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Introduction This study investigated the efficacy of scopolamine (an anticholinergic agent) ointment against clozapine-induced hypersalivation. Methods The patients enrolled in this study consisted of 10 clozapine-treated schizophrenia patients and 10 healthy adult men. A prospective, randomized, double-blind, crossover, placebo-controlled clinical trial was designed. Results A total of 10 patients and 10 healthy adult men completed the study. No significant reduction in the saliva production of the clozapine-treated patients was observed; however, that of the healthy adult men decreased significantly. Discussion Scopolamine ointment was not effective against clozapine-induced hypersalivation. A further study is necessary for confirming its effect. [ABSTRACT FROM AUTHOR]

Background/Aims: To investigate the potential inhibitory effects of 18 clinically available antidepressants on acetylcholine (ACh)-induced contractions in guinea pig urinary bladder smooth muscle (UBSM) in order to predict whether they may induce voiding impairment. Methods: Concentration-response curves for ACh-induced contractions in guinea pig UBSM strips were obtained in the absence or presence of selected antidepressants. When inhibitory effects indicated competitive antagonism, pA2 values against ACh were calculated and compared to plausible antidepressant blood concentrations. Results: ACh-induced contraction was antagonized competitively within clinical dose ranges by tricyclic antidepressants (imipramine, amitriptyline, trimipramine, clomipramine, nortriptyline, and amoxapine), maprotiline (a tetracyclic antidepressant), and mirtazapine (a noradrenergic and specific serotonergic antidepressant). ACh-induced contraction was also significantly inhibited by mianserin (a tetracyclic antidepressant), paroxetine and sertraline (serotonin-selective reuptake inhibitors, SSRIs), and duloxetine (a serotonin noradrenaline (norepinephrine) reuptake inhibitor, SNRI), albeit at concentrations that substantially exceeded clinically achievable blood levels. However, ACh-induced contractions were not significantly affected by fluvoxamine and escitalopram (SSRIs), milnacipran (an SNRI), trazodone (a serotonin 5-HT2A receptor antagonist), sulpiride (a dopamine D2receptor antagonist), or aripiprazole (a dopamine partial agonist). Conclusion: These findings suggest that in addition to tricyclics, some relatively novel antidepressants such as mirtazapine can induce voiding impairment, attributed to diminished UBSM contractility from the inhibition of muscarinic receptors in the UBSM. [ABSTRACT FROM AUTHOR]

Background: It is debatable whether mechanical thrombectomy has benefits in a real-world setting outside the more rigid and selective clinical trial environment., Objective: To evaluate clinical outcomes, efficacy, and safety of mechanical thrombectomy in single-center retrospective cohort case series., Methods: We reviewed prospectively collected data from our large-vessel occlusion stroke database to identify patients undergoing mechanical thrombectomy using Penumbra catheters (Penumbra, Almeida, California) as first-line devices. The primary outcomes were the modified Rankin Scale score at 90 d and recanalization rate. The secondary outcomes included the rates of hemorrhagic complications and mortality., Results: The entire study population included 298 patients. Thrombolysis in Cerebral Infarction Scale ≥2b was achieved in 86.6% of patients. Fifty-five patients (18.5%) were outside the 6 hr time window and 82 patients (27.5%) were over 80-yr old. The posterior circulation thrombectomy rate was 12.4%. At 90 d from onset, 49.3% of patients had favorable outcomes. The parenchymal hemorrhage type 2 (PH2) and subarachnoid hemorrhage rates were 2.3% and 11.7%, respectively. In multivariate analyses, cerebral blood flow/cerebral blood volume mismatch (odds ratio [OR] = 9.418; 95% confidence interval [CI], 3.680-27.726; P < .0001), onset to recanalization time (OR = 0.995; 95% CI, 0.991-0.998; P = .0003), and hemorrhagic complications including PH2 and subarachnoid hemorrhage (OR = 0.186; 95% CI, 0.070-0.455; P = .0002) were associated with favorable outcomes., Conclusion: A direct aspiration first pass technique with an adjunctive device demonstrated high recanalization rates in old Japanese patients. Our patient cohort may reflect the application of endovascular techniques in acute ischemic stroke treatment in a real-world setting., (Copyright © 2018 by the Congress of Neurological Surgeons.)

Introduction: Many studies describe aneurysms measuring ≤3mm as "very small" or "tiny, " with a risk of intraoperative rupture higher than that of most cerebral aneurysms. We evaluated the results of endovascular coil embolization for very small aneurysms with diameter ≤3mm., Material and Methods: The same interventional neurosurgeon performed coil embolization for 14 tiny aneurysms in 14 patients(8male and 6 females)at our institution between May 2015 and June 2017. Patient age range was 42-88 years(average 65.6 years). Five aneurysms had ruptured and 9 were unruptured. Of the 9 unruptured aneurysms, 3 were associated with a previous ruptured aneurysm. We assessed the procedural complications, type of microcatheter and coils used, total number and length of coils, and angiographic results immediately after the procedure., Results: In 14 aneurysm cases, 8 used only 1 pre-shaped microcatheter, 4 used 2, and 2 used 3;cases using multiple microcatheters added final shaping. Only one case used a helical first coil and the remaining 13 cases used a 3-dimensional coil. The number of coils used was 1 in 3 cases, 2 in 7 cases, 3 in 2 cases, and 4 in 2 cases. The total length of coils inserted was <5 cm in 5 cases, 5-10 cm in 5 cases, and >10 cm in 4 cases. The total length of coils used was <10cm in 70% of cases. Immediately after coil embolization, complete occlusion and a neck remnant were achieved in 11 and 3 cases, respectively. Ballooning was induced by intentionally introducing a balloon-assist technique during surgery in 7 cases, and the balloon was actually inflated in 4 cases. Complications were seen in 2 ruptured cases;1 had an intraoperative rupture, the other had parent artery occlusion, and both patients recovered., Conclusion: Coil embolization for tiny aneurysms can be performed comparatively safely by understanding the pitfalls and by using appropriate procedures and tools. Placing the catheter tip at the aneurysm neck is the first step and endovascular treatment is usually performed with ≤3 coils measuring ≤10 cm in total length. Complete embolization should be attempted, but even incomplete embolization is acceptable. More delicate coil embolization is required.

The stabilization of a guiding catheter is a very important factor for successful endovascular treatment. However, it is sometimes difficult to obtain sufficient stabilization because of the tortuosity of the approach route. A Goose Neck Snare is useful for the retrieval of intravascular foreign bodies and can be used to hold the guiding catheter. We describe five cases of endovascular treatment performed while using the Goose Neck Snare via the brachial artery to hold the guiding catheter. We discuss the utility of this strategy.

We describe a case of deep cerebral venous sinus thrombosis(DCVST)that was successfully treated by oral administration of the Xa inhibitor edoxaban. A 53-year-old man was admitted to our hospital because of a headache and undifferentiated dizziness. Computed tomography(CT)demonstrated a low-density area in the bilateral thalamus and high-density lesions in the internal cerebral veins(ICVs)and vein of Galen. Magnetic resonance imaging with diffusion-weighted images detected areas of hyperintensity in the bilateral thalamus. Additionally, the inferior sagittal sinus, ICV, and vein of Galen were not detected by CT venography or cerebral angiography. We therefore diagnosed DCVST and started anticoagulation therapy with heparin(IV)and warfarin. A week after admission, lesions that showed hypointensity on T2 * images and high density on CT scans were detected in the bilateral thalamus. We thought that hemorrhagic infarction had occurred in association with DCVST, and changed the anticoagulation therapy to oral administration of edoxaban on day 9. The patient's symptoms gradually diminished, and CT venography indicated partial recanalization of the DCV from the ICV to the vein of Galen on day 72. We report our experience, and discuss the safety and usefulness of the Xa inhibitor for treating DCVST with hemorrhagic infarction.

Involuntary movement is a rare clinical manifestation of transient ischemic attack (TIA). However, limb-shaking TIA is well described presentation of carotid occlusive disease. We present the case of a patient who developed limb-shaking TIA associated with high-grade stenosis of middle cerebral artery (M1), which was treated with percutaneous transluminal angioplasty (PTA). The procedure was performed successfully without complication and the symptom disappeared immediately after the procedure. The patient remained free of symptoms at the 38-month follow-up. There was no tendency of restenosis of M1. In this case, PTA was technically feasible and beneficial for limb-shaking TIA with M1 stenosis. Limb-shaking TIA can be a symptom of high-grade stenosis of M1.

We report a case of intraorbital varix. A 16-year-old girl showed sudden left-sided exophthalmos after vomiting. After several episodes of vomiting, she developed complete loss of vision in the left eye, followed by orbital pain, disruption of eye movement, and periorbital swelling. No change in symptoms or signs was observed after the Valsalva maneuver or jugular vein compression. Computed tomography (CT), magnetic resonance imaging (MRI), and angiography were inconclusive. Transcranial surgery revealed a large varix near the optic nerve. The lesion could not be completely resected because the orbital fat interfered with its complete visualization. We cauterized the lesion to reduce its volume. The patient's symptoms improved markedly after surgery and cauterization. Thus, cauterization appears to be an effective strategy to reduce the volume of an unresectable intraorbital varix.

Numerous approaches have been used to access aneurysms of the vertebral artery(VA)-posterior inferior cerebellar artery(PICA)complex for microsurgical clipping. Here, we report the case of a patient with an unruptured aneurysm of the left VA-PICA complex that was successfully treated using a contralateral suboccipital approach. Computed tomography angiography demonstrated a small saccular aneurysm arising from the lateral aspect of the left V4 segment just distal to the PICA origin. The aneurysm deviated to the right from the midline at the level of the jugular tubercle on angiographic evaluation, so we selected a contralateral suboccipital approach. The aneurysm was completely obliterated by neck clipping. After surgery, slight dysphagia and hoarseness appeared, but dysphagia disappeared within several days and hoarseness disappeared within 5 months. VA-PICA aneurysms can vary in their relationship to cranial nerves, brainstem, and bones of the skull base. Neurosurgeons should consider using a contralateral approach for certain aneurysms arising from a tortuous VA that has crossed the midline.

The effects of concomitant antiepileptic drugs on the serum carbamazepine concentration (C1) were analyzed quantitatively. Primidone (PRM), phenobarbital (PB), phenytoin (PHT), valproic acid (VPA), zonisamide (ZNS), clonazepam (CZP), and ethosuximide (ETS) were coadministered with carbamazepine (CBZ). Routine therapeutic drug monitoring data, obtained from epileptic patients who were treated with the repetitive oral administration of CBZ fine granules/tablets, were used for the analysis. A total of 119 patients were administered CBZ alone, and 91, 39, 19, and 6 patients were coadministered one, two, three, and more than four different antiepileptic drugs, respectively. Using the data obtained from the patients administered CBZ alone, Ct could be expressed approximately as a function of the daily dose per extracellular water volume (D/VECW) as Ct = A(D/VECW)B (A, B: parameter). By comparing the regression line on log Ct vs. log(D/VECW) for CBZ alone with that for CBZ plus another concomitant drug, Ct was thus found to be affected at each definite ratio by PB and PHT, but not by VPA and ZNS. We postulated a model showing that Ct is affected by each concomitant antiepileptic drug i at each definite ratio. We defined the parameter Ri(i = 1, 2, ..., 7) representing the effect of each concomitant antiepileptic drug on Ct. A linear polynomial expression, in which both members of this model are converted into common logarithms, was used for a multiple regression analysis. The analysis clarified that PB and PHT lowered Ct to 0.770 and 0.710 the value of CBZ alone, respectively. On the other hand, VPA and ZNS did not affect Ct. The number of patients coadministered PRM, CZP, and/or ETS was not sufficient to detect the effect on Ct based on a test of significance. In the case of the addition or discontinuation of concomitant antiepileptic drugs in the same patient, the estimated Ct values were calculated using the value of each Ri and compared with the measured Ct values. Both values were in good agreement, and thus our results appear valid.