Brainstem anesthesia during removal operation of ventriculoperitoneal shunt – A case report

Background:

Brainstem anesthesia is a transient loss of brainstem function usually associated with retrobulbar block and rarely seen by neurosurgeons.

Case Description:

Here, we report a case of brainstem anesthesia during shunt revision operation in a 79-year-old woman. Local anesthesia administered at the end of surgery was thought to have infiltrated the subarachnoid space through a burr hole, causing prolonged unconsciousness and cranial nerves’ impairment. Spontaneous resolution occurred during systemic support.

Conclusion:

As brainstem anesthesia may occur by leakage of local anesthetic through small burr holes, timing injections carefully can avoid this rare complication.

Dural Sinus Thrombosis with Nonsymptomatic Persistent Falcine Sinus: A Case Report

A 24-year-old woman was admitted to our hospital after convulsive status epilepticus. A cerebral magnetic resonance venography revealed a persistent fetal falcine sinus. Additionally, the posterior third of the superior sagittal sinus was hypoplastic and the abnormal deep venous drainage was accompanied. These abnormalities had already been detected by magnetic resonance imaging several years ago. In the present scan, we discovered a sinus thrombosis in the hypoplastic superior sagittal sinus. In the cerebral angiography, we observed delayed venous return in the left parieto-occipital lobe and hypothesized that cerebral venous stasis due to the thrombus caused the convulsive status epilepticus. The patient was treated with intravenous administration of heparin along with an antiepileptic drug, and she recovered with no neurological defects. In the present case, the falcine sinus and the anomalous venous return were likely congenital while the status epilepticus was derived from thrombosis in the hypoplastic superior sagittal sinus. Although the falcine sinus functioned as an alternative pathway for the superior sagittal sinus, the hypoplastic superior sagittal sinus itself may also play an important role as a venous drainage channel.

Meningeal carcinomatosis presenting with leukoencephalopathy-like imaging findings

Meningeal carcinomatosis is a unique and rare form of metastasis observed in patients with malignant tumours. Diagnosis is simple when the primary lesion of the malignant tumour is clear, and when multiple miliary lesions are confirmed via cranial contrast MRI; however, many patients exhibit atypical imaging findings. In the present report, we discuss the case of a 72-year-old man who presented with subacute consciousness impairment and MRI findings suggestive of progressive, bilateral leukoencephalopathy-like lesions around the ventricles. Idiopathic hydrocephalus was initially suspected due to increased cerebrospinal fluid (CSF) pressure accompanied by normal cell counts. Although the patient underwent a ventriculoperitoneal shunt operation, his symptoms did not improve. Whole-body CT revealed findings suggestive of adenocarcinoma in the left lung. Paraneoplastic syndrome was suspected, and he was treated with three courses of high-dose intravenous methylprednisolone. However, his neurological symptoms did not improve, and he died 2 months after admission. The patient was ultimately diagnosed with meningeal carcinomatosis due to lung adenocarcinoma upon autopsy. In this case, we suspected that the white matter lesions observed on MRI resulted from secondary hydrocephalus due to obstruction of the CSF circulation. This is the first reported case of progressive leukoencephalopathy-like imaging findings in a patient with meningeal carcinomatosis.

Logistic Regression of Ligands of Chemotaxis Receptors Offers Clues about Their Recognition by Bacteria

Because of relative simplicity of signal transduction pathway, bacterial chemotaxis sensory systems have been expected to be applied to biosensor. Tar and Tsr receptors mediate chemotaxis of Escherichia coli and have been studied extensively as models of chemoreception by bacterial two-transmembrane receptors. Such studies are typically conducted using two canonical ligands: l-aspartate for Tar and l-serine for Tsr. However, Tar and Tsr also recognize various analogs of aspartate and serine; it remains unknown whether the mechanism by which the canonical ligands are recognized is also common to the analogs. Moreover, in terms of engineering, it is important to know a single species of receptor can recognize various ligands to utilize bacterial receptor as the sensor for wide range of substances. To answer these questions, we tried to extract the features that are common to the recognition of the different analogs by constructing classification models based on machine-learning. We computed 20 physicochemical parameters for each of 38 well-known attractants that act as chemoreception ligands, and 15 known non-attractants. The classification models were generated by utilizing one or more of the seven physicochemical properties as descriptors. From the classification models, we identified the most effective physicochemical parameter for classification: the minimum electron potential. This descriptor that occurred repeatedly in classification models with the highest accuracies, This descriptor used alone could accurately classify 42/53 of compounds. Among the 11 misclassified compounds, eight contained two carboxyl groups, which is analogous to the structure of characteristic of aspartate analog. When considered separately, 16 of the 17 aspartate analogs could be classified accurately based on the distance between their two carboxyl groups. As shown in these results, we succeed to predict the ligands for bacterial chemoreceptors using only a few descriptors; single descriptor for single receptor. This result might be due to the relatively simple topology of bacterial two-transmembrane receptors compared to the G-protein-coupled receptors of seven-transmembrane receptors. Moreover, this distance between carboxyl groups correlated with the receptor binding affinity of the aspartate analogs. In view of this correlation, we propose a common mechanism underlying ligand recognition by Tar of compounds with two carboxyl groups.

Intracranial infection caused by minor skin contusion associated with previous craniotomy

Minor damage to the scalp may lead to intracranial infection. Moreover, the postoperative state of the scalp, skull and meninges is especially noteworthy with respect to invasion of pathogens into the skull. Therefore, a detailed medical history should be obtained from patients with even minor scalp injuries to avoid intracranial infection. We herein report a case of intracranial infection caused by a minor scalp injury associated with previous craniotomy, which was missed at first.

Metronomic treatment of malignant glioma xenografts with irinotecan (CPT-11) inhibits angiogenesis and tumor growth

Irinotecan (CPT-11) has shown emerging promise in the treatment of malignant gliomas. It is believed the mechanism of action of irinotecan is to sensitize glioma cells to the cytotoxic action of radiation therapy and alkylating agents. However, clinical trials using weekly or three-weekly doses of CPT-11 have demonstrated imaging responses in only 10-15% of patients. In this study, we evaluated another mechanism of action, angiosuppression by CPT-11 of ACNU-resistant gliomas, using a metronomic administration schedule. Two different types of treatment, (1) conventional and (2) metronomic, were applied to the subcutaneous U87 model. We found that metronomic administration of CPT-11 significantly inhibited malignant glioma growth by inhibiting angiogenesis; this treatment procedure reduced the number of tumor vessels and the area of hypoxic lesions and reduced expression of VEGF and HIF-1alpha, the most important angiogenic factors in gliomas. Metronomic treatment was superior to conventional treatment with regard to the severe systemic side effect of body weight loss. The growth inhibitory effect was very similar for both low and high doses of CPT-11. These angiosuppressive effects of CPT-11 show promise for another use of CPT-11 in metronomic and scheduled angiosuppressive chemotherapy with low dose and long-term administration for malignant gliomas without systemic side effects.

Lumbosacral subdural hematoma. Case report

An 18-year-old man presented with a rare spinal subdural hematoma (SSH) manifesting as headache, which developed following diving into the sea the day before. Computed tomography of the head revealed no abnormality. His headache persisted followed by neck stiffness and mild lumbago. He came to see us 6 days after the first visit. He underwent lumbar puncture to eliminate the possibility of meningitis. The cerebrospinal fluid showed xanthochromia. Cerebral angiography showed no abnormality. Magnetic resonance imaging of the spine revealed lumbosacral subdural hematoma. The hematoma and his symptoms regressed spontaneously during several weeks of conservative treatment. A sharp increase in intraabdominal and/or intrathoracic pressures following diving may have caused the bleeding. Headache may be an initial symptom associated with subarachnoid hemorrhage concomitant with SSH. Delayed progression of lumbosacral SSH must be considered if the patient complains of lumbago following minor trauma.

Primary Cerebral Angiitis Containing Marked Xanthoma Cells With Massive Intraparenchymal Involvement-Case Report-

A 27-year-old woman was referred to our hospital with mild disorientation, bilateral abducens nerve palsy, and mild left hemiparesis. Magnetic resonance (MR) imaging revealed diffuse mass lesions resembling malignant glioma in the right frontal intraparenchymal region, with enhancement of multiple meningeal and intraparenchymal nodules. Partial resection of the frontal lesion was performed. Histological examination revealed that the specimens consisted of brain tissue, with marked perivascular infiltration of histiocytes and sheets of xanthomatous cells. The diagnosis was primary cerebral angiitis containing marked xanthoma cells. Steroid therapy was administered over 1 week. MR imaging showed that the remaining lesions resolved gradually, and had disappeared 2 years after surgery. No neurological symptoms or recurrence of the tumor has been observed during the 6-year period since the operation.

Small unruptured cerebral aneurysms presenting with oculomotor nerve palsy

OBJECTIVE

Symptomatic unruptured aneurysms have been considered at relatively high risk for future rupture, and the majority of aneurysms that cause symptoms of mass effect are large. Unruptured aneurysms smaller than 1 cm in diameter sometimes cause neurological symptoms, but their clinical aspects remain obscure. In this article, we review our experience with small unruptured aneurysms presenting with oculomotor nerve palsy.

METHODS

Sixteen patients with unruptured aneurysms smaller than 1 cm presenting with oculomotor nerve palsy were included in this study. The patients' clinical profiles were reviewed, and factors affecting the recovery of oculomotor function were determined.

RESULTS

The mean size of the aneurysms was 5.8 +/- 1.4 mm. Eleven patients (68.8%) had preceding retrobulbar pain. Fifteen patients underwent successful microsurgical clipping or intravascular embolization, but one patient died of aneurysm rupture before surgery. Seven patients (43.8%) had a complete recovery of oculomotor function, six (37.5%) had an incomplete recovery, and two (12.5%) remained unchanged after treatment. The mean interval between the onset of oculomotor nerve palsy and treatment was 4.7 +/- 3.3 days in patients with complete recovery, 24.2 +/- 15.5 days in patients with incomplete recovery, and 41.0 +/- 12.7 days in unchanged patients. Early surgery resulted in more complete recovery of neural function (P < 0.01).

CONCLUSION

Unruptured aneurysms smaller than 1 cm can cause neurological symptoms of mass effect. We recommend timely surgery, preferably within 5 days, to avoid not only aneurysm rupture but also functional disability even in patients with unruptured aneurysms smaller than 1 cm.

Utilization of Extracorporeal Pump during Local Intra-arterial Fibrinolysis in the Treatment of Acute Cerebral Arterial Occlusion. A Case Report

SUMMARY

Local intra-arterial fibrinolysis may improve the outcome of patients with ischemic cerebrovascular disease. A favorable prognosis is thought to be related to early re-establishment of blood flow into the affected brain. To minimize the time to revascularization during local intraarterial fibrinolysis, we employed an extracorporeal pump to deliver oxygenated blood into the affected brain through a microcatheter. The patient, a 57-year-old man, showed disturbance of consciousness with left hemiparesis and was admitted to our hospital one hour after onset of symptoms. Cerebral angiography demonstrated an acute occlusion of the right middle cerebral artery, and the patient underwent local intra-arterial fibrinolysis with an extracorporeal pump. Oxygenated blood was successfully delivered through a microcatheter into the affected brain before recanalization. Subsequently, recanalization was obtained by intra-arterial fibrinolysis with a tissue plasminogen activator. The outcome of this patient was excellent. Thus, local intra- arterial thrombolysis with extracorporeal pump may be an effective method by which to increase the residual blood flow and widen the therapeutic window for fibrinolysis.

An early experience of endovascular treatment for cerebral aneurysms harboring blebs

SUMMARY

Re-rupture of cerebral aneurysms often occurs at their blebs, and the treatment of cerebral aneurysms harboring blebs has been considered difficult. To prevent rupture during embolization, the authors have tried to deliver coils only into aneurysm domes, without inserting coils, a microcatheter, or a microguidewire into the blebs. Here, to prove such a treatment strategy, the authors report early experience in 3 cases with cerebral aneurysms harboring blebs.