Brain and nerve = Shinkei kenkyū no shinpo
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Warfarin is underused because it has many disadvantages for clinical use despite it has been used more than a half century as an only oral anticoagulant. Dabigatran is a direct thrombin inhibitor, which is not metabolized by cytochrome P450, and thus does not require blood coagulation monitoring or vitamin K intake limitation, or produce drug interaction. ⋯ Dabigatran is expected to be approved as a more effective and safer oral anticoagulant than warfarin for stroke prevention in patients with atrial fibrillation. Randomized controlled trials of many factor Xa inhibitors in comparison with warfarin are also ongoing in patients with atrial fibrillation.
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Surgery is a better treatment option than prolonged medical therapy for patients with temporal lobe epilepsy. Randomized trials on surgery for epilepsy are feasible and appear to yield precise estimates of the effects of surgical treatment. This study includes 56 patients who underwent anterior temporal lobectomy with a mean follow-up of 11.3 years. ⋯ No significant relationships were found between objective indices of change and subjective ratings for postoperative memory function. A new surgical method based on multiple subpial transections for the hippocampus was developed in 2006. It remains unclear whether mesial resection involving a larger area leads to better seizure outcomes.
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Despite the advances in pharmacologic treatments for epilepsy, approximately one-third of patients with epilepsy continue to have seizures, and alternative treatment approaches are necessary in such cases. For many patients, resective surgery can be an alternative for achieving seizure freedom; however, its success depend on identifying seizure foci before surgery. Many patients with medically intractable epilepsy are not suitable candidates for surgery. ⋯ The responsive neurostimulator, which can be called a brain pacemaker, is another stimulation device for the treatment of epilepsy. A clinical trial involving the Neuropace system is in progress in the USA. Preliminary results indicating the efficacy of the Neuropace study were presented at the annual American Epilepsy Society meeting in 2010; the final results of this study are awaited.
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Cerebral autosomal recessive arteriopathy with subcortical infarcts and leukoencephalopathy (CARASIL) is a single-gene disorder directly affecting the cerebral small blood vessels, that is caused by mutations in the HTRA1 gene encoding HtrA serine peptidase/protease 1 (HTRA1). CARASIL is the second known genetic form of ischemic, nonhypertensive, cerebral small-vessel diseases with an identified gene, following CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy). The exact prevalence of CARASIL is currently unknown, and so far about 50 patients have been reported, most of them from Japan and two from China. ⋯ CARASIL is a prototype single-gene disorder of cerebral small vessels, secondary to and distinct from CADASIL. CARASIL-associated mutant HTRA1s exhibited decreased protease activity and failed to repress transforming growth factor-β (TGF-β) family signaling, indicating that the increased TGF-β signaling causes arteriopathy in CARASIL. Therefore, HTRA1 represents another new gene to be considered in future studies of the mechanisms and therapeutic strategies of cerebral small-vessel diseases, as well as alopecia and degenerative vertebral/disk diseases.
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Cavernous malformations (CMs) consist of dilated vascular channels that have a characteristic appearance on MRI. They can present with seizures, neurological deficits due to lesion hemorrhage, or as incidental findings on neuroradiological studies. Treatment options include conservative therapy; medical management of seizures; surgical intervention; and in selected cases, stereotactic radiosurgery. ⋯ We reviewed previously published papers on CMs with respect to hemorrhage rates, seizure control, and radiation-induced morbidity in order to better understand the balance of benefits and risks associated with the radiosurgical treatment for CMs. The data in this review provides convincing evidence that stereotactic radiosurgery is a relatively safe procedure with acceptable risks of morbidity and that its use could reduce the rebleeding rate and the frequency of seizures caused by for CMs located in the high-surgical-risk regions of the brain. We also present our experience of treating for 16 patients with CMs and show that our results were comparable to those previously reported.