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This study investigated the impact of polymorphisms of metabolic enzymes on plasma concentrations of cilostazol and its metabolites, and the influence of the plasma concentrations and polymorphisms on the cardiovascular side effects in 30 patients with cerebral infarction. Plasma concentrations of cilostazol and its active metabolites, and CYP3A5*3 and CYP2C19*2 and *3 genotypes were determined. The median plasma concentration/dose ratio of OPC-13213, an active metabolite by CYP3A5 and CYP2C19, was slightly higher and the median plasma concentration rate of cilostazol to OPC-13015, another active metabolite by CYP3A4, was significantly lower in CYP3A5*1 carriers than in *1 non-carriers (p = 0.082 and p = 0.002, respectively). The CYP2C19 genotype did not affect the pharmacokinetics of cilostazol. A correlation was observed between changes in pulse rate from the baseline and plasma concentrations of cilostazol (R = 0.539, p = 0.002), OPC-13015 (R = 0.396, p = 0.030) and OPC-13213 (R = 0.383, p = 0.037). A multiple regression model, consisting of factors of the plasma concentration of OPC-13015, levels of blood urea nitrogen, and pulse rate at the start of the therapy explained 55.5% of the interindividual variability of the changes in pulse rate. These results suggest that plasma concentrations of cilostazol and its metabolites are affected by CYP3A5 genotypes, and plasma concentration of OPC-13015, blood urea nitrogen, and pulse rate at the start of therapy may be predictive markers of cardiovascular side effects of cilostazol in patients with cerebral infarction.

Background and importance Traditionally, it has been believed that the plexal segment of the anterior choroidal artery (AChoA) can be sacrificed safely. Here, we present a case of choroid plexus arteriovenous malformation (AVM) in which the capsulothalamic artery originated from distal plexal segment of the AChoA. Clinical presentation A 45-year-old man was diagnosed with arteriovenous malformation involving the left inferior horn in screening MRI. Preceding stereotactic radiosurgery, transarterial target embolization was performed. In this procedure, 20% n-butyl-2-cyanoacrylate (NBCA) was successfully injected from the lateral plexal branch of the AChoA. After embolization, right homonymous hemianopsia developed due to cerebral infarction on the left optic radiation. This infarction was considered to be within the territory of the capsulothalamic artery. Conclusion This anomalous capsulothalamic artery might be formed by hemodynamic compromise of the brain surrounding AVM in early gestation. We must be aware of this unusual anatomical variation to avoid ischemic complication in embolization of the AChoA.

Cerebral aneurysm clipping is a curative surgical procedure. Regrowth of previously clipped aneurysms is rare. Surgical intervention for recurrent aneurysms is more difficult than initial surgeries. In recent years, endovascular treatment may be performed as an effective procedure in such conditions. However, endovascular treatment can be difficult in some cases. Therefore, in some cases, removal of the previous clip can be useful. Removal of the previous clip has several potential advantages. In the current report, we describe a precise technical method and also discussed adaptive cases where removal of previous clips was possible. Keywords: Clip removal, Recurrent cerebral aneurysm, Subarachnoid hemorrhage, Clipping, Surgical technique

Background Dissection of the internal carotid artery (ICA) can cause occlusion or severe stenosis and is known to be one of the major causes of ischemic stroke in the young. Endovascular treatment is one of the useful options for carotid dissections, but passing the guidewire through the occlusion (lesion-cross) and confirmation of the true lumen are sometimes difficult. Case presentation A 40-year-old right-handed man complaining of dysarthria and gait disturbance consulted our hospital. Magnetic resonance imaging and angiography revealed right ICA dissection. Because of worsening symptoms with conservative treatment, we performed endovascular treatment. Prior to the lesion-cross, a microcatheter was navigated to the third segment of the internal maxillary artery and a balloon-guiding catheter was navigated to the proximal ICA. Under balloon occlusion of the ICA, superselective angiography via the ipsilateral maxillary artery and slow evacuation from the balloon-guiding catheter were performed. Thereafter, the course of the true lumen was clearly visualized, and we were able to navigate another microcatheter without difficulty. Subsequently, angioplasty and stent placement were successfully accomplished. Conclusion We presented a case of ICA dissection and demonstrated a novel technique for a safe lesion-cross for occlusive ICA dissection.

Background Cranioplasty is a standard neurosurgical procedure which is performed after decompressive craniotomy. Fatal complications associated with this procedure are not well documented. Here, we report a case of fatal cerebral swelling after cranioplasty and discuss the possible mechanism of this complication. Case description A 64-year-old man was admitted with the diagnosis of cerebral hemorrhage, and emergency surgery for hemorrhage removal and decompressive craniotomy were performed. One month after surgery, cranioplasty was performed using a titanium mesh plate. Sixteen hours after the surgery, the patient became comatose with bilateral dilated pupils followed by blood pressure lowering. Computed tomography of the brain showed bilateral massive cerebral edema. The titanium mesh plate was immediately removed, however, the patient's neurological condition did not recover and he died 7 days after the surgery. We speculated that the negative pressure difference and increase in cerebral blood flow after cranioplasty may have attributed to the fatal cerebral swelling. Conclusion Fatal cerebral swelling after cranioplasty is a rare but devastating complication. Although it is rare, neurosurgeons should keep in mind that this fatal complication can follow cranioplasty.

Background The standard neurosurgical procedure for chronic subdural hematoma is a burr-hole surgery. Postoperative hemorrhage is one of the complications after burr-hole surgery. The hemorrhage generally occurs at the surgical site; however, remote hemorrhage is rare. Here, we report two cases of remote hemorrhage after burr-hole surgery for chronic subdural hematoma and discuss the possible mechanism underlying this rare complication. Case description Two patients presented remote hemorrhages after burrhole surgery for chronic subdural hematoma. In the first case, hemorrhage occurred in the interhemispheric fissure and contralateral subdural space. In the second case, hemorrhage occurred in the subdural space of the posterior fossa. Conclusion Postoperative remote hemorrhage is a rare complication, and it can occur after both craniotomy surgery and burr-hole surgery. Neurosurgeons should consider the possibility of this rare complication, and sufficient care should be taken to select the most appropriate surgical procedure to prevent remote hemorrhage.

Recently, endovascular coil embolization is more often used than surgical clipping in the treatment of cerebral aneurysms. However, young neurosurgeons, who have less opportunity to perform and learn surgical clipping than senior surgeons did, must be able to achieve a good outcome when using it. The training in surgical clipping for young neurosurgeons consists of not only knowledge, but also microsurgical skills and experience. A lot of opinions by expert surgeons in surgical clipping are reported, and young neurosurgeons must learn surgical clipping to comprehend them. However, there are no reports from a beginner's point of view on surgical clipping. This paper aims at training in surgical clipping from a beginner's point of view. From 2002 to 2004, among 13 unruptured cerebral aneurysm clipping cases, 14 aneurysms (male 4, female 9 cases), there were 8 middle cerebral artery aneurysms, 3 anterior communicating artery aneurysms and 3 internal carotid artery aneurysms. We analyze operation time, postoperative complications, asymptomatic brain injury and intraoperative rupture. The mean size of the aneurysms and the mean operation time were 5 (4-9) mm and 335 minutes, respectively. There were no postoperative complications, but 3 asymptomatic brain injuries and 2 intraoperative ruptures had occurred. Retrospectively, we know that such surgical complications are avoided by expert neurosurgeons with deep knowledge based on experience. We elucidate the concept of training in surgical clipping for unruptured cerebral aneurysms from the point of view of a beginner learning microsurgery. Beginners, as members of a surgical team, should reflect on every aspect of the surgery to obtain a deep knowledge in surgical clipping.

A 48-year-old woman presented with subarachnoid hemorrhage originating from a dissecting aneurysm of the left vertebral artery (VA). Internal trapping with proximal flow arrest was planned. The origin of the left VA was too tortuous to allow positioning of an occlusion balloon catheter and a microcatheter in the left VA via the femoral artery. Therefore, the temporary subclavian steal technique was used for proximal flow arrest, by placing an occlusion balloon catheter in the subclavian artery proximal to the VA origin via the femoral artery. Thereafter, coil embolization was achieved through the left axillary artery. The patient recovered well after the procedure.

急性期椎骨脳底動脈域狭窄・閉塞に対する脳血管内手術6症例(7回)の検討を行った.年齢は56～77歳(平均68歳),全例男性.病変部位は椎骨動脈(以下VA)2例(3回),脳底動脈(以下BA)3例,後大脳動脈1例.GOS,狭窄の改善率,NIHSSの改善度について検討した.結果,GR3例,MDl例,SD1例,DI例であり,狭窄改善率は0～80%(平均63%)であった.平均NIHSSは術前24,術後16であり改善傾向を認めた.術前のNIHSS23点以上の重症例3例に関しては,急性期血行再建を行ってもD1例,SD2例と予後不良であり,重症例については急性期血管内治療による血行再建術の適応は乏しいと考えられた.しかし,NIHSS中等例についてはPTAを中心とした急性期椎骨脳底動脈狭窄・閉塞に対する血管内手術は血行再建術の有効な手段であり,その予後改善効果を期待できる治療であると思われる.

The purpose of the present work is to establish the design method of methanol steam-reformer for application to chemical recuperation in a gas turbine system. The reaction rate of the methanol steam-reforming was measured with a small amount of catalyst using the gaseous mixture of methanol, water, hydrogen, and carbon dioxide as a simulated product gas. The reaction rate equation could be expressed by power law of methanol mole fraction and total pressure. The reaction and heat transfer in the catalyst-packed bed was analyzed numerically using the reaction rate equation. The analytical results of temperature distribution and conversion were compared with the experimental results using a reforming tube. These results agreed well except for the region of high methanol conversion.

Seven patients, six females and one male aged 26 to 39 years old, presented with headache in the upright posture, which was completely relieved in the recumbent posture. Radioisotope cisternography with technetium-99m-human serum albumin detected cerebrospinal fluid (CSF) leakage at the cervicothoracic level in six patients, and at the high cervical level in one patient. The diagnosis was intracranial hypotension due to spontaneous CSF leakage. Complete bed rest for more than 2 weeks resulted in complete resolution of the headache in all patients, and follow-up cisternography showed no leakage. Radioisotope cisternography is useful for the diagnosis of spontaneous CSF leakage, and complete bed rest for more than 2 weeks may be the best method of treatment.

A 59-year-old male presented with repeated transient hemianopsia and hemiparesis on the left. Emergency magnetic resonance angiography showed stenosis of the right posterior cerebral artery (PCA). Endovascular recanalization with percutaneous transluminal angioplasty was performed immediately after the diagnosis. Patency of the PCA was successfully restored. The patient was discharged without neurological deficits. Progressive stroke in the PCA territory is rare. However, emergency endovascular recanalization is possible after prompt clinical diagnosis based on repeated diffusion-weighted magnetic resonance imaging and angiography after a 24-hour interval.

Evaporation heat transfer coefficients depend on the mass flux and quality. When a non-azeotropic mixture is used as a working fluid, this dependence is significant due to the suppression of nucleate boiling. It is possible to improve the heat transfer performance if the channel cross-sectional area is enlarged at the latter part of the evaporator, namely, the mass flux is reduced in the high-quality region where the pressure drop is large. This work involves an analytical investigation on the enhancement effect by varying the channel cross section. It was assumed that the working fluid was a mixture of refrigerants R123 and R134a, and that the tubes used were smooth or spirally grooved. As a result, the heat transfer area and the channel volume were reduced by more than 20% with a permissible pressure drop. © 1998 Scripta Technica, Heat Trans Jpn Res, 26(3): 143–158, 1997.

Evaporation heat transfer coefficients depend on the mass flux and quality. When a non-azeo-tropic mixture is used as a working fluid, this dependence is significant due to the suppression of nucleate boiling. It is possible to improve the heat transfer performance if the channel cross-sectional area is enlarged at the latter part of the evaporator, namely, the mass flux is reduced in the high-quality region where the pressure drop is large. This work involves an analytical investigation on the enhancement effect by varying the channel cross section. It was assumed that the working fluid was a mixture of refrigerants R 123 and R 134 a, and that the tubes used were smooth or spirally grooved. As a result, the heat transfer area and the channel volume were reduced by more than 20% when the pressure drop is permissible enough.

This work presents an experimental and analytical investigation of heat and mass transfer with condensation in a fibrous insulation slab, one side of which is exposed to high temperature and high humidity, and the other side bounded by a cold surface. The analysis carried out is based on a model in which condensation occurs on the cold surface and in the interior of the fibrous insulation, and condensate falls away under gravity. Predicted heat transfer coefficients agreed well with experimental data at atmospheric pressure and temperatures up to 100°C. It was also indicated by the analysis that the convective contribution is appreciable in higher pressure and temperature environments.

A 67-year-old man was admitted for evaluation of left homonymous hemianopsia. Carotid ultrasonography showed that the right common carotid artery (CCA) was occluded up to just proximal to the carotid bifurcation, and the patent external carotid artery showed retrograde flow to the patent internal carotid artery via the carotid bifurcation. The Doppler waveform pattern of the external carotid artery showed high end-diastolic flow velocity and low pulsatility index. The diagnosis was Riles type 1A CCA occlusion. Digital subtraction angiography and iodine-123 N-isopropyl-p-iodoamphetamine single photon emission computed tomography were performed to confirm the collateral circulation and adequate intracranial hemodynamic sufficiency. Nonsurgical treatment with antiplatelet therapy was performed for the CCA occlusion. No stroke events have occurred within the 2-year follow-up period.

The incidence of traumatic subdural effusion (TSE) was analyzed to clarify the relationship with subsequent chronic subdural hematoma (CSH) in 500 patients with head injury evaluated over a 36-month period. TSE occurred in 108 patients (21.6%), and CSH developed in 29 (5.8%) of these. The incidence of TSE was high, although only hospitalized patients were included because of the necessity for serial computed tomography. TSE frequently developed into CSH, and all CSH followed TSE. Therefore, TSE is closely associated with CSH and subdural effusion is probably a preliminary stage necessary for the formation of CSH.

This paper presents an experimental investigation of the forced convective boiling of refrigerant HCFC123 in a mini-tube. The inner diameters of the test tubes, D, were 0.51 mm and 0.30 mm. First, two-phase frictional pressure drops were measured under adiabatic conditions and compared with the correlations for conventional tubes. The frictional pressure drop data were lower than the correlation for conventional tubes. However, the data were qualitatively in accord with those for conventional tubes and were correlated in the form φL 2 −1/Xtt . Next, heat transfer coefficients were measured under the conditions of constant heat flux and compared with those for conventional tubes and for pool boiling. The heat transfer characteristics for mini-tubes were different from those for conventional tubes and quite complicated. The heat transfer coefficients for D = 0.51 mm increased with heat flux but were almost independent of mass flux. Although the heat transfer coefficients were higher than those for a conventional tube with D = 10.3 mm and for pool boiling in the low quality region, they decreased gradually with increasing quality. The heat transfer coefficients for D = 0.30 mm were higher than those for D = 0.51 mm and were almost independent of both mass flux and heat flux.Copyright © 2010 by ASME

The authors report a case of subarachnoid hemorrhage and spinal root injury caused by an acupuncture needle buried in the posterior neck about 30 years before onset. A 33-year-old female presented with sudden onset of severe occipital headaches. Plain x-ray films of the cervical spine revealed a fine gold needle, about 1.5 cm in length, between the C1 and C2 vertebrae. The needle was piercing the spinal nerve root through the dural vein, and was removed. Postoperatively, the pain exacerbated by neck movement disappeared.

A goose neck snare is a useful device not only for the retrieval of intravascular foreign bodies, such as detachable coils and catheter fragments, but also for holding a guiding catheter. In carotid artery stenting, the guiding catheter should be kept stable in the proximal of the stenotic lesion, but it is sometimes difficult because of the tortuousity of the proximal common carotid artery. We present a case of carotid artery stenting for proximal part common carotid artery stenosis and discuss the usefulness of the goose neck snare from the brachial artery for holding the guiding catheter.

There are no reports of surgical treatment for non-functioning pituitary adenomas in the 9th decade of life, and it is thought that these patients often select conservative treatment and observation, because of their worry about deterioration of their general condition due to invasive surgery and because hypopituitarism and other medical problems are often present. However, it is also true that there is necessity for considering surgical treatment for the pituitary adenomas even in the 9th decade when there is a complaint of visual disturbance. We carried out the palliative surgical removal of three non-functioning pituitary adenomas with visual disturbance in the 9th decade and report these surgical treatments and outcomes. The improvement of visual disturbance was obtained in all three cases. The only perioperative complication was pneumothorax caused by barotrauma. The palliative transsphenoidal surgical removal of non-functioning pituitary adenomas for the purpose of improvement of visual disturbance is a safe procedure in the 9th decade of life.

Cranioplasty performed after external decompression for brain swelling due to cerebral infarction, injury and hemorrhage may be difficult because of the development of adhesions between the dura and the temporal muscle, subcutaneous layer. Preventing such adhesions, we have used Seprafilm instead of Gore-Tex membranes which had been used in neurosurgery. Seprafilm were placed between the temporal muscle and the dura with dural plasty using periostium or temporal fascia. Insertion of Seprafilm makes it easy for subsequent cranioplasty, to decrease operating time and blood loss, and avoids injury to the temporal muscle and dura. In addition, the price of Seprafilm is lower than Gore-Tex. Seprafilm is a safe and inexpensive material for preventing the adhesions after external decompression.

A 48-year-old woman presented with subarachnoid hemorrhage originating from a dissecting aneurysm of the left vertebral artery (VA). Internal trapping with proximal flow arrest was planned. The origin of the left VA was too tortuous to allow positioning of an occlusion balloon catheter and a microcatheter in the left VA via the femoral artery. Therefore, the temporary subclavian steal technique was used for proximal flow arrest, by placing an occlusion balloon catheter in the subclavian artery proximal to the VA origin via the femoral artery. Thereafter, coil embolization was achieved through the left axillary artery. The patient recovered well after the procedure.

Ruptured vertebral artery (VA) dissecting aneurysms are associated with a higher incidence of rebleeding than saccular aneurysms, so, it is encouraged that diagnosis be followed by early treatment. The standard treatment for VA dissecting aneurysms is internal trapping using an endovascular technique. In this procedure, a proximal flow arrest is sometimes used to ensure safety. In this report, we demonstrated the usefulness of proximal flow arrest. The subjects consisted of seven patients treated with endovascular treatment for ruptured VA dissecting aneurysms from 1997 to 2005. Two of the seven patients were treated without proximal flow arrest and one of the two encountered rerupture of the aneurysm at coil embolization. Five patients were treated with proximal flow arrest. Internal trapping was safely completed in these patients. Overall outcomes measurment by Glasgow Outcome Scale were good recovery in three, moderate disability in one, vegetative state in one and dead in two. Proximal flow arrest is considered to be useful for the following four reasons: 1) for the prevention of distal embolism; 2) for the prevention of distal coil migration; and 3) to block blood flow upon rerupture; 4) for the balloon occlusion test, but the necessity of this technique is now controversial. However it is difficult to prove the necessity, we believe it is an effective optional technique for safety embolization.

We describe a case of traumatic panhypopituitarism following head injury. Generally considered, posttraumatic hypopituitarism occurs in patients who have suffered from severe head injury. However there were a few case reports of panhypopituitarism due to mild and moderate head injury. A 51-year-old male presented with a history of blunt head injury caused by a concrete block hitting his head directly during work. On admission, initial Glasgow Coma Scale was 14. Open depressed skull fracture was suspected. Emergency craniectomy and debridement were performed. Ten days after surgery, hypothermia, lethargy and appetite loss were manifested. Endocrinological examination showed panhypopituitarism with diabetes insipidus. MRI revealed ruptured pituitary stalk and pituitary gland hemorrhage. Coronal and sagittal MRI was helpful for the diagnosis of traumatic panhypopituitarism. General condition was recovered by hormone replacement therapy. It is important for medical staff carefully to observe vital signs and clinical symptoms, even if mild brain injury. Pituitary function test should also be undergone, if panhypopituitarism was suspected from clinical condition.

A spin-1 ferromagnetic Bose-Einstein condensate subject to a certain magnetic field exhibits a broken-axisymmetry phase in which the magnetization tilts against the applied magnetic field due to the competition between ferromagnetism and linear and quadratic Zeeman effects. The Bogoliubov analysis shows that in this phase two Goldstone modes associated with U(1) and SO(2) symmetry breakings exist, in which phonons and magnons are coupled to restore the two broken symmetries., Comment: 11 pages, 6 figures

An 11-year-old boy gradually developed headache, vomiting and diplopia over a period of 1 month. Repeated examinations of head CT scan revealed an arachnoid cyst in the right middle cranial fossa and bilateral subdural effusion of enlarging size. Papilledema was absent on admission, but it became evident after 1 week, and lumbar puncture disclosed very high pressure (800 mmH2O) of the cerebrospinal fluid. Fenestration of the cyst to the basal cisterms quickly alleviated his symptoms of intracranial hypertension as well as the bilateral subdural effusion on CT. Macroscopically, there was a small tear on the wall of the arachnoid cyst, and it probably served as a communication valve with the subdural space. Since he had no history of head trauma in the past few months, the reason of the tear formation was unclear. Intracranial arachnoid cyst is a relatively common congenital malformation of usually benign and non-pathogenic nature. However, it may occasionally cause non-traumatic subdural effusion and intracranial hypertension.