廣瀬 雄一

The vascular type of Ehlers-Danlos syndrome (vEDS) is an autosomal dominant hereditary disease characterized by connective tissue fragility throughout the body, including the arteries, viscera, and gastrointestinal tract. We report a case in which we performed transvenous embolization (TVE) via direct superior ophthalmic vein (SOV) approach to treat a direct carotid-cavernous fistula (CCF) in a patient with Ehlers-Danlos syndrome (EDS). The patient was a 37-year-old woman who developed tinnitus in her left ear and a headache during examination in the outpatient clinic of another hospital in order to make a definitive diagnosis of vEDS, and she was referred to our hospital and examined. Based on the results of all of the studies she was diagnosed with a CCF. Conservative treatment was attempted, but was not very effective. Because of progressing aphasia, TVE was performed via the SOV direct cut. There were no intraoperative or postoperative complications. It has been reported that cerebral angiography is generally contraindicated in vEDS and that the morbimortality associated with endovascular treatment is very high. When performing treatment it is necessary to be sufficiently aware of the risks it entails.

Our assumption that blood pressure (BP) in supratentorial hypertensive intracerebral hemorrhage patients does not differ significantly according to the hemispheric laterality has never been verified before. This study was carried out to explore the possibility of hemispheric BP differences and whether this might influence the outcomes. A review of the charts/radiographic images of 281 patients with putaminal/thalamic hemorrhages diagnosed within 6 h of symptom onset was performed. Immediately after arrival, they received a continuous intravenous nicardipine infusion to lower and maintain systolic BP (SBP) between 120 and 160 mmHg. They were quadrichotomized as follows: left putamen (LP, n=89), right putamen (RP, n=69), left thalamus (LT, n=68), and right thalamus (RT, n=55). Two-group or four-group comparisons were made on demographic variables, BPs, and outcomes. Patients with left-sided hemorrhages presented with significantly worse neurologic scores in both hemorrhage categories and tended to sustain larger hematomas than their right-sided counterparts. Significant differences in SBPs between LP and RP (205 +/- 31 vs. 189 +/- 29 mmHg, P<0.01) as well as in diastolic BPs between LT and RT (109 +/- 19 vs. 97 +/- 20 mmHg, P=0.03) were noted. Multivariate regression analysis showed that patients with SBPs of at least 220 mmHg were 2.9 times more likely to harbor left-sided hemorrhages. There were no significant intergroup differences in responsiveness to a continuous intravenous nicardipine infusion or 30-day mortality rates. Although the differences in BPs are unlikely to have influenced outcomes, future trials involving supratentorial hypertensive intracerebral hemorrhages may benefit from considering hemispheric differences in BP and other demographic variables. (C) 2014 Wolters Kluwer Health vertical bar Lippincott Williams & Wilkins.

近年画質が向上し、脳動脈～脳動脈瘤の拍動を再現し得る心電同期再構成3D-CTA(4D-CTA)のデータを用いて、脳動脈瘤の弾性に考慮した解析を行った。得られたデータとそれぞれの時相での血流速度を挿入し、WSSやpressureを解析した。この擬似弾性モデルと通常の剛性モデルでのCFD解析結果を比較したところ、pressureにおいて、ブレブ部分で疑似拍動モデルと剛性モデルの間で若干の違いを認めた。さらなる検証が必要であるが、今後、4D-CTAデータがCFDによる脳動脈瘤解析に必要となる可能性がある。(著者抄録)

Background: Malignant hemispheric infarction is a life-threatening condition with a high mortality rate. Decompressive hemicraniectomy (DHC) is frequently a life-saving procedure that has shown the highest grade of evidence for patients 18 to 60 years of age. However, the efficacy of DHC in patients >60 years of age has rarely been investigated. Methods: A retrospective study was conducted in a single academic institution. Surrogates of patients with clinical signs of impending brain herniation despite standard medical therapy were offered the option of DHC regardless of age or the side of the lesion. The clinical data from 18 patients >60 years of age who underwent DHC for malignant hemispheric infarction in our institution were analyzed. Patients were classified into the following 2 groups: 61-70 and >70 years of age, and their demographics and surgical outcomes were compared. The variables compared included the male: female ratio, side of the lesion, type of stroke, site of vascular occlusion, use of thrombolytic therapy, National Institutes of Health Stroke Scale score, stroke onset-to-DHC interval, duration of hospital stay, infectious complications, and 90-day mortality rate. Results: There were no significant intergroup differences in any of the demographic variables evaluated. However, the 30-day mortality rate was significantly higher in the group that was >70 years of age (0% v 60%; P = .01) than in the group that was 61 to 70 years of age. Conclusions: We suggest that the efficacy of DHC in malignant hemispheric stroke patients between 61 and 70 years of age be further investigated in future randomized trials. By contrast, it appears unlikely that patients >70 years of age would benefit from DHC.

Management of gliomas depends on histological diagnosis; there are, however, limitations to the systems presently used. Tumors in the same entity can have different clinical courses, especially when they are diagnosed as WHO grade II-III. Previous studies revealed that genetic subgrouping of gliomas provides useful information that could help establishment of treatment procedures on the basis of the genetic background of the tumors. Recently, the authors analyzed the chromosomal copy number aberrations (CNAs) of adult supratentorial gliomas by comparative genomic hybridization using microdissected tissue sections. The tumors were classified into subgroups according to chromosomal CNAs. WHO grade II-III gliomas contained a variety of genetic subgroups that correlated well with the clinical course. Of these, long progression-free survival was observed for tumors with +7q and those with -1p/19q, low-grade tumors of 2 major lineages, and, in our preliminary data, both were closely correlated with mutation of IDH1. Furthermore, in contrast with +7q tumors, the great majority of +7 or +7/-10q groups had wildtype IDH1. Genetic studies suggest that cytogenetic characterization may provide an additional classification system for gliomas, and new criteria could help to establish rational and objective means for analysis of treatment procedures.

【目的】妊婦に対する脳血管内治療には,放射線被曝や造影剤,抗血栓療法など,さまざまな問題が存在する.今回,人体ファントム(ランドファントム)を用いて下腹部被曝線量を測定し,胎児に与えうる放射線被曝の影響につき検討したので,自験例2例とともに報告する.【方法】ランドファントムと熱蛍光線量計素子を用いて,頭部血管造影(右上腕穿刺)・脳血管内治療に準じた透視・撮影を行い,生殖腺に相当する部位における被曝線量を計測した.【結果】頭部(外後頭隆起周辺)で最大約800mGy程度の被曝線量に対し,生殖腺相当部位の下腹部における被曝線量は平均0.05mGy程度であり,妊娠中であっても胎児に与える影響は極めて低いことが予想される結果であった.【結論】妊婦に対する脳血管内治療に対して胎児に生じる被曝の影響は極めて低いと考えられた.妊娠中の脳血管内治療には,被曝以外にもさまざまな問題はあるものの,諸注意点に留意すれば安全かつ有効に治療を行うことが可能と考えられる.(著者抄録)

Chronic subdural haematoma (CSDH) is an uncommon but potentially serious complication of clipping unruptured cerebral aneurysms. We conducted a study to identify the patients who are at risk of developing postoperative CSDH. The data from 713 consecutive patients who underwent clipping of unruptured anterior circulation aneurysms were reviewed, and risk factors correlated with CSDH were identified by multivariate regression analysis of demographic variables. Fifteen patients (2.1%) developed CSDH after the surgery. Advanced age (odds ratio [OR] 1.151, 95% confidence interval [CI] 1.051-1.261) and male gender (OR 3.167, 95% CI 1.028-9.751) were correlated with CSDH. Subsequently, all 713 patients were quadrichotomized on the basis of gender and age, with 70 years as the cut-off value for age. The frequency of CSDH in men <70 years of age was 1.3% and that in men 70 years of age was 15.1%, with risk of CSDH was significantly higher in the older men (OR 13.39; 95% CI: 3.42-52.44). The frequency of CSDH in women <70 years of age was 0.6% and that in women >= 70 years of age was 3.7%. As in men, the risk of CSDH was significantly higher in the older women (OR 6.69, 95% CI 1.10-40.73). The interval between the aneurysm clipping and CSDH development was 0.5-6 months, suggesting that clinical observation should be continued up to 6 months after surgery. Although prognosis for patients with a. postoperative CSDH complication is generally favourable, the risk of CSDH should be taken into account when considering elective clipping of unruptured aneurysms in patients >= 70 years of age. (C) 2012 Elsevier Ltd. All rights reserved.

悪性神経膠腫に対して、2013年よりカルムスチン脳内留置用剤を腫瘍摘出腔に留置することが可能となった。脳内留置用剤の有効かつ安全な留置を目的とした、べリプラストPコンビセットエアーレスデバイスを用いた当施設での使用経験に関して報告する。(著者抄録)

The role of three-dimensional computed tomography angiography (3D-CTA) in management of aneurysms has been fairly acknowledged in the past. There have been numerous articles in the literature regarding its potential threat to the conventional "gold standard", i.e. digital subtraction angiography (DSA). We study the technology used at a tertiary care hospital in Japan which performs,a large number of aneurysm surgeries a year and review the recent literature to gain an insight into the current role of 3D-CTA in detection of aneurysms and if it can be a front line modality of investigation from a neurosurgeon's point of view. At many centres including those in India, DSA is still treated as the first choice of investigation. Although 3D CTA has some limitations, it can provide an unmatched multi-directional view of the aneurysmal morphology and its surroundings including relations with the skull base and blood vessels. This may provide an invaluable help to a neurosurgeon who is usually concerned about many other associated factors involved in approaching an aneurysm.

Objective To evaluate the feasibility and limitations of the contralateral approach to unruptured superior hypophyseal artery (SHA) aneurysms. Methods Data regarding eight cases of superior hypophyseal artery aneurysms operated on by a contralateral pterional approach at our center from January 2008 to September 2010 were collected and evaluated retrospectively. Of these eight cases, six were male and two were female. The mean age was 57.1 years (range 28 years to 77 years). All the aneurysms were unruptured; five were on right side and three were on left side. The surgical technique and outcome of patients were reviewed. Results All aneurysms were successfully clipped without complication and patency of all superior hypophyseal arteries was preserved. Postoperative three-dimensional computed tomography angiography revealed residual aneurysm in only one case. None of the patients had deterioration of visual acuity or field after surgery. The contralateral pterional approach was found to be appropriate for fully exposing the aneurysmal dome and neck without retraction of the optic nerve or the carotid artery in five cases. Slight retraction of the optic nerve was required in two cases, and significant manipulation of the optic nerve was required in one case. Conclusions The contralateral pterional approach for clipping of unruptured superior hypophyseal artery aneurysms is technically feasible and safe in a select group of patients where optimal results can be achieved without significant retraction of near by neurovascular structures.

Objective: We retrospectively analyzed thromboembolic complications for unruptured cerebral aneurysms treated with stent assisted coil embolization (SAC).<br>Patients and methods: Between 2010 September and 2012 March, 36 unruptured broad neck aneurysms in 35 patients were treated by SAC following dual antiplatelet medication with aspirin and clopidogrel. Aspirin and clopidogrel were started 1–14 days before the procedure. After the procedure, diffusion weighted MR imaging (DWI) was performed within seven days. DWI findings were graded into A to D depending on the number and the size of bright spots: A, no bright lesions; B, 1–5 small (＜10 mm) lesions; C, six or more small lesions; D, any large (≧10 mm) lesions.<br>Results: Angiography showed complete occlusion was achieved in 13 aneurysms (36%), neck remnant in nine (25%), and body filling in 14 (39%). Symptomatic thromboembolic complications occurred in six cases (17%). The symptoms were transient in four of the six patients, and two patients had persisting minor symptoms (modified Rankin Scale 1 and 2). The DWI grade of SAC cases was A in two patients, B in six, C in 16, and D in eight. Among SAC cases, there was a tendency of higher incidence of Grade D when clopidogrel was started earlier than three days before the procedure.<br>Conclusions: SAC is a feasible and effective technique for treating broad neck aneurysms. Starting clopidogrel three or more days before the procedure may half reduce thromboembolic complications. <br>

AIMS: Indoxyl sulfate, a uremic toxin, is considered a risk factor for arteriosclerosis in patients with chronic kidney disease (CKD). We previously reported the actions of indoxyl sulfate including crosstalk with platelet-derived growth factor (PDGF) signaling in vascular smooth muscle cells (VSMCs). The present study examines whether indoxyl sulfate enhances angiotensin II (Ang II) signaling because serum levels of Ang II are elevated in patients with CKD. MAIN METHODS: The effect of indoxyl sulfate and Ang II on phosphorylation of ERK and epidermal growth factor receptor (EGFR), and migration were determined using VSMCs. The expression of EGFR was determined using not only VSMCs but also artery of normal, uremic, and indoxyl sulfate-administrated uremic rats. KEY FINDINGS: Ang II-dependent phosphorylation of ERK and EGFR, and migration of VSMCs were augmented by a prior 24-h incubation with indoxyl sulfate even in the absence of indoxyl sulfate during Ang II stimulation. The expression of EGFR was increased in indoxyl sulfate-stimulated cultured VSMCs. In arterial VSMCs of rats, serum levels of indoxyl sulfate reflected the expression level of EGFR. The upregulated EGFR expression by indoxyl sulfate was suppressed by the antioxidant, N-acetylcysteine. An EGFR inhibitor, AG1478, repressed the enhancement of Ang II-induced cellular effects by indoxyl sulfate. Taken together, these findings indicate that indoxyl sulfate enhances Ang II signaling through reactive oxygen species-induced EGFR expression. SIGNIFICANCE: The actions of indoxyl sulfate including crosstalk with Ang II signaling may be closely involved in the pathogenesis of CKD associated with arteriosclerosis.

We consider the formation of finite-size domains in lipid bilayers consisting of saturated and hybrid lipids. First, we describe a monolayer model that includes a coupling between a compositional scalar field and a two-dimensional vectorial order parameter. Such a coupling yields an effective two-dimensional microemulsion free energy for the lipid monolayer, and its characteristic length of compositional modulations can be considered as the origin of finite-size domains in biological membranes. Next, we consider a coupled bilayer composed of two modulated monolayers and discuss the static and dynamic properties of concentration fluctuations above the transition temperature. We also investigate the micro-phase separation below the transition temperature and compare the micro-phase separated structures with statics and dynamics of concentration fluctuations above the transition.

A 71-year-old woman presented with a rare case of geriatric ependymoma originating from the fourth ventricle manifesting as progressive gait and memory disturbance. Imaging studies revealed an extraaxial mass in the fourth ventricle protruding into the right cerebellomedullary cistern, with concomitant obstructive hydrocephalus. Surgery achieved subtotal removal since the tumor tightly adhered to the right vestibular area of the fourth ventricular floor. The histological diagnosis was ependymoma, which was also confirmed by comparative genetic hybridization. Although she developed severe laryngeal edema and worsening of the hydrocephalus postoperatively which required additional treatment, she recovered with residual mild gait disturbance, and was transferred to a rehabilitation facility. Fourth ventricle ependymoma in the elderly is rare. Comparative genetic hybridization may be important in the diagnosis of geriatric ependymoma and in the choice for adjuvant therapy as well as in estimating the prognosis for patients with rare types of ependymoma.

AIM: In the forthcoming super-aging society, the appropriate assessment of functional and cognitive conditions of disabled elderly people will become increasingly significant in providing care services. Care level and household composition would be key factors to assess function. There might also be an interaction between the two factors with the function. The present study examined the associations of household composition and care level with functional and cognitive status among the disabled elderly living in a suburban apartment complex with a high rate of aged residents (39% in 2009). METHODS: Participants were 190 disabled elderly persons aged 65 years and over who lived in the apartment complex. Cross-sectional data were collected between May 2009 and August 2010, including care level, household composition, basic activities of daily living (BADL), instrumental activities of daily living (IADL) and the independence level in relation to cognitive status. Lower scores meant less independence in BADL and IADL, and as determined by the cognitive/independence scale. RESULTS: Approximately half of the participants lived alone. Generalized linear model procedure showed significant interactions with the BADL score and cognitive/independence scale between household composition and care level. Scores for BADL and the cognitive/independence scale in groups receiving a higher care level were lower; however, the slope of the trend for the elderly living alone was more gradual than for the elderly living with others. CONCLUSION: It is important for health-care providers to assess in detail the status of the disabled elderly considering both their household composition and care level in planning and providing assistance for them.

Hemodynamic factors are thought to play important role in the initiation, growth, and rupture of cerebral aneurysms. However, hemodynamic features in the residual neck of incompletely occluded aneurysms and their influences on recanalization are rarely reported. This study characterized the hemodynamics of incompletely occluded aneurysms that had been confirmed to undergo recanalization during long-term follow-up using computational fluid dynamic analysis. A ruptured left basilar-SCA aneurysm was incompletely occluded and showed recanalization during 11 years follow-up period. We retrospectively characterized on three-dimensional MR angiography. After subtotal occlusion, the flow pattern, wall shear stress (WSS), and velocity at the remnant neck changed during long-term follow-up period. Specifically, high WSS region and high blood flow velocity were found near the neck. Interestingly, these area of the remnant neck coincided with the location of aneurysm recanalization. High WSS and blood flow velocity were consistently observed near the remnant neck of incompletely occluded aneurysm, prone to future recanalization. It will suggest that hemodynamic factors may play important roles in aneurismal recurrence after endovascular treatment.

Patients with poor-grade subarachnoid hemorrhage (SAH) are often complicated with acute cardiopulmonary dysfunctions, particularly neurogenic pulmonary edema (NPE) and takotsubo-like cardiomyopathy (TCM). This study retrospectively investigated the incidence, demographics, clinical characteristics, and outcomes of patients with SAH complicated with both NPE and TCM (NPE-TCM). The effects of aneurysm location and other clinical variables on the incidence of NPE-TCM were also investigated. Among 234 SAH patients treated during 5-year period, 16 (7%) presented with NPE, and transthoracic ultrasonography revealed that 14 of these 16 patients (88%) also had TCM. All 14 patients with NPE-TCM had poor-grade SAH (World Federation of Neurosurgical Societies grades IV and V). Ruptured posterior circulation aneurysm was predictive of NPE-TCM, but other clinical variables were not. Eight of the 14 patients with NPE-TCM could undergo treatment for ruptured aneurysm. Long-term outcomes were favorable in 5 of the 8 patients. Grade IV SAH patients had significantly better outcomes than grade V patients. TCM develops frequently in SAH patients presenting with NPE, and transthoracic ultrasonography should be conducted routinely in that population. Patients with ruptured posterior circulation aneurysm may have elevated risk of developing NPE-TCM. Endovascular obliteration of the aneurysm may be preferable to open surgery, but the optimal treatment modality needs to be evaluated further. Considering the limited number of SAH patients complicated with NPE-TCM, a multi-center cooperative study may be required.

【目的】遺残三叉神経動脈（persistent trigeminal artery；PTA）に合併した未破裂脳動脈瘤に対し，tandem balloonによるballoon test occlusion（BTO）で親動脈閉塞に対する耐性を評価した上で，血管内治療を施行した一例を経験したのでその有用性を報告する．【症例】37歳，女性．複視，左眼瞼下垂を主訴に当院受診．血管造影上左PTAと内頚動脈の分岐部に大径の未破裂脳動脈瘤を認めた．脳動脈瘤のtrappingに伴う耐性を評価するには，PTAを介する逆行性血流も遮断する必要性があり，動脈瘤の遠位と近位にそれぞれballoonをtandemに用いてBTOを施行した．治療は浅側頭動脈中大脳動脈吻合術を行った上で，動脈瘤および母血管閉塞術を合併症なく施行した．【結論】本症例はPTAの遺残に伴い複雑な血行動態を呈していたが，tandem BTOで側副血行を評価することが可能であり，本法の有用性が示唆された．

【目的】ISAT（International Subarachnoid Hemorrhage Aneurysm Trial）の報告以降，破裂脳動脈瘤に対してコイル塞栓術が第1選択の治療法として行われる機会が増えている．しかし，脳動脈瘤の診断は，3次元画像診断を主とした低侵襲診断が普及し，脳血管撮影を行う機会が減少している．また，脳動脈瘤コイル塞栓術は，施設によって治療症例数が異なり，治療の安全性を高めるためにもoff the jobのトレーニングが不可欠である．近年，高度のコンピューターシミュレーターが開発され，臨場感あふれるシミュレーションが可能になっている．そこで，脳動脈瘤コイル塞栓術においてコンピューターシミュレーターVIST（Vascular Interventional Simulation Trainer，Mentice Corporation Sweden）を用いてハンズオントレーニングを行い，実際の血管内治療の経験と技能判定の各種パラメーターとの関係を検討した．【対象および方法】VISTを用いたハンズオンを受講した22名を対象とした．コンピューター内に組み込まれている脳底動脈先端部動脈瘤を用い，コイル塞栓術を行った．技能判定のパラメーターとして，1）全手技に必要とした時間，2）使用造影剤量，3）全透視時間，4）使用コイル数，5）塞栓率（VER）％を検討した．日常診療における脳動脈瘤塞栓術の治療経験数がA群20例以下の12名とB群21例以上の10名に分類し，パラメーターをもとに両群を比較検討した．【結果】平均塞栓率はA群36.4％，B群47.0％（p≦0.01）であり，日常診療における脳動脈瘤塞栓術の治療経験数が多いほどVISTで良好な塞栓率（VER）％が得られる傾向が認められた．【結論および考察】実臨床での経験数が多いことがシミュレーターにおいてVER高値として反映された．脳動脈瘤コイル塞栓術におけるコンピューターシミュレーター（VIST）を用いたハンズオンは受講者のスキルを判定できるだけでなく，繰り返し行うことより実症例における手技の向上にも繋がることが期待できる．