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The "Izumo Study" revealed the incidence rate of subarachnoid hemorrhage (SAH) in Izumo City, Shimane Prefecture, Japan, from 1980 to 1998. However, no study has been published regarding the incidence of SAH in Shimane Prefecture after 1998. Most studies reporting the incidence of SAH in Japan have been conducted before 2000, although a few have been reported after 2000. This study aimed to assess the estimated age-adjusted incidence rate (AAIR) of SAH in Shimane Prefecture after 1998, following the Izumo Study. A retrospective study was conducted to identify the estimated AAIR of SAH in Shimane Prefecture, using the age-adjusted SAH mortality rate for this population from 1999 to 2017 and assuming that the case-fatality rate of SAH decreased by 0.7% annually from 45% in 1999 to 32.4% in 2017. We used linear regression analysis for trend to the estimated AAIR of SAH. Sensitivity analyses were also conducted by various case-fatality rates of SAH using assuming case-fatality rate based on previous reports. The estimated AAIR of SAH in Shimane Prefecture declined from 33.6 (95% confidence interval [CI]: 29.7-37.9) per 100,000 person-years in 1999, by 26.5%, to 24.7 (95% CI: 21.4-28.5) in 2017 (p < 0.01, r = 0.58). Declining trend of incidence rate of SAH in Shimane Prefecture from 1999 to 2017 was confirmed in this study.

The objective of this phase I/II study was to examine the efficacy and toxicity profile of temozolomide (TMZ) plus nimustine (ACNU). Patients who had received a standard radiotherapy with one or two previous chemo-regimens were enrolled. In phase I, the maximum-tolerated dose (MTD) by TMZ (150 mg/m 2 /day) (Day 1-5) plus various doses of ACNU (30, 35, 40, 45 mg/m 2 /day) (Day 15) per 4 weeks was defined on a standard 3 + 3 design. In phase II, these therapeutic activity and safety of this regimen were evaluated. Forty-nine eligible patients were enrolled. The median age was 50 years-old. Eighty percent had a KPS of 70-100. Histologies were glioblastoma (73%), anaplastic astrocytoma (22%), anaplastic oligodendroglioma (4%). In phase I, 15 patients were treated at four cohorts by TMZ plus ACNU. MTD was TMZ (150 mg/m 2 ) plus ACNU (40 mg/m 2 ). In phase II, 40 patients were treated at the dose of cohort 3 (MTD). Thirty-five percent of patients experienced grade 3 or 4 toxicities, mainly hematologic. The overall response rate was 11% (4/37). Sixty-eight percent (25/37) had stable disease. Twenty-two percent (8/37) showed progression. Progression-free survival (PFS) rates at 6 and 12 months were 24% (95% CI, 12-35%) and 8% (95% CI, 4-15%). Median PFS was 13 months (95% CI, 9.2-17.2 months). Overall survival (OS) at 6 and 12 were 78% (95% CI, 67-89%) and 49% (95% CI, 33-57%). Median OS was 11.8 months (95% CI, 8.2-14.5 months). This phase I/II study showed a moderate toxicity in hematology and may has a promising efficacy in OS, without inferiority in PFS., Competing Interests: The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices in the article. All authors who are members of The Japan Neurosurgical Society (JNS) have registered online Self-reported COI Disclosure Statement Forms through the website for JNS members. This manuscript has no COI that should be disclosed.

Cancer stem cells (CSCs) are the sole population possessing high self-renewal activity in tumors, with their existence affecting tumor recurrence. However, the invasive activity of CSCs has yet to be fully understood. In this article, we established a tumor sphere culture of RSV-M mouse glioma cells (RSV-M-TS) and evaluated their migration and invasion activities. Histological analysis of a tumor formed by cranial injection of the RSV-M-TS cells showed highly invasive properties and similarities with human malignant glioma tissues. When the migration activity of both RSV-M and RSV-M-TS cells were compared by intracranial injection, rapid migration of RSV-M-TS cells was observed. To confirm the invasive capabilities of RSV-M-TS cells, a three-dimensional collagen invasion assay was performed in vitro using RSV-M, RSV-M-TS, and RSV-M-TS cells cultured with medium containing serum. RSV-M and RSV-M-TS cultured with medium containing serum for 8 days indicated low migration activity, while moderate invasion activity was observed in RSV-M-TS cells. This activity was further enhanced by incubation with medium containing serum overnight. To identify the genes involved in this invasion activity, we performed quantitative polymerase chain reaction (PCR) array analysis of RSV-M and RSV-M-TS cells. Of 84 cancer metastasis-related genes, up-regulation was observed in 24 genes, while 4 genes appeared to be down-regulated in RSV-M-TS cells. These results suggest that the enhanced invasive activity of glioma sphere cells correlates with a number of tumor metastasis-related genes and plays a role in the dissemination and invasion of glioma cells.

Knowledge of anatomy visualized endoscopically is necessary to perform endoscopic surgical procedures safely. The cavernous sinuses are complicated structures with major blood vessels and nerves seated deeply in the center of the skull base. Anatomical orientation during surgery is essential for deep and narrow skull base surgery. While performing surgery involving the cavernous sinuses, understanding of the structures identifiable via a transsphenoidal view can allow comprehension of the relationship between a lesion and the surrounding structures, thus preventing intraoperative complications. The objective of this study was to dissect the neurovascular structures in the cavernous sinus deeply inside the oculomotor trigone through a transsphenoidal view, and to determine the relationships among anatomical landmarks in the path of surgery. Ten fresh silicone-injected cadaveric heads were evaluated. Four millimeter-diameter rigid endoscopes with 0° and 30° rod-lenses were utilized to perform an endonasal transsphenoidal approach. The detailed position and course of the major components in each cavernous sinus were assessed under panoramic view. We also validated the utility of this approach by successfully excising a huge pituitary adenoma.

Knowledge of anatomy visualized endoscopically is necessary to perform endoscopic surgical procedures safely. The cavernous sinuses are complicated structures with major blood vessels and nerves seated deeply in the center of the skull base. Anatomical orientation during surgery is essential for deep and narrow skull base surgery. While performing surgery involving the cavernous sinuses, understanding of the structures identifiable via a transsphenoidal view can allow comprehension of the relationship between a lesion and the surrounding structures, thus preventing intraoperative complications. The objective of this study was to dissect the neurovascular structures in the cavernous sinus deeply inside the oculomotor trigone through a transsphenoidal view, and to determine the relationships among anatomical landmarks in the path of surgery. Ten fresh silicone-injected cadaveric heads were evaluated. Four millimeter-diameter rigid endoscopes with 0° and 30° rod-lenses were utilized to perform an endonasal transsphenoidal approach. The detailed position and course of the major components in each cavernous sinus were assessed under panoramic view. We also validated the utility of this approach by successfully excising a huge pituitary adenoma.

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.

The preventive effect of aggressive blood pressure lowering on hematoma enlargement was investigated in patients with ultra-acute spontaneous intracerebral hemorrhage (ICH). Retrospective review of 248 patients (145 males, 103 females) with spontaneous ICH treated in our hospital between 2005 and 2008 identified patients with ultra-acute ICH who were directly taken to our institute by ambulance within 3 hours after onset. Patients who could not be assessed twice by computed tomography (CT) within 24 hours after arrival were excluded. Systolic blood pressure (SBP) was aggressively controlled in all patients using intravenous nicardipine to below 140 mmHg as soon as possible after diagnosis of ICH with CT. Hematoma enlargement was defined as increase in volume of more than 33% or more than 12.5 ml in the first 24 hours. Hematoma enlargement was observed in 11 of the 73 patients (15.0%). The time course of SBP change was not significantly different in patients with and without hematoma enlargement. The incidence of hematoma enlargement in patients with ultra-acute ICH in this study was 15.0%, which was lower than that in other series in which blood pressure was not reduced aggressively. This finding suggests that aggressive SBP lowering to below 140 mmHg has a preventive effect on hematoma enlargement in patients with ultra-acute ICH.

A 67-year-old woman presented with symptomatic infarction in the territory of the anterior inferior cerebellar artery manifesting as vertigo, vomiting, and right facial weakness. Basiparallel anatomic scanning (BPAS) magnetic resonance (MR) imaging combined with MR angiography demonstrated the occluded anterior inferior cerebellar artery. Common anatomic variations and limited detection of the smaller branches on MR angiography sometimes hinder evaluation of the occluded artery. BPAS-MR imaging may have a supplementary role to MR angiography in the diagnosis of cerebellar artery occlusions.

The validity of regular use of antiplatelet agents was retrospectively assessed in 106 patients with intracerebral hemorrhage (ICH) (supratentorial hemorrhage 92, lobar 22 and deep 70; and infratentorial hemorrhage 14) who underwent T(2)*-weighted gradient-echo magnetic resonance (MR) imaging between January 2005 and December 2006 in Kishiwada City Hospital. The prevalence of cerebral microbleeds was 54.7% (58/106), and the presence was significantly associated with higher age (odds ratio 3.09, p = 0.007), presence of white matter hyperintensity on T(2)-weighted MR imaging (odds ratio 2.36, p = 0.032), and previous ICH and/or cerebral infarction (odds ratio 4.77, p = 0.020). Previous ICH and/or cerebral infarction was independently associated with the presence of cerebral microbleeds after adjustment for age, white matter hyperintensity, and hypertension (odds ratio 4.07, p = 0.043). Regular use of antiplatelet agents was not associated with the presence of cerebral microbleeds, whether the patients had cerebrovascular diseases or not. Our findings suggest that antiplatelet medication can be justified for patients with cerebral microbleeds.

A 45-year-old man presented with bilateral acute subdural hematomas (ASDHs) without subarachnoid hemorrhage (SAH). He was found comatose in a parked car. Computed tomography showed left frontal intracerebral hemorrhage (ICH) and bilateral ASDHs but no signs of SAH. Magnetic resonance angiography demonstrated an internal carotid artery dorsal wall aneurysm. Emergent surgical intervention was performed. However, he died of cerebral herniation 6 days later. We inferred that massive intracranial bleeding might have ruptured through the cortex and lacerated the arachnoid membrane. Aneurysm rupture generally results in unilateral SDH, whereas trauma is the usual cause of bilateral ASDHs with ICH. Our case suggests that ruptured aneurysm should be considered in patients with non-traumatic bilateral ASDHs without SAH.