AIM:A reduction in low-density lipoprotein cholesterol (LDL-C) is beneficial for vascular diseases; however, lower LDL-C levels may be associated with an increased risk of spontaneous intracerebral hemorrhage (sICH). The present study investigated the relationship between the LDL-C levels and in-hospital mortality after sICH using data from the Juntendo Registry of Spontaneous Intra-Cerebral Hemorrhage (J-ICH registry). METHODS:Patients aged ≥ 20 years with non-traumatic sICH admitted to five Juntendo-affiliated hospitals between September 2016 and December 2019 were enrolled in this study. The relationships between the LDL-C levels and in-hospital mortality, statin therapy, and antithrombotic therapy were analyzed. RESULTS:Among the 1,017 patients with sICH, lower LDL-C levels were associated with older age, a lower BMI, a larger hematoma volume, more severe neurological deficits, and a higher in-hospital mortality. A logistic regression analysis confirmed that LDL-C ＜100 mg/dL independently increased the risk of in-hospital death, along with age, the NIHSS score, hematoma volume, and intraventricular hemorrhage. Subgroup analyses showed that the association between low LDL-C levels and mortality was particularly evident in patients with deep/infratentorial intracerebral hemorrhage, those managed without surgery, and those without prior statin use. Prior statin use was associated with a potential protective effect against in-hospital mortality and hematoma volume. CONCLUSION:This study demonstrated that lower LDL-C levels were associated with a higher in-hospital mortality after sICH, whereas prior statin use was not associated with poorer outcomes and may instead offer a protective effect.

The superior thyroid cornu (STC) is a normal anatomic structure that forms part of the thyroid cartilage. Here, we report a patient with unusually elongated and ossified STC that might result in recurrent cerebral embolisms. During a second endovascular therapy for recurrent middle cerebral artery embolism, a segment with an irregular filling defect was noted in the internal carotid artery (ICA), at the C1 level. This defect was unnoticed during the initial endovascular procedure. Three-dimensional computed tomography angiography performed after the second endovascular procedure revealed an ICA segment located between the STC and C1 with a tortuous course and irregular wall of the ICA. Therefore, we assumed that STC compression of the ICA could have resulted in thrombus formation at the site and consequent cerebral embolism. The STC should be considered a structure responsible for cerebral embolism. Careful evaluation of the entire ICA course is imperative prior to performing an endovascular thrombectomy for acute embolic occlusion of the middle cerebral artery.

Spontaneous intracerebral hemorrhage (SICH) remains a devastating form of stroke. Prior use of antiplatelets or warfarin before SICH is associated with poor outcomes, but the effects of direct oral anticoagulants (DOACs) remain unclear. This study aimed to clarify trends in prior antithrombotic use and to assess the associations between prior use of antithrombotics and in-hospital mortality using a multicenter prospective registry in Japan. In total, 1085 patients were analyzed. Prior antithrombotic medication included antiplatelets in 14.2%, oral anticoagulants in 8.1%, and both in 1.8%. Prior warfarin use was significantly associated with in-hospital mortality (odds ratio [OR] 5.50, 95% confidence interval [CI] 1.30-23.26, P < 0.05) compared to no prior antithrombotic use. No such association was evident between prior DOAC use and no prior antithrombotic use (OR 1.34, 95% CI 0.44-4.05, P = 0.606). Concomitant use of antiplatelets and warfarin further increased the in-hospital mortality rate (37.5%) compared to warfarin alone (17.2%), but no such association was found for antiplatelets plus DOACs (8.3%) compared to DOACs alone (11.9%). Prior use of warfarin remains an independent risk factor for in-hospital mortality after SICH in the era of DOACs. Further strategies are warranted to reduce SICH among patients receiving oral anticoagulants and to prevent serious outcomes.

There are only a few case reports in which cholesterol crystals were found in the thrombus retrieved by mechanical thrombectomy for cryptogenic stroke, leading to a definitive diagnosis. We herein report a case of aortogenic embolic stroke diagnosed by the presence of rich cholesterol crystals in the retrieved thrombus and review the previously reported cases. A woman in her 80s was transferred as an emergency due to consciousness disturbance, right conjugate deviation, and severe left hemiparesis. Magnetic resonance imaging showed occlusion of the right middle cerebral artery (MCA) and acute infarction in the territory. The MCA was recanalized by thrombectomy using an aspiration catheter and stent retriever, and the symptoms improved. Although the physiological examination did not detect the embolic source during hospitalization, pathological examination of the thrombus revealed atheroma with numerous cholesterol crystal clefts and intermixing of fibrin. Contrast-enhanced computed tomography performed based on the pathological results showed atheromatous lesions in the aortic arch as the embolic source. As a subsequent treatment, medications of a strong statin and an antiplatelet agent were continued, and the patient had no recurrence. The finding that the retrieved thrombus is a simple atheroma containing cholesterol crystals with poor hemocytes suggests embolism due to plaque rupture. Pathological examination of the thrombus obtained by thrombectomy is one of the useful diagnostic approaches for stroke etiology and the determination of its treatment.

A 70-year-old man, who had previously undergone surgical resection of left parasagittal meningioma involving the middle third of the superior sagittal sinus (SSS) two times, presented with recurrence of the tumor. We performed removal of the tumor combined with SSS resection as Simpson grade II. After tumor removal, since a left dominant bilateral chronic subdural hematoma (CSDH) appeared, it was treated by burr hole surgery. However, because the CSDH rapidly and repeatedly recurred and eventually changed to acute subdural hematoma, elimination of the hematoma with craniotomy was accomplished. The patient unfortunately died of worsening of general condition despite aggressive treatment. Histopathology of brain autopsy showed invasion of anaplastic meningioma cells spreading to the whole outer membrane of the subdural hematoma. Subdural hematoma is less commonly associated with meningioma. Our case indicates the possibility that subdural hematoma associated with meningioma is formed by a different mechanism from those reported previously.

Trigeminal neuralgia (TN) is usually caused by vascular compression of the trigeminal nerve root entry zone, but can be caused by other factors such as tumors, vascular disorders, and demyelination in multiple sclerosis. We present a rare case with a huge osteoma located on the cerebellopontine angle (CPA) and causing TN. A 48-year-old woman presented with TN caused by a huge left CPA bone tumor. Surgery was performed by the lateral suboccipital approach under neuronavigation system guidance and regional decompression of the trigeminal nerve root entry zone was achieved. Intraoperative, neuro-navigation system was very useful for identification of the trigeminal nerve entry zone because normal anatomy had been obscured by the huge osteoma. Her pain disappeared completely immediately after surgery. The histological diagnosis was osteoma. TN is an expectative symptom of CPA tumors. Osteomas should be considered in patients with CPA tumors.

【目的】当院における過去10年間の脳卒中診療の，内容とその変化について総括した．【方法】1997∼2001年までを前期，2002∼2006年までを後期とし，疾患分布や診療内容について検討した．【結果】総患者数は2,699人（前期1,238・後期1,461），疾患の内訳は虚血性（CI）/脳出血（ICH）/クモ膜下出血（SAH）が前期・後期でそれぞれ59.2%/26.5%/14.3%・62%/24.2%/12.9%であった．治療内容での変化は動脈瘤治療における血管内手術の増加（10%→25%）と，超急性期脳梗塞に対するtPA療法の導入（H16.12∼）であった．予後良好例はCIが，死亡率はSAHが最も多い傾向があった．またICHは機能予後不良例が最も多かった．【結論】当院における脳卒中の治療成績は前後期で大きな改善はなかったが，患者の平均年齢は前後期を比較すると2.4歳高齢化し，平均在院日数は27.2日から23.5日と3.7日短縮した．また，全脳卒中急性期患者の19.6%に外科的治療を要した．

特発性正常圧水頭症(iNPH)に対する,圧可変式+重力可変式のハイブリッドなシャントシステムでの治療経験13例を報告した.全例で何らかの症状改善がみられ,術後1年で圧変更を要したのは3例であった.重力可変式システムは,体位にかかわらず生理的な状態に近い脳室内圧が維持できることが,術後の圧測定から裏付けられた.また,調節が不良の場合には圧可変装置が必要であるが,従来の圧可変式のみのシステムと比較すると,圧変更の必要性は非常に少なくできる可能性も示唆された.われわれの用いたハイブリットなシステムは,繊細な調節を必要とするiNPHのシャント治療には,非常に有効である可能性が示された.

We report a case of intracranial hemorrhage due to amphetamine abuse in a young adult. A 34-year-old, confused woman was transferred to our emergency room with right hemiparesis and aphasia. CT at admission demonstrated intracerebral hemorrhage in the left frontal and parietal lobes, associated with subarachnoid hemorrhage. MRA shortly after admission revealed no intracerebral vascular anomaly. Cerebral angiography following admission showed irregularity of the vessel wall in the left anterior and middle cerebral arteries. Later, a toxicology screen test for urine was found to be positive for amphetamines and metamphetamines. These findings suggested that cerebral vasculitis and hypertensive surge induced by amphetamines caused intracranial and subarachnoid hemorrhage. Amphetamine abuse should always be considered as a cause of intracranial hemorrhage in young adults.

初回血管撮影で出血源が確定出来なかったくも膜下出血(SAHUE)例の臨床像について,自験例で検討した.1997.1～2005.6までに当院に入院した非外傷性SAH連続325例中,初回血管撮影で出血源が診断されなかった34例を対象.最終的に出血源不明で,再出血もきたさなかった15例をgroup A,出血源が判明した,或るいは再出血をきたした19例をgroup Bとして,その臨床像を比較検討した.Group Bはgroup Aに比べて,入院時症状・CT上の血腫量・症候性血管攣縮・水頭症の有無・最終的予後,のいずれについても重症度が高い傾向があきらかであった.最終的に出血源が判明したのは15例で,内頚動脈系と椎骨脳底動脈系が各6例と多かった.前者のうち,5例がいわゆる内頚動脈前壁動脈瘤(ICA)であった.SAHUEは,明らかな出血源がみられず予後良好な群は半数程度で,破裂動脈瘤の存在する通常のSAHも多く含まれている.中でも特に予後不良な転帰をとる例はICAの含まれている可能性が高く,注意を要する.

BACKGROUNDThe mechanism of continuous massive hemorrhage into the subperiosteal space in children without coagulation defects is unknown. We report a case of giant expanding cephalhematoma reversed by the administration of blood coagulation factor XIII concentrate.METHODThe patient was an 8-year-old boy with a history of minor head trauma who developed a giant expanding cephalhematoma with intraorbital extension. The laboratory data showed severe anemia, but a routine blood coagulation test showed no abnormalities except for a low factor XIII level.RESULTThe administration of factor XIII concentrate completely reversed the symptoms in 2 weeks.CONCLUSIONWe speculate that one of the possible mechanisms of cephalhematoma expansion without blood coagulation defects might be acquired factor XIII deficiency from severe hemorrhage in a hematoma. (C) 2003 Elsevier Inc. All rights reserved.

Recently, unusual examples of tumors of the mixed glioneuronal type have been reported, including the papillary glioneuronal tumor (PGNT). A 23-year-old woman with a 2-3 months history of headache and insomnia presented with a tumor. Neuroimaging showed a right temporal lobe cystic tumor with a mural nodule enhanced by contrast medium. She underwent gross total resection of the tumor. The tumor was histologically marked by a mixture of glial and neural components. A pseudopapillary component was comprised of highly hyalinized vessels surrounded by a single layer of thin spindle cells stained for glial fibrillary acidic protein. Specific abortive glial cells stained for vimentin/S-100 protein accompanied pseudopapillary structure. Intervening neural areas were occupied by neural cells of varying size, including neurocyte-like cell and ganglionic cells. Ganglionic cells demonstrated abnormal cluster, lack of normal polarity and epiperikaryal immunoreactivity for synaptophysin staining suggesting neural neoplastic nature. No mitotic activity or necrosis was noted. A MIB-1 labeling index was 1.8%. Our patient remains free of disease 33 months after surgical treatment.

A 9-year-old girl with a 1-month history of generalized seizure presented with a distinctive tumor resembling pleomorphic xanthoastrocytoma. Neuroimagings showed a right frontotemporal lobe tumor. Histological examination of the resected tumor indicated similarity to pleomorphic xanthoastrocytoma without staining for glial fibrillary acidic protein. The neuronal immunoreactivity and ultrastructural features showed two discrepancies: Numerous cytoplasmic processes containing rich structures suspected to be microtubules and neurofilaments were present, but neurofilament protein 70 kd/200 kd staining was negative; and many tumor cells showed synaptophysin staining, but no synaptic structures or vesicles were observed. She suffered recurrence 14 months after the first surgery. The specimen from the second operation revealed no malignant transformation with a MIB-1 labeling index of 1.9%. Only 2 months after the second operation, there was a second recurrence. Irradiation was administered (60.2 Gy). Twenty-eight months later, no tumor progression was seen. This tumor was an unconventional type with "abortive" or "aberrant" neuronal differentiation or an extreme variant of pleomorphic xanthoastrocytoma.

立位と臥位でのシャント開放圧を自動的に変化させる機構をもったバルブであるdual switch valve(DSV)の臨床経験と,術後の脳室サイズ・脳室内圧について検討した,DSVを用いてシャント手術を施行した26例(男性13/女性13,平均年齢62.7歳)の水頭症患者を対象とし,sophy圧可変式シャントバルブ(PAVS)を用いた33例と比較した、DSV群では,脳室の平均縮小比率が9.0%で,PAVS(15.6%)に比べ軽度であった.また,脳室内圧は臥位で43mmH_2O,座位で-37mmH_2O(いずれも平均)と,生理的な範囲内にコントロールされていた.過剰排液による合併症はみられず,その他の合併症の頻度はPAVS群と比べ変わらなかった.

We report 5 cases of dural AVMs, in which MRA images were considered very useful for evaluating the effectiveness of treatments, such as transvenous embolization therapy. MRA by time of flight method (TOF) with contrast medium for dural AVMs involving the cavernous sinus (dural CCFs) is necessary to assess the caliber of superior ophthalmic veins (SOVs) prior to treatment as well as immediately after treatment and during follow-up. MRA for dural AVM at the transverse-sigmoid sinus is useful for verifying thrombosed sinus in the dural AVM prior to transvenous embolization therapy and necessary to determine the approach to the nidus of the dural AVM2.

A case of a primary pineal embryonal carcinoma occurring in a middle aged man is reported. A 42-year-old man suffering from headache and nausea was referred to our department. A neurological examination revealed that he had Parinaud's sign. Head CT and MRI showed a tumor in the pineal region. He was operated on using the occipital trans-tentorial approach. The tumor was partially removed and an intra-operative specimen was used to diagnose a kind of germ cell line tumor. However, the tumor was diagnosed afterwards as a pure embryonal carcinoma. Three courses of PE chemotherapy followed by 30 Gy of whole craniospinal irradiation and 30 Gy of extended local irradiation were completed. An MRI showed the tumor to be in complete remission. Despite careful follow-up with chemotherapy every three months, a re-operation and linac radio-surgery, the tumor recurred, and disseminated. The patient died due to an intra-tumoral hemorrhage. A pure primary pineal embryonal carcinoma occurring in a middle-aged person has never been reported previously in detail.

We present 3 cases of acute subdural hematomas as a result of ruptured intracranial aneurysm. Acute subdural hematoma is a recognized but unusual complication of intracranial aneurysmal rupture. And rupture of intracranial aneurysm should be considered the source of hemorrhage in patients showing acute subdural hematoma without a history or signs of trauma. If the case is not rapidly fatal, conventional angiography is indicated as soon as possible to rule out aneurysm, AVM or other source of intracranial bleeding. The management of the patient poses a dilemma if the case shows rapidly fatal intracranial hemorrhage. Even the presence of slight SAH at the basal cistern strongly suggests the existence of ruptured aneurysm, but aneurysmal clipping without angiography should be avoided judging from the poor results in previous case reports. Our recent experience suggests that, at the present time, immediate MR angiography is a time saving and promising examination for such patients.

We report a case in which bilateral occipital brain metastases and neoplastic cerebral aneurysms developed from primary cardiac malignant fibrous histiocytoma. The origin of metastases was confirmed at autopsy. The clinical presentation, radiographic features, and autopsy findings are presented along with a histopathologic analysis of the tumor.