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The involvement of de novo nitric oxide synthase (NOS) induction in the development of cerebral vasospasm after subarachnoid hemorrhage (SAH) was examined using a rat model of SAH. SAH was induced by endovascular perforation with Nylon thread. The rats were killed at different time intervals, from one day to seven days after endovascular perforation. Inducible NOS messenger RNA (mRNA) expression was determined by reverse-transcription polymerase chain reaction (RT-PCR) and the distribution of iNOS positive cells was immunohistochemically examined. In the vascular tissue with a subarachnoid membrane, iNOS mRNA was expressed from one day to seven days after SAH. Inducible NOS positive cells were mainly recognized in the vascular tissue, but not in the brain parenchyma. The distribution of nitrotyrosine, an indicator of peroxynitrite production was also examined immunohistochemically and nitrotyrosine-positive cells were observed almost at the same sites of iNOS induction. To determine the role of iNOS in the development of cerebral vasospasm, we measured the diameter of the middle cerebral artery in animals either treated or not treated with aminoguanidine (AG), a selective inhibitor of iNOS. AG ameliorated the vasoconstrictive change after SAH. These results are thus considered to provide molecular and immunohistochemical evidence showing that iNOS expression following SAH and NO produced by iNOS can develop cerebral vasospasm after SAH.

The possible expression of the inducible isoform of nitric oxide synthase (iNOS) was examined in a rat model of subarachnoid hemorrhage (SAH). Subarachnoid hemorrhage was induced by the injection of autologous blood into the cisterna magna using stereotactic technique under general anesthesia. The rats were then killed at specific time intervals between 4 hours to 7 days after SAH. Reverse-transcriptional polymerase chain reaction (RT-PCR) revealed the expression of iNOS mRNA in the homogenate obtained from the tissue around the circle of Willis one day after SAH (Day 1). No iNOS mRNA was detected either in the sham-operated animals, or at any of the other time intervals after SAH. An immunohistochemical study was performed to examine the localization of iNOS-positive cells in the central nervous system. Inducible NOS immunoreactivity was thus observed in the mononuclear cells and polymorphonuclear cells infiltrating into the subarachnoid space of the basal cistern on Day 1. This immunoreactivity persisted faintly on Day 2, but had completely disappeared on Day 7. A vascular diameter study disclosed a vasoconstrictive change in the middle cerebral artery after SAH. Taken together, these results are thus considered to confirm the expression of iNOS in the infiltrated inflammatory cells after the insult of SAH, which may therefore play an introductory role in the development of the pathological series of events after SAH, including vasospasm.

An unruptured intracranial aneurysm is an uncommon but possible embolic source to the brain. We report a young patient who developed recurrent ischemic strokes occurring mainly in the left internal carotid arterial territory within a short interval; the first stroke occurred midway through a long-distance race, and the second stroke occurred immediately following a bowel movement. The angiographical contrast deficit indicated a thrombus in the left anterior cerebral artery as a result of the embolism. A saccular aneurysm of the left distal internal carotid artery was the only detectable potential embolic source. Initially anticoagulant therapy was given, and then surgical clipping of the aneurysm was performed. The patient has been free from stroke recurrence. As a cause of ischemic stroke in young adults, a carotid saccular aneurysm should be considered. Hard exercise and a Valsalva maneuver may be important triggers of thrombus detachment from the aneurysm.

Low-flow bypass, such as superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis, can result in cerebral hyperperfusion syndrome (CHS). The present study evaluated the pathophysiological conditions of CHS through the use of repeated electroencephalography (EEG). Among a total of 22 patients who underwent STA-MCA anastomosis over a course of 4 years, 3 patients were diagnosed with CHS based on clinical symptoms and neuroradiological examinations, including cerebral blood flow evaluation. Case 1 and Case 2 developed CHS on postoperative day 1, when EEG demonstrated focal slow waves on the frontal region of the operated side, indicating cortical dysfunction in these areas. Although prompt recovery of these EEG findings was noted with improvement of the clinical symptoms in Case 1, Case 2 developed an intracranial hemorrhage on postoperative day 5, when EEG clearly depicted persistent nonconvulsive status epilepticus (NCSE) after control of convulsive status epilepticus. In contrast, the clinical onset in Case 3 was delayed to postoperative day 6 and EEG revealed frequent ictal discharges in the operated hemisphere, although convulsive seizures were not apparent. Administration of anticonvulsants was performed after the diagnosis of NCSE, and complete recovery from CHS was achieved. Although the pathophysiology of CHS is cortical dysfunction, ictal hyperperfusion associated with NCSE could be included. The present findings emphasize the importance of repeated EEG examinations in the differential diagnosis of the various types of pathophysiological conditions of CHS.

A 43-year-old woman with progressive gait disturbance and dysesthesia of the limbs and trunk visited our hospital. Upon examination, a thoracocervical giant perimedullary arteriovenous fistula(GPMAVF)was detected. The GPMAVF was fed by both of the highest intercostal arteries and the thyrocervical trunk. The dilated drainage vein widely compressed the spinal cord from the upper thoracic to the cervical regions. Transarterial embolization with n-butyl 2-cyanoacrylate was performed, and the fistula was completely obliterated. The dilated drainage vein was thrombosed, and it decreased in size after treatment. The patient's symptoms and magnetic resonance imaging results significantly improved. We suggest that endovascular treatment is effective for GPMAVFs, given sufficient analysis of the anatomical architecture.

Background Cerebral hyperperfusion after carotid endarterectomy (CEA) is defined as an increase in ipsilateral cerebral blood flow (CBF). Practically, however, prompt and precise assessment of cerebral hyperperfusion is difficult because of limitations in the methodology of CBF measurement during the perioperative period. Arterial spin labeling (ASL) is a completely noninvasive and repeatable magnetic resonance perfusion imaging technique that uses magnetically-labelled blood water as an endogenous tracer. To clarify the usefulness of ASL in the management of cerebral hyperperfusion, we investigated signal changes by ASL with a single 1.5-s post-labeling delay on visual inspection. Methods Thirty-two consecutive patients who underwent CEA were enrolled in this retrospective study. Results On postoperative day 1, 22 (68.8%) and 4 (12.5%) patients exhibited increased ASL signals bilaterally (Group A) and on the operated side (Group B), respectively. Follow-up ASL showed improvement in these findings. Six (18.8%) patients showed no change (Group C). There was no apparent correlation between ASL signals on postoperative day 1 and the preoperative hemodynamic state, including the cerebrovascular reserve (P = 0.2062). Three (9.4%) patients developed cerebral hyperperfusion syndrome (two in Group A and one in Group B). Coincidence in the localization of increased ASL signals and electroencephalographic abnormalities was noted in these patients. Conclusion Visual analysis of ASL with a single post-labeling delay overestimates CBF and cannot identify patients at risk of cerebral hyperperfusion syndrome probably because of the strong effect of the shortened arterial transit time immediately after CEA. However, ASL may be used as for screening.

Vagus nerve stimulation (VNS) is a palliative treatment for medically intractable epilepsy and has been covered by public health insurance in Japan since July 1, 2010. The frequency of the use of VNS during the first year of insurance coverage was determined by assessing the number of cases for which VNS was performed in Kyushu Rosai Hospital, the number of registered cases, and the questionnaire survey filled by 68 surgeons who are board certified as both epileptologists and neurosurgeons. VNS devices were placed in 98 patients from July 2010 to June 2011. These devices were placed in an average of 4.4 patients per month from July 2010 to November 2010 and in an average of 10.9 patients from December 2010 to June 2011. However, we did not observe an increasing trend. Almost all of the surgeries were performed in the Kanto (56 patients in 8 institutes) and Tokai (24 patients in 2 institutes) areas. VNS was not performed in many institutes primarily because VNS was not indicated for any of the patients. The questionnaire survey indicated that the use of VNS was likely to increase with an increase in the number of neurologists who decide on performing VNS preoperatively and regulate the conditions of the vagus nerve stimulator postoperatively. In conclusion, VNS is currently being applied in a limited number of institutes in the Kanto and Tokai areas, and a close association between the epileptologists and neurologists during preoperative and postoperative periods will increase the use of VNS.

Background: Cerebral vasospasm (VS) is the most common cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage (SAH). Reversal of VS by intra-arterial infusion of cyclic adenosine monophosphate (cAMP)-elevating agents has been reported; however, the preventive role in the development of VS is not fully understood. This study is designed to evaluate the possible efficacy of using cilostazol, a selective inhibitor of phosphodiesterase type 3 and a cAMP-elevating agent, in patients with SAH. Methods: In this prospective randomized study, we enrolled 100 SAH patients who met the following criteria: neck clipping within 72 h after onset, Hunt and Hess (HH) score ≤4, modified Rankin scale (mRS) score ≤2 prior to ictus, and no serious cardiovascular complications. Patients were divided into control and cilostazol groups; we focused on the effects of cilostazol on the decrease in the incidence of symptomatic VS, cerebral infarction, and the mRS score at discharge. Result: Patients’ age, male/female ratio, mRS score prior to ictus, HH grade, Fisher group, site of the aneurysm, drugs prescribed during the observation period, and length of hospital stay were not different between the groups. Cilostazol did not significantly decrease the incidence of symptomatic VS (37.3% in the control vs. 22.4% in the cilostazol group, p = 0.183) and cerebral infarction (27.5% in control vs. 10.2% in the cilostazol, p = 0.091). However, mRS score was significantly improved at discharge (2.6 in controls vs. 1.5 in the cilostazol group, p = 0.041). Patients’ age being ≤65 years (OR = 8.47, 95% CI = 2.45–29.32, p = 0.0007), Fisher group ≤3 (OR = 4.64, 95% CI = 1.00–21.45, p = 0.049), HH grade ≤2 (OR = 4.31, 95% CI = 1.27–14.59, p = 0.019), no hydrocephalus (OR = 8.55, 95% CI = 1.72–19.23, p = 0.0046), and cilostazol use (OR = 5.52, 95% CI = 1.61–18.90, p = 0.0065) were independent predictors of good outcomes (mRS score ≤2). Conclusion: Cilostazol may improve outcomes after SAH, but further double-blind, placebo-controlled studies are required for a definitive conclusion.

Myeloschisis is the most serious and complex congenital anomaly in spina bifida manifesta (cystica). However, with improvements in medical care and increased understanding of its pathophysiology, the associated long-term morbidity and mortality rates have been significantly reduced. This article reviews various issues associated with the neurosurgical management of patients with myeloschisis, such as perinatal management, repair surgery for myeloschisis, neurosurgical management of hydrocephalus, Chiari malformation type II, tethered cord syndrome and epilepsy, and intrauterine fetal surgery.

We report a case of cerebral air embolism resulting from accidental air infection during cerebral angiography. A 60-year-old man was accidentally injected with air via the left subclavian artery. Angiography demonstrated air within the basilar artery. The patient showed signs of posterior circulation ischaemia (confusion, blindness, gaze palsy and hemiparesis). However, MRI, including diffusion-weighted imaging, showed no abnormality 4 h later. The patient was treated with hyperbaric oxygen within 5 h of the embolism. All symptoms and signs resolved completely within a week.

Cerebral vasospasm (CV) remains a major cause of mortality and morbidity in patients with subarachnoid hemorrhage (SAH). Here, we examined the effectiveness and safety of intra-arterial injection of colforsin daropate hydrochloride (CDH).A consecutive series of 29 patients with angiographically confirmed CV received intra-arterial CDH (IAC) therapy. Angiographic changes in spastic vessels and the cerebral circulation time (CCT) were assessed before and after IAC treatment, together with the change in clinical status.IAC treatment was performed in 53 procedures in 29 patients. Angiographic improvement was observed following all procedures (100%), and clinical improvement was observed following 36 of 42 procedures (86%) in symptomatic cases. CCT improved significantly. At the 3-month follow-up, 19 patients (66%) showed good recovery or moderate disability on the Glasgow Outcome Scale. Major adverse effects were headache and increased heart rate.IAC treatment was effective and safe for the treatment of CV after SAH.

The champagne bottle neck (CBN) sign refers to a reduction in the diameter of the proximal portion of the internal carotid artery that resembles a CBN, and is a characteristic feature of Moyamoya disease. A 43-year-old woman with an infarction of the posterior limb of the left internal capsule was diagnosed with Moyamoya syndrome associated with Graves’ disease. The CBN sign was observed bilaterally. Cerebral revascularization surgery was performed, including left-sided superficial temporal artery to middle cerebral artery anastomosis. During four years of follow-up, she maintained a euthyroid state and did not have any further cerebral ischemic events. The CBN signs remained unchanged on both sides during this time. This is the first report of the CBN sign in a patient with Moyamoya syndrome associated with Graves’ disease.

We examined whether intracarotid infusion of bradykinin altered circulation in the normal canine brain. Twenty-four anesthetized dogs were divided into four groups receiving different doses of bradykinin (1, 2.5, 5, and 10 micrograms kg-1 min-1). Regional cerebral blood flow (rCBF) was measured continuously using laser Doppler flowmetry through a burr hole in the frontal bone. Systemic blood pressure (SBP) and heart rate (HR) were monitored simultaneously. Higher doses of bradykinin significantly but temporarily decreased rCBF and SBP immediately after the start of infusion; these parameters rapidly recovered and then were stable through the rest of the infusion. During this period, percent change in rCBF and SBP was small, and differences between groups were not significant. On the other hand, HR increased during infusion and remained high. SBP, rCBF, and HR returned to pre-infusion levels after bradykinin was stopped. The results suggest that intracarotid infusion of bradykinin for treatment of brain tumors would be safe in terms of circulation to the uninvolved brain.

The case of a 10-month-old boy with cranial fasciitis is described. The patient had a rapidly growing subcutaneous mass in the left frontotemporal region. Computed tomography and magnetic resonance imaging clearly demonstrated a mass in the left temporoparietal bone extending both intra- and extracranially. The tumor seemed to originate from the calvarium, being located between the periosteum and the dura mater. Total resection of the tumor was performed, and the tumor was histologically identified as cranial fasciitis. A brief review of the literature is included that emphasizes the need for further investigation of this benign lesion that is frequently confused with a malignant neoplasm.

Background The utility of corticospinal tract (CST)-tractography-integrated navigation was reported for brain tumors near pyramidal tracts. However, the efficacy of arcuate fasciculus (AF)-tractography-integrated navigation is unclear. Awake craniotomy is recommended to preserve language function for glioma located near the language area, although the patients' condition can limit its application. In such cases, AF-tractography-integrated navigation may help protect neurological function. Methods We performed a retrospective analysis of AF-tractography-integrated navigation. We evaluated 11 patients who underwent glioma surgery near the language area using AF-tractography-integrated navigation. Six patients received intraoperative awake language functional mapping, whereas five did not due to adverse preoperative or intraoperative conditions. Language function was evaluated using the Western Aphasia Battery or Standard Language Test of Aphasia both preoperatively and postoperatively (2–4 weeks and 2–3 months after surgery). Results Extent of resection (EOR) ranged from 59.5% to 100% (mean 82.1%). Language function at 2–3 months after surgery was improved in one patient, intact in nine, and moderately disturbed in one compared with preoperative function. Among the non-awake craniotomy group, EOR ranged from 78.7% to 100% (mean 89.82%). Language function at 2–3 months after surgery was improved in one patient, intact in three, and moderately disturbed in one, in whom tumor removal very close to the AF tract was performed following preoperative patient's intent. Conclusions AF-tractography-integrated navigation is useful for glioma surgery near the language area, especially for patients with unsuitable conditions for awake craniotomy.