Bypass-Assisted Microsurgical Clipping for an Endovascular Treatment-Resistant Ruptured Internal Carotid-Posterior Communicating Artery Aneurysm, Recurring Two Decades Postinitial Clipping: 2-Dimensional Operative Video

Salvage treatment of postclipping recurrent aneurysms remains challenging.1,2 The salvage microsurgical clipping is a possible intervention but sometimes difficult because of tissue adhesions around the aneurysm and previously installed clips; therefore, salvage coil embolization may have certain advantages.1-5 However, when coil embolization is not applicable,6 microsurgical clipping is a stand-alone curative treatment, requiring proficient and reliable microsurgical techniques. This article describes a unique case of a 70-year-old female patient complaining of a severe headache with subarachnoid hemorrhage due to a recurrent ruptured left internal carotid-posterior communicating artery aneurysm after microsurgical clipping 23 years ago. An initial attempt at coil embolization proved unsuccessful because of the aneurysm shape. Consequently, the salvage microsurgical clipping was planned. Given the additional time for trapping the internal carotid artery for the old clip removal, a superficial temporal artery-middle cerebral artery bypass was also planned. The operation entailed a superficial temporal artery-middle cerebral artery bypass, a Sylvian fissure dissection, the old clip removal, and aneurysm clipping. Intraoperatively, the complete aneurysm neck clipping was successfully performed without any complication, and patient postoperative course was uneventful. A wide surgical field should be obtained to be able to manipulate the aneurysm and old clip safely under a microscope. It is also important to temporarily trap the main artery to ensure removal of old clips and to prepare for intraprocedural ischemia using bypass after a precise assessment of hemodynamics before surgery. The patient provided informed consent for the procedure and the publication of the case along with its pertinent imaging, and this report was approved by the institutional review board at our hospital.

Associations of age-adjusted coefficient of variation of R-R intervals with autonomic and peripheral nerve function in non-elderly persons with diabetes

AIMS/INTRODUCTION

Early diagnosis of diabetes-associated cardiac autonomic neuropathy using the coefficient of variation of R-R intervals (CVRR) may improve outcomes for individuals with diabetes. The present study examined the associations of decreased CVRR at rest and during deep breathing (DB) with other autonomic nerve function parameters.

MATERIALS AND METHODS

The electronic records of 141 inpatients with diabetes (22-65 years) admitted to our hospital between March 2015 and March 2019 were analyzed retrospectively. After assessment by exclusion criteria, 51 inpatients were included. All inpatients were assessed for peripheral and autonomic nerve function, clinical characteristics, and physical abilities.

RESULTS

Inpatients with decreased CVRR at rest (n = 9 (17.6%)) and during DB (n = 12 (23.5%)) had a longer duration of known diabetes, a higher prevalence of diabetic retinopathy, lower body mass index (BMI), skeletal mass index (SMI), and knee extension strength, and a higher proportion of impaired standing balance. Decreased CVRR at rest was associated with a greater fall in diastolic BP from supine to standing, higher resting HR, longer QTc, longer time of voiding, and sensory symptoms.

CONCLUSIONS

Decreased CVRR at rest and during deep breathing was associated with lower BMI, SMI, and knee strength and a higher proportion of impaired standing balance among non-elderly inpatients with diabetes. Decreased CVRR at rest appeared more strongly associated with a greater orthostatic BP decline, higher resting heart rate, longer QTc, lower urinary tract dysfunction, and sensory symptoms than a decreased CVRR during deep breathing.

Orbital Arteriovenous Fistula Causing Only Visual Impairment due to Compression of the Optic Nerve by the Dilated Superior Ophthalmic Vein

Orbital arteriovenous fistula (AVF) is a rare disease, and its standard therapeutic strategy has not been established. A 70-year-old male consulted an ophthalmologist due to a visual field defect in his left eye. Neurological findings showed visual impairment but no symptoms such as exophthalmos, conjunctival congestion, or diplopia. Magnetic resonance imaging showed marked dilation of the left superior ophthalmic vein (SOV). Cerebral angiography revealed an AVF that was limited to the left orbit. The feeder was a branch of the ophthalmic artery that originated from the first portion, and the drainer was the SOV, which was meandering and significantly dilated. Since the only symptom was visual impairment, the etiology was considered to be compression of the optic nerve due to a dilated SOV rather than increased venous pressure. Transvenous embolization via the facial vein was performed, and a visual field examination 1 week after the operation revealed marked improvement. Orbital AVF that develops only with visual impairment is extremely rare. As demonstrated with this case, coil embolization for proper position and reduction of the venous pressure, which relieves compression on the optic nerve, may be useful in improving the visual impairment.

Comprehensive collection of genes and comparative analysis of full-length transcriptome sequences from Japanese larch (Larix kaempferi) and Kuril larch (Larix gmelinii var. japonica)

BACKGROUND

Japanese larch (Larix kaempferi) is an economically important deciduous conifer species that grows in cool-temperate forests and is endemic to Japan. Kuril larch (L. gmelinii var. japonica) is a variety of Dahurian larch that is naturally distributed in the Kuril Islands and Sakhalin. The hybrid larch (L. gmelinii var. japonica × L. kaempferi) exhibits heterosis, which manifests as rapid juvenile growth and high resistance to vole grazing. Since these superior characteristics have been valued by forestry managers, the hybrid larch is one of the most important plantation species in Hokkaido. To accelerate molecular breeding in these species, we collected and compared full-length cDNA isoforms (Iso-Seq) and RNA-Seq short-read, and merged them to construct candidate gene as reference for both Larix species. To validate the results, candidate protein-coding genes (ORFs) related to some flowering signal-related genes ​were screened from the reference sequences, and the phylogenetic relationship with closely related species was elucidated.

RESULTS

Using the isoform sequencing of PacBio RS ll and the de novo assembly of RNA-Seq short-read sequences, we identified 50,690 and 38,684 ORFs in Japanese larch and Kuril larch, respectively. BUSCO completeness values were 90.5% and 92.1% in the Japanese and Kuril larches, respectively. After comparing the collected ORFs from the two larch species, a total of 19,813 clusters, comprising 22,571 Japanese larch ORFs and 22,667 Kuril larch ORFs, were contained in the intersection of the Venn diagram. In addition, we screened several ORFs related to flowering signals (SUPPRESSER OF OVEREXPRESSION OF CO1: SOC1, LEAFY: LFY, FLOWERING Locus T: FT, CONSTANCE: CO) from both reference sequences, and very similar found in other species.

CONCLUSIONS

The collected ORFs will be useful as reference sequences for molecular breeding of Japanese and Kuril larches, and also for clarifying the evolution of the conifer genome and investigating functional genomics.

STA-A3 Bypass Using Radial Artery Graft for Progressive Cerebral Infarction of Bilateral ACA Region after STA-MCA Bypass Surgery for Moyamoya Disease

Direct revascularization surgery, such as superficial temporal artery (STA)-middle cerebral artery (MCA) bypass, is effective in preventing ischemia and hemorrhage for moyamoya disease. On the other hand, when ischemia of the anterior cerebral artery (ACA) region progresses after ipsilateral STA-MCA bypass, it is difficult to perform revascularization from the viewpoint of the donor artery. A 55-year-old woman with right hemiparesis was diagnosed with cerebral infarction due to moyamoya disease. Left STA-MCA bypass was performed with no postoperative complications, but memory impairment and decreased motivation were observed 2 months after the operation. Magnetic resonance imaging and angiography revealed new infarction in the bilateral ACA area and deterioration in the signal intensity of bilateral ACAs. Revascularization of the bilateral ACA regions was considered necessary, but the left STA was already used in the previous surgery. Therefore, STA-radial artery (RA)-A3 bypass using RA graft combined with right STA-MCA bypass was performed. STA-A3 bypass using an RA graft may be the optimal treatment for ischemia of the ACA region that progresses after STA-MCA bypass.

Longitudinal effects of one-leg standing time on neuropathy outcomes in association with glycemic control in non-elderly patients with type 2 diabetes

Aims/Introduction

Diabetic neuropathy leads to postural instability. This study compared longitudinal changes in neuropathy outcomes relative to long‐term glycemic control in patients aged <60 years with uncontrolled type 2 diabetes with and without a short one‐leg standing time (OLST <60 s).

Materials and Methods

In this retrospective study, 58 hospitalized patients with type 2 diabetes (glycated hemoglobin [HbA1c] >7.0%; aged 17–59 years), who underwent re‐evaluation of neuropathic sensory symptoms, ankle reflexes and nerve conduction attributes, and cardiac autonomic function (R‐R interval), >1 year after discharge were divided into OLST <60 and ≥60 s groups. Patients were followed up every 2–3 months for HbA1c levels for up to 8 years. Neuropathy outcomes relative to OLST and HbA1c levels at baseline and over follow up were compared.

Results

Additional development of sensory symptoms (one patient) and abnormal ankle reflexes (five patients) were identified during follow up, and decreased peripheral and cardiac autonomic function at both baseline and follow up, only in patients with OLST <60 s. Mean HbA1c levels were significantly higher in patients with OLST <60 s versus ≥60 s (7.8 ± 0.9% vs 7.2 ± 1.2%; P = 0.022). Better glycemic control during follow up was associated with better neuropathy outcomes only in patients with OLST ≥60 s.

Conclusion

Non‐elderly type 2 diabetes patients with OLST <60 s and decreased peripheral nerve function at baseline are at increased risk for intractable diabetic neuropathy. Better glycemic control alone might not improve neuropathy outcomes in these patients.

Characteristics and outcomes of avoidant/restrictive food intake disorder in Japanese elementary-school students on total parenteral nutrition

The clinical outcomes of adolescents with avoidant/restrictive food intake disorder (ARFID) remain unclear. Furthermore, no report has compared the characteristics of ARFID and restricting-type anorexia nervosa (R-AN) in elementary-school students on total parenteral nutrition (TPN). This study retrospectively reviewed inpatients diagnosed with ARFID or R-AN between 2005 and 2019. Patients with ARFID (two boys and seven girls) and R-AN (13 girls) were hospitalized because of rapid physical deterioration, and nutrition therapy was continued without withdrawal. The ARFID group exhibited significantly lower body weights at admission than the R-AN group and gained an average of 6.5 kg during hospitalization; furthermore, the monthly weight gain during hospitalization was significantly higher, and no relapse was observed. Early physical improvement in ARFID resulted in good recovery. In conclusion, TPN can be easily introduced to patients with ARFID, in whom aversive eating is a concern, and is a suitable treatment for ARFID.

Extradural Middle Fossa and Transcavernous Approach for Resection of Trigeminal Neurinoma at Lateral Cavernous Sinus

We present a 52-year-old male case of right trigeminal neurinoma at lateral cavernous sinus. The tumor was 40 mm in maximum diameter, obviously compressed temporal lobe and encased internal carotid artery. Extradural middle fossa and transcavernous approach was applied and the tumor was resected via Parkinson's triangle. This approach enabled safe and effective tumor resection, sufficient visualization, and operative field ( Figs. 1 and 2 ). We performed dissection of the tumor from trigeminal nerve, tentorium, and middle fossa and resect the tumor around internal carotid artery sufficiently. Postoperative course was good without any new neurological deficit. This surgical method is considered safe and effective for the resection of the tumor at lateral cavernous sinus.

The link to the video can be found at: https://youtu.be/2ekuILIgEuo.

IntSplice2: Prediction of the Splicing Effects of Intronic Single-Nucleotide Variants Using LightGBM Modeling

Prediction of the effect of a single-nucleotide variant (SNV) in an intronic region on aberrant pre-mRNA splicing is challenging except for an SNV affecting the canonical GU/AG splice sites (ss). To predict pathogenicity of SNVs at intronic positions −50 (Int-50) to −3 (Int-3) close to the 3’ ss, we developed light gradient boosting machine (LightGBM)-based IntSplice2 models using pathogenic SNVs in the human gene mutation database (HGMD) and ClinVar and common SNVs in dbSNP with 0.01 ≤ minor allelic frequency (MAF) < 0.50. The LightGBM models were generated using features representing splicing cis-elements. The average recall/sensitivity and specificity of IntSplice2 by fivefold cross-validation (CV) of the training dataset were 0.764 and 0.884, respectively. The recall/sensitivity of IntSplice2 was lower than the average recall/sensitivity of 0.800 of IntSplice that we previously made with support vector machine (SVM) modeling for the same intronic positions. In contrast, the specificity of IntSplice2 was higher than the average specificity of 0.849 of IntSplice. For benchmarking (BM) of IntSplice2 with IntSplice, we made a test dataset that was not used to train IntSplice. After excluding the test dataset from the training dataset, we generated IntSplice2-BM and compared it with IntSplice using the test dataset. IntSplice2-BM was superior to IntSplice in all of the seven statistical measures of accuracy, precision, recall/sensitivity, specificity, F1 score, negative predictive value (NPV), and matthews correlation coefficient (MCC). We made the IntSplice2 web service at https://www.med.nagoya-u.ac.jp/neurogenetics/IntSplice2.

T11/T12 ossification of the yellow ligament contributing to thoracic myelopathy in patient with posterior fossa arachnoid cyst and acquired incidental Chiari I malformation/syrinx

Background:

Thoracic ossification of the yellow ligament (OYL) may contribute to myelopathy. In the case presented, the patient additionally had a chronic posterior fossa arachnoid cyst with an acquired Chiari I malformation and cervicothoracic syrinx.

Case Description:

A 40-year-old female with a posterior fossa arachnoid cyst found 17 years ago, and newly acquired Chiari I malformation (tonsils down 5 mm) with a C7-T5 syrnix, presented with the new onset of lower extremity myelopathy. The MR documented marked dorsolateral cord compression due to T11/T12 OYL. Six months following a laminectomy for resection of OYL, the patient was asymptomatic.

Conclusion:

In patients presenting with the new onset of lower extremity myelopathy, evaluation of the complete neuraxis may be warranted. Here, the patient has an unchanged posterior fossa arachnoid cyst with an acquired Chiari I malformation/C7-T5 syrinx. However, the patient’s symptoms were fully attributed to the MR-documented T11/T12 OYL that was successfully resected.

Adolescent eating disorder with catheter-related bloodstream infection

BACKGROUND

Treatment of adolescent eating disorder requires early improvement of nutritional status. Central venous hyperalimentation is used but catheter-related bloodstream infection (CRBSI) is a complication. There have been no reports examining risk factors for CRSBI in eating disorders.

METHODS

The subjects were 51 patients who received nutritional therapy with the use of a peripherally inserted central catheter (PICC) from January 2012 to December 2019. The courses of weight and white blood cell (WBC) count were examined retrospectively during nutritional therapy. Onset factors for CRBSI were determined and a case series of CRBSI caused by Candida parapsilosis is presented.

RESULTS

The day of minimum weight occurred on or before day 7 in 37 of the 51 patients, and this day was preceded by the day with the lowest WBC at a significant rate. The minimum weight day was significantly delayed in CRSBI cases compared with non-CRBSI cases (P = 0.02). In the case series of CRBSI caused by C. parapsilosis, the median WBC count before CRBSI decreased to 2,570 (1,680-3,270)/μL at a median of day (12-90) 36. Catheter-related bloodstream infection developed at a median of day (26-133) 38. The PICC was immediately removed and an antifungal drug was started, leading to cure with no after effects in all subjects.

CONCLUSIONS

In patients with an eating disorder treated with nutritional therapy using a PICC, prolonged resistance to weight gain became a risk factor for developing CRBSI. White blood cell counts recover after weight gain, which suggests that there is a risk of developing CRBSI, even with improved appetite and weight gain.

Impact of Extracranial-Intracranial Bypass on Cognitive Function in a Patient with Chronic Cerebral Ischemia

Extracranial–intracranial (EC-IC) arterial bypass surgery was developed to prevent subsequent stroke by improving hemodynamics distal to the occluded intracranial artery, but its utilization has been decreasing due to the development in medical treatment. However, EC-IC bypass surgery may be effective for arresting or reversing cognitive decline in patients with cerebral ischemia. A 69-year-old man with the left internal carotid artery occlusion that manifested as scattered cerebral infarction of the left hemisphere presented with dysarthria and transient right hemiparesis. Hemodynamic condition was impaired in the left side, and therefore, EC-IC bypass surgery was performed to prevent recurrence of cerebral infarction. Neuropsychological examination at 6 months after the surgery showed marked improvement as compared to the preoperative examination and there was no recurrence of stroke in the patient. EC-IC bypass may contribute to the improvement of cognitive function as well as the prevention of recurrence of cerebral infarction in patients with hemodynamic insufficiency, but there might be a threshold of hemodynamic impairment with respect to the reversibility of cognitive performance. Investigation of the target and timing can identify cases in which the cognitive function is improved by surgery.

Emergent surgical embolectomy for middle cerebral artery occlusion related to cerebral angiography followed by neck clipping for an unruptured aneurysm in the anterior communicating artery

Background:

Intracranial embolism related to cerebral angiography is rare but one of the complications of the procedure. However, the standard management of acute intracranial embolism for this etiology has not been established, and there have been very few reports in the past.

Case Description:

A 68-year-old male was incidentally found to have an unruptured aneurysm of anterior communicating artery (ACoA). Immediately after the cerebral angiography for the purpose of detailed examination of the aneurysm, the right partial hemiparalysis and mild aphasia developed. Magnetic resonance imaging/angiography (MRI/A) revealed an occlusion in the peripheral part of the left middle cerebral artery (MCA). Due to the existence of magnetic resonance angiography-diffusion mismatch, emergent craniotomy was immediately performed to remove intra-arterial thrombus. We also performed clipping for an unruptured ACoA aneurysm with this approach. Postoperative MRI/A showed that the occluded artery was recanalized and a slight infarction was observed in the left cerebral hemisphere. The patient was discharged on foot and followed at outpatient clinic over 4 years without no neurological deficit.

Conclusion:

Emergent surgical embolectomy for distal MCA occlusion related to cerebral angiography followed by neck clipping for an unruptured aneurysm of the ACoA was successful in treating acute occlusion of the peripheral part of the MCA in a patient with an unruptured aneurysm. As there are few similar cases, there is controversy about the best management, but this surgical method can be a safe and effective treatment.

Candida guilliermondii-induced chorioretinitis in a patient with eating disorder

Candidemia is a life-threatening fungal infection among patients undergoing long-term intravenous catheterization, hematopoietic stem cell transplantation, or immunosuppressive therapy, as well as patients with severe immunodeficiency or cancer. Endophthalmitis is a rare but severe form of ocular inflammation caused by infection of the intraocular cavity, which can lead to irreversible visual loss if not treated properly and promptly. The initial manifestation typically involves chorioretinitis, which requires early diagnosis and appropriate treatment. Candida guilliermondii is a non-Candida albicans yeast species; its frequency of detection in Japan has increased in recent years, and many drug-resistant and less-chorioretinitis-related strains are known. Here, we describe a 17-year-old girl with an eating disorder who exhibited chorioretinitis because of catheter-related bloodstream infection (CRBSI) caused by C. guilliermondii. The patient was hospitalized with severe weight loss, and she was presumed to develop candidemia because of immunosuppression during central parenteral nutrition therapy with a peripherally inserted central catheter. After onset of CRBSI, the catheter was immediately removed. Antifungal therapy was modified following fundus examination, fungal species confirmation, and drug sensitivity confirmation; thus, the patient recovered without long-term complications. To the best of our knowledge, this is the first report of C. guilliermondii-induced chorioretinitis in a patient with an eating disorder. Prolonged malnutrition and immunosuppression during nutritional therapy create a risk of candidemia in patients with eating disorders. After the onset of CRBSI, early administration and appropriate use of antifungal agents, with respect to specific ocular complications, are important for reduction of both mortality and ocular complications.

Superficial temporal artery-superior cerebellar artery bypass and proximal occlusion through anterior petrosal approach for subarachnoid hemorrhage due to basilar artery dissection

Background:

Subarachnoid hemorrhage (SAH) due to rupture of basilar artery dissection (BAD) is extremely rare and often has a poor prognosis. Since ruptured BAD has high rate of rebleeding and mortality, treatment to prevent rerupture is mandatory in the acute phase. However, to date, no optimal treatment has been established which satisfies secure prevention of rerupture and ischemia simultaneously. Herein, we report a case of SAH due to BAD treated with proximal occlusion of basilar artery with superficial temporal artery (STA)-superior cerebellar artery (SCA) bypass, preventing rebleeding securely and ensuring adequate blood flow in the upper basilar region.

Case Description:

A 48-year-old male presenting with headache and altered mental status was found to have SAH and BAD. To prevent rerupture, proximal occlusion of basilar artery with STA-SCA bypass using anterior transpetrosal approach was performed. The postoperative course was relatively good and there is no evidence of recurrent arterial dissection.

Conclusion:

Proximal occlusion of the basilar artery combined with STA-SCA bypass was successful in preventing rerupture of BAD and ensuring blood flow in the upper basilar region. Although there is controversy regarding acute treatment for ruptured BAD, direct proximal occlusion with sufficient revascularization using bypass skull base technique may be one of the optimal treatments even in this era of endovascular treatment.

Rechallenge of voriconazole successfully tolerated after hepatic toxicity

Infections caused by Aspergillus species are often life-threatening. Drugs effective for Aspergillus infection are limited. Voriconazole is one of the most important drugs, however, considerable portion of patients experience liver toxicity and have to stop the drug administration. We frequently experience liver toxicity even though the serum concentration of voriconazole is within the target range. Historically, in some life-threatening situations like tuberculosis, where a suitable alternative is unavailable, rechallenge has been attempted. However, there have been no report on the rechallenge of voriconazole. We report cases of successful re-administration of voriconazole after liver toxicity.

Association of One-Leg Standing Time with Discontinuation of Injectable Medications During Hospitalization Among Patients with Type 2 Diabetes

INTRODUCTION

Persons with type 2 diabetes (T2D) are known to experience impaired physical ability even at the early stages of the disease. However, less attention has been paid to increasing physical ability than to increasing physical activity in the treatment of T2D. The aim of this study was to assess whether improved physical ability parameters are associated with the discontinuation of injectable medications once glycemic targets have been achieved among inpatients with inadequately controlled T2D across a wide range of ages.

METHODS

Forty-three patients with glycated hemoglobin levels of ≥ 7.5% (58 mmol/mol) aged between 19 and 82 years who received insulin, glucagon-like peptide-1 receptor agonists or both at admission were enrolled in the study. Muscle strength for knee extension, one-leg standing time with eyes open test(OLST), whole-body reaction time and maximal oxygen uptake were assessed as parameters of physical ability.

RESULTS

At admission, patients who during hospitalization discontinued injectable medications (n = 29; Discontinued group) had a shorter duration of diabetes, lower fat mass and higher skeletal muscle mass and performed better on all of the physical ability test parameters than those who continued on injectable medications during hospitalization (n = 14; Continued group). At discharge, patients in the Discontinued group had achieved better glycemic control than those in the Continued group, as indicated by lower mean plasma glucose levels according to the 7-point profile. Stepwise logistic regression analysis that included those variables that were significantly different between the Continued group and the Discontinued group, with the aim to identify candidate(s) of explanatory variables, revealed that only OLST was significantly associated with the discontinuation of injectable medication. Patients with an OLST of ≥ 60 s were more likely to discontinue injectable medication than those with an OLST of < 60 s (odds ratio 18.9; 95% confidence interval 2.0-178.8; p = 0.011).

CONCLUSIONS

Among inpatients with inadequately controlled T2D diabetes, longer OLST appear to be associated with discontinuing injectable medications during hospitalization. OLST could possibly be useful as a novel patient factor to consider in de-intensifying injectable medication.

Trapping, dome puncture, and direct suction decompression in conjunction with assistant superficial temporal artery- middle cerebral artery bypass to clip giant internal carotid artery bifurcation aneurysm

Background:

Very large and giant aneurysms (≥20 mm) of the internal carotid artery (ICA) bifurcation (ICAbif) are definitely rare, and optimal treatment is not established. Endovascular treatments are reported as suboptimal due to difficulties of complete occlusion and tendencies to recanalization. Therefore, direct surgery remains an effective strategy if the clipping can be performed safely and reliably, although very difficult.

Case Description:

Two cases of ICAbif aneurysms (>20 mm) were treated. Prior assistant superficial temporal artery (STA)-middle cerebral artery (MCA) bypass was performed to avoid ischemic complications during prolonged temporary occlusion of the arteries in both cases. In Case 1 (22-mm aneurysm), the dome was inadvertently torn in applying the clip because trapping had resulted in insufficient decompression. Therefore, in Case 2 (28-mm aneurysm), almost complete trapping of the aneurysm and subsequent dome puncture was performed, and the aneurysm was totally deflated by suction from the incision. This complete aneurysm decompression allowed safe dissection and successful clipping.

Conclusion:

Trapping, deliberate aneurysm dome puncture, and suction decompression from the incision in conjunction with assistant STA-MCA bypass can achieve complete aneurysm deflation, and these techniques enable safe dissection of the aneurysm and direct clipping of the aneurysm neck. Direct clipping with this technique for very large and giant ICAbif aneurysms may be the optimal treatment choice with the acceptable outcome if endovascular treatment remains suboptimal.

P2623Measurement of liver fibrosis marker: type IV collagen 7S among patients with acute heart failure and its relationship with the Enhanced Liver Fibrosis (ELF) score

Background

Hemodynamic disturbance in acute heart failure (HF) can cause injury to extra-cardiac organs such as the liver. Organ injury in HF might evoke a profibrotic response, which could adversely affect the prognosis.

Methods

Among 189 patients with acute HF, we simultaneously determined the liver fibrosis marker, type IV collagen 7S (P4NP 7S) and the Enhanced Liver Fibrosis (ELF) Score consisting of tissue inhibitor of metalloproteinases 1 (TIMP-1), amino-terminal propeptide of type III procollagen (PIIINP) and hyaluronic acid (HA) on admission and at discharge.

Results

During hospitalization, P4NP 7S and ELF score significantly decreased from 7.1 ng/mL to 6.1 ng/mL (P<0.001) and 10.39 to 10.13 (P<0.001), respectively. P4NP 7S and ELF score were correlated with each other on admission (r=0.4, P<0.001) and at discharge (r=0.4, P<0.001). %Change of (Δ) P4NP 7S during hospitalization was correlated with ΔBNP and ΔELF score (r=0.3, P<0.001 and r=0.4, P<0.001, respectively). Among the components of ELF score, PIIINP and HA were correlated with P4NP 7S on admission (r=0.5, P<0.001 and r=0.3, P<0.001, respectively) and at discharge (r=0.4, P<0.001 and r=0.3, P<0.001, respectively). ΔP4NP 7S was also correlated with ΔTIMP-1, ΔPIIINP and ΔHA (r=0.3, P<0.001, r=0.4, P<0.001 and r=0.3, P<0.001, respectively). Each patient was followed up up to 365 days after discharge. 69 patients died or were hospitalized for HF. When the patients were divided into two groups according to the median value of each marker at discharge, the cumulative 1-year incidences of all cause death or HF hospitalization were 32.0% and 45.5% in P4NP 7S-low and P4NP 7S-high group, respectively (log-rank P=0.051) and 43.2% and 34.9% in ELF score-low and ELF score-high group, respectively (log-rank P=0.44). After adjustment by the clinically relevant factors including age, sex, hemoglobin, sodium and left ventricular ejection fraction, P4NP 7S showed independent prognostic value (adjusted hazard ratio: 1.12, P=0.02), while ELF score did not (adjusted hazard ratio: 1.04, P=0.79).

Conclusion

Parallel elevation of P4NP 7S and ELF score were documented during acute phase of HF. P4NP 7S at discharge may identify patients at high risk for subsequent HF related events.

Resection of Cerebellopontine Angle Meningioma via Retrosigmoid Approach Aiming for Hearing Improvement

We present a 71-year-old female case of left cerebellopontine angle (CPA) meningioma who presented with progressive hearing loss. The tumor was 35 mm in maximum diameter, obviously compressed the brain stem and cerebellum, and also displaced cranial nerves 7th and 8th anteriorly ( Fig. 1 ). Retrosigmoid approach was chosen to resect the tumor aiming for hearing improvement. We performed dissection of the tumor from cranial nerves 7th and 8th gently and resection of the tumor except for the part adhesive to these cranial nerves ( Fig. 2 ). Postoperative course was good without any new neurological deficit. Postoperative examination also showed improvement of high-frequency hearing of the left side, and auditory brainstem response demonstrated wave 2 to 5, which was not identify on preoperative examination. These procedures enabled safe and effective resection of the tumor and contributed to hearing improvement.

The link to the video can be found at: https://youtu.be/hkRSCxtV3bY .

[A Case of Recurrent Hyperammonemic Encephalopathy during Adjuvant Chemotherapy(Modified FOLFOX6)for Colorectal Cancer]

A 60-year-old woman was administered mFOLFOX6 therapy as postoperative adjuvant chemotherapy for fStage III a ascending colon cancer. The patient developed a disorder of consciousness(Japan Coma Scale[JCS]III-200)immediately after the completion of the therapy. Blood ammonia levels were high at 319 mg/dL, and a diagnosis of disturbance of consciousness due to hyperammonemia was made. The patient's state of consciousness improved on the following day as blood ammonia levels decreased due to treatment with branched chain amino acid(BCAA)formulation and oxygen. Two months later, mFOLFOX6 therapy was again administered with strengthening measures for side effects to nausea and vomiting and reducing 5-FU, but the patient again developed a disorder of consciousness(JCS III-200). The 5-FU administration rate was considered as a potential cause of hyperammonemia. Hyperammonemia induced by 5-FU is relatively rare, with a reported incidence of 5-9%; however, caution is required with high dosage regimens of 5-FU that are currently recommended for colorectal cancer therapy because hyperammonemia is an important side effect.

Recurrent Embolic Stroke Caused by Large Cavernous Carotid Aneurysm: Stroke Recurrence Prevention with High-Flow Bypass Followed by Proximal Occlusion

Intracranial aneurysms may cause embolic stroke. Medical or surgical management is selected on an individual basis, as the optimal treatment strategy has not been established. A 79-year-old woman with a large cavernous carotid aneurysm suffered repeated embolic stroke after enlargement and partial thrombosis of the aneurysm, in spite of antiplatelet therapy. Coil embolization of the primitive trigeminal artery and ligation of the internal carotid artery (ICA) at the cervical portion followed by high-flow bypass from the cervical external carotid artery to the middle cerebral artery were performed. The aneurysm was thrombosed, and prevention of further stroke was achieved. Acute enlargement and thrombosis of large or giant cavernous carotid aneurysm may cause repeated embolic stroke, and requires emergent exclusion of the aneurysm from circulation by proximal ICA occlusion together with distal revascularization before devastating embolic stroke occurs.

Combined Interhemispheric and Transsylvian Approach for Resection of Craniopharyngioma

We present a 37-year-old male case of cystic suprasellar huge craniopharyngioma, who presented with significant memory disturbance due to obstructive hydrocephalus. Combined interhemispheric and pterional approach was chosen to resect huge suprasellar tumor. Interhemispheric trans-lamina terminalis approach was quite effective to resect third ventricular tumor, while pterional approach was useful to dissect tumor out of basilar perforators and stalk.

The link to the video can be found at: https://youtu.be/BoYIPa96kdo .

Functional properties of anti-inflammatory substances from quercetin-treated Bifidobacterium adolescentis

The genus Bifidobacterium is well known to have beneficial health effects. We discovered that quercetin and related polyphenols enhanced the secretion of anti-inflammatory substances by Bifidobacterium adolescentis. This study investigated characteristics of the anti-inflammatory substances secreted by B. adolescentis. The culture supernatant of B. adolescentis with quercetin reduced the levels of inflammatory mediators in activated macrophages. Spontaneous quercetin degradant failed to increase anti-inflammatory activity, while the enhancement of anti-inflammatory activity by quercetin was sustained after washout of quercetin. Physicochemical treatment of the culture supernatant indicated that its bioactive substances may be heat-stable, non-phenolic, and acidic biomolecules with molecular weights less than 3 kDa. Acetate and lactate have little or no effect on nitric oxide production. Taken together, the anti-inflammatory substances secreted by B. adolescentis may be small molecules but not short chain fatty acids. In agreement with these findings, stearic acid was tentatively identified as a bioactive candidate compound.

Combined interhemispheric translamina terminalis and pterional approach for a dorsum sellae meningioma

This video demonstrates a surgical technique of resecting dorsum sellae meningioma using a combined interhemispheric translamina terminalis approach and pterional approach with clinoidectomy. The tumor, 5 cm in maximum diameter, originated from the dorsum sellae, compressed the third ventricle and the midbrain, and displaced the pituitary stalk ventrally. Feeding arteries of the tumor were bilateral meningohypophyseal trunks, mainly from the right side. The authors performed devascularization of the tumor via a right pterional approach following frontotemporal craniotomy, and debulking of the tumor via an interhemispheric translamina terminalis approach following bifrontal craniotomy. These procedures with two separate craniotomies enabled safe and effective resection of the tumor. The video can be found here: https://youtu.be/DEnKOC5zQ_M .

Headache in patients with chronic subdural hematoma: analysis in 1080 patients

Headache is a major symptom in chronic subdural hematoma (CSDH) patients. However, some CSDH patients do not complain headache although the hematoma is thick with definite midline shift. This clinical study was performed to identify the mechanism of headache in CSDH patients. We compiled clinical data of 1080 surgically treated CSDH patients (711 males and 369 females), and in 54 cases, the pressure of hematoma was measured during burr hole surgery using a glass-stick manometer. Headache was recognized in 22.6% of patients, while nausea or vomit suggesting increased intracranial pressure was detected in only 3.0%. Ophthalmological examination was performed in 238 patients, and papilledema was identified in only one patient (0.4%). The mean age of patients with headache (59.8 ± 16.9 years) was significantly younger than that of those without (75.7 ± 11.2 years) (P < 0.01). In 54 cases, the mean hematoma pressure was not significantly different between patients with (17.1 ± 6.2 mmH₂O) and without (18.4 ± 7.2 mmH₂O) headache (P > 0.10). Hematoma thickness was significantly greater in patients without headache (P < 0.01), but the ratio of midline shift to hematoma thickness was significantly greater in patients with headache (P < 0.01). In our results, the status of increased intracranial pressure was rare in CSDH patients, and high hematoma pressure was not a cause of headache. Midline shift was the most influenced factor for headache in our study, and based on the results, the authors consider that the potential cause of headache in CSDH might be stretching or twisting of the pain-sensitive meninges and meningeal arteries or veins.

Giant cavernous carotid aneurysm causing pituitary dysfunction: Pituitary function recovery with high-flow bypass

Background:

Giant internal carotid artery (ICA) aneurysms extending into the sellar region, mimicking pituitary tumors, and causing pituitary dysfunction are relatively rare. Open surgery or endovascular treatment can treat these aneurysms, but achieving recovery of endocrine function is difficult.

Case Description:

A 56-year-old man presented with giant aneurysm of the ICA causing pituitary impairment, leading to disturbance of consciousness due to hyponatremia. High-flow bypass from the cervical external carotid artery to the middle cerebral artery and ligation of the ICA at the cervical portion were performed. One year after the operation, his pituitary function recovered well; he was followed up as an outpatient without hormonal replacement therapy for 8 years after the operation.

Conclusion:

Giant ICA aneurysm causing pituitary dysfunction is relatively rare, but it is important to consider in the differential diagnosis for hypopituitarism. Treatment with high-flow bypass using radial artery graft can achieve both prevention of aneurysm rupture and recovery of pituitary function.

Middle cerebral artery dissection causing subarachnoid hemorrhage and cerebral infarction: Trapping with high-flow bypass preserving the lenticulostriate artery

Background:

Spontaneous intracranial arterial dissection (IAD) is an increasingly important cause of stroke, such as subarachnoid hemorrhage (SAH) and hemodynamic or thromboembolic cerebral ischemia. IAD usually occurs in the posterior circulation, and is relatively rare in the anterior circulation including the middle cerebral artery (MCA). Various surgical and endovascular methods to reduce blood flow in the dissected lesion have been proposed, but no optimum treatment has been established.

Case Description:

An 80-year-old woman with dissection in the M1 portion of the MCA manifesting as SAH presented with repeated hemorrhage and cerebral infarction in the area of the inferior trunk of the MCA. High-flow bypass to the MCA was performed and the dissecting lesion was trapped. Prevention of repeated hemorrhage was achieved, and blood flow was preserved to the lenticulostriate artery as well as the MCA area distal to the lesion.

Conclusions:

Treatment strategy for IAD of the MCA should be planned for each patient and condition, and surgery should be performed promptly to prevent critical rebleeding given the high recurrence rate. In addition, preventing re-rupture of the IAD, and preserving important perforators around the lesion and blood flow distal to the dissection should be targeted by the treatment strategy.

Surgical strategy to minimize ischemia during trapping/resection of giant extracranial carotid artery aneurysm stratified by collateral evaluation

BACKGROUND

Extracranial carotid artery aneurysm (ECAA) is a rare clinical entity, and no standard treatment strategy has been established for this condition.

METHODS

Data from three patients who underwent surgical treatment of enlarging giant ECAAs were retrospectively reviewed. Based on the collateral status, as evaluated by preoperative digital subtraction angiography (DSA), surgical strategy was stratified into (1) high flow bypass followed by cervical ICA (internal carotid artery) ligation, when the collateral status was judged as poor/fair or (2) direct cervical repair with patch application after aneurysmal wall resection when the collateral status was judged as robust. Postoperative results were evaluated by magnetic resonance imaging (MRI).

RESULTS

Postoperative follow-up (day 0 to 1, as well as midterm at approximately 6 months) confirmed completely trapped aneurysm with successful robust bypass and robust anterograde flow of the reconstructed cervical carotid artery on magnetic resonance angiography with no additional ischemic lesions on diffusion weighted imaging and T2-weighted imaging when compared with preoperative imaging in all three patients. Postoperatively, there was no stroke event during the midterm follow-up at 6 months.

CONCLUSIONS

Clinical results of ECAAs treated by a surgical strategy stratified based on collateral status, as evaluated by preoperative DSA, were favorable, without postoperative ischemic event, and with satisfactory mid-term MRI results.

Yogurt Containing Lactobacillus gasseri Mitigates Aspirin-Induced Small Bowel Injuries: A Prospective, Randomized, Double-Blind, Placebo-Controlled Trial

BACKGROUND

Although there is evidence about the beneficial effects of probiotics, their effects on aspirin-induced small bowel injuries have not been well examined. We evaluated the effects of the probiotic Lactobacillus gasseri OLL2716 (LG) on aspirin-induced small intestinal lesions, such as ulcers, erosions, reddened lesions, and bleeding.

SUMMARY

This study enrolled 64 patients who received aspirin for more than 1 month and provided written informed consent to be part of the study. The patients received 112 ml of yogurt containing LG or placebo twice daily for 6 weeks. Small bowel injuries were evaluated by capsule endoscopy before and after consuming the yogurt. The effect of LG on patient symptoms was also assessed using the Frequency Scale for the Symptoms of Gastroesophageal Reflux Disease (FSSG) and Gastrointestinal Symptom Rating Scale (GSRS) questionnaires before and after 6 weeks of treatment. There was no significant difference in any baseline characteristics and the number of small bowel mucosal breaks between the 2 groups. In contrast with the placebo group, the LG group had significantly fewer small bowel mucosal breaks and reddened lesions after 6 weeks (p < 0.01). The FSSG and GSRS scores were also significantly improved in the LG group but not in the placebo group. Key Messages: This double-blind, placebo-controlled study found that LG may be useful in reducing aspirin-induced small bowel injuries and in mitigating gastrointestinal symptoms.

Changes of superoxide dismutase activity and ascorbic acid in focal cerebral ischaemia in rats

Free radical reactions are supposed to cause ischaemic brain damage, and active oxygens can initiate these chains reaction. If active oxygens play important roles in ischaemic brain damage, the activity of superoxide dismutase, scavenger of superoxide anion, is supposed to decrease in ischaemic brain. The reduced form of ascorbic acid also scavenges superoxide anion. In rat middle cerebral artery focal ischaemia, we investigated the changes in superoxide dismutase activity and the concentration of reduced ascorbate up to 48 hours. Middle cerebral artery territory of each cerebral hemisphere was homogenized. The supernatant was divided into two aliquots; one was dialysed to remove ascorbate and the other was not. The enzyme activity of the dialysed specimen from the ischaemic hemisphere did not decrease within 4 h after the arterial occlusion. The activity of the dialysed specimen from the nonischaemic side remained unchanged during the examination. Reduced ascorbate levels in nondialysed samples showed similar changes to the superoxide dismutase activities in the dialysed samples. Our data suggest that ascorbic acid may exert the enzyme activity and that the enzyme activity remains at the normal level in the early phase of ischaemia despite the irreversible ischaemic changes that take place within 4 h after the onset of ischaemia.

Change of xanthine dehydrogenase and xanthine oxidase activities in rat brain following complete ischaemia

We studied the activities of xanthine dehydrogenase and xanthine oxidase in rat forebrain after complete ischaemia. Complete ischaemia was induced by decapitation after transcardiac infusion with saline. The activities of xanthine dehydrogenase and xanthine oxidase immediately after ischaemia were 93.3 +/- 38.7 and 18.8 +/- 7.7 microU/mg protein, respectively, and at 24 h after ischaemia were 183.5 +/- 75.1 and 60.8 +/- 15.2 microU/mg protein, respectively. The ratios of xanthine dehydrogenase/xanthine oxidase immediately and 24 h after ischaemia were 5.04 +/- 1.03 and 3.04 +/- 0.99, respectively. These data indicate that xanthine dehydrogenase and xanthine oxidase activities were maintained even 24 h after complete ischaemia. Conversion of xanthine dehydrogenase to xanthine oxidase proceeds slowly during complete ischaemia.

Tailored flow sequestration treatment using high-flow and low-flow bypass for partially thrombosed giant internal carotid artery aneurysm-a technical case report

Direct clipping of giant partially thrombosed intracranial internal carotid artery (ICA) aneurysms is challenging, especially when important perforating arteries are involved. Proximal occlusion with bypass represents a possible alternative approach. An 80-year-old female presented with worsening visual acuity and severe headache caused by partially thrombosed giant (38 mm in diameter) aneurysms of the right ICA, suggestive of impending rupture. Direct clipping in conjunction with temporary occlusion of the lesion involving the anterior choroidal artery (AChA) was considered too risky. Thus, we sequestrated the ipsilateral ICA flow into a low-flow and a high-flow system using two external carotid artery (ECA)-ICA bypasses and one in situ bypass with cervical ICA ligation. As a result, the low-flow system by the superficial temporal artery-middle cerebral artery (MCA) bypass perfused mainly the proximal MCA lesions and aneurysm, whereas the high-flow system by ECA-radial artery-M2 bypass exclusively supplied the residual distal MCA area. This tailored flow sequestration successfully interrupted intra-aneurysmal flow and accelerated near-complete thrombosis of the aneurysm while preserving the AChA and avoiding any significant neurological deterioration. We conclude that this method is effective for the management of giant partially thrombosed aneurysms of the ICA, especially when direct clipping is difficult.