Dural Arteriovenous Fistula Treated with Transvenous Embolization via the Upper Limb Cutaneous Vein.

Objective: In recent years, the transradial artery approach has gained prominence and is increasingly employed in neurovascular angiography and therapy due to its safety, reduced complications, and minimal invasiveness. While various venous approaches, including the conventional transfemoral vein approach, exist for procedures such as transvenous embolization, recent reports have highlighted methods involving upper extremity cutaneous veins. However, the practicality and efficacy of these approaches remain unclear. Case Presentations: This study presents our experience with three cases of dural arteriovenous fistulas, where transvenous embolization was performed via upper limb cutaneous veins. In all instances, the arteriovenous approach was successfully executed using a single upper extremity, leading to the successful completion of treatment. Conclusion: This technique demonstrates significant advantages, not only in terms of its minimal invasiveness but also due to its simplicity and safety. Anticipating broader acceptance in the future, this approach offers a promising avenue for further exploration in neurovascular interventions.

A Case of Ruptured Cerebral Aneurysm with Asymmetric Fusion of Basilar Apex.

Objective: We report a case of a ruptured cerebral aneurysm in which a bifurcation pattern at the tip of the basilar artery was asymmetric fusion type and the superior cerebellar artery (SCA) branched from the posterior cerebral artery (PCA) on the caudal fusion type side. Case Presentation: A 45-year-old woman presented with a subarachnoid hemorrhage with a headache. Cerebral angiography revealed that the right SCA diverged from the PCA and a small cerebral aneurysm had developed at this site. This cerebral aneurysm was successfully treated by coil embolization. Conclusion: There have been no previous reports on cerebral aneurysms at the site of this normal variation.

Choroid Plexus Hyperplasia with Intractable Ascites and a Resulting Communicating Hydrocele following Shunt Operation for Hydrocephalus.

Choroid plexus hyperplasia/papilloma and resulting hyperproduction of cerebrospinal fluid is a rare cause of hydrocephalus. In these patients, intractable ascites can occur after a ventriculoperitoneal (VP) shunting operation. However, shunt-related hydrocele is a rare complication of VP shunting. Previous reports have indicated catheter-tip migration to the scrotum as a cause of hydrocele. Here, we present the first documented case of choroid plexus hyperplasia that led to intractable ascites after shunting and a resulting hydrocele without catheter-tip migration into the scrotum.

Elevated Serum Fibrinogen Degradation Products on Admission Is a Novel Predictive Factor for Recurrence of Chronic Subdural Hematoma.

BACKGROUND: Previous studies reported an association of hematologic parameters, including white blood cells, neutrophil, eosinophils, or coagulation-related factors, with prognosis in cerebrovascular disorders. However, an association of recurrence rate with serum coagulation-related factors (e.g., D-dimer or fibrinogen degradation products [FDP]) in chronic subdural hematoma (CSDH) is unclear. METHODS: Ninety-two patients who experienced first-time CSDH treated with burr-hole hematoma evacuation were included in this study. Laboratory data on admission were used to divide patients into 2 groups: serum FDP >5 µg/mL or FDP ≤5 µg/mL (within normal range), based on the reference range of our institute. We retrospectively compared the recurrence rate of CSDH within 90 days after the first operation between these groups. Statistical significance was accepted at P < 0.05. RESULTS: Patients with an FDP greater than 5 µg/mL showed a significantly increased recurrence rate compared with those with a normal FDP (≤5 µg/mL; 27.3% vs. 10.2%, respectively; P = 0.03). Patients with an FDP greater than 5 µg/mL also showed a significantly higher recurrence rate within 30 days after the operation (15.2% vs. 3.4%, respectively; P = 0.04), but no difference in the recurrence rate at 31-90 days after the operation (12.1% vs. 6.8%, respectively; P = 0.38). In multivariable analysis, monolayer hematoma (odds ratio, 7.61; P = 0.003) and an FDP >5 µg/mL (odds ratio, 5.04; P = 0.01) were independent predictive factors for recurrence within 90 days. CONCLUSIONS: Elevated serum FDP on admission is a novel predictive factor for the recurrence of CSDH. These patients require careful follow-up, and recurrence within 30 days after the first operation should be considered.

Extracranial glioblastoma diagnosed by examination of pleural effusion using the cell block technique: case report.

Metastatic glioblastoma is a rare condition, and several studies have reported the involvement of multiple organs including the lymph nodes, liver, and lung. The lung and pleura are reportedly the most frequent sites of metastasis, and diagnosis using less invasive tools such as cytological analysis with fine needle aspiration biopsy is challenging. Cytological analysis of fluid specimens tends to be negative because of the small number of cells obtained, whereas the cell block technique reportedly has higher sensitivity because of a decrease in cellular dispersion. Herein, the authors describe a patient with a history of diffuse astrocytoma who developed intractable, progressive accumulation of pleural fluid. Initial cytological analysis of the pleural effusion obtained by thoracocentesis was negative, but reanalysis using the cell block technique revealed the presence of glioblastoma cells. This is the first report to suggest the effectiveness of the cell block technique in the diagnosis of extracranial glioblastoma using pleural effusion. In patients with a history of glioma, the presence of extremely intractable pleural effusion warrants cytological analysis of the fluid using this technique in order to initiate appropriate chemotherapy.

Primary Central Nervous System Hodgkin Lymphoma-Like Posttransplant Lymphoproliferative Disorder.

BACKGROUND: Posttransplant lymphoproliferative disorder (PTLD) is a rare condition occurring after organ transplantation. PTLD comprises 4 subtypes, of which Hodgkin lymphoma (HL) type and HL-like type (currently included in polymorphic type) account for only about 1%-3% of cases. Primary central nervous system PTLD is also rare; most cases are Epstein-Barr virus-positive, B-cell PTLD. To our knowledge, no case of HL-like PTLD has been documented. CASE DESCRIPTION: A 43-year-old woman who underwent kidney transplantation for IgA nephropathy 14 years previously presented to the emergency department with seizure. Gadolinium-enhanced T1-weighted magnetic resonance imaging showed a ring-enhancing mass in the left temporal lobe. Gross total removal of the tumor was performed, and pathologic examination revealed findings consistent with HL-like PTLD. The patient's immunosuppressants were subsequently reduced, and she received postoperative systemic therapy with rituximab and radiation therapy. Follow-up magnetic resonance imaging showed no signs of relapse. CONCLUSIONS: This represents an extremely rare case of a patient with HL-like PTLD occurring as a primary central nervous system lesion.

Adult-Onset Hemorrhagic Quasi-Moyamoya Disease with Unilateral Steno-occlusive Lesion in a Patient with Neurofibromatosis Type 1.

BACKGROUND: Quasi-moyamoya disease is a condition that occurs in association with a specific underlying condition or disease such as atherosclerotic disease or neurofibromatosis type 1 (NF1). Pediatric cases are frequently reported, and an ischemic and bilateral presentation is more common than a hemorrhagic and unilateral presentation. CLINICAL PRESENTATION: A 39-year-old woman previously diagnosed with NF1 presented to our department with nausea and left hemiparesis. She was diagnosed with right temporal intracerebral hemorrhage by initial computed tomography. Subsequent angiography showed an occlusion of the terminal portion of the right internal carotid artery, and magnetic resonance imaging showed multiple flow voids in the right basal ganglia, suggesting quasi-moyamoya disease. The hematoma was surgically removed, and her neurological condition improved after the operation. CONCLUSIONS: This is the first reported case of quasi-moyamoya disease with a rare combination of characteristics, including an adult-onset, hemorrhagic presentation and a unilateral lesion in a patient previously diagnosed with NF1.

Hypertensive Cerebral Hemorrhage in a Patient with Turner Syndrome Caused by Deletion in the Short Arm of the X Chromosome.

Turner syndrome is a chromosomal disorder usually caused by complete deletion of an X chromosome, with deletion in the short arm of the X chromosome being a rare cause of the condition. Patients with Turner syndrome commonly develop hypertension, and associated vascular complications such as aortic dissection or cerebral hemorrhage have been reported. Cerebral hemorrhage in Turner syndrome is a rare complication, and only a few reports have been published. In these reports, all patients have XO karyotypes or a mosaic type as the cause of Turner syndrome, while no other Turner syndrome types have been documented. In this report, we present for the first time a patient with Turner syndrome caused by deletion in the short arm of the X chromosome who experienced hypertensive hemorrhage as a late complication.

Peritoneal catheter knot formation in ventriculoperitoneal shunting: an intraoperative artificial phenomenon?

BACKGROUND: Peritoneal catheter knot formation is a rare complication associated with ventriculoperitoneal shunting. In most reports, the knot formation was also considered to be the cause of shunt malfunction. DISCUSSION: In this study, we demonstrate the possible misinterpretation of peritoneal catheter knot formation in ventriculoperitoneal shunting. We found a knot in the peritoneal catheter intraoperatively, while no knot was noted on the abdominal X-ray taken 1 day prior to the operation. Our findings indicate that the knot had actually formed intraoperatively. This case suggests that we should not immediately conclude that a knot is the cause of shunt malfunction in such an operation.

Intrathecal Baclofen Pump Implantation for Type 2 Gaucher Disease.

Gaucher disease (GD) is the most common type of lysosomal storage disease, with type 2 being the most severe subtype. Type 2 GD patients suffer significant progressive neurological impairment, including spasticity, opisthotonus, seizure, and apnea. The recently developed enzyme replacement therapy (ERT) has shown therapeutic benefit for GD. However, as the enzymes do not cross the blood-brain barrier, ERT does not ameliorate neurological impairment in GD. Intrathecal baclofen therapy (IBT) is indicated for spastic neurological diseases, such as cerebral palsy, and studies have shown its therapeutic benefit in improving several manifestations of GD, such as scoliosis caused by muscle spasticity and respiratory function. To date, the potential benefits of IBT for treating lysosomal storage diseases such as GD have not been examined. Here we provide the first report of a patient with type 2 GD treated with IBT, and demonstrate its therapeutic benefit in ameliorating the neurological aspects of this disease.

Presence of a Malignant Tumor as a Novel Predictive Factor for Repeated Recurrences of Chronic Subdural Hematoma.

BACKGROUND: Various risk factors for recurrence of chronic subdural hematomas (CSDHs) have been reported, including alcohol addiction and diabetes mellitus. However, the significance of malignant tumors with respect to CSDH recurrence remains unclear. METHODS: We retrospectively evaluated 281 patients with a first-time CSDH from 2006 to 2016. The difference in the recurrence rate within 100 days postoperatively was compared between patients with a past or present extracranial malignant tumor and those with neither a past nor present extracranial malignant tumor at presentation. Patients in the former group were further divided into 2 subgroups: those with present tumors and those with past tumors. Statistical significance was defined as P < 0.05. RESULTS: A significantly greater repeated recurrence rate (>2 recurrences) was observed in patients with than without a past or present malignant tumor (8.5% vs. 1.7%, respectively; P = 0.01); no significant difference in the first recurrence rate was observed (19.1% vs. 16.2%, respectively; P = 0.63). Furthermore, patients with a present malignant tumor showed a marginally increased repeated recurrence rate than did patients with a past malignant tumor (20.0% vs. 3.1%, respectively; P = 0.053). In the multivariate analysis, a monolayer hematoma was the only risk factor for first recurrence (odds ratio, 3.16; P = 0.003), while a present malignant tumor was the only significant risk factor for repeated recurrences (odds ratio, 16.49; P = 0.002). CONCLUSIONS: The presence of a malignant tumor can be a novel predictive factor for repeated CSDH recurrences. Patients with malignant tumors should be carefully followed, and treatment options such as subcutaneous reservoir placement may be considered to prevent further recurrences.

Prefectural difference in spontaneous intracerebral hemorrhage incidence in Japan analyzed with publically accessible diagnosis procedure combination data: possibilities and limitations.

OBJECTIVES: Annually reported, publically accessible Diagnosis Procedure Combination (DPC) data from the Japanese government is a part of the total DPC database of the Japanese medical reimbursement system for hospitalization. Although medical issues can be evaluated with these data promptly, the applicability of these data in epidemiological analyses has not been assessed. METHODS: We performed analyses using only statistical indices reported on the a government website. As a preliminary step, the prefectural consistency of spontaneous intracerebral hemorrhage (sICH) was examined with prefectural mortality over 20 years. Then the prefectural incidence of sICH for four years was calculated, utilizing publically accessible DPC data. To determine its reliability, the consistency was examined, and correlations were analyzed with three prefectural factors expected to have an effect: the elderly rate, mortality due to sICH, and the non-DPC bed rate. In addition, a comparison model between prefectures with this method was developed by analyzing other prefecture-specific factors. RESULTS: Prefectural mortality due to sICH and prefectural sICH incidence in the DPC database were both consistent over the years. Prefectural sICH incidence had a constant positive correlation with the elderly rate, a partial correlation with mortality due to sICH, but no correlation with the non-DPC bed rate, which is one of the major biases when utilizing the DPC database. In the comparison model, the factors of low income and alcohol consumption showed increased sICH incidence. CONCLUSIONS: Although careful attention to its limitations is required, publically accessible DPC data will provide insights into epidemiological issues.

Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) as a Cognitive Evaluation Tool for Patients with Normal Pressure Hydrocephalus.

External lumbar drainage (ELD) is recognized as a screening method for ventriculo-peritoneal shunting (VPS) candidacy for possible normal pressure hydrocephalus (NPH). This study focused on the ELD predictability of the cognitive outcome after VPS for NPH. In addition, Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) was examined in ELD cognition screening. ELD results were considered positive with any improvement in gait and/or cognition. Among 36 patients examined for possible NPH, 26 underwent VPS because of positive ELD. Cognitive outcome after VPS was assessed at 6-month follow-up. The RBANS scores, examined pre- and post-ELD, were evaluated statistically to identify consistency with the neuropsychologist judgment and the predictability of cognitive outcome after VPS. Among 26 shunted patients, gait was improved in 24. Cognitive improvement was rated in 19, and there were 9 false negative and 5 false positive in ELD cognition screening. The neuropsychologist judgment in ELD cognition screening is most consistent with the RBANS score in delayed memory. The patients rated as improved in cognition after VPS had significantly lower RBANS scores pre-ELD in immediate memory and delayed memory. If both scores at pre-ELD were ≤ 80 (13 patients), all were rated as improved in cognition after VPS. ELD screening was highly predictive of clinical gait improvement but not of cognitive improvement after VPS for possible NPH. Particularly among patients with a positive ELD gait response, pre-ELD low RBANS scores in memory predicted cognitive improvement after VPS. RBANS seems effective in evaluating cognition for NPH.

Eosinopenia in Children following Traumatic Intracranial Hemorrhage Is Associated with Poor Prognosis and Prolonged Hospital Admission.

BACKGROUND: Neutrophilia is associated with brain injury and is frequently accompanied by eosinopenia. Although eosinopenia is a poor prognostic indicator for various diseases, its significance in intracranial events has not been investigated. METHODS: We retrospectively included 22 pediatric patients (≤18 years old) who experienced traumatic intracranial hemorrhage between 2002 and 2015. Patients were divided into two groups based on the presence or absence of eosinopenia on admission, i.e. the proportion of eosinophils to total white blood cells <1.0%. RESULTS: The mean Glasgow Coma Scale score was marginally lower in the eosinopenia group (14.1 vs. 12.0, p = 0.06). The mean Glasgow Outcome Scale-Extended (GOSE) score was significantly lower in the eosinopenia group (7.5 vs. 5.7, p = 0.02), and the mean length of hospital stay tended to be longer in patients with eosinopenia (7.8 vs. 28.4, p = 0.10). In our multivariate logistic regression analysis, eosinopenia was the only significant risk factor for poor outcome (GOSE score 1-7, OR 29.7, p = 0.03) and prolonged hospital stay (>2 weeks, OR 7.1, p = 0.047). CONCLUSION: These results demonstrate the significance of eosinopenia as a novel prognostic factor in traumatic intracranial hemorrhage in children.

[Treatment choice for patients with hemorrhagic cerebral stroke expected to be in a disabled condition--An analysis of questionnaire responses of patients' families].

AIM: Many patients with cerebral stroke are successively treated with the latest advances in medical therapies. Surgical hematoma evacuation is a treatment option for patients with hemorrhagic cerebral stroke, however; it may result in a prolonged vegetative state. The difficult choice of whether or not such surgery should be performed is mostly made by the family, frequently in an urgent manner, and nurses need to understand the factors affecting this decision-making. METHODS: We performed statistical analyses on the responses of 30 patients' families who answered our questionnaire, presuming disabilities after the surgery were expected. Multiple answers were obtained according to the severity of the expected disabilities after the surgery. RESULTS: The refusal of surgery increased as the expected disabilities worsened, and the statistically significant factor affecting the decision-making process was "what they would wish if they suffered a stroke themselves." The 18 nurses working in the neurological ward who responded to the same questionnaire wished surgery more in the case of the patient's cognition being preserved. CONCLUSIONS: Since it is rare for patients with stroke to have an advance directive, patients' families have to decide the treatment choice in most cases. In the clinical setting, such decisions frequently need to be made rapidly, however; the decision should be made by speculating on the patients' own will, and it is desirable for medical staff to explain the expected outcomes of the surgery in detail as far as possible.

Geographical analysis of aneurysmal subarachnoid hemorrhage in Japan utilizing publically-accessible DPC database.

Since the launch of the novel medical reimbursement system Diagnosis Procedure Combination (DPC) in 2003 in Japan, inpatient data has been accumulated over time as part of a Japanese governmental nationwide database. This is partially accessible by the public, and this study examined the adequacy of this database as epidemiological research material by extracting the data relating to aneurysmal subarachnoid hemorrhage (aSAH) with special attention given to the limitations that this involves. Datasets after 2010 are considered suitable for analysis because of the numbers of participating hospitals and the analysis term. Extracting the data by prefecture, those with a continuously high aSAH incidence were Aomori, Iwate, Akita, Yamagata, Kochi and Kumamoto Prefectures, and those with low aSAH incidence were Kanagawa, Shiga, Kyoto, Shimane and Ehime Prefectures. Although these obtained results are informative, a publically-accessible DPC database has several limitations. Some limitations have been resolved: the analyzed term each year is now 12-months and the number of participating hospitals seems to have stabilized around 1700. However, other limitations such as masking the numbers in each hospital reporting less than 10 patients still exist, so careful and critical interpretation is necessary in utilizing a publically-accessible DPC database. Considering the potential of this database as material for epidemiological research, future analysis of the entire DPC database by qualified researchers is desirable.

Diffuse Presence of Myeloblasts in Chronic Subdural Hematoma of a Young Adult Patient without Systemic Hematologic Disorder.

Objective Myeloblasts are rarely found in the composition of a chronic subdural hematoma (CSH), and reported cases with myeloblasts in CSH have all been associated with systemic hematologic disorders. We present a young man with CSH manifesting the diffuse presence of myeloblasts, although no systemic hematologic disorders were identified. Participant A 27-year-old man, complaining of a headache lasting for a few months, was diagnosed with right CSH, and the aspirated hematoma was sent for cytological evaluation because no apparent etiologic episode was found. The diffuse presence of precursor cells, such as myeloblasts and erythroblasts, mimicking the aspirated bone marrow, was confirmed. This finding was suggestive of a systemic hematologic disorder, although the systemic evaluations were negative. Results The patient's hematoma reaccumulated twice, and finally hematoma and enhanced dura were removed by craniotomy under general anesthesia. Further histologic evaluation did not show any precursor cells, and he has remained asymptomatic for > 2 years without any evidence of the hematologic disorder. Conclusion We believe this is the first case with CSH that contained myeloblasts as well as erythroblasts in an otherwise healthy patient. A possible etiology was considered for the origin of precursor cells in his CSH.

Mechanical ventilation for comatose patients with inoperative acute intracerebral hemorrhage: possible futility of treatment.

BACKGROUND: Comatose patients with acute intracerebral hemorrhage (ICH) diagnosed as inoperative due to their severe comorbidity will be treated differently between countries. In certain countries including Japan, aggressive medical care may be performed according to the patients' family requests although the effects on the outcome are obscure. For respiratory distress in comatose patients with inoperative acute ICH, the role of mechanical ventilation on the outcome is unknown. We speculated that the efficacy of a ventilator in such a specific condition is limited and possibly futile. METHODS: We retrospectively evaluated the in-hospital mortality and further outcome of 65 comatose patients with inoperative ICH. Among the patients, 56 manifested respiratory distress, and the effect of the ventilator was evaluated by comparing the patients treated with and without the ventilator. RESULTS: The in-hospital mortality was calculated as 80%. A statistically significant parameter affecting the mortality independently was the motor subset on the Glasgow Coma Scale (P = 0.015). Among the patients who manifested respiratory distress, 7.7% of patients treated with a ventilator and 14.0% of patients not treated with a ventilator survived; an outcome is not significantly different. The mean survival duration of patients treated with a ventilator was significantly longer than the mean survival duration of patients not treated with a ventilator (P = 0.021). Among the surviving 13 patients, 7 patients died 5 to 29 months after onset without significant consciousness recovery. Another 6 patients suffered continuous disablement due to prolonged severe consciousness disturbances. CONCLUSION: The current results indicate that treating comatose patients resulting from inoperative acute ICH may be futile. In particular, treating these patients with a ventilator only has the effect of prolonging unresponsive life, and the treatment may be criticized from the perspective of the appropriate use of public medical resources.