廣瀬 雄一

Genetic subgrouping of gliomas has been emphasized recently, particularly after the finding of isocitrate dehydrogenase 1 (IDH1) mutations. In a previous study, we investigated whole-chromosome copy number aberrations (CNAs) of gliomas and have described genetic subgrouping based on CNAs and IDH1 mutations. Subsequently, we classified gliomas using simple polymerase chain reaction (PCR)-based methods to improve the availability of genetic subgrouping. We selected IDH1/2 and TP53 as markers and analyzed 237 adult supratentorial gliomas using Sanger sequencing. Using these markers, we classified gliomas into three subgroups that were strongly associated with patient prognoses. These included IDH mutant gliomas without TP53 mutations, IDH mutant gliomas with TP53 mutations, and IDH wild-type gliomas. IDH mutant gliomas without TP53 mutations, which mostly corresponded to gliomas carrying 1p19q co-deletions, showed lower recurrence rates than the other 2 groups. In the other high-recurrence groups, the median progression- free survival (PFS) and overall survival (OS) of patients with IDH mutant gliomas with TP53 mutations were significantly longer than those of patients with IDH wild-type gliomas. Notably, most IDH mutant gliomas with TP53 mutations had at least one of the CNAs +7q, +8q, -9p, and -11p. Moreover, IDH mutant gliomas with at least one of these CNAs had a significantly worse prognosis than did other IDH mutant gliomas. PCR-based mutation analyses of IDH and TP53 were sufficient for simple genetic diagnosis of glioma that were strongly associated with prognosis of patients and enabled us to detect negative CNAs in IDH mutant gliomas.

A rare case of pediatric neurogenic stunned myocardium (NSM) associated with a brain tumor is reported. A previously healthy 6-year-old boy presented with coma, and imaging studies revealed a brain tumor. On hospitalization day 3, he developed NSM and neurogenic pulmonary edema necessitating intensive cardiopulmonary support. Although blood marker levels of cardiac injury were elevated, his plasma and urinary norepinephrine levels were within normal limits. His cardiorespiratory functions markedly improved by hospitalization day 8. This case report may be one of the first to document plasma and urinary catecholamine levels in pediatric NSM. While solid conclusion cannot be drawn based on experience from a single case, these results suggest that pediatric NSM may not be catecholamine-induced.

Functional preservation is critical in glioma surgery, and the extent of resection influences survival outcome. Neoadjuvant chemotherapy is a promising option because of its potential to facilitate tumor shrinkage and maximum tumor resection. The object of this study was to assess the utility of the neoadjuvant strategy in a prospective series of gliomas with favorable molecular status. Twenty-six consecutive cases of diffuse gliomas of WHO grade II or III with either 1p19q codeletion or MGMT methylation were treated with upfront chemotherapy following maximal safe removal. In cases of incomplete initial surgery, second-look resection was intended after tumor volume decrease by chemotherapy. Among 22 evaluable cases, chemotherapy led to a median change in the sum of the product of perpendicular diameters of -35 %, and 14 out of the 22 cases (64 %) showed objective response. Second-look resection after tumor volume decrease was performed in 12 out of 19 cases of incomplete initial surgery (GTR/STR 9, removal of residual methionine PET uptake 3). The median progression-free survival among the 22 patients with grade II tumors was 57 months, with some cases showing durable progression-

Functional preservation is critical in glioma surgery, and the extent of resection influences survival outcome. Neoadjuvant chemotherapy is a promising option because of its potential to facilitate tumor shrinkage and maximum tumor resection. The object of this study was to assess the utility of the neoadjuvant strategy in a prospective series of gliomas with favorable molecular status. Twenty-six consecutive cases of diffuse gliomas of WHO grade II or III with either 1p19q codeletion or MGMT methylation were treated with upfront chemotherapy following maximal safe removal. In cases of incomplete initial surgery, second-look resection was intended after tumor volume decrease by chemotherapy. Among 22 evaluable cases, chemotherapy led to a median change in the sum of the product of perpendicular diameters of -35 %, and 14 out of the 22 cases (64 %) showed objective response. Second-look resection after tumor volume decrease was performed in 12 out of 19 cases of incomplete initial surgery (GTR/STR 9, removal of residual methionine PET uptake 3). The median progression-free survival among the 22 patients with grade II tumors was 57 months, with some cases showing durable progression-free survival after second-look resection. MIB-1 indices of the second-look resected tumors were lower than those of the initial tumors, and the methylation status of the MGMT gene was unchanged. Neoadjuvant chemotherapy based on molecular guidance often produces significant volume decrease of incompletely resected gliomas. Radical second-look resection is an optional advantage of upfront chemotherapy for chemosensitive gliomas compared with initial radiotherapy.

The objective of this study was to report the frequency and clinical characteristics of early rebleeding in subarachnoid haemorrhage (SAH) patients who underwent intensive blood pressure (BP) management. Patients with aneurysmal SAH frequently present to the emergency department (ED) with elevated BP. Intensive BP management has been recommended to lower the risk of early rebleeding. However, few studies have reported the frequency of early rebleeding in SAH patients undergoing BP management. In our institution, SAH patients with systolic BP (SBP) > 140 mmHg received continuous intravenous nicardipine to maintain their SBP within 120 20 mmHg after diagnosis. An attempt to implement intensive BP management was made on 309 consecutive SAH patients who presented to our ED within 48 hours of SAH onset. Overall, 24 (7.8%) of the 309 patients sustained early rebleeding. Fifteen patients sustained early rebleeding before the implementation of BP management, and the other nine sustained early rebleeding after the implementation of BP management. Therefore, the frequency of early rebleeding under BP management was 3.1% (9/294). When the 309 patients were dichotomised using ED SBP of 140 mmHg as a cut off (SBP > 140 mmHg; n = 239 versus SBP <= 140 mmHg; n = 70), the latter counter-intuitively exhibited a significantly higher frequency of early rebleeding (5.9% versus 14.2%; p = 0.04). This relatively low frequency of early rebleeding under BP management may be acceptable. However, early rebleeding is not eradicated even with strict BP control as factors other than elevated BP are involved. ED SBP within the target range (SBP <= 140 mmHg) does not negate the risk of early rebleeding. Other treatment options that reduce the risk should also be explored. (C) 2015 Elsevier Ltd. All rights reserved.

The prognostic significance of 1p19q loss in astrocytic gliomas has been inconclusive. We collected 57 gliomas with total 1p19q loss from among 218 cases of WHO grade-II/III gliomas operated at Keio University Hospital between 1990 and 2010. These tumors were classified as oligodendroglial or "astrocytic" by a WHO-criteria-based institutional diagnosis. Chromosomal copy number aberrations (CNAs), IDH 1/2 mutations, MGMT promoter methylation, and expression of p53 and ATRX were assessed. Survival outcome was compared between the two histological groups. Of the 57 codeleted gliomas, 37, 16, and four were classified as oligodendroglial, "astrocytic", and unclassified, respectively. Comparative genomic hybridization revealed that although chromosome 7q/7 gain was more frequent in "astrocytic" gliomas, other CNAs occurred at a similar frequency in both groups. None of the "astrocytic" gliomas showed p53 accumulation, and ATRX loss was found in three of the 15 "astrocytic" gliomas. The estimated overall survival (OS) curves in the patients with codeleted oligodendroglial and "astrocytic" gliomas overlapped, and the median OS was 187 and 184 months, respectively. Histopathological re-assessment by a single pathologist showed consistent results. Gliomas with total 1p19q loss with "astrocytic" features have molecular and biological characteristics comparable to those of oligodendroglial tumors.

Objective High blood pressure (HBP) is observed frequently in patients with spontaneous intracerebral haemorrhage (SICH). Although HBP at admission has been associated with poor outcomes, most studies from which such conclusions were derived had been carried out decades earlier, when aggressive BP management was not implemented. In our institution, SICH patients showing HBP undergo aggressive BP management by intravenous nicardipine with target systolic BP (SBP) less than 140mmHg. We investigated whether responsiveness to intravenous nicardipine, haematoma expansion rate and activity of daily living 90 days after admission differed by the degree of admission SBP. Patients and methods A retrospective study was carried out by reviewing charts of 120 SICH patients admitted within 6 h of onset who were quadrichotomized on the basis of SBP: <140 mmHg (n=6), 140-184 mmHg (n=49), 185-219 mmHg (n=38) and >= 220 mmHg (n=27). The six patients with SBP less than 140 mmHg were excluded, and demographic and outcome variables of the latter three groups were compared. Whether plasma catecholamine levels differed among the three groups was also investigated. Results Optimal BP management (target SBP<140mmHg) within 2 h of arrival was achieved in 98%, haematoma expansion occurred in 7% and the 90-day mortality rate was 11%. Responsiveness to intravenous nicardipine, haematoma expansion rate and activity of daily living were not significantly different. Furthermore, plasma catecholamine levels did not differ significantly. Conclusion The lack of difference in the demographic and outcome variables in SICH patients managed by aggressive treatment to normalize the BP indicates that the previously reported association between HBP at admission and poor outcomes needs to be re-evaluated. Copyright (C) 2015 Wolters Kluwer Health, Inc. All rights reserved.

Background and objective Acute hypertensive response, defined as systolic blood pressure (SBP) 140 mmHg or more within 24 h of onset, is frequently observed in hemorrhagic stroke patients. Although catecholamine surge is pivotal in its pathogenesis, few studies have evaluated the relationship between admission SBP and plasma catecholamine levels. Patients and methods A prospective observational study was carried out to investigate potential differences in the acute hypertensive reaction between subarachnoid hemorrhage (SAH) and spontaneous intracerebral hemorrhage (SICH) by analyzing 200 SAH and 200 SICH patients. In each category, patients were quadrichotomized on the basis of their SBPs in emergency department: less than 140 mmHg, 140-184 mmHg, 185-219 mmHg, and 220 mmHg or more. The plasma catecholamine levels were compared among the four groups. Furthermore, multivariate regression analyses were carried out to identify variables correlated with hypertensive emergency (SBP = 185 mmHg). Results In SAH patients, there was a proportional increase in norepinephrine levels relative to the graded SBPs, and norepinephrine levels in the 220 mmHg or more group were significantly higher than those in the less than 140 mmHg group (1596 +/- 264 vs. 853 +/- 124 pg/ml, P = 0.03). By contrast, no proportional increase in norepinephrine levels to the graded SBPs was observed in SICH patients. Multivariate regression analyses showed that the initial Glasgow Coma Scale scores of 8 or less (odds ratio 2.251, 95% confidence interval 1.002-5.117) and plasma norepinephrine levels (odds ratio 1.002, 95% confidence interval 1.001-1.003) were correlated with hypertensive emergency in SAH patients. By contrast, none of the variables evaluated were correlated with hypertensive emergency in SICH patients. Conclusion An acute hypertensive response may be more complex, multifactorial, and less catecholamine dependent in SICH patients compared with SAH patients. Copyright (C) 2015 Wolters Kluwer Health, Inc. All rights reserved.

Spontaneous intracranial hypotension (SIH) is a syndrome in which hypovolemia of the cerebrospinal fluid (CSF) results in various symptoms. Although its prognosis is usually benign, cases with a rapid neurologic deterioration resulting in an altered mental status have been reported. One of the characteristic radiographic findings in such cases is the presence of bilateral accumulation of subdural fluid (hematoma/hygroma). When SIH-related subdural hematoma is present only unilaterally with a concomitant midline shift, making an accurate diagnosis may be challenging, and inadvertent hematoma evacuation may result in further neurologic deterioration. We report a 58-year-old woman with an altered mental status who had visited a local hospital and in whom a brain CT showed a unilateral subdural hematoma with a marked midline shift. She was referred to our department because of her neurologic deterioration after hematoma evacuation. A CT myelography revealed a massive CSF leakage in the entire thoracic epidural space. She made a full neurologic recovery following blood patch therapy. Our case is unique and educational because the suspicion for SIH as an underlying cause of subdural hematoma is warranted in nongeriatric patients not only with bilateral but also unilateral lesions. An immediate search for CSF leakage may be important in cases with failed hematoma evacuation surgery.

Primary intraventricular brain abscesses are rare, and there are no established treatment guidelines for this condition. We report a case in which isolated ventricular dilatation and unilateral hydrocephalus developed after seemingly successful conservative management and which required surgical diversion of the cerebrospinal fluid. A 59-year-old woman presented to our emergency department with high-grade fever and headache. Brain magnetic resonance imaging (MRI) revealed abscesses in the bilateral posterior horn. Although surgical evacuation of the abscesses was considered, conservative management with antibiotics was selected because of the paucity of severe neurological deficits and the concern that an attempt to evacuate the intraventricular abscess might lead to inadvertent rupture of the abscess capsule and acute ventriculitis. Despite reduction in the abscess volume, the patient developed an altered mental status 4 weeks after admission. Follow-up MRI revealed isolated dilation of the left inferior horn, compressing the brainstem. Emergency fenestration of the dilated inferior horn was performed, and endoscopic observation revealed an encapsulated abscess with adhesion to the ventricular wall which was thought responsible for the ventricular dilation and unilateral hydrocephalus. Two weeks after the initial surgery, the unilateral hydrocephalus was treated by placement of a ventriculoperitoneal shunt. Eradication of the intraventricular brain abscesses without surgical evacuation may justify the conservative management of this patient. However, the possibility that earlier surgical evacuation might have prevented development of the isolated ventricular dilation cannot be denied. Additional clinical experience is required to determine which treatment (surgical vs. conservative) is more appropriate in patients with primary intraventricular brain abscesses.

レンチキュラ方式を用いた3Dディスプレイにより専用眼鏡なしで高品質3D画像を描出することが可能となり、医学教育をはじめ多方面の医療分野への応用が期待される。本システムの脳腫瘍手術教育への応用の概要と今後の展望を紹介する。(著者抄録)

Background: In embolizing a cerebral aneurysm, achievement of a high-volume embolization ratio (VER: volume of inserted coils / aneurysm volume) is important because it may prevent coil compaction and recanalization. The goal of the study is to examine whether use of softer and longer coils gives an adequate VER with fewer coils, particularly for small aneurysms. Methods: Aneurysm volumes, VERs, and numbers of inserted coils were investigated in 23 cases of small aneurysms embolized using Infini coils, a long soft coil with a primary diameter of 0.010 inches (Infini group). An aneurysm volume-and VER-matched control (non-Infini) group of 59 cases was selected from patients treated at our facility. Data were also compared between subgroups of patients (n = 18 and n = 34 in the Infini and non-Infini groups, respectively) who were not treated with thicker coils with primary diameters of 0.0135-0.015 inches (18-type coils), since these coils affect the number of coils by increasing VER rapidly. Results: Average aneurysm volumes and VERs did not differ significantly between the Infini and non-Infini groups. Significantly fewer coils were used per 0.1 ml aneurysm volume in the Infini group (4.08 coils in average) compared with the non-Infini group (5.67) (p < 0.001). In the non-18-type subgroups, the number of coils used remained significantly smaller in the Infini group (4.49) compared with the non-Infini group (6.72), (p < 0.001). Conclusion: To achieve VER >= 20%, use of Infini coils significantly decreased the number of coils required per unit volume of a small aneurysm.

There are many reports on positionrelated complications in neurosurgical literature but so far, continuous quantification of the patient's position during the surgery has not been reported. This study aims to explore the utility of a new surgical table system and its software in displaying the patient's body positions during surgery on real-time basis. More than 200 neurosurgical cases were monitored for their positions intra-operatively. The position was digitally recorded and could be seen by all the members in the operating team. It also displayed the three-dimensional relationship between the head and the heart positions. No position-related complications were observed during the study. The system was able to serve as an excellent indicator for monitoring the patient's position. The recordings were analyzed and even used to reproduce or improve the position in the subsequent operations. The novel technique of monitoring the position of the head and the heart of the patients and the operating table planes are considered to be useful during delicate neurosurgical procedures thereby, preventing inadvertent procedural errors. This can be used to quantify various surgical positions in the future and define safety measures accordingly.

Background: Delayed hematoma expansion is common in intracerebral hemorrhage (ICH) patients using warfarin. Dabigatran induces fewer hemorrhagic complications compared with warfarin. However, the natural history of dabigatran-related ICH remains unclear. This study aims to clarify whether dabigatran increases the risk of delayed hematoma expansion in a rat ICH model. Methods: Male Wistar rats were treated with 2 dosages of dabigatran etexilate (DE: 10 mg/kg, n = 4; 20 mg/kg, n = 3) 30 minutes before ICH induction using intraparenchymal collagenase infusion. Five rats that received saline were used as controls. Magnetic resonance imaging was performed 24 and 48 hours after ICH induction, and serial hematoma volume measurements were obtained using T2-weighted images. Expanded hematoma volumes were calculated by subtracting hematoma volumes at 48 hours from those at 24 hours; the hematoma expansion rate was defined as the ratio of the expanded hematoma volume to that at 24 hours. Results: The mean hematoma volumes (mm(3)) at 24 hours were 13.3 +/- 3.3 in the control group, 14.9 +/- 2.0 in the 10 mg/kg DE group, and 18.9 +/- 7.6 in the 20 mg/kg DE group with no significant intergroup differences (P = .26). The mean hematoma volumes at 48 hours (mm(3)) were 21.7 +/- 4.9 in the control group, 22.1 +/- 5.0 in the 10 mg/kg DE group, and 23.4 +/- 5.8 in the 20 mg/kg DE group with no significant intergroup differences (P = .90). Consequently, there were no significant intergroup differences in the hematoma expansion rates (P = .33). Conclusions: This experimental study of a rat ICH model indicates that dabigatran-related ICH may not increase the risk of delayed hematoma expansion.

Aim: High blood pressure is observed frequently in patients with subarachnoid hemorrhage who present to the emergency department. Although extremely high blood pressure is known to predict poor outcomes in patients with spontaneous intracerebral hemorrhage, the relationship between high blood pressure and outcomes has been studied less frequently in patients with subarachnoid hemorrhage. Methods: A retrospective study was carried out to evaluate whether high blood pressure observed in the emergency department was predictive of poor outcomes in patients with subarachnoid hemorrhage. Three-hundred and twelve subarachnoid hemorrhage patients who were admitted to our institution were quadrichotomized based on their initial systolic blood pressure: <140 mmHg (n = 60), 140-184 mmHg (n = 144), 185-219 mmHg (n = 64), and ≥220 mmHg (n = 44). Demographics including subarachnoid hemorrhage severity (World Federation of Neurosurgical Societies grade) and outcome variables evaluated with the modified Rankin scale 30 days after admission were compared among the four blood pressure groups. Furthermore, an effort was made to delineate a threshold value of systolic blood pressure predictive of outcomes by receiver operating characteristic curve analysis. Results: The frequency of grade V subarachnoid hemorrhage in the ≥220 mmHg group (55%) was significantly higher than in the other three blood pressure groups. The frequency of patients scoring 5-6 on the modified Rankin scale in the ≥220 mmHg group (54%) was significantly higher than in the other three blood pressure groups. The cut-off systolic blood pressure value predicting poor outcomes (modified Rankin scale 5-6) determined by receiver operating characteristic curve analysis was 189 mmHg. Conclusions: The higher proportion of grade V patients may be responsible for the worse outcomes in the group with systolic blood pressure ≥220 mmHg. Initial systolic blood pressure ≥220 mmHg may be a crude indicator of poor outcomes in patients with subarachnoid hemorrhage.

We present our experience with elective microsurgical clipping of unruptured intracranial aneurysms (UIA) and analyze this management. A total of 150 patients with UIA were reviewed and data were collected with regard to age, sex, presence of symptoms, location and size of the aneurysms, surgical complications and postoperative I year outcomes. Aneurysm size was assessed either by three-dimensional CF angiography or digital subtraction angiogram. Glasgow Outcome Scale was used to assess clinical outcomes. One hundred and fifty patients with 165 aneurysms were treated in this series. The mean size of the UIA was 5.6 mm. Eighty aneurysms (48.5%) were less than 5 mm in size, and 73 (44.2%) were from 5 to 10 mm. Ten (6.1%) of the aneurysms were large and two (1.2%) were giant. One hundred and forty-three were asymptomatic and seven were symptomatic before surgery. The outcome was good in 147 patients (98%), and only three patients (2%) had a treatment-related unfavorable outcome. Five patients experienced transient neurological deficits and one patient experienced permanent neurological deficits. Overall 98.7% of the treated aneurysms were satisfactorily obliterated. Wound complications were seen only in three patients. In conclusion, UIA pose a significant challenge for neurosurgeons, where a delicate balance between benefits and possible risks must be weighed. If the requisite expertise is available, they can be treated surgically with low morbidity and a good outcome at specialized neurovascular centers. (C) 2014 Published by Elsevier Ltd.

Neuroepithelial cyst is considered an unusual differential diagnosis for cysts in the posterior fossa. Here, we present a paediatric case with such a pathology and review the pertinent literature. A 12-year old girl with headache, vertigo and disturbed gait was diagnosed with a cystic lesion in the fourth ventricle after brain MRI study. She was operated with the pre-operative diagnosis of arachnoid cyst. A transparent, colourless cyst was observed intra-operatively. As frozen sections were consistent with endodermal cyst, total removal of the cyst was attempted. Definite histopathological studies and immunohistochemistry stains were in favour of neuroepithelial cyst. No regrowth of the cyst or recurrence of the symptoms was observed in her 2-year follow-up. As neuroepithelial cyst is rarely encountered in the posterior fossa, the clinical, radiological and pathological characteristics of our case along with similar cases in the literature were reviewed and discussed.

Lesions in the medulla oblongata may be causally associated with cardiac wall motion abnormality (WMA). Although subarachnoid hemorrhage (SAH) patients occasionally develop WMA, the relationship between aneurysmal locations and the frequency of WMA has rarely been investigated. The objective of this study was to evaluate whether the frequency of WMA was higher after the rupture of vertebral artery (VA) aneurysms than that of non-VA aneurysms. We performed a retrospective chart analysis of 244 SAH patients who underwent transthoracic echocardiography and plasma catecholamine measurements. The frequencies of WMA and electrocardiographic (ECG) abnormalities were compared among patients classified by the location of aneurysms. Multivariate regression analysis was conducted to identify variables correlated with WMA. Furthermore, the relationship between plasma catecholamine levels and aneurysmal locations was evaluated. The frequency of WMA was significantly higher in patients with VA aneurysms than in those with non-VA aneurysms (45 vs. 22 %, p = 0.01). However, there was no significant difference in the frequency of ECG abnormalities. Multivariate regression analysis showed that VA aneurysms (OR, 3.317; 95 % CI, 1.129-9.745), poor-grade SAH (OR, 2.733; 95 % CI, 1.320-5.658) and concomitant hydrocephalus (OR, 3.658; 95 % CI, 1.690-7.917) correlated with WMA. There were no significant intergroup differences in plasma catecholamine levels. VA aneurysms are close to several medullary nuclei that integrate autonomic inputs. A transient deformation and ischemia of the medulla oblongata caused by the mechanical stress related to the rupture of a VA aneurysm and/or a concomitant hydrocephalus may be responsible for the disproportionately high frequency of WMA.

Exogenous fibrin glue (FG) is highly suitable for neurosurgical procedures, because of its viscosity and adhesive properties. Several FGs are commercially available, but only few reports detail their differences. In the present study, we investigated the viscosity and adhesive performance of two types of FG: one is derived from blood donated in Europe and the United States (CSL Behring's Beriplast (R), BP) and the other is derived from blood donated in Japan (the Chemo-Sero-Therapeutic Research Institute's Bolheal (R), BIT). The viscosity test that measured fibrinogen viscosity revealed that BP had significantly higher viscosity than BH. Similarly, the dripping test showed that BP traveled a significantly shorter drip distance in the vertical direction than BIT, although the transverse diameter of the coagulated FG did not differ statistically significantly. In the tensile strength test, BP showed superior adhesion performance over BH. The histological study of the hematoxylin-eosin-stained specimens in both groups showed favorable adhesion. Although further studies are required on its manufacturing and usage methods, FG shows differences in viscosity and adhesive performance according to the blood from which it is derived. We conclude that it is desirable to select the type and usage method of FG according to the characteristics of the surgical operation in question. Our findings suggest that FG produced from the blood donated in Europe and the United States might be more suitable for use in surgical procedures that demand an especially high degree of viscosity and rapid adhesive performance.

Cavernous malformation with trigeminal neuralgia is relatively rare; only 10 cases have been reported. In deciding treatment strategies, it is helpful to classify cavernous malformation according to its origin, as follows: in the Gasserian ganglion (Type G); between the cisternal and intra-axial portions of the trigeminal nerve root (Type C); in the intra-axial trigeminal nerve root in the pons (Type P); or in the spinal tract of the trigeminal nerve root (Type S). A 62-year-old male presented with left trigeminal neuralgia (V2 area) and left facial hypoesthesia. Imaging studies revealed a cerebellopontine angle mass lesion with characteristics of a cavernous malformation and evidence of hemorrhage. The lesion was completely removed via a left anterior transpetrosal approach. The mass was attached to the trigeminal nerve root; it was located between the cisternal and intra-axial portions of the nerve root, and feeding off microvessels from the trigeminal nerve vascular plexus. Histological examination confirmed a cavernous malformation. In this case, the cavernous malformation was Type C. We review cases of cavernous malformation with trigeminal neuralgia and discuss therapeutic strategies according to the area of origin. (C) 2014 Elsevier B.V. All rights reserved.

脳梗塞とクモ膜下出血を併発した前大脳動脈解離の1例を文献的考察と共に報告する。症例は既往に高血圧がある43歳女性。突然の失語・右片麻痺・意識障害を主訴に当院救急搬送された。来院時の頭部単純CTでクモ膜下出血を認め、造影CTでは左前大脳動脈領域のcerebral blood flow/cerebral blood volume低下と左A2描出不良を認めた。第1病日に施行されたDSAでは左recurrent artery of Heubner分岐直後から末梢にかけてpearl & string signを認め、以上の所見から梗塞・出血同時発症の左前大脳動脈解離と診断した。recurrent artery of Heubner領域の梗塞は生じていなかった。既に左前大脳動脈領域の梗塞巣が完成していた為、血行再建術は併用せずrecurrent artery of Heubnerを温存する形で血管内手術による母血管閉塞を施行した。術後は降圧による保存的治療を施行した。術後2週間のfollow up DSAで塞栓部近位側へ解離が進行している可能性が考えられたものの、recurrent artery of Heubner温存目的で追加塞栓は行わずにそのまま保存的治療を継続した。その後は解離の進行や再出血所見を認めず良好な経過を辿っている。前大脳動脈解離で脳梗塞とクモ膜下出血を併発する症例は稀であり、我々が調査し得た限りでは報告されているのは自験例を含めて16症例のみである。半数以上は保存的治療で良好な経過を辿っているが、同様の発症形式で外科的治療を必要とする再出血ハイリスク症例が存在する可能性がある。報告症例数の少ない現時点では困難だが、効果的な治療選択をする上で今後は症例の蓄積と共に再出血ハイリスク因子の同定が必要だと考えられた。(著者抄録)

Many epidemiological studies on unruptured cerebral aneurysms have reported that the larger the aneurysm, the higher the risk of rupture. However, many ruptured aneurysms are not large. Electrocardiography (ECG)-gated 3D-computed tomography angiography (4D-CTA) was used to detect pulsation in unruptured cerebral aneurysms. The differences in the clinical course of patients in whom pulsation was or was not detected were then evaluated. Forty-two patients with 62 unruptured cystiform cerebral aneurysms who underwent 4D-CTA and follow-up 3D-CTA more than 120 days later were studied. The tube voltage, tube current, and rotation speed were 120 kV, 270 mA, and 0.35 s/rot., respectively. ECG-gated reconstruction was performed, with the cardiac cycle divided into 20 phases. Patients with heart rates higher than 80 bpm were excluded, so 37 patients with 56 aneurysms were analyzed. Pulsation was detected in 20 of the 56 unruptured aneurysms. Of these 20 aneurysms, 6 showed a change in shape at the time of follow-up. Of the 36 aneurysms in which pulsation was not detected, 2 showed a change in shape at follow-up. There was no significant difference in the follow-up interval between the two groups. The aneurysms in which pulsation was detected were significantly more likely to show a change in shape (P = 0.04), with a higher odds ratio of 7.286. Unruptured aneurysms in which pulsation was detected by 4D-CTA were more likely to show a change in shape at follow-up, suggesting that 4D-CTA may be useful for identifying aneurysms with a higher risk of rupture.

Background: Our assumption that prognosis of patients with traumatic acute subdural hematoma (ASDH) does not differ significantly according to the hemispheric laterality has never been verified. Methods. A review of the charts/radiographic images of 61 adult traumatic ASDH patients (33 left/28 right) was conducted. Intergroup comparison was made on the demographics, autonomic/laboratory data, and outcomes (90-day mortality rate). Based on the presence of concomitant brain contusion, patients were further quadrichotomized as: left ASDH with contusion (n = 14), right ASDH with contusion (n = 16), left ASDH without contusion (n = 19), and right ASDH without contusion (n = 12). Comparisons were made on demographic and outcome variables between the left ASDH with contusion and right ASDH with contusion, and between the left ASDH without contusion and right ASDH without contusion. Multivariate regression analysis was conducted to identify clinical variables correlated with fatality. Results: There were no significant differences in the demographic, autonomic, and laboratory data between the left and right ASDH patients. However, 90-day mortality rate was significantly higher in the left ASDH patients when concomitant contusion was present (79% vs. 25%, p = 0.009). However, there were no significant hemispheric differences in the mortality rate among those without contusion (32% vs. 33%, p = 0.77). Multivariate regression analysis showed that left ASDH was correlated with fatality among those with contusion (OR: 6.620 95% CI: 1.219-46.249). Conclusions: This study is probably the first to report that the left ASDH patients fared substantially worse than the right-sided counterparts. Future trials on traumatic ASDHs may benefit from considering hemispheric differences in the outcomes. © 2014 Inamasu et al. licensee BioMed Central Ltd.