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This is the second report of an atypical peri-implant femoral fracture occurring at the distal screw after intramedullary nail fixation of a pertrochanteric fracture. A 94-year-old Japanese female with a 5-year history of alendronate intake presented with prodromal pain in her right thigh after intramedullary nail fixation. Plain radiographs showed an incomplete noncomminuted transverse fracture at the distal screw, suggesting an atypical peri-implant femoral fracture. The pathogenesis of an atypical peri-implant femoral fracture could be a combined systemic bone metabolism disorder and repetitive overloading at the screw, similar to the pathogenesis of an atypical periprosthetic femoral fracture around stem implantation.

第3回観測ロケットシンポジウム（2021年3月24-25日. オンライン開催), 3rd Sounding Rocket Symposium (March 24-25, 2021. Online Meeting), 著者人数: 21名PDF再処理の為、2023年3月17日に差替, 資料番号: SA6000162001, レポート番号: Ⅰ-1

令和二年度宇宙輸送シンポジウム（2021年1月14日-15日. オンライン開催), Space Transportation Symposium FY2020 (January 14-15, 2021. Online Meeting), 著者人数: 21名PDF再処理の為、2023年2月27日に差替, 資料番号: SA6000160027, レポート番号: STCP-2020-027

This was a retrospective analysis of 12 consecutive cases of middle cerebral artery stenosis and 9 consecutive cases of middle cerebral artery occlusion that presented to our hospital with acute cerebral ischemia. The degree and area of the cerebral infarctions were assessed with the Alberta Stroke Program Early CT Score (ASPECTS) and ASPECTS-DWI (APSECTS with assessment of white matter lesion using diffusion-weighted image). As for cerebral infarctions in the region of the perforating artery, lesions that were more than 20 mm long in the caudal-cranial direction were diagnosed as branch atheromatous disease (BAD). Activities of daily living (ADL) were poorer in the cases with lower ASPECTS and ASPECTS-DWI. ADL tended to be worse in cases with BAD than in those without. The prognosis was significantly poorer in the group with ASPECTS≤7 points. ASPECTS tended to be lower in cases with BAD than in those without. ADL, ASPECTS and the presence of BAD were not significantly different between the stenosis and obstruction groups. In summary, the neurological prognosis was dependent on the extent of the cerebral infarction and was related to BAD to some extent. These findings will be important when considering medical treatment at the outpatient clinic setting.

To clarify the effect of surgery on the prevention cerebral hemorrhage in adult moyamoya disease, we compared postoperative courses between superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis and conservative therapy. The study subjects were 30 adults with moyamoya disease. Unilateral STA-MCA anastomosis was conducted in 7 of these 30 cases, and bilateral STA-MCA anastomosis was conducted in 8 of these 30 cases. Therefore, anastomosis was performed in a total of 23 sides. The postoperative clinical course was observed for more than 5 years after the STA-MCA anastomosis. Cerebral hemorrhage occurred after operation in 2 sides (8.7%) among the 23 sides that received STAMCA anastomosis. On the contrary, hemorrhage occurred during conservative therapy in 5 sides (13.5%) among 37 non-operation sides (no significance in χ2 test). Cerebral infarction occurred in 3 sides (13%) among 23 sides treated with STA-MCA anastomosis. However, the infarction occurred in 2 sides (5.4%) among the 37 non-operation sides (no significance in χ2 test). Cerebral hemorrhage tended to occur less frequently after STA-MCA anastomosis, and bypass surgery was suggested to have some beneficial effect in preventing cerebral hemorrhage in adult moyamoya disease. However, it was revealed that STA-MCA anastomosis exacerbated the brain ischemia. Therefore, strict management is mandatory in the perioperative period.

This report presents 8 cases of internal carotid artery aneurysms, 1 case of a middle cerebral artery aneurysm, and 2 cases of anterior cerebral artery aneurysms, together with a discussion of the treatment of aneurysms in anterior circulation. All cases showed subarachnoid hemorrhage. Two of the 8 internal carotid artery aneurysms were trapped with a low-flow bypass; however, both patients died of an immediate hemodynamic infarction or vasospasm-induced infarction. Five of the 8 internal carotid artery aneurysms were trapped after revascularization with high flow bypass. Four of those patients were self-supporting at discharge, but one patient was discharged in a vegetative state due to the sacrifice of arterial branches which were included in the dissecting portion. One case of the dissecting aneurysm in the M2 portion of the middle cerebral artery was trapped after low-flow bypass. This patient was self-supporting at discharge. In 2 cases of anterior cerebral artery aneurysms, the lesions were first wrapped with Bemsheets, and then the aneurysmal clip was applied on the wrapped dome. Trapping following high-flow bypass is the best method for treating a dissecting aneurysm in the internal carotid artery. Trapping also can be used to treat a dissecting aneurysm of the middle cerebral artery, after low-flow bypass. Clipping on the wrapped aneurysm can also be performed successfully in the anterior cerebral artery aneurysm.

Revascularization with a vein graft is a mandatory method for treatment of dissecting or pseudoaneurysms of the internal carotid artery. We report the necessity for an air vent from the vein graft and explain its use in our two cases. In Case 1, we searched for a great saphenous vein around its junction with a femoral vein during the harvest of vein graft. An accessory branch of that great saphenous vein was also found around the junctional region with a femoral vein, and was temporarily ligated. At first, anastomosis was completed on both the distal and proximal sides. After the proximal side of a vein graft was opened and the ligation of the branch was loosened, an air vent could be made through the branch of the vein graft. Multiple air bubbles and a large quantity of white microemboli were discharged through this branch. The postoperative course was uneventful. In Case 2, the air vent was omitted to shorten ischemia. During the opening of the vein graft, the migrated air was observed to move to the middle cerebral artery. A computed tomography scan demonstrated that brain infarction and dysarthria occurred postoperatively. The air vent of the vein graft is essential in extracranial-intracranial bypass surgery, because the air bubbles or microthrombi are easily trapped around the valve and cause cerebral infarction. An air vent can be easily made if the branch of a vein graft exists in the outflow pathway, because intraluminal air or thrombus can be washed out through the branch at the final stage of surgery.

This study retrospectively analyzed 12 patients with brain abscesses. Half of the patients were diagnosed inaccurately in the initial stage, and 7.2 days were required to achieve the final diagnosis of brain abscess. The patients presented only with a moderately elevated leukocyte count, serum CRP levels, or body temperatures during the initial stage. These markers changed, first with an increase in the leukocyte count, followed by the CRP and body temperature. The degree of elevation tended to be less prominent, and the time for each inflammatory index to reach its maximum value tended to be longer in the patients without ventriculitis than in those with it. The causative organisms of a brain abscess were detected in 10 cases. The primary causative organisms from dental caries were Streptococcus viridians or milleri, and Fusobacterium nucleatum. Nocardia sp. or farcinica were common when the abscess was found in other regions. The primary causative organisms of unrecognized sources of infection were Streptococcus milleri and Prolionibacterium sp. Nocardia is resistant to many antibiotics. However, carbapenem, tetracycline and quinolone were effective for Nocardia as well as many other kinds of bacteria. In summary, the brain abscesses presented with only mildly elevated inflammatory markers of body temperature, leukocyte and CRP. These inflammatory markers were less obvious in the patients without ventriculitis and/or meningitis. The source of infection tended to suggest some specific primary causative organism. It was reasonable to initiate therapy with carbapenem.

A 47-year-old female had noticed diminished visual acuity in both eyes 2 months previously. The patient had vision loss (no light perception) in her right eye on admission. Her left visual acuity was 1.2 (naked vision) and an upper temporal quadrant hemianopsia was revealed in her left eye. Optic disc atrophy was also found bilaterally during a fundus examination. The tumor was located at the tuberculum sella. The first operation was performed using a right pterional approach. The right optic nerve was thin and atrophic and was severely encased by the tumor. Considering the deterioration of her visual evoked potential, the operation was terminated in the remaining major part of the tumor. Postoperatively, the patient suffered visual loss in her right eye (no light perception), decreased visual acuity (naked: 0.6 (corrected: 1.0)), and deteriorated visual field defects (upper temporal quadrant hemianopsia) in her left eye. The tumor remnant was resected again 2 weeks later using the right frontobasal and pterional approaches. The tumor around the bilateral internal carotid arteries and optic nerves was not resected. Light perception in the right eye appeared 2 weeks after the operation. Although an opthalmological examination revealed right optic atrophy, finger counting was possible in the upper nasal visual field of the right eye three months after the second operation. Her visual acuity was 0.7 (1.0), and the upper temporal quadrant hemianopia of the left eye improved in comparison with the preoperative one. Our case demonstrated the possibility of a recovery from blindness.

Four cases of schwannoma originating from the lower cranial nerves are presented. Case 1 is a schwannoma of the vagus nerve in the parapharyngeal space. The operation was performed by the transcervical approach. Although the tumor capsule was not dissected from the vagus nerve, hoarseness and dysphagia happened transiently after the operation. Case 2 is a schwannoma in the jugular foramen. The operation was performed by the infralabyrinthine approach. Although only the intracapsular tumor was enucleated, facial palsy, hoarseness, dysphagia and paresis of the deltoid muscle occurred transiently after the operation. The patient’s hearing had also slightly deteriorated. Case 3 is a dumbbell-typed schwannoma originating from the hypoglossal nerve. The hypoglossal canal was markedly enlarged by the tumor. As the hypoglossal nerves were embedded in the tumor, the tumor around the hypoglossal nerves was not resected. The tumor was significantly enlarged for a while after stereotactic irradiation. Case 4 is an intracranial cystic schwannoma originating from the IXth or Xth cranial nerves. The tumor was resected through the cerebello-medullary fissure. The tumor capsule attached to the brain stem was not removed. Hoarseness and dysphagia happened transiently after the operation. Cranial nerve palsy readily occurs after the removal of the schwannoma originating from the lower cranial nerves. Mechanical injury caused by retraction, extension and compression of the nerve and heat injury during the drilling of the petrous bone should be cautiously avoided.

Sixteen operative cases of parasagittal and falx meningioma were analyzed retrospectively. Parasagittal meningioma totaled 12 cases and falx meningioma numbered 4 cases. Preoperative symptoms were paresis of a lower extremity in 7 cases and disturbed consciousness or mentality in 6 cases. Paresis and/or consciousness deteriorated just after the operation in 11 cases. The deterioration was identified in paresis (6 cases), consciousness (3 cases), paresis and consciousness (2 cases). Motor function further deteriorated postoperatively when the patients had shown preoperative paresis. The cause of postoperative deterioration of motor function and/or consciousness level was intracerebral hematoma in 1 case, and newly-developed brain edema in 1 case. There was no obvious explanation for the symptomatic exacerbation in the other 9 cases. At discharge, 5 cases showed deterioration of motor function in comparison to their preoperative condition, and 3 cases showed an improvement. Eleven cases showed no change of consciousness in comparison to the preoperative condition, and 5 cases showed improvement at discharge. Surgical result was good for consciousness or mentality, but was relatively poor for motor function. It was considered that surgery should be performed carefully in patients with preoperative paresis.

The patient had thyroid cancer and underwent subtotal thyroidectomy. Local recurrence occurred on both sides 5 years and 6 months later. The sterno-hyoid muscle and sterno-thyroid muscle were severed and the tumor around the cricoid cartilage was removed. The tumor extended into the space between the right common carotid artery and internal jugular vein and was located under the right common carotid artery and vagus nerve on the lateral side. The carotid sheath was peeled off of the carotid artery quite easily. The right common carotid artery ruptured abruptly at the distal side during this procedure. The right common carotid artery had two layers, which were very fragile, so the direct suture or repair with a graft was impossible. The carotid artery could not be trapped with ligation because the cerebral vascular supply was not examined preoperatively. This portion was repaired using the remaining carotid sheath. However, re-bleeding occurred at the proximal portion of the previous laceration spontaneously. Fibrin glue with oxidized cellulose was initially used to seal the second small hole in this lesion. The second ruptured section was repaired using the remaining sterno-thyroid and sterno-hyoid muscles. The proximal portion of the right common carotid artery was reinforced with the harvested external jugular vein. These procedures resulted in hemostasis. Three-dimensional CT angiography showed irregular stenosis just after the operation, but it recovered 11 days later. No cerebral infarction occurred after the operation and the patient’s general condition was good.

高齢者人口の増加に伴い,骨粗鬆 症関連骨折である大腿骨近位部骨折 (大腿骨頚部・転子部骨折)も増加 の一途をたどっている.本骨折は寝 たきりの原因となるばかりではなく 受傷後の生命予後を確実に短縮させ るため,医療経済的問題と併せて大 きな社会問題とも考えられ,その治 療法ならびに予防法の標準化は喫緊 の課題である. 外傷治療に関する診療ガイドライ ンは少なく,特に本邦では種々の治 療法が科学的根拠に基づくことなく 選択されてきた.本骨折においても 同様で,この現状を改善するべく日 本整形外科学会により2005年に大腿 骨頚部/転子部骨折診療ガイドライ ンが作成された.2010年8月現在, その改定作業がほぼ終了しつつあ り,改定案がパブリックコメント募 集のため日本骨折治療学会のホーム ページ上で公開された(http:// www. imic.or. jp/society/jsfr/ index.html,2010年7月30日~同8 月31日の間,公開).本稿ではこれら のガイドラインに基づいた本骨折の 治療と予防を中心に概説する.