Frequency and risk factors for sepsis resulting from neuroendovascular treatment.

OBJECTIVE: Endovascular treatments are minimally invasive and rarely cause complicating infections. Although cases complicated by device infections have been reported, we could not find any studies evaluating infections following neuroendovascular treatment in particular. Therefore, we assessed the frequency of sepsis and other associated risk factors. METHODS: From September 2006 to May 2008, we investigated 256 prospective neuroendovascular treatment cases at our facility. We examined the frequency of sepsis and other associated risk factors as well as organisms and the early detection tests such as various cultures and serodiagnoses. RESULTS: The rate of sepsis due to complications was 8.6% in the aggregate and 5.7% in 193 procedures without a central venous catheter and hemodialysis. All sepsis cases were successfully treated with antibiotics. However, in 2 cases, the patients developed methicillin-resistant STAPHYLOCOCCUS AUREUS infections, which were intractable. The highest risk factors for sepsis were a large sheath size [>7 F; OR =5.03; P =0.01; 95% confidence interval (CI) 1.29-19.47] and meningioma embolization (OR =13.25; P =0.04; 95% CI 1.07-163.56). The degree to which experienced staff (OR =0.09; P =0.05; 95% CI 0.09-0.97) affected the incidence of sepsis was less significant. Microorganisms were isolated from half the operating field, and the risk factor, in this case, depended on inexperienced surgical staff (OR =1.98; P =0.03; 95% CI 1.07-3.67). Although we were unable to find a means to predict sepsis, we presumed antibiotic prophylaxis would be useful. CONCLUSIONS: The frequency of sepsis following neuroendovascular treatment is high. We should pay particular attention to the sterilization process and the operating field when undertaking neuroendovascular treatment that requires the use of a large-size sheath in patients with serious conditions.

Dural arteriovenous fistula presenting as an acute subdural hemorrhage that subsequently progressed to a chronic subdural hemorrhage: case report.

OBJECTIVE AND IMPORTANCE: Non-traumatic subdural hemorrhage (SDH) caused by dural arteriovenous fistula (DAVF) is rare and is usually accompanied by intracerebral hemorrhage (ICH) and/or subarachnoid hemorrhage (SAH). This report describes a very rare case of DAVF that caused non-traumatic acute SDH without ICH or SAH, which subsequently progressed into chronic SDH. CASE REPORT: The patient presented with a sudden-onset severe headache, and was diagnosed with acute SDH by computed tomography. Cerebral angiography showed a DAVF on the left convexity adjacent to the superior sagittal sinus (SSS). This DAVF drained to the SSS and to the pterygoid venous plexus via the left middle fossa without retrograde flow (Type I according to the Cognard classification). The SDH was thickest at the lower convexity, which suggested that the draining vein of the DAVF was responsible for the bleeding. INTERVENTION: The SDH slowly progressed for two weeks. The DAVF was successfully treated with transarterial embolization using N-butyl 2-cyanoacrylate. The SDH was resolved via burr-hole drainage surgery. CONCLUSION: This is the first reported case of DAVF that caused non-traumatic progression to SDH. As DAVF can be the cause of acute and chronic SDH, cerebral angiography is recommended for non-traumatic acute SDH as well as for intractable chronic SDH.

Two cases of a dural arteriovenous fistula mimicking a brain tumor.

SUMMARY: Dural arteriovenous fistula (d-AVF) is relatively rare. Some cases of atypical locations are often difficult to distinguish from other vascular disorders or tumors because those d-AVFs show various onsets, such as subcortical bleeding and venous infarctions. We encountered two cases of d-AVF with severe brain edema that took adequate time to distinguish from brain tumors. A 68-year-old man visited his local physician complaining of dizziness. He was diagnosed with a cerebral infarction due to the presence of an abnormal cerebellar signal on magnetic resonance imaging (MRI) and was treated by drip infusion. However, he did not recover and was admitted to our hospital with suspicion of a brain tumor. A 75-year-old woman with an onset of progressive dementia and gait disturbance showed severe edema of the right-front temporal lobe on MRI. Both these cases were examined by single photon emission computed tomography or positron emission tomography and were scheduled for craniotomy and biopsy based on the diagnosis of brain tumor. We performed preoperative angiography and found d-AVFs. We embolized the d-AVFs with liquid material and both patients recovered well. Brain edema from d-AVF or a tumor can be distinguished by carefully reading the MRI with findings such as the distribution of the edemas, differences on diffusion-weighted images, and contrast-enhanced images. Therefore, it is important to provide initial accurate diagnoses to prevent patient mistrust and irreversible disease conditions.

A successful treatment with carotid arterial stenting for symptomatic internal carotid artery severe stenosis with ipsilateral persistent primitive hypoglossal artery: case report and review of the literature.

A 68-year-old male presented with a syncopal attack subsequent to acute myocardial infarction. His ultrasonographic and radiological examination revealed severe left internal carotid artery (ICA) stenosis and the presence of a persistent primitive hypoglossal artery (PPHA) immediately distal to the stenosis. The bilateral anterior and left middle cerebral arteries, and the vertebrobasilar system were opacified via the stenotic ICA. Carotid arterial stenting was selected as the treatment method because the lesion was high and a shunt placement during carotid endarterectomy was considered to be technically difficult. A self-expanding stent was successfully deployed with flow control, and the patient was discharged six days after surgery without any neurological deficit. There are sixteen reported cases including ours of PPHA associated with ICA stenosis presenting with ischemic attacks of the vertebrobasilar system. To the best of our knowledge, the current case is the first report of a cervical ICA stenosis with ipsilateral carotid-basilar anastomosis treated with carotid arterial stenting.

Experience in endovascular treatment of recurrent chronic subdural hematoma.

SUMMARY: Most cases with chronic subdural hematoma (CSDH) are treated by simple irrigation and drainage, then more than eighty percent of them result in good recovery. But we sometimes encounter intractable cases with hematoma re-collection, which is considered of repeated bleeding from macrocapillary in the hematoma capsule. Embolization of the middle meningeal artery (MMA) is considered to be useful to eliminate the blood supply to this structure. The authors experienced seven cases of intractable CSDH treated by MMA embolization and no recurrence took place in all cases for up to 15 months. Endovascular treatment may be a good alternative modality for recurrent CSDH.

Usefulness of intraoperative magnetic resonance imaging for glioma surgery.

BACKGROUND: Radical resection of gliomas can increase patient's survival. There is known concern, however, that aggressive tumour removal can result in neurological morbidity. The objective of the present study was to evaluate the usefulness of low magnetic field strength (0.3 Tesla) open intraoperative magnetic resonance imaging (iMRI) for complete resection of glioma with emphasis on functional outcome. METHODS: From 2000 to 2004, 96 patients with intracranial gliomas underwent tumour resection with the use of iMRI in Tokyo Women's Medical University. There were 50 men and 46 women; mean age was 39 years. Tumour volume varied from 1.2 ml to 198 ml (median: 36.5 mL). Resection rate and postoperative neurological status were compared between control group (46 cases, operated on during the initial period after installation of iMRI), and study group (50 most recent cases, in whom surgery was done using established treatment algorithm and improved image quality). FINDINGS: Overall, mean resection rate was 93%, and medial residual tumour volume was 0.17 ml. Total tumour removal was achieved in 44 cases (46%). Compared to control group, resection rate in the study group was significantly higher (91%, vs. 95%; P < 0.05), whereas residual tumour volume was significantly smaller (1.7 mL vs. 0.025 mL; P < 0.001). Nine patients in the control group (20%) and 24 in the study group (48%) experienced temporary postoperative neurological deterioration (P < 0.01), however, the rate of permanent morbidity evaluated 3 months after surgery did not differ significantly between the groups investigated (13% vs. 14%). CONCLUSIONS: Use of iMRI during surgery for intracranial gliomas permits to attain aggressive tumour resection with good functional outcome. Nevertheless, surgical experience with the iMRI system, establishment of treatment algorithm, and improvement of image quality are of paramount importance for optimal results.

Minimally invasive management of the third ventricle glioma in a patient without hydrocephalus: neurofiberscopic biopsy followed by gamma knife radiosurgery.

There is usually concern that ventricular enlargement is necessary for safe neuroendoscopic procedures. However, newly developed models of neurofiberscopes with a small outer diameter can be effectively used even in patients without ventriculomegaly. We present the case of a successful neurofiberscopic biopsy of a third ventricle anaplastic astrocytoma in a previously shunted patient without hydrocephalus. Subsequent gamma knife radiosurgery led to complete disappearance of the tumor. It seems that presence of collapsed ventricles, and even symptoms consistent with the slit ventricle syndrome, should not be considered as contraindications for neurofiberscopic surgery when brain compliance is sufficiently preserved. The latter should be considered as the key point of safe endoscopic manipulations. The combination of the neuroendoscopy and stereotactic radiosurgery provides wide possibilities for minimally invasive management of selected intracranial tumors.

Infantile gliosarcoma: a case and a review of the literature.

INTRODUCTION: Gliosarcoma in infant is a very rare entity. CASE REPORT: The authors present a case of gliosarcoma in a 23-month-old boy. The patient was admitted to our hospital with persistent headache and frequent vomiting. MR imaging demonstrated a large frontal well-circumscribed lesion with a heterogeneous gadolinium enhancement. Although macroscopically the tumor was totally extirpated, the boy died of rapid tumor regrowth 2 months after surgery. The surgical specimens obtained from the tumor showed an admixture of two distinctive neoplastic tissues. One was a malignant mesenchymal feature. Its fibrosarcomatous nature was characterized by spindle-shaped cells with fine fibers that were deeply stained in silver preparations for reticulin. The other was gliomatous tissue forming islands surrounded by the sarcomatous tissues. Its glioblastomatous nature was obvious, as it was characterized by endothelial proliferation and perinecrotic pseudopalisading. Both tissues were histologically malignant, as evidenced by mitotic figure, high cellularity, atypical features, and variability. DISCUSSION: The literature concerning gliosarcomatous tumors is reviewed, and pathological and clinical features of the tumor are briefly discussed.

Reduction in serotonin synthesis following acute and chronic treatments with paroxetine, a selective serotonin reuptake inhibitor, in rat brain: an autoradiographic study with alpha-[14C]methyl-L-tryptophan(2).

Serotonin (5-HT) synthesis rates were calculated on the basis of the assumption that trapping of alpha-[14C]methyl-L-tryptophan (alpha-[14C]MTrp) is directly related to brain 5-HT synthesis. In the first series of experiments, an acute intraperitoneal injection of paroxetine (10 mg/kg) produced a significant reduction in 5-HT synthesis in brain structures containing serotonergic cell bodies (the dorsal, median, and pallidum raphe nuclei), as well as in most projection areas: the ventral tegmental area, median forebrain bundle, hippocampus CA3 region, and nigrostriatal structures (substantia nigra, lateral and medial caudate nuclei). The reductions in the projection areas were greater (between 25 and 53%) than in those areas containing serotonergic cell bodies (between 18 and 23%). In the cerebral cortex, 5-HT synthesis rates were not modified by acute paroxetine treatment. In a second series of experiments, rats were treated with paroxetine (10 mg/kg/day, s.c., delivered by osmotic minipumps) for 14 days. There was a marked decrease (39-69%) in 5-HT synthesis in every structure examined. In conclusion, the present data suggest that the effects of paroxetine on 5-HT synthesis in the cerebral cortex are different from its effects in the cell body area of the brainstem.

Effects of selective 5-HT1A receptor antagonists on regional serotonin synthesis in the rat brain: an autoradiographic study with alpha-[14C]methyl-L-tryptophan.

The effects of acute and chronic administration of WAY100635 and WAY100135, serotonin (5-HT)1A antagonists, on 5-HT synthesis rates, calculated from the trapping of alpha-[14C]methyl-L-tryptophan (alpha-MTrp), were evaluated in the rat brain using autoradiography. In the acute treatment studies, WAY100635 (1 mg/kg) induced a significant increase in 5-HT synthesis in the median raphe nucleus and some nerve terminal structures (range between 18 and 53%), while WAY100135 (10 mg/kg) produced a significant decrease of synthesis, in the range between 16 and 33%, in the raphe magnus nucleus and several projection areas. The action of WAY100635 given acutely was likely a result of antagonist actions at the 5-HT1A somato-dendritic autoreceptors. WAY100135 probably acted acutely as a partial agonist. In the chronic treatment studies, WAY100635 (1 mg/kg/day) and WAY100135 (10 mg/kg/day) were administered for 7 days as s.c. injections once a day. Chronic treatment with both compounds significantly reduced the rate of 5-HT synthesis in the nerve terminal structures and produced a significant increase in the raphe nuclei. These treatments did not have any effect on the plasma free or total tryptophan.

Comparison of source localization of interictal epileptic spike potentials in patients estimated by the dipole tracing method with the focus directly recorded by the depth electrodes.

The purpose of the study was to investigate the accuracy of location of equivalent current dipoles estimated by the dipole tracing method (DT) utilizing a realistic 3-shell (scalp-skull-brain) head model (SSB-DT). Three patients with intractable complex partial seizures, diagnosed as having typical temporal seizures were investigated. We recorded the interictal spike potentials with surface electrodes (International 10/20 system) and with intracerebral depth electrodes simultaneously. We compared the location of dipoles of the spikes estimated by the SSB-DT with the focus of the spikes determined by the recording from the depth electrodes. We found that the location of the dipoles estimated by SSB-DT corresponded to the location of the depth electrodes, which could record the epileptic spikes. This finding proved that SSB-DT is reliable and valid for estimating neural activity in deep locations such as the limbic system.

Microanatomy of medial temporal area and subtemporal amygdalohippocampectomy.

For seizure control in temporal lobe epilepsy, the head of the hippocampus to the choroidal point, parahippocampal gyrus, entorhinal area, uncus, and at least the basolateral nucleus of the amygdala should be completely removed. The subtemporal approach should be selected for removal of these structures, and it does not interrupt the temporal stem and optic radiation. Pre- and postoperative neuropsychological examinations revealed that there is no significant decline of scores of various examinations including WAIS, WMS, Randt memory, and verbal associates learning tests, even if the resection were performed on the language dominant side. Seizure control for the 20 non-lesional patients operated with this approach is 60% (Class I and II), without definite permanent complications.

Acute and chronic D-fenfluramine treatments have different effects on serotonin synthesis rates in the rat brain: an autoradiographic study.

The effects of acute and chronic treatments with D-fenfluramine on the regional rates of serotonin (5-hydroxy-tryptamine; 5-HT) synthesis were investigated using the alpha-[14C]methyl-L-tryptophan (alpha-[14C]MTrp) autoradiographic method. In the first series of experiments, acute D-fenfluramine treatment (5 mg/kg; i.p.) given 20 min before the tracer injection significantly (p<0.05) decreased 5-HT synthesis in the dorsal raphe, and significantly (p<0.05) increased the rates in the cerebral cortices and caudate nucleus, when compared to the rates in the control rats (saline treated). In a second series of experiments, following a 7-day treatment with D-fenfluramine (5 mg/kg/day; i.p.), a significant (p<0.05) decrease of 5-HT synthesis, in the dorsal raphe was observed, and significant (p<0.05) increases were observed in the hypothalamus, the dorsal thalamus, the medial and lateral geniculate body and some brain stem regions (locus ceruleus, inferior and superior colliculus). No significant changes were observed in the cerebral cortices.

Effects of acute and chronic administration of the serotonin1A agonist buspirone on serotonin synthesis in the rat brain.

The effects of acute and chronic administration of buspirone, a serotonin 5-HT1A agonist, on the 5-HT synthesis rates in various rat brain structures were investigated using alpha-[14C]methyl-L-tryptophan (alpha-[14C]MTrp) and an autoradiographic method. In the acute treatment study, buspirone (10 mg/kg) was injected subcutaneously 30 min before alpha-[14C]MTrp administration (30 microCi over 2 min) into a femoral vein. In the chronic treatment study, buspirone was given in a sustained fashion (10 mg/kg/day) for 14 days using an osmotic minipump implanted subcutaneously. Rats were killed 60 and 150 min after alpha-[14C]MTrp administration (two-time point method). A single dose of buspirone induced a significant decrease of 5-HT synthesis throughout the brain with the exception of the pineal body. However, the chronic treatment with buspirone did not induce significant differences in 5-HT synthesis in the brain. There was no significant difference in plasma free tryptophan concentration between any of the groups. The unaltered 5-HT synthesis rates in the chronic treatment study likely reflect a normalization of this parameter due to a desensitization of 5-HT1A autoreceptors on the cell body of 5-HT neurons, which has been previously shown to occur following long-term treatment with 5-HT1A agonists.

Natural history of arteriovenous malformations: analysis of non-radically treated patients.

The natural history of cerebral arteriovenous malformations (AVMs) was studied in 115 patients with untreated or incompletely obliterated AVM. Sixty-six patients had histories of hemorrhage, 20 had seizures, 18 had progressive ischemic neurologic deficits and 8 had headache. Three patients had no symptoms attributable to the AVM. Twenty-seven (23%) AVMs rebled or newly bled and the cumulative bleeding or rebleeding rate was 72.5% (4.2% per year). The cumulative bleeding rate of the neurologic deficit group, however, was significantly lower than the cumulative rebleeding rate of the hemorrhagic group (P < 0.05) and that of the seizure group (P < 0.05). No significant differences were found in regard to the initial clinical manifestations. The cumulative survival rate was 84% and the average mortality rate was 1.4% per year. Fifty patients (43%) were below 90 in Karnofsky's Index at the end of the follow-up period and the average morbidity rate was 6.0% per year.

Augmented reality visualization system for intravascular neurosurgery.

We aimed to construct an augmented reality-based visualization system to support intravascular neurosurgery and evaluate it in clinical environments. Three-dimensional (3D) vascular models are overlaid on motion pictures from X-ray fluoroscopy by 2D/3D registration using fiducial markers. The models are reconstructed from 3D data obtained from X-ray computed tomographic angiography or from magnetic resonance angiography using the marching-cube algorithm. Intraoperative X-ray images are mapped as texture patterns on a screen object which is displayed with the vascular models. Distortion of X-ray fluoroscopy is eliminated by a new technique of screen mesh deformation. A quantity called reprojection distance was introduced to evaluate the reliability of the displayed images. It predicts the maximum registration error around the registered objects. Analyses of reprojection distances were performed using synthetic data consisting of marker coordinates with 2D or 3D errors. The tolerance of reprojection distance for the clinical environment was determined to be 3.0 mm. The system was tested in two clinical cases in which reprojection distances of 2.6 and 2.09 mm were obtained. Construction and evaluation of our prototype system were successfully carried out. Further development is planned employing a range sensor to permit markerless registration.

[Diffusion bonding of hydroxyapatite ceramics and biometals].

To improve the mechanical characteristics of hydroxyapatite (HAP) ceramics, a metal-ceramic composite formed by a solid state direct diffusion bonding system was studied. The joining treatment was carried out of a high vacuum and high temperature, for the bioactive ceramics (HAP) and the following biometals; platinum, gold-platinum alloy, titanium and titanium alloys, zirconium, niobium and aluminium alloy. The effects of the variations of thermal expansion mismatch and the interactive reactions at the interface were investigated by fractographic observation (SEM), X-ray diffraction method and EPMA analysis. On some of these joining combinations, the bonding strength had the same bonding strength as the adhesive materials. The results of interface observations showed that the bonding strength is affected by the interface reactions and the diffusion phenomena.