[Acute Subdural Hematoma in Snowboarders:A Multivariate Analysis of 79 Cases].

Snowboarding-related head injuries have become less common as the number of snowboarders has decreased;however, severe head injuries, such as acute subdural hematomas, occur every snowboarding season. We investigated the characteristics of cases of snowboarding-related acute subdural hematoma treated at our hospital. A total of 3,632 patients with snowboarding-related head injuries seen at our hospital between the 1995/96 and 2012/13 snowboarding seasons were enrolled in this study. Seventy-nine(2.2%)patients were diagnosed with acute subdural hematomas using computed tomography. We statistically analyzed the patient questionnaire responses, clinical records, and radiological findings. We compared the findings of the acute subdural hematoma(ASDH)group with those of the non-ASDH group. Among beginners, falling on a slope, incidents involving gentle slopes, and injuries of unknown origin were significantly more common in the ASDH group. On the other hand, among the intermediate snowboarders, incidents involving jumps, jump failure, and collisions with other snowboarders were more common in the non-ASDH group. Secondly, in an analysis involving subjects who had an ASDH, we compared the beginner group with the intermediate/advanced group. Falling on a slope, incidents involving gentle slopes, pure ASDH, diffuse brain swelling, and death were more common in the beginner group, and ASDH combined with contusions or subarachnoid hemorrhaging and incidents involving a jump were more common in the intermediate/advanced group. Finally, we summarized the cases of 10 subjects with an ASDH as well as diffuse brain swelling. Nine of the 10 patients died, 8 were first-timers or beginners, 6 had incidents involving flat or gentle slopes, and 5 had fallen on a slope. Snowboarding is a recreational sport;therefore, snowboarders must take responsibility for their actions. However, snowboarders, especially beginners, could decrease their risk of ASDH if they are informed about ASDH and take precautions to reduce their risk of falling on gentle slopes. Educational activities related to this topic should continue.

[Multiple and simultaneous intracranical hemorrhages with homocysteinemia].

A decreased intake of brightly colored vegetables results in increased levels of serum homocysteine, and homocysteinemia is associated with the progression of arteriosclerosis. Moreover, homocysteinemia is a known risk factor for cerebral infarction. Here, we report three cases wherein multiple simultaneous intracranial hemorrhages developed in the presence of homocysteinemia. The dietary habits of the patients involved indicated that decreased intake of brightly colored vegetables and the consequent progression of arteriosclerosis caused intracranial hemorrhage. Thus, in daily medical care, the measurement of serum homocysteine levels is useful for managing dietary habits and progression of arteriosclerosis.

[Analysis of Rupture during Follow-up of Unruptured Aneurysm].

OBJECT: To elucidate clinical aspects of ruptured aneurysms, we retrospectively investigated associations between risk factors and ruptured and unruptured cases during conservative management. METHODS: Two hundred and twenty-nine patients with 291 unruptured cerebral aneurysms treated between 2000 and 2012 were analyzed. Mean duration of observation was 62 months (1183.4 person-years). We investigated the following six risk factors: history of subarachnoid hemorrhage;multiplicity;location of aneurysms;aneurysm size ≤5mm;bleb or irregular forms;and follow-up period <1 year. RESULTS: Twenty-two aneurysms in 22 patients (19 women;86.4%) ruptured during this study. The annual rate of rupture was 1.86%. In ruptured cases, mean age was 66.7 years. According to univariate analysis, aneurysm size≥5mm(p=0.000), bleb or irregular form(p=0.006)and duration of observation<1 year (p =0.000) were significantly associated with aneurysmal rupture. In multivariate analysis of these factors, aneurysm size≥5mm(p =0.0188;odds ratio(OR), 3.4;95% confidence interval (CI), 1.2-9.7) and duration of observation<1 year (p=0.006;OR, 5.0;95% CI, 1.6-14.9) represented independent risk factors for aneurysm rupture. CONCLUSIONS: The results of this study were almost the same as those of the UCAS Japan study. In addition, duration of observation <1 year was a risk factor for aneurysm rupture. When we decide on surgical treatment after considering factors such as aneurysm size, form, and surgical risk, surgery should be performed as soon as possible.

Subdural empyema due to Lactococcus lactis cremoris: case report.

Lactococcus lactis cremoris (L. lactis cremoris) infections are very rare in humans. Only three case reports of brain abscess have been reported and the infectious routes and pathological features are still unknown. We experienced a subdural empyema due to L. lactis cremoris in an immunocompetent adult. A 33-year-old man was admitted with fever, right facial pain, left hemiparesis, and left hemianopsia. Computed tomography demonstrated low density fluid collection in the right falcotentorial subdural space. Magnetic resonance (MR) images revealed a high signal lesion on a diffusion-weighted image (DWI) and fluid attenuated inversion recovery (FLAIR) images in the right paratentorial and parafalcine subdural space, right maxillary sinus, and bilateral ethmoidal sinus. He underwent two sequential open surgeries for removal and drainage of empyema and was treated with antibiotics including meropenem and ampicillin. To our knowledge, this is the first report of subdural empyema caused by L. lactis cremoris infection. We report the case and discuss the pathological features with the previous literature.

[An operated case of a meningioma causing acute subdural hematoma].

We report a rare case of a meningioma causing acute hematoma. A 67-year-old woman presented with sudden headache. No evidence of trauma was seen. CT demonstrated a subdural hematoma in the convexity of the fronto-temporal lobe. Magnetic resonance imaging showed marked signal heterogeneity in the convexity of the frontal lobe. One week later, the patient underwent hematoma evacuation and tumor resection including the attached dura mater. The histological diagnosis was meningothelial meningioma. The clot was connected directly to the tumor and the origin of the subdural hematoma was identified as the meningioma. Postoperative course was uneventful, and the headache improved. Meningiomas have a relatively benign course but rarely present with hemorrhage. Surgical exploration is the effective and recommended treatment.

[Childhood transverse sinus dural arteriovenous fistula treated with endovascular and direct surgery: a case report].

Infantile dural arteriovenous fistula is a rare cerebrovascular malformation carrying a poor prognosis with an anatomic cure of only 9%. Endovascular embolization is mainly selected to treat this entity, aiming to obtain normal development of the patients. We present a case of a 20-month-old girl with epilepsy. Digital subtraction angiography revealed a dural arteriovenous fistula involving the right transverse sinus. The arteriovenous fistula was fed by multiple dural branches from the middle meningeal, occipital, meningohypophyseal, and anteroinferior cerebellar arteries. The right transverse sinus was transvenously embolized with platinum coils. Although the shunt flow remained, the patient was liberated from epilepsy. Nine months later, the patient suffered from a recurrence of epilepsy. Digital subtraction angiography demonstrated some increase in shunt flow. Right middle meningeal, occipital, posterior deep temporal, and tentorial arteries were transarterially embolized using N-butyl cyanoacrylate, followed by complete surgical resection of the right transverse sinus. The shunt flow disappeared after surgery, and her epilepsy improved significantly. Our experience suggests that the combination of endovascular and surgical treatment is effective for recurrent infantile dural arteriovenous fistula.

Differences in clinical characteristics of head injuries to snowboarders by skill level.

BACKGROUND: Many reports have compared head injuries between snowboarding and skiing. However, detailed studies comparing snowboarding head injuries between beginners and intermediates/experts have been lacking. PURPOSE: The authors investigated differences in clinical characteristics of head injuries to snowboarders between beginners (group B) and intermediates/experts (group IE). STUDY DESIGN: Descriptive epidemiology study. METHODS: The study population included 2367 patients treated at Saito Memorial Hospital and Yuzawa Community Health Medical Center, Niigata Prefecture, Japan, during 9 seasons from 1999-2000 to 2007-2008. RESULTS: Group B comprised 959 patients (mean age, 23.0 years; 52% males). Group IE comprised 1408 patients (mean age, 24.8 years; 72% males). Accidents in group B predominantly occurred as falls on gentle slopes (37%) and intermediate slopes (33%), whereas accidents in group IE occurred mostly during jumping (48%). The impact point on the head was predominantly occipital in both groups, but group IE showed a significantly higher frequency of trauma to the frontal region. The ratio of neurologic abnormalities was significantly higher in group IE. However, the ratio of surgical cases was significantly higher in group B (n = 10, 1.04%) than in group IE (n = 5, 0.36%). More acute subdural hematomas were seen in group B, but more fractures, contusions, and acute epidural hematomas were seen in group IE. Four moderate disabilities, 2 comatose patients, and 2 deaths were seen in group B, and 1 moderate disability, 2 severe disabilities, and 1 death were seen in group IE during this study. CONCLUSION: The data suggest significant differences in clinical states between beginners and intermediates/experts. Preventive methods for severe head injuries among snowboarders need to be devised based on differences in skill levels.

[Bickerstaff's brainstem encephalitis with positive findings on head MRI--case report].

We report a case of Bickerstaff's brainstem encephalitis (BBE) with positive findings on head MRI. Abnormal lesions on head MRI were detected in approximately 30% cases of BBE. An 81-year-old female presented with disturbance of consciousness (Japan Coma Scale 200), ophthalmoplegia (downward deviation) and tetraplegia. Cerebrospinal fluid examination revealed mild pleocytosis 244 cells in 3 microl of CSF with normal glycorrhachia. Head MRI showed high-intensity abnormalities extending over the brain stem. The patient was diagnosed with BBE. It was thought that her symptoms were believed to arise from the lesion in reticular formation, rostral interstitial nucleus of the medial longitudinal fasciculus, and the pyramidal tract. At discharged after 1 month, she had no sequela.

Ubiquitin-interacting motifs of Epsin are involved in the regulation of insulin-dependent endocytosis.

Epsin is a key molecule in receptor-mediated endocytosis. Epsin is phosphorylated and ubiquitinated, and these post-translational modifications are necessary for the regulation of endocytosis. Since human Epsin (hEpsin) has two ubiquitin-interacting motifs (UIMs), we investigated the roles of these UIMs in endocytosis. hEpsin formed a complex with ubiquitinated proteins but did not bind to monoubiquitin. Neither of the two UIMs of hEpsin alone was sufficient to form a complex with ubiquitinated proteins: both UIMs were necessary. Mutations of Asp209 and Asp210 to Ala in UIM (hEpsinDA) abolished the binding activity of hEpsin to ubiquitinated proteins. However, hEpsinDA interacted with Eps15, POB1, and AP-2, which are involved in receptor-mediated endocytosis, as efficiently as wild-type hEpsin. Expression of hEpsinDA in CHO-IR cells affected neither the binding of insulin to nor insulin-dependent autophosphorylation of its receptor. Expression of wild-type hEpsin inhibited the internalization of insulin, whereas that of hEpsinDA did not. These results suggest that the UIM motifs of hEpsin interact with proteins modified with ubiquitin, and that the complex formation is involved in insulin-dependent receptor endocytosis.

Interaction of POB1, a downstream molecule of small G protein Ral, with PAG2, a paxillin-binding protein, is involved in cell migration.

POB1 was previously identified as a RalBP1-binding protein. POB1 and RalBP1 function downstream of small G protein Ral and regulate receptor-mediated endocytosis. To look for additional functions of POB1, we screened for POB1-binding proteins using a yeast two-hybrid method and found that POB1 interacts with mouse ASAP1, which is a human PAG2 homolog. PAG2 is a paxillin-associated protein with ADP-ribosylation factor GTPase-activating protein activity. POB1 formed a complex with PAG2 in intact cells. The carboxyl-terminal region containing the proline-rich motifs of POB1 directly bound to the carboxyl-terminal region including the SH3 domain of PAG2. Substitutions of Pro(423) and Pro(426) with Ala (POB1(PA)) impaired the binding of POB1 to PAG2. Expression of PAG2 inhibited fibronectin-dependent migration and paxillin recruitment to focal contacts of CHO-IR cells. Co-expression with POB1 but not with POB1(PA) suppressed the inhibitory action of PAG2 on cell migration and paxillin localization. These results suggest that POB1 interacts with PAG2 through its proline-rich motif, thereby regulating cell migration.