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The treatment for cerebral aneurysms has been changing along with the advancements in endovascular treatment. In particular, the induction of a flow-diverter stent can treat even cavernous portion aneurysms, which have been difficult to treat without parent artery occlusion. The definite advantages of the open surgery are low recurrence rates, high angiographic outcome, and bypass. Herein, we describe the bypass method for treating cerebral aneurysms. The purpose of the bypass, difference between high-flow and low-flow bypasses, how to select the donor artery, and variation of bypass technique are described.

A 47-year-old woman with a history of mitral valve replacement (MVR) through a median sternotomy was admitted to our hospital due to dyspnea on exertion. Echocardiography showed bioprosthetic valve dysfunction with mitral stenosis. Right heart catheter examination revealed severe pulmonary hypertension and right ventricular dysfunction. We considered that she could not tolerate the hemodynamic changes during induction of general anesthesia without any cardiopulmonary support. Therefore, the percutaneous cardiopulmonary support was started before induction of anesthesia. To avoid the risk of injury to cardiac structures, we performed redo mitral valve replacement via right mini-horacotomy in the 4th intercostal space. Severe calcification was found in the leaflets of the prosthetic valve. She was discharged home on postoperative day 42.

Thrombocytopenia is often caused by myelosuppression during chemotherapy. However, when platelet transfusions are required, pathological conditions such as idiopathic thrombocytopenic purpura(ITP)and thrombotic thrombocytopenic purpura( TTP)also occur. We report a case of Merkel cell carcinoma complicated with severe thrombocytopenia treated with carboplatin/etoposide regimen after surgery. The patient's platelet count did not increase in spite of platelet transfusions. However, the platelet count increased after steroid treatment was chosen under the diagnosis of ITP. Subsequent examinations revealed that the patient had HLA antibody, which caused the platelet transfusion refractoriness. When the platelet count does not increase in spite of platelet transfusions during chemotherapy, the possibility that the platelet transfusion refractoriness is due to the presence of HLA antibody should be considered.

Background and Purpose: In general, upper basilar artery aneurysms are treated following the transsylvian or subtemporal approach. These approaches have both advantages and disadvantages. Therefore, we followed the anterior temporal approach that provides a wider surgical field in the retro-carotid space., Methods: We reviewed the clinical records of 37 patients with an upper basilar artery aneurysm operated on following the anterior temporal approach between 2002 and 2012 in our institute, and evaluated the usefulness of this approach., Results: In 23 cases, several additional techniques were performed. In all these cases a wide operation field was obtained in the retro-carotid space and the aneurysm was completely obliterated. The post operative adverse events were temporary oculomotor palsy in 6 cases, permanent oculomotor palsy in 3 and temporary epilepsy, aphasia due to venous infarction and asymptomatic cerebral infarction in 1 case each., Conclusions: The anterior temporal approach allows the additional use of several techniques and provides a wide surgical field. Therefore, we consider this approach is useful to reach and treat upper basilar artery aneurysms.

It can be difficult to judge the degree of arborization of diminutive central pulmonary arteries (cPA) in patients with major aortopulmonary collateral arteries (MAPCA). Even through preoperative cardiac catheterization may not give adequate information. We introduce intra-operative direct angiography of diminutive cPA for patients with MAPCA. This would be one of the good options to judge the degree of arborization of the diminutive cPA, and to decide an initial surgical treatment. In this case, unifocalization of MAPCA without patch augmentation of pulmonary arteries, and an aortopulmonary shunt were performed at the 1st procedure. As enough growth of the cPA was obtained, this patient did not require additional patch augmentation of the pulmonary artery at the time of complete repair.

We investigated factors for aspiration by videofluoroscopy (VF) and swallowing exercises in stroke patients. Subjects were 102 stroke patients aged 34-101 years (mean 72.8+/-13.8 years) including 72 males and 30 females and for whom VF was performed because of suspected swallowing difficulty. They consisted of 64 patients with cerebral infarction, 33 patients with cerebral hemorrhage, and 5 patients with subarachnoid hemorrhage. Aspiration was classified into aspiration with choking and silent aspiration (SA) by the presence of a cough reflex. Eating instructions such as foodstuffs and intake methods and outcome were investigated. On VF, aspiration with foodstuffs was found in 59 of 102 (57.8%) patients and SA was found in 44 of them (44.1%). Some patients ate food on the ward in spite of SA in VF. Such patients were given eating instructions by the judgment of the attending physician, but foodstuffs and intake methods based on the results of VF could be changed in most cases. As for swallowing training, direct training was conducted only in a few patients in the group that presented overt aspiration in this study. On the other hand direct training was possible in the majority of patients if foodstuffs and intake methods were handled appropriately in SA. If these strok patients were approached with attention paid to the forms of foodstuffs and intake method on the basis of detailed evaluation on VF using mimic foodstuffs, eating was possible without aspiration in many cases.

We report here a case of amnestic syndrome with executive dysfunction and attention deficit caused by cerebral infarction in the right temporal lobe was reported. An 80-year-old, right-handed female with complaints of memory impairment, was admitted to our hospital. She had neither motor paresis nor sensory disturbances. She exhibited disorientation, retrograde amnesia, anterograde amnesia, executive dysfunction and attention deficit. Although her immediate recall and remote memory were almost intact, her recent memory was moderately impaired. Both verbal memory and non-verbal memory were impaired. Brain MRI revealed cerebral infarction in the right temporal lobe involving the parahippocampal gyrus, and SPECT demonstrated low perfusion areas in both the cerebral hemispheres involving basal ganglia and the right thalamus. After a 4-month rehabilitation program, her memory impairment improved considerably. We consider that the reason that contributed to these improvement include the fact that her lesion was unilateral and that her executive dysfunction and attention deficit also improved. This finding suggests that memory is related to attention and executive function.

This study was investigated clinical factors for aspiration in stroke patients by videofluoroscopy (VF). Subjects were 102 patients with strokes aged between 34 and 101 years including 72 males and 30 females and for whom VF was performed for swallowing difficulty or suspected swallowing difficulty. They consisted of 64 patients with cerebral infarction, 33 patients with cerebral hemorrhage, and 5 patients with subarachnoid hemorrhage. Before VF, pharyngeal reflex, physical status, and cognitive function were evaluated as bedside clinical assessment. As for swallowing evaluation at bedside, the repetitive saliva swallowing test (RSST) and water swallowing test were performed. Aspiration was classified into aspiration with choking and silent aspiration (SA) by presence of a cough reflex. As results, aspiration with foodstuffs on VF was found in 59 of 102 (57.8%) patients and SA was found in 44 of them (43.1%). In patients with not only pharyngeal reflex but also cervical and maintaining a position stability, and those who were decreased in cognitive function, aspiration should always be supposed and the observation for eating behavior against aspiration should be needed. We divided patients into three groups; no aspiration, SA and aspiration with choking. Significant difference was observed between the groups in Mini-Mental State Examination, Barthel Index, and RSST. Although in the water-swallowing test, swallowing was possible without choking, SA was observed on VF in most cases. Therefore, in cases with serious disability and cognitive dysfunction with advanced age, RSST and water swallowing test should not be overestimated, it is worth conducting VF when aspiration is suspected from neurological assessment.

The correlation between periodontal disease and osteoporosis was evaluated by comparing age, panoramic radiographic and clinical parameters of periodontal disease. Diagnosis of osteoporosis in periodontal diseased patients was evaluated by panoramic radiographic parameters (mandibular cortical width:MCW). Subjects which had more than 20 teeth and examined by panoramic radiography were untreated adults with periodontal disease who were free of other systemic disease. The following parameters were examined on panoramic X-ray film:alveolar bone loss (ABL), mandibular bone mass with the use of mandibular cortical width (MCW). ABL was significantly higher and MCW significantly lower in the postmenopausal group (>6 years after menopause). The number of teeth was significantly lower and CAL significantly higher in the postmenopausal group (>11 years after menopause). Age and ABL correlated positively in men and women. Years after menopause and ABL and MCW and CAL in the postmenopausal group were correlated positively. Women whose MCW was less than mean - 2 SD should be diagnosed with osteoporosis. Our results demonstrated that periodontal disease correlates with osteoporosis, and MCW could be useful in detecting of osteoporosis in women with periodontal disease.

We tried outpatient chemotherapy with continuous intravenous infusion of 5-fluorouracil (5-FU) and cisplatin (CDDP) for patients with recurrent renal cell carcinoma or advanced prostate carcinoma. This study was designed to evaluate the efficacy of our drug delivery system using two disposable balloon pumps and subcutaneous port, subjective symptoms caused by chemotherapy, and quality of life (QOL). There were 12 patients, including 7 cases of recurrent renal cell carcinoma and 5 cases of advanced prostate carcinoma. Their performance status (PS) was grade 0 or 1. The protocol for renal cell carcinoma consisted of combined chemotherapy with continuous infusion of 5-FU 250 mg/m2/day and CDDP 3 mg/m2/day in 2 weeks for 1 cycles (4 weeks). 5-FU and CDDP were administered with the Baxter infuser pumps (Intermate LV 1.5) and after 1 week we changed the new pumps. In treating advanced prostate carcinoma, Honvan 100 mg/day was substituted for 5-FU. We experienced 2 cases of problems with the drug delivery system during 10 months, which needed a change of the subcutaneous port. QOL score and subjective symptoms showed that patients were not always free because of carrying pumps and the side effects of chemotherapy, but they can return to social life and family instead of spending much time in the hospital. In conclusion, our drug delivery system is safe for outpatient chemotherapy, and QOL of patients with home anti-cancer chemotherapy is higher than that of patients with chemotherapy in the hospital.

Unlabelled: We compared myocardial viability evaluated by 18F-deoxyglucose (FDG) SPECT in 14 old myocardial infarction patients with that evaluated by 201TI SPECT and 123I-beta-methyl-iodophenyl pentadecanoic acid SPECT as imaging of fatty acid metabolism. FDG-SPECT was performed after oral administration of glucose. From each SPECT image which was divided into 7 segments, the degree of accumulation of each radioisotope (RI) was visually classified into four grades of defect score (ranging from 0 as normal to 3 as severe defect). The % uptake in the same area was also quantitatively calculated., Results: The degree of accumulation of myocardial Rl relative to regional wall motion. FDG is the most wide for a range of accumulation of Rl of infarct area. Also, at FDG, in the area of wall motion had done a disorder, the degree of accumulation was higher than other two methods. In the infarcted area, the degree of accumulation on FDG-SPECT in the area of decreased wall motion was greater than that on the other two procedures. These results suggest that FDG-SPECT is useful for evaluating myocardial viability.

Splenectomy has been reported to reduce the immune function. Fischer rats were subjected to 1), splenectomy, 2) splenectomy and autotransplantation and 3) sham control, respectively and examined for the production of antibodies against heterogeneic red blood cells, natural killer (NK) activity of peripheral blood lymphocytes (PBL), and the effects against tumor metastasis. Autotransplanted spleen started to produce antibody against the intravenously injected the sheep red blood cells (SRBC) even 2 weeks after autotransplantation and produce high titer of antibody as like sham operated rats 8 weeks after the operation. NK activity was decreased 2 weeks after splenectomy, but not after splenic autotransplantation. Immunohistopathological examination with monoclonal antibody against rat's lymphocytes showed the similar regeneration of B cells and T cells with normal spleen. Fischer rats which had been inoculated with FMC7 (fibrosarcoma) had their tumors resected 12 days after the inoculation and were divided into the 3 groups according to the operative procedures mentioned above and were operated on respectively. Then FMC7 were challenged intravenously or intraperitoneally, and their survival times were examined. No significant difference was found in the groups of intraperitoneal inoculation. But in the case of intravenous challenge, averaged survival time was significantly prolonged in the group of sham operation. These results suggested the spleen worked against intravenous antigens including even tumor cells. Heterotopic splenic autotransplantation is a method to restore some parts of the splenic immune function.

Examination was made of clinical, histological and biological prognostic factors in 207 patients with invasive breast cancer, and determination was made as to whether variable prognostic factors, especially internal mammary lymph node metastases, would serve as a basis for the prognosis of breast cancer. In a univariate study, overall survival was significantly corrected with tumor size, axillary lymph node status, axillary and internal mammary lymph node metastases and DNA ploidy status. In a multivariate study, however, only axillary and internal mammary lymph node metastases were recognized as important, and independent prognostic factors on survival. Neither axillary lymph node status nor DNA ploidy status appeared an important prognostic factor. Axillary and internal mammary lymph node metastases could not be predicted from their clinical assessment. Only axillary lymph node dissection and biopsy of first and second intercostal spaces were concluded to be useful for accurately indicating the status of these lymph nodes.

Two types of operative fiberoptic nephroureteroscopes were developed with the cooperation of the Olympus Optical Company mainly to remove the upper urinary tract calculi. Removal of the renal and upper ureteral stones was attempted in nine cases. The ureter was dilated with olive tip, balloon and Teflon dilators alone or in combination. The combination of balloon and Teflon dilators seemed the most promising. As a result of ureteral dilation, operative fiberoptic nephroureteroscopes, 4.5 mm and 3.5 mm in diameter, could be passed into the ureter in all the cases and the stones could be visualized clearly. Four of the 7 upper ureteral stones and 1 of the 2 pelvic stones could be removed. The success ratio was 56%. The method of stone removal still requires improvement. At present, application of the operative fiberoptic nephroureteroscope is indicated for upper ureteral and renal stones less than 1.0 cm in diameter. With the improved techniques of stone removal using this fiberscope, the indications of extracorporeal shock-wave lithotripsy or percutaneous nephrolithotripsy will probably be greatly reduced in the near future.