RNF213 p.Arg4810Lys Wild Type is Associated with De Novo Hemorrhage in Asymptomatic Hemispheres with Moyamoya Disease

Clinical implications of RNF213 genetic variants, other than p.Arg4810Lys, in moyamoya disease (MMD), remain unclear. This study aimed to investigate the association of RNF213 variants with clinical phenotypes in MMD. This retrospective cohort study collected data regarding the clinical characteristics of 139 patients with MMD and evaluated the angioarchitectures of 253 hemispheres using digital subtraction angiography at diagnosis. All RNF213 exons were sequenced, and the associations of clinical characteristics and angiographical findings with p.Arg4810Lys, p.Ala4399Thr, and other rare variants (RVs) were examined. Among 139 patients, 100 (71.9%) had p.Arg4810Lys heterozygote (GA) and 39 (28.1%) had the wild type (GG). Fourteen RVs were identified and detetcted in 15/139 (10.8%) patients, and p.Ala4399Thr was detected in 17/139 (12.2%) patients. Hemispheres with GG and p.Ala4399Thr presented with significantly less ischemic events and more hemorrhagic events at diagnosis (p = 0.001 and p = 0.028, respectively). In asymptomatic hemispheres, those with GG were more susceptible to de novo hemorrhage than those with GA (adjusted hazard ratio [aHR] 5.36) with an increased risk when accompanied by p.Ala4399Thr or RVs (aHR 15.22 and 16.60, respectively). Within the choroidal anastomosis-positive hemispheres, GG exhibited a higher incidence of de novo hemorrhage than GA (p = 0.004). The GG of p. Arg4810Lys was a risk factor for de novo hemorrhage in asymptomatic MMD hemispheres. This risk increased with certain other variants and is observed in choroidal anastomosis-positive hemispheres. A comprehensive evaluation of RNF213 variants and angioarchitectures is essential for predicting the phenotype of asymptomatic hemispheres in MMD.

Genome-Wide Association Study of Intracranial Artery Stenosis Followed by Phenome-Wide Association Study

The genetic background of intracranial artery stenosis (ICAS), a major cause of ischemic stroke, remains elusive. We performed the world's first genome-wide association study (GWAS) of ICAS using DNA samples from Japanese subjects, to identify the genetic factors associated with ICAS and their correlation with clinical features. We also conducted a phenome-wide association study (PheWAS) of the top variant identified via GWAS to determine its association with systemic disease. The GWAS involved 408 patients with ICAS and 349 healthy controls and utilized an Asian Screening Array of venous blood samples. The PheWAS was performed using genotypic and phenotypic data of the Biobank Japan Project, which contained information on 46 diseases and 60 quantitative trait data from > 150,000 Japanese individuals. The GWAS revealed that the East Asian-specific functional variant of RNF213, rs112735431 (c.14429G > A, p.Arg4810Lys), was associated with ICAS (odds ratio, 12.3; 95% CI 5.5 to 27.5; P = 7.8 × 10^-10). Stratified analysis within ICAS cases demonstrated that clinical features of those with and without the risk allele were different. PheWAS indicated that high blood pressure and angina were significantly associated with RNF213 rs112735431. The first GWAS of ICAS, which stratifies subpopulations within the ICAS cases with distinct clinical features, revealed that RNF213 rs112735431 was the most significant variant associated with ICAS. Thus, RNF213 rs112735431 shows potential as an important clinical biomarker that characterizes pleiotropic risk in various vascular diseases, such as blood pressure and angina, thereby facilitating personalized medicine for systemic vascular diseases in East Asian populations.

Initial evaluation of a novel electrocardiography sensor-embedded fabric wear during a full marathon

Sudden cardiac accident (SCA) during a marathon is a concern due to the popularity of the sport. Preventive strategies, such as cardiac screening and deployment of automated external defibrillators have controversial cost-effectiveness. We investigated the feasibility of use of a new electrocardiography (ECG) sensor-embedded fabric wear (SFW) during a marathon as a novel preventive strategy against SCA. Twenty healthy volunteers participated in a full marathon race. They were equipped with a SFW hitoe® with a transmitter connected via Bluetooth to a standard smartphone for continuous ECG recording. All data were stored in a smartphone and used to analyze the data acquisition rate. The adequate data acquisition rate was > 90% in 13, 30-90% in 3, and < 10% in 4 runners. All of 4 runners with poorly recorded data were female. Inadequate data acquisition was significantly associated with the early phase of the race compared with the mid phase (P = 0.007). Except for 3 runners with poor heart rate data, automated software calculation was significantly associated with manual analysis for both the mean (P < 0.001) and maximum (P = 0.014) heart rate. We tested the feasibility of continuously recording cardiac data during a marathon using a new ECG sensor-embedded wearable device. Although data from 65% of runners were adequately recorded, female runners and the early phase of the race tended to have poor data acquisition. Further improvements in device ergonomics and software are necessary to improve ability to detect abnormal ECGs that may precede SCA.

Changes in the Risk of Stroke in Dialysis Patients: A Retrospective Analysis over the Last 40 Years

The stroke incidence in hemodialysis (HD) patients is high, but the associated factors remain largely unknown. This study aimed to analyze stroke incidence in HD patients and changes in risk factors. Data of 291 patients were retrospectively analyzed. The cumulative stroke incidences were 21.6% at 10 years and 31.5% at 20. Diabetic nephropathy (DN) significantly increased overall stroke (hazard ratio (HR), 2.24; 95% confidence interval (CI), 1.21-4.12; p = 0.001) and ischemic stroke (HR, 2.16; 95% CI, 1.00-4.64; p = 0.049). Patients treated with online HDF were less likely to have overall stroke (HR, 0.13; 95% CI, 0.03-0.56; p = 0.006) and ischemic stroke (HR, 0.08; 95% CI, 0.01-0.60; p = 0.014). DN (HR, 1.56; 95% CI, 1.08-2.27; p = 0.019) and age >80 years at HD initiation (20-49 years old; HR 0.13, 95% CI, 0.05-0.35, p < 0.001 and age 50-79 years; HR 0.42, 95% CI, 0.26-0.66, p < 0.001 (reference: age >80 years)) were significantly associated with stroke and/or death events. Over time, stroke risk increased in HD patients, due to the increasing number of DN. Although dialysis technology has advanced over time, these advances could not overcome other risk factors for stroke. Further increase in stroke and mortality due to aging remains a concern.

Hemorrhagic Onset Intracranial Artery Dissection of Middle Cerebral Artery Followed by Progressive Arterial Stenosis with Genetic Variant RNF213 p.Arg4810Lys (rs112735431)

BACKGROUND

Intracranial arterial dissection (IAD) is known to exhibit various patterns of arterial imaging features such as stenosis and dilation; however, the genetic background of IAD has not been elucidated so far. RNF213 was recently identified as a susceptibility gene for moyamoya disease (MMD) and intracranial artery stenosis (ICAS). More recently, RNF213 p.Arg4810Lys also has been shown to be associated with various systemic vascular diseases. RNF213 p.Arg4810Lys is beginning to attract attention as a genetic factor that causes systemic vascular disease.

CASE DESCRIPTION

Herein, we report a rare case of de novo progression of the intracranial vascular lesion with the RNF213 p.Arg4810Lys variant, which first presented IAD of the middle cerebral artery (MCA) with subarachnoid hemorrhage, second progressed into ICAS, and finally evolved into MMD-like angiogenesis over 6 years.

CONCLUSIONS

This case suggests that IAD of the MCA could be associated with RNF213 p.Arg4810Lys variant. This genetic variant could also have a key role in the overlap among the different disease states. A large-scale genetic analysis study of the IADs of the anterior circulation is needed. To qualify the significance of RNF213 p.Arg4810Lys variant as a stroke risk allele, accumulation of various cases of cerebrovascular lesions would be essential.

Risk Factors and Outcomes of Cerebral Stroke in End-Stage Renal Disease Patients Receiving Hemodialysis

OBJECTIVE

Dialysis patients have a higher incidence of stroke, and outcomes are often poor. Diabetic nephropathy (DN) is a stroke risk-factor, but the importance is unclear in dialysis patients. This study investigated the stroke features and risk factors in hemodialysis (HD) patients.

METHODS

All end-stage renal disease patients undergoing HD at Teraoka Memorial Hospital dialysis center were identified, with 195 recruited. Baseline clinical characteristics were collected, and the clinical outcomes and related factors of stroke in HD patients were retrospectively analyzed. The incidence rate of stroke and mortality were calculated using Kaplan-Meier survival analysis. Factors potentially related to stroke were analyzed by the log-rank test and Cox proportional hazards model for univariate and multivariate analysis.

RESULTS

In total, 21.0% (41 of 195) patients developed stroke. The incidence rates of stroke per 1000 patient-years were 53.6, 65.2, and 34.0 in all HD patients, DN patients, and non-DN patients, respectively. The cumulative incidence rates of stroke in all HD patients, DN patients, and non-DN patients per 5 years, and per 10 years were 22.6%, 43.5%; 28.8%, 59.6%; and 17.6%, 31.1%, respectively. The incidence rate of stroke in the DN patients was significantly higher than in the non-DN patients (P = .013). DN was the significant risk factor for stroke by multivariate analysis (hazard ratio 2.63, 95% confidence interval 1.08-7.85; P = .032).

CONCLUSIONS

This study revealed the trends of stroke in HD patients at a single institution in Japan. DN was shown to be a significant risk factor for stroke in HD patients.

A case of conservative management for left ventricular giant pseudoaneurysm without ST segment changes

Left ventricular (LV) rupture after myocardial infarction (MI) occasionally results in formation of LV pseudoaneurysm (LVPA) which is prone to rupture because of its thin wall. However, cases of LVPA without ST changes including segment elevation in electrocardiogram (ECG) are rare. In this case, we describe a patient who had relatively mild symptoms and giant LVPA with no specific ECG changes following MI with a confirmed diagnosis via transthoracic echocardiography. Although surgical treatment options are often recommended, conservative therapy was adopted, following which the patient had been well-medicated using antihypertensive drugs and anticoagulants. <Leaning objectives: Left ventricular pseudoaneurysm (LVPA) is usually accompanied by ST segment changes on electrocardiogram (ECG) due to myocardial damage. However, we should take into account a LVPA without ECG specific changes, so echocardiography is better to be considered for an identification. Although many LVPA patients undergo surgery because of risk for rupture, some cases with stable hemodynamic status can have long-term survival with conservative therapy such as anti-hypertension and coagulation.>.

Is the evidence of the Supreme Court Ruling of gefitinib litigation in Japan scientific?

BACKGROUND

Plaintiffs of the gefitinib (Iressa) lawsuits in Japan started in 2004 were defeated in the Supreme Court in 2013. The Court judged it was not possible to foresee the outbreak of deaths caused by interstitial pneumonia due to gefitinib from death cases before approval of this drug.

OBJECTIVE

We attempted to verify validity of this judgment.

METHODS

We estimated the 95% confidence interval (CI) of the proportion of onset and death cases among 23 onset and 13 death cases occurring from "within 1 week" to "within 4 weeks" from clinical data before approval of this drug using data admitted to the Court.

RESULTS

For death cases, all of the upper limits of the 95% CI exceeded 50% within 1-4 weeks. This fact suggested that the cases of acute interstitial pneumonia were included in the clinical trial before the approval of gefitinib.

CONCLUSION

It was possible to foresee the outbreak of death cases after drug approval. This conclusion showed the Court's ruling was not reasonable and was unscientific.

[A fundamental proposal to establish an investigative system for medical accidents]

For more than a decade, numerous disputes over medical errors and other safety issues in the healthcare system have occurred and attracted growing interest from society. As a result, through the Model Project for the Investigation of Death Associated with Medical Practice, the Outline Proposal of the Measure to Establish an Investigative Commission on Medical Accidents was proposed by the Japanese Ministry of Health, Labour and Welfare. However, this measure was not finalized. The course of the controversies involved has various implications. The Project Committee of the Japan Medical Association proposed the fundamental viewpoints to establish an exploratory system for medical accidents and to change the stressful medical environment for both physicians and patients based on the principle of the occupational autonomy of physicians.

Intramedullary recurrence of germinoma in the spinal cord 15 years after complete remission of a pineal lesion

The authors present a case of germinoma that was initially found in the pineal region and recurred 15 years later in the intramedullary cervical spinal cord after intensive chemo- and radiotherapy and diagnosis of complete remission. This 28-year-old man initially presented with seizures. Hydrocephalus and a pineal tumor were found on radiological examination, and partial resection of the tumor was performed. Histological diagnosis showed a pure germinoma. Following surgery, the patient received a combination of chemo- and radiotherapy, and a complete remission was shown. However, after 15 years of follow-up, he presented with gait disturbances. Spinal MRI showed an intramedullary mass lesion in the cervical spinal cord. The cervical lesion was biopsied, and histological examination again revealed a pure germinoma. With germinomas, the possibility of a drop metastasis from an intracranial lesion to the spinal cord must be considered during follow-up. However, in the present case, analysis of a CSF sample showed no abnormalities as in previously published cases. In recent years, multidisciplinary treatments have demonstrated good event-free survival rates in cases of pure germinomas, but long-term outcomes over the decades are not fully known. Continual follow-up of such cases is recommended even after complete remission has been achieved.

Prediction of the incidence of spontaneous intracerebral hemorrhage from meteorological data

We analyzed the relationship between the incidence of spontaneous intracerebral hemorrhage (ICH) and various meteorological data (daily atmospheric air pressure, air temperature, precipitation, humidity, presence of typhoons, occurrence of the rainy season, wind velocity, and wind direction) for patients at Teraoka Memorial Hospital in Shin-ichi Town, Japan, from January 1, 2001 to December 31, 2003. All data were analyzed by contingency table analysis and multivariate regression analysis. From January 1, 2002 to December 31, 2003, we identified high-risk ICH days as those days for which the preceding 3 days mean recorded air pressure of 1,015 hPa or more and then conducted a statistical comparison of the incidence of ICH on high-risk ICH days with that on the other days. Our subjects were 164 patients with ICH. The relative risk of high-risk ICH days is 1.46 (Fisher's exact test, p=0.04). Mann-Whitney's U-tests indicate ICH tends to occur on days with lower maximum air temperature. Multivariate logistic regression analysis revealed that 3 incidences influence the occurrence of intracerebral hemorrhage (p<0.01 each): (1) days associated with 4-day periods of mean air pressure in excess of 1,015 hPa; (2) days during which a typhoon was approaching; and (3) days with west or southwest wind . Detailed examination of meteorological data indicates a relationship with the incident rate of ICH.

Relationship between the occurrence of spontaneous intracerebral hemorrhage and holidays and traditionally unlucky days in Fukuyama City, Hiroshima Prefecture, Japan

To investigate whether calendrical information influences the occurrence of spontaneous intracerebral hemorrhage, we statistically compared the incidence of intracerebral hemorrhage for inpatients at Teraoka Memorial Hospital (164 patients), against various calendrical factors such as the day of the week, national holidays, and RokuYo (a recurring six-day series of lucky and unlucky days in the Japanese traditional calendar) over the period from January 1, 2001 to December 31, 2003. On Japanese national holidays the relative risk of intracerebral hemorrhage is significantly higher than on other days, certainly due to much more alcohol consumption on holidays. During RokuYo, the relative risk of intracerebral hemorrhage is extremely low on the traditionally unlucky days of ButsuMetsu and TomoBiki, as many Japanese people restrain their activities on these days. Certain days of the year and certain times of the Japanese supplemental calendars correlate significantly with the incidence of intracerebral hemorrhage.

Endoscopy-guided removal of spontaneous intracerebral hemorrhage: comparison with computer tomography-guided stereotactic evacuation

BACKGROUND AND PURPOSE

Spontaneous intracerebral hemorrhage (ICH) continues to be a major medical and socioeconomic problem. While the surgical procedure failed to show benefits over functional outcome, a less invasive and quicker surgical decompression might improve the outcome. The authors introduced endoscopy-guided evacuation in managing ICH and reports the benefits over the conventional method.

MATERIALS AND METHODS

Twenty-seven cases underwent endoscopic evacuation of ICH (Group E). The clinical features and outcomes were compared to the retrospective data of 20 cases who underwent computer tomography (CT)-guided stereotactic removal of ICH (Group C). Confidence level less than 0.05 was considered statistically significant.

RESULTS

While the clinical features of the two groups were not significantly different except for the ICH volume, outcomes were better in all aspects in Group E. The patients in Group E required shorter operative time (72 min vs 102 min, p < 0.01) with better hematoma evacuation (95.5% vs 75%, p < 0.01), shorter stay in the intensive care unit (ICU; 4.2 days vs 6.9 days, p < 0.01) and less frequent CT scanning (6.4 times vs 8.6 times, p < 0.01) compared to the patients in Group C. Neurological outcome improved significantly in Group E 1 week after surgery (p < 0.01), but not in Group C. Glasgow outcome scale at 6 months were better in Group E than in Group C (p < 0.05). Nine patients (33%) showed good recovery at 6 months postoperatively after endoscopic evacuation of ICH.

CONCLUSION

Endoscopic hematoma evacuation provided the quick, adequate decompression of ICH. The outcomes were better than the CT-guided hematoma removal. Further study is necessary to evaluate the real benefit of this surgical procedure over the functional outcome of ICH.

[Relationship between classification of CSDH according to the Internal architecture and hematoma contents]

BACKGROUND

Based on the finding of temporal changes in the internal architecture on CT scans, we classified CSDH into 4 types: the homogeneous type, the laminar type, the separated type, and the trabecular type. The purpose of this study was to statistically analyze the relationship between the type of CSDH and the hematoma contents.

METHODS

This study assessed 45 consecutive CSDH patients. All of them were assigned to our 4 types of CT classification of CSDH, and the counts of blood cells including WBC, RBC, Hb, Ht, and platelets, as well as FDP and fibrinogen levels in the hematoma and peripheral venous blood were examined.

RESULTS

The mean RBC count was 345.3 (SD = 177.9) in all the subjects versus 426.4 (SD = 165.6) in Hm, 408.3 (SD = 79.2) in Lm, 357.2 (SD = 298.7) in Sp, and 200.0 (SD = 129.2) in Tr. The mean Hb concentration was 10.2 (SD = 5.2) in all the subjects versus 12.9 (SD = 5.3) in Hm, 12.3 (SD = 2.7) in Lm, 9.2 (SD = 6.5) in Sp, and 5.9 (SD = 4.2) in Tr. The eosinophil and lymphocyte counts were high in all the types (15.0% and 48.4% on average). The FDP concentration was high in all patients (500-5,000). Fibrinogen levels were less than 10 in all hematoma types. CRP was an average of 3.1 (SD = 4.9) in all the subjects versus 7.5 (SD = 9.8) in Hm, 2.5 (SD = 1.6) in Lm, 3.0 (SD = 2.9) in Sp, and 1.1 (SD = 1.6) in Tb.

CONCLUSION

There were relationships between the type of CSDH and the RBC, Hb, Ht, and CRP values.

[Efficacy of dynamic CT perfusion imaging in conjunction with three dimensional CT angiography for the evaluation of acute ischemic stroke]

BACKGROUND AND PURPOSE

Through the use of a high-speed spiral CT scanner (GEMedical HiSpeedZX/i), CT/P/A technique, where conventional CT, CT perfusion imaging (CTP) and CT angiography (CTA) are consecutively performed, can now be performed with an imaging time of 90 seconds and a total contrast medium volume of 100 ml. A prospective clinical study was performed to ascertain the effectiveness of CT/P/A in diagnosing acute ischemic strokes.

METHODS

29 consecutive patients of Teraoka Memorial Hospital suspected of suffering from the occlusion or constriction of cerebral arteries and who underwent CT/P/A within 3 hours from the onset served as subjects. The sensitivity, specificity, or Odds ratio of CTP and CTA in detecting lesions that caused cerebral infarction was calculated.

RESULTS

CTP detected a hypoperfusion area with a sensitivity, specificity, and Odds ratio of 80%, 64%, and 7.2. The sensitivity in lobar infarcts, white matter infarcts, basal ganglia infarcts, and brainstem infarcts was 100%, 100%, 100%, 0% (p = 0.0022). The sensitivity and Odds ratio of CT/P/A in cerebral infarcts differed according to the diameter of the infarcts. That with infarcts of 10 mm or more was 91%, 20. That with infarcts smaller than 10 mm was 50%, 2. CTA detected arterial lesions that caused cerebral ischemic attack with a sensitivity of 94% and specificity of 90%. The examination time for CT/P/A was 18 minutes, total radiation time being 90 seconds.

CONCLUSIONS

Although CT/P/A was ineffective for the diagnosis of brainstem infarcts and lesions smaller than 10 mm, CT/P/A was useful in detecting moderate-sized hypoperfusion areas and arterial lesions three-dimensionally before an infarct is completed.

MRI of secondary changes in the thalamus following a cerebral infarct

We investigated acute secondary degeneration in the thalamus following a cerebral infarct in 21 patients with an infarct in the territory of the middle cerebral artery, using serial MRI at various time after the stroke. Secondary degeneration in the ventral nuclei of the thalamus was seen as regions of slightly low signal on proton-density and/or T2-weighted images, mostly obtained a few weeks after the onset. An area of slightly high signal was observed in the dorsomedial nucleus of the thalamus on T2-weighted images about 6 weeks after the onset. Damage to the superior and anterior thalamic radiation caused degeneration in the ventral and dorsomedial nucleus, respectively. Thus, the time of detection and the abnormalities seen on MRI in secondary degeneration vary depending upon which area of the thalamus is involved. The mechanism underlying the degeneration is therefore also likely to differ in these areas.

Dissecting aneurysms at the A1 segment of the anterior cerebral artery--two case reports

Two rare cases of dissections which involve the anterior cerebral artery (ACA) are reported. A 58-year-old woman presented with a ruptured dissecting aneurysm manifesting as sudden onset of severe headache and consciousness disturbance followed by aphasia, right hemiparesis, paresis of the left lower extremity, and choreoathetotic movements of the upper arms and face. Computed tomography and angiography revealed subarachnoid hemorrhage due to a dissecting aneurysm at the left A1 segment. The dissecting aneurysm was trapped surgically on the day of onset. Her neurological deficits disappeared within a month. A 39-year-old woman experienced continuous dull headache from the day before onset, and then suffered right hemiparesis. Magnetic resonance (MR) imaging revealed cerebral infarction at the left globus pallidus. Angiography and MR imaging revealed a dissecting aneurysm at the left A1 segment and occlusion of the left Heubner's artery. She received conservative treatment and her neurological findings were improved. Dissections or dissecting aneurysms involving the ACA can be classified into three types: Extension of a dissection to the ACA from the internal carotid artery, dissection at the A1 segment, and dissection at the A2-A4 segments. These types of dissection have distinct uniform clinical features.

Platelets expressing P-selectin and platelet-derived microparticles in stored platelet concentrates bind to PSGL-1 on filtrated leukocytes

The levels of interleukin-6 and platelet-derived microparticles (PMPs) were measured in the blood of 137 patients with side effects from platelet concentrate (PC) transfusion with leukocyte removal filtration, P-selectin-expressing platelet and PMPs in stored PC before and after the filtration, and filtered leukocytes positive for P-selectin glycoprotein ligand-1. The side effects, which were observed in 203 transfusions for 84 patients with hematologic disease and 53 patients with nonhematologic disease with no significant difference between the two groups, included urticaria (75.9%), erythema (18.7%), and fever (17.2%), but no anaphylactic reactions. The levels of interleukin-6 and PMP correlated in both groups, and were significantly higher in the hematologic disease group than in the nonhematologic disease group. The level of PMP, but not interleukin-6, was significantly higher for patients testing positive for allergic reaction than for those testing negative. In the stored PC prior to filtration, the level of interleukin-6 was normal. The level of P-selectin-expressing platelets and PMPs was elevated before filtration, but was significantly lower after filtration. Taken together, the results suggest that PMP is involved in the generation of transfusion reactions, and indicate that both platelets and PMP displaying P-selectin bind to P-selectin glycoprotein ligand-1 of leukocytes retained by the leukocyte filter.

A transparent sheath for endoscopic surgery and its application in surgical evacuation of spontaneous intracerebral hematomas. Technical note

The authors advocate the use of a transparent sheath for guiding an endoscope, a simple and unique tool for endoscopic surgery, and describe preliminary results of its application in the evacuation of hypertensive intracerebral hematomas. This sheath is a 10-cm-long tube made of clear acrylic plastic, which greatly improves visualization of the surgical field through a 2.7-mm nonangled endoscope inserted within. Between April 1997 and December 1998, the authors performed endoscopic evacuation of intracerebral hematomas by using this sheath inserted into the patients' heads through a burr hole. In nine consecutive cases in which the hematoma was larger than 40 ml in volume, nearly complete evacuation (86-100%) of the lesion was achieved without complication. Excellent visualization of the border between the brain parenchyma and the hematoma facilitated accurate intraoperative orientation, and also allowed easy identification of the bleeding point. Thus, this combination of sheath and endoscope achieves both minimal invasiveness and the maximum extent of hematoma removal with secure hemostasis. This tool will reduce the inherent disadvantage of endoscopic procedures and may expand their application in other areas of neurosurgical management.

[A study on methamphetamine psychosis in a psychiatric clinic--comparison of acute and chronic-type cases]

This study compares patients with acute methamphetamine psychosis to those with chronic methamphetamine psychosis and it investigates how the two groups differ in terms of psychosomatic findings, social background, and so on. The subjects consisted of 100 outpatients diagnosed at our clinic as having methamphetamine-induced psychosis over a period of sixteen years (1979 to 1995). Of these patients, 73 were of the acute type (currently using the drug or totally abstinent for less than 3 months), and 27 were of the chronic type (totally abstinent from the drug from 2 to 38 years). Psychosomatic Findings Ninety five patients (68 acute-type and 27 chronic-type) were classified into six clinical clusters, depending on which of the following states was dominant: paranoid-hallucinatory state, schizophrenia-like state, short-tempered and impulsive state, manic-depression-like state, neurosis-like state, and permanent-encephalopathic state. In the clinical cluster of paranoid-hallucinatory state, all 32 patients were of the acute-type. On the other hand, of those patients in the clinical cluster of neurosis-like state, the majority (N = 25) were of the chronic-type. Social Background The social background of 99 patients (72 acute-type and 27 chronic-type) was investigated under the three headings of: gangsters, criminal records and broken families. Of 19 patients who are gangsters, 18 cases were acute and the remaining case was chronic. Of 64 patients with criminal records, 51 were acute and 13 were chronic. Of 24 patients who come from broken families, 20 were acute and 4 were chronic. In all of these three items, the rate of acute-type patients was significantly higher than that of chronic-type patients. Based on the results obtained, the medical treatment and the prognosis of the patients, the author refers to preventive measures for stimulant-drug abuse.

Clinical features of progressive lacunar infarction--retrospective analysis of patients with motor syndromes

The clinical features of progressive lacunar infarction were analyzed in 20 patients with lacunar infarction. Seven of the 20 patients experienced paresis progression and the remaining 13 patients had a stable course. The mean age of progressive lacunar infarction patients (78.6 +/- 4.30 yrs) was significantly higher than that of stable lacunar infarction patients (65.1 +/- 7.68 yrs) (p < 0.01). Patients presenting with pure motor stroke were more likely to have progressive stroke (7/13) than those presenting with sensorimotor stroke (0/7) (p < 0.05). Paresis aggravation began on Day 1 and ceased on Day 2 in most patients. Progressive paresis began to improve after reaching the nadir. Hemiparesis was only slightly worse after 1 month compared with that on admission. Older patients are more likely to have a progressive course. Paresis progression in lacunar patients does not preclude the possibility of recovery and is not necessarily associated with a poor prognosis.

High cervical chordoma--case report

A 42-year-old male presented with a high cervical chordoma detected at an early stage and manifesting only as neck pains. Serial cervical roentgenograms over 8 years confirmed the slow growth character of this malignant tumor. Computed tomography and magnetic resonance imaging provided clear visualization of the tumor localized in the anterior aspect of the C-2 vertebral body. The tumor was totally removed through a transoral approach. Early diagnosis of vertebral chordoma is difficult due to the slow growth character and insidiousness of initial symptoms, but meticulous examination of serial roentgenograms, followed by neuroimaging, can achieve early detection of cervical chordoma.

Intracranial vertebral artery dissections: clinical, radiological features, and surgical considerations

We reviewed 24 patients with intracranial vertebral artery dissections treated during the last 12 years. Sixteen patients were admitted with subarachnoid hemorrhage (SAH) and 8 did not have SAH. The mean age at the time of onset was 50.0 years. Male preponderance was noted. Among 21 patients with acute onset, 6 (29%) experienced prodromal neck pain and 3 (60%) of 5 SAH patients showed nuchal stiffness when examined within 6 hours of onset. The preoperative angiographical findings were uniform in SAH cases in contrast to the varied angiographical findings seen in non-SAH cases. So-called pearl and string sign was observed in most SAH cases, but the "string" was often so short and wide that the term "constriction" appeared more suitable. From intraoperative observations, the angiographical point of constriction seemed to represent the proximal or distal end of dissection. As for treatment, 19 patients underwent 20 surgeries. Trapping was performed in eight surgeries, base clipping was performed in five, and proximal clipping was performed in seven. Both trapping and base clipping prevented further bleeding, but trapping was associated with a high rate of postoperative lower cranial nerve palsy. Postoperative neurological complications were less frequent after proximal clipping, but subsequent postoperative bleeding occurred in one patient treated by this technique. The overall long-term outcome in the surgically treated cases in our series was favorable, but most patients suffered from various degrees of uncomfortable dysphagia or hoarseness for some period after surgery. It was also noted that, in half of the disabled cases, the major disability was attributable to lower cranial nerve palsy and respiratory troubles that developed postoperatively.

Nonsurgical treatment of unruptured intracranial vertebral artery dissection with serial follow-up angiography

The question of whether unruptured intracranial vertebral artery dissections should be treated surgically or nonsurgically still remains unresolved. In this study, six consecutive patients with intracranial vertebral artery dissection presenting with brain-stem ischemia without subarachnoid hemorrhage (SAH) were treated non-surgically with control of blood pressure and bed rest, and five received follow-up review with serial angiography. No further progression of dissection or associated SAH occurred in any of the cases, and all patients returned to their previous lifestyles. In the serial angiograms in five patients, the findings continued to change during the first few months after onset. Four cases ultimately showed "angiographic cure," while fusiform aneurysmal dilatation of the affected vessel persisted in one case. In one patient, arterial dissection was visualized on the second angiogram despite negative initial angiographic findings. These results indicate that intracranial vertebral artery dissection presenting without SAH can be treated nonsurgically, with careful angiographic follow-up monitoring. Persistent aneurysmal dilatation as a sequela of arterial dissection seemed to form a subgroup of fusiform aneurysms of the posterior circulation. These aneurysms may be prone to late bleeding and may require surgical treatment.

Magnetic resonance imaging study of intracranial vertebrobasilar artery dissections

BACKGROUND AND PURPOSE

The purpose of this study is to demonstrate the magnetic resonance features of intracranial vertebrobasilar artery dissections and to determine the potential and limitations of magnetic resonance imaging in their diagnosis.

METHODS

We studied five consecutive patients with angiographically verified intracranial vertebrobasilar artery dissection with magnetic resonance imaging (0.5 T) in regard to the shapes of the intramural hematoma and the chronological change of its signal intensity. We also estimated the sensitivity of magnetic resonance imaging for diagnosing dissection.

RESULTS

We observed intramural hematoma in four patients on the first magnetic resonance scan and in all five patients during the course of the study. The shapes of the intramural hematomas were curvilinear, crescentic, "bamboo-cut," "band-like," and spotty. The intensity of the intramural hematoma varied according to its age. On the T1-weighted and the proton images, the intramural hematomas appeared isointense to slightly hyperintense in the first few days and became hyperintense thereafter. The intramural hematomas became isointense or unrecognizable 2 months after onset. The T1-weighted image and the proton images were superior to the T2-weighted image in demonstrating the intramural hematomas.

CONCLUSIONS

Magnetic resonance imaging is a sensitive tool for diagnosing intracranial vertebrobasilar artery dissection, particularly in the subacute to early chronic stage. Magnetic resonance imaging is complementary to angiography in that it can directly visualize intramural hematomas.

Intradural, purely extramedullary hemangioblastoma of the spinal cord--case report

An unusual, purely extramedullary hemangioblastoma of the spinal cord occurred in a 59-year-old female. Myelography revealed a filling defect at the Th6 level, and computed tomographic myelography demonstrated an extramedullary intradural isodense mass at the same level. The mass was homogeneously enhanced on postcontrast computed tomographic scans. T1-weighted magnetic resonance imaging showed an isointense mass, homogeneously enhanced by contrast medium. The tumor was removed en bloc.

Degeneration of the ipsilateral substantia nigra following cerebral infarction in the striatum

BACKGROUND AND PURPOSE

In rats, degeneration of the ipsilateral substantia nigra occurs a few weeks after occlusion of the middle cerebral artery. The aim of this study was to clarify whether similar change is observed in stroke patients.

METHODS

Eighteen patients with striatal infarction and six patients with cortical infarction in the territory of the middle cerebral artery were examined by means of sequential magnetic resonance imaging.

RESULTS

In all patients with striatal infarction, T2-weighted images revealed a high-signal-intensity spot in the ipsilateral substantia nigra. Changes in the ipsilateral substantial nigra appeared at day 14 after stroke on average and then became less intense and smaller a few months after the stroke. By contrast, we observed no nigral changes in any patient with cortical infarction.

CONCLUSIONS

The degenerative change in the ipsilateral substantia nigra initially found in the rat model similarly occurred in patients with striatal infarction. This remote change in the substantia nigra may represent magnetic resonance imaging detection of neuropathologic changes in this region through the striatonigral pathway.

Determination of the minimal concentrations of contact activation factors in deficient substrate plasmas required to assess accurately factor XII, factor XI, factor IX, and high molecular weight kininogen

Using combined deficient plasmas prepared by passage of a deficient plasma over an anti-factor XI-monoclonal antibody column, we have determined the threshold concentrations of each coagulation factor of contact phase in factor-deficient substrate plasmas required to determine accurately the functional activities of factor XII, factor XI, factor IX and high molecular weight kininogen (HMWK). In order to reliably quantitate factor XI and factor IX activity levels, at least 20% factor XII and 20% factor XI, respectively, were required in the deficient substrate plasmas. In the assessment of factor XII activity, approximately 40% factor XI was required in the factor XII-deficient substrate plasma. On the other hand, only 11-12% factor XI or HMWK was required in the deficient substrate plasmas in the assessment of these two clotting factors. Our data emphasize that deficiencies of other clotting factors may reduce the apparent activity of the clotting factor in question if their concentration is rate-limiting in the clotting assay.

[Dissecting aneurysm of the posterior inferior cerebellar artery--a case report]

The authors present a case of dissecting aneurysm of the right posterior inferior cerebellar artery (PICA) in a 47-year-old female, who suffered from mild subarachnoid hemorrhage. Right vertebral angiogram showed typical "pearl and string" sign of the PICA, but we could not fully understand the condition until a surgical exposure revealed a purple sausage-like dissecting aneurysm of the PICA. The aneurysm was wrapped with muscle pieces. Postoperatively she developed Wallenberg's syndrome, but it subsided gradually. No specific disorder concerning the mural dissection was found in this patient, except for a history of mild hypertension. This case is unusual because it affected not an arterial trunk but a small branch and we could find only one other case reported in the literature. Other formerly reported cases were of arterial trunks. The intracranial dissecting aneurysm has been known as a rare cause of cerebral infarct in children and adolescents. Infants are also affected and referred to as "infantile hemiplegia". It mainly affects one of the trunk arteries and cause a severe ischemic stroke, and surgically treatable case is rare. But as the typical angiographic findings are commonly known the number of the reported cases is increasing at an accelerating rate, and some of them are being noted to need surgical treatment because they cause subarachnoid hemorrhage. We here emphasize that not only trunk arteries but also small branch arteries can develop mural dissection, leading to subarachnoid hemorrhage. Dissecting aneurysm of a smaller artery would be milder in symptom, and would give more chance for surgical intervention.(ABSTRACT TRUNCATED AT 250 WORDS)

[Evaluation of regional brain circulation by dynamic computer tomography]

Regional brain circulation was evaluated by dynamic computed tomography with iodine enhancement. The CT number (Hounsfield unit)-time curve provided us three parameters, namely, peak value, rapid washout ratio and filling time. It was indicated that these three parameters were related to different components. Peak value was related to blood volume, rapid washout ratio to transit time and filling time to filling velocity and/or distance from the point of injection to the site of measurement. In 10 patients with brain edema, both peak value and rapid washout ratio were decreased, comparing to these of 5 normal subjects. In 24 patients with cerebral infarction, decreased peak value was a main finding. In 3 patients with occlusion of internal carotid artery, delayed filling time was demonstrated in every patient. Clinical application of dynamic computed tomography was discussed.

Treatment of bilateral mycotic intracavernous carotid aneurysms. Case report

A case of bilateral mycotic intracavernous carotid aneurysms is reported. Because of progressive bilateral ophthalmoplegia, the internal carotid artery (ICA) was ligated on both sides, combined with bilateral extracranial-intracranial arterial bypass. A superficial temporal artery-middle cerebral artery anastomosis was performed first on the right side followed by ligation of the right ICA at the neck. After an interval of 20 days, a bypass and ICA ligation was carried out on the left side. The patient developed mild hemiparesis and dysphasia during and immediately after the second operation, but these neurological deficits disappeared after elevation of systemic blood pressure.

Xanthogranulomas of the choroid plexus in a neuro-epileptic child. Case report

Bilateral xanthogranulomas arising from both choroid plexues were found in a 6-year-old child with epileptic seizures and psychomotor retardation. Both masses were surgically removed without adding any neurological deficits. The xanthogranulomas were fairly large, and the posterior part of both lateral ventricles were slightly dilated, but clinical symptoms and the location of the xanthogranulomas could not be clearly correlated in this case.