Genomic characterization of Staphylococcus aureus isolated from patients admitted to intensive care units of a tertiary care hospital: epidemiological risk of nasal carriage of virulent clone during admission

We conducted a molecular epidemiological study of Staphylococcus aureus using whole-genome sequence data and clinical data of isolates from nasal swabs of patients admitted to the intensive care unit (ICU) of Hiroshima University hospital. The relationship between isolate genotypes and virulence factors, particularly for isolates that caused infectious diseases during ICU admission was compared with those that did not. The nasal carriage rates of methicillin-resistant S. aureus (MRSA) and methicillin-susceptible S. aureus (MSSA) in patients admitted to the ICU were 7.0% and 20.1%, respectively. The carriage rate of community-acquired (CA)-MRSA was 2.3%, accounting for 32.8% of all MRSA isolates. Whole-genome sequencing analysis of the MRSA isolates indicated that most, including CA-MRSA and healthcare-associated (HA)-MRSA, belonged to clonal complex (CC) 8 [sequence type (ST) 8] and SCCmec type IV. Furthermore, results for three disease foci (pneumonia, skin and soft tissue infection, and deep abscess) and the assessment of virulence factor genes associated with disease conditions [bacteremia, acute respiratory distress syndrome (ARDS), disseminated intravascular coagulopathy (DIC), and septic shock] suggested that nasal colonization of S. aureus clones could represent a risk for patients within the ICU. Particularly, MRSA/J and MSSA/J may be more likely to cause deep abscess infection; ST764 may cause ventilation-associated pneumonia, hospital-acquired pneumonia and subsequent bacteremia, and ARDS, and tst-1-positive isolates may cause DIC onset.IMPORTANCENasal colonization of MRSA in patients admitted to the intensive care unit (ICU) may predict the development of MRSA infections. However, no bacteriological data are available to perform risk assessments for Staphylococcus aureus infection onset. In this single-center 2-year genomic surveillance study, we analyzed all S. aureus isolates from nasal swabs of patients admitted to the ICU and those from the blood or lesions of in-patients who developed infectious diseases in the ICU. Furthermore, we identified the virulent clones responsible for causing infectious diseases in the ICU. Herein, we report several virulent clones present in the nares that are predictive of invasive infections. This information may facilitate the design of preemptive strategies to identify and eradicate virulent MRSA strains, reducing nosocomial infections within the ICU.

Properties and Anti-Hiv Activity of Hairpin Antisense Oligonucleotides Containing 2′-Methoxynucleosides with Base-Pairing in the Stem Region at the 3′-End

A new type of hairpin antisense oligodeoxyribo-nucleotide, containing 2′-methoxynucleosides with base-pairing in the stem region at the 3′-end, was tested for 3′-exonuclease resistance and anti-HIV activity. An increased resistance to nuclease degradation has been observed by incubation of the hairpin oligo-nucleotides with DNA polymerase and foetal bovine serum. Of particular interest is the hairpin antisense oligonucleotide containing 2′-methoxynucleosides with base-pairing in the stem region at the 3′-end, which has increased nuclease resistance and hybridizes effectively with a complementary RNA. Furthermore, these compounds were assayed for inhibition of virus replication in HIV-1 infected MT-4 cells. In the anti-HIV activity test, the hairpin oligonucleotide phosphorothioate derivatives showed higher anti-HIV activities compared to their linear counterparts.

Endovascular treatment for dural arteriovenous fistula of the anterior condylar confluence involving the anterior condylar vein. A report of two cases

SUMMARY

Anterior condylar confluence (ACC) dural arteriovenous fistula (AVF) is a rare anomaly. We describe two cases of ACC dural AVF involving the anterior condylar vein that were successfully treated with selective transvenous coil embolization. The first patient presented with headache and right pulse-synchronous tinnitus, and demonstrated abnormal flow medial to the jugular bulb within the right hypoglossal canal on source image of magnetic resonance angiography (MRA). Arterioangiography disclosed a dural AVF in this area, supplied mainly by the meningeal branches of the bilateral ascending pharyngeal artery. We diagnosed ACC dural AVF involving the anterior condylar vein and transvenous embolization was successfully performed. The second patient presented with right pulse-synchronous tinnitus. Views of source image of MRA and arterioangiography were similar to the first case and, again, transvenous embolization was successfully performed. ACC dural AVF is a rare condition and knowledge of the anatomy of the venous system around the craniocervical junction is required for successful treatment.

Rtf1-mediated eukaryotic site-specific replication termination

The molecular mechanisms mediating eukaryotic replication termination and pausing remain largely unknown. Here we present the molecular characterization of Rtf1 that mediates site-specific replication termination at the polar Schizosaccharomyces pombe barrier RTS1. We show that Rtf1 possesses two chimeric myb/SANT domains: one is able to interact with the repeated motifs encoded by the RTS1 element as well as the elements enhancer region, while the other shows only a weak DNA binding activity. In addition we show that the C-terminal tail of Rtf1 mediates self-interaction, and deletion of this tail has a dominant phenotype. Finally, we identify a point mutation in Rtf1 domain I that converts the RTS1 element into a replication barrier of the opposite polarity. Together our data establish that multiple protein DNA and protein-protein interactions between Rtf1 molecules and both the repeated motifs and the enhancer region of RTS1 are required for site-specific termination at the RTS1 element.

[Dissecting aneurysm of the anterior cerebral artery with persistent pearl & string sign on cerebral angiograms over a period of eight years]

We present a rare case of a dissecting aneurysm of the left anterior cerebral artery (ACA) with persistent pearl & string sign on cerebral angiograms over a period of 8 years. A 43-year-old woman with disturbance of consciousness and right sided hemiparesis was conservatively treated. Computed tomographic (CT) scan revealed a low-density area in the left frontal lobe. Initial angiography, which was performed at 6 months after the onset, showed a pearl & string sign at the A2 portion of the left ACA. After 8 years, repeat angiography again showed persistent pearl & string sign at the same portion of the left ACA. We discussed the changes in findings usually obtained in cerebral angiography concerning dissecting aneurysms in ACA.

A modified burr-hole method in galeoduroencephalosynangiosis for an adult patient with probable moyamoya disease--case report and review of the literature

A 49-year-old woman with probable moyamoya disease was surgically treated by combined direct and indirect methods, superficial temporal to middle cerebral artery anastomosis and galeoduroencephalosynangiosis by a burr-hole method developed by Kawamoto et al. Transient ischemic attacks and motor weakness of bilateral lower extremities disappeared completely within 1 month and never recurred during 1-year follow-up. Galeoduroencephalosynangiosis by a burr-hole method appears useful for preventing ischemic damage of the territory of the anterior cerebral artery in adult patients with probable moyamoya disease.

Defective plasmid partition in ftsH mutants of Escherichia coli

FtsH is an ATP-dependent protease that is essential for cell viability in Escherichia coli. The essential function of FtsH is to maintain the proper balance of biosynthesis of major membrane components, lipopolysaccharide and phospholipids. F plasmid uses a partitioning system and is localized at specific cell positions, which may be related to the cell envelope, to ensure accurate partitioning. We have examined the effects of ftsH mutations on the maintenance of a mini-F plasmid, and have found that temperature-sensitive ftsH mutants are defective in mini-F plasmid partition, but not replication, at permissive temperature for cell growth. A significant fraction of replicated plasmid molecules tend to localize close together on one side of the cell, which may result in failure to pass the plasmid to one of the two daughter cells upon cell division. By contrast, an ftsH null mutant carrying the suppressor mutation sfhC did not affect partitioning of the plasmid. The sfhC mutation also suppressed defective maintenance in temperature-sensitive ftsH mutants. Using this new phenotype caused by ftsH mutations, we also isolated a new temperature-sensitive ftsH mutant. Mutations in ftsH cause an increase in the lipopolysaccharide/ phospholipid ratio due to stabilization of the lpxC gene product, which is involved in lipopolysaccharide synthesis and is a substrate for proteolysis by the FtsH protease. It is likely that altered membrane structure affects the localization or activity of a putative plasmid partitioning apparatus located at positions equivalent to 1/4 and 3/4 of the cell length.

Trends in incidence and case fatality rates of aneurysmal subarachnoid hemorrhage in Izumo City, Japan, between 1980-1989 and 1990-1998

BACKGROUND AND PURPOSE

With aging of the population, the profile of subarachnoid hemorrhage (SAH) is likely to change; however, evaluation of long-term trends for incidence and case fatality rates of SAH is still limited.

METHODS

We compared the incidence and case fatality rates of aneurysmal SAH during the 9-year period 1990-1998 with those during the 10-year period 1980-1989 in Izumo City, Japan.

RESULTS

During 1980-1989 and 1990-1998, we diagnosed 170 and 188 patients as having aneurysmal SAH, respectively. The percentage of very elderly patients aged >/=80 years increased from 5% (8 patients) during 1980-1989 to 18% (33 patients) during 1990-1998 (P<0.001). The age-specific incidence rate of SAH has a tendency to increase with increasing age. The crude and the age- and sex-adjusted incidence rates using the 1995 population statistics for Japan were 21 and 23 per 100 000/y for all ages during 1980-1989 and 25 and 23 per 100 000/y during 1990-1998, respectively. The 3-month case fatality rate of patients aged </=79 years decreased from 38% during 1980-1989 to 26% during 1990-1998 (P=0.021), whereas the case fatality rates in patients aged >/=80 years were very high (63% and 79%, respectively) regardless of study periods. Consequently, the overall case fatality rates for patients with SAH were similar for the 2 study periods (39% and 36%).

CONCLUSIONS

The age- and sex-adjusted incidence rates of aneurysmal SAH were stable over the 19-year period since 1980 and, despite improvement of outcome in patients aged </=79 years, the overall case fatality rate was not lower because the improvements were counterbalanced by increasing numbers of very elderly patients

[Two cases with coil embolization following incomplete neck clipping]

We report two cases with embolization (coil embolization) using Guglielumi detachable coils of residual aneurysms following incomplete neck clipping. The first case, a 75-year-old woman suffered from a subarachnoid hemorrhage due to the rupture of a left internal carotid posterior communicating aneurysm in June, 1997. Neck clipping of the aneurysm was performed at day 1. Follow-up angiogram at day 7 showed a residual aneurysm involving the dome of the initial aneurysm. We performed coil embolization of the residual aneurysm following the angiogram. Almost complete obliteration of the aneurysm lasted during the follow-up period of two and a half years. The second case, a 71-year-old woman suffered from a subarachnoid hemorrhage due to the rupture of a right internal carotid posterior communicating aneurysm in May, 1999. Neck clipping of the aneurysm was performed at day 1. Follow-up angiogram at day 7 showed a residual aneurysm involving only a part of the initial aneurysm near the neck. Because no spontaneous thrombosis of the residual aneurysm was obtained after 2 months, we performed coil embolization of the residual aneurysm. Almost complete obliteration of the aneurysm lasted during the follow-up period of 7 months. These patients were discharged with good performance status. We consider the morphologic feature of the residural aneurysm to be most important for determining when to perform coil embolization of such residual aneurysms.

Primary intracerebral and aneurysmal subarachnoid hemorrhage in Izumo City, Japan. Part I: incidence and seasonal and diurnal variations

OBJECT

The purpose of this community-based study was first to estimate the incidence rates of primary intracerebral hemorrhage (ICH) and aneurysmal subarachnoid hemorrhage (SAH) in Izumo City, Japan, and second to investigate whether there were seasonal and diurnal periodicities in their onset.

METHODS

During 1991 through 1996, 267 patients with primary ICH and 123 with aneurysmal SAH were treated in Izumo City. The crude and the age- and sex-adjusted annual incidence rates per 100,000 population for all ages were 52 and 48 for ICH and 24 and 23 for SAH, respectively. These incidence rates were higher than those previously published for any other geographical region. The incidence rates of both ICH and SAH increased almost linearly with age. For ICH, a significant seasonal pattern was observed in men and in patients younger than 65 years, with a peak in winter and a trough in summer. However, no significant seasonal fluctuation was found in women or in individuals aged 65 years or older. There was no significant seasonal periodicity for SAH, even when patients were analyzed according to sex and age. Diurnal variations in the onset of both ICH and SAH were significant (except in men with SAH), with a nadir between midnight and 6:00 a.m.

CONCLUSIONS

The actual incidence rates of both primary ICH and aneurysmal SAH seem to be much higher than have been reported so far. In addition, the data indicate the existence of seasonal periodicity for men and younger patients with ICH, and that the risk of both ICH and SAH is lower during nighttime.

Primary intracerebral and aneurysmal subarachnoid hemorrhage in Izumo City, Japan. Part II: management and surgical outcome

OBJECT

The purpose of this study was to assess the overall management and surgical outcome of primary intracerebral hemorrhage (ICH) and aneurysmal subarachnoid hemorrhage (SAH) among the 85,000 residents of Izumo City, Japan.

METHODS

During 1991 through 1996, 267 patients with ICH and 123 with SAH were treated in Izumo. Of the 267 patients with ICH, 25 underwent hematoma removal by open craniotomy or suboccipital craniectomy and 34 underwent stereotactic evacuation of the hematoma, whereas aneurysm clipping was performed in 71 of the 123 patients with SAH; operability rates were thus 22% for ICH and 58% for SAH (p < 0.0001). The overall 30-day survival rates were 86% for ICH and 66% for SAH (p < 0.0001) and the 2-year survival rates were 73% and 62% (p = 0.0207), respectively. In patients who underwent surgery, 30-day and 2-year survival rates were 93% for ICH and 100% for SAH (p = 0.0262), and 75% for ICH and 97% for SAH (p = 0.0002), respectively. In patients with ICH, the most important predictors of 30-day case-fatality rates were the volume of the hematoma, the Glasgow Coma Scale (GCS) score, rebleeding, and midline shifting, whereas those for 2-year survival were the GCS score, age, rebleeding, and hematoma volume. In patients with SAH, the most important determinants of 30-day case-fatality rates were the GCS score and age, whereas only the GCS score had a significant impact on 2-year survival.

CONCLUSIONS

The overall survival rates for patients with ICH or SAH in Izumo were more favorable than those in previously published epidemiological studies. However, despite improved surgical results, the overall management of ICH and SAH still produced an unsatisfactory outcome, mainly because of primary brain damage.

Dissection from fundus to neck for ruptured anterior and middle cerebral artery aneurysms at the acute surgery

It is generally believed that a ruptured aneurysm should be dissected from its neck to its fundus or that only the neck should be dissected. This study was conducted to clarify whether, during the acute stage, intra-operative bleeding occurs at the same site as the initial rupture point when aneurysms are dissected completely without clipping. The subjects were 170 patients with ruptured anterior or middle cerebral artery aneurysms who were surgically treated by day 7. These aneurysms were operated on through an interhemispheric or a pterional route, respectively. Most of the aneurysms were dissected from the fundus to the neck. Complete exposure of entire aneurysms without temporary clipping was performed in 118 of 170 patients (69%). Intra-operative aneurysmal rupture occurred during 16 (9%) operative procedures. There were no significant correlations between the rate of intra-operative aneurysmal rupture occurrence and the timing of the operation, pre-operative grade or location of ruptured aneurysms. Intra-operative aneurysmal rupture occurred during dissection of the aneurysm itself in 8 patients, during dissection of the artery adhering to the aneurysm in 5 and during clip application in 3. In all the patients whose aneurysms ruptured during aneurysmal dissection, the rupture was caused by injury to the aneurysm and was not directly related to complete exposure of the aneurysm. Intra-operative bleeding did not occur at the same site as the initial rupture point even when the entire aneurysmal complex was dissected from the fundus to the neck without clipping.

Chronic hydrocephalus in elderly patients following subarachnoid hemorrhage

BACKGROUND

With the aging of the population, surgery for ruptured intracranial aneurysms is increasing among the elderly. We sought to clarify the characteristics of chronic hydrocephalus following aneurysmal subarachnoid hemorrhage (SAH) in elderly patients.

METHODS

Of the 576 surgically treated patients, 289 were aged 59 years or younger, 169 were 60 to 69, and 118 were 70 years or older. The relationship between chronic hydrocephalus and the causative factors was analyzed for each age group.

RESULTS

Of the 576 patients, chronic hydrocephalus was observed in 215 (37%), with the incidence increasing significantly with age (p < 0.001) and being the highest in the oldest age group. In elderly patients, the incidence of chronic hydrocephalus was relatively high, even after mild SAH. The incidence of chronic hydrocephalus was high regardless of age in patients with severe SAH, such as in those with H&H grades III-IV, SAH grades III-IV, acute hydrocephalus, symptomatic vasospasm, and intraventricular hemorrhage, and in those with vertebro-basilar artery aneurysms.

CONCLUSION

In the elderly, the incidence of chronic hydrocephalus following SAH was significantly higher than in younger patients, even after mild SAH. In elderly patients, careful observation and individualized treatment are necessary even if SAH is mild.

Dissecting the role of a conserved motif (the second region of homology) in the AAA family of ATPases. Site-directed mutagenesis of the ATP-dependent protease FtsH

Escherichia coli FtsH is an ATP-dependent protease that belongs to the AAA protein family. The second region of homology (SRH) is a highly conserved motif among AAA family members and distinguishes these proteins in part from the wider family of Walker-type ATPases. Despite its conservation across the AAA family of proteins, very little is known concerning the function of the SRH. To address this question, we introduced point mutations systematically into the SRH of FtsH and studied the activities of the mutant proteins. Highly conserved amino acid residues within the SRH were found to be critical for the function of FtsH, with mutations at these positions leading to decreased or abolished ATPase activity. The effects of the mutations on the protease activity of FtsH correlated strikingly with their effects on the ATPase activity. The ATPase-deficient SRH mutants underwent an ATP-induced conformational change similar to wild type FtsH, suggesting an important role for the SRH in ATP hydrolysis but not ATP binding. Analysis of the data in the light of the crystal structure of the hexamerization domain of N-ethylmaleimide-sensitive fusion protein suggests a plausible mechanism of ATP hydrolysis by the AAA ATPases, which invokes an intermolecular catalytic role for the SRH.

Ruptured de novo aneurysm induced by ethyl 2-cyanoacrylate: case report

OBJECTIVE AND IMPORTANCE

We report a rare case of a ruptured de novo aneurysm induced by ethyl 2-cyanoacrylate.

CLINICAL PRESENTATION

A 44-year-old woman had undergone microvascular decompression for a right-sided facial spasm. The preoperative vertebral angiogram did not show any aneurysmal dilation. The right anteroinferior cerebellar artery, which was compressing the exit zone of the facial nerve, was detached and fixed to the dura mater with ethyl 2-cyanoacrylate. Nine years later, the patient suffered a subarachnoid hemorrhage caused by the rupture of a newly developed aneurysm of the right anteroinferior cerebellar artery.

INTERVENTION

The aneurysm was clipped 2 days after onset of the subarachnoid hemorrhage. It consisted of two bulges in the arterial wall on the proximal side of the meatal loop. One bulge was stuck to the dura mater of the pyramis by ethyl 2-cyanoacrylate, which had been used in the microvascular decompression 9 years previously.

CONCLUSION

This is the first reported clinical case of a de novo aneurysm induced by a cyanoacrylate adhesive. Ethyl 2-cyanoacrylate can damage the arterial wall and induce a de novo aneurysm.

What are the actual incidence and mortality rates of subarachnoid hemorrhage?

BACKGROUND

From 1987-92 in Izumo City, Japan, we diagnosed 123 patients as having subarachnoid hemorrhage (SAH) by computed tomography, autopsy, or surgery (proven SAH); the crude incidence rate was 25/100,000/year for all ages. However, to estimate the actual incidence and mortality rates, we should take into account the decedents who died without confirmation by these methods but were presumed to have died of SAH.

METHODS

From 1987-92, we reviewed all of 3562 death certificates for the city of Izumo (population 82,679), and calculated the incidence and mortality rates of SAH by combining proven and possible SAH.

RESULTS

We diagnosed 36 patients as having possible SAH on death certificates. When adding these 36 patients to the 123 with proven SAH, the crude and the age-adjusted and sex-adjusted incidence rates for all ages became 32/ 100,000/year and 29/100,000/year, respectively. Of these, 40% (64) died by day 3 (day 0 defined as the day of hemorrhage), 43% (69) within 1 week, and 53% (84) within 1-6 months, respectively.

CONCLUSIONS

When including the patients who may have died of SAH, the actual incidence rate of SAH is much higher than that which has been reported to date, and the actual mortality rate is still very high.

5'-linked lipid-oligodeoxyridonucleotide derivatives as inhibitors of human immunodeficiency virus replication

The covalent attachment of a phospholipid moiety, bound to the 5'-ends of phosphodiester and phosphorothioate oligonucleotides (L-ODNs and LS-ODNs), was achieved using H-phosphonate chemistry, and the lipid-oligonucleotides were assayed for the inhibition of virus replication in HIV-1 infected MT-4 cells. In the anti-HIV activity test, lipid-phosphorothioate oligonucleotides showed higher anti-HIV activities than non-lipid-phosphorothioate oligonucleotides, at the low concentration of 0.04 microM. LS-ODNs can inhibit HIV-1 reverse transcriptase activity through interactions with the enzyme. We found that the covalent attachment of a phospholipid group to the 5'-end of the phosphorothioate oligonucleotide enhances its nonsequence specific anti-HIV activity.

[A case of multiple cerebral arteriovenous malformations treated by gamma knife radiosurgery]

We reported a case of multiple cerebral arteriovenous malformations (AVMs) treated by gamma knife radiosurgery. A 6-year-old girl was admitted because of systemic tonic convulsion. At the first admission, we performed only vertebral angiography, which showed a 15 mm cerebral AVM. It was fed by the right posterior cerebral artery and drained into the great vein of Galen. Seven years after the first admission, the patient returned again with severe headache. Four-vessel cerebral angiograms showed another 7 mm AVM fed by the left frontopolar artery. We treated both cerebral AVMs bv gamma knife radiosurgery. Follow-up angiograms performed 2 years after radiosurgery confirmed the disappearance of both AVMs. We then discuss treatment of multiple cerebral AVMs.

[A case of cranial metastasis of hepatocellular carcinoma]

A case of cranial metastasis of hepatocellular carcinoma is reported. A 77-year-old woman with an elastic hard tumor in the right temporal region was referred to our department on April 30, 1992. On admission, the patient had slight weakness of the left upper limb. Plain skull X-ray and computed tomography (CT) showed bone destruction in the right temporal region. Magnetic resonance images (MRI) showed that the tumor was hypo-intense with T1-sequences and hyper-intense with T2-sequences, and included hyper-intense spots on both T1- and T2-images. Right carotid angiography showed that the tumor was fed by the middle meningeal and accessory meningeal arteries. The patient became disoriented, and the left hemiparesis worsened on May 4, 1992. CT scan revealed an irregular high-density area in the tumor because of intratumoral hemorrhage. After embolization of the arteries feeding the tumor, surgery was performed on May 8, 1992, and the tumor was totally removed. Histological examination of the tumor specimen revealed that it was a metastatic hepatocellular carcinoma. The patient died 8 months after initial diagnosis because of hepatocellular carcinoma.

Rapid spontaneous diminution of cisternal blood on computed tomography in patients with subarachnoid hemorrhage

BACKGROUND

The purpose of this study is to investigate whether rapid spontaneous diminution of cisternal subarachnoid hemorrhage (SAH) alleviates vasospasm in the corresponding arterial territory.

METHODS

The subjects were 103 patients in whom initial computed tomography scans were performed within 24 hours after SAH and repeated within 72 hours. We analyzed the effect of diminution of cisternal SAH on vasospasm in 16 sites in each patient. Of the total 1642 cisterns. SAH was found in 1362 (83%), of which 539 (40%) had a decrease in SAH. The highest diminution rate was 64% in quadrigeminal cistern, and the lowest rate was 27% in frontal interhemispheric fissure (IHF). In basal frontal IHF, both the incidence of diminution of SAH and its degree were significantly lower in patients with ruptured anterior cerebral artery aneurysms than in those with other site aneurysms, while in suprasellar cisterns, sylvian stems, and sylvian fissures, diminution of SAH was not affected by the side of ruptured aneurysms. The diminution of SAH in basal frontal IHF and sylvian stems was associated with less vasospasm in adjacent arteries.

CONCLUSIONS

We concluded that in patients with SAH, rapid spontaneous diminution of cisternal blood, which is affected by several factors, makes vasospasm in the corresponding arterial territory less likely.

Surgical removal of pineal region meningioma--three case reports

Three patients with large or huge meningiomas of the pineal region presented with headache, vomiting, gait and visual disturbance, apraxia, agnosia, and transient amnestic aphasia. Computed tomographic scans revealed round, high-density areas of 8 x 7 x 7 cm, 5 x 5 x 4 cm, and 3 x 3 x 3 cm in the pineal region. Angiography revealed that the bilateral internal cerebral veins and the great vein of Galen were stretched and significantly displaced upward in one patient, and downwards in the other two. The meningiomas appeared to originate from the verum interpositum and falcotentorial junction, respectively. The tumors were removed subtotally or totally via an occipital interhemispheric transtentorial approach and/or infratentorial supracerebellar approach. The postoperative courses were uneventful, and no neurological deficit was detected postoperatively. Pineal region tumors with a maximum diameter of 5 cm or larger should be operated on via a unilateral or bilateral occipital interhemispheric transtentorial approach, regardless of the angiographic findings, because this permits a wide operative field and can be followed, if necessary, by an infratentorial supracerebellar approach. Selection of the operative approach for a relatively small pineal region tumor should depend on the angiographic findings: downward displacement of the bilateral internal cerebral veins and the great vein of Galen indicates an occipital interhemispheric transtentorial approach, whereas upward displacement indicates an infratentorial supracerebellar approach.

Study of aneurysmal subarachnoid hemorrhage in Izumo City, Japan

BACKGROUND AND PURPOSE

Estimation of the actual incidence rate of subarachnoid hemorrhage and evaluation of the treatment require the inclusion of all patients in a defined geographic area.

METHODS

During 1987 through 1992 in Izumo City, Japan, we estimated the incidence rate of subarachnoid hemorrhage by including dead-on-arrival patients and by further adding the results obtained after reviewing all death certificates registered in this city in the corresponding period. In addition, we compared the management and surgical outcomes in hospitalized patients from 1987 through 1992 with outcomes from 1980 through 1986.

RESULTS

During 1987 through 1992, we diagnosed 123 patients as having subarachnoid hemorrhage. The crude and the age- and sex-adjusted incidence rates using the 1990 population statistics for Japan were 25 (95% confidence interval, 21 to 30) per 100,000/y and 23 (95% confidence interval, 19 to 28) per 100,000/y for all ages, respectively; these occurrences are the highest among those reported to date. Of these patients, 8% died before receiving medical attention, 27% in the first week, and 39% at 1 month. The survival curve for 2 years improved significantly from 1980-1986 to 1987-1992 in patients with admission grades 4 and 5 (P = .035) and in operated patients with preoperative grades 1 through 3 (P = .036). However, there was little improvement in the overall management results (P = .168), possibly because patients with high risk and/or old age were admitted and/or diagnosed more often in the latter period.

CONCLUSIONS

The incidence rate of subarachnoid hemorrhage is much higher than that reported so far in the literature, and despite improvement of management and surgical therapy, the actual case-fatality rate is still high, mainly because of the high mortality rate directly associated with the primary bleeding.

Effect of ultra-early referral on management outcome in subarachnoid haemorrhage

A study was conducted to clarify whether ultra-early referral of patients with subarachnoid haemorrhage (SAH) is effective for improving the management outcome. The subjects were 455 patients who were admitted within 6 h after initial SAH. Of these patients, 289 were treated surgically, 159 of them within 24 h. At 6 months, 228 patients (50%) had a favourable outcome including good recovery or moderate disability, 37 (8%) had severe disability, and 190 (42%) had an unfavourable outcome including vegetative state or death. Of 214 patients with an admission grade IV or V, 47 (22%) had a favourable outcome. In 10 patients, emergency procedures such as haematoma removal or ventriculostomy were definitely effective, and in 13, early surgery may have been the reason for the improved outcome. However, in 24 patients, the reasons for a favourable outcome were not related directly to ultra-early referral; in 19 of them, there was spontaneous improvement of clinical grade and/or no SAH on computed tomography. Of 218 patients with admission grade I or II, 30 (14%) had an unfavourable outcome, and in 12 of them, this was ascribed to rebleeding. The rebleeding rate and severity of vasospasm were not significantly reduced by surgery carried out within 24 h after SAH, in comparison with surgery carried out between 24 and 48 h, and there was no significant difference in surgical outcome between them. It is concluded that although ultra-early referral of patients with SAH was expected to improve the outcome in emergency cases, no substantial improvement in overall management outcome seems to have been achieved by this policy.

Intracerebral hematoma in patients with ruptured cerebral aneurysms

BACKGROUND

Intracerebral hematoma from ruptured aneurysms is one of the unfavorable factors for outcome in patients with subarachnoid hemorrhage. In this study, the clinical characteristics of intracerebral hematoma in patients with ruptured aneurysms were examined.

METHODS

The subjects were 512 patients who had been admitted by day 3 after aneurysmal rupture without episodes of rebleeding before the initial computed tomography (CT) scan. They were divided into two groups according to the findings of initial CT; groups 1 and 2 comprised patients with and without intracerebral hematoma, respectively.

RESULTS

Of the 512 patients, intracerebral hematoma was observed in 98 (19%). The incidence of intracerebral hematoma was higher in patients with distal anterior cerebral and middle cerebral artery aneurysms, compared with those at other sites (both, p < 0.01). Interhemispheric, callosal, and temporal lobe/sylvian hematomas were observed more frequently in patients with anterior communicating, distal anterior cerebral, and middle cerebral artery aneurysms, respectively, than in those with aneurysms at other sites. The incidence of rebleeding was 22% in group 1 and 14% in group 2 (p < 0.05). Clinical grades on admission were higher and outcome at 6 months after onset was less favorable in group 1 than in group 2 (both, p < 0.01). The larger the intracerebral hematoma, the higher was the clinical grade and the less favorable the outcome. However, when comparing management and surgical outcome under the same clinical grades, there was no significant difference between the two groups.

CONCLUSIONS

There was a close correlation between the site of hematoma and that of the ruptured aneurysm. Poor outcome in patients with intracerebral hematoma seems to be related to severity of clinical grade on admission.

A case of spinal low-grade astrocytoma with exophytic and intracranial extension

BACKGROUND

Ventral exophytic growth of a spinal intramedullary glioma into the cranial cavity is an unusual condition.

CASE DESCRIPTION

A 16-year-old boy was admitted because of lower cranial nerve dysfunction and acute hydrocephalus. Magnetic resonance images showed an intramedullary mass lesion in the upper cervical spinal cord with exophytic extension into the medullary and prepontine cisterns. The patient underwent suboccipital craniectomy and C1-2 laminectomy for decompression and histologic evaluation. The histopathologic findings were characteristic of astrocytoma grade II. Although radiotherapy was performed, the patient died 7 months later.

CONCLUSIONS

This is considered to be a rare case of spinal low-grade astrocytoma with ventral exophytic intracranial extension.

A case of traumatic internal carotid artery occlusion diagnosed by MRI

The case of a 4-year-old boy with traumatic internal carotid artery occlusion is reported. This patient developed left upper limb monoparesis and convulsions 62 h after injury. Magnetic resonance imaging (MRI) showed absence of a flow void and a high signal in the C5 portion of the right internal carotid artery. The proximal side of the right carotid siphon was not demonstrated by MR angiography. Carotid angiography revealed occlusion of the right internal carotid artery about 2 cm distal from the cervical carotid bifurcation. MRI appears to be useful to diagnose traumatic internal carotid artery occlusion, especially in children.

[A case of meningioma associated with intracerebral hemorrhage and acute deterioration]

We report a case of convexity meningioma associated with sudden onset of intracerebral hemorrhage followed by acute deterioration. A 76-year-old previously healthy male suddenly collapsed into coma and was admitted to our department. On admission, he was deeply comatose. Computerized tomography (CT) scan revealed intracerebral hemorrhage in the right frontal lobe, together with an isodense mass lesion of about 5 cm in diameter. The density on the fronto-medial side of the mass increased after administration of contrast medium, probably due to extravasation. However, there was no enhancement of the mass lesion. Cerebral angiography revealed marked prolongation in circulation time and extravasation via the right middle internal frontal artery. The right middle meningeal artery was dilated and elongated, but no tumor stain was found. The patient died on the following day. Autopsy disclosed massive hemorrhage in the right frontal lobe together with a convexity meningioma. Histological examination showed that the tumor was a fibroblastic meningioma. We review previously reported cases of convexity meningioma associated with intracranial hemorrhage, and discuss mainly the mechanism of bleeding.

Development of a fistula between an internal mammary artery graft and the pulmonary vasculature following coronary artery bypass grafting: report of a case

We report herein the rare case of a 56-year-old man who gradually developed congestive cardiac failure 6 months after undergoing coronary artery bypass grafting and was found to have a fistula between the internal mammary artery and the pulmonary artery of the upper lobe diagnosed by selective left internal mammary arteriogram. A second sternotomy was performed and demonstrated dense adhesion between the fissure surrounding the internal mammary artery and the upper lobe, and the fistula was resected. We believe that the patient's increasing cardiac failure was almost certainly caused by coronary seal.

Effect of rapid spontaneous diminution of subarachnoid hemorrhage on cerebral vasospasm

In patients with subarachnoid hemorrhage (SAH), the effect of clot removal on cerebral vasospasm is still in dispute. The purpose of this study is to investigate whether rapid spontaneous diminution of subarachnoid blood alleviates vasospasm. We analyzed the effect of diminution of SAH on vasospasm in 36 patients with SAH grades III-IV who were operated on by the same surgeon by day 6 after SAH. The diminution of subarachnoid blood became more apparent with shorter interval between hemorrhage and initial computed tomography (CT) scan, with increasing patient age, and with higher SAH grades. The incidences of angiographic vasospasm grades III-IV, permanent symptomatic vasospasm, and low-density area on CT scans decreased with the increase in the degree of diminution of subarachnoid blood. Permanent symptomatic vasospasm and low-density area on CT scans were found in 5 of 9 patients with no diminution, whereas they occurred only in 5 of 27 patients with diminution (p < .05). We concluded that spontaneous diminution of subarachnoid blood in the acute stage after SAH seems to reduce the severity of vasospasm.

Ultra-early rebleeding within six hours after aneurysmal rupture

During 1980-85, cerebral angiography was performed as soon as possible for early operation of ruptured aneurysms. However, during that period, the incidence of rebleeding during angiography conducted within 6 hours after the initial rupture was approximately two-fold higher than the rate of rebleeding within 6 hours for the total series. Therefore, since 1986, patients with grades I-IV have been managed with complete bed rest, and angiography has been withheld during the first 6 hours after rupture, except in patients in whom emergency operation was anticipated. To investigate whether this change of policy has been effective in decreasing ultra-early rebleeding within 6 hours after rupture, patients admitted during 1986-92 were compared with those admitted during 1980-85. Of the total 418 patients who were admitted within 6 hours after initial rupture, 61 (15%) had ultra-early rebleeding: 18 prior to and 43 after admission. The rebleeding rate during angiography within 6 hours after rupture was 7%. In patients with grades I-IV, the percentage of patients receiving angiography within 6 hours after rupture decreased from 45% during 1980-85 to 13% during 1986-92 (p < 0.01), and the ultra-early rebleeding rate decreased from 15% during 1980-85 to 5% during 1986-92 (p < 0.01). However, with the increase in number of patients referred in the ultra-early stage, the number of rebleeding cases during transfer increased. In conclusion, in order to reduce the rate of ultra-early rebleeding, withholding aggressive management such as angiography in this stage seems to be effective, and if there is no need for emergency operation, it is better to withhold patients' transfer in this stage and commence it soon after 6 hours following subarachnoid hemorrhage.

Timing of admission and management outcome in patients with subarachnoid hemorrhage

The purpose of this study is to investigate the overall management outcome in patients with subarachnoid hemorrhage who were admitted in the ultra-early stage. A total of 601 patients with subarachnoid hemorrhage were classified into three groups, that is, those admitted within 6 hours (group 1: 371 cases, 62%), those admitted from 6 hours to day 3 (group 2: 145 cases, 24%) and those admitted from day 4 to 30 (group 3: 85 cases, 14%). The shorter the interval from hemorrhage to admission, the worse were the clinical and subarachnoid hemorrhage grades on admission. The operability rate of group 1 was lower than that of group 2 or 3-62%, 73%, and 71%, respectively. At 6 months the overall outcome of group 1 was significantly poorer than that of group 2 or 3; the mortality rate was 39%, 27%, and 19%, respectively. The poor outcome in group 1 was a result of a worse neurologic state compared with groups 2 and 3. By life-table analysis, the survival curve of group 1 was also significantly poorer than that of group 2 or 3; the 5-year survival probability was 50%, 64%, and 67%, respectively. However, when analyzing the survival curves in patients with admission grades I-III or in those who were operated on, differences among the three groups were insignificant. Regarding age, the long-term survival probability as well as the short-term outcome were definitely inferior in patients aged > or = 70 years, especially in group 1. It is concluded that while the management outcome in patients admitted in the ultra-early stage after subarachnoid hemorrhage was poorer than in those admitted at later stages, if the subjects were restricted to those with good risk or those who underwent surgery, the results were not necessarily poor.

Complication of silastic dural substitute 20 years after dural plasty

A 63-year-old woman was admitted because of right hemiparesis. Both computed tomography scan and magnetic resonance imaging revealed a mass lesion in the left parieto-occipital lobe. Twenty years previously, meningioma of the left parieto-occipital region was removed at another hospital, and a dural plasty was performed using a silastic dural substitute. The patient was operated on under the diagnosis of recurrent meningioma. However, most of the mass lesion was composed of an old hematoma, which seemed to be a complication of the silastic dural substitute.

A case of meningioangiomatosis without von Recklinghausen's disease. Report of a case and review of 13 cases

Meningioangiomatosis is rare disease and is classified as hamartoma in central neurofibromatosis. Unlike most cases of meningioangiomatosis, the very rare case reported here was not associated with von Recklinghausen's disease. We could find only 12 previous cases reported in the literature. A review was carried out of the clinical features, imaging characteristics, and histopathological findings in those 12 plus ours for a total 13 cases. Several types of convulsion were identified as clinical symptoms in 11 of the 13 cases. They were treated surgically. Prognosis was satisfactory in most cases. Proliferation of small blood vessels accompanied by endothelial cells with glial tissue as background and proliferation of fibroblasts or meningothelial cells in the perivascular space were observed to be the most frequent histopathological features.

A case of tinnitus and hearing loss after cerebellar hemorrhage

BACKGROUND

Approximately 10% of cases of hypertensive intracerebral hemorrhage are cerebellar hemorrhage. We report a case of intracerebellar hemorrhage in which the initial symptoms were hearing loss and tinnitus.

SUMMARY OF REPORT

A 45-year-old man suddenly complained of hearing loss and tinnitus on the right side. Computed tomography demonstrated a high-density area 1.2 cm in diameter in the right cerebellar peduncle. Because of enlargement of the high-density area, the patient underwent surgery based on the diagnosis of hypertensive intracerebellar hemorrhage, and the hematoma was evacuated. The right-sided acoustic nerve was remarkably swollen by a subpial hematoma.

CONCLUSIONS

In this case, hemorrhage of the right cerebellar peduncle extended to the eighth nerve through the subpial space, causing hearing loss and tinnitus.

Management outcome in the elderly patient following subarachnoid hemorrhage

The purpose of this study was to investigate whether the overall management outcome for elderly patients with subarachnoid hemorrhage (SAH), especially for those aged 70 to 79 years, has improved. To this end, the author compared data for the period between 1986 and 1990 (Study Period 2) with those obtained between 1980 and 1985 (Study Period 1). Of 503 patients who were admitted by Day 3 after SAH during the two study periods, 243 (48%) were 59 years of age or younger, 129 (26%) were 60 to 69 years of age, 102 (20%) were 70 to 79 years of age, and 29 (6%) were 80 years of age or older. The percentage of patients aged 70 years or more doubled from 17% during Study Period 1 to 34% during Study Period 2. During Study Period 1, the older patients had a lower operability rate; during Study Period 2, the operability rate for patients aged 70 to 79 years (69%) was similar to that for patients aged 50 to 69 years. At 6 months after SAH for patients aged 70 to 79 years, the overall management and surgical results of good recovery or moderate disability were 18% and 36%, respectively, during Study Period 1, and improved to 41% and 60%, respectively, during Study Period 2. During Study Period 1, the cumulative 5-year survival probabilities for overall management were 58% for patients aged 59 years or less, 53% for those aged 60 to 69 years, and 24% for those aged 70 to 79 years; during Study Period 2, these probabilities improved to 70%, 58%, and 47%, respectively. The 5-year survival rates of surgically treated patients in these three age groups increased from 77%, 68%, and 44% to 88%, 77%, and 69%, respectively.

Unruptured intracranial aneurysms in elderly patients

A total of 556 patients with 769 intracranial aneurysms, of which 256 were unruptured and 513 were ruptured, were included in the present study. The patients were divided into three age groups: those aged 59 years or younger, those aged 60 to 69 years, and those aged 70 years or older. Small aneurysms of 4 mm or less in diameter were more common in the series of unruptured aneurysms than in the ruptured aneurysms. The rupture rate in anterior communicating artery aneurysms was the highest, and it increased with age. A follow-up study was performed on 47 patients with 55 unruptured aneurysms, and only one giant basilar artery aneurysm ruptured during the average follow-up period of 5.2 years. Direct operation was performed on 52 patients with unruptured aneurysms. While the surgical mortality rate was 0%, the morbidity rate was 6% (three of 52 cases), which was not directly related to the patients' age. When considering surgery for unruptured aneurysms, rupture rate of aneurysms at each site is one of the most important factors, especially in elderly patients.

Cerebral vasospasm in elderly patients treated by early operation for ruptured intracranial aneurysms

Cerebral vasospasm in elderly patients was studied under strict criteria. A total of 145 patients, who had been operated on in the acute stage after subarachnoid haemorrhage, were classified into two age groups. Those aged 59 years or younger were in group 1 (76 cases, 52%), and those aged 60 years or older were in group 2 (69 cases, 48%). The severities of both the subarachnoid haemorrhage on computed tomography scan and the angiographic vasospasm were graded from 0 to IV. Close correlations were found in both groups for the angiographic vasospasm grades to the incidences of both symptomatic vasospasm and low-density areas on computed tomography scan. Angiographic vasospasm was observed in 95% of group 1 and in 91% of group 2 patients. The incidences of permanent symptomatic vasospasm were 14% in group 1 and 19% in group 2. Low-density areas on computed tomography occurred in 16% of group 1 and in 17% of group 2. Generally, the higher the clinical grades and/or the higher the subarachnoid haemorrhage grades, the more severe were the vasospasms. These tendencies were more apparent in subarachnoid haemorrhage grading. The mortality rates were 8% in group 1 and 17% in group 2. However, when both the clinical grades and the subarachnoid haemorrhage grades were analyzed, there were no significant differences between groups 1 and 2 in either the severity of vasospasm or in the outcome. It must be concluded that neither the angiographic vasospasm grades nor the incidence of symptomatic vasospasm are significantly effected by age.