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Non-traumatic subarachnoid hemorrhage (SAH) is a type of stroke that still has a high mortality rate. Some patients with SAH have electrocardiography (ECG) abnormalities or asymptomatic left ventricular apical ballooning, and requires intervention by cardiologists. However, the impact of cardiac abnormalities after SAH onset remains unclear. We investigated whether ECG abnormalities, myocardial damage, sympathetic nervous activity or echocardiographic left ventricular wall motion abnormalities (WMA) could provide additional risk stratification in patients with SAH.We studied 118 SAH patients (78 women, age 63 ± 15) without a history of heart disease. Neurological grade (Hunt and Kosnik Grade) and clinical factors were evaluated. A standard 12-lead ECG, echocardiography and blood samples were obtained within 48 h after SAH onset. ECG abnormalities were defined as abnormal Q wave, ST elevation, giant T-wave inversion or QT prolongation.Twenty of 118 patients (17%) died during the follow-up (35 ± 31 months). Death was significantly associated with higher age (p 0.0001), neurological grade (p 0.0001), elevated BNP level (p 0.0001), increased plasma norepinephrine levels (p 0.0001) and WMA (p = 0.0070), while ECG abnormalities were not significantly associated. Neurological grade (p 0.0001), age (p = 0.0047) and BNP (p = 0.0014, hazard ratio 1.0255 for each 1 pg/mL increase in BNP, 95%CI 1.0088 to 1.0499) were independently associated with death. Patients with BNP ≥ 96.6 had a higher risk of death (log- rank p 0.0001).Plasma BNP might provide an additional risk stratification in patients with non-traumatic SAH that requires intervention by cardiologists for both its prevention management after onset.

Background The effectiveness of surgical microvascular decompression (MVD) of the vertebral artery (VA) for treating conditions such as trigeminal neuralgia or hemifacial spasm is well known. However, the use of MVD for a case in which the posterior inferior cerebellar artery (PICA) is directly compressing the high cervical cord has not been reported. Case Description A 48-year-old male was diagnosed with a rare case of myelopathy due to the PICA directly compressing the high cervical cord. The patient had a C-2 segmental type of VA that penetrated the intradural space at the C1 level. The VA-PICA portion was located just after where the intradural space was penetrated, and the branching PICA strongly and vertically compressed the high cervical cord. Conclusions MVD of the PICA was performed, and the patient experienced rapid improvement of myelopathy. The patient immediately improved postoperative day 1 and was doing well at his 1-year follow-up. This is a rare case of the PICA directly compressing the cervical cord and causing myelopathy. MVD of the PICA resulted in good patient recovery.

We assessed the relationship between fractional anisotropy (FA) values of magnetic resonance-diffusion tensor imaging (DTI) and long-term outcome (3-7 months after onset) in patients with hemiparesis after intracerebral hemorrhage (N = 12). DTI data were obtained on days 14-18. FA values within the cerebral peduncle were analyzed using a computer-automated method. Motor outcome of hemiparesis was evaluated using Brunnstrom stage (six-point scale: severe to normal) for separate shoulder/elbow/forearm, wrist/hand, and lower extremity functions when patients were discharged from a long-term rehabilitation facility 3-7 months after onset. In addition, the motor component of the functional independence measure (FIM-motor) was scored. The ratio of FA values in the affected hemisphere to those in the unaffected hemisphere (rFA) was assessed in relation to the clinical data (Spearman's rank correlation test, P < 0.05). Analysis revealed a statistically significant relationship between rFA and upper extremity function (R = 0.863 for shoulder/elbow/forearm; 0.834 for wrist/hand). Although statistically significant, the relationship between rFA and lower extremity function was less evident (R = 0.609). In contrast, analysis of rFA and FIM-motor scores did not reveal statistical significance. FA values within the cerebral peduncle are tightly associated with long-term outcomes of upper extremity function.

This study examined the clinical usefulness of magnetic resonance-diffusion tensor imaging (DTI) for predicting motor outcome in patients with intracerebral hemorrhage. We studied 15 subjects (age range, 31-81 years) diagnosed by conventional computed tomography with thalamic hemorrhage, putaminal hemorrhage, or both. DTI data were obtained on days 14-18 after diagnosis. Mean fractional anisotropy (FA) values within the right and left cerebral peduncles were estimated by a computer-automated method. Using logistic regression analyses, the ratios of FA values in the affected and unaffected hemispheres (rFA) were modeled in relation to motor outcome scores at 1 month after onset, assessed using the Medical Research Council (MRC) scale (0 = null to 5 = full). The rFA values ranged from 0.628 to 1.001 (median value, 0.856). Analyses showed that the relationships between rFA and MRC scale matched the logistic probabilities for both the upper extremities (R(2) = 0.272; P.001) and lower extremities (R(2) = 0.247; P.001). When estimated rFA values were0.7, the estimated probability of an MRC score of 0-1 was close to 80% for the upper extremities and 65% for the lower extremities. Meanwhile, when estimated rFA values were0.9, the estimated probability of an MRC score of 3-5 was close to 60% for the upper extremities and 80% for the lower extremities. Our data indicate that for patients with intracerebral hemorrhage, DTI is a useful tool for quantitatively predicting motor outcome, suggesting wider clinical applicability of this method for outcome prediction.

Diffusion tensor imaging (DTI) using a 3.0 tesla magnetic resonance scanner was used to investigate white matter changes caused by idiopathic normal pressure hydrocephalus (INPH) in 10 patients diagnosed by clinical symptoms (gait disturbance, dementia, and/or urinary incontinence) and Evans index >0.3, and compared with findings for 10 age-matched controls (≥60 years). Then, using a computer-automated method, fractional anisotropy (FA) brain maps were generated and finally transformed into the standard space. Voxel-based FA values within two regions of interests (ROIs), the forceps minor and corticospinal tracts, were then separately evaluated. Within each ROI, statistical comparisons of results from the INPH and control groups were performed. In addition, for INPH patients, grading scores for clinical symptoms and FA values were correlated. The forceps minor mean FA value was much smaller for the INPH group (0.504) than for the control group (0.631). The corticospinal tract mean FA value was slightly smaller for the INPH group (0.588) than for the control group (0.632). Additional analyses indicated that lower FA values within the forceps minor tended to be associated with clinical symptoms such as urinary incontinence and gait disturbance. Our findings indicate FA values decreased in the forceps minor of INPH patients. We also found that lower values were associated with severer clinical symptoms, implying that DTI techniques may be developed for more accurate diagnosis.

症例は72歳，男性．200X年某日午前11時半頃テニスの休憩中にベンチで崩れるように倒れ意識を失い，12時10分当院に救急搬送され入院した．入院時JCS I-1，構音障害，左半側空間無視，病態失認を認めた．右への共同偏視，左同名性半盲，左中枢性顔面神経麻痺を認めた．深部腱反射は左上下肢にて亢進し，Chaddock，Babinski反射陽性であった．左片麻痺(上肢0/5，下肢1/5)，左側表在感覚鈍麻を認めた．頭部CTでは島皮質に淡い低吸収域を認め，ASPECTS 6点であったが，家族の希望があったためtPA投与を行った(発症後100分で開始)．投与30分後に左下肢筋力は1–2/5になった．入院日に行った心エコーで左房粘液腫と診断し，後日他院にて腫瘍が摘出され病理学的に確認された．これまで左房粘液腫による脳梗塞に対しtPA治療を行った症例は少数であるため，文献的考察を加え報告した．

症例は66歳女性．他院にて経動脈的冠動脈形成術が施行され，特変なく終了したが術後1時間から右眼瞼下垂，めまいが出現したため当院を紹介され入院した．入院時意識清明，脳神経系では右眼瞼下垂を認めたが瞳孔に左右差はなかった．眼球運動は，両眼とも水平方向と上転は保たれていたが，下転障害と輻輳障害を認めた．深部反射・運動系・感覚系に異常はなかった．協調運動では，右上肢で指鼻指試験が拙劣で，両膝踵試験は軽度拙劣であった．入院時の頭部MRI水平断上では明らかな異常を認めなかったが，脳幹梗塞を疑い抗血小板・脳保護療法を行った．第2病日に頭部MRIを冠状断にて再検査したところ，左中脳水道腹側に小梗塞を認め，中脳梗塞と診断した．片側性障害でも両側性下方注視障害を呈する可能性があり，眼球運動に関する病態を理解するうえで貴重な症例と考えられた．

Quick and reliable setting of programmable pressure valves (PPVs) is important in the treatment of idiopathic normal pressure hydrocephalus (iNPH), especially for reducing overdrainage complications and related medical costs. A new quick reference table (QRT) was developed for improved PPV control and outcome. Shunt control can be based on the pressure environment in the sitting condition, given as hydrostatic pressure (HP) = intracranial pressure + PPV setting + intraabdominal pressure (IAP). Using this relationship, and estimating HP and IAP from the patient's height and body mass index, respectively, a QRT was designed, consisting of a matrix of the patient's height and weight. The QRT was used to make initial PPV settings in 25 patients with iNPH and the clinical outcomes were evaluated. Postoperative readjustments of the PPV were not necessary in 15 of the 25 patients. At 1 month after operation, the PPV setting was decreased once in 5 patients and increased once in 2 patients. Four of these 7 patients improved after a single readjustment. Three patients required further readjustments. At 3 months after operation, another 3 patients required a single readjustment and all improved after this readjustment. The readjustment rate was 40% and readjustment number was 0.68 times/patient. The mean PPV setting at 1 year after operation was 15.5 +/- 3.9 cmH(2)O. Use of the QRT in non-bedridden iNPH patients results in a low incidence of PPV readjustment.

A 20-year-old male presented with an extremely rare spontaneous epidural pneumocephalus which was successfully treated by a single neurosurgical intervention. The patient had a habit of nose blowing and a 1-year history of progressive headache and nausea. Cranial computed tomography (CT) revealed a 2 x 7 cm right temporo-occipital epidural pneumocephalus with extensive hyperpneumatization of the mastoid cells. Right temporo-occipital craniotomy with a right superficial temporal artery and vein flap repair resulted in radiographic resolution of the pneumocephalus, and he remained neurologically free of symptoms at 1-year follow-up examination. Early identification and monitoring of symptomatic pneumocephalus followed by decompression and prevention of infection via closure of the bone defect can avoid possible serious consequences. The underlying mechanisms may involve a congenital petrous bone defect and a ball-valve effect due to excessive nose blowing in our case.

症例は75歳男性. 既往歴に高血圧, 糖尿病がある. 起床時よりふらつきを自覚し当院に紹介入院した. 入院時, 眼球運動は左方視時に右眼の内転障害と左眼の眼振を認めたが, 輻輳反射は保たれていた (MLF症候群). 左上下肢に協調運動障害を認め, 歩行は独歩可能であったが, 軽度開脚歩行で左へ偏移する傾向にあり, つぎ足歩行は不可能であった. 入院当日の頭部MRI水平断 (DWIを含む) では, 明らかな虚血病変は認めなかった. 脳幹梗塞を疑い第4病日に頭部MRIを前額断にて再検査したところ, 右中脳水道背側に小梗塞を認め中脳梗塞と診断した. 第7病日には左眼の外転時単眼性眼振は消失し, 歩行障害も軽減し第13病日退院した. MLF症候群と運動失調のみで発症する中脳の小梗塞はまれであり, 病巣診断には前額断を含むMR検査が重要であると考えられた.

A new irrigation sucker (Delta Irrigation Sucker®) was designed for microneurosurgery. The Delta Irrigation Sucker® has a unique trigonal pyramid-shape thumb piece, providing a very stable grip. Irrigation is achieved easily by pushing a small button just behind the pressure-regulating pore. Stable hold of the sucker and easy handling of the irrigation button enable irrigation without unsteadiness of the sucker. The Delta Irrigation Sucker® is available in six sizes, with diameters from 1.5 mm to 4.0 mm at 0.5 mm intervals. Irrigation force is provided by a pressure bag, and a normal sterile transfusion set can be used as the irrigation circuit. The Delta Irrigation Sucker® was used in 20 cases of clipping for ruptured cerebral aneurysm, five cases of tumor resection, and three cases of anterior clinoidectomy and opening of the internal auditory meatus. Subarachnoid clot was easily removed and the bleeding points were easily confirmed. Irrigation, controlled by natural finger movement, did not cause unsteadiness of the sucker.

The authors report a successful reconstruction of an extensive frontotemporal bone defect after craniotomy, which was complicated with infection and necessitated removal of frontal and temporal bones. The large frontotemporal bone defect was reconstructed using prefabricated hydroxyapatite blocks in combination with the free vastus lateralis muscle flap. The patient's functional and cosmetic restoration has been maintained for 10 months' follow-up.

Introduction Arteriovenous malformations (AVM) are considered to be static congenital lesions; however, a subset may possess dynamic pathophysiological capabilities of growth, regression or other morphological changes with time. We report on an adult patient harboring a pineal AVM who presented with progressive symptoms of obstructive hydrocephalus and was successfully treated by endoscopic third ventriculostomy (ETV). Clinical presentation This 63-year-old man was incidentally diagnosed 8 years previously with an asymptomatic unruptured pineal AVM and followed conservatively until he developed a progressive impairment in consciousness with gait apraxia and incontinence over a period of 2 months. Magnetic resonance imaging (MRI) revealed obstructive hydrocephalus due to nidal compression at the level of the aqueduct. Treatment by ETV resulted in resolution of neurological deficits and ventriculomegaly without evidence of complications at 18-months follow-up. Conclusion Treatment by ETV in adults with obstructive hydrocephalus due to deep pineal AVMs is a reasonable option in selected cases. A discussion of the pathological mechanisms and therapeutic options for this rare entity is presented.

Magnetic resonance-diffusion tensor imaging (DTI) was used to predict motor outcome for patients with intracerebral hemorrhage. We compared the predictive accuracy of data sampled from the cerebral peduncle with data from the corona radiata/internal capsule. This study included 32 subjects with thalamic or putaminal hemorrhage or both.DTI data were obtained on days 14 to 18. Mean values of fractional anisotropy (FA) within the cerebral peduncle and the corona radiata/internal capsule were analyzed using a computer-automated method. Applying ordinal logistic regression analyses, the ratios between FA values in the affected and unaffected hemisphere (rFA) were modeled in relation to motor outcome scores at 1 month after onset, assessed using the Medical Research Council (MRC) scale (0 = null to 5 = full).For both cerebral peduncle and corona radiata/internal capsule, the relationships between rFA and MRC matched logistic probabilities. While cerebral peduncle rFA values had statistically significant relationships with MRC scores (upper extremity R(2) = 0.271; lower extremity R(2) = 0.191), rFA values for the corona radiata/internal capsule showed less significant relationships (upper extremity R(2) = 0.085; lower extremity R(2) = 0.080). When estimated cerebral peduncle rFA values were0.7, estimated probability of MRC 0 to 2 was close to 85% for the upper and 60% for the lower extremities. Meanwhile, when estimated rFA values were0.9, estimated probability for MRC 4 to 5 nearly equaled 50% for the upper and 60% for the lower extremities.FA values from within the cerebral peduncle more accurately predicted motor outcome and is a promising technique for clinical application.

OBJECTIVE Neurenteric cysts (NCs) typically arise as benign ventral intradural extramedullary developmental malformations of the spine which contain heterotopic epithelium resembling the intestinal or respiratory tracts. Intracerebral NCs are extremely rare, though the frequency of symptomatic reports and incidental findings is increasing, perhaps because of advances in neuroimaging. Recognition of the unique radiographic and histopathologic features of this entity is of growing importance in the treatment of cysts of the neural axis. We present an unusual case of an NC arising at the lower clivus. CLINICAL PRESENTATION A 58-year-old man presented with occipitalgia, diplopia, a bilateral hearing deficit, and mild dysphagia. Computed tomography and magnetic resonance imaging demonstrated a 5 x 2 x 3-cm extra-axial cystic midline mass anterior to the brainstem at the lower clivus with posterior cyst wall enhancement. INTERVENTION The patient underwent a left lateral suboccipital total macroscopic resection of the lesion. Microscopic examination and histopathologic findings were consistent with a diagnosis of NC. CONCLUSION We describe the clinical presentation, imaging, and histopathologic characteristics, and discuss the diagnosis and surgical treatment of this rare lesion and related pathologic entities. Because of the remote possibility of delayed recurrence, even in cases of apparent total cyst wall removal, long-term serial imaging and a consideration of reoperation for recurrences is advisable.

A new irrigation sucker (Delta Irrigation Sucker) was designed for microneurosurgery. The Delta Irrigation Sucker has a unique trigonal pyramid-shape thumb piece, providing a very stable grip. Irrigation is achieved easily by pushing a small button just behind the pressure-regulating pore. Stable hold of the sucker and easy handling of the irrigation button enable irrigation without unsteadiness of the sucker. The Delta Irrigation Sucker is available in six sizes, with diameters from 1.5 mm to 4.0 mm at 0.5 mm intervals. Irrigation force is provided by a pressure bag, and a normal sterile transfusion set can be used as the irrigation circuit. The Delta Irrigation Sucker was used in 20 cases of clipping for ruptured cerebral aneurysm, five cases of tumor resection, and three cases of anterior clinoidectomy and opening of the internal auditory meatus. Subarachnoid clot was easily removed and the bleeding points were easily confirmed. Irrigation, controlled by natural finger movement, did not cause unsteadiness of the sucker.

We describe a rare case of an arteriovenous malformation (AVM) embedded in the vestibulocochlear nerve presenting with subarachnoid hemorrhage (SAH) treated by microsurgical elimination of the main feeding artery and partial nidus volume reduction with no permanent deficits. This 70-year-old woman was incidentally diagnosed 4 years previously with two small unruptured tandem aneurysms (ANs) on the right anterior inferior cerebral artery feeding a small right cerebellopontine angle AVM. The patient was followed conservatively until she developed sudden headache, nausea and vomiting and presented to our outpatient clinic after several days. Magnetic resonance imaging demonstrated findings suggestive of early subacute SAH in the quadrigeminal cistern. A microsurgical flow reduction technique via clipping between the two ANs and partial electrocoagulation of the nidus buried within the eighth cranial nerve provided radiographical devascularization of the ANs with residual AVM shunt flow and no major deficits during the 2.5 year follow-up. This is only the second report of an auditory nerve AVM. In the event of recurrence, reoperation or application of alternative therapies may be considered.

Ca2+-dependent cyclic nucleotide phosphodiesterase (Ca2+-PDE) activity was stimulated by poly(L-aspartic acid) but not by poly(L-glutamic acid), poly(L-arginine), poly(L-lysine), and poly(L-proline). This activation was Ca2+ independent and did not further enhance the activation of Ca2+-PDE by Ca2+-calmodulin (CaM). Poly(L-aspartic acid) produced an increase in the Vmax of the phosphodiesterase, associated with a decrease in the apparent Km for the substrate, such being similar to results obtained with Ca2+-CaM. Poly(L-aspartic acid) did not significantly stimulate myosin light chain kinase and other types of cyclic nucleotide phosphodiesterase. CaM antagonists such as N-(6-aminohexyl)-5-chloro-1-naphthalenesulfonamide (W-7), trifluoperazine, and chlorpromazine selectively antagonized activation of the enzyme by poly(L-aspartic acid). Kinetic analysis of W-7-induced inhibition of activation of phosphodiesterase by poly(L-aspartic acid) was in a competitive fashion, and the Ki value was 0.19 mM. On the other hand, prenylamine, another type of calmodulin antagonist that binds to CaM at sites different from the W-7 binding sites, did not inhibit the poly(L-aspartic acid)-induced activation of Ca2+-dependent cyclic nucleotide phosphodiesterase. These results imply that poly(L-aspartic acid) is a calcium-independent activator of Ca2+-dependent phosphodiesterase and that aspartic acids in the CaM molecule may play an important role in the activation of Ca2+-PDE.

Troponin I inhibited, concentration-dependently, [3H]-N-(6-aminohexyl)-5-chloro-1-naphthalenesulfonamide (W-7) and [3H]-trifluoperazine (TFP) binding to purified bovine brain calmodulin (CaM). Selective oxidation of methionine residues of CaM by N-chlorosuccinimide resulted in a rapid decrease in [3H]-W-7, [3H]-TFP and [14C]-chlorpromazine binding concomitant with the loss of CaM activity. Carbethoxylation of histidine residues, nitration of tyrosine residues and chemical modification of arginine residues with 1,2-cyclohexanedione produced no significant changes either in [3H]-W-7 binding to CaM or in the ability of CaM to stimulate phosphodiesterase. Our results suggest that the binding sites of these CaM antagonists on CaM may be located between the second and third Ca2+-binding loops.

We have demonstrated calcium-dependent hydrophobic interactions among calmodulin, S-100 protein and troponin-C and a homologous series of ω-aminoalkyl-agaroses. The three Ca 2+ -binding proteins were retained on the column of agarose substituted with ω-aminooctyl or even longer with alkylamine, in the presence of Ca 2+ and 0.15 M NaCl. As these proteins were not retained on the column with shorter alkylamine ‘arms’ ( N = 2, 4), they are probably successively absorbed with a higher affinity to the hydrophobic agarose column. Calmodulin and S-100 protein were eluted from the aminooctyl-agarose column with 1 mM EGTA in the presence of 0.15 M NaCl and the elution of troponin-C was Ca 2+ -independently carried out with 0.3 M NaCl. On the other hand, S-100 and troponin-C were eluted Ca 2+ -dependently from aminodecyl-agarose in the presence of 1 M NaCl and half the amount of the calmodulin applied was eluted with 1 M NaCl. As there are obvious differences among the three Ca 2+ -binding proteins with regard to chromatographic behavior on ω-aminoalkyl-agarose columns, our results suggest that these three proteins expose different hydrophobic regions following Ca 2+ -induced conformational changes and, if so, such would explain the interaction with aminoalkyl-agaroses.