining into the right parietal cortical vein without communication to the superior sagittal sinus, and this dAVF was classified as Borden type III and Cognard type IV. Transarterial embolization was performed using particles of polyvinyl alcohol and glue of n-butyl 2-cyanoacrylate. After embolization, the dAVF had completely disappeared and the patient was discharged without any symptom. Angiogram one year after embolization showed no recanalization of dAVF. Transarterial glue embolization is a safe and effective treatment of dAVF with cortical venous reflux.

[A case of cavernous sinus dural arteriovenous fistula presenting with intracranial hemorrhage].

Intracranial cavernous sinus dural arteriovenous fistula (CS-dAVF) rarely causes intracranial hemorrhage. We report a case of CS-dAVF presenting with intracranial hemorrhage. A 62-year-old man presented tonic clonic convulsion with consciousness disturbance and was transferred to our hospital. CT scan revealed subarachnoid hemorrhage and right frontal subcortical hemorrhage. Angiography revealed right CS-dAVF which drained only into the vein of the right sylvian fissure. Transvenous embolization was performed using detachable coils. After embolization, CS-dAVF had completely disappeared and the patient was discharged without any symptom. We summarized the fourteen reported cases, including ours, of CS-dAVF with intracranial hemorrhage. All of them had retrograde drainage through cerebral veins.

Conformational change of single-stranded RNAs induced by liposome binding.

The interaction between single-stranded RNAs and liposomes was studied using UV, Fourier Transform Infrared spectroscopy (FTIR) and Circular Dichroism spectroscopy (CD). The effect of the surface characteristics of liposomes, which were composed of 1-palmitoyl-2-oleoyl-sn-glycero-3-phosphocholine (POPC) and modified with cholesterol (Ch) or 1,2-dioleoyl-3-trimethylammonium propane (DOTAP), on the liposome-RNA interaction was investigated. The fluorescence of 6-(p-toluidino)naphthalene-2-sulfonate (TNS) embedded in the liposome surface (ε = 30-40) was decreased in the presence of tRNA, suggesting that single-stranded tRNA could bind onto the liposome. The dehydration of -PO2⁻-, guanine (G) and cytosine (C) of tRNA molecules in the presence of liposomes suggested both an electrostatic interaction (phosphate backbone of tRNA and trimethylammonium group of POPC, DOTAP) and a hydrophobic interaction (guanine or cytosine of tRNA and aliphatic tail of lipid). The tRNA conformation on the liposome was determined by CD spectroscopy. POPC/Ch (70/30) maintained tRNA conformation without any denaturation, while POPC/DOTAP(70/30) drastically denatured it. The mRNA translation was evaluated in an Escherichia coli cell-free translation system. POPC/Ch(70/30) enhanced expression of green fluorescent protein (GFP) (116%) while POPC/DOTAP(70/30) inhibited (37%), suggesting that the conformation of RNAs was closely related to the translation efficiency. Therefore, single-stranded RNAs could bind to liposomal membranes through electrostatic and hydrophobic attraction, after which conformational changes were induced depending on the liposome characteristics.

Unusual cisternal coil migration in the follow-up period after aneurysm perforation during endovascular coiling.

A 61-year-old woman suffered cisternal coil migration in the follow-up period after endovascular coil embolization for a ruptured cerebral aneurysm. She presented with sudden onset of headache. Computed tomography demonstrated diffuse subarachnoid hemorrhage, and cerebral angiography disclosed a left anterior choroidal artery aneurysm. The aneurysm was treated by endovascular embolization with Guglielmi detachable coils. During the embolization procedure, the microcatheter perforated the aneurysm. For direct closure of the perforation site with coils, the microcatheter was withdrawn and coils were deployed partially in the subarachnoid space and partially in the aneurysm sac. The coil mass was spread in the subarachnoid space around the aneurysm immediately after embolization. The patient was discharged with no neurological deficit. Three months later, follow-up radiography demonstrated obvious reduction in the size and compaction of the coil mass. Magnetic resonance angiography and digital subtraction angiography demonstrated stable occlusion of the aneurysm. The coil mass probably spread in the cistern around the aneurysm and was compacted by the shape memory of the coils and pulsation of the brain and vessels, as the subarachnoid clots around the aneurysm had disappeared. This case suggests that cisternal coil migration should be considered in the follow up of intracranial aneurysm treated with detachable coils.

Oxidative stress can affect the gene silencing effect of DOTAP liposome in an in vitro translation system.

Oxidative stress can affect in vitro GFP expression through its control of the gene silencing effect of the liposome prepared by 1,2-dioleoyl-3-trimethyl-ammonium propane (DOTAP). The gene silencing effect of cationic DOTAP liposome in in vitro GFP expression, especially focusing on its translation process, and the effects of oxidative stress on its silencing effect were investigated. GFP expression, initiated by mRNA, was found to be thoroughly inhibited in the presence of DOTAP liposome at concentration of more than 2.5 mM, though its inhibitory effect was reduced in the presence of hydrogen peroxide. The analyses of (i) the interaction of mRNA with DOTAP, (ii) the chemical structure of DOTAP, and (iii) the membrane fluidity of DOTAP liposome imply the possible role of gene expression by the liposome membrane and stress conditions.

[Transient homonymous hemianopsia due to thrombosis of the confluence of sinuses after occipital transtentorial removal of pineal region tumor].

The authors report a case of 74-year-old woman suffering thrombosis of the confluence of sinuses after the left occipital transtentorial removal of a pineal region epidermoid cyst. Four days after the operation, the patient developed left homonymous hemianopsia. Magnetic resonance imaging revealed a venous infarct in the right occipital lobe and magnetic resonance venography disclosed a signal defect of the posterior part of the confluence of sinuses. The patients' neurological symptom recovered soon after anticoagulation treatment, and magnetic resonance venography after the sixth week showed recanalization of the confluence of sinuses. Although it might be rare, thrombosis of the dural sinus should be recognized as a complication of craniotomy.

Liposomes destabilize tRNA during heat stress.

Biomembranes play an important role in cellular response to heat stress. In this study, we focus on the interaction between liposomes and tRNA. Upon heat treatment we determined circular dichroism spectra of tRNA in presence of liposomes prepared from POPC (1-palmitoyl-2-oleoyl-sn-glycero-3-phosphocholine) and cholesterol (Ch). To compare thermal stability, midpoint temperature (T(m)) of tRNA was calculated from normalized theta(208). Addition of POPC/Ch liposomes decreased the T(m) value of tRNA from 48 degrees C to 38 degrees C. We conclude that POPC/Ch liposomes interact with tRNA and destabilize its conformation under heat stress.