Treatment of restenosis after percutaneous transluminal angioplasty for internal carotid artery stenosis

The efficacy of repeated percutaneous transluminal angioplasty (PTA) and carotid endarterectomy (CEA) was examined in patients with restenosis after PTA for carotid stenosis. After percutaneous transluminal angioplasty (PTA) for 63 cases of internal carotid stenoses 13 cases of restenosis appeared. They were treated by PTA or carotid endarterectomy. The treatment was chosen by the patient after explanation of each treatment. We initially treated seven patients by repeat PTA and six by carotid endarterectomy. The degree of stenosis improved from 82% to 30% on average after repeated PTA. However, one patient in the PTA group had restenosis, and carotid endarterectomy was then performed. The other cases also had restenosis and were treated by PTA. The six cases treated by carotid endarterectomy were successfully treated without difficulty. The success rate of PTA was 5/7 (71%) in the restenosis cases. Patients with a greater residual stenosis after initial PTA had significantly more frequent restenosis. Repeat PTA and CEA both appeared effective treatment for restenosis after initial PTA, although PTA had a restenosis rate similar to that of initial PTA.

[Dural arteriovenous fistula at the cranio-cervical junction presenting transient ischemic attack: a case report]

A 58-year-old male was admitted to our hospital because of repeated transient ischemic attack of right hemiparesis and speech disturbance. A CT scan did not demonstrate any remarkable findings. No significant cerebral arterial stenosis or occlusion was found on angiography. However, dural arteriovenous fistula fed by the radiculo-meningeal artery was found at the cranio-cervical junction on left vertebral angiography. The shunt flow from the arteriovenous fistula drained into the superior petrosal sinus and sigmoid sinus in a retrograde fashion. On the angiographic findings when his transient ischemic attack (TIA) had disappeared, the venous drainage had returned to its normal fashion. Venous hypertension around the brain stem was supposed to have caused the transient ischemic attack in this case. We performed coagulation of the draining vein and fistula surgically. After surgery, the patient's TIA completely disappeared. We report the first case of dural arteriovenous fistula at the cranio-cervical junction presenting transient ischemic attack.

Transcortical sensory aphasia due to a left frontal subcortical haemorrhage

A case of transcortical sensory aphasia caused by a cerebral haemorrhage in the left frontal lobe is presented. A 72-year-old right-handed woman was admitted to the hospital, with a history of acute onset of speech disturbance and headache. On initial assessment, her spontaneous speech was fluent. She had no difficulty initiating speech, articulated normally, and did not exhibit logorrhea. Her ability to repeat phonemes and short sentences (5-6 words) was fully preserved, however she had severe difficulty with visual recognition of words, and with aural comprehension at the word level, although she was able to read words aloud. Computed tomography and magnetic resonance imaging showed cerebral haemorrhage in the left frontal lobe, involving the superior and middle frontal gyrus. Single photon emission CT revealed a wider area of low perfusion over the entire left frontal lobe, including the superior, middle and inferior frontal gyrus. The aphasia symptoms, mainly poor comprehension, disappeared quickly several weeks after the event. This may have been due to a reduction in the size of the haematoma and a resolution of the oedema around the haematoma. Clinically, the transcortical sensory aphasia in this case was indistinguishable from that caused by damage to the posterior language areas. Further case reports of transcortical sensory aphasia associated with frontal lobe lesions would help to confirm whether a relatively rapid recovery is characteristic in cases such as this.

[Construct validity of a new computer-assisted cognitive assessment battery in normal adults]

A computer-assisted battery for neuropsychological tests (CNT) has been designed to screen adults for cognitive impairment. The aim of this study was to gather evidence for the construct validity of CNT and also investigate the relationship between CNT and conventional neuropsychological tests. Subjects were 45 healthy adults (21 men and 24 women), who ranged in age from 20 to 70 years (mean = 33.5, SD = 1.9) with no history of substance abuse, or of psychotic or neurological disorders. The CNT in our study consists of six subtests designed to assess various components of driving, such as digit span, visual scanning, visual and verbal memory, complex reaction time, and vigilance. Mini-mental state test, Kana-hiroi test, word fluency, the auditory-verbal learning test and Raven's colored progressive matrices were also performed as conventional neuropsychological tests. Results showed there were high correlations between each CNT subtests and conventional neuropsychological tests. A factor analysis (with varimax rotation) identified 4 factors with eigen values greater than 1, which accounted for over 70% of the variance. CNT was able to estimate each factor related to cognitive function such as learning and memory, attention, judgment, and visual scanning selectively. CNT may thus be a useful tool for detection of cognitive impairment, although this test has important limitations. Broader applications of these tests will require extensive population-based validation.

[A case of agraphia due to cerebral infarction in the left parietal lobe]

A case of agraphia due to cerebral infarction in the left parietal lobe was reported. A 63-year-old right-handed man was admitted to our hospital with writing disturbance. His spontaneous speech was fluent, and object naming, word fluency, repetition, verbal comprehension, and reading were fully preserved. However, his writing was slow and required effort. He showed hesitation in spontaneous writing and dictation. His power to copy was better than his power to write spontaneously or to take dictation, but he had some difficulty in copying letters and complex figures. The patient showed abnormal sequences of strokes and completed his strokes by piecing out of several fragments. CT scan and MRI showed a cerebral infarction in the left parietal lobe which included the superior parietal lobule. The amytal (Wada) test, which was performed via the left internal carotid artery, revealed that the left hemisphere was dominant for language. The characteristics of his agraphia much more closely resembled "apractic agraphia", as reported by Alexander et al (1992), than spatial agraphia or pure agraphia. Agraphia in this patient might result partially from the loss or unavailability of the memory of motor patterns necessary for writing letters.

Percutaneous Transluminal Angioplasty for Bilateral ICA Occlusive Lesions

SUMMARY

We performed Percutaneous Transluminal Angioplasty (PTA) in 50 patients with internal carotid artery (ICA) stenosis. Fifteen of these patients also showed signs of contralateral ICA occlusive lesions. Various neurological symptoms, such as hemiparesis or convulsions, frequently appeared in these patients with contralateral lesions during PTA. The balloon inflation time was restricted in 2 patients who experienced convulsions during PTA, resulting in an unsuccessful dilatation in one case. No permanent neurological deficits appeared as a result of PTA in these cases. The treatment for these cases is discussed in this report.

An aneurysm of the right gastroepiploic artery

A palpable mass was unexpectedly found in the upper abdomen of a 67-year-old woman. Computed tomography (CT) and abdominal angiography both indicated an aneurysm of the right gastroepiploic artery. An aneurysmectomy was performed, and the aneurysm was found to be spherical with a diameter of 7.5 x 7.7 cm. The patient was eventually discharged in good condition. The histological findings of the aneurysmal wall revealed medial fibrosis and atherosclerosis. Gastroepiploic artery aneurysms are rare among splanchnic artery aneurysms and most such aneurysms are found to be ruptured. The present report described a quite rare case of an asymptomatic giant gastroepiploic artery aneurysm and also includes a review of the 10 reported cases of gastroepiploic artery aneurysms in the English literature to date. Since gastroepiploic artery aneurysms have a high risk of rupture it is essential that appropriate surgical measures be taken immediately.

Synthesis and biological properties of a new series of anti-MRSA beta-lactams; 2-(thiazol-2-ylthio)carbapenems

A series of 1 beta-methylcarbapenems containing variously C-2 substituted thiazol-2-ylthio groups were synthesized, and their in vitro anti-MRSA activity was examined. Among them, 1 beta-methyl-2-(4-arylthiazol-2-ylthio)carbapenems exhibited superior anti-MRSA activity. Introduction of a cationic moiety in the C-2 side chain not only reduced the binding to HSA but also increased the stability against DHP-I, without affecting the anti-MRSA activity. It was also found that the distance between the cationic moiety and the carbapenem skeleton was related to the strength of HSA binding and the stability against DHP-I.

A comparison of open and laparoscopic cholecystectomy for patients with cirrhosis

To evaluate the benefits of performing laparoscopic cholecystectomy (LC) in patients with cirrhosis, data on 13 patients with liver cirrhosis who underwent cholecystectomy for gallstones between 1989 and 1995 were retrospectively collected from charts filed at Fukuoka City Hospital. These 13 patients were classified into two groups; one, comprised of 7 who underwent LC, and another, comprised of 6 who underwent open cholecystectomy (OC). No statistical differences were observed in the duration of surgery or the intraoperative blood loss between the two groups; however, the C-reactive protein (CRP) level in the serum was significantly higher in the OC group than in the LC group. LC was followed by a significantly earlier resumption of a normal diet (P < 0.05) and a shorter hospital stay (P < 0.05) in comparison to OC. All of the patients who underwent OC had an uneventful clinical course; however, one of the patients who underwent LC suffered from intractable ascites postoperatively. The difference in the cost of hospitalization between the two groups was not statistically significant. These findings suggest that the therapeutic significance of performing LC in patients with cirrhosis should be assessed after carefully evaluating all factors including mortality, morbidity, and cost-effectiveness. Thus, further controlled trials are necessary.

Endoscopic injection sclerotherapy for esophageal varices associated with concomitant portal venous thrombus of hepatocellular carcinoma

Between 1983 and 1994, we treated 51 patients with esophageal varices and portal trunk and main branch invasion of hepatocellular carcinoma, using endoscopic injection sclerotherapy. Variceal bleeding was controlled in 28 of 29 patients (96.6%), esophageal varices were completely eradicated in 28 (54.9%), and only 2 of 28 (7.1%) bled from small, dilated, venous vessels after eradication. The cumulative nonbleeding rate at 3 years was 87.5%. Death caused by hepatocellular carcinoma accounted for 89.4% of the patients, whereas the rate of bleeding from esophageal varices was 4.3%. Variables significantly associated with the duration of survival were Okuda's clinical stage, alpha-fetoprotein, eradication of esophageal varices by sclerotherapy, and treatment of hepatocellular carcinoma, as determined in a univariate analysis. Multivariate analysis showed that eradication of esophageal varices by sclerotherapy, Okuda's clinical stage, and age were independent factors which significantly influenced survival time. We propose that complete eradication of esophageal varices and close follow-up using endoscopy may lead to a reduction in bleeding from esophageal varices, and hence may reduce mortality rates related to this bleeding.

Surgical excision of hemophilic pseudotumor of the ilium

The iliac hemophilic pseudotumor is a rare complication of hemophilia occurring in 1-2% of patients with Factor VIII or Factor IX deficiency. It is frequently disabling and life threatening. This report presents a comparative study of postoperative results of two cases of hemophilic pseudotumor of ilium. One patient undergoing partial resection showed a favorable postoperative course, whereas the patient with complete resection of the pseudotumor died of postoperative bleeding and sepsis. Studies on the postoperative results of these two cases indicate that careful preoperative consideration of tumor size and degree of infiltration is of the utmost importance in operative management. Early excision of tumors eliminates the possibility of endogenous infection. Even partial resection of huge tumors, leaving the lateral wall intact for compression, can promote recovery of functions.

Over-tube is preferable to free-hand technique to avoid recurrence of varices after endoscopic injection sclerotherapy. Prospective randomized trial

One hundred and two patients undergoing sclerotherapy of esophageal varices, using 5% ethanolamine oleate, were randomly allocated to either the over-tube (O-T) or the free-hand (F-H) group, and 100 patients could be followed at monthly intervals for a period of 30.8 +/- 14.7 months (mean +/- SD) after the varices had been eradicated. Endoscopy performed one month after the final session of sclerotherapy revealed circumferential ulcers and scarring in the lower esophagus in 42 of 50 patients (84%) in the O-T group and in 16 of 50 patients (32%) of the F-H group, the difference being statistically significant (P less than 0.01). In the remaining 8 and 34 patients in the O-T and the F-H groups, respectively, a partly fibrotic residual mucosa was seen. There was a recurrence of the varices in the residual mucosa in 14 (28%) in the F-H group during the mean follow-up period of 25.6 months, while there were five patients (10%) with a recurrence of varices in the O-T group, the difference being statistically significant (P less than 0.05). The survival rates showed no statistical significance. Two patients in the F-H group had recurrent bleeding. We conclude that the over-tube technique of sclerosing esophageal varices reduces the rate of recurrence of the varices, in the long term follow-up, and after formation of a circumferential scarring in the lower esophagus.

Synthesis and biological properties of 1 beta-methylcarbapenems with N-methylpyrrolidinylthio group at C-2 position

A series of 1 beta-methylcarbapenem compounds, which have a 5'-substituted-N-methylpyrrolidin-3'-ylthio group as a C-2 side chain, have been prepared and their biological properties were investigated. Substitution with a methyl group on the nitrogen atom in the C-2 side chain effectively enhanced stability to renal dehydropeptidase-I as well as introduction of methylene spacer between the aminocarbonyl group and the pyrrolidine ring of the 5'-aminocarbonylpyrrolidin-3'-ylthio group.

Sclerotherapy vs. esophageal transection vs. distal splenorenal shunt for the clinical management of esophageal varices in patients with child class A and B liver function: a prospective randomized trial

Ninety-six patients with good liver function (Child class A or B) and esophageal varices were randomly assigned to one of three groups given different treatments: endoscopic injection sclerotherapy (n = 32), esophageal transection (n = 32) or distal splenorenal shunt (n = 32). Five patients (5.2%) had to be excluded from this study because severe chronic pancreatitis made separation of the distal splenic vein from the pancreatic bed difficult. Esophageal transection was performed for these patients. No deaths occurred during the 30 days of treatment. The 5-yr cumulative bleeding rates were 0%, 5.9% and 12.9% in the endoscopic injection sclerotherapy, esophageal transection and distal splenorenal shunt groups, respectively (no statistical significance). In no case in the three groups did death occur because of variceal bleeding. Sixteen patients died, mainly because of underlying liver disease; four were in the endoscopic injection sclerotherapy group, five were in the esophageal transection group and seven were in the distal splenorenal shunt group. No statistically significant difference in survival rate among the three groups was found. These results show that endoscopic injection sclerotherapy is a satisfactory alternative to esophageal transection or distal splenorenal shunt for the clinical management of patients with esophageal varices.

Endoscopic injection sclerotherapy for 1,000 patients with esophageal varices: a nine-year prospective study

We report here the results of endoscopic injection sclerotherapy performed in 1,000 consecutively treated Japanese patients with esophageal varices. This prospective study covered the period from 1982 to 1990. Variceal bleeding was controlled in 215 (97.7%) of 220 patients. Esophageal varices were completely eradicated in 778 patients (77.8%); the mean number of sessions was 4.2. In only 3 of the 778 patients did esophageal varices of the same size recur. Small, dilated, venous vessels that required additional sclerotherapy in follow-up endoscopy at 3-mo intervals appeared in 171 (22.2%) of 778 patients. The cumulative nonbleeding rate at 5 yr was 94.5% in patients in whom the varices had been eradicated. Deaths caused by upper gastrointestinal bleeding accounted for 2.6% of cases, whereas the rates of liver failure and hepatoma were 4.6% and 47.3%, respectively. The 5-yr cumulative survival rate was 54.1% in patients without concomitant hepatoma; it was 12.0% in patients with hepatomas. Multivariate analysis showed that hepatoma, Child classification, indication (acute, elective or prophylactic) and eradication were independent factors that significantly influenced survival time. This study clearly shows that close follow-up with endoscopy and complete eradication lead to significant reduction in bleeding from esophageal varices and reduction of mortality related to this bleeding.

Gastric bleeding after endoscopic injection sclerotherapy for esophageal varices may be fatal

Among 457 Japanese cirrhotic patients with esophageal varices, 28 (6%) bled from the upper gastrointestinal tract after the initial session of endoscopic injection sclerotherapy (EIS); 13 bled during the course of repeated EIS and 15 bled mainly from gastric lesions after eradication of the varices. Of these 28 patients, bleeding from gastritis occurred in 13 (46%), from esophageal varices in 10 (36%), from gastric varices in 4 (14%) and from gastric ulcer in one (4%). Six of 13 patients with gastritis-related bleeding and 3 of 4 patients with gastric variceal bleeding died of uncontrollable hemorrhage complicated liver failure, while 9 of 10 patients with esophageal variceal bleeding were controlled and reinjection was feasible. Ten (36%) of the 28 patients, with Child's grade B or C and severe ascites, died, mainly following bleeding from gastric lesions. This study shows that bleeding from gastric lesions after EIS can be uncontrollable and fatal in patients with poor liver function.