Fatal convexity and interhemispheric acute subdural hematoma from a falx meningioma: A case report

Background

Hemorrhagic meningiomas are rare. We report a rare case of nontraumatic convexity and interhemispheric acute subdural hematoma (ASDH) caused by a falx meningioma.

Case Description

An 84-year-old woman with a history of atrial fibrillation and hypertension who was taking warfarin presented to our emergency department with a sudden disorder of consciousness. The patient had no traumatic events associated with her symptoms. Computed tomography (CT) revealed right convexity and interhemispheric ASDH, mass lesions in the left frontal lobes, and brain herniation. Contrast-enhanced CT revealed vascular structures within the mass lesion. CT angiography (CTA) revealed no aneurysm or arteriovenous malformation, and the venous phase revealed occlusion in the anterior portion of the superior sagittal sinus. The patient had her right convexity and interhemispheric ASDH removed endoscopically. A mass lesion located on the falx, which was easily bleeding, soft, and suctionable, was immediately detected. Histopathological examination revealed fibrous meningioma, a benign meningioma of the World Health Organization grade 1. Despite undergoing aggressive treatment, the patient's general condition deteriorated.

Conclusion

Hemorrhagic meningiomas can easily be missed with plain CT, and the enhancement effect of CTA and tumor shadow on digital subtraction angiography may not be observed during the acute phase. Surgery for nontraumatic ASDH should be performed considering the possibility that a meningioma causes it.

Usefulness of non-slip element percutaneous transluminal angioplasty scoring balloons in treating severe calcified lesions of the carotid artery for carotid artery stenting: A case report

Background

Treatment of calcified lesions with conventional angioplasty balloons can be difficult due to insufficient lumen expansion, high dissection rates, and repeated revascularization. We report a case in which a scoring balloon was used in lesions resistant to angioplasty with a semi-compliant balloon.

Case Description

A 72-year-old man presented with severe stenosis and a highly calcified lesion in the right cervical internal carotid artery. Right carotid artery stenting (CAS) was planned to prevent future ischemic stroke events. Conventional semi-compliant balloon angioplasty was unsuccessful. Three inflations of a non-slip element (NSE) percutaneous transluminal angioplasty (PTA) scoring balloon (Nipro, Osaka, Japan) successfully achieved CAS without complications.

Conclusion

This is the first report to describe the use of this scoring balloon in de novo carotid artery disease. NSE PTA scoring balloon catheters can be a useful option for refractory, highly calcified stenosis.

A view on the skin-bone axis: unraveling similarities and potential of crosstalk

The phrase "skin as a mirror of internal medicine," which means that the skin reflects many of the diseases of the internal organs, is a well-known notion. Despite the phenotypic differences between the soft skin and hard bone, the skin and bone are highly associated. Skin and bone consist of fibroblasts and osteoblasts, respectively, which secrete collagen and are involved in synthesis, while Langerhans cells and osteoclasts control turnover. Moreover, the quality and quantity of collagen in the skin and bone may be modified by aging, inflammation, estrogen, diabetes, and glucocorticoids. Skin and bone collagen are pathologically modified by aging, drugs, and metabolic diseases, such as diabetes. The structural similarities between the skin and bone and the crosstalk controlling their mutual pathological effects have led to the advocacy of the skin-bone axis. Thus, the skin may mirror the health of the bones and conversely, the condition of the skin may be reflected in the bones. From the perspective of the skin-bone axis, the similarities between skin and bone anatomy, function, and pathology, as well as the crosstalk between the two, are discussed in this review. A thorough elucidation of the pathways governing the skin-bone axis crosstalk would enhance our understanding of disease pathophysiology, facilitating the development of new diagnostics and therapies for skin collagen-induced bone disease and of new osteoporosis diagnostics and therapies that enhance skin collagen to increase bone quality and density.

IgG4-related pachyleptomeningitis with inflammatory pseudotumor

•We report the first case of IgG4-related pachyleptomeningitis.•Our case showed also an inflammatory pseudotumor on the side ipsilateral to the pachyleptomeningitis.•The pachyleptomeningitis is probably due to inflammation from the dural pseudotumor spreading along the adjacent meninges.

Robotic distal gastrectomy plus spleen-preserving distal pancreatectomy: optimal resection for simultaneous gastric cancer and intraductal papillary mucinous neoplasm of the pancreatic body

BACKGROUND

Organ-preserving surgery has recently gained increasing attention. However, performing the surgery for duplicated gastric and distal pancreatic tumors is difficult because of procedural complexity and concerns of remnant gastric necrosis. We present the first case of simultaneous robotic distal gastrectomy plus spleen-preserving distal pancreatectomy in a patient with overlapping gastric cancer and intraductal papillary mucinous neoplasm.

CASE PRESENTATION

A 78-year-old man was diagnosed with gastric cancer in the middle stomach and intraductal papillary mucinous neoplasm of the pancreatic body. Radical cure surgery was performed using the da Vinci Xi robotic system. Conventional distal gastrectomy was initially completed using near-infrared ray guidance when transecting the stomach. After dividing the pancreas, the parenchyma of the distal pancreas was detached from the splenic artery and vein; multiple branches from these splenic vessels were dissected. Indocyanine green imaging confirmed sufficient blood flow in the splenic vessels and perfusion of the remnant stomach. Ultimately, gastrointestinal reconstruction was performed, and the postoperative course was uneventful.

CONCLUSIONS

The robotic distal gastrectomy plus spleen-preserving distal pancreatectomy procedure was safely performed. Compared to the total gastrectomy plus distal pancreatectomy with splenectomy procedure, this technique may improve the quality of dietary life, reduce weight loss, and prevent complications associated with splenectomy.

Acceleration and transport of relativistic electrons in the jets of the microquasar SS 433

SS 433 is a microquasar, a stellar binary system that launches collimated relativistic jets. We observed SS 433 in gamma rays using the High Energy Stereoscopic System (H.E.S.S.) and found an energy-dependent shift in the apparent position of the gamma-ray emission from the parsec-scale jets. These observations trace the energetic electron population and indicate that inverse Compton scattering is the emission mechanism of the gamma rays. Our modeling of the energy-dependent gamma-ray morphology constrains the location of particle acceleration and requires an abrupt deceleration of the jet flow. We infer the presence of shocks on either side of the binary system, at distances of 25 to 30 parsecs, and that self-collimation of the precessing jets forms the shocks, which then efficiently accelerate electrons.

Delayed Diagnosis of Spinal Dural Arteriovenous Fistula: A Case Report and Scoping Review

Spinal dural arteriovenous fistula (SDAVF) is among the most common arterial shunt diseases typically found in middle aged or older men. Herein, we aimed to clarify the reasons for misdiagnoses and delayed diagnoses of SDAVF, determine how these affect prognoses, and establish how they can be prevented. We conducted a PubMed/MEDLINE literature search using "spinal dural arteriovenous fistula", "delayed diagnosis", "late diagnosis", and "misdiagnosis" terms. We identified 18 articles, including 965 SDAVF cases. Patients were predominantly males (71.8-100.0%) (mean age: 53.5-71.0 years). Misdiagnoses rates varied (17.5-100.0%) and encompassed many conditions. The mean time between early manifestations and confirmed diagnosis was approximately 10-15 months and from the first radiologic image revealing dural arteriovenous fistula (DAVF) features to diagnosis was 9.2-20.7 months. Posttreatment outcomes showed a significant improvement in motor functions, gait, and micturition, particularly in patients exhibiting preoperative symptoms over a short period. SDAVF is frequently misdiagnosed or subject to delayed diagnosis, causing poor clinical outcomes. SDAVF symptoms including progressive lower-limb weakness, paresthesia, and vesicorectal dysfunction are indications for spinal magnetic resonance imaging with subsequent spinal angiography, wherein DAVF is evidenced by extensive T2 hyperintensity and flow-void abnormalities. We reported a representative case with delayed diagnosis.

Laparoscopic pancreas-preserving duodenectomy: Minimally invasive surgery for superficial nonampullary duodenal epithelial tumors

No consensus exists regarding the optimal treatment for superficial nonampullary duodenal epithelial tumors. Herein, we describe a laparoscopic pancreas-preserving duodenectomy for the treatment of a 30-mm adenoma located in the third portion of the duodenum. The adenoma was located on the pancreatic side, further hindering safe endoscopic resection. Via laparoscopy, the jejunum was transected first. After releasing the third portion of the duodenum from the retroperitoneal space, the jejunum was pulled to the right side of the superior mesenteric artery and separated from the pancreas. Under endoscopic guidance, the duodenum was then transected and duodenojejunostomy performed intracorporeally. Laparoscopic pancreas-preserving duodenectomy can be considered minimally invasive, achieving tumor radicality while preserving organs and causing minimal destruction to the abdominal wall. In conclusion, although technically demanding, laparoscopic pancreas-preserving duodenectomy is a valuable treatment option for superficial nonampullary duodenal epithelial tumors.

Early diagnosis of thoracic spinal dural arteriovenous fistula using lumbar magnetic resonance imaging: A case report

In middle-aged and older men, clinicians often suspect lumbar spine disease when gait is impaired with intermittent claudication, but spinal dural arteriovenous fistula (SDAVF) may be the etiology. An understanding of the key magnetic resonance imaging findings of SDAVF is necessary for early diagnosis, appropriate treatment, and minimization of complications.

Spinal magnetic resonance imaging artifacts in lumboperitoneal shunt surgery using adjustable valve implantation on the paravertebral spinal muscles

BACKGROUND

Adjustable shunt valves that have been developed for managing hydrocephalus rely on intrinsically magnetic components ; thus, artifacts with these valves on magnetic resonance imaging (MRI) are inevitable. No studies on valve-induced artifacts in lumboperitoneal shunt (LPS) surgery have been published. Therefore, this study aimed to evaluate valve-induced artifacts in LPS.

METHODS

We retrospectively reviewed all MRIs obtained between January 2023 and June 2023 in patients with an implanted Codman CERTAS Plus adjustable shunt valve (Integra Life Sciences, Princeton, New Jersey, USA). The valve was placed <1 cm subcutaneously on the paravertebral spinal muscle of the back, with its long axis perpendicular to the body axis. The scans were performed using a Toshiba Medical Systems 1.5 Tesla scanner. The in-plane artifact sizes were assessed as the maximum distance of the artifact from the expected region of the back.

RESULTS

All spinal structures or spinal cords can be recognized, even with valve-induced artifacts. The median maximum valve-induced artifact distance on T1-weighted axial imaging was 25.63 mm (mean, 25.98 mm ; range, 22.24-30.94 mm). The median maximum valve-induced artifact distance on T2-weighted axial imaging was 25.56 mm (mean, 26.27 mm ; range, 21.83-29.53 mm).

CONCLUSION

LPS surgery with adjustable valve implantation on paravertebral muscles did not cause valve-induced artifacts in the spine and spinal cord. We considered that LPS could simplify the postoperative care of these patients. J. Med. Invest. 71 : 154-157, February, 2024.

Prevalence of idiopathic normal pressure hydrocephalus in patients with vertebral compression fractures

Background

Patients with idiopathic normal pressure hydrocephalus (iNPH) may be more prone to all fracture types due to falls. Vertebral compression fractures (VCFs) are a global burden that temporarily or permanently affects millions of elderly people. This study aimed to investigate the prevalence of iNPH in patients with VCFs.

Methods

We retrospectively reviewed 128 patients aged 60-102 years who underwent balloon kyphoplasty (BKP) for VCFs between November 1, 2017, and March 31, 2020. We also assessed the presence of the iNPH triad (i.e., gait disturbance, cognitive impairment, and urinary incontinence). Patients with Evans' index (EI) >0.3 and the iNPH triad were defined as having possible iNPH, those with clinical improvement after a cerebrospinal fluid tap test were defined as having probable iNPH, and those with clinical improvement after a shunt surgery were defined as having definite iNPH.

Results

Of the 128 patients, seven were excluded due to a history of intracranial disease that could cause ventricular enlargement or gait disturbance. Another 70 patients who did not undergo head computed tomography or magnetic resonance imaging one year before or after BKP were excluded from the study. Finally, 51 patients with a mean age of 78.9 years were enrolled. The mean EI value of these 51 patients was 0.28, with 18 patients showing EI >0.3. Moreover, 18 had possible iNPH, one had probable iNPH, and one had definite iNPH.

Conclusion

Screening for iNPH in elderly patients with VCFs can allow early diagnosis of iNPH and benefit them more from surgical treatment.

Hands-on neuroendovascular practice for nonselective undergraduate medical students increases interest and aspirations in pursuing neurosurgery as a specialization

Background

The number of medical students aspiring to become neurosurgeons has decreased worldwide, mainly due to poor work-life balance among neurosurgeons; therefore, recruiting students for neurosurgery is essential to ensure the availability and appropriate quality of neurosurgical treatment. This study aimed to evaluate the efficacy of hands-on neuroendovascular practice for nonselective undergraduate medical students to determine whether this increases their interest in neurosurgery and contributes to their aspirations of becoming neurosurgeons.

Methods

Hands-on neuroendovascular practice for mechanical thrombectomy was performed by undergraduate 5th-year medical students during their 2-week clinical rotation in the Department of neurosurgery at our university hospital between April 2021 and March 2023. After the neurosurgery practice, a questionnaire about their understanding of neurosurgery and aspirations for this specialization before and after the practice was anonymously completed by all students.

Results

Overall, 153 students completed the questionnaire. Of these, 140 (91.5 %) showed increased interest in neurosurgery after participating in the hands-on practice. Through this practice, the number of students who considered neurosurgery as their first choice or one of their specialty choices increased from 8 (5.2%) to 12 (7.8%) (P = 0.3534) and from 19 (12.4%) to 52 (34.0%) (P < 0.0001), respectively. Furthermore, the number of students with no aspiration to become neurosurgeons decreased from 95 (62.1%) to 43 (28.1%) (P < 0.0001).

Conclusion

Hands-on neuroendovascular practice for nonselective undergraduate medical students effectively increased their interest in neurosurgery specialization and their desire to become neurosurgeons. Therefore, this practice can help recruit medical students for neurosurgery specialization.

Severe esophageal stricture after perforation and necrotizing esophagitis: unusual presentation of a duodenal gastrinoma

Gastrinomas are pancreatic or duodenal endocrine tumors that secrete excess gastrin, which causes gastroesophageal reflux disease, peptic ulcers, and chronic diarrhea. Due to the rarity of the disease, nonspecific symptoms, and the outstanding effect of proton pump inhibitors, diagnosing gastrinomas is difficult. Here, we present the case of a 58-year-old woman who had a duodenal gastrinoma that caused rare but critical events, including esophageal perforation, necrotizing esophagitis, and severe esophageal stricture. She presented with a non-malignant severe lower esophageal stricture, which was resistant to endoscopic dilatation. During esophagectomy, a duodenal mass was excised and diagnosed as gastrinoma. This was considered the main cause of all events. Gastrinomas are rarely encountered in clinical practice, but early diagnosis is necessary to avoid serious conditions. Therefore, whenever we encounter a patient with gastroesophageal reflux disease requiring long-term treatment or is refractory, we must not forget to screen for gastrinomas.

Rare complication of lumboperitoneal shunt with distal catheter migration into the inguinal hernia sac in two adults: A case report

Background

Despite the proven benefits of lumboperitoneal shunt (LPS) for idiopathic normal-pressure hydrocephalus, complications such as catheter migration remain a problem. Inguinal complications of the distal catheter are rare in adults, and their management is uncertain. Herein, we present two cases of distal catheter migration into the inguinal hernia sac after LPS in adults and recommend their management.

Case Description

An 86-year-old man presented with inguinal swelling. In another 82-year-old man who did not show any improvement after LPS, shunt angiography revealed LPS dysfunction due to lumbar catheter occlusion and distal LPS catheter in the right inguinal hernia sac, and lumbar catheter reconstruction was performed. Both patients did not have any symptoms, except inguinal swelling, and were followed up. After 2 weeks and 4 days, the distal catheter moved into the peritoneal cavity.

Conclusion

Inguinal complications due to the migration of the distal catheter into the inguinal hernia sac are rare in LPS because frequent movements of the distal catheter due to trunk rotation dislodge it from the inguinal hernia sac for a short period. Urgent surgery was not recommended because the catheter was moved in a short period and the patients did not wish to undergo hernia repair.

[Initial Management of Traumatic Brain Injury]

To reduce the number of preventable trauma deaths(PTD), a standardized approach has been established with various training courses and guidelines such as the Japan Advanced Trauma Evaluation and Care and Guidelines for the Diagnosis and Treatment of Traumatic Brain Injury. To prevent PTD, initial treatment, including resuscitation, is crucial in the care of traumatic brain injury(TBI). The Japan Neurotrauma Data Bank recently reported that the number of patients with TBI is increasing. Patients on antithrombotic drugs are also increasing. Although the mortality rate is decreasing, the percentage of patients with favorable outcomes is also decreasing. Therefore, to prevent secondary brain injury, rapid and systematic assessment of physiological abnormalities and resuscitation using the ABCDE approach, diagnosis and treatment of impending D, administration of tranexamic acid(an antifibrinolytic drug), and timely administration of anticoagulant neutralizers are important.

A Case of Two-stage Surgery Using Intracranial Pressure Monitoring for Hemorrhagic Infarction during Direct Oral Anticoagulant Medication

Direct oral anticoagulants (DOACs) are considered to cause a few hemorrhagic complications, including hemorrhagic infarction; these are administered in the acute phase of cerebral infarction for secondary prevention of cerebral embolism. Hemorrhagic infarction with cerebral herniation requires urgent decompressive craniectomy and can become fatal. Perioperative management is challenging because patients are often on antithrombotic therapy. In this study, we report on a case of a 61-year-old man with left-sided hemiparesis and impaired consciousness; he suffered from a hemorrhagic infarction with cerebral herniation during oral DOAC treatment after endovascular recanalization for the middle cerebral artery occlusion. As the patient was on apixaban for <3 h, performing decompressive craniectomy was considered difficult to stop hemostasis. We then opted to perform a small craniotomy to remove the hematoma, control the intracranial pressure (ICP), and administer fresh frozen plasma. We waited for the effect of apixaban to diminish before performing decompressive craniectomy. Gradually, his level of consciousness was noted to improve. Hemorrhagic cerebral infarction while on DOAC medications can be safely treated with small craniotomy and ICP monitoring followed by decompressive craniectomy. Thus, this case highlights the value of staged surgery under ICP monitoring in the absence of an immediate administration of DOAC antagonists.

Comparison of the Efficacy of Low Dose Tadalafil with Tamsulosin against Lower Urinary Tract Symptoms and Sexual Dysfunction after Low Dose Rate Prostate Brachytherapy

PURPOSE/OBJECTIVE(S)

Patients with clinically localized prostate cancer (PCa) can be curatively treated with different modalities, including low dose rate (LDR) prostate brachytherapy (PB). LDR-PB allows the patient a relatively short recovery time compared with other treatment modalities such as prostatectomy. However, PB might exert distinct impact on quality of life, lower urinary tract symptoms (LUTS) and sexual dysfunction (SD) are two major concerns. The aim of present study was to assess prospectively the efficacy of low dose tadalafil treatment on both SD and LUTS compared with tamsulosin treatment in patients treated PB for localized PCa.

MATERIALS/METHODS

Patients scheduled for PB with I-125 seeds for low or intermediate-risk localized PCa at our institution were eligible for this study. The prescribed dose was set at 160 gray. Participants were randomized into two groups; those started treating with a daily use of 0.2 mg of tamsulosin hydrochloride or 5 mg of tadalafil just after PB. The duration of the study was 12 months and the patients were assessed for urinary and sexual function status at baseline, and 1, 3, 6, and 12 months after PB. The primary study endpoints were both changes from baseline in urinary and sexual function status.

RESULTS

Between July 2015 and August 2020, 120 participants were enrolled in this study. The median age was 68 years with the median PSA of 6.5 ng/ml. A total 15 patients were excluded within 6 months after randomization. All subjective LUTS findings, including International Prostate Symptom Score (IPSS), and Over Active Bladder Symptom Score (OABSS), were significantly deteriorated at 1, 3, and 6 months after PB compared with baseline in both groups, respectively (p<0.05). Among objective LUTS findings, a significant decrease in maximum urinary flow rate (Qmax) was found at 1, 3, 6, and 12 months after PB compared with baseline in both groups, respectively (p<0.05). A significant increase in post void residual urine (PVR) was found at 1, 3, and 6 months after PB compared to baseline in tadalafil group, whereas no significant increase was seen in tamsulosin group. There were no statistically significant differences between the 2 groups in scores of the total International Index of Erectile Function (IIEF)-15 and Erection Hardness Score (EHS) before and at 1 month post PB. The EHS was significantly higher in tadalafil group compared with tamsulosin group at 3, 6 and 12 months (p = 0.001, p = 0.004, and p = 0.019, respectively). The EHS after PB in tadalafil group was not significantly decreased from baseline.

CONCLUSION

After LDR-PB, tamsulosin treatment significantly decreased PVR compared with tadalafil. On the other hand, tadalafil contributed to maintain erection hardness compared with tamsulosin.

Contrast Injection from an Intermediate Catheter Placed in an Intradural Artery is Associated with Contrast-Induced Encephalopathy following Neurointervention

BACKGROUND AND PURPOSE

Contrast-induced encephalopathy can result from neurotoxicity of contrast medium in the affected area. The development of intermediate catheters has allowed guidance of catheters to more distal arteries. This study focused on the association between contrast-induced encephalopathy and contrast injection from an intermediate catheter guided into a distal intradural artery during neurointervention for cerebral aneurysms.

MATERIALS AND METHODS

We retrospectively reviewed 420 consecutive aneurysms in 396 patients who underwent neurointervention for extracranial aneurysms and unruptured intracranial aneurysms at our institution from February 2012 to January 2023. Patients were divided into a group with contrast-induced encephalopathy and a group without. To identify risk factors for contrast-induced encephalopathy, we compared clinical, anatomic, and procedural factors between groups by multivariate logistic regression analysis and stepwise selection.

RESULTS

Among the 396 patients who underwent neurointervention for cerebral aneurysms, 14 (3.5%) developed contrast-induced encephalopathy. Compared with the group without contrast-induced encephalopathy, the group with contrast-induced encephalopathy showed significantly higher rates of patients on hemodialysis, previously treated aneurysms, intradural placement of a catheter for angiography, nonionic contrast medium, and flow-diversion procedures in univariate analyses. Stepwise multivariate logistic regression analysis revealed intradural placement of a catheter for angiography (OR = 40.4; 95% CI, 8.63-189) and previously treated aneurysms (OR = 8.20; 95% CI, 2.26-29.6) as independent predictors of contrast-induced encephalopathy.

CONCLUSIONS

Contrast injection from an intradural artery and retreatment of recurrent aneurysms were major risk factors for contrast-induced encephalopathy. Attention should be paid to the location of the intermediate catheter for angiography to avoid developing contrast-induced encephalopathy.

Endoscopic-assisted removal of bilateral traumatic intracerebral hemorrhage: A case report

Background

Decompressive craniectomy or craniotomy is an effective method for reducing intracranial pressure in patients with traumatic brain injury. However, contralateral intracranial hematoma is a rare but serious complication. Recently, the endoscopic technique has been described as a minimally invasive, safe, and effective treatment for intracranial hematoma evacuation. To the best of our knowledge, no technical report has described bilateral traumatic intracerebral hemorrhage (TICH) evacuation using a neuroendoscope.

Case Description

A 62-year-old man was admitted to the hospital after a fall due to intoxication. His initial Glasgow Coma Scale (GCS) score was 14. Initial computed tomography (CT) revealed a right temporal skull fracture, bilateral frontal and right temporal tip contusions, and acute subdural hematoma. During admission, his condition deteriorated to a GCS score of 6 points, and follow-up CT showed hemorrhagic progression of left frontal and right temporal contusion with midline shift and brainstem compression. Emergency surgery was performed for TICH in the left frontal lobe and right temporal lobe. A burr hole was made in each of the left frontal and right temporal regions, and we used a neuroendoscope to assist in the evacuation of the hematoma. Postoperative CT showed adequate evacuation of the hematoma. The patient regained consciousness and was discharged after 2 months.

Conclusion

Bilateral TICH was rapidly and sequentially removed by burr-hole craniotomy and endoscopic hematoma evacuation without rapid decompression by craniotomy. The hematoma did not increase. This report demonstrates that the endoscopic-assisted technique allows the safe treatment of bilateral TICH.

Surgical Treatment of Vertebral Compression Fracture in a Patient with Idiopathic Normal Pressure Hydrocephalus

Idiopathic normal pressure hydrocephalus (iNPH) with gait disturbance can be effectively treated with a cerebrospinal fluid shunt. Furthermore, balloon kyphoplasty (BKP) is a successful minimally invasive treatment for osteoporotic vertebral compression fractures (VCFs). This case report presents the surgical management of an elderly patient with iNPH who presented after a VCF due to a fall. A 77-year-old woman who had been experiencing progressive gait disturbance for five years reported experiencing back pain one month after a fall. Imaging revealed a recent L1 VCF that did not compromise the spinal canal. Furthermore, the Mini-Mental State Examination results and the timed up-and-go test were 20 points and 17.96 seconds, respectively. Magnetic resonance imaging revealed ventriculomegaly with an Evans' index of 0.35. Her symptoms improved temporarily after a tap test, and she was diagnosed with probable iNPH. BKP was performed for VCFs, followed by the lumboperitoneal (LP) shunt placement for iNPH one month later. Following the operation, her symptoms improved without complications. After one month of performing BKP, an LP shunt would be placed to prevent shunt complications, such as infection and catheter-related neurological symptoms. Screening for iNPH in the elderly who present after VCFs due to a fall may identify iNPH patients who may benefit more from surgical treatments.

Seasonal ecosystem linkages contribute to the maintenance of migratory polymorphism in a salmonid population

The influence of resource subsidies on animal growth, survival and reproduction is well understood, but their ultimate effects on life history have been less explored. Some wild species have a partially migratory life history, wherein migration is dictated based upon threshold traits regulated in part by the seasonal availability of resources. We conducted a large-scale field manipulation experiment where we provided a terrestrial invertebrate subsidy to red-spotted masu salmon. Individuals in stream reaches that received a subsidy had, on average, a 53% increase in growth rate relative to those in control reaches. This increased growth resulted in a greater proportion of individuals reaching the threshold body size and smolting in the autumn. Consequently, 19-55% of females in subsidized reaches became migratory, whereas 0-14% became migratory in the control reaches. Our findings highlight seasonal ecosystem linkage as a key ecosystem property for maintaining migratory polymorphism in partially migratory animals.

The cisplatin-induced acute kidney injury is a novel risk factor for postoperative complications in patients with esophageal cancer: a retrospective cohort study

BACKGROUND

Cisplatin-induced acute kidney injury (AKI) is common during preoperative chemotherapy for esophageal cancer. The purpose of this study was to investigate the association between AKI after preoperative chemotherapy and postoperative complications in patients with esophageal cancer.

METHODS

In this retrospective cohort study, we included patients who had received preoperative chemotherapy with cisplatin and underwent surgical resection for esophageal cancer under general anesthesia from January 2017 to February 2022 at an education hospital. A predictor was stage 2 or higher cisplatin-induced AKI (c-AKI) defined by the KDIGO criteria within 10 days after chemotherapy. Outcomes were postoperative complications and length of hospital stays. Associations between c-AKI and outcomes including postoperative complications and length of hospital stays were examined with logistic regression models.

RESULTS

Among 101 subjects, 22 developed c-AKI with full recovery of the estimated glomerular filtration (eGFR) before surgery. Demographics were not significantly different between patients with and without c-AKI. Patients with c-AKI had significantly longer hospital stays than those without c-AKI [mean (95% confidence interval (95%CI)) 27.6 days (23.3-31.9) and 43.8 days (26.5-61.2), respectively, mean difference (95%CI) 16.2 days (4.4-28.1)]. Those with c-AKI had higher C-reactive protein (CRP) levels and prolonged weight gain after surgery and before the events of interest despite having comparable eGFR trajectories after surgery. c-AKI was significantly associated with anastomotic leakage and postoperative pneumonia [odds ratios (95%CI) 4.14 (1.30-13.18) and 3.87 (1.35-11.0), respectively]. Propensity score adjustment and inverse probability weighing yielded similar results. Mediation analysis showed that a higher incidence of anastomotic leakage in patients with c-AKI was primarily mediated by CRP levels (mediation percentage 48%).

CONCLUSION

c-AKI after preoperative chemotherapy in esophageal cancer patients was significantly associated with the development of postoperative complications and led to a resultant longer hospital stay. Increased vascular permeability and tissue edema due to prolonged inflammation might explain the mechanisms for the higher incidence of postoperative complications.

Simultaneous robotic distal gastrectomy and distal pancreatectomy: Avoiding total gastrectomy using indocyanine green fluorescence imaging

Remnant gastric ischemia is the most significant complication in distal pancreatectomy (DP) after distal gastrectomy (DG). Some studies have reported the safety of asynchronous DP in patients who underwent DG. We report a case of simultaneous robotic DG and DP. A 78-year-old man was diagnosed with gastric and pancreatic cancer. We preoperatively confirmed the absence of anomalies in the left inferior phrenic artery. Robotic simultaneous DG and DP was performed; subtotal resection of the stomach was carried out, enabling the left inferior phrenic artery to maintain perfusion of the remnant stomach, even after ligation of the splenic artery. The remnant stomach was preserved as scheduled, and indocyanine green fluorescence imaging confirmed sufficient remnant stomach tissue perfusion. Robotic surgery using the da Vinci surgical system (with a fluorescence imaging system and technology enabling surgical precision) is suitable for this surgical procedure because it considers tumor radicality and allows for function preservation.

High-frequency spin torque oscillation in orthogonal magnetization disks with strong biquadratic magnetic coupling

In this study, we numerically investigate the spin transfer torque oscillation (STO) in a magnetic orthogonal configuration by introducing a strong biquadratic magnetic coupling. The orthogonal configuration consists of top and bottom layers with in-plane and perpendicular magnetic anisotropy sandwiching a nonmagnetic spacer. The advantage of an orthogonal configuration is the high efficiency of spin transfer torque leading a high STO frequency; however, maintaining the STO in a wide range of electric current is challenging. By introducing biquadratic magnetic coupling into the orthogonal structure of FePt/spacer/Co₉₀Fe₁₀, Ni₈₀Fe₂₀ or Ni, we were able to expand the electric current region in which the stable STO is realized, resulting in a relatively high STO frequency. For example, approximately 50 GHz can be achieved in an Ni layer at a current density of 5.5 × 10⁷ A/cm². In addition, we investigated two types of initial magnetic state: out-of-plane and in-plane magnetic saturation; this leads to a vortex and an in-plane magnetic domain structure after relaxation, respectively. The transient time before the stable STO was reduced to between 0.5 and 1.8 ns by changing the initial state from out-of-plane to in-plane.

Utility of 5-aminolaevulinic acid fluorescence-guided endoscopic biopsy for malignant mesothelioma in a cat and dog

Malignant mesothelioma (MM) is uncommon in cats and dogs and can be challenging to diagnose. Adequate tissue sampling is required for superior diagnostic accuracy. Protoporphyrin IX, a metabolite of 5-aminolaevulinic acid (5-ALA), is a photosensitiser for photodynamic diagnosis (PDD). To the best of our knowledge, no study has reported the use of 5-ALA-PDD to detect MM in veterinary medicine. The present study describes the use of 5-ALA-PDD for MM diagnosis in a cat and dog, as well as the effectiveness of intracavitary chemotherapy. We evaluated the use of PDD with 5-ALA hydrochloride (5-ALA-PDD) in two cases of MM. A 12-year-old cat presented with a 1-month history of respiratory distress, and a 9-year-old dog presented with a 3-month history of mild abdominal distention. We endoscopically biopsied lesions in both the cases using 5-ALA-PDD. Histopathological examination revealed mesothelioma, and immunohistochemical staining was positive for calretinin. Both patients were treated with carboplatin. The cat died of respiratory failure. Although, the dog's condition improved 21 days after the first chemotherapeutic drug administration, the dog died on day 684 owing to cardiac-related issues. 5-ALA-PDD is thus, safe and feasible for the diagnosis of MM in veterinary medicine.

Challenges in the Treatment of Severe Traumatic Brain Injury Based on Data in the Japan Neurotrauma Data Bank

The Japan Neurotrauma Data Bank is a source of epidemiological data for patients with severe traumatic brain injury (TBI) and is sponsored by the Japan Society of Neurotraumatology. In this report, we examined the changes in the treatment of severe TBI in Japan based on data of the Japan Neurotrauma Data Bank. Controlling and decreasing intracranial pressure (ICP) are the primary objective of severe TBI treatment. Brain-oriented whole-body control or neurocritical care, including control of cerebral perfusion pressure, respiration, and infusion, are also increasingly considered important because cerebral tissues require oxygenation to improve the outcomes of patients with severe TBI. The introduction of neurocritical care in Japan was delayed compared with that in Western countries. However, the rate of ICP monitoring increased from 28.0% in 2009 to 36.7% in 2015 and is currently likely to be higher. Neurocritical care has also become more common, but the functional prognosis of patients has not significantly improved in Japan. Changes in the background of patients with severe TBI suggest the need for improvement of acute-phase treatment for elderly patients. Appropriate social rehabilitation from the subacute to chronic phases and introduction of cellular therapeutics are also needed for patients with TBI.

Robotic gastrectomy for remnant gastric cancer after pancreaticoduodenectomy

The utility of robotic surgery for remnant gastric cancer remains unclear. We report a case of a robotic gastrectomy for remnant gastric cancer after pancreaticoduodenectomy and Child reconstruction with Braun enteroenterostomy. Adhesiolysis, lymphadenectomy, and gastrectomy were robotically performed. Indocyanine green fluorescence imaging confirmed the tissue perfusion of the reconstructive tract. The patient's postoperative course was uneventful. Robotic surgery facilitates safety for gastrectomy after pancreaticoduodenectomy because of its precise manipulation; its advantages can be further exploited by maximizing usage of the assistant's forceps. Indocyanine green fluorescence imaging capability of the da Vinci Xi Surgical System allows timely evaluation of tissue perfusion at the site of interest, leading to a more reliable procedure.

Endoscopic hematoma evacuation for acute subdural hematoma with improvement of the visibility of the subdural space and postoperative management using an intracranial pressure sensor

Background

The first choice to treat acute subdural hematoma (ASDH) is large craniotomy under general anesthesia. However, increasing age or the comorbid burden of patients may render invasive treatment strategy inappropriate. These medically frail patients with ASDH may benefit from a combination of small craniotomy and endoscopic hematoma removal, which is less invasive. We proposed covering with protective sheets to prevent brain injury due to contact with the endoscope and suction cannula and improve visualization of the subdural space. Moreover, we placed an intracranial pressure (ICP) sensor after endoscopic hematoma removal. In this article, we attempted to clarify the use of small craniotomy evacuation with endoscopy for ASDH.

Methods

Between January 2015 and December 2019, nine patients with ASDH underwent hematoma evacuation with endoscopy at our hospital. ASDH was removed using a suction tube with the aid of a rigid endoscope through the small craniotomy (5-6 cm). Improvement of the clinical symptoms and procedure-related complications was evaluated.

Results

No procedure-related hemorrhagic complications were observed. The outcomes of our endoscopic surgery were satisfactory without complications or rebleeding. The outcomes were not inferior to those of other reported endoscopic surgeries.

Conclusion

The results suggest that small craniotomy evacuation with endoscopy and postoperative management using an ICP sensor is a safe, effective, and minimally invasive treatment approach for ASDH in appropriately selected cases.

Poor Health Behaviors among Housebound Japanese Community-Dwelling Older Adults Due to Prolonged Self-Restraint during the First COVID-19 Pandemic: A Cross-Sectional Survey

BACKGROUND

Prolonged self-restraining behaviors induced by the coronavirus disease 2019 (COVID-19) pandemic's containment measures can limit various positive health behaviors.

OBJECTIVE

We examined the decline in going-out and certain other positive health behaviors and investigated the relationship between excessive decreases in going-out frequency and declining engagement in positive health behaviors among community-dwelling older adults during the self-restraint period.

DESIGN

This study employed a cross-sectional survey design.

SETTING

This study was conducted in Nishi Tokyo City, Tokyo, Japan.

PARTICIPANTS

The participants were 294 respondents (150 women) aged 50 years and older who lived in public housing that were permitted to be surveyed during the self-restraint period.

MEASUREMENTS

Their pre-pandemic going-out frequency around February 2020 and going-out frequency during the self-restraint period starting in April 2020 were reported. We mainly assessed the existence of home health behaviors (i.e., exercise, in-person and phone conversations, and healthy diet). A self-report questionnaire was used to obtain data.

RESULTS

Going-out frequency decreased in 41.2% of the 294 respondents owing to the government's request for self-restraint. In total, 13 individuals had been going out less than one time per week (housebound) before the request. Of the 281 people who were not housebound before the government's self-restraint request, 13.9% were newly housebound. Newly housebound individuals were 5.3 times less likely to exercise, had 2.1 times fewer social contacts, and 2.6 times less balanced or healthy diets than those who maintained their frequency of going out.

CONCLUSIONS

Prolonged self-restraint due to the COVID-19 pandemic may lead to housebound status and poor health behaviors. Public health intervention is needed to prevent excessive self-restraint, along with new measures integrating information and communication technologies to enable older adults to live active lives.

Laparoscopic gastrectomy for gastric cancer with two left gastric arteries: Safe and adequate lymphadenectomy in a rare arterial abnormality

Clinical studies have established the safety and advantages of laparoscopic surgery for gastric cancer; therefore, laparoscopic gastrectomy (LG) in clinical practice is increasing. We report the case of a 77-year-old patient with gastric cancer who was referred to our center for LG. Esophagogastroduodenoscopy revealed a type 3 tumor identified as adenocarcinoma on biopsy. Three-dimensional computed tomography-angiography revealed two left gastric arteries (LGAs) branching from the celiac trunk. By laparoscopically performing the outermost layer-oriented lymphadenectomy (OML-OL), the two LGAs were detected and appropriately divided. Subtotal gastrectomy was completed, and the patient had an uneventful postoperative course. The OML-OL was appropriate for LG in this situation. This case demonstrates the necessity of preoperative three-dimensional computed tomography-angiography with 1-mm slices and the importance of performing OML-OL.

Impact of the Comprehensive Awareness Modification of Mouth, Chewing and Meal (CAMCAM) Program on the Attitude and Behavior Towards Oral Health and Eating Habits as Well as the Condition of Oral Frailty: A Pilot Study

OBJECTIVES

Preserving sufficient oral function and maintaining aadequate nutrition are essential for preventing physical frailty and the following long-term care. We recently developed the 6-month Comprehensive Awareness Modification of Mouth, Chewing And Meal (CAMCAM) program, in which participants gather monthly to learn about oral health and nutrition while eating a textured lunch together. This study examined whether the CAMCAM program could improve attitude and behavior towards oral health, mastication, and diet as well as ameliorate oral frailty in community-dwelling older adults.

DESIGN

Single-arm pre-post comparison study.

SETTING AND PARTICIPANTS

A total of 271 community-dwelling adults (72.3 ± 5.7 years of age; 159 women [58.7%]) in 4 Japanese municipalities were recruited, of which 249 participants (92%) were assessed at the final evaluation.

INTERVENTION

Participants gathered once a month at community centers to learn about oral health and nutrition while eating a "munchy" textured lunch containing proper nutrition.

MEASUREMENTS

Oral frailty, frailty, and eating behavior were evaluated with the Oral Frailty Index-8 (OFI-8), Kihon checklist (KCL), and CAMCAM checklist, respectively. Participants were divided into Oral frailty (OF) and Robust groups according to OFI-8 scores. The differences in KCL and CAMCAM checklist results between the OF and Robust groups were statistically tested along with changes in scores after the program.

RESULTS

KCL and CAMCAM checklist scores were significantly lower in the OF group at the initial assessment. OFI-8 and KCL findings were significantly improved in the OF group after completing the program (all P <0.05). Regarding the CAMCAM checklist, awareness of chewing improved significantly in the Robust group (P=0.009), with a similar tendency in the OF group (P=0.080).

CONCLUSION

The findings of this pilot study suggest that the CAMCAM program may improve both oral and systemic frailty in addition to attitudes towards chewing, oral health, and meals, especially in individuals with oral frailty. The CAMCAM program merits expansion as a community-based frailty prevention program.

Fact-Finding Survey of Treatment of Traumatic Brain Injury in Japan: Standardization of Care and Collaboration Between Neurosurgery and Emergency Departments

BACKGROUND

Standardization of seamless treatment from prehospital injury care to initial injury and specialized care through collaboration among departments have been promoted in Japan since 2000. This survey was conducted to examine the current status of the system for treatment of traumatic brain injury (TBI) in Japan.

METHODS

In February 2022, questionnaires on the treatment system and TBI care were sent to 869 facilities that participated in a training program held by the Japan Neurosurgical Society. Responses were received from 480 facilities (55.2%). These responses were compared with those in a similar survey performed in 2008.

RESULTS

Among the responding facilities, 39.4% had neurosurgeons in emergency departments. Initial care for TBI was the responsibility of the neurosurgery department in 42.3% of the facilities, the emergency department in 26.0%, and jointly between these departments in 29.6%; and neurocritical care was managed by the neurosurgery department in 81.9%, the emergency department in 5.2%, and jointly in 12.1%. For patients with acute-phase TBI, intracranial pressure monitoring was performed in 72.1%. Active normothermia was performed in 86.0%, and decompressive craniectomy in 99.4%, as required. There was compliance with guidelines for treatment and management of TBI in 93.3%.

CONCLUSIONS

Comparison with the 2008 results suggested role-sharing between 2 departments in TBI treatment is increasing. TBI treatment compliance with the guidelines was high. In-hospital mortality of Japanese patients with TBI has decreased since 2000. This may be due to the progress with standardization of TBI treatment and collaboration among departments in compliance with guidelines.

Imaging and Manipulation of Plasma Membrane Fatty Acid Clusters Using TOF-SIMS Combined Optogenetics

The plasma membrane (PM) serves multiple functions to support cell activities with its heterogeneous molecular distribution. Fatty acids (FAs) are hydrophobic components of the PM whose saturation and length determine the membrane's physical properties. The FA distribution contributes to the PM's lateral heterogeneity. However, the distribution of PM FAs is poorly understood. Here, we proposed the FA cluster hypothesis, which suggested that FAs on the PM exist as clusters. By the optogenetic tool translocating the endoplasmic reticulum (ER), we were able to manipulate the distribution of PM FAs. We used time-of-flight combined secondary ion mass spectrometry (TOF-SIMS) to image PM FAs and discovered that PM FAs were presented and distributed as clusters and are also manipulated as clusters. We also found the existence of multi-FA clusters formed by the colocalization of more than one FA. Our optogenetic tool also decreased the clustering degree of FA clusters and the formation probability of multi-FA clusters. This research opens up new avenues and perspectives to study PM heterogeneity from an FA perspective. This research also suggests a possible treatment for diseases caused by PM lipid aggregation and furnished a convenient tool for therapeutic development.

A complete thrombotic large aneurysm at the nonbranching segment of the distal anterior cerebral artery mimicking a cavernous malformation: illustrative case

BACKGROUND

Thrombotic aneurysms at the nonbranching segment of the distal anterior cerebral artery (ACA) are extremely rare and difficult to differentiate from cavernous malformations by radiographic features alone.

OBSERVATIONS

Computed tomography and magnetic resonance imaging of a 30-year-old female patient with a chronic headache complaint revealed a 22-mm frontal lobe mass. The mass showed heterogeneous mixed intensity and hemosiderin deposits on magnetic resonance images. It was not visualized by conventional angiography, indicating that the mass and ACA/other vessels were not connected. The patient was preoperatively diagnosed with a cavernous malformation. However, during resection, the mass surface was white and smooth, different from a cavernous malformation. Although the mass was adherent to the pericallosal artery branch, no luminal continuity was observed. After detachment, the mass was completely resected. Pathological and immunohistochemical findings indicated a vessel wall and interior thrombus. The patient was rediagnosed with a thrombotic aneurysm at the distal ACA nonbranching segment and discharged 10 days postsurgery without neurological deficits.

LESSONS

Because radiographic findings of thrombotic aneurysm and cavernous malformation are similar, mass lesions in contact with major arteries should be differentiated as thrombotic aneurysms, even when the artery lumen appears disconnected from the mass.

Glutaraldehyde and uranyl acetate dual fixation combined sputtering/unroofing enables intracellular fatty acids TOF-SIMS imaging with organelle-corresponding subcellular distribution

Fatty acids (FAs) have diverse functions in cellular activities. The intracellular distribution of FAs is critical for their functions. Imaging of FAs by time-of-flight secondary ion mass spectrometry (TOF-SIMS) has been achieved. However, TOF-SIMS images of FAs so far do not have subcellular distribution due to inadequate sample preparation methods. In this study, we developed a chemical fixation method using glutaraldehyde (GA) with uranyl acetate (UA), which preserved cellular structure and intracellular FA distribution well. Combining GA+UA fixation with sputtering-based methods and unroofing-based methods, respectively, we successfully imaged intracellular lipids with the subcellular distribution.

Unilateral C1 Posterior Arch Screw-C2 Laminar Screw Posterior Fixation for Vertebral Artery Preservation in Bow Hunter's Syndrome

Pedicle or lateral mass screws, which are usually used to fix atlantoaxial instability, increase the risk of vertebral artery (VA) injury in patients with bone or arterial anomalies or osteoporotic bone. Here, we report the use of a unilateral C1 posterior arch screw-C2 laminar screw posterior fixation with a contralateral C1 lateral mass screw for VA preservation in a patient with bow hunter's syndrome (BHS). A 65-year-old male presented with recurrent loss of consciousness in the right rotational and backward-bending head positions for 1 year. Cerebral angiography in the same head position showed that the left VA was disrupted at C1/2 and the right VA was hypoplastic. The patient was diagnosed with BHS. C1-2 posterior fixation and iliac bone grafting were performed. The left VA was on the dominant side, and the VA was in a high position; thus, a C1 posterior arch screw was selected for the left side, a C1 lateral mass screw was selected for the right side, and a C2 laminar screw with O-arm navigation and a C-arm was used to prevent arterial injury. Intraoperative findings revealed no VA injury, and postoperative computed tomography showed the screw at the planned site. In a patient with BHS, posterior fixation with a unilateral C1 posterior arch screw-C2 laminar screw prevented VA injury because the screw could be inserted while avoiding the VA.

Benefits of laparoscopic trans-hiatal approach with Heller-Dor surgery in a case of mid-esophageal diverticulum

Compared to the more common epiphrenic diverticula, those located at the central section of the esophagus are quite rare. Minimally invasive approaches for mid-esophageal diverticula have lacked standardization. Certain mid-esophageal diverticula, like epiphrenic diverticula, have been attributed to esophageal motility disorders. Thus, we believe that surgery for esophageal diverticula requires preoperative evaluation of esophageal function, with additional surgery being performed in case of abnormalities. The laparoscopic trans-hiatal approach has been a common technique for managing epiphrenic diverticula but can also be used for mid-esophageal diverticula located far from the esophagogastric junction provided that the port location is carefully considered. Laparoscopic surgery is also preferable given that it is a minimally invasive procedure and allows for diverticulum resection and Heller myotomy and Dor surgery to prevent reflux in the same field of view. Hence, laparoscopic surgery may be a beneficial alternative to the traditional thoracic or thoracoabdominal techniques.

Creating of “fascial sheath” around subcutaneous lumboperitoneal shunt catheters largely prevents postoperative subcutaneous shunt catheter migration

Background:

Spinal catheter migration into the subcutaneous tissue is common after lumboperitoneal shunt (LPS) placement. This study proposed a new method (i.e., wrapping fascia around the catheter like a sheath) to prevent LPS spinal catheter migration.

Methods:

After a LPS spinal catheter was inserted under routine fluoroscopic guidance, and the paravertebral muscle fascia was closed, the fascia was sutured to wrap the catheter like a sheath using intermittent sutures.

Results:

Before the introduction of this technique, the rate of LPS spinal catheter subcutaneous migration was 4.6%. In this study, following LPS shunt placement in 18 consecutive patients with normal pressure hydrocephalus, no further spinal catheter migrations were observed.

Conclusion:

This novel method of “wrapping the LPS catheter with intermittent suture like a sheath” was found to be safe and effective for preventing further spinal catheter subcutaneous migration.

Rapid Change in Shape of Unruptured Intracranial Aneurysm with Acute Perforating Infarction

Acute ischemic stroke is a rare complication resulting from an unruptured intracranial aneurysm (UIA). Ischemic stroke adjacent to the aneurysms is considered the risk of rupture of aneurysms. However, there is presently no consensus on the optimal strategy for the management of UIAs with ischemic stroke. A 27-year-old woman presented with sudden onset left hemiparesis. Acute infarction of the right basal ganglia and an aneurysm of the right middle cerebral artery were discovered on brain imaging. Antiplatelet therapy was used to treat her. The diagnosis revealed ischemic stroke caused by a thrombosed aneurysm due to the change in the shape of the aneurysm on day 4. The UIA clipping procedure was performed on day 21 due to the risk of subarachnoid hemorrhage (SAH). The findings of the surgery and indocyanine green imaging revealed a partially thrombosed aneurysm and occlusion of a perforating artery. As is well known, enlargement of aneurysm size indicates increasing rupture risk. In the present case, after ischemic events developed, magnetic resonance angiography revealed enlargement of the aneurysm. The findings of the surgery revealed possible pathogenic mechanisms were perforating artery occlusion due to local extension of the luminal thrombus. Clinicians should be aware of the risk of ischemic stroke due to luminal thrombosis of the UIA and SAH and should consider urgent treatment of the UIA even immediately after ischemic stroke.

A Case of Suspected Radiation-Induced Meningioma That Developed 36 Years after Radiotherapy for a Suprasellar Tumor

Recently, the improvements in the prognosis of childhood brain tumors have made it necessary to consider the risk of radiation-induced brain tumor development in long-term survivors. In this report, we describe a case of radiation-induced meningioma (RIM) treated surgically 36 years after radiotherapy. A 46-year-old woman, who underwent craniotomy for suprasellar germ cell tumor at 10 years of age with additional postoperative radiotherapy, was admitted to the emergency room with consciousness disturbance and right hemiplegia. One year earlier, magnetic resonance imaging (MRI) revealed a 1-cm diameter tumor in the left middle cranial fossa. This MRI showed an enlarged brain tumor in same lesion with clearly enhanced by gadolinium. A RIM located on a left sphenoid ridge with a fast growth rate was diagnosed, and the gross total removal was achieved by a left frontotemporal craniotomy. Histological diagnosis of atypical meningioma (World Health Organization grade II) was made. RIMs are frequently atypical, anaplastic meningiomas that have already been treated with radiotherapy, making additional postoperative radiotherapy difficult; the removal rate must be increased to achieve a good prognosis. In the case of long-term survivors after childhood radiotherapy, a strict follow-up with the occurrence of RIM in mind is necessary.

Stent retriever angioplasty for acute atherosclerotic occlusion of internal carotid artery: A case report

Background:

Despite the proven benefit of stent retriever thrombectomy for acute ischemic stroke caused by large-vessel embolic occlusion, acute revascularization in the setting of underlying intracranial, atherosclerosis-related, and emergent large-vessel occlusion remains to be a challenge. In this case report, we present a novel revascularization technique that can be used to treat acute ischemic stroke caused by suspected intracranial, atherosclerosis-related, and emergent large-vessel occlusion of the internal carotid artery (ICA).

Case Description:

This case report presents two patients with intracranial, atherosclerosis-related, and emergent large-vessel occlusion of the ICA: a 73-year-old man with a right-sided hemiparesis and aphasia and a 60-year-old man with altered level of consciousness. These patients were treated using the prolonged deployment and partial resheath method with a stent retriever, using the following devices: Solitaire Platinum, Trevo Trak 21, and AXS catalyst 6 for suction. On prolonged deployment of the Solitaire Platinum device, underlying focal atherosclerotic disease was noted. The device remained in place for more than 10 min, until the blood vessel was occluded. Next, the device was partially resheathed into the Trevo Trak 21 to reduce the radial force and minimize vessel injury during the pull. The partially constrained device was then retrieved under continuous aspiration at the lesion site and blood flow was successfully restored. Both patients recovered without any new deficits.

Conclusion:

The prolonged deployment and partial resheath method using a stent retriever may be safe and effective in the treatment of intracranial, atherosclerosis-related, and emergent large-vessel occlusion of the ICA.

The development of a new, ultra-fine, and flexible neuroendoscope for intracranial observation

Background:

A neuroendoscope is a technical advance that allows surgeons to visualize certain regions of the brain that was previously inaccessible through the use of a surgical microscope. Several neuroendoscope designs have been implemented by other neurosurgeons over the past 5 years. The advantage of a neuroendoscope is the addition of a flexible and narrow tip that allows for safe entry into intracranial structures for clinical observation. However, there are some limitations to this approach. Here, we report the use of a modified angioscope as a newly developed neuroendoscope to be employed in observing intracranial structures.

Methods:

We report the use of an angioscope that is 1.8 mm in diameter and has both a thin and flexible tip. In this study, the angioscope was inserted into the lumen of an aspirator tube, and the tip of the device was placed at the intracranial area of intended observation area. Image findings were evaluated using an established in vivo goat brain model.

Results:

The angioscope was light in weight and maneuverable and could be reached and observed in the blind spot using a surgical microscope. From the cerebellopontine angle, the lower cranial nerves and trigeminal nerve could be observed, and from the cisterna magna, the floor of the fourth ventricle and the aqueduct could be seen.

Conclusion:

The angioscope is a useful instrument to observe intracranial locations safely and effectively even within a limited surgical field. Further modifications will be required to use the angioscope in various craniotomy procedures.

Atezolizumab plus bevacizumab versus lenvatinib or sorafenib in non-viral unresectable hepatocellular carcinoma: an international propensity score matching analysis

BACKGROUND

A growing body of evidence suggests that non-viral hepatocellular carcinoma (HCC) might benefit less from immunotherapy.

MATERIALS AND METHODS

We carried out a retrospective analysis of prospectively collected data from consecutive patients with non-viral advanced HCC, treated with atezolizumab plus bevacizumab, lenvatinib, or sorafenib, in 36 centers in 4 countries (Italy, Japan, Republic of Korea, and UK). The primary endpoint was overall survival (OS) with atezolizumab plus bevacizumab versus lenvatinib. Secondary endpoints were progression-free survival (PFS) with atezolizumab plus bevacizumab versus lenvatinib, and OS and PFS with atezolizumab plus bevacizumab versus sorafenib. For the primary and secondary endpoints, we carried out the analysis on the whole population first, and then we divided the cohort into two groups: non-alcoholic fatty liver disease (NAFLD)/non-alcoholic steatohepatitis (NASH) population and non-NAFLD/NASH population.

RESULTS

One hundred and ninety patients received atezolizumab plus bevacizumab, 569 patients received lenvatinib, and 210 patients received sorafenib. In the whole population, multivariate analysis showed that treatment with lenvatinib was associated with a longer OS [hazard ratio (HR) 0.65; 95% confidence interval (CI) 0.44-0.95; P = 0.0268] and PFS (HR 0.67; 95% CI 0.51-0.86; P = 0.002) compared to atezolizumab plus bevacizumab. In the NAFLD/NASH population, multivariate analysis confirmed that lenvatinib treatment was associated with a longer OS (HR 0.46; 95% CI 0.26-0.84; P = 0.0110) and PFS (HR 0.55; 95% CI 0.38-0.82; P = 0.031) compared to atezolizumab plus bevacizumab. In the subgroup of non-NAFLD/NASH patients, no difference in OS or PFS was observed between patients treated with lenvatinib and those treated with atezolizumab plus bevacizumab. All these results were confirmed following propensity score matching analysis. By comparing patients receiving atezolizumab plus bevacizumab versus sorafenib, no statistically significant difference in survival was observed.

CONCLUSIONS

The present analysis conducted on a large number of advanced non-viral HCC patients showed for the first time that treatment with lenvatinib is associated with a significant survival benefit compared to atezolizumab plus bevacizumab, in particular in patients with NAFLD/NASH-related HCC.

Prognostic impact of acute kidney injury following tricuspid transcatheter edge-to-edge repair

Background

A considerable risk of acute kidney injury (AKI) following transcatheter interventions without iodinated contrast agents has also been recognized; however, little is known about the incidence and clinical relevance of post-procedural AKI in patients undergoing transcatheter edge-to-edge repair (TEER) for tricuspid regurgitation (TR).

Purpose

This study aimed to investigate the prognostic impact and predictors of post-procedural AKI following TEER for TR.

Methods

We retrospectively analyzed 218 consecutive patients who underwent TEER for TR. Post-procedural AKI was defined as an increase in serum creatinine of ≥0.3 mg/dl within 48 hours or of ≥50% within seven days after the procedure, compared to baseline. Procedural success was defined as at least one grade reduction in TR severity upon discharge. We determined the association between post-procedural AKI and the composite outcome consisting of all-cause mortality and re-hospitalization due to heart failure within one year after the procedure.

Results

Overall, the mean age of the patients was 79±7 years, and 46.3% of the patients were male. Post-procedural AKI occurred in 32 patients (14.7%) (Figure 1). Among baseline characteristics, male sex and an estimated glomerular filtration rate of &lt;60 ml/min/m2 were associated with the occurrence of AKI. In addition, patients without procedural success had a higher incidence of post-procedural AKI (30.4% vs. 1.8%; p=0.024).

Patients with AKI had a higher incidence of in-hospital mortality compared to those without AKI (12.5% vs. 1.1%; p=0.005). Moreover, AKI was associated with the incidence of the composite outcome within one year after TEER for TR (adjusted hazard ratio: 2.06; 95% confidence interval: 1.11–3.84; p=0.023). In addition, our restricted cubic spline curve showed that a post-procedural increase in the creatinine level within seven days after the procedure was associated with a linear trend of the risk of the composite outcome after TEER (Figure 2).

Conclusions

Post-procedural AKI occurred in 14.7% of patients undergoing TEER for TR, despite the absence of iodinated contrast agents, which was associated with worse clinical outcomes. Male sex and CKD at baseline were related to the occurrence of AKI, and the procedural success of TEER was associated with a lower incidence of AKI. Our findings highlight the clinical impact of AKI following TEER for TR and should help with identifying patients at high risk of AKI.

Funding Acknowledgement

Type of funding sources: None.

Effectiveness of transcatheter edge-to-edge repair for atrial secondary mitral regurgitation

Background

Atrial secondary mitral regurgitation (ASMR) is a subtype of SMR that is characterized by normal left ventricular (LV) function, an enlarged left atrium and mitral annulus, and flattened leaflets. This anatomical feature is different from ventricular SMR (VSMR) and might therefore impact the procedural results of transcatheter edge-to-edge repair (TEER). The effectiveness and durability of TEER in patients with ASMR has not yet been well-studied.

Purpose

This study aimed to investigate the effectiveness of TEER and anatomical characteristics related to optimal MR reduction in patients with ASMR.

Methods

We retrospectively analyzed consecutive patients who underwent MitraClip at our institution. ASMR was defined as cases that met all of the following criteria: 1) normal mitral leaflets without organic disorder, 2) LV ejection fraction &gt;50%, and 3) absence of LV enlargement and segmental abnormality. The primary outcome measure was MR reduction to ≤1+, and its predictors were explored in a logistic regression analysis. Leaflet-to-annulus index (LAI) was measured using the mid-esophageal long-axis view in the A2-P2 segment as follows: (anterior leaflet length + posterior leaflet length) / anteroposterior length of the mitral annulus.

Results

Among 415 patients with SMR, 118 patients met the criteria for ASMR (mean age: 80±8 years; male: 39.8%) (Figure 1). Patients with ASMR had a larger mitral annulus diameter, shorter mobile posterior leaflet length, and smaller coaptation depth compared to those with VSMR.

The technical success rate was 90.7%, and the MR reduction to ≤1+ after TEER was achieved in 94 (79.7%) patients with ASMR, which was comparable with VSMR. The in-hospital mortality rate was 2.5%. In multivariable logistic analysis, a large left-atrial (LA) volume index and a low LAI were associated with a lower rate of MR reduction to ≤1+ after TEER for ASMR (odds ratio [OR]: 0.98; 95% confidence interval [CI]: 0.97–0.99, and OR per 0.1 increase: 1.98; 95% CI: 1.13–3.45, respectively). The combined assessment of the LA volume index and LAI stratified the risk of residual MR ≥2+ after TEER (Figure 2).

In addition, the use of a newer generation of the MitraClip systems (NTR/XTR or G4 systems) was associated with a higher rate of MR reduction to ≤1+ compared to older generations (OR: 4.65; 95% CI: 1.67–13.00).

Conclusions

TEER with the MitraClip system achieved a high rate of MR reduction to ≤1+ in patients with ASMR. Furthermore, the new generations of the MitraClip system may provide a more effective reduction in ASMR. Although our findings suggest that TEER with the MitraClip system is a safe and feasible approach in patients with ASMR, the combined assessment of the LA volume index and LAI might be useful to refine the device selection for transcatheter mitral valve treatment in this subgroup of SMR patients.

Funding Acknowledgement

Type of funding sources: None.