Postoperative seizure-free outcome, psychiatric condition, intellectual function, and employment status were reviewed to demonstrate the usefulness of focus resection in 71 patients who underwent resective epilepsy surgery between 2000 and 2010 for the treatment of medication-resistant epilepsy. The psychiatric problems were assumed to be present only if the patient received psychotropic drug therapy. Seizure-free outcome was obtained in 53 (75%) patients. The patients were followed up for 2.0-12.0 years (mean 7.2 years) after surgery. Temporal lobe epilepsy (TLE), late seizure onset, short seizure duration, and magnetic resonance imaging lesions were all significantly associated with cessation of seizures. Psychotropic drug therapy was performed in 3 (4.2%) patients before surgery and in 12 (17.0%) patients at 2 years or later after surgery. TLE and preoperative psychotropic drugs were significantly associated with postoperative psychiatric problems. Among the 71 patients, 65 underwent full Wechsler Adult Intelligence Scale-Revised (WAIS-R) examinations both before and after surgery. The mean WAIS-R score was 82.5 ± 18.7 points for total intelligence quotient (IQ) preoperatively and 89.6 ± 20.3 points for total IQ postoperatively. Before surgery, 19 (27%) patients were engaged in full-time employment. After surgery, 2 patients lost and 9 patients newly entered full-time employment, so a total of 26 (37%) patients were engaged in full-time employment after surgery. Resective epilepsy surgery resulted in overall improvements in seizure control, intellectual functions, and employment status. However, patients with TLE had some risk of postoperative psychiatric disorder.
Acute phase rehabilitation is an important treatment for improving the functional outcome of patients after stroke. The present cohort study analyzed the feasibility and safety of acute phase rehabilitation using the hybrid assistive limb robot suit in 22 patients, 7 males and 15 females (mean age 66.6 ± 17.7 years). Neurological deterioration, mortality, or other accidents were recorded as adverse events. Baseline characteristics of each patient were recorded at the first hybrid assistive limb rehabilitation. Hybrid assistive limb rehabilitation was conducted for 12.1 ± 7.0 days with the patients in stable condition. Acute phase hybrid assistive limb rehabilitation was performed a total of 84 times with no adverse events recorded except for orthostatic hypotension. Good functional outcomes were obtained in 14 patients. Orthostatic hypotension was observed during the first hybrid assistive limb rehabilitation in four patients, and was significantly associated with intracerebral hemorrhage (p = 0.007) and lower Brunnstrom stage (p = 0.033). Acute phase rehabilitation using the hybrid assistive limb suit is feasible and safe. Patients with intracerebral hemorrhage and lower Brunnstrom stage should be carefully monitored for orthostatic hypotension.
Vasoconstriction of arteries induced by serotonin (5-hydroxytryptamine: 5-HT) is mediated by 5-HT2A and 5-HT1B receptors localized on smooth muscle. The present study investigated the impact of sarpogrelate, a 5-HT2A receptor antagonist, on cerebral artery diameter in the presence and absence of exogenous 5-HT. Diameter measurements were obtained in vitro from rabbit cerebral arteries pressurized to 60 mmHg. In the absence of 5-HT, arteries exhibiting pressure-induced myogenic tone dilated to sarpogrelate in a concentration-dependent manner (half maximal inhibitory concentration [IC50] ≈ 2.3 μM). In a separate experimental series, exogenous application of 5-HT (0.01 μM) caused further constriction of myogenically active arteries, decreasing cerebral artery diameter by an additional 25%. In the presence of 5-HT, sarpogrelate caused concentration-dependent vasodilation (IC50 ≈ 2.3 μM) that was similar to that observed in the absence of exogenous 5-HT. Dilation induced by sarpogrelate was not affected by physical removal of the endothelium or inhibition of nitric oxide synthase with Nω-nitro L-arginine. The highest concentration of sarpogrelate (100 μM) induced near maximal dilation, comparable to dilation induced by the L-type voltage-dependent calcium channel antagonist diltiazem. These findings suggest that in rabbit cerebral arteries, sarpogrelate has direct vasodilator effects on vascular smooth muscle.
To investigate cerebral reactions to cognitive rehabilitation tasks, oxyhemoglobin changes were compared in 9 patients with cognitive impairments after traumatic brain injury (TBI) and 47 healthy controls using functional near infrared spectroscopy (fNIRS) during nine cognitive rehabilitation tasks employed at Nagoya City Rehabilitation Center. Forty-seven measurement channels were placed on the frontal to temporal cortices, and organized into seven channel regions. Oxyhemoglobin changes were normalized based on the mean oxyhemoglobin value at the resting state, and integrated throughout a task. Statistical analyses of the differences between the TBI patients and controls were performed with the two-sided Mann-Whitney U test. Oxyhemoglobin changes were high for both controls and TBI patients in the lateral frontal regions. Oxyhemoglobin changes in TBI patients tended to be higher than controls in the medial frontal regions for most training tasks, and significant differences (p < 0.05) were seen for two tasks in the medial frontal regions. Different regions were activated during the tasks in TBI patients compared to controls. fNIRS measurement is useful in the evaluation of changes of neuronal activities during rehabilitation tasks in TBI patients.
Surgical clipping has been the primary treatment option for ruptured distal anterior cerebral artery (DACA) aneurysms. Therefore, the literature on endovascular therapy is sparse. The present study investigated the feasibility and efficacy of endovascular therapy for ruptured DACA aneurysms in 31 patients, 26 females and 5 males (mean age 63.2 ± 12.6 years). Mean aneurysm size and neck width were 4.8 ± 2.3 mm and 2.2 ± 0.7 mm, respectively. The Hunt and Hess (H/H) grades just prior to the treatment were scored as H/H grades 1-3 in 20 patients and H/H grades 4-5 in 11 patients. Fifteen patients had an intraparenchymal hematoma (IPH) surrounding the ruptured aneurysm on the initial computed tomography. Overall, 22 patients had a modified Rankin scale (mRS) score of 0-2 and 9 had a mRS score of 3-6 at discharge. H/H grade was closely related to the clinical outcomes, whereas the presence of IPH was not. Overall immediate angiographic outcomes were complete occlusion in 15, residual neck in 11, and residual aneurysm in 5. The overall recurrence rate was 35.3%. Complications including posttreatment rebleeding occurred in 5 patients. Symptomatic vasospasm occurred in 1 of the 18 patients with H/H grades 1-3. Endovascular therapy of ruptured DACA aneurysms is feasible and effective. However, the risks of recurrence and posttreatment bleeding remain to be resolved.
The treatment of very small aneurysms with diameter of less than 3 mm remains a challenge for both endovascular and surgical treatment. Endovascular treatment of these lesions may be difficult and is associated with a high risk of complications because of their small size. The present study evaluated the safety, feasibility, and efficacy of the endovascular treatment using sole stenting technique for uncoilable very small aneurysms of the intracranial internal carotid artery (ICA). From August 2004 through January 2010, eight very small aneurysms of intracranial ICA in eight patients were treated with endovascular sole stenting technique. All very small aneurysms were ruptured (n = 3) or aneurysms associated with another ruptured (n = 2) and unruptured aneurysms (n = 3) in the same artery. Stents were Neuroform and balloon expandable coronary stents. Stent deployment was carried out without difficulty in all patients. Single stent deployment was done for six aneurysms, and double stents in two aneurysms. The immediate angiographic results were partial occlusion in one case and no occlusion in seven cases. One direct carotid-cavernous fistula occurred during coronary stenting without permanent neurological deficit. No neurological deterioration or hemorrhagic complication was seen during the follow-up period in seven patients. Follow-up angiography (mean 9 months) was available in six patients and revealed complete occlusion in four and no occlusion in two cases. Sole stenting technique may be a feasible and effective therapeutic alternative for uncoilable very small aneurysms. The long-term efficacy and durability of stenting for these lesions remains to be determined in a large series.
This study investigated the frequency of poor outcome at discharge of acute subdural hematoma (SDH) patients with and without microbleeds. We retrospectively examined the records of 37 patients with acute SDH who were surgically treated with hematoma removal and received magnetic resonance (MR) imaging within 2 weeks of head injury onset. MR images were used to determine the presence or absence of microbleeds and contusional hemorrhage (CH). Patient outcome was categorized as good (moderate disability or good recovery) or poor (severely disability, vegetative state, or dead) according to the Glasgow Outcome Scale at discharge. Microbleeds were found in 23 patients (62%) and CH was found in 26 patients (70%). Fifteen patients (41%) had both microbleeds and CH. Poor outcome at discharge was more common in SDH patients with both microbleeds and CH than in SDH patients with neither microbleeds nor CH (14/15, 93% vs. 14/22, 64%; p = 0.04). Poor outcome at discharge was more common in SDH patients under 60 years of age with microbleeds (6/8, 75%) than patients under 60 years of age without microbleeds (0/4, 0%; p = 0.03). The location of the microbleed was not related to the outcome at discharge. These results suggest that the presence of microbleeds and CH on MR images may indicate poor prognosis in patients with acute SDH.
The aim of this study was to clarify the clinical characteristics and pathophysiology of conservatively treated cases of acute subdural hematoma (ASDH) that ultimately require surgery in the subacute or chronic stage, and devise an appropriate form of management for them. A total of 50 patients with ASDH were admitted to our institution during a 5-year period. Hematoma removal in the subacute or chronic stage was performed in 8 patients. The ASDH had been caused by a fall in 5 patients. Five patients had been treated with antiplatelet agents. Fluid-attenuated inversion recovery magnetic resonance (MR) imaging demonstrated an irregularly shaped hematoma with gyrus patterns in 4 of 5 patients. Diffusion-weighted MR imaging demonstrated a two-layered hematoma structure in 3 of 4 patients. The hematoma was removed via a craniotomy, a small craniotomy, and a burr hole in 1, 1, and 6 patients, respectively. At surgery in the craniotomy case, a solid clot was located beneath the dura, and a liquid hematoma was located close to the brain. After hematoma removal, no inner membrane was observed on the brain surface. One patient had typical chronic subdural hematoma in the subacute stage, and 2 patients had so-called subacute subdural hematoma (SASDH) in the chronic stage. Although the majority of such cases can be treated by burr-hole surgery, a small craniotomy or craniotomy ought to be considered as a further surgical option if SASDH is diagnosed on the basis of clinical and radiological data, especially diffusion-weighted MR imaging.
Bone resorption is a known complication of cranioplasty after decompressive craniectomy (DC). A peculiar group of insidious, progressive, invalidating neurological symptoms was observed in patients presenting with incomplete resorption and abnormal mobility of the re-implanted bone. Such symptoms were similar, but with time more severe, to those encountered in the sinking flap syndrome. Are we facing a sort of Sinking Bone Syndrome? We accurately analyze these cases and review the literature. Over a 7-years period, 312 DCs were performed at our Institution. In 7 patients, headache, vertigo, gait ataxia, confusion, blurred speech, short-term memory impairment, hemiparesis, sudden loss of consciousness, and third cranial nerve palsy were observed in a time period ranging from 18 months to 5 years after cranioplasty. Clinical and neuroradiological examinations were performed to disclose the possible etiopathogenesis of this condition. Collected data showed partial resorption of the repositioned bone and its unnatural inward movements during postural changes. Bone movements were interpreted as the major cause of the symptoms. A new cranioplasty was then performed in every case, using porous hydroxyapatite in 6 patients and polyetherketone implant in the other. Full resolution of symptoms was always obtained 3 to 20 days after the second surgery. No further complications were reported. We believe that long-term follow up in patients operated on by cranioplasty after DC will be needed regularly for years after skull reconstruction and that newly appearing symptoms should never go underestimated or simply interpreted as a long-term consequence of previous brain damage.
This study evaluated the aneurysm wall thickness by high-resolution T1-weighted imaging and the contact between the aneurysm and surrounding tissue by steady-state free precession (SSFP) imaging. The surgical findings were prospectively compared with these preoperative magnetic resonance (MR) imaging findings in 35 consecutive patients with 37 unruptured cerebral aneurysms (UCAs). The aneurysm wall was not visible in 13 UCAs, but was visible in 23. Subarachnoid space between the aneurysm and surrounding tissue was visible in 16 UCAs, a visible layer of cerebrospinal fluid (CSF) between the aneurysm and surrounding tissue in 12, and no visible layer in 7. MR imaging predicted the surgical findings in 29 UCAs (78%), showed different findings in six UCAs (16%), and two (5%) could not be evaluated due to insufficient quality of preoperative MR images. Among the UCAs with different findings, five UCAs had a partially thin wall even though high-resolution T1-weighted imaging had shown a visible wall, and one UCA showed less contact with the surrounding tissue even though the SSFP imaging had shown no visible CSF layer. In conclusion, high-resolution T1-weighted imaging and SSFP imaging provided significant additional preoperative information regarding UCAs and the surrounding tissue.
Subarachnoid hemorrhage (SAH) is usually elicited by cerebrovascular disease and infrequently by brain tumors. A 64-year-old woman presented with SAH with a left petrous meningioma and an unruptured left internal carotid-posterior communicating artery (IC-PcomA) aneurysm. She suffered sudden onset of headache and nausea followed by consciousness disturbance 7 days after onset. Computed tomography (CT) revealed diffuse SAH and a tumor at the petrous portion. Angiography demonstrated a left IC-PcomA aneurysm. Under a diagnosis of a ruptured aneurysm and a coincidental meningioma, we performed neck clipping of the aneurysm. However, intraoperatively we found that the aneurysm was unruptured and we subsequently performed tumor resection. Intraoperatively we could not find the cause of SAH during resection of the meningioma. The histological diagnosis was transitional meningioma with deposition of fibrin on the surface of the tumor. The findings of initial CT and magnetic resonance imaging, and pathological results could not conclude the definitive etiology of SAH in this case.
Silicone models of cerebral aneurysms are used for evaluation of devices, training, or hemodynamic studies. We report preoperative simulations of endovascular treatment for a case with an unruptured wide-neck aneurysm of the anterior communicating artery using a patient-specific silicone model. Using a rapid prototyping system, we created a silicone model based on the vascular image obtained by three-dimensional rotational angiogram. The aneurysm and vessels formed a cavity in the silicone block model. We performed endovascular simulations using several difference devices and attempted possible methods for coil embolization. We designed treatment strategies based on the simulations and performed balloon-assisted coil embolization of the aneurysm. The simulations were especially useful in navigation of a microcatheter by planning the shape of its tip beforehand. There was one significant difference between the silicone model simulations and actual treatment: the shape of the vessel in the silicone block model was not changed by insertion of a catheter or guidewire. This is the first study to describe preoperative endovascular simulations using a patient-specific silicone model. Our methods of creating a patient-specific model are relatively simple and easy. Although this is a single case, we demonstrate that the simulations are feasible and helpful for designing a treatment strategy and safe manipulation of endovascular devices by experiencing their behavior before actual treatment.
[Neurol Med Chir (Tokyo) 53, 259-262, 2013] Reference 20 on page 262 To the Readership: Reference 20 was incorrectly reported in the Reference section of the above-mentioned article. Incorrect: 20) Wada M, Harada N, Higuchi K, Misawa N, Nakatsubo N, Tsukamoto K, Hashimoto S: Journal of Health and Welfare Statistics 55: 137-141, 2008 (Japanese) Correct: 20) Health and Welfare Statistics Association: Journal of Health and Welfare Statistics 55: 137-141, 2008 (Japanese)