Late-Onset Massive Epistaxis due to a Ruptured Traumatic Internal Carotid Artery Aneurysm: A Case Report

A traumatic internal carotid artery (ICA) aneurysm is rare and difficult to treat. Trapping of ICA is commonly performed owing to the difficulty of directly approaching ICA aneurysms. Recently, coiling the aneurysm itself was recommended if possible. However, it is controversial which of methods are best to completely treat aneurysm. We present the case of a 74-year-old man, who had experienced a head injury 8 years previously, with recurrent severe epistaxis. An ICA aneurysm was detected on computed tomography. The trapping and bypass was planned. However, sudden epistaxis occurred, we performed trapping to stop the bleeding and save his life. After the operation, no right ICA or aneurysm was detected. However, severe epistaxis recurred two months after the operation. In the second operation, a ligation of the common -/- external carotid artery and a severance of an ICA portion between the ophthalmic artery and the aneurysm were insufficient to stop the bleeding. This case indicates ICA trapping, even if a trapping portion is below an ophthalmic artery, is insufficient to treat an ICA aneurysm. ICA aneurysms should be suspected when a patient present with recurrent -/- massive epistaxis, who has a head injury history, even if it is far past.

Histamine H2-Blocker and Proton Pump Inhibitor Use and the Risk of Pneumonia in Acute Stroke: A Retrospective Analysis on Susceptible Patients

BACKGROUND

Although histamine H2-blockers (H2B) and proton pump inhibitors (PPI) are used commonly to prevent gastrointestinal bleeding in acute stroke, they are implicated in the increased risk of pneumonia in other disease populations. In acute stroke, the presence of distinctive risk factors of pneumonia, including dysphagia and impaired consciousness, makes inclusive analysis vulnerable to confounding. Our aim was to assess whether acid-suppressive drugs increase pneumonia in acute stroke in a population controlled for confounding.

METHODS

We analyzed acute stroke patients admitted to a tertiary care hospital. To minimize confounding, we only included subjects who could not feed orally during 14 days of hospitalization. Exposure was defined as H2B or PPI, given in days; the outcome was development of pneumonia within this period. The incidence was calculated from the total number of pneumonias divided by the sum of person-days at risk. We additionally performed multivariate Poisson regression and propensity score analyses, although the restriction largely eliminated the need for multivariate adjustment.

RESULTS

A total of 132 pneumonias occurred in 3582 person-days. The incidence was 3.69%/person-day (95% confidence interval (CI); 3.03-4.37%/day). All subjects had dysphagia. Stroke severity and consciousness disturbances were well-balanced between the groups exposed to H2B, PPI, or none. The relative risk (RR) compared with the unexposed was 1.22 in H2B (95%CI; 0.83-1.81) and 2.07 in PPI (95% CI; 1.13-3.62). The RR of PPI compared with H2B was 1.69 (95%CI; 0.95-2.89). In multivariate regression analysis, the RRs of H2B and PPI were 1.24 (95% CI; 0.85-1.81) and 2.00 (95% CI; 1.12-3.57), respectively; in propensity score analyses they were 1.17 (95% CI; 0.89-1.54) and 2.13 (95% CI; 1.60-2.84).

CONCLUSIONS

The results of this study suggested that prophylactic acid-suppressive therapy with PPI may have to be avoided in acute stroke patients susceptible to pneumonia.

Malignant isolated cortical vein thrombosis with type II protein S deficiency: a case report

Background

The incidence of cerebral venous thrombosis (CVT) is low, and in particular, isolated cortical vein thrombosis (ICVT) is very rare. The diagnosis of ICVT is difficult by using conventional computed tomography (CT) and magnetic resonance imaging (MRI). However, with appropriate treatment, ICVT has a good prognosis.

Case presentation

Herein, we present a rare case of a 40-year-old woman with ICVT and type II protein S (PS) deficiency, who experienced a stroke. She initially presented with generalized convulsions. A CT scan showed intracerebral hemorrhage (ICH) in the left temporoparietal region. However, her condition rapidly deteriorated and she went into a coma approximately 20 h after admission. A second CT scan revealed significant ICH expansion and transfalcine herniation. Decompressive hemicraniectomy with duraplasty was performed, and ICVT was confirmed owing to abnormal vascular tone and black appearance of the cortical vein. She underwent anticoagulation therapy and rehabilitation, and gradually recovered.

Conclusion

We experienced an extremely rare case of isolated cortical vein thrombosis related with type II PS deficiency. CT-digital subtraction angiography is a useful supportive technique in the diagnosis of ICVT. Decompressive hemicraniectomy is effective for hemorrhage extension cases, and ICVT with hemorrhage might require early anticoagulation therapy.

Povidone-Iodine Ointment and Gauze Dressings Associated With Reduced Catheter-Related Infection in Seriously Ill Neurosurgical Patients

Povidone-iodine ointment and gauze covered by transparent dressings were compared with transparent dressings alone in historical controls (both changed twice weekly) in neurosurgical patients needing catheter placement for prolonged periods. Colonization and bloodstream infection were both reduced with the new method (P<.01 and P= .062, respectively).

Importance of preserved periosteum around jugular foramen neurinomas for functional outcome of lower cranial nerves: anatomic and clinical studies

BACKGROUND

Surgical removal of jugular foramen (JF) neurinomas remains controversial because of their radicality in relation to periosteal sheath structures.

OBJECTIVE

To clarify the particular meningeal structures of the JF with the aim of helping to eliminate surgical complications of the lower cranial nerves (LCNs).

METHODS

We sectioned 6 JFs and examined histological sections using Masson trichrome stain. A consecutive series of 25 patients with JF neurinomas was also analyzed, and the MIB-1 index of each excised tumor was determined.

RESULTS

In the JF, meningeal dura disappeared at the nerve entrance, forming a jugular pocket. JF neurinomas were classified into 4 types: subarachnoid (type A by the Samii classification), foraminal (type B), epidural (type C), and episubdural (type D). After an average follow-up of 9.2 years, tumors recurred in 9 cases (36%). Type A tumors did not show regrowth, unlike type B tumors, in which all recurred. Radical surgery by the modified Fisch approach did not contribute to tumor radicality in type C and D tumors, even in cases in which LCN function was sacrificed. In preserved periosteum, postoperative LCN deterioration was decreased. Bivariate correlation analysis revealed that jugular pocket extension, tumor removal, MIB-1 greater than 3%, and reoperation or gamma knife use were significant recurrence factors.

CONCLUSION

For LCN preservation, the periosteal layer covering the cranial nerves must be left intact except in patients with a subarachnoid tumor. To prevent tumor regrowth, postoperative gamma knife treatment is recommended in tumors with an MIB-1 greater than 3%.

[A case of glomerulonephritis associated with ventriculo-atrial shunt]

Nephritis associated with a chronically infected ventriculo-atrial (VA) or ventriculo-peritoneal (VP) shunt is known as shunt nephritis. A 60-year-old woman who had a VA shunt implanted for hydrocephalus began to show intermittent low-grade fever of an unknown origin, as well as hypertension and lower leg edema. Laboratory findings showed renal insufficiency with proteinuria, and a percutaneous renal biopsy was performed. Light microscopy revealed findings of membranoproliferative glomerulonephritis. Shunt nephritis was suspected. The VA shunt was removed and the VP shunt was replaced subsequently. Signs of renal impairment were recovered after surgery. However, a new VA shunt was implanted because of a shunt malfunction. Shunt nephritis is a rare complication associated with shunt system implantation. It can be treated successfully by removing the shunt system immediately. It should be considered that shunts, especially VA shunts, always carry a risk of nephritis.

[A case of multifocal fibrosclerosis presenting with chronic subdural hematoma]

Multifocal fibrosclerosis(MFS) is a rare disorder of unknown etiology, characterized by chronic inflammation with dense fibrosis and lymphoplasmacytic infiltration into the connective tissue of various organs. Recently, MFS was classified as IgG4-related systemic disease. In this paper, we report a 60-year-old man with no history of head injury presenting with chronic subdural hematoma(CSDH). After surgery, he complained of severe, continuous headache and persistent high-grade fever. Extensive evaluation, including ⁶⁷Ga scintigraphy suggesting inflammations in various organs, liver needle biopsy showing sclerosing cholangitis, and blood examination showing elevated serum IgG4 levels, led to the diagnosis of MFS. To our knowledge this is the first report of MFS causing CSDH. The mechanism of the formation of CSDH is presumed to involve reactive granular membrane together with exudative subdural collection caused by MFS, which gives rise to minor and repeated bleeding. In this case, oral corticosteroid therapy was dramatically effective in the treatment of the condition.

Functional analysis of HOXD9 in human gliomas and glioma cancer stem cells

Background

HOX genes encode a family of homeodomain-containing transcription factors involved in the determination of cell fate and identity during embryonic development. They also behave as oncogenes in some malignancies.

Results

In this study, we found high expression of the HOXD9 gene transcript in glioma cell lines and human glioma tissues by quantitative real-time PCR. Using immunohistochemistry, we observed HOXD9 protein expression in human brain tumor tissues, including astrocytomas and glioblastomas. To investigate the role of HOXD9 in gliomas, we silenced its expression in the glioma cell line U87 using HOXD9-specific siRNA, and observed decreased cell proliferation, cell cycle arrest, and induction of apoptosis. It was suggested that HOXD9 contributes to both cell proliferation and/or cell survival. The HOXD9 gene was highly expressed in a side population (SP) of SK-MG-1 cells that was previously identified as an enriched-cell fraction of glioma cancer stem-like cells. HOXD9 siRNA treatment of SK-MG-1 SP cells resulted in reduced cell proliferation. Finally, we cultured human glioma cancer stem cells (GCSCs) from patient specimens found with high expression of HOXD9 in GCSCs compared with normal astrocyte cells and neural stem/progenitor cells (NSPCs).

Conclusions

Our results suggest that HOXD9 may be a novel marker of GCSCs and cell proliferation and/or survival factor in gliomas and glioma cancer stem-like cells, and a potential therapeutic target.

Our Method of Povidone-Iodine Ointment and Gauze Dressings Reduced Catheter-Related Infection in Serious Cases

In experiment 1, we evaluated our method of catheter care at subclavian vein insertion sites for the control of catheter-related infections in seriously ill neurosurgical patients who needed prolonged catheter placement, compared with an older method. In our method, the insertion site was prepared with 10% povidone-iodine solution, followed by application of 10% povidone-iodine ointment, and covered with sterile gauze and a transparent polyurethane dressing. The older method was based on 1996 guidelines for the prevention of intravascular device-related infections. Catheter colonization and mortality were both found to be significantly reduced with our method (p = 0.0214, p = 0.0379, respectively). In experiment 2, we evaluated whether a regimen of catheter care with 10% povidone-iodine ointment was more effective than that without povidone-iodine ointment for the prevention of infections. This suggested effectiveness of 10% povidone-iodine ointment for reduction of infection. Our method of catheter care was useful even in seriously ill neurosurgical patients.

Jugular foramen papillary meningioma: A case report

Jugular foramen meningioma is very rare. Papillary meningioma, the histological aspects and clinical behavior of which are highly malignant, is also very rare. Only 55 cases of jugular foramen meningioma have been reported in the literature. To our knowledge, this is the first report of a jugular foramen papillary meningioma. A 25-year-old woman presented with hoarseness and right hearing disturbance. Neurological examination showed deficits of the right hypoglossal and vagus nerves with palsy. Magnetic resonance imaging (MRI) revealed a mass on the right jugular foramen extending intracranially and extracranially, with weak contrast enhancement. The intracranial tumor was removed via the right lateral suboccipital approach. Histopathological examination confirmed the diagnosis of papillary meningioma. We report here the first case of jugular foramen papillary meningioma. No completely effective treatment for papillary meningiomas exists at present, with the exception of surgery.

Spinal accessory schwannoma mimicking a tumor of the fourth ventricle: case report

OBJECTIVE AND IMPORTANCE

Spinal accessory schwannomas unassociated with neurofibromatosis are very rare, and only 30 cases have been reported in the literature. To our knowledge, this is the first report of a spinal accessory schwannoma mimicking a tumor of the fourth ventricle.

CLINICAL PRESENTATION

A 50-year-old man presented with neck pain after being involved in a motor vehicle accident. There were no neurological deficits, but a computed tomographic scan revealed a large hypodense mass with punctuate calcifications in the fourth ventricle. The tumor exhibited low intensity on the T1-weighted magnetic resonance imaging scan and high intensity on the T2-weighted scan, and it showed inhomogeneous contrast enhancement.

INTERVENTION

The tumor was totally removed by a bilateral suboccipital craniectomy and C1 laminectomy. Dissection of the surgical specimen revealed that the tumor had originated from the left spinal accessory nerve. Histopathological examination confirmed the diagnosis of schwannoma. The patient experienced transient postoperative cerebellar ataxia but recovered completely.

CONCLUSION

Intracisternal-type spinal accessory schwannomas sometimes mimic a tumor of the fourth ventricle. Total surgical resection can be achieved with good outcome.

Spontaneous resolution of nontraumatic bilateral intracranial vertebral artery dissections

A 49-year-old man presented with nontraumatic bilateral intracranial vertebral artery dissections without subarachnoid hemorrhage manifesting as Wallenberg's syndrome on the right. Magnetic resonance imaging revealed an infarct in the right dorsolateral aspect of the medulla oblongata. Antiplatelet therapy was administered. Vertebral angiography performed on the 9th hospital day (Day 9) revealed pearl and string sign in the right vertebral artery and narrowing of the left vertebral artery. Second angiography performed on Day 25 showed no change, but third angiography performed on Day 74 revealed spontaneous resolution of the bilateral vertebral artery dissections. Magnetic resonance angiography performed on Day 250 showed no evidence of dissection. However, magnetic resonance imaging revealed a small infarct in the splenium of the corpus callosum. Spontaneous resolution of stenotic dissections of the bilateral vertebral arteries is extremely unusual. Serial cerebral angiography and magnetic resonance angiography are very important for monitoring the time course of changes in patients with vertebral artery dissections.

[The usefulness of 3D-CTA for the diagnosis of a ruptured aneurysm at the origin of the duplicated middle cerebral artery: case report]

Duplication of the middle cerebral artery is known as a rare anomalous vessel arising from the internal carotid artery and an aneurysm at the origin of the duplicated middle cerebral artery is very rare. We presented a case of ruptured aneurysm at the origin of the duplicated middle cerebral artery and discussed the usefulness of 3D-CTA (three-dimensional computed tomographic angiography) for its diagnosis. A 34-year-old female suffered from severe headache and was admitted to our hospital. CT scan revealed diffuse subarachnoid hemorrhage and angiography revealed duplication of the right middle cerebral artery and dilatation at its origin. We could not identify it as an aneurysm by angiography, so we performed 3D-CTA. 3D-CTA was able to demonstrate clearly the aneurysm at the origin of the duplicated middle cerebral artery and we performed neck clipping of the ruptured aneurysm. To our knowledge, previously there have been only 14 cases which reported such an aneurysm at the origin of a duplicated middle cerebral artery. We reviewed the 15 cases including ours and found that, in 4 cases, the aneurysm could not be detected by the initial angiography. We suspected that most of these aneurysms were small, so the detection of the aneurysms by angiography was difficult. We conclude that 3D-CTA is useful for diagnosing aneurysms at the origin of the duplicated middle cerebral artery even when thy can't be detected by angiography.

[Spontaneous partial thrombosis of an unruptured peripheral, superior cerebellar artery aneurysm: a case report]

A 52-year-old female suddenly developed headache and dizziness. On admission she complained of gait disturbance with dizziness but cranial nerve palsy could not be detected. CT scan revealed a mild high density lesion in the right ambient cistern and the density of the lesion had become much higher 5 days after admission. MRI revealed a homogeneous iso-intense lesion on T1WI, T2WI 2 days after admission and the lesion had changed to homogeneous high. The lesion was suspected to be a fresh thrombus. Right vertebral angiography showed a part of aneurysm arising from the ambient segment of the right superior cerebellar artery and we diagnosed the lesion as a partially thrombosed superior cerebellar artery aneurysm. About forty cases of peripheral superior cerebellar artery aneurysm have been described in the literature, but cases of spontaneous thrombosis of the aneurysms have been very rare. Spontaneous thrombosis of aneurysms was usually thought to occur in large aneurysms, but the aneurysm in our case was not large. We suspected that in our case spontaneous thrombosis may have been caused by occlusion of the parent artery of the aneurysm.

[Aspiration and drainage for a gas-producing brain abscess causing delayed bleeding from the abscess capsule--a case report]

A 65-year-old man was admitted with the complaint of gait disturbance. CT scan revealed a low density lesion in the right parietal lobe. MRI was carried out 3 days after admission, the lesion showing low intensity on T1 WI and T2 WI. Gd-DTPA enhanced T1 WI showing abnormal enhancement surround it. CT scan then revealed a gas bubble in the lesion 12 days after admission, so we diagnosed it as gas-producing brain abscess and aspiration, drainage and irrigation with antibiotics were performed. Although, the brain abscess was reduced in size after the operation, the lesion expanded again 2 weeks after the operation. MRI was performed and the lesion showed iso-intensity on T1 WI and high intensity on T2 WI. Emergent aspiration and drainage were performed and uncoagulated old-hematoma-like matter such as chronic subdural hematoma was removed. As significant neovascularization with inflammatory cells had been detected in the capsule of the brain abscess, we suspected that aspiration and drainage surgery for brain abscess may cause delayed bleeding from the capsule of the abscess. We conclude that attention should be drawn to such a complication.

[Amount of mercury from dental amalgam filling released into the atmosphere by cremation]

Mercury in dental amalgam filling is released into the atmosphere by cremation and is a suspected source of mercury pollution. The amount of mercury released was measured at three crematoriums. First, mercury levels in the atmosphere were measured. Mercury existed mainly in the gaseous form in ambient air. The concentration of atmospheric mercury at the three crematoriums (S, T and M) ranged from 4.3 to 19.7ng/m3, which was nearly identical to levels in our university surveyed as the control area and also to the levels of atmospheric mercury in general in Japan. Secondly, the amount of mercury release from T crematorium was estimated using official published statistical data in Japan and calculated as follows: sigma[(age specific number of dead that were cremated) x (the number of restored teeth by age category) x (mercury content per amalgam filling (0.6 g))] x (prevalence rate of restoration with amalgam). The amount of mercury released from this crematorium was estimated to be approximately 9.4 kg per year, or a daily release of 26 g into the ambient air. These results indicate that mercury release by cremation is similar to that from other man-made sources.