Analysis of Age, Sex, Lack of Response to Intravenous Immunoglobulin, and Development of Coronary Artery Abnormalities in Children With Kawasaki Disease in Japan

IMPORTANCE

Initial intravenous immunoglobulin (IVIG)-refractory status and prolonged fever are established risk factors for the development of coronary artery abnormalities (CAAs) among patients with acute-phase Kawasaki disease (KD). However, whether different risk factors exist for initial unresponsiveness to IVIG and CAA development remains unclear.

OBJECTIVE

To evaluate whether different risk factors exist for initial unresponsiveness to IVIG and CAA development among patients with KD (stratified by age at disease onset).

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study included a consecutive sample of 2414 patients from a database of patients with KD from October 1, 1999, to September 30, 2019. The data were based on annual surveys (response rate, 100%) using hospital medical records across Wakayama Prefecture, Japan. Data were analyzed from March 6 to March 26, 2022.

EXPOSURES

The patient's age and diagnosis of KD by board-certified pediatricians using the criteria established by the Japan KD Research Committee.

MAIN OUTCOMES AND MEASURES

Initial unresponsiveness to IVIG, defined as treatment with optional or advanced therapies, and development of CAAs. Echocardiograms performed 1 month after KD onset using the Japanese Ministry of Health criteria evaluated the presence or absence of CAAs. Odds ratios (ORs) with 95% CIs of patient age at KD onset for unresponsiveness to IVIG and developing CAAs were calculated using multivariable logistic regression models.

RESULTS

A total of 2414 patients (1403 male patients [58.1%]; median age at onset of KD, 25 months [range, 1-212 months]) were included in the study: 550 younger than 12 months, 1342 aged 12 to 47 months, and 522 older than 47 months. A total of 535 patients (22.2%) received optional or advanced treatment and 68 patients (2.8%) developed CAAs 1 month after disease onset. The sex-adjusted OR among patients younger than 12 months for unresponsiveness to IVIG was 0.77 (95% CI, 0.59-0.99) and for development of CAAs was 1.94 (95% CI, 1.07-3.52); among those older than 47 months, the OR for unresponsiveness to IVIG was 1.32 (95% CI, 1.05-1.67) and for development of CAAs was 2.47 (95% CI, 1.39-4.39). After adjusting for IVIG administration, ORs among boys older than 47 months for unresponsiveness to IVIG was 1.14 (95% CI, 0.84-1.56) and for development of CAAs was 2.15 (95% CI, 1.08-4.30); among girls younger than 12 months, the OR for unresponsiveness to IVIG was 1.02 (95% CI, 0.65-1.60) and for development of CAAs was 3.79 (95% CI, 1.21-11.90).

CONCLUSIONS AND RELEVANCE

The results of this study suggest that risks of unresponsiveness to IVIG and the development of CAAs differ between infants with KD and older patients with KD. Residual risk factors for KD-related CAAs other than initial unresponsiveness to IVIG should be addressed, particularly in infants.

The Strategy of Dural Arteriovenous Fistula with Isolated Sinus

We treated 7 cases of dural arteriovenous fistulas (dAVF) with isolated sinus by transvenous direct embolization.

The fistulas located in the transverse-sigmoid sinus in 5 cases, superior sagittal sinus in 1 case and transverse-sigmoid and superior sagittal sinus in 1 case.

The initial symptoms were generalized convulsion in 2 cases, disturbed consciousness in 1 case, tinnitus in 2 cases and transient ischemic attack in 2 cases. We performed sinus packing with coils in all cases following transarterial embolization.

All patients improved neurologically after the treatments and AVFs completely disappeared in all cases.

Endovascular Treatment for Internal Carotid Stenoses

Seventy four cases of internal carotid stenoses greater than 60% were treated by PTA and/or stenting 86 times. Sixty one cases of cervical ICA stenosis were treated 71 times. 11 cases of high cervical - intracranial ICA stenosis were treated 13 times. Two cases of ICA dissection were treated by stent deployment.

Stenotic ratio reduced from 79% to 29% in cervical ICA stenosis and 71 % to 32% in high cervical to intracranial ICA stenosis in average. Morbidity related to PTA and/or stenting was 2/74 (2.7%) and mortality was 0%. One was an ischemic complication and the other was a hemorrhagic complication due to hyperperfusion. Restenosis (stenosis greater than 70%) rate was 32%. Asymptomatic cerebral embolism were found in three cases (4.2%) on angiogram immediately after PTA and/or stenting. The complication rate related to PTA and/stenting was low but asymptomatic emboli were found in three cases.

Considering these results, the indication for PTA and/stenting should be restricted to patients with high risk group, such as cases with high medical risks or difficult CEA cases, if appropriate protective systems for cerebral emboli were not available.

The study on the patency of the perforating arteries after stent placement in atherosclerosis induced rabbits

SUMMARY

The number of successful case reports with percutaneous transluminal angioplasty (PTA) / stenting for intracranial atherosclerotic stenoses is recently increasing with the advent of flexible coronary stents. However, it is not well known whether the perforating artery is occluded or not after stent placement in the atherosclerotic stenotic vessels. We investigated this issue using five New Zealand white rabbits. We deployed stainless steel stents in the atherosclerosis-induced abdominal aorta across the lumbar artery in which the diameters of the abdominal arteries were similar to those of human intracranial arteries. We evaluated the patency of lumbar artery by angiography and scanning electron microscopy three months after stent placement. The lumbar arteries were patent in four out of five rabbits. However, SEM findings demonstrated stent struts were covered with thick neointima and the ostia between stent struts were partially occluded. It is possible that stent placement in the atherosclerotic arteries can cause the obliteration of the perforating arteries.

Clinical results of percutaneous transluminal angioplasty and stenting for intracranial vertebrobasilar atherosclerotic stenoses and occlusions

SUMMARY

Eighteen patients with intracranial vertebrobasilar stenosis and occlusion were treated by PTA or stenting. In 11 of 18 cases, only PTA was performed and in seven of 18 cases, we used stents. The mean stenosis before and after PTA/stenting was 82.8% and 22.3%, respectively. In 11 cases of PTA only, the stenotic rate decreased from 81.8% to 29.6%, while 85.0% of the stenotic rate remarkably reduced to 6.0% in seven cases of stenting. The 30 days morbidity and 30 days mortality rate were 5.5% and 5.5%, respectively. There was only one haemorrhagic complication (cerebellar haemorrhage) in cases of stenting, and no ischemic events during or after the procedures. Restenosis (more than 50% stenosis) occurred in four of 18 cases(22.2%) during mean followup period of 12 months. Two patients with VA occlusion before treatment, developed restenosis and reocclusion. Complete total occlusion seems to be a high-risk lesion and strict follow-up is required. In this study, PTA/stenting for intracranial vertebrobasilar artery stenosis or occlusion is an effective treatment, but strict indications may be required because procedure-related 30 days morbidity rate was 5.5% in addition to unclear natural history.

Traumatic bilateral common carotid artery dissection due to strangulation. A case report

SUMMARY

We report a case of bilateral common carotid artery dissection due to strangulation successfully treated by stent placement, with a review of the literature. A 61-year-old woman was strangled by an apron strap. She was admitted to our hospital with tetraparesis, because of spinal cord injury. On the next day, her left hemiparesis aggravated and left facial palsy newly appeared. Diffusion weighted magnetic resonance imaging (MRI) showed new ischemic lesions in the right cerebral hemisphere. Aortography revealed bilateral common carotid artery dissection. Moreover, thrombus or intimal flap was recognized in the right common carotid artery. The right common carotid dissection was fixed with deployment of self expanding stents to prevent the aggravation of ischemic stroke at that time. The contralateral lesion was also treated ten days later because small ischemic lesions were newly recognized in the left hemisphere on MRI. No new neurological deficit appeared after bilateral carotid artery stenting. Her paraparesis completely improved two months after the spinal cord injury. Carotid artery stenting using self expanding stents was especially effective as the treatment for bilateral carotid artery dissection.

Balloon or Stent-assisted Coil Embolization for Acutely Ruptured Wide-necked Aneurysms

SUMMARY

In this paper, we report five cases with acutely ruptured wide-necked aneurysms, which were treated with coil embolization using a balloon or stent-assisted technique. Balloon-assisted coil embolization using Equinox balloon, Commodore balloon, and Hyperform balloon were performed for four patients and stent-assisted coil embolization using BX velocity for one patient. We discuss problems of coil embolization for acutely ruptured wide-necked aneurysms with a balloon or stent-assisted technique.

Endovascular coil embolization for cerebral aneurysms solely using ultrasoft coils

SUMMARY

We report a series of coil embolizations for small aneurysms solely using GDC ultrasoft coils and discuss the advantages of this method. Seven small aneurysms (< 4.0 mm) were embolized solely with ultrasoft coils. Ultrasoft coils were sequentially inserted into aneurysms. Immediately after embolization, five aneurysms were completely occluded, and two exhibited body filling. All cases were treated successfully without any complications. In conclusion, ultrasoft coils were found efficacious for the treatment of small, irregular-shaped, and ruptured aneurysms; their softness and malleability facilitated their compaction into an aneurysm.

Coil embolization training using a rabbit saccular aneurysm model

SUMMARY

We developed a rabbit saccular aneurysm model for coil embolization training. Elastaseinduced aneurysms were created successfully in about 80% of the rabbits. The aneurysms were usually broad in the neck and lengthy. At the 28(th) postoperative day, the aneurysms were about 1.5 times larger in both width and height than they had been at the 14(th) day. All aneurysms were successfully embolized with 18-sized electrically detachable (ED) platinum coils. After embolization, almost all aneurysms had a neck remnant. In conclusion, this model is useful not only for learning the technique of coil embolization but also for testing new embolic materials. The rabbit aneurysm model proved to be an efficacious training modality for endovascular coil embolization.

Endovascular treatment of unruptured cerebral aneurysms

76 consecutive patients with 78 unruptured cerebral aneurysms underwent endovascular therapy from July 1999 to May 2004 in our institute. For the wide-necked aneurysms, the remodeling technique, double microcatheter technique, or stent-assisted coil embolization was used, while a parent artery occlusion or covered stent was applied for the giant or fusiform aneurysms. Immediate angiographical results demonstrated 33 complete occlusions, 26 neck remnants, and 14 dome fillings. Four cases were treated with parent occlusion or stenting only, and one case was not treated with embolization but with clipping due to the rupture of the aneurysm during coil embolization. Immediate angiographic findings demonstrated that in aneurysms between 5 to 10 mm, the rate of complete occlusion was 48%, that of neck remnants 33%, and that of dome fillings 27%. In aneurysms between 11 to 25 mm, the rate of complete occlusion was 14%, that of neck remnants 28%, and that of dome fillings was 58%. In the angiographic follow-up results, all aneurysms smaller than 5 mm showed complete occlusion. In aneurysms between 5 to 10 mm, 74% of the aneurysms showed complete occlusion, and 21% showed neck remnants, and 5% showed dome filling. In aneurysms between 10 to 24 mm, 25% showed complete occlusion, while 75% showed dome filling. The overall mortality rate was 0% and the morbidity rate was 3.7% (2 major strokes, 1 minor stroke) at 30-days after embolization. In the clinical follow-up study, one case of a large basilar tip aneurysm caused a fatal rupture 28 months after the initial embolization. Endovascular therapy was performed on the unruptured aneurysms and was found to be an acceptable treatment, except for durability in cases of large aneurysms.

Technique and Clinical Results of Carotid Stenting under Distal Protection

SUMMARY

We perfomed carotid artery stenting(CAS) in 215 patients from August 1997 to October 2003 mainly using the distal protection technique. Our technique and clinical results are described in this paper.

Analysis of Complications related to Endovascular Therapy for Dural Arteriovenous Fistulae

SUMMARY

In this paper, we reviewed our cases of dural arteriovenous fistulae (dural AVFs) and analyzed periprocedural complications. In 157 procedures, we encountered 14 complications. Overall, complication rate of 9% was seen.We divided these complications into five subgroups such as cranial nerve palsy, coil-related trouble, thromboembolic complication, vessel perforation, and radiation-related trouble. There were five transient abducent nerve palsies in cases with cavernous sinus dural AVFs. There were two cases of coil unraveling and two cases of coil migration. In two cases, direct puncture of the internal jugular vein was performed to retrieve the unraveled coil by using dual microcatheter and guidewire snare technique. We encountered two thromboembolic complications. In one case, venous infarction was recognized after polyvinyl alcohol particle embolization. In two cases of vessel perforations, there were no new neurological deficits except one case with transient Gerstmann syndrome. In endovascular treatment of dural AVF, serious complications are rare and can be prevented if maximum attention is paid during the procedure.

Standard Technique of PTA/stenting for Atherosclerotic Intracranial Arterial Stenosis

SUMMARY

PTA/stenting for the intracranial arteriosclerotic lesion is effective and novel treatment. Our standard technique to avoid serious complications, such as vessel rupture or acute occlusion was introduced in this paper.

Complications associated with stenting for cerebral arteries

SUMMARY

We have experienced total 116 stenting for 102 of cranio-cephalic arteries and 14 of intracranial arteries including occlusive cerebrovascular diseases, aneurysms, and fistulas.Ten complications were encountered. Three were ischemic complication, four stent migration, two restenosis, and one aneurysmal perforation during coiling across the stent strut. The mechanism and preventive method of these complications were discussed in this paper.

The mitochondrial acetoacetyl-CoA thiolase (T2) deficiency in Japanese patients: urinary organic acid and blood acylcarnitine profiles under stable conditions have subtle abnormalities in T2-deficient patients with some residual T2 activity

Mitochondrial acetoacetyl-CoA thiolase (T2) deficiency is an inborn error of metabolism affecting isoleucine and ketone bodies in the catabolic process. Mutation analysis and expression analysis of mutant cDNAs have facilitated the division of T2-deficient patients into two groups: those with null mutations in either allele (group 1) and those with mutation(s) retaining some residual T2 activity in at least one of two mutant alleles (group II). Among 5 Japanese T2-deficient patients, GK01 belonged to group I and the other patients (GK19, GK19B, GK30 and GK31) to group II. As we have suggested previously, the severity of ketoacidotic episodes in the group II patients was similar to that in the group I patient. However, the urinary organic acid and blood spot acylcarnitine profiles under stable conditions differed between the two groups. The group I patient had typical profiles for the T2 deficiency. In contrast, in all four patients in group II, tiglylglycine was not or was only faintly detected and the 2-methyl-3-hydroxybutyrate levels were less than the cutoff value. Their tiglylcarnitine levels were within the normal range and 2-methyl-3-hydroxy-, butyrylcarnitine was detected just around the cutoff value in our newborn screening pilot test. Hence, these analyses under stable conditions are not reliable for diagnosing the T2 deficiency in the group II patients. The T2 deficiency (group II) can be misdiagnosed as normal if these analyses are performed under nonepisodic conditions and possibly during the newborn screening for inborn errors of metabolism.

Silent cerebral infarction and cognitive function in middle-aged neurologically healthy subjects

We sought to clarify whether apparently silent cerebral infarcts and periventricular hyperintensities are associated with depressed cognitive function in middle-aged subjects. Subjects were 84 middle-aged neurologically normal adults who wished to undergo a screening examination of the brain. We performed magnetic resonance imaging (MRI) of the brain and neuropsychologic tests in all subjects. Silent cerebral infarcts and periventricular hyperintensities, respectively, were detected in 21 and 14 of 84 subjects. Mini-mental state (MMS) and Raven's colored progressive matrices (RCPM) scores were significantly lower in subjects with than without silent cerebral infarcts. By two-factor analysis of variance, MMS score was affected by silent cerebral infarcts or periventricular hyperintensities, with interactions between the two lesion types (P < 0.05). Silent cerebral infarcts may be an independent factor in the pathogenesis of intellectual dysfunction, but truly independent analysis is difficult because many subjects with silent cerebral infarcts also have periventricular hyperintensities.

Transcortical mixed aphasia due to cerebral infarction in left inferior frontal lobe and temporo-parietal lobe

We present a case of transcortical mixed aphasia caused by a cerebral embolism. A 77-year-old right-handed man was admitted to our hospital with speech disturbance and a right hemianopia. His spontaneous speech was remarkably reduced, and object naming, word fluency, comprehension, reading and writing were all severely disturbed. However, repetition of phonemes and sentences and reading aloud were fully preserved. Although magnetic resonance imaging (MRI) showed cerebral infarcts in the left frontal and parieto-occipital lobe which included the inferior frontal gyrus and angular gyrus, single photon emission CT revealed a wider area of low perfusion over the entire left hemisphere except for part of the left perisylvian language areas. The amytal (Wada) test, which was performed via the left internal carotid artery, revealed that the left hemisphere was dominant for language. Hence, it appears that transcortical mixed aphasia may be caused by the isolation of perisylvian speech areas, even if there is a lesion in the inferior frontal gyrus, due to disconnection from surrounding areas.

Transient crossed aphasia and persistent amnesia after right thalamic haemorrhage

A 45-year-old right-handed woman suffered transient aphasia and persistent amnesia after a right thalamic haemorrhage. This patient appeared to have crossed aphasia, although it disappeared within 8 weeks. It is noteworthy that the patient had a unilateral right thalamic lesion but exhibited both verbal and non-verbal memory impairment. Computed tomography and magnetic resonance imaging revealed cerebral haemorrhage in the right thalamus involving the ventral anterior nucleus, medioventral nucleus, mamillothalamic tract, internal medullary lamina, and mediodorsal nucleus. An amytal test was performed and suggested that the right hemisphere was dominant for language functions and the left hemisphere was dominant for visuospatial functions. Single photon emission CT revealed a low perfusion area only in the right thalamus. These findings suggest that the right hemisphere might be dominant for both verbal and non-verbal memory function in this patient, although visuospatial function was lateralized in the left hemisphere.

Memory impairment and spatial disorientation following a left retrosplenial lesion

We treated a patient in whom a left retrosplenial lesion resulted in memory impairment and spatial disorientation. A 31 year old, right handed man was admitted to our hospital after the sudden onset of headache. He was alert, attentive and cooperative, and showed no motor or sensory deficits. Although intelligence was preserved, memory was obviously deficient. The patient proceeded in wrong directions after he left his hospital room and subsequently his home. Neuroimaging revealed a subcortical hematoma in the left cingulate isthmus, while single-photon emission computed tomography demonstrated decreased perfusion in the splenium and left parietal lobe.

Haemorrhagic complication following percutaneous transluminal angioplasty for carotid stenosis

We report 2 cases with haemorrhagic complications following percutaneous transluminal angioplasty (PTA) for carotid stenosis. Computed tomography (CT) scanning of these cases demonstrated diffuse subarachnoid haemorrhage in 1 case, and intracerebral haemorrhage in the other case on the next day after PTA. In the latter case, we measured cerebral blood flow velocity and mean transit time with transcranial doppler (TCD) and dynamic CT scan, which demonstrated remarkable increases in the blood flow velocity and peak height, respectively. From these results, postoperative hyperperfusion was suggested to have caused haemorrhagic complications.

Endovascular Surgery for Internal Carotid Stenoses. Results of PTA vs. Stenting

SUMMARY

This paper will overview our results of endovascular therapy (PTA or stenting) for cervical ICA stenosis and discuss the advantages and disadvantages of each treatment. 60 cases with 62 lesions were treated with PTA 68 times, while 36 cases with 37 lesions were treated with stenting 37 times. A total of 99 lesions were treated with PTA or stenting 105 times. In the PTA group arterial stenosis improved from 76.4% to 21%. In the stent group the stenosis improved from 82.3% to 8.3%. The morbidity rate was 2/60 (3.3%) in PTA group, although two cases had minor neurological deficits, while in stent treated group, morbidity rate was 1/36 (2.8%), although it showed one major neurological deficit. Mortality was 0% in each group. The restenosis rate in PTA group was 15/58 (26%), while it was 0/20 (0%) in stent treated group. Stenting brings significant reduction of stenosis and reduces the rate of restenosis compared to PTA. However, stenting has its own disadvantages such as hypotension and distal kinks when deployed in tortuous ICA stenosis.

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.