トクシマ ダイガク ビョウイン ニオケル ノウソッチュウ ケア ユニット ノ イギ ト コンゴ ノ カダイ

Cerebral Stroke such as cerebral infarction, intracerebral hemorrhage and subarachnoid hemorrhage is a leading cause of being a bed-ridden state, thus measures against cerebral stroke are still ongoing issue. The university hospital which provides optimal treatment using advanced techniques must struggle to develop emergency medicine including acute cerebral stroke management. Stroke care unit was founded in 1999 in Tokushima university hospital and has contributed to educate medical students, to train junior residents and to promote clinical research with multidisciplinary approach. Furthermore, we adopted i-Stroke system which allows us to browse clinical data including radiological images and to discuss each other by smartphone. This system provided urgent management decision in acute stroke and contribute to improvement not only patients’ outcome but physicians’ quality of life. The university hospital must also construct a supporting system on medically underpopulated region in future

Bazedoxifene, a selective estrogen receptor modulator, reduces cerebral aneurysm rupture in Ovariectomized rats.

BackgroundEstrogen deficiency is thought to be responsible for the higher frequency of aneurysmal subarachnoid hemorrhage in post- than premenopausal women. Estrogen replacement therapy appears to reduce this risk but is associated with significant side effects. We tested our hypothesis that bazedoxifene, a clinically used selective estrogen receptor (ER) modulator with fewer estrogenic side effects, reduces cerebral aneurysm rupture in a new model of ovariectomized rats.MethodsTen-week-old female Sprague-Dawley rats were subjected to ovariectomy, hemodynamic changes, and hypertension to induce aneurysms (ovariectomized aneurysm rats) and treated with vehicle or with 0.3 or 1.0 mg/kg/day bazedoxifene. They were compared with sham-ovariectomized rats subjected to hypertension and hemodynamic changes (HT rats). The vasoprotective effects of bazedoxifene and the mechanisms underlying its efficacy were analyzed.ResultsDuring 12 weeks of observation, the incidence of aneurysm rupture was 52% in ovariectomized rats. With no effect on the blood pressure, treatment with 0.3 or 1.0 mg/kg/day bazedoxifene lowered this rate to 11 and 17%, almost the same as in HT rats (17%). In ovariectomized rats, the mRNA level of ERα, ERβ, and the tissue inhibitor of metalloproteinase-2 was downregulated in the cerebral artery prone to rupture at 5 weeks after aneurysm induction; the mRNA level of interleukin-1β and the matrix metalloproteinase-9 was upregulated. In HT rats, bazedoxifene restored the mRNA level of ERα and ERβ and decreased the level of interleukin-1β and matrix metalloproteinase-9. These findings suggest that bazedoxifene was protective against aneurysmal rupture by alleviating the vascular inflammation and degradation exacerbated by the decrease in ERα and ERβ.ConclusionsOur observation that bazedoxifene decreased the incidence of aneurysmal rupture in ovariectomized rats warrants further studies to validate this response in humans

Hyperhomocysteinemia induced by excessive methionine intake promotes rupture of cerebral aneurysms in ovariectomized rats.

BackgroundHyperhomocysteinemia (HHcy) is associated with inflammation and a rise in the expression of matrix metalloproteinase-9 (MMP-9) in the vascular wall. However, the role of HHcy in the growth and rupture of cerebral aneurysms remains unclear.MethodsThirteen-week-old female Sprague-Dawley rats were subject to bilateral ovariectomy and ligation of the right common carotid artery and fed an 8 % high-salt diet to induce cerebral aneurysms. Two weeks later, they underwent ligation of the bilateral posterior renal arteries. They were divided into two groups and methionine (MET) was or was not added to their drinking water. In another set of experiments, the role of folic acid (FA) against cerebral aneurysms was assessed.ResultsDuring a 12-week observation period, subarachnoid hemorrhage due to aneurysm rupture was observed at the anterior communicating artery (AcomA) or the posterior half of the circle of Willis. HHcy induced by excessive MET intake significantly increased the incidence of ruptured aneurysms at 6-8 weeks. At the AcomA of rats treated with MET, we observed the promotion of aneurysmal growth and infiltration by M1 macrophages. Furthermore, the mRNA level of MMP-9, the ratio of MMP-9 to the tissue inhibitor of metalloproteinase-2, and the level of interleukin-6 were higher in these rats. Treatment with FA abolished the effect of MET, suggesting that the inflammatory response and vascular degradation at the AcomA is attributable to HHcy due to excessive MET intake.ConclusionsWe first demonstrate that in hypertensive ovariectomized rats, HHcy induced by excessive MET intake may be associated with the propensity of the aneurysm wall to rupture

キュウセイキ ノウコウソク ニ タイシ t‐PA リョウホウ ガ ムコウ デ アッタ ショウレイ ニ タイスル ケイドウミャクテキ ケッセン ハサイ キュウイン ジュツ ノ ユウヨウセイ

Endovascular thrombectomy have emerged as crucial treatment options for patients with acute ischemic stroke who are ineligible for intravenous tissue plasminogen activator（tPA）or in whom such therapy has failed. We assessed the efficacy of mechanical thrombectomy for acute ischemic stroke patients who failed intravenous tPA. Five of６patients achieved recanalization by means of endovascular technique and showed favorable outcome. Endovascular thrombectomy after intravenous tPA can be safe and effective for the ischemic stroke with major artery occlusion

Treatment with the PPARγ Agonist Pioglitazone in the Early Post-ischemia Phase Inhibits Pro-inflammatory Responses and Promotes Neurogenesis Via the Activation of Innate- and Bone Marrow-Derived Stem Cells in Rats

Neurogenesis is essential for a good post-stroke outcome. Exogenous stem cells are currently being tested to promote neurogenesis after stroke. Elsewhere, we demonstrated that treatment with the PPARγ agonist pioglitazone (PGZ) before cerebral ischemia induction reduced brain damage and activated survival-related genes in ovariectomized (OVX) rats. Here, we tested our hypothesis that post-ischemia treatment with PGZ inhibits brain damage and contributes to neurogenesis via activated stem cells. Bone marrow (BM) cells of 7-week-old Wistar female rats were replaced with BM cells from green fluorescent protein-transgenic (GFP+BM) rats. Three weeks later, they were ovariectomized (OVX/GFP+BM rats). We subjected 7-week-old Wistar male and 13-week-old OVX/GFP+BM rats to 90-min cerebral ischemia. Male and OVX/GFP+BM rats were divided into two groups, one was treated with PGZ (2.5 mg/kg/day) and the other served as the vehicle control (VC). In both male and OVX/GFP+BM rats, post-ischemia treatment with PGZ reduced neurological deficits and the infarct volume. In male rats, PGZ decreased the mRNA level of IL-6 and M1-like macrophages after 24 h. In OVX/GFP+BM rats, PGZ augmented the proliferation of resident stem cells in the subventricular zone (SVZ) and the recruitment of GFP+BM stem cells on days 7–14. Both types of proliferated stem cells migrated from the SVZ into the peri-infarct area. There, they differentiated into mature neurons, glia, and blood vessels in association with activated Akt, MAP2, and VEGF. Post-ischemia treatment with PGZ may offer a new avenue for stroke treatment through contribution to neuroprotection and neurogenesis

ノウソッチュウ ノ イリョウ レンケイ : ケンナンブ イリョウ ノ カイゼン オ メザシテ

Background : Cerebrovasucular disease have been known as“brain attack”since introduction of the treatment with recombinant tissue plasminogen activator against cerebral infarction. Emergent transport of apoplexy patients to hospitals with stroke care unit is needed. But nowadays, shortage of doctors appeared in Kaifu county of Tokushima Prefecture. Objectives : The aim of this study was to clarify problems on patients with apoplexy in this district. Methods : Three representative clinical cases are presented. Results : They were suffered from acute cerebral infarction, subarachnoid hemorrhage, or chronic cerebral infarction complicated with aspiration pneumonia and bed-sores. Conclusions : In order to treat patients with cerebrovasucular diseases effectively in this district, organic and friendly co-operation among doctors of stroke care units, physicians belonging to the Tokushima Medical Association, and staffs of the geriatric health service facilities is needed

シンコウセイ ニ ゾウアク オ キタシ ケッカンナイ チリョウ オ シコウ シタ ミギナイ ケイドウミャク ヘイソク ノ 1レイ

A ７７-year-old man was admitted to our hospital in July ２００９ with monoparesis of the left upper extremity. His magnetic resonance images（MRI）demonstrated multiple infarction in the right temporoparietal lobe, and his emergent cerebral angiography revealed total occlusion of the right internal carotid artery（ICA）at the origin. We diagnosed atherothrombotic infarction and started to treat with antiplatelet drugs. But, his symptoms were gradually progressing despite medical treatment and his MRI showed an enlargement of ischemic lesion８days after admission. Because the hemodynamic enlargement due to ICA occlusion and DWI-PWI mismatch was detected, we performed emergent PTA（percutaneous transluminal angioplasty）and CAS（carotid artery stent placement）at that time. The ICA was completely recanalized without any complications. His symptoms were getting better, and his cerebral blood flow improved at rest on single photon emission computed tomography（SPECT）６days after treatment. He was transferred to another hospital１７days after the onset. This case experience suggests that endovascular revascularization can be considered as potential treatment for symptomatic ICA occlusion based on atherosclerosis even in the subacute stage of the stroke patients

トクシマケン ナンブ ノ キュウキュウ イリョウ ノ ゲンジョウ ト アラタナ トリクミ : ノウシンケイ ゲカ ノ タチバ カラ

A regular neurosurgeon was absent in the southern part II health demographic division of medical services where Kaifu-gun of South Tokushima was located after 2008 and was the present conditions that stroke treatment could not perform enough in comparison with prefecture central part. Furthermore, medical care collapse progressed with the obstetrics and gynecology department and pediatrics closedown at one sweep from the same period and, at the prefectural Kaifu Hospital which was this local nucleus hospital, became hard to maintain the emergency care, and increase of closedown of the emergency outpatient department on Saturday and the emergency transportation to the prefecture central part became remarkable, and it was with a big social problem for Tokushima. A medical difference might occur about stroke medical care in central part and the southern part in Tokushima. We performed the epidemiology survey by stroke patient in the southern II demographic division of medical services （popular name “Kaifu project”） as a President of University of Tokushima discretion project for this fact-finding individually in the University of Tokushima neurosurgery classroom. In addition, I worked on the enlightenment for inhabitants in Kaifu-gun. “Local neurosurgical medical treatment part” was established as a college course financially maintained by private donations of Tokushima University Hospital from November 1，2011． Kaifu Hospital neurosurgery medical treatment was enabled daylong, and emergency correspondence came to be in this way possible. The Kaifu Hospital devises the maintenance policy about Tokushima, local inhabitants, a medical association, a local government and the figure which there should be of “the new Kaifu Hospital” for a tsunami now in the plan of the full-scale reconstruction move to the hill in 2015