Subcortical hemorrhage caused by cerebral amyloid angiopathy compared with hypertensive hemorrhage

OBJECTIVES

Most published reports on lobular hemorrhage in cerebral amyloid angiopathy (CAA) include patients diagnosed only by imaging studies. This study analyzed patients with subcortical hemorrhage histologically diagnosed as CAA or non-CAA (hypertensive).

METHODS

This is a retrospective study analyzing data from 100 craniotomy cases. Tissue of hematoma cavity wall was collected for histological investigation in hematoma removal by surgery in patients with subcortical hemorrhage. Statistical analyses of blood pressure, hematoma location and volume, outcome, and mortality was performed in CAA and non-CAA groups.

RESULTS

There were 47 CAA and 53 non-CAA cases, and average age was significantly older in the CAA group (p < 0.01). Blood pressure was significantly lower (p < 0.01) but hematoma volume was significantly greater (p < 0.05) in the CAA group. Rebleeding occurred in two CAA cases and one non-CAA case, but no re-operations were required. Average score of modified Rankin Scale, which is used to measure the degree of disability in patients who have had a stroke, at three months after surgery was not significantly different between the two groups (CAA: 3.94 ± 1.28, non-CAA: 3.58 ± 1.50). There were seven deaths in the CAA and six in the non-CAA group, and intraventricular hemorrhage highly complicated in the death cases in both groups. In the CAA group, average age of the fatal cases was significantly older than that of the surviving cases (p < 0.05) and six cases demonstrated dementia before onset of hemorrhage.

CONCLUSIONS

Surgical removal of a subcortical hemorrhage caused by CAA is not contraindicated. However, age > 80 years, complication with intraventricular hemorrhage, hematoma volume ≥ 50 ml, and dementia before onset of hemorrhage contribute to high mortality, and craniotomy should be carefully considered for such patients. A limitation of this study is that comparison between CAA and non-CAA groups was performed in the patients with only surgically indicated ICH, and does not evaluate entire ICH cases with CAA. However, this study appropriately compared pathologically diagnosed CAA and non-CAA in patients with moderate to severe lobular ICH with surgical indications.

Midline Shift Induced by the Drainage of Cerebrospinal Fluid in Three Patients With External Decompression

It is not rare that progressive hydrocephalus worsens clinical conditions in a patient with external decompression and drainage or shunt surgery is required. However, spinal drainage or shunt surgeries potentially carry a risk of causing paradoxical herniation in a patient with decompressive craniectomy, particularly in a comatose case with wide craniectomy. Careful and strict observations are necessary for such patients. In our three comatose cases with craniectomy, paradoxical herniation occurred due to excessive drainage after 5-7 days of shunt surgery and lumbar drainage, although the drainage pressure was set at more than 10 cmH2O. Fortunately, in the three cases, the herniation improved within a few days after the drain was clamped and the bed was flattened. However, the Trendelenburg position and epidural blood patch might be necessary if paradoxical herniation occurs acutely after lumbar puncture or drainage because delayed resolution can be fatal in the herniation.

What is the impact of vasospasm on traumatic subarachnoid hemorrhage: Two cases of report

It is difficult to predict that vasospasm would occur in traumatic subarachnoid hemorrhage (SAH) patients. Younger age, a lower score of Glasgow coma scale (GCS≦8) on admission, and greater cisternal blood volume are considered to correlate with post-traumatic vasospasm. We present two cases of traumatic SAH with post-traumatic vasospasm; one was a 74-year-old man and the other was a 72-year-old woman. They were alert without any neurological deficits on admission, although the SAH was focally thick as if caused by an aneurysmal rupture. The thick SAH was still identified on follow-up CT performed in a few days. The patients demonstrated cognitive dysfunction at the 4th and 5th day of admission, respectively, and imaging studies revealed vasospasm at the artery in the thick SAH. After treatments, the vasospasm resolved and both patients recovered from the disorientation completely in three weeks. The authors considered that focally thick traumatic SAH with poor clearance is the most influential factor to post-traumatic vasospasm independent of age or a GCS score. A low GCS score in head trauma patients might be mainly associated with existence of brain contusion, intracerebral hemorrhage, epidural, or subdural hemorrhages, which are frequently associated with traumatic SAH. If the traumatic SAH is focally thick with poor clearance, it might be better to initiate prompt treatments for vasospasm within 3 days after trauma. The delay in treatments for vasospasm contributes to poor outcomes.

The stability of the metabolic turnover of arachidonic acid in human unruptured intracranial aneurysmal walls is sustained

OBJECTIVE

Intracranial aneurysm (IA) is considered a chronic inflammatory condition that affects intracranial arteries. Cyclooxygenase 2 (COX2) and prostaglandin E2 (PGE2) are considered potential targets of specific medical treatment for IAs. Previous studies have reported the elevated COX2 expression in the IA wall. However, not much has been studied about the upstream regulation of COX2 and PGE2, and the metabolism of arachidonic acid (AA) in human IAs. In this study, we aimed to elucidate the distribution of fatty acids in human IA walls for the first time.

METHODS

Samples from 6 ruptured and 5 unruptured human IAs were surgically resected after the aneurysmal clipping and analyzed using desorption electrospray ionization imaging mass spectrometry.

RESULTS

AA and AA-containing phospholipids were not detected in the unruptured IA walls. On the contrast, significantly larger amounts of AA and AA-containing phospholipids were detected in the ruptured IA walls compared to unruptured IA walls.

CONCLUSIONS

This study showed for the first time that AA was not detected in unruptured human IA walls. Our findings suggest that the stability of the turnover of AA in human unruptured IA walls is sustained. In contrast, this study showed that larger amounts of AA and AA-containing phospholipids were detected in the ruptured IA walls. More cases and further analysis are necessary to interpret our present results.

Clinical and Morphological Characteristics of Ruptured Small (<5 mm) Posterior Communicating Artery Aneurysms

Context:

Small intracranial aneurysms (IAs) are considered to have a low risk of rupture; however, in clinical practice, we often encounter patients with subarachnoid hemorrhage (SAH) due to rupture of small IAs.

Aims:

This study aims to clarify the clinical and morphological characteristics of ruptured small IA, focusing on posterior communicating artery (PCoA) aneurysms as a prone site.

Settings and Design:

We retrospectively reviewed 102 consecutive patients with SAH due to ruptured PCoA aneurysm who underwent microsurgical or endovascular aneurysm repair between April 2013 and March 2018.

Subjects and Methods:

All PCoA aneurysms were diagnosed using three-dimensional rotation angiography or three-dimensional computed tomography angiography. Information regarding the following clinical characteristics was collected: age, sex, past medical history, current smoking, antithrombotic therapy, multiplicity, hydrocephalus, intracerebral hemorrhage, intraventricular hemorrhage, and World Federation of Neurosurgical Societies (WFNS) Grade on admission.

Statistical Analysis Used:

We analyzed factors of ruptured small IA, focusing on PCoA aneurysms using univariate and multivariate regression analyses.

Results:

Univariate and multivariate analyses revealed that low aspect ratio (AR) (odds ratio [OR] = 0.33, P = 0.01) and nonfetal type of PCoA (OR = 0.31, P = 0.02) might be independent characteristics of ruptured small PCoA aneurysms. However, age, sex, past medical history, WFNS grade, and treatment outcome were not different between the small and nonsmall PCoA aneurysms. The aneurysm size was not associated to the selection of treatment, proportion of complications, and treatment outcome.

Conclusions:

In cases of ruptured PCoA aneurysms, low AR and nonfetal type of PCoA might be associated with rupture of small aneurysms.

Tentorial Branch of the Superior Cerebellar Artery with Retrograde Flow to Partially Thrombosed Large Superior Cerebellar Artery Aneurysm

BACKGROUND

Although the tentorial branch of the superior cerebellar artery (SCA) was reported to be a frequent finding in living subjects in 1 study, its clinical relevance, especially in surgery for aneurysms, has not been elucidated. We present our experience with the tentorial branch of the SCA identified during surgical intervention of a distal SCA aneurysm and discuss its clinical relevance.

CASE DESCRIPTION

A 71-year-old woman presented with cerebral infarction in the SCA area, and a partially thrombosed, large, fusiform aneurysm was found in the lateral pontomesencephalic segment of the SCA. Despite trapping of the aneurysm, arterial flow was observed on postprocedural Doppler flow examination and indocyanine green angiography. Careful inspection of the area led to the identification of a small tentorial branch of the SCA as a retrograde feeder. Coagulation of the artery led to the successful completion of the trapping. Postoperatively, the patient did not develop new neurologic deficits.

CONCLUSIONS

This is the first report to our knowledge of a clinical association of the tentorial branch of the SCA with a distal SCA aneurysm, which played an important role in achieving complete obliteration of the aneurysm. The recognition of this small artery is potentially important for successful cure of distal SCA aneurysms.

Clinical Features of Neurogenic Pulmonary Edema in Patients with Subarachnoid Hemorrhage

OBJECTIVE

Neurogenic pulmonary edema (NPE) is a clinical syndrome characterized by acute onset after central nervous system injury. Here, we investigated the clinical features of NPE in patients with subarachnoid hemorrhage (SAH).

METHODS

We retrospectively analyzed a total of 350 patients with SAH who were treated at our hospital from April 2014 to September 2017. Patient demographics, aneurysm size and location, clinical characteristics, and patient outcomes were reviewed and compared between an NPE and a non-NPE group.

RESULTS

Sixteen patients (4.6%) presented with NPE at admission. Ten of these (62.5%) recovered from NPE immediately, and ventilatory support was withdrawn within 2 days from onset. A univariate analysis showed that patients with NPE were younger (P = 0.04), had a higher rate of vertebral artery dissection (P < 0.01), more severe World Federation of Neurosurgical Societies (WFNS) grades (P = 0.01), and lower systolic blood pressure on admission (P = 0.01). A multivariate analysis revealed significant differences in the frequency of vertebral artery dissection (odds ratio 4.83, 95% confidence interval 1.50-15.56, P < 0.01) and in WFNS grades (odds ratio 3.73, 95% confidence interval 1.02-13.66, P = 0.04) between the groups. No significant group differences were found in other factors including heart rate, radiographic sign (Fisher grade), aneurysm size and location, blood sample tests on admission, and neurologic outcomes.

CONCLUSIONS

Vertebral artery dissection and severe WFNS grade on admission were confirmed as significant risk factors for NPE. However, neurologic outcomes at discharge did not differ between groups, suggesting that poor outcomes due to NPE could be reduced by appropriate diagnosis and treatment.

"Mass Reduction" Clipping Technique for Large and Complex Intracranial Middle Cerebral Artery Aneurysm

BACKGROUND

Treatment of complex unruptured middle cerebral artery (MCA) aneurysms that are untreatable with conventional surgical techniques are rare, and direct aneurysmal clipping usually remains the first-line treatment for large and giant saccular MCA aneurysms. Tandem clipping and multiple clipping techniques represent neck reconstruction in direct clipping surgeries that address these aneurysms.

CASE DESCRIPTION

The authors describe a simple variation of neck reconstructive clipping techniques for the large MCA unruptured aneurysm in a patient with an unruptured 20-mm MCA bifurcation aneurysm. The key of this technique is the application of an appropriate initial clip, the "mass reduction clip"; this clip is inserted not into the aneurysmal neck but on the center of the aneurysmal dome so as to compress the dome at first, which yields a change in the aneurysm's shape and reduces the size of the whole aneurysmal mass. This technique facilitates the ensuing neck reconstruction according to the concept of the ideal closure line using few clips.

CONCLUSIONS

"Mass reduction" clipping, which changes the shape of the aneurysm and reduces the size of the whole aneurysmal mass, is a useful variation for the treatment of large aneurysms when conventional clipping across the neck is feasible.

Distal transsylvian keyhole approach for unruptured anterior circulation small aneurysms

Background

To reduce complications associated with conventional pterional craniotomy, a transsylvian keyhole approach for unruptured small anterior circulation aneurysms is proposed.

Methods

A 7-cm linear scalp incision is made along the hairline, beginning at the zygoma, followed by minimal temporal muscle dissection. Two burr holes are drilled out at McCarty’s point and the temporal bone, and a 3-cm equilateral triangle bone flap is made, whose apex is located above the sylvian point. After the sphenoid ridge is drilled off, aneurysms are exposed and clipped with conventional microsurgical instruments.

Conclusions

This approach permits access to aneurysms via the transsylvian corridor with a smaller area of potential injury of superficial structures.

Electronic supplementary material

The online version of this article (10.1007/s00701-017-3378-7) contains supplementary material, which is available to authorized users.

Abstract TP409: Altered Expression of Microrna-15a and Kruppel-like Factor 4 in SAH Patients Contribute to Vascular Phenotype Alteration

Background: Cerebral vasospasm (CVS) is a major determinant of prognosis in patients with subarachnoid hemorrhage (SAH). Alteration in the vascular phenotype contributes to development of CVS. However, little is known about the role of microRNAs (miRNAs) in the phenotypic alteration after SAH. We investigated the expression profile of miRNAs and the chronological changes in the expression of microRNA-15a (miR-15a) and Kruppel-like factor 4 (KLF4), a potent regulator of vascular phenotype modulation that modulates the expression of miR-15a, in the plasma and cerebrospinal fluid (CSF) of SAH patients.

Methods: Peripheral blood and CSF samples were collected from eight aneurysmal SAH patients treated with endovascular obliteration. Samples obtained from three patients without SAH were used as controls in the analysis. Exosomal miRNAs were isolated and subjected to microarray analysis with the 3D-gene miRNA microarray kit. The time course of the expression of miR-15a and KLF4 was analyzed using quantitative real-time PCR.

Results: Microarray analysis demonstrated that 12 miRNAs including miR-15a were up- or down-regulated both in the CSF and plasma after SAH within three days. Quantitative real-time PCR revealed that miR-15a expression was significantly increased in both the CSF and plasma, with a peak around 3 to 5 days after SAH, whereas the expression of KLF4 was significantly decreased around 1 to 3 days after SAH and remained lower than in controls.

Conclusion: Our results suggest that an early and persistent decrease in KLF4 followed by an increase in miR-15a may contribute to the altered vascular phenotype, resulting in development of CVS.

Abstract TP400: Acute Catecholamine Surge Reflects the Prognosis in Patients With Aneurysmal Subarachnoid Hemorrhage

Objective: We investigated that the characteristics of serum catecholamine concentration at the hyper-acute phase of aneurysmal subarachnoid hemorrhage (SAH) and its relationship between patient outcome and delayed vasospasm.

Methods: Patients with aneurysmal SAH (n=170) were prospectively enrolled between 2008 and 2011. Baseline demographic data and physiological parameters, including plasma concentrations of adrenaline (AD), noradrenaline (NA) and dopamine (DP) were evaluated.

Results: On admission, plasma AD, NA and DP levels were significantly higher in patients with a poor clinical grade on admission (Hunt and Kosnik: IV-V), compared to those with a good clinical grade on admission (Hunt and Kosnik: I-III). AD showed a significantly high concentration immediately after the onset of SAH and then rapidly decreased. The levels of NA peaked within 6 hours after onset, then significantly decreased. The time course of the elevation of DP showed a similar trend to that of NA. The each catecholamine levels significantly correlated with each other. Multivariate analyses demonstrated age, poor clinical grade, plasma AD and NA levels were predictors of poor patient outcome. Poor clinical grade, Fisher scale and plasma AD level were predictors of the development of delayed vasospasm.

Conclusion: The present study suggests that sympathetic activation in patients in the acute phase of SAH reflects the severity of SAH, and is closely related to the development of delayed vasospasm, leading to the subsequent immune response and inflammatory reactions. Suppressing catecholamine surge in hyper-acute phase may contribute to prevention of vasospasm and improvement of patient outcome.

Abstract TP410: Microcirculatory Impairment is Caused by Independent Mechanisms From Major Arterial Spasm Both in the Acute and Chronic Phase After Experimental SAH

Background & Objectives: The mechanism of microcirculatory disturbance following subarachnoid hemorrhage (SAH) remains to be elucidated. In this study, we investigated the correlation between the cerebral microcirculatory change and the time-dependent alteration of major arterial vasoconstriction after SAH using rabbit SAH model.

Methods: CT angiography and perfusion were repeated at 0, 1, 6, 24, 48 hours after first hemorrhage for acute changes observation group (n=8), and on days 0, 3, 5, 7 for chronic changes observation group (n=8) using multi-detector raw CT. Regional cerebral blood flow (rCBF), cerebral blood volume (CBV), mean transit time (MTT) and basilar artery (BA) diameter were calculated at each time point.

Results: In acute group, immediately after hemorrhage, BA narrowed, both CBV and rCBF were decreased and MTT was increased, transiently. After 6 hours, BA narrowed again and both CBV and rCBF were increased progressively. MTT restored over 24 hours. In chronic group, BA narrowing reached a peak on day 5 and restored after day 7. Both CBV and rCBF were persistently decreased after day 3, while MTT was increased after day 5. In both groups, no significant changes were observed in CBV, rCBF and MTT between in BA territory and other territory.

Conclusions: Delayed cerebral ischemia may be caused by the microcirculatory disturbance which is regulated by independent mechanisms from major arterial vasospasm both in the acute and chronic phase after SAH in rabbit model.

Multiple simultaneous intracerebral hemorrhages: Clinical presentations and risk factors

OBJECTIVE

Multiple simultaneous intracerebral hemorrhages (MSICH) are a rare clinical entity. The mechanism and risk factors have yet to be elucidated. The purpose of this study was to clarify clinical presentations and risk factors of MSICH compared with solitary intracerebral hemorrhages (ICH).

PATIENTS AND METHODS

Medical records of 313 consecutive patients with ICH admitted to our institution between April 2011 and September 2014 were retrospectively reviewed. Seventeen cases of MSICH were identified, and 10 clinical and neuroimaging variables were compared between MSICH cases and solitary ICH cases using the unpaired t-test, chi-square test, and multiple logistic regression analysis.

RESULTS

There were significant differences in size between larger hematomas (mean 59.2±69.1mL) and smaller hematomas (mean 1.7±2.1mL) in patients with MSICH (p=0.001). Larger hematoma volume was the only independent risk factor for MSICH in multiple logistic regression analysis (OR=1.012, 95%CI 1.004-1.021, p=0.004).

CONCLUSIONS

Patients with MSICH have clinical characteristics and outcomes similar to patients with solitary ICH. They present with two significantly different hematoma sizes, both of which are significantly larger than patients with solitary ICH, suggesting that a larger hematoma can trigger smaller hematomas. A future prospective study with a larger number of patients will explore the precise mechanism of this rare entity.

Altered Expression of MicroRNA-15a and Kruppel-Like Factor 4 in Cerebrospinal Fluid and Plasma After Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Cerebral vasospasm (CVS) is a major determinant of prognosis in patients with subarachnoid hemorrhage (SAH). Alteration in the vascular phenotype contributes to development of CVS. However, little is known about the role of microRNAs (miRNAs) in the phenotypic alteration after SAH. We investigated the expression profile of miRNAs and the chronologic changes in the expression of microRNA-15a (miR-15a) and Kruppel-like factor 4 (KLF4), a potent regulator of vascular phenotype modulation that modulates the expression of miR-15a, in the plasma and cerebrospinal fluid (CSF) of patients with SAH.

METHODS

Peripheral blood and CSF samples were collected from 8 patients with aneurysmal SAH treated with endovascular obliteration. Samples obtained from 3 patients without SAH were used as controls in the analysis. Exosomal miRNAs were isolated and subjected to microarray analysis with the three-dimensional-gene miRNA microarray kit. The time course of the expression of miR-15a and KLF4 was analyzed using quantitative real-time polymerase chain reaction.

RESULTS

Microarray analysis showed that 12 miRNAs including miR-15a were upregulated or downregulated both in the CSF and in plasma after SAH within 3 days. Quantitative real-time polymerase chain reaction showed that miR-15a expression was significantly increased in both the CSF and plasma, with a peak around 3-5 days after SAH, whereas the expression of KLF4 was significantly decreased around 1-3 days after SAH and remained lower than in controls.

CONCLUSIONS

Our results suggest that an early and persistent decrease in KLF4 followed by an increase in miR-15a may contribute to the altered vascular phenotype, resulting in development of CVS.

High expression of ABCG2 induced by EZH2 disruption has pivotal roles in MDS pathogenesis

Both proto-oncogenic and tumor-suppressive functions have been reported for enhancer of zeste homolog 2 (EZH2). To investigate the effects of its inactivation, a mutant EZH2 lacking its catalytic domain was prepared (EZH2-dSET). In a mouse bone marrow transplant model, EZH2-dSET expression in bone marrow cells induced a myelodysplastic syndrome (MDS)-like disease in transplanted mice. Analysis of these mice identified Abcg2 as a direct target of EZH2. Intriguingly, Abcg2 expression alone induced the same disease in the transplanted mice, where stemness genes were enriched. Interestingly, ABCG2 expression is specifically high in MDS patients. The present results indicate that ABCG2 de-repression induced by EZH2 mutations have crucial roles in MDS pathogenesis.

Oculomotor Nerve Palsy in a Patient with a Ruptured Middle Cerebral Artery Aneurysm

We describe a case of acute oculomotor nerve palsy caused by a ruptured middle cerebral artery (MCA) aneurysm. A 59-year-old female presenting with headache and nausea was admitted to our hospital. Her consciousness was alert, and had no other neurological deficit without left oculomotor nerve palsy. A computed tomography (CT) showed SAH extending from left sylvian cistern to basal cistern. CT angiography revealed a left MCA aneurysm which protruded toward internal carotid artery. The patient was successfully treated with surgical clipping. The oculomotor nerve palsy resolved immediately after the surgery. Perioperative radiological evaluation revealed that there were no evidence of midbrain hemorrhage or stroke, vessel anomaly of basilar, posterior cerebral or superior cerebellar artery, vasospasm, and uncal herniation. Furthermore, intraoperative findings revealed that the aneurysm was projected toward the affected carotid cistern and oculomotor nerve. From these findings and time course of oculomotor nerve palsy, it is suggested that the jet flow of bleeding from the ruptured MCA aneurysm caused oculomotor nerve palsy in the patient. J. Med. Invest. 64: 165-167, February, 2017.

Abstract WP386: Acute Catecholamine Surge in Patients with Aneurysmal Subarachnoid Hemorrhage: Characteristics and Prognostic Value

Objectives: The characteristics of serum catecholamine concentration at the hyper-acute phase of aneurysmal subarachnoid hemorrhage (SAH) and its relationship between patient outcome and delayed vasospasm were investigated.

Methods: Patients with aneurysmal SAH (170) were prospectively studied between August 2008 and June 2011. Baseline demographic data and physiological parameters, including plasma concentrations of adrenaline (AD), noradrenaline (NA) and dopamine (DP) were evaluated for all patients.

Results: On admission, plasma AD, NA and DP levels were significantly higher in patients with a poor clinical grade on admission (Hunt & Kosnik: IV-V), compared to those with a good clinical grade on admission (Hunt & Kosnik: I-III). AD showed a markedly high concentration immediately after the onset of SAH and then rapidly decreased. NA levels peaked within 6 hours after onset, then significantly decreased. The increase of DP with time was not significant, but showed a similar trend to that of NA. The level of each catecholamine showed significant mutual correlation. Multivariate analyses demonstrated age, poor clinical grade, plasma AD and NA levels were predictors of poor patient outcome, and.poor clinical grade, Fisher scale and plasma AD level were predictors of the development of delayed vasospasm.

Conclusions: The present findings suggest that sympathetic activation in patients in the acute phase of SAH reflects the severity of SAH, and is closely related to the development of delayed vasospasm, leading to the subsequent immune response and inflammatory reactions. Strategies for suppressing catecholamine at the hyperacute phase may contribute to vasospasm prevention and improve patient outcome.

Abstract TP430: Analyses of CSF and Serum miRNA Expression in Subarachnoid Hemorrhage Patients Suggest Important Roles in Restoration of Impaired Vascular Homeostasis

Backgrounds: MicroRNAs (miRNAs) play important roles in the regulation of gene expression at the post-transcriptional level. Furthermore, in various human disease, miRNAs have been identified as potential biomarkers. However, it remains to be elucidated whether and how miRNAs play roles in the development of cerebral vasospasm (CVS) or delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH). The purposes of this study are to detect differential miRNAs in cerebrospinal fluid (CSF) and serum in SAH patients and to identify possible miRNAs involved in the mechanisms of the vascular proliferation or phenotypic changes after SAH.

Methods: The CSF and serum samples were taken every other day for 2 weeks after SAH in patients with endovascular aneurysm repair. Microarray analysis of exosomal miRNA from samples was performed using 3D-Gene miRNA labeling kit (Toray). The temporal changes in the expression of differentially expressed miRNAs in early phase after SAH and its associated molecules were evaluated using quantitative RT-PCR.

Results: Among over 2500 miRNAs screened out, microarray analysis revealed 12 diffrentially expressed genes which were up- and/or down-regulated (FC>2-fold) both in the CSF and serum during early phase after SAH. RT-PCR analysis revealed that miRNAs involving vascular angiogenesis were up-regulated on day3 in serum and day5 in CSF. Contrarily, RT-PCR also revealed mRNAs of those associated molecules which exert anti-angiogenic and anti-proliferative effects were down-regulated on day1 in CSF and day3 in serum. These results suggest that these miRNAs expressions are controlled by negative-feedback regulation of associated molecules participating in maintaining vascular homeostasis.

Conclusion: Our present study indicates that some miRNAs and molecules may be involved in vascular proliferation or angiogenesis by interacting each other after SAH.

Successful Treatment of Hemifacial Spasm Caused by an Ectatic Vertebral Artery Accompanying Agenesis of the Carotid Artery

We report the successful treatment of a patient with hemifacial spasm due to a tortuous vertebral artery that appeared to have developed to compensate for agenesis of the ipsilateral carotid artery. The 51-year-old man presented with a 1-year history of progressive left hemifacial spasm. His medical history was otherwise unremarkable except for untreated mild hypertension. Magnetic resonance angiography and bone window computed tomography demonstrated congenital agenesis of the left carotid artery and compression of the root exit zone of the left facial nerve by a tortuous left vertebral artery (VA). Microvascular decompression was performed via a left suboccipital craniotomy, and the offending vessel was identified using endoscopy. The vertebral artery was successfully transposed using polytetrafluoroethylene (PTFE) tape and a PTFE ball (Bard PTFE felt, Tempe, Arizona). This is the first report of a patient with hemifacial spasm caused by an ectatic VA associated with agenesis of the ipsilateral carotid artery.

Ruptured posterior spinal artery aneurysm: intraoperative and histologic findings with appreciable thrombosis

BACKGROUND CONTEXT

Little is known on the natural course of ruptured spinal artery aneurysm, and a treatment strategy remains to be elucidated.

PURPOSE

This case report aims to describe a rare case of a posterior spinal artery aneurysm that showed progressive thrombosis following subarachnoid hemorrhage.

STUDY DESIGN

This is a case report and literature review.

METHODS

A 54-year-old man presented with subarachnoid hemorrhage due to posterior spinal artery aneurysm at the T10 level. The patient underwent surgery 19 days after onset.

RESULTS

Most of the aneurysm appeared unenhanced on intraoperative indocyanine green video angiography, and total resection was performed. Histologic examination confirmed spontaneous thrombosis of the lesion. A review of the literature identified 19 cases of ruptured posterior spinal artery aneurysm. Thrombosed aneurysm and thrombosed parent artery were observed in 7 (44%) of the 16 cases treated with surgical or endovascular interventions. In the three cases treated conservatively, fatal rebleeding in the acute stage was noted in one case, whereas the lesion disappeared spontaneously in the chronic stage without rebleeding in two cases.

CONCLUSIONS

Ruptured spinal artery aneurysms are prone to spontaneous thrombosis. The healing process of the lesion was well documented in the present case. Repeated angiographic follow-up offers a feasible alternative in the management of this fairly rare aneurysm.

Hyperperfusion syndrome after aneurysm surgery: a case report

A 74-year-old woman exhibited sensory aphasia with abrupt blood pressure elevation 3 h after clipping of an unruptured large left middle cerebral artery aneurysm. Perfusion computed tomography and single-photon emission computed tomography demonstrated hyperperfusion in one of the distal parent artery areas. She gradually improved and was discharged without neurological deficits. Increased distal blood flow after occlusion of the large cerebral aneurysm and postischemic reperfusion after temporary occlusion of the parent artery during surgery presumably played an important role in the occurrence of this fairly rare condition associated with aneurysm surgery.

Abstract T P244: Correlation between Vasospasm and Microcirculatory Disturbance in Early and delayed Phase following Experimental Subarachnoid Hemorrhage

Background & Objectives: Role of cerebral vasospasm in cerebral microcirculatory disturbance after subarachnoid hemorrhage (SAH) remains to be elucidated. This study investigated the correlation between changes of cerebral microcirculation and time course of arterial narrowing after SAH using rabbit cisterna magna double-blood injection model.

Methods: Using 256-multidetector-row computed tomography (CT), CT angiography and CT perfusion were repetitively performed at 0, 1, 6, 24, 48 hours after initial hemorrhage for early changes observation group (ECOG; n=8), and on days 0, 3, 5, 7 for delayed changes observation group (DCOG; n=8). Regional cerebral blood flow (rCBF), cerebral blood volume (CBV), mean transit time (MTT) and mean cross-sectional area of basilar artery (BA) were evaluated at each time point.

Results: In ECOG, BA transiently narrowed immediately after SAH and progressively narrowed again after 6 hours. CBV and rCBF were transiently decreased immediately after SAH and restored, and then progressively increased after 6 hours. MTT was transiently prolonged immediately after SAH and gradually restored over 24 hours. In DCOG, basilar arterial narrowing reached a peak on day 5 and improved after day 7. CBV and rCBF were persistently decreased after day 3, while MTT was prolonged after day 5. In both observation groups, there were no significant differences in CTP parameters between in perfusion territory of BA and that of non-BA.

Conclusions: Presumably, in this model, delayed cerebral ischemia is caused by the cerebral microcirculatory disturbance which is regulated by independent mechanisms from vasospasm of major arteries both in the early phase and delayed phase following SAH.

Abstract T P249: Upregulation of Relaxin After Experimental Subarachnoid Hemorrhage

Background and Purpose: Relaxin is a pregnancy hormone which exerts vasodilatory effects by activating nitric oxide synthase and matrix metalloproteinases through receptor (RXFP1). Recently, this vasodilatory effect has been considered useful as a potential therapeutic target in acute heart failure. However, the role of relaxin in the cerebral artery has not been fully explored. In this study, we investigated the role of relaxin in rabbit basilar artery (BA) after subarachnoid hemorrhage (SAH).

Methods: Basilar arteries were collected from a rabbit SAH model on days 3, 5, and 7 after SAH. Total RNA was extracted from the BA and a cDNA microarray containing 43,623 genes was performed. The expression of relaxin and RXFP1 mRNA was investigated by quantitative RT-PCR. Serum and cerebrospinal fluid (CSF) relaxin concentrations were measured by ELISA. Perfusion fixation was performed on days 0, 3, 5 and 7, and the localization of RXFP-1 in the BA was examined using immunohistochemistry. Results: The expression of relaxin mRNA was significantly up-regulated on days 5 and 7 compared to the control sample. The expression of RXFP1 mRNA was significantly down-regulated on day 3 and sustained on day 7. The serum relaxin concentration in the rabbit SAH model was not significantly changed after SAH, whereas the CSF relaxin concentration was significantly elevated on days 5 and 7. Immunohistochemistry revealed strong RXFP1 staining in media of the BA on day 0, and showed weak staining on days 3, 5 and 7. Conclusions: Relaxin expression in the BA and relaxin concentration in the CSF increase after SAH, and considerably, relaxin expression is negatively correlated with the RXFP1 expression in the rabbit BA after SAH.

Removing arsenic from groundwater in Cambodia using high performance iron adsorbent

In Cambodia, groundwater has been contaminated with arsenic, and purification of the water is an urgent issue. From 2010 to 2012, an international collaborative project between Japan and Cambodia for developing arsenic-removing technology from well water was conducted and supported by the foundation of New Energy and Industrial Technology Development Organization, Japan. Quality of well water was surveyed in Kandal, Prey Veng, and Kampong Cham Provinces, and a monitoring trial of the arsenic removal equipment using our patented amorphous iron (hydr)oxide adsorbent was performed. Of the 37 wells surveyed, arsenic concentration of 24 exceeded the Cambodian guideline value (50 μg L(-1)), and those of 27 exceeded the WHO guideline for drinking water (10 μg L(-1)). Levels of arsenic were extremely high in some wells (>1,000-6,000 μg L(-1)), suggesting that arsenic pollution of groundwater is serious in these areas. Based on the survey results, 16 arsenic removal equipments were installed in six schools, three temples, two health centers, four private houses, and one commune office. Over 10 months of monitoring, the average arsenic concentrations of the treated water were between 0 and 10 μg L(-1) at four locations, 10-50 μg L(-1) at eight locations, and >50 μg L(-1) at four locations. The arsenic removal rate ranged in 83.1-99.7%, with an average of 93.8%, indicating that the arsenic removal equipment greatly lower the risk of arsenic exposure to the residents. Results of the field trial showed that As concentration of the treated water could be reduced to <10 µg L(-1) by managing the As removal equipment properly, suggesting that the amorphous iron (hydr)oxide adsorbent has high adsorbing capacity for As not only in the laboratory environment but also in the field condition. This is one of the succeeding As removal techniques that could reduce As concentration of water below the WHO guideline value for As in situ.

Factors associated with blunt cerebrovascular injury in patients with cervical spine injury

Blunt cerebrovascular injury (BCVI) is known to be a potentially fatal complication of cervical spine injury (CSI). Methods for screening the appropriate population remain to be elucidated, especially in Japan. This retrospective study was conducted to predict the risk factors relevant to BCVIs. Among 92 patients with CSI transferred to our institution from April 2007 to March 2012, 40 patients (35 men, 5 women) with neurological deficits and/or significant cervical spine fracture including fracture of transversarium, facet, body, lamina, and spinous process, underwent multi-detector computed tomography angiography (MDCTA) and magnetic resonance angiography (MRA), which identified 10 patients with BCVI [2 carotid artery injuries (BCAIs) and 9 vertebral artery injuries (BVAIs); 1 patient suffered both]. Univariate analyses exploring associations between individual risk factors and BCVI and BVAI were performed using Fisher's exact test and Chi-square test for dichotomous variables and the unpaired t-test for continuous variables. Multiple logistic regression analyses for BCVI and BVAI were carried out using stepwise methods. On univariate and multivariate analysis, hyperextension injury was significantly associated with BVAI (p = 0.01 and p = 0.02), and subluxation (dislocation of vertebral body > 5 mm) was a significant predictor of BCVI (p = 0.04 and p = 0.03) and BVAI (p = 0.01 and p = 0.01). Prompt evaluation for BCVIs is recommended in CSI patients with hyperextension injury and dislocation of the vertebral body.

A practical prediction model for early hematoma expansion in spontaneous deep ganglionic intracerebral hemorrhage

OBJECTIVE

Early hematoma expansion is a known cause of morbidity and mortality in patients with intracerebral hemorrhage (ICH). The goal of this study was to identify clinical predictors of ICH growth in the acute stage.

MATERIALS AND METHODS

We studied 201 patients with acute (<6 h) deep ganglionic ICH. Patients underwent CT scan at baseline and hematoma expansion (>33% or >12.5 ml increase) was determined on the second scan performed within 24 h. Fourteen clinical and neuroimaging variables (age, gender, GCS at admission, hypertension, diabetes mellitus, kidney disease, stroke, hemorrhagic, antiplatelet use, anticoagulant use, hematoma density heterogeneity, hematoma shape irregularity, hematoma volume and presence of IVH) were registered. Additionally, blood pressure was registered at initial systolic BP (i-SBP) and systolic BP 1.5 h after admission (1.5 h-SBP). The discriminant value of the hematoma volume and 1.5 h-SBP for hematoma expansion were determined by the receiver operating characteristic (ROC) curves. Factors associated with hematoma expansion were analyzed with multiple logistic regression.

RESULTS

Early hematoma expansion occurred in 15 patients (7.0%). The cut-off value of hematoma volume and 1.5 h-SBP were determined to be 16 ml and 160 mmHg, respectively. Hematoma volume above 16 ml (HV>16) ([OR]=5.05, 95% CI 1.32-21.36, p=0.018), hematoma heterogeneity (HH) ([OR]=7.81, 95% CI 1.91-40.23, p=0.004) and 1.5 h-SBP above 160 mmHg (1.5 h-SBP>160) ([OR]=8.77, 95% CI 2.33-44.56, p=0.001) independently predicted ICH expansion. If those three factors were present, the probability was estimated to be 59%.

CONCLUSIONS

The presented model (HV>16, HH, 1.5 h-SBP>160) can be a practical tool for prediction of ICH growth in the acute stage. Further prospective studies are warranted to validate the ability of this model to predict clinical outcome.

Safety and efficacy of water-in-oil-in-water emulsion vaccines containing Newcastle disease virus haemagglutinin-neuraminidase glycoprotein

Subunit vaccines containing haemagglutinin-neuraminidase (HN) glycoprotein of Newcastle disease virus (NDV), formulated as water-in-oil-in-water (W/O/W) emulsions, were prepared. First, the suitable constituents of a W/O/W emulsion adjuvant were investigated with polyvalent vaccines using NDV, infectious bronchitis virus and Haemophilus paragallinarum. The W/O/W emulsion adjuvant, composed of the antigen in phosphate-buffered saline (PBS), liquid paraffin, squalene, diglyceryl monooleate, polysorbate 80 and PBS in a 30:25:10:5:2:28 ratio, induced a good antibody response with less adverse local reactions. HN protein of NDV was expressed by an improved baculovirus expression vector, a hybrid nucleopolyhedrovirus (HyNPV) between Autographa californica NPV and Bombyx mori NPV,and was prepared from silkworm pupae infected with the recombinant baculovirus, HyNPV-HN. Then, the W/O/W emulsion vaccine containing HN protein was prepared using the aforementioned constituents. Chickens showed 100, 100 and 80% protection against challenge exposure to virulent NDV at 4 weeks after vaccination with W/O/W emulsion vaccines containing 30, 6 and 3% of HyHPV-HN-infected pupae, respectively. The vaccines containing HN protein did not induce adverse local reactions at the site of injection. The subunit vaccine for NDV containing HN protein expressed in the recombinant baculovirus-infected pupae, formulated as a W/O/W emulsion vaccine composed of the antigen in PBS, liquid paraffin, squalene, diglyceryl monooleate, polysorbate 80 and PBS in a 30:25:10:5:2:28 ratio, was therefore found to be safe and effective.

[Hematoma of the abdominal wall. A case report: pitfall of Seldinger method via femoral artery]

We reported a case of an abdominal wall hematoma which caused by Seldinger method via the femoral artery. A 48-year-old female, suffered from direct carotid cavernous fistula, was treated by transfemoral transvenous embolization (TVE). The whole procedure was completed without difficulty except minor resistance of guide wire manipulation during left femoral artery catheterization. Four hours later, the patient became hypotensive and showed the sign of impending shock without definitive causes. Nine hours after the embolization a huge hematoma of the abdominal wall was found. It required the total 1200 m/ of blood transfusion before her blood pressure returned to normal. She recovered fully from this event and discharged uneventfully. There is a speculation that a deep circumflex iliac artery (DCIA) was injured with an angle-shaped guide wire and bled into the abdominal wall. And subsequent systemic heparinization prevented the coagulation process, resulting a large hematoma. Anatomically, an angle-shaped guide wire is easily able to migrate into DCIA. To prevent a vascular injury, it is very important to manipulate a guide wire under fluoroscopic control and to select a J-shaped guide wire instead of an angle-shaped one.

An incidentally discovered small and asymptomatic para-aortic paraganglioma

Preoperative diagnosis of asymptomatic paraganglioma is difficult due to the lack of specific symptoms. In this report, we present a rare case of a small and asymptomatic para-aortic paraganglioma. A 34-year-old woman who complained of back pain was admitted for further examination. No abnormal findings were observed on physical or laboratory examinations. An abdominal CT scan and an abdominal MRI incidentally noted a mass about 3 cm in diameter adjacent to the right edge of the inferior vena cava. The following aortic angiography showed the tumor with a feeding artery diverting directly from the aorta. The tumor was completely resected by laparotomy. The resected tumor, 3 x 3 x 3 cm in size, was soft, dark-reddish and encapsulated. Immunohistochemical examinations showed that it was positive for neuron-specific enolase, chromogranin A and adrenocorticotropin. Under these findings, the diagnosis of para-aortic paraganglioma was determined. Seven years after the operation, she remains asymptomatic and free of disease.

Methylenetetrahydrofolate reductase C677T is not associated with expression of pyrimidine metabolic enzyme genes in colorectal cancer

Methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism may influence the chemosensitivity of colorectal cancers to fluorouracil (5-FU) by increasing intracellular 5,10-methylenetetrahydrofolate. The effect of this polymorphism on the expression of thymidylate synthase (TS), dihydropyrimidine dehydrogenase (DPD), orotate phosphoribosyl transferase (OPRT) and thymidine phosphorylase (TP) in colorectal cancer was investigated. The MTHFR C677T polymorphism was analysed and TS, DPD, OPRT and TP mRNA expression was measured in tumour and adjacent normal mucosal tissue. In all patients, the genotypes of the tumour and normal tissues were identical. No differences were found in the expression of TS, DPD or TP mRNA by genotype in either tumour or normal tissue. Although the OPRT mRNA level in tumour tissue was not associated with the genotype, normal mucosa with the TT genotype showed a significantly higher OPRT mRNA level than mucosa with other genotypes. The MTHFR C667T polymorphism is not associated with intratumoural expression of TS, DPD, OPRT or TP.

Effects of a kappa-receptor agonist U-50488 on bulbar respiratory neurons and its antagonistic action against the mu receptor-induced respiratory depression in decerebrate cats

The function of kappa receptor-mechanisms in bulbar respiratory network was investigated in decerebrate cats. Intravenous injection of U-50488 (0.3-3.0 mg/kg) dose-dependently decreased the phrenic nerve discharge and shortened inspiration and expiration. U-50488 caused hyperpolarization, and decreased input resistance and the action potential discharge in respiratory neurons. The effects of U-50488 were antagonized by nor-binaltorphimine. DAMGO (0.3 mg/kg, i.v.) decreased the phrenic discharge and prolonged inspiration and expiration. U-50488 partially reversed the respiratory depression induced by DAMGO. These results suggest that the activation of K receptors by itself depresses the central respiratory activity, while it opposes the mu receptor-mediated respiratory depression.

Treatment of ruptured hepatocellular carcinoma

BACKGROUND

The problem of whether surgical or conservative treatment is indicated for ruptured hepatocellular carcinoma (HCC) has not been analyzed from the viewpoint of long-term development of hepatitis viral infection from liver fibrosis to liver cirrhosis. Although transcatheter arterial embolization (TAE) for hemostasis followed by two-stage hepatectomy has been established as the best treatment for ruptured HCC, there still remain difficulties in the treatment of some patients.

METHODS

Twelve patients with ruptured HCC who were surgically or conservatively treated were retrospectively analyzed in terms of modality of treatment, liver function, extension of HCC, complications, survival rate, and cause of death.

RESULTS

Tumor rupture can occur either in the early phase or in the terminal phase during the development from liver fibrosis to liver cirrhosis, while tumor rupture occurs at the advanced stage in terms of HCC extension. TAE for emergent hemostasis or prevention of re-bleeding was performed in ten patients, while TAE was contraindicated in one patient and emergent laparotomy for hemostasis was performed in one patient. In four patients, elective extended surgical resection was performed, because liver function was evaluated as clinical stage 1 according to the General rules for the clinical and pathological study of primary liver cancer of the Liver Cancer Study Group of Japan. In seven patients, conservative or medical treatment was selected, because liver function was evaluated as poor. The surgically treated group, who could tolerate extensive operation, survived longer than the conservatively treated group.

CONCLUSIONS

While TAE remains the best method to employ for hemostasis, it still has limitations. Hence, we should be mindful of other possible modalities for hemostasis and their outcomes. Rupture of HCC at an early phase in the development of liver fibrosis is a good indication for elective surgical treatment and should be distinguished from rupture in the terminal phase of liver cirrhosis, which should be treated conservatively. Although elective surgical treatment can be performed in selected patients, tumor size and location of HCC, in addition to liver function, should be taken into consideration.

Glutamic acid decarboxylase-immunoreactivity of bulbar respiratory neurons identified by intracellular recording and labeling in rats

To distinguish the GABAergic neuron in the ventral respiratory group (VRG) of rats, immunohistochemical staining of glutamic acid decarboxylase (GAD) was performed in neurons that had been individually identified by in vivo intracellular recording and labeling with neurobiotin. A total of five types of respiratory neurons were identified and labeled; augmenting inspiratory (aug-I, n=12), decrementing or early inspiratory (early-I, n=3), inspiration-expiration phase spanning or late inspiratory (late-I, n=3), decrementing expiratory or postinspiratory (PI, n=8), and augmenting or stage 2 expiratory (E2, n=3). In addition, expiration-inspiration phase-spanning or pre-inspiratory neurons (pre-I, n=2) were recorded, but not labeled. The membrane potential trajectory of each neuron type resembled that previously described in cat, suggesting a comparable neuronal organization between the two species. According to the axonal arborization, those labeled neurons were further classified as propriobulbar (6 aug-I, all early-I, all late-I, and 3 PI), bulbospinal (2 aug-I and all E2) and cranial-motor neurons (4 aug-I and 5 PI). GAD-immunoreactivity was consistently detected in the propriobulbar neurons, while it was not seen in cranial-motor and bulbospinal neurons. In addition, GAD-immunoreactive varicosities were found surrounding the somatic and dendritic surface of all labeled neurons. The present results illustrate that the propriobulbar types of early-I, aug-I, late-I and PI neurons are GABAergic inhibitory neurons and virtually all types of respiratory neurons receive GABAergic inputs in the rat's VRG.

Extreme discrepancy between macroscopic diagnosis and pathological findings of gallbladder cancer treated by hepatopancreatoduodenectomy

Diagnosis of gallbladder cancer in terms of invasion depth and spread is an important factor in determining cumulative survival after surgical treatment. However, diagnostic methods available at present occasionally fail to judge staging correctly. We report a case of gallbladder cancer which showed extreme discrepancy between the preoperative macroscopic and imaging diagnosis (positive direct invasion to the liver and invasion to the bile duct and duodenum through the serosal layer; S3, Hinf3, Binf2, and stage IV by the Japanese Society of Biliary Surgery classification) and the pathological findings (limited in vasion within the subserosal layer; ss, hinf0. binf0, and stage II). This discrepancy allowed us to perform curative treatment by hepatopancreatoduodenectomy, including extended right lobectomy of the liver, external bile duct resection, resection of the mesocolon, and lymph node dissection. Surgeons should aim for curability of advanced gallbladder cancer by radical resection until accurate methods for the preoperative diagnosis of cancer spread are available, because the clinical picture may be modified by inflammatory changes.

Induction of hepatocellular carcinoma with high metastatic potential in WS/Shi rats: discovery of an inbred strain highly susceptible to the liver carcinogen N-nitrosomorpholine

We investigated the susceptibility of three inbred strains of rats to the hepatocarcinogen, N-nitrosomorpholine (NNM), to establish a spontaneous metastatic model of hepatocellular carcinoma (HCC). WS/Shi. SD/gShi, and F344/DuCrj rats were given 0.02% NNM in drinking water for 8 weeks and thereafter left without any treatment. The experiment ceased at week 20, because mortality markedly increased after this time point in WS/Shi rats. Liver weight was highest in WS/Shi rats among the three strains examined. The incidence of HCC was 15/15 (100%) in WS/Shi rats, 1/16 (6%) in SD/gShi rats, and 13/16 (81%) in F344/DuCrj rats surviving after NNM treatment. Metastasis to the lung was observed in HCC-bearing rats at an incidence of 13/15 (87%) in WS/Shi, 1/1 in SD/gShi, and 6/13 (46%) in F344/DuCrj. Four-week administration of NNM resulted in a significantly higher BrdU-labeling index of hepatocytes in WS/Shi rats than in the other strains. These findings indicated that WS/Shi is the most sensitive strain to NNM and may be the most suitable strain for use as a spontaneous metastatic model of HCC among the strains of rats examined in the present study.