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Background and Purpose: High blood pressure increases bleeding risk during treatment with antithrombotic medication. The association between blood pressure levels and the risk of recurrent stroke during long-term secondary stroke prevention with thienopyridines (particularly prasugrel) has not been well studied. Methods: This was a post hoc analysis of the randomized, double-blind, multicenter PRASTRO-I trial (Comparison of Prasugrel and Clopidogrel in Japanese Patients With Ischemic Stroke-I). Patients with noncardioembolic stroke were randomly assigned (1:1) to receive prasugrel 3.75 mg/day or clopidogrel 75 mg/day for 96 to 104 weeks. Risks of any ischemic or hemorrhagic stroke, combined ischemic events, and combined bleeding events were determined based on the mean level and visit-to-visit variability, including successive variation, of systolic blood pressure (SBP) throughout the observational period. These risks were also compared between quartiles of mean SBP level and successive variation of SBP. Results: A total of 3747 patients (age 62.1±8.5 years, 797 women), with a median average SBP level during the observational period of 132.5 mm Hg, were studied. All the risks of any stroke (146 events; hazard ratio, 1.318 [95% CI, 1.094–1.583] per 10-mm Hg increase), ischemic stroke (133 events, 1.219 [1.010–1.466]), hemorrhagic stroke (13 events, 3.247 [1.660–6.296]), ischemic events (142 events, 1.219 [1.020–1.466]), and bleeding events (47 events, 1.629 [1.172–2.261]) correlated with increasing mean SBP overall. Similarly, an increased risk of these events correlated with increasing successive variation of SBP (hazard ratio, 3.078 [95% CI, 2.220–4.225] per 10-mm Hg increase; 3.051 [2.179–4.262]; 3.276 [1.172–9.092]; 2.865 [2.042–4.011]; 2.764 [1.524–5.016], respectively). Event rates did not differ between the clopidogrel and prasugrel groups within each quartile of SBP or successive variation of SBP. Conclusions: Both high mean SBP level and high visit-to-visit variability in SBP were significantly associated with the risk of recurrent stroke during long-term medication with either prasugrel or clopidogrel after stroke. Control of hypertension would be important regardless of the type of antiplatelet drugs. Registration: URL: https://www.clinicaltrials.jp ; Unique identifier: JapicCTI-111582.

Background: Patients with minor acute ischemic stroke or transient ischemic attack are at high risk for subsequent stroke, and more potent antiplatelet therapy in the acute setting is needed. However, the potential benefit of more intense antiplatelet therapy must be assessed in relation to the risk for major bleeding. The SOCRATES trial (Acute Stroke or Transient Ischemic Attack Treated With Aspirin or Ticagrelor and Patient Outcomes) was the first trial with ticagrelor in patients with acute ischemic stroke or transient ischemic attack in which the efficacy and safety of ticagrelor were compared with those of aspirin. The main safety objective was assessment of PLATO (Platelet Inhibition and Patient Outcomes)–defined major bleeds on treatment, with special focus on intracranial hemorrhage (ICrH). Methods: An independent adjudication committee blinded to study treatment classified bleeds according to the PLATO, TIMI (Thrombolysis in Myocardial Infarction), and GUSTO (Global Use of Strategies to Open Occluded Coronary Arteries) definitions. The definitions of ICrH and major bleeding excluded cerebral microbleeds and asymptomatic hemorrhagic transformations of cerebral infarctions so that the definitions better discriminated important events in the acute stroke population. Results: A total of 13 130 of 13 199 randomized patients received at least 1 dose of study drug and were included in the safety analysis set. PLATO major bleeds occurred in 31 patients (0.5%) on ticagrelor and 38 patients (0.6%) on aspirin (hazard ratio, 0.83; 95% confidence interval, 0.52–1.34). The most common locations of major bleeds were intracranial and gastrointestinal. ICrH was reported in 12 patients (0.2%) on ticagrelor and 18 patients (0.3%) on aspirin. Thirteen of all 30 ICrHs (4 on ticagrelor and 9 on aspirin) were hemorrhagic strokes, and 4 (2 in each group) were symptomatic hemorrhagic transformations of brain infarctions. The ICrHs were spontaneous in 6 and 13, traumatic in 3 and 3, and procedural in 3 and 2 patients on ticagrelor and aspirin, respectively. In total, 9 fatal bleeds occurred on ticagrelor and 4 on aspirin. The composite of ICrH or fatal bleeding included 15 patients on ticagrelor and 18 on aspirin. Independently of bleeding classification, PLATO, TIMI, or GUSTO, the relative difference between treatments for major/severe bleeds was similar. Nonmajor bleeds were more common on ticagrelor. Conclusions: Antiplatelet therapy with ticagrelor in patients with acute ischemic stroke or transient ischemic attack showed a bleeding profile similar to that of aspirin for major bleeds. There were few ICrHs. Clinical Trial Registration: URL: http://www.clinicaltrials.gov . Unique identifier: NCT01994720.

Echographic examination for leg vein thromboembolism was carried out in 123 patients scheduled for thoracic surgery. Preventive measures for thromboembolism were conducted after the risk assessment. Echography was done after surgery in 72 cases, most of which were cases of lung malignant tumors, and thromboembolism was detected in 4 cases. Thus, the incidence rate of venous thromboembolism was 5.6%( 4/72). There was no patients who developed pulmonary thromboembolism during the examination period, suggesting reasonable risk assessment and preventive measures in our procedure.

Objective Deep intracerebral hematoma (ICH) is frequently associated with microbleed (MB) arising from degenerated MB. Increased numbers of MB are correlated with increased age, and we examined a possible relationship between MB number and ICH onset in younger patients. Methods Excluding patients with ICH and a history of ICH, we examined the number of MB and other risk factors in 195 patients with deep ICH (97 male, 98 female) consecutively admitted to our hospital. The patients were equally divided into 3 subgroups according to age (groups A, B, and C). Odds ratios were estimated from logistic regression analyses. Results The number (percentage) of MB in group A (≤60 years old, n=64) 5.0 ± 9.6 (65.6%) was less than group B (61-69 years old, n=63) 6.6 ± 9.1 (79.4%) or group C (≥70 years old, n=68) 6.0 ± 7.0 (86.8%). Multivariate analyses demonstrated that MB greater than or equal to 3 was significantly associated with higher age in group A versus B (odds ratio: 2.3; 95% confidence interval: 1.01-5.3; P = .046) and in group A versus C (odds ratio: 2.6; 95% confidence interval: 1.1-6.2; P =.030). Conclusions Our findings suggest that risk factors for the development of ICH may differ with age, and younger patients with deep ICH have fewer MB.

Background and Purpose. Dot-like low intensity spots (dot-like hemosiderin spots: dotHSs) on gradient echo T2*-weighted MRI have been histologically diagnosed to represent old cerebral microbleeds associated with microangiopathies. They have also been correlated to the fragility of small vessels and the tendency to bleed. Therefore, a substantial number of dotHSs might be associated with a large-sized, deep intracerebral hematoma (ICH). On the other hand, dotHSs may reflect old microbleeds that did not enlarge to symptomatic size. Methods. To investigate how dotHSs are related to the size (maximal diameter) of primary deep ICH, we analyzed the diameter and the number of dotHSs in 151 patients with deep ICH not associated with subarachnoid hemorrhage or intraventricular hemorrhage (75 males and 76 females, age ranged from 37 to 90 [65.7 ± 11.3 years old] who were consecutively admitted to Hakodate Municipal Hospital. The hazard ratio (HR) for a maximal diameter of deep ICH ≤2 cm was estimated, using the number of dotHSs and risk factors for stroke. Results. The number of dotHSs associated with the diameter ≤2 cm was 9.2 ± 11.5, significantly larger than that with the diameter ≥2 cm (4.7 ± 7.0, P= .012). Multivariate analysis revealed that a maximal diameter of deep ICH of ≤2 cm was found in patients with dotHS (HR, 3.7; 95% confidence interval [CI], 1.4-10.1; P= .009). Conclusion. Though small sample size limited the power of our analyses, these findings suggest that the number of dotHSs may be associated with a small diameter of deep ICH.

Background and purpose Microangiopathy, a disorder often related to hypertension, is an important cause of deep intracerebral hematoma (ICH). The microangiopathy is associated with dot-like low-intensity spots (a dot-like hemosiderin spot: dotHS) on gradient-echo T2*-weighted MR images that have been histologically diagnosed as old microbleeds. The locations of dotHS are consistent with deep ICH. Methods To investigate how dotHS or other risk factors contribute to nonhypertensive deep ICH, the number and location of dotHSs, as well as other risk factors were examined in 213 deep ICH patients (106 males, 107 females, age: 37-94 (65.8 +/- 11.2) years) consecutively admitted to Hakodate Municipal Hospital. Patients were divided into two subgroups according to the presence or absence of hypertension. DotHSs were also divided into deep and subcortical dotHS and investigated independently. Odds ratios (ORs) were estimated from logistic regression analyses. Furthermore, nonhypertensive ICH patients were compared with nonhypertensive healthy volunteers matched for age and sex. Results No risk factors were identified in the 31 nonhypertensive deep ICH patients that differed from those found in the 182 hypertensive deep ICH patients. Deep dotHS > or = 1 (OR: 25.5; 95% CI: 4.76-137; P = .0002), subcortical dotHS > or = 1 (OR: 9.0; 95% CI: 1.79-44.9; P = .046), diabetes mellitus (OR: 9.0; 95% CI: 1.53-52.3; P = .015), and smoking (OR, 9.6; 95% CI; 1.8-49.8, P = .007) significantly elevated the risk of nonhypertensive ICH, compared to the healthy volunteers. Conclusions Our findings suggest that deep and subcortical dotHSs may be risk factors for the development of non-hypertensive deep ICH.

A 58-year-old male presented with severe consciousness disturbance and left hemiparesis. Computed tomography (CT) revealed subarachnoid hemorrhage (SAH) and acute subdural hematoma caused by a ruptured right middle cerebral artery aneurysm. The aneurysm was clipped and the hematoma was evacuated. The patient had almost recovered without new neurological deficits on the next day. Arterial systolic blood pressure was postoperatively controlled within 120 to 150 mmHg. Continuous ventricular and cisternal drainage from the level 10 cm above the external auditory meatus was performed to drain bloody cerebrospinal fluid and prevent vasospasm. Three days after surgery, the patient suddenly lapsed into a coma. CT demonstrated diffuse SAH and bilateral intraventricular hemorrhage caused by rupture of an anterior communicating artery aneurysm. Neck clipping was performed immediately. Unfortunately, the patient died of primary damage due to SAH 3 days after the second surgery. In this case, cisternal drainage was probably important in the aneurysm rupture because of decreased intracranial pressure and change in the perianeurysm environment. Postoperative management of patients with residual untreated aneurysms must consider the possibility that cisternal drainage may result in higher transmural pressure, leading to rupture of the untreated aneurysms.

BACKGROUND AND PURPOSE Lipohyalinosis is considered an important cause of cerebral small vessel disease (SVD), including hypertensive intracerebral hematoma (ICH) and lacunar infarction. Dot-like low-intensity spots (dot-like hemosiderin spots [dotHSs]) on gradient-echo T2*-weighted (T2*-w) magnetic resonance imaging (MRI) have been histologically diagnosed as old microbleeds associated with microangiopathies (lipohyalinosis, amyloid angiopathy) and located in territories of perforating arteries (deep dotHSs) and subcortical regions (subcortical dotHSs). If dotHSs indicate the severity of lipohyalinosis, larger numbers of deep dotHSs may be associated with past history of SVD. METHODS The number of dotHSs was investigated in 213 patients with deep ICH (106 men, 107 women, 37 to 94 years old, mean age = 65.8 +/- 11.2 years). Patients were divided into 2 subgroups according to past history of SVD. Odds ratio (OR) for the history was estimated from logistic regression analyses of the number of deep or subcortical dotHSs, as well as other factors. RESULTS Of 213 patients, 36 had a past history of SVD (symptomatic deep ICH in 18, symptomatic lacunar infarction in 17, and both in 1). An increased rate of history of SVD was found for patients with subcortical dotHSs. The OR per 1 subcortical dotHS was 1.09 (95% confidence internal (CI), 1.03-1.17; P =.005), and per deep dotHS, the OR was 1.07 (95% CI, 1.00-1.13; P =.039). CONCLUSIONS The findings suggest that deep and subcortical dotHSs on T2*-w MRI may indicate the severity of microangiopathy and may predict recurrence of SVD in patients with deep ICH.

Object. The cause and indication for enlargement of chronic subdural hematomas (CSDHs) have remained unresolved. The authors observed a black band on the inner membrane of a CSDH on T2*-weighted magnetic resonance (MR) images obtained in patients with symptoms. After surgical treatment, the band disappeared. The T2*-weighted sequence of MR imaging is an excellent diagnostic tool for detecting ferromagnetic substances, but it is rarely performed in cases of a CSDH. The authors speculate that the black band may be associated with the development of CSDH. Methods. To investigate how the black band observed on T2*-weighted MR images contributes to the development of a CSDH, 59 lesions in 50 patients with CSDH (41 men and nine women, mean age 70 ± 11 years [range 48–93 years]) were investigated prospectively. The incidence of black bands on the first T2*-weighted MR image obtained in patients with symptomatic CSDH was 97% (31 of 32 CSDHs), which was significantly higher than that associated with asymptomatic CSDH (11% [three of 27 CSDHs], p < 0.001). The black bands associated with symptomatic CSDH disappeared soon after surgical treatment in 31 CSDHs and became fainter in another. In two instances the CSDH recurred with reappearance of the band. Twenty-four of 27 asymptomatic CSDHs had no accompanying black band. Follow-up MR images demonstrated a later formation of bands in two of 24 asymptomatic CSDHs that enlarged to symptomatic size. Logistic regression analysis revealed that the heterogeneity and thickness of the CSDH on computerized tomography scans were independently and significantly associated with the black band. Conclusions. The dynamics of the black band may depend on the enlargement or shrinkage of the CSDH.

We report here a case of a primitive neuroectodermal tumor involving the frontal skull base in a 5-month-old male infant. He presented with rapidly progressing exophthalmos on the left side. Preoperative magnetic resonance imaging revealed a well-demarcated, enhanced mass of 6 cm in diameter in the intradural extra-axial frontal region. The tumor was totally removed by surgery. Pathological findings were consistent with a primitive neuroectodermal tumor (PNET). Intradural extra-axial PNET is very rare, and its prognosis is poor.

BACKGROUND Spinal dural arteriovenous fistulas are abnormal arteriovenous connections on the surface of the dura. The site of the fistula is most commonly in the thoracic and lumbosacral regions and they are rarely located in the cervical region. CASES The patients had two asymptomatic dural arteriovenous fistulas of the cervicomedullary junction fed by the left posterior meningeal artery and draining to the dilated coronal venous plexus and the radiculomedullary vein. RESULTS The lesions were successfully treated by surgical interruption of the intrathecal vein with coagulation via a suboccipital transcondylar approach and a condylar fossa approach. Both patients left the hospital without significant deficits. CONCLUSIONS We recommend that dural arteriovenous fistulas in the cervical region be surgically treated.

The authors observed dotlike, low-intensity spots in T2*-weighted magnetic resonance imaging (MRI), subsequently diagnosed histologically as previous microbleeds associated with lipofibrohyalinosis, amyloid angiopathy, and small vessel disease. The nature of dotlike hemosiderin spots (dotHSs), however, is still unknown. This case report seeks to demonstrate the dynamics of dotHSs associated with an intracerebral hematoma (ICH). T2*-weighted MRI of a 72-year-old man with a history of hypertension demonstrated 4 dotHSs 24 months after a left putaminal hemorrhage. Follow-up T2*-weighted MRI 40 months after the acute event demonstrated the asymptomatic formation of 3 more dotHSs, even with good control of blood pressure. Fifty months after the stroke, T2*-weighted MRI showed that 2 of the new dotHSs had become fainter, whereas the hemosiderin associated with the ICH scar remained detectable. To the authors' knowledge, this is the first description of dotHS dynamics associated with ICH.

A prototype knowledge-based diagnostic system for understanding the problems in prestressed concrete bridges is presented. The object-oriented approach is used for the system development. The system is completely interactive, making extensive use of pictures and diagrams along with textual explanation to explain difficult concepts in a multilingual environment. The system compares the new case of damage with the various types of damages that are stored in the knowledge base. It explains to the user the details of design and construction that may lead to this damage and the related repair methods. The system indicates the applicability of textual and pictorial explanations in developing an environment for the diagnosis of problems in prestressed concrete bridges.

A 9-year-old girl underwent total removal of a cerebellar astrocytoma complicated by hydrocephalus after postoperative meningitis, requiring a ventriculoperitoneal shunt. Five months later, headache, vomiting, and gait disturbance appeared and computed tomography detected enlarged fourth ventricle. A fourth ventriculoperitoneal shunt resulted in immediate relief of all symptoms. After 2 months, obstruction of the peritoneal tube required shunt reconstruction. This recurred three times in 8 months. At the last operation, tumor cells were detected in the cerebrospinal fluid and the substance clogging the tube. This suggested that the tumor had recurred and clogging by tumor cells had caused the repeated episodes of isolated fourth ventricle. Radiation therapy prevented further shunt obstruction and achieved remission of all signs and symptoms.

We report a rare case of postoperative infarction in the territory of the contralateral recurrent artery of Heubner (RAH) after surgery. A 67-year-old male was treated by the right pterional approach with clipping surgery for an unruptured anterior communicating artery aneurysm projecting inferiorly. Postoperative CT scan revealed infarctions in the left caudate head and the left putamen. In this case, the RAH probably coursed inferiorly to the A1 segment and was behind the aneurysmal dome. These infarctions were considered to result from occlusion of the left RAH because the clip blade extended too far beyond the aneurysmal neck.

A 72-year-old male was admitted with subarachnoid hemorrhage associated with a ruptured cerebral aneurysm. The aneurysm was treated with clipping soon after radiological examination. Eight weeks after the treatment, the patient suffered from secondary hydrocephalus resulting from blockage of the subarachnoid space due to subarachnoid granulation. Previous pathological examination revealed the granulation was associated with hemosiderin deposition. We investigated subarachnoid hemosiderin deposition in this patient using T2*-weighted (T2*-w) magnetic resonance image (MRI), a sensitive method for hemosiderin detection. computed tomography (CT) cisternography demonstrated that cerebrospinal fluid (CSF) flow was disturbed adjacent to sites of subarachnoid hemosiderin deposition on T2*-w MRI. Placement of a ventriculo-peritoneal shunt contributed to neurological improvement. In this case, T2*-w MRI was an effective means of diagnosing the location of disturbed CSF flow associated with subarachnoid hemosiderin deposition.

The problem of non-proportionality between the substituent field parameter (σF) and substituent electronegativity (Δι or σχ) was clarified by the introduction of the ‘charge-separation parameter’ (λ), which is the component for the direction of the HX axis of the distance between positive and negative poles of the dipole in the HX molecule. Thus σF was correlated with Δι or σχ by the equation σF = aΔιλ (or σF = a′σχλ). The above proposal was further supported by performing an energy decomposition analysis for the isodesmic reaction in the isolated molecule system ( or XH…HCO) at shorter distances (2·0–4·5 A). It was further shown that field parameters such as σi, F and σF(theor), and the pKa values in the series of aliphatic acids, and spectral data (UPS and 13C-SCS) were also well correlated with Διλ or σχλ. It is concluded that λ and Δι or σχ are essential parameters for interpreting the electrostatic field effect in aliphatic substituent effects, and that the transmission due to the σ-inductive effect is considered to be not as significant as the field effect after a few bonds away from the substituent.

BACKGROUND AND PURPOSE Dot-like low-intensity spots (dot-like hemosiderin spots: dotHSs) on gradient echo T2*-weighted (-w) brain magnetic resonance imaging (MRIs) are frequently associated with cerebral small vessel disease (SVD), including deep intracerebral hemorrhages and lacunar infarctions. This study investigated how numbers of newly appeared dotHSs contribute to recurrent SVD. METHODS We prospectively analyzed numbers of newly appeared dotHSs in 12 patients with prior SVD (8 males, 4 females; mean 67.6 +/- 10.7 years old) readmitted with recurring SVD between October 2001 and March 2003. Numbers of appeared dotHSs per year were counted on T2*-w MRI scans after SVD recurrence and compared to previous MRIs. Seventy-one outpatients (35 males, 36 females; mean 64.3 +/- 9.6 years old) with histories of intracerebral hemorrhages (ICH) that came to the hospital during the study period served as controls. The hazard ratio (HR) for recurrence was estimated from a multivariate logistic regression model, using the number of appeared dotHSs (per year) and other risk factors. RESULTS Multivariate analyses revealed that an elevated rate of recurrence was found in patients with substantial numbers of appeared dotHSs (>or=5/year) (HR, 7.34; P= 0.0008). We also analyzed factors associated with the numbers of appeared dotHSs. A number of appeared dotHSs (>or=5/year) was significantly and independently associated with the initial number of dotHSs (>or=10) on T2*-w MRIs following the first SVD (HR, 18.6; P= 0.0001). CONCLUSIONS Though a small sample size limited the power of our analyses, our findings suggest that a number of newly appeared dotHSs may be associated with SVD recurrence.

ment of hypertension reduces the risk of ischaemic Patients were eligible for inclusion if they were stroke.[4-10] Moreover, a BP reduction in subacute admitted to Hakodate Municipal Hospital with and chronic stroke may also prevent lipohyalinosis symptomatic lacunar infarction from October 2000 and other vascular lesions associated with stroke. to September 2001. Infarctions were 90mm Hg or a systolic BP of >150mm Hg 3 weeks the lower limit of CBF autoregulation downwards in after the onset of lacunar infarction. Patients with spontaneously hypertensive rats.[16] Amlodipine lacunar infarction associated with embolism (exdoes not significantly affect relative indices of CBF cluding atrial fibrillation or ulcerations of the cerviin elderly hypertensive patients after BP lowering[17] cal internal carotid arteries) or lacunar infarction and it reduces the rate of carotid artery atherosclerorelated to the stenosis of a main trunk of a cerebral sis.[18] BP lowering with amlodipine has been shown artery, as determined by magnetic resonance angioto reduce stroke occurrence.[9] Such findings suggest graphy and/or digital subtraction angiography, were that amlodipine may be a suitable antihypertensive excluded. medication for elderly patients with acute stroke. Written informed consent was obtained from In our experience, reduction of systolic/diastolic either the patient or their closest relative. The study BP to normal (

A 75-year-old female with history of putamenal hemorrhage 8 years earlier was admitted to our hospital with generalized convulsion lasting 40 minutes. Convulsion responded quickly to intravenous administration of diazepam, but deep coma persisted thereafter. Although renal function had normalized before this episode, urinary output was immediately estimated to be limited. Drip-infusion of Ringer's solution and the combined administration of furosemide and mannitol were started. The laboratory values 6 hours after admission demonstrated extremely elevated GOT, GPT, CPK, BUN and Cr levels, suggesting rhabdomyolysis. Urinalysis confirmed myoglobinuria. Despite massive diuretic therapy, renal dysfunction did not improve and she died on hospital day 4. The treatment outcome was probably influenced by her general condition of dehydration and acidosis at admission, as well as muscle damage caused by convulsion. Myoglobinuria can induce life-threatening renal failure, and may be caused by convulsion.

Objective and importance Acquired factor VIII inhibitors in patients without hemophilia is rare event characterized by severe bleeding as a result of antibody against factor VIII. We describe a patient who developed subcutaneous and epidural bleeding after the clipping of an unruptured aneurysm. Clinical presentation A 57-year-old man suddenly developed coagulopathy after undergoing a neurosurgical operation. Coagulation tests showed a prolongation of activated partial thromboplastin time and a marked reduction in factor VIII activity. Measurement of the factor VIII inhibitor level revealed 2 Bethesda units/ml. Intervention The hematoma was removed surgically, and bleeding was controlled with recombinant factor VIII. The patients then received prednisolone (80 mg/d) and cyclosporine. The laboratory tests normalized within 8 weeks. In the 5 years since cessation of corticosteroids, the clinical and laboratory courses of the patient have been uneventful. Conclusion Autoimmune factor VIII inhibitors associated with a neurosurgical procedure are rare. Our case supports an association between surgery and the triggering of factor VIII inhibitors. This complication was probably the result of the surgical procedure or anesthetic agents or other drugs administrated during the perioperative period.

A 58-year-old male presented with severe consciousness disturbance and left hemiparesis. Computed tomography (CT) revealed subarachnoid hemorrhage (SAH) and acute subdural hematoma caused by a ruptured right middle cerebral artery aneurysm. The aneurysm was clipped and the hematoma was evacuated. The patient had almost recovered without new neurological deficits on the next day. Arterial systolic blood pressure was postoperatively controlled within 120 to 150 mmHg. Continuous ventricular and cisternal drainage from the level 10 cm above the external auditory meatus was performed to drain bloody cerebrospinal fluid and prevent vasospasm. Three days after surgery, the patient suddenly lapsed into a coma. CT demonstrated diffuse SAH and bilateral intraventricular hemorrhage caused by rupture of an anterior communicating artery aneurysm. Neck clipping was performed immediately. Unfortunately, the patient died of primary damage due to SAH 3 days after the second surgery. In this case, cisternal drainage was probably important in the aneurysm rupture because of decreased intracranial pressure and change in the perianeurysm environment. Postoperative management of patients with residual untreated aneurysms must consider the possibility that cisternal drainage may result in higher transmural pressure, leading to rupture of the untreated aneurysms.

Dotlike hemosiderin spots ongradient-echo T2(*)-weighted magnetic resonance imaging of the brain have been histologically diagnosed as old microbleeds associated with small vessel disease (SVD). The authors hypothesize that the presence of many dotHSs may be correlated with the fragility of small vessels and the recurrence of SVD, including lacunar infarction and deep intracerebral hemorrhage (ICH).To investigate how dotHSs are related to past history of SVD, the number of subcortical or deep dotHSs was investigated in 146 patients with lacunar infarctions (95 men, 51 women, age 38 to 90 [66.6+/-9.4] years). They were divided into 2 subgroups according to history of deep ICHs or lacunar infarctions. The odds ratio (OR) for past history was estimated from logistic regression analyses with the number of subcortical or deep dotHSs as well as other factors.Of 146 patients with lacunar infarctions, 11 had past symptomatic ICHs and 19 had past symptomatic lacunar infarctions. An elevated rate of history of ICH was found for lacunar infarction patients with many deep dotHSs (or=3; OR, 9.1; 95% confidence interval, 1.6-51, P=.015). However, history of lacunar infarction was not significantly associated with the number of subcortical or deep dotHSs.Our findings suggest that many deep dotHSs on T2(*)-weighted magnetic resonance imaging may be correlated with deep ICH-lacunar infarction type of SVD recurrence but not lacunar infarction-lacunar infarction type.

Object. Microangiopathy associated with hypertension is a notable cause of cerebral small vessel disease (SVD), including deep intracerebral hemorrhage (ICH) and lacunar infarct. Dotlike low-intensity spots (dotlike hemosiderin spots: dotHSs) on T2*-weighted magnetic resonance (MR) images have been histologically diagnosed as old cerebral microbleeds associated with lipohyalinosis, amyloid angiopathy, or other microangiopathies and located in deep or subcortical regions. The aim of this study was to determine whether dotHSs indicate the severity of microangiopathy, and if so, whether large numbers of deep dotHSs are associated with SVD recurrence. Methods. The authors prospectively analyzed the number of dotHSs in 337 patients—191 men and 146 women with a mean age of 66 ± 10.4 years (range 37–94 years)—with SVD (199 ICHs and 138 lacunar infarcts) who had been consecutively admitted to Hakodate Municipal Hospital. The follow-up period was 3.5 to 42 months (22.5 ± 13.1 months). Patients were divided into two groups based on the recurrence. The hazard ratio (HR) for recurrence was estimated based on the Cox proportional hazard model by using the number of deep and subcortical dotHSs as well as other factors. Of 337 patients, 20 were readmitted with recurrence. Results of a multivariate analysis revealed an elevated rate of recurrence in patients with many subcortical dotHSs (≥ 5, HR 4.36, p = 0.0019) or a history of ICH (HR 3.82, p = 0.014). A trend toward a positive correlation (Pearson correlation coefficient 0.548, p < 0.0001) was found between the number of deep and subcortical dotHSs. Conclusions. Although a small sample size limited the power of analyses, the findings indicate that a large number of subcortical dotHSs may predict SVD recurrence.

We have observed dot-like low intensity spots (a dot-like hemosiderin spot: dotHS) on T2*-weighted (T2*-w) MRI, subsequently diagnosed histologically as previous microbleeds associated with lipohyalinosis, amyloid angiopathy and cerebral small vessel disease (SVD) including an intracerebral hematoma (ICH) and a lacunar infarction. According to the literature, primary aldosteronism (PA), characterized by hypertension, is related to SVD. A 49-year-old female with a long history of untreated hypertension secondary to PA was admitted to our hospital for medical examinations on July 18th, 2000. She had the stepwise development of dementia, dysarthria and gait disturbance (right hemiparesis). CT and MRI demonstrated multiple lacunar infarctions. She was readmitted to our hospital on Jan 23rd, 2002. A neurological examination revealed right hemiparesis, dysarthria and consciousness disturbance. CT on admission demonstrated ICH in the left midbrain. Six days after the hemorrhage, T2*-w MRI showed thirty-two dotHSs in the basal ganglias and the cortical-subcortical regions. The incidence of ICH in patients with hypertension secondary to PA is reported to be higher than in patients with essential hypertension. Multiple dotHS may be associated with ICH, lacunar infarction, and severe microangiopathy related to hypertension secondary to PA.

A 55-year-old woman first underwent total thyroidectomy in 1973, and the histopathology was medullary thyroid carcinoma. There was no familial history of endocrine neoplasm. She remained asymptomatic for the next 19 years. Neck and tracheal recurrence was treated with tracheal stent and radiation, in 1997. On July 1998, she presented with headache. Magnetic resonance imaging revealed a gadolinium enhanced mass in the left inferior temporal gyrus. Angiogram revealed a marked tumor stain feeding from the middle and inferior temporal artery. The tumor was successfully excised via a temporal craniotomy. Histopathological sections of the resected specimen confirmed the diagnosis, it demonstrated the medullary pattern that was composed of vascular stroma and clumps of cells. Immunocytochemistry, using carcino-embryonic antigen and calcitonin showed a strongly positive reaction, and MIB-1 was 5.4%. The patient subsequently underwent a course of whole brain radiotherapy, a total of 30 Gy/10 fr. She remains asymptomatic 14 months after treatment. Brain metastasis from medullary carcinoma of the thyroid is extremely rare and it does not usually occur distant spread. Thyroid carcinoma with brain metastasis tends to be identified in patients with older age, larger primary tumor, more frequent evidence of extrathyroidal invasion, and more aggressive histologies. The number of medullary thyroid carcinoma with brain metastasis is small and there has been little evidence from benefit of therapy. Neither is it clear wether radiation therapy is beneficial also is not clear. In this case, surgical resection and radiation therapy was effective against recurrence of other lesion.

Background and Purpose— Subarachnoid hemorrhage (SAH) is very difficult to diagnose several months after its onset. We thus investigated subarachnoid hemosiderin deposition well after SAH by T2*-weighted MRI, a sensitive method for hemosiderin detection. Methods— To investigate how hemosiderin deposition as confirmed by T2*-weighted MRI contributes to the determination of prior SAH and how the extent of hemosiderin deposition is associated with a number of clinical factors, we retrospectively analyzed 58 patients >3 months after SAH associated with ruptured aneurysms. We also investigated 209 healthy volunteers as controls. Results— T2*-weighted MRI demonstrated subarachnoid hemosiderin deposition in 72.4% of the SAH patients, whereas no deposition was seen in the healthy volunteer group. The hemosiderin was preferentially deposited in the subarachnoid space near a ruptured aneurysm. Odds ratios (ORs) were estimated from logistic regression analyses correlating hemosiderin deposition with other factors. Age (≥54 years) (OR, 5.1; 95% CI, 1.03 to 25.0; P =0.046), Fisher grade 3 on initial CT (OR, 8.0; 95% CI, 1.26 to 50.4; P =0.027), and Karnofsky Scale score ≤80% 6 months after onset of SAH (OR, 12.8; 95% CI, 1.97 to 83.3; P =0.0077) were all found to be independently associated with hemosiderin deposition levels. Conclusions— T2*-weighted MRI is an effective means of diagnosing prior SAH and may also reveal the location of a ruptured aneurysm. The extent of hemosiderin deposition was significantly associated with several factors, including age, CT findings, and poor prognosis.

Dot-like low intensity spots (a dot-like hemosiderin spot: dotHS) on T2*-weighted MR images (T2*WI), which is regarded as a sensitive method for hemosiderin detection, have been histologically diagnosed as old microbleeds associated with microangiopathies. The clinical significance of the dotHS, however, is still under debate. Therefore, we investigated the factors associated with dotHS.We investigated 209 healthy volunteers in our hospital (sex: 106 males, 103 females; age: 38 to 78 years old, mean age: 56.4 +/- 8.3 years old) using "Brain Dock", a formalized screening system for asymptomatic brain diseases. The Odds ratio (OR) was estimated from multiple logistic regression analyses using the dotHS and variables.T2*WI demonstrated dotHS in 7.7% of volunteers, and the mean number of dotHS was 0.16 +/- 0.78. The hemosiderin was preferentially deposited in the basal ganglia and thalamus. Ageor = 65 years old (OR: 5.9; 95% confidence interval [CI]: 1.4-25.9; p = 0.02), hypertension (OR: 7.0; 95% CI: 1.4-34.7; p = 0.02), and headache (OR: 5.8; 95% CI: 1.4-24.6; p = 0.02) were all found to be independently associated with dotHS.The dotHS was significantly associated with several factors, including age, hypertension and headache.

Cerebral fat embolism (CFE) is serious complication of a long-bone fracture. We reported magnetic resonance (MR) diffusion-weighted (DWI) and fluid attenuated inversion recovery (FLAIR) images in a patient suffered with CFE. A 26-year-old man with a right femoral bone fracture lapsed into a semicoma eight hours later. Eighteen hours after the depressed consciousness, DWI and FLAIR images on MR imaging showed multiple high-intensity spots in corona radiata, basal ganglia, thalamus, corpus callosum, brain stem and cerebellum. Thereby, he was diagnosed as CFE. These multiple lesions were more detectable on FLAIR images than DWI, particularly in posterior fossa. Eight days after the onset, follow-up DWI, FLAIR, and T 2-weighted MR image (T 2 WI) showed most of the lesions disappeared or shrunk. The resolution of the lesions suggests that most of the lesions were brain edema as a result of the unique pathophysiological condition of CFE. The remained lesions were diagnosed as cerebral infarctions. The consciousness of the patient improved alert. Three months later, follow-up MRI showed almost complete resolution of the abnormal intensities. Follow up DWI and FLAIR images observed in the patient indicated that many small lesions occurs throughout the whole brain without a preferential region, and many of the lesions can subside or attenuate in CFE.

Two thirds of patients suffer from moderate to severe pain after frontotemporal craniotomy. We think neurosurgeons must try to reduce the postoperative pain, which may induce postoperative hypertension, restlessness, and pathological pains. To investigate how preemptive analgesia effects postoperative pain, we assessed the pain in 20 consecutive patients who underwent neck clipping for non-ruptured cerebral aneurysms of anterior circulation systems by frontotemporal craniotomies. Ten patients underwent preemptive analgesia with four procedures (preemptive group) as follows, 1) oral administration of long-acting non-steroid anti inflammatory drug (NSAID, ampiroxicam) two hours before the surgical operation, 2) nerve blockades of the supra-orbital nerve and the infra-orbital nerve by bupivacaine, 3) local anesthesia of the scalp along the marker of a skin incision by xylocaine, 4) local anesthesia by bupivacaine along a skin incision after the skin closure. Ten patients of the control group underwent only procedure No. 3. Visual analog pain score (VAS) for postoperative pain 6, 12, and 24 hours, and 3, 5, 7, and 14 days after operation and NSAID administration for the pain were evaluated. Patients of the preemptive group had significantly less postoperative pain during the whole post-surgery period and required less administration of NSAID than the control group. Preemptive analgesia procedures No. 1, 2 and 4 reduced the postoperative pain and the total administration of NSAID. Postoperative pain may be reduced after other types of brain surgery, with proper nerve blocks like procedure No. 2, procedures No. 1, 3 and 4.

Background Dural sinus thrombosis is a relatively rare syndrome, often with a very poor prognosis. Systemic anticoagulant therapy has produced poor results; therefore rapid recanalization of the affected vessels is essential. The recent advancements in angiographic technique and catheter technology enable us to perform direct selective venography. Case report We observed a case of acute superior sagittal sinus thrombosis in a pregnant woman. The patient’s consciousness level and motor function gradually deteriorated. Direct thrombolysis was performed via venography. Results The patient was treated successfully by thrombolysis with infusion of t-PA via selective venography within 2 days of rapid clinical deterioration and sustained a dramatic improvement of her neurological deficits. Conclusions Direct thrombolysis via selective venography is considered a safe and useful treatment for dural sinus thrombosis in the acute phase.

A very rare case of a large-sized brain metastasis of lung cancer without perifocal edema is reported. This case suggested that the degree of perifocal edema may depend on the localization of the tumor.

The diamagnetic contribution of the hydrogen atom, in the C–H bond and that from its bonded carbon have been semi-empirically expressed. By considering the “ring-current” effect in addition to such contributions, a semi-empirical expression has been obtained for 1H chemical shifts relative to the unsubstituted compound in substituted aromatic side-chains. The applicability of the expression has been examined for m- and p-substituted phenylacetylenes, styrenes, toluenes, and benzaldehydes.

The contributions to 13C shifts from the diamagnetic term of the neighboring carbon atom and from the “ring-current” have been estimated by means of the equations given in a previous paper (J. Niwa, Bull. Chem. Soc. Jpn., 48, 118 (1975)). A semi-empirical expression has been derived for the substituent-induced 13C chemical shift in an aromatic side chain by considering such contributions in addition to the local diamagnetic and paramagnetic terms of the carbon atom in question. The applicability of the expression has been examined for α-carbons of 4-substituted derivatives of styrenes and α-methylstyrenes, and for 1′-carbons of 4-substituted biphenyls.

A semi-empirical equation for predicting the 1H chemical shift induced by substituents in an aromatic system (J. Niwa, Bull. Chem. Soc. Jpn., 48, 118, 1637 (1975)) has been applied to the ring protons of 1-substituted naphthalenes. The predictions of the equation are tested against the available experimental data for six representative substituents and are also compared with those of the electric-field model.

Linear relationship between substituent electronegativity parameter (Δl or γX) and field parameter (γI(g)) was obtained by using the charge separation parameter (λ) between positive and negative poles in H-X molecule calculated by ab initio MO method.

Cultured cells in vitro from estrogen-induced rat prolactin-secreting adenomas (prolactinomas) were examined by indirect immunofluorescence microscopy for the distribution of cytoskeletal proteins and alterations of cytoskeleton after treatment with bromocriptine, colchicine and cytochalasin B (CB). After 8 days in culture, prolactinoma cells were well expanded and developed cytoplasmic processes were seen. The cytoplasmic microtubules were observed as fine reticular networks radiating from perinuclear portions toward the cell periphery when decorated with an antibody against tubulin. On the other hand, the actin filaments showed diffuse and spotty distribution when detected with an anti-actin antibody. Contaminated fibroblasts showed a reticular distribution of microtubules and a parallel array of actin cables which corresponds to "stress fibers" throughout the cytoplasm. After treatment with bromocriptine, the reticular distribution of microtubules in prolactinoma cells changed into a coarse and sparse pattern, which was identical with the changes in the distribution of tubulin after treatment with colchicine. On the other hand, distribution of actin was not affected by bromocriptine. Bromocriptine treatment did not alter the distribution of microtubules and actin filaments in fibroblasts, whereas colchicine changed the distribution of microtubules in both prolactinoma cells and fibroblasts. CB treatment changed the localization of actin filaments in both kinds of cells. These in vitro studies indicated bromocriptine would selectively affect the cytoplasmic microtubular system of prolactinoma cells.

An asymptomatic case of a large calcified chronic subdural hematoma was examined. The calcified mass was nearly totally removed at operation using a high-speed air drill. Immediately after the operation signs of brain compression seen in computed tomography scanning were somewhat relieved. However, at follow-up after 3 months, the shift was resumed and the calcification reap-peared 10 months after the operation.

A 65-year-old female with an intracerebral cyst was examined in our clinic. It was suspected to be a cystic glioma by the preoperative neuroradiological studies, even with the use of sophisticated CT techniques. By operative and histopathological examination, it was confirmed as an arachnoid cyst mainly embedded in the parenchyma.

Substituent effects have been modeled using both substituted hydrogens and substituted benzenes perturbed with point charges in order to separate the inductive (field) effect from the mesomeric effect with the use of ab initio techniques. Several pure dipole ‘substituents’ have been introduced to derive the scale of inductive effects common to both aliphatic and aromatic systems. In the above systems the interaction energies have been estimated by dividing into electrostatic interaction and polarization. Calculations with the use of 4-31G basis set show satisfactory correlations with the experimentally determined substituent constants. The propriety of the present approach has also been examined for the gas-phase acidities of phenols.

Ab initio calculations have been carried out for 2,4-dithia- (5), 2,4-dioxa- (6), 6-oxa- (8), 6-thiabicyclo[3.1.0]hexanes (9), bicyclo[3.1.0]hexane (7), and some of the corresponding cyclohexane derivatives 10–12 using 3-21G, 3-21 G(*) and 6-13G* basis sets. Relative total energies and geometries have been obtained for both boat and chair forms of these compounds. The calculated geometries are in good agreement with observed ones for 7–9. The boat form is more stable than the chair form in the bicyclic systems 7–9, while both the forms have almost equal stability for 5 and the chair form of 6 is slightly more stable than the boat form. The relative stability of the boat form in the bicyclic systems compared with that in the monocyclic cyclohexane derivatives can be explained in terms of the stabilizing orbital interaction. Inversion barriers between the boat and chair forms for 5–7 have also been estimated and are briefly discussed. A similar calculation for bicyclo[3.2.0]hept-6-ene also shows that the bo...

The 13C chemical shifts of carboxyl carbons of substituted benzoic acids in dimethyl sulfoxide-d6 show a linear relationship with pKa-values for m- and electron-withdrawing p-substituents, whereas for electron-donating p-substituents they show upfield deviations from the regression line. The chemical shifts are determined by Yukawa–Tsuno’s equation with a negative r-value.

Reactions des derives lithies du dithia-7,9tricyclo [4.3.1.0] decadiene-2,4 et du dimethyl-1,5 dithia-2,4bicyclo [3.1.0] hexane avec des electrophiles tels que le dioxyde de carbone, le benzaldehyde, les halogenures d'alkyles et DCl

A 63-year-old female was admitted with a 5-day history of left hemiparesis. Computed tomography showed an enhanced mass with perifocal edema in the right frontal parasagittal region and an irregular-shaped, high-density mass anterior to the tumor. Right carotid angiography disclosed the prominent middle meningeal artery (MMA) to be the main feeding vessel of the tumor. In the venous phase, the superior sagittal sinus (SSS) was obstructed and a dilated middle meningeal vein (MMV) drained downward to the sphenoparietal sinus. Left carotid angiography demonstrated similar findings. There was a filling defect in the lumen of the MMV due to the MMA running within the vein. At surgery, careful manipulation was required, as the venous blood in the left MMV drained not only from the tumor but also from the anterior half of the SSS. The left MMA was found to run through the cavity of the dilated MMV. The SSS was invaded by tumor. There was an old hematoma cavity containing xanthochromic fluid in the brain parenchyma adjacent to the tumor. Histological examination showed meningothelial meningioma. The postoperative course was uneventful, although the right MMV was opacified on carotid angiography. It was suspected that obstruction of the SSS by tumor invasion had caused dilatation of the bilateral MMV and peritumoral hemorrhage due to disturbance of the venous drainage.