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Bronchopulmonary dysplasia (BPD) is the most common morbidity complicating preterm birth and affects long-term respiratory outcomes. The objectives of this study were to establish whether serum periostin at birth, day of life (DOL) 28, and corrected 36 weeks' gestational age could be potential biomarkers for BPD.A total of 98 preterm Japanese infants born at 32 weeks and comparing 41 healthy controls born at term, were divided into BPD (n = 44) and non-BPD (n = 54) cohorts. Serum periostin levels were measured using an enzyme-linked immunosorbent assay.Among 98 preterm infants, the median serum periostin levels at birth were higher with BPD (338.0 ng/mL) than without (275.0 ng/mL, P 0.001). Multivariate analysis revealed that serum periostin levels at birth were significantly associated with BPD (P = 0.013). Serum periostin levels at birth with moderate/severe BPD (345.0 ng/mL) were significantly higher than those with non-BPD/mild BPD (283.0 ng/mL, P = 0.006).Serum periostin levels were significantly correlated with birth weight and gestational age, and serum periostin levels at birth in BPD infants were significantly higher than that in non-BPD infants.This study found higher serum periostin levels at birth in preterm infants subsequently diagnosed with bronchopulmonary dysplasia. It also emerged that serum periostin levels at birth significantly correlated with gestational age and birth weight. The mechanism by which serum periostin is upregulated in BPD infants needs further investigation.

Intraoperative motor-evoked potential (MEP) monitoring is widely used in the neck clipping of cerebral aneurysms. Little is known regarding the usefulness of intraoperative MEP monitoring in endovascular aneurysm surgery. The purpose of this study was to validate the feasibility of intraoperative MEP monitoring during the coil embolization of anterior choroidal artery (AChA) aneurysms. Clinical and angiographic data of consecutive patients who underwent coil embolization for unruptured AChA aneurysms with or without intraoperative MEP monitoring between January 2014 and December 2018 at our institute were abstracted and analyzed retrospectively. Twenty-three unruptured AChA aneurysms were treated. Eleven patients received MEP monitoring, and three of them experienced intraoperative reduction or disappearance of the MEP wave. Even during MEP changes, AChA filling showed no change in any of the three cases. Although one case with MEP monitoring encountered the disappearance of AChA filling, there was no change in MEP. This might be due to retrograde filling of the AChA from the anastomosis with the lateral posterior choroidal artery. AChA blood flow detected by angiography did not always reflect MEP status. When comparing the presence or absence of MEP monitoring, the volume embolization ratio of coiled aneurysms was significantly better in the MEP group. Intraoperative MEP monitoring during endovascular coiling for AChA aneurysms may be feasible. AChA blood flow detected by angiography does not always reflect MEP status.

Heterotopic pregnancy (HP), a coexistence of intrauterine and ectopic pregnancies, is extremely rare. Although there have been many reports of maternal outcomes in pregnant women with HP, they have not described fetal neurodevelopmental outcomes and survival. A 30-year-old Japanese woman in early gestation who had undergone two previous cesarean deliveries was transferred to our hospital with vital signs of shock. HP was confirmed by ultrasonography and laparoscopic surgery, and right salpingectomy was performed. At term, a 2,875 g neonate was delivered via cesarean section without any complications.

Recent computational fluid dynamics (CFD) studies have demonstrated the concurrence of atherosclerotic changes in regions exposed to prolonged blood residence. In this proof-of-concept study, we investigated a small but homogeneous cohort of large, cavernous carotid aneurysms (CCAs) to establish the clinical feasibility of CFD analysis in treatment planning, based on the association between pathophysiology and hemodynamics. This study included 15 patients with individual large CCAs. We identified calcifications, which indicated atherosclerotic changes, using the masking data of digital subtraction angiography. We conducted a CFD simulation under patient-specific inlet flow rates measured using magnetic resonance (MR) velocimetry. In the post-CFD analysis, we calculated the blood residence time ( $$\xi$$ ) and segmented the surface exposed to blood residence time over 1 s ( $${S}_{\xi >1}$$ ). We measured the decrease in volume after flow diversion using the original time-of-flight MR angiography data. Calcifications were observed in the region with $${S}_{\xi >1}$$ . In addition, the ratio of $${S}_{\xi >1}$$ to the surface of the aneurysmal domain exhibited a negative relationship with the rate of volume reduction at the 6- and 12-month follow-ups. Post-CFD visualization demonstrated that intra-aneurysmal swirling flow prolonged blood residence time under the condition of a small inlet flow rate, when compared to the aneurysmal volume. The results of this study suggest the usefulness of CFD analysis for the diagnosis of atherosclerotic changes in large CCAs that may affect the therapeutic response after flow diversion.

Background Dietary modifications are considered a first-line intervention for chronic disease management, yet graduating doctors still report not feeling competent to counsel patients on their diet. Research has focused on methods to address this shortfall in physician competency, including culinary medicine. Culinary medicine is an approach to education that involves hands-on food and cooking learning experiences to equip participants with tools for improving the nutrition behaviour and health of their future patients. Despite positive findings in the efficacy of these interventions, they differ markedly in approach and target, which therefore fails to provide adequate evidence that could serve to guide future culinary medicine interventions. Objective A scoping review to synthesize the existing literature on culinary medicine interventions that are offered during medical training. Methods Online databases were used to identify literature published prior to April 2022 that involve a hands-on culinary medicine component to nutrition and examine academic impact, feasibility and acceptability. Results Twenty-four studies met the eligibility criteria. Despite promising gains in nutrition knowledge, confidence and high acceptability of the programs, large variations exist in delivery method, setting, and course content between programs. There is a lack of program cost reporting and long-term follow up of participants, inconsistent evidence for improved nutrition attitudes amongst participants, as well as geographically limited adoption of such programs. Conclusions The findings of this research demonstrate a clear increase in interest in the use of hands-on culinary medicine programs as educational tools, evidence of feasibility in implementation, and improved student nutritional knowledge, skill and counseling compared to a traditional didactic curriculum. The quality of culinary medicine research studies is increasing and the aims of research are narrowing to focus on how culinary medicine can positively impact medical education. The findings from this review will aid in legitimising culinary medicine as an effective delivery method of nutritional education in medical programs.

Objective Coil embolization with Y stenting is recognized as a suitable treatment for complex wide-necked aneurysms. Y stenting comprises crossing-Y stenting, in which a stent is passed through the interstices of another stent, and kissing-Y stenting, in which 2 stents are arranged in parallel. The purpose of this study was to elucidate how to distinguish between use of the 2 Y-stenting techniques. Methods Clinical and angiographic data of patients who underwent coil embolization with Y stenting at our department from 2015 to 2019 were retrospectively analyzed. Basic characteristics, endovascular procedure, complications, and outcomes were compared between kissing-Y and crossing-Y stenting groups. Results Thirty-eight intracranial aneurysms in 38 consecutive patients were included in this study. Nineteen patients (50%) were treated with coil embolization with kissing-Y stenting and 19 (50%) with crossing-Y. Endovascular procedures were successfully performed in all but 1 patient, in the kissing-Y group, who had stent migration. One hemorrhage (2.6%) recurred 12 months after coiling with kissing-Y stenting. Angiographic follow-up (mean, 15.8 months) was available in 35 patients. Adequate occlusion was shown in 14 patients (77.8%) and 13 patients (76.5%) in the kissing-Y and crossing-Y groups, respectively. Larger, wider-necked, and more proximal aneurysms were treated with kissing-Y stenting than with crossing-Y stenting, although there were no significant differences between the groups in complication rates or clinical outcomes. Conclusions Kissing-Y and crossing-Y stenting of intracranial aneurysms were both feasible and yielded reasonable angiographic and clinical results. The choice between the kissing-Y or crossing-Y-stenting technique should be decided according to the angioarchitecture of targeted aneurysms.

Background While breastfeeding provides benefits for infants and the mother, many women either do not breastfeed or terminate breastfeeding earlier than recommended. The aim of this analysis was to identify factors associated with early discontinuation of breastfeeding in Japanese women. Methods This study used data from medical records of women delivering a singleton live birth between March 2017 and August 2019 in Iwase General Hospital, Fukushima Prefecture, Japan to assess cessation of breastfeeding by the 1-month postpartum appointment. Demographic (age at birth, and employment status), medical (parity, and physical and mental condition of the mother; and infant medical factors, such as sex, Apgar score, and jaundice, among other), and family factors (husband/partner, family members living at the same house, among others) in 734 women who had initiated breastfeeding during their delivery hospital stay were examined, and multiple logistic regression was used to determine significant predictors of early cessation of exclusive breastfeeding. Results Bivariate analysis revealed that women who were primipara, unmarried, exposed to secondhand smoke, and employed; those who smoked before pregnancy; and those who had asthma were more likely to discontinue exclusive breastfeeding than other women. Infant factors associated with discontinuation were lower birthweight, earlier gestational age, neonatal intensive care unit admission, treatment for jaundice, or lower weight gain. Multivariable analysis revealed that primiparity, passive smoking before pregnancy, maternal employment, and neonatal jaundice therapy were associated with discontinuation of breastfeeding. Conclusions In particular, women whose partners smoked before pregnancy may need to be targeted for additional support for breastfeeding.

Objective Ruptured blister aneurysms of the internal carotid artery are challenging to treat because of their difficult diagnosis and the fragility of the wall structure. Here, we sought to clarify the efficacy of extracranial-intracranial bypass followed by trapping (bypass/trapping) for ruptured blister aneurysms. Methods A retrospective study identified 45 patients with ruptured blister aneurysms between 1998 and 2017. Our principle was to attempt bypass/trapping as early as possible after diagnosis (early surgery). If early diagnosis was difficult, patients underwent elective surgery in the later stage when aneurysms were detected (elective surgery). Patient characteristics, radiologic findings, clinical course, and outcomes were analyzed. Results Forty-three patients were treated by bypass/trapping. Twenty-eight patients were classified as early surgery and 15 as elective surgery. Two patients experienced fatal rebleeding and did not undergo surgery. All 15 patients in the elective surgery group showed rebleeding and/or aneurysmal growth while awaiting surgery. In the elective surgery group, 10 aneurysms were missed initially by catheter angiography. In the early surgery group, 9 patients were assessed by vessel wall magnetic resonance imaging, which showed circumferential enhancement along the aneurysm wall, most of which was shown as only a small bulge in the angiography. Postoperative rebleeding did not occur in any of the patients. Conclusions Bypass/trapping is effective to prevent rebleeding. Early surgery may be beneficial, because most patients in the elective surgery group showed rebleeding or aneurysmal growth. Vessel wall magnetic resonance imaging is a useful adjunct for early diagnosis and may contribute to prompt early surgery.

Introduction: Superficial temporal artery (STA)-middle cerebral artery (MCA) anastomosis is an effective surgical procedure for adult patients with moyamoya disease (MMD) and is known to have the potential to prevent cerebral ischemia and/or hemorrhagic stroke. Cerebral hyperperfusion (CHP) syndrome is one of the serious complications of this procedure that can result in deleterious outcomes, such as delayed intracerebral hemorrhage, but the prediction of CHP before revascularization surgery remains challenging. The present study evaluated the diagnostic value of preoperative three-dimensional (3D)-time-of-flight (TOF) magnetic resonance angiography (MRA) for predicting CHP after STA-MCA anastomosis for MMD. Materials and Methods: The signal intensity of the peripheral portion of the intracranial major arteries, such as the anterior cerebral artery (ACA), MCA, and posterior cerebral artery (PCA) ipsilateral to STA-MCA anastomosis, on preoperative MRA was graded (0–2 in each vessel) according to the ability to visualize each vessel on 97 affected hemispheres in 83 adult MMD patients. Local cerebral blood flow (CBF) at the site of anastomosis was quantitatively measured by N-isopropyl-p-[123I]-iodoamphetamine single-photon emission computed tomography 1 and 7 days after surgery, in addition to the preoperative CBF value at the corresponding area. Then, we investigated the correlation between the preoperative MRA score and the development of CHP. Results: The CHP phenomenon 1 day after STA-MCA anastomosis (local CBF increase over 150% compared with the preoperative value) was evident in 27 patients (27/97 hemispheres; 28%). Among them, 8 (8 hemispheres) developed CHP syndrome. Multivariate analysis revealed that the hemispheric MRA score (0–6), the summed ACA, MCA, and PCA scores for the affected hemisphere, was significantly associated with the development of CHP syndrome (p = 0.011). The hemispheric MRA score was also significantly correlated with the CHP phenomenon, either symptomatic or asymptomatic (p < 0.001). Conclusion: The signal intensity of the intracranial major arteries, including the ACA, MCA, and PCA, on preoperative 3D-TOF MRA may identify adult MMD patients at higher risk for CHP after direct revascularization surgery.

Background Modern imaging techniques can identify adverse factors for tumor removal such as cavernous sinus invasion before surgery, but surgeries for giant pituitary adenomas often reveal discrepancies between preoperative imaging and intraoperative findings because pituitary adenomas have feeding arteries with narrow diameters. Current imaging methods are not suitable for tumors with not only large vascular beds but also slow arterial filling. Patients and Methods This prospective study recruited 13 male subjects and 9 female subjects with giant pituitary adenomas between November 2011 and 2018. All the patients were investigated with three-dimensional magnetic resonance (MR) imaging, bone image computerized tomography (CT), and digital subtraction angiography (DSA) using a C-arm cone-beam CT scanner with a flat-panel detector and 50% diluted contrast medium. Fine angioarchitecture was evaluated and the tumor blush was quantified using newly developed region of interest (ROI) analysis to establish surgical strategies. Results Seven patients demonstrated no or very faint tumor blushes. In these patients, feeding arteries run centripetally from the surface of the tumor. Fifteen patients showed significant tumor blushes, and the feeding arteries penetrated centrifugally from the inferoposterior pole to the upper pole of the tumor. All the patients were treated according to the angiographic information with successful hemostasis. The patients showed improvement and/or disappearance of the neurologic deficits. The faint and significant blush groups showed significant differences in intraoperative bleeding (p Conclusion Specialized evaluation focused on vascularization is required for successful therapy of giant pituitary adenomas.

Some anesthetic agents or adjunct medications administered during general anesthesia can cause an accelerated idioventricular rhythm (AIVR), which is associated with higher vagal tone and lower sympathetic activity. We encountered AIVR induced by vagal response to injection-related pain following local anesthetic infiltration into the oral mucosa during general anesthesia. A 48-year-old woman underwent extraction of a residual tooth root from the left maxillary sinus under general anesthesia. Routine preoperative electrocardiogram (ECG) was otherwise normal. Eight milliliters of 1% lidocaine (80 mg) with 1:100,000 epinephrine (80 μg) was infiltrated around the left maxillary molars over 20 seconds using a 23-gauge needle and firm pressure. Widened QRS complexes consistent with AIVR were observed for ∼60 seconds, followed by an atrioventricular junctional rhythm and the return of normal sinus rhythm. A cardiology consultation and 12-lead ECG in the operating room produced no additional concerns, so the operation continued with no complications. AIVR was presumably caused by activation of the trigeminocardiac reflex triggered by intense pain following rapid local anesthetic infiltration with a large gauge needle and firm pressure. Administration of local anesthetic should be performed cautiously when using a large gauge needle and avoid excessive pressure.

Oligodendrogliomas are defined by mutation in isocitrate dehydrogenase (NADP(+)) (IDH)1/2 genes and chromosome 1p/19q codeletion. World Health Organisation diagnosis endorses testing for 1p/19q codeletion to distinguish IDH mutant (Mut) oligodendrogliomas from astrocytomas because these gliomas require different treatments and they have different outcomes. Several methods have been used to identify 1p/19q status; however, these techniques are not routinely available and require substantial infrastructure investment. Two recent studies reported reduced immunostaining for trimethylation at lysine 27 on histone H3 (H3K27me3) in IDH Mut 1p/19q codeleted oligodendroglioma. However, the specificity of H3K27me3 immunostaining in this setting is controversial. Therefore, we developed an easy-to-implement immunohistochemical surrogate for IDH Mut glioma subclassification and evaluated a validated adult glioma cohort. We screened 145 adult glioma cases, consisting of 45 IDH Mut and 1p/19q codeleted oligodendrogliomas, 30 IDH Mut astrocytomas, 16 IDH wild-type (Wt) astrocytomas, and 54 IDH Wt glioblastomas (GBMs). We compared immunostaining with DNA sequencing and fluorescent in situ hybridization analysis and assessed differences in H3K27me3 staining between oligodendroglial and astrocytic lineages and between IDH1-R132H and non-canonical (non-R132H) IDH1/2 Mut oligodendroglioma. A loss of H3K27me3 was observed in 36/40 (90%) of IDH1-R132H Mut oligodendroglioma. In contrast, loss of H3K27me3 was never seen in IDH1-R132L or IDH2-mutated 1p/19q codeleted oligodendrogliomas. IDH Mut astrocytoma, IDH Wt astrocytoma and GBM showed preserved nuclear staining in 87%, 94%, and 91% of cases, respectively. A high recursive partitioning model predicted probability score (0.9835) indicated that the loss of H3K27me3 is frequent to IDH1-R132H Mut oligodendroglioma. Our results demonstrate H3K27me3 immunohistochemical evaluation to be a cost-effective and reliable method for defining 1p/19q codeletion along with IDH1-R132H and ATRX immunostaining, even in the absence of 1p/19q testing. Supplementary Information The online version contains supplementary material available at 10.1186/s40478-021-01194-7.

The phenotype of an unbalanced translocation is characterized by the dosage effects of the affected genes in the translocated chromosome. We present the case of a fetus with a paternally derived unbalanced 46,XY,der(10)t(6;10)(p22;q26.1) translocation, detected following growth retardation and cardiac malformation. In trisomy 6p and 10q26 monosomy, external surface malformations, including characteristic facial abnormalities, and neurological or higher effects have been reported. Developmental delay and hypotonia are reported in ≤ 80% of cases of 10q monosomy. Herein, low birth weight, cephalic abnormalities including microcephaly, low-set ears and a high arched palate, ambiguous genitalia including scrotal hypoplasia and cryptorchidism, and congenital heart defects, including ventricular septal defect and pulmonary atresia, were observed. Neurological impact was not evaluated due to neonatal death. The mortality rate and frequency of low birth weight in such translocations has been seldom reported. In this case, severe cardiac malformation and low birth weight may have caused early neonatal death. Whilst Trisomy 6 is associated with low birth weight and perinatal death, few studies have reported these outcomes in 10q26 deletion syndrome. Our findings therefore contribute to the evidence base regarding unbalanced translocations and may improve the clinical management of such patients.

Moyamoya syndrome (MMS) is an uncommon late complication after cranial irradiation. Its hemorrhagic presentation from the associated pseudo-aneurysm is extremely rare, and the optimal management strategy is undetermined. We herein report a 36-year-old man who developed intraventricular hemorrhage from a pseudo-aneurysm at the extended left anterior choroidal artery as an abnormal collateral of MMS 30 years after surgical removal and cranial irradiation for childhood craniopharyngioma. Catheter angiography confirmed the diagnosis of MMS, and multiple pseudo-aneurysms were evident at the ipsilateral abnormal choroidal collateral, one of which was considered to be a source of bleeding. The patient underwent left superficial temporal artery (STA)-middle cerebral artery (MCA) anastomosis with indirect pial synangiosis based on the observation that the development of choroidal collateral may be associated with a high rebleeding risk in hemorrhagic moyamoya disease. The patient was discharged without neurological deficit, and postoperative magnetic resonance angiography confirmed the STA-MCA bypass to be patent. Catheter angiography 1 year after revascularization surgery revealed the complete disappearance of the pseudoaneurysms with the apparently patent STA-MCA bypass. The patient did not exhibit any cerebrovascular events during the follow-up period of 16 months. In conclusion, hemorrhagic MMS with choroidal collateral as a dangerous anastomosis was effectively managed by STA-MCA anastomosis. Although long-term follow-up is necessary to evaluate our strategy, the favorable disappearance of pseudoaneurysms after revascularization surgery in the present case strongly suggests that STA-MCA anastomosis has a potential role for preventing rebleeding in MMS after cranial irradiation.

Background: Circumferential enhancement along the aneurysm wall (CEAW) by magnetic resonance (MR) vessel wall imaging has been reported to be a useful indicator for the biological activity of intracranial aneurysms such as growth and rupture. However, the significance of CEAW in vertebral artery dissection (VAD) has not been examined in detail. We quantitatively analyzed CEAW on VAD focusing on the differences in the clinical onset type. Methods: The subjects were 37 patients diagnosed with VAD who were evaluated by MR imaging in the acute phase of onset between January 2014 and May 2019. The clinical onset of VAD was categorized into 3 subtypes: (1) incidentally detected (incidental group), (2) sudden headache without cerebral ischemia and/or intracranial hemorrhage (headache group), and (3) hemorrhagic onset (hemorrhage group). Three-dimensional T1-weighted fast spin echo sequences were obtained before and after contrast material injection, and the contrast ratio (CR) of the aneurysm wall against the pituitary stalk was calculated as the indicator of CEAW. Results: The CR values of VAD in the hemorrhage group were significantly higher than those in the headache group (0.95 vs. 0.65, p < 0.05), and the headache group had significantly higher CR values than the incidental group (0.65 vs. 0.56, p < 0.05). On receiver operating characteristic curve analysis, the optimal cutoff value of CR to distinguish the hemorrhage group from the headache group was 0.83 and that to distinguish the headache group from the incidental group was 0.61. Conclusion: The extent of CEAW precisely reflected the deleterious impact of VAD in the acute stage, including hemorrhagic presentation. The predictive value of CEAW for the prognosis of unruptured VAD should be evaluated in future studies.

Intracranial aneurysm rupture is the main fatal complication of coil embolization for an intracranial aneurysm performed in conjunction with systemic heparinization. We answered five clinical questions about anesthesia, systemic heparinization, intraoperative aneurysmal rupture, the balloon-assisted technique, and the next step of initial response in case of aneurysmal rupture. It is crucial to understand when and why intraoperative aneurysmal rupture occurs to reduce its mortality rate. In cases of intraoperative problems, never pull the microcatheter or coil when perforating an aneurysm; lowering blood pressure, administering protamine for the reversal of heparin, and occluding blood flow into an aneurysm by inflating balloon(s) will help in the treatment. It is our pleasure that this chapter will help in your daily care.

In an amyloid PET for visualizing amyloid beta plaque accumulated in the brain, an amyloid imaging agent generally tends to adsorb to the inner walls of materials used in routes of administration to the patient. Therefore, we evaluated the adsorption of the amyloid imaging agent

Bronchopulmonary dysplasia (BPD) is the most common morbidity complicating preterm birth. Red blood cell distribution width (RDW), a measure of the variation of red blood cell size, could reflect oxidative stress and chronic inflammation in many diseases such as cardiovascular, pulmonary, and other diseases. The objectives of the present study were to evaluate perinatal factors affecting RDW and to validate whether RDW could be a potential biomarker for BPD. A total of 176 preterm infants born at P < 0.001) and DOL 28 (22.2% vs. 18.2%, P < 0.001) were significantly higher in BPD infants. Multivariate analysis revealed that RDW at DOL 28 was significantly higher in BPD infants (P = 0.001, odds ratio 1.63; 95% CI 1.22–2.19). Receiver operating characteristic analysis for RDW at DOL 28 in infants with and without BPD yielded an area under the curve of 0.87 (95% CI 0.78–0.91, P P < 0.001), moderate BPD (18.1% vs. 21.2%, P < 0.001), and severe BPD (18.1% vs. 24.0%, P < 0.001) were significantly higher than those with non-BPD, respectively. Furthermore, there are significant differences of RDW at DOL 28 among mild, moderate, and severe BPD. In summary, we conclude that RDW at DOL 28 could serve as a biomarker for predicting BPD and its severity. The mechanism by which RDW at DOL 28 is associated with the pathogenesis of BPD needs further elucidation.

Internal trapping (IT) is a treatment option for intracranial vertebral artery dissecting aneurysms (VADAs). Medullary infarction (MI) is a complication linked to this treatment. This study aims to clarify the outcomes of IT for VADAs and the risk factors for MIs. We retrospectively reviewed the databases from 2010 to 2017 to identify patients with VADAs treated by IT at seven collaborating institutions. Radiological findings, clinical courses, and outcomes were analyzed. Perforating arteries were classified into terminal or longitudinal types using preoperative angiography. IT was completed in 90 patients (74 ruptured and 16 unruptured VADA). Postoperative rebleeding did not occur in any ruptured VADA patients. Postoperative MRI detected MIs in 26 patients (28.9%). The incidence of MIs in the ruptured VADA (32%) was higher compared with that in the unruptured VADA (13%), though it was not significant. In the MI group, the occlusion or blind alley of the terminal-type and longitudinal-type perforator was confirmed in 23 patients (88%) and 11 patients (42%), respectively. The occlusion or blind alley of the terminal-type perforator was an independent risk factor for MIs in the logistic regression analysis (OR 5.81; 95% CI 1.34–25.11; p = 0.018). In ruptured VADA, postoperative MI (OR 12.2; 95% CI 3.19–64.55; p = 0.0001) and high-grade SAH (OR 8.02; 95% CI 2.32–37.70; p = 0.0006) were independent risk factors of an unfavorable clinical outcome. In conclusion, MIs were an independent risk factor for unfavorable outcomes after IT, especially for a ruptured VADA. The occlusion or blind alley of the terminal-type perforator caused by the IT was associated with postoperative MIs.

Endovascular trapping of the vertebral artery dissecting aneurysms (VADAs) carries a risk of medullary infarction due to the occlusion of the perforating arteries. We evaluated the detectability and anatomical variations of perforating arteries arising from the vertebral artery (VA) using three-dimensional DSA. In 120 patients without VA lesions who underwent rotational vertebral arteriography, the anatomical configurations of perforating arteries from the VA were retrospectively evaluated on the bi-plane DSA and reconstructed images to reach the consensus between two experienced reviewers. The images were interpreted by focusing on the numbers and types of perforating arteries, the relationships between the number of perforators and the anatomy of the VA and its branches. Zero, 1, 2, 3, 4, and 6 perforators were detected in 2, 51, 56, 9, 1, and 1 patient, respectively (median of 2 perforators per VA). The 200 perforators were classified into 146 terminal and 54 longitudinal course types and into 32 ventral, 151 lateral, and 17 dorsolateral distribution types. All ventral type perforators were also terminal type. In contrast, the longitudinal type was seen in 28.5% of lateral types and in 65% of dorsolateral types. Regarding the difference in the origin of the posterior inferior cerebellar artery (PICA), non-PICA type VAs gave off larger number of perforators than the other types of VAs. Non-PICA type VAs give off a significantly larger number of perforators than other types, indicating that the trapping of non-PICA type VAs is associated with a risk of ischemic complications.

Innate immune signaling via TLR4 plays critical roles in pathogenesis of metabolic disorders, but the contribution of different lipid species to metabolic disorders and inflammatory diseases is less clear. GM3 ganglioside in human serum is composed of a variety of fatty acids, including long‐chain (LCFA) and very‐long‐chain (VLCFA). Analysis of circulating levels of human serum GM3 species from patients at different stages of insulin resistance and chronic inflammation reveals that levels of VLCFA‐GM3 increase significantly in metabolic disorders, while LCFA‐GM3 serum levels decrease. Specific GM3 species also correlates with disease symptoms. VLCFA‐GM3 levels increase in the adipose tissue of obese mice, and this is blocked in TLR4‐mutant mice. In cultured monocytes, GM3 by itself has no effect on TLR4 activation; however, VLCFA‐GM3 synergistically and selectively enhances TLR4 activation by LPS/HMGB1, while LCFA‐GM3 and unsaturated VLCFA‐GM3 suppresses TLR4 activation. GM3 interacts with the extracellular region of TLR4/MD2 complex to modulate dimerization/oligomerization. Ligand‐molecular docking analysis supports that VLCFA‐GM3 and LCFA‐GM3 act as agonist and antagonist of TLR4 activity, respectively, by differentially binding to the hydrophobic pocket of MD2. Our findings suggest that VLCFA‐GM3 is a risk factor for TLR4‐mediated disease progression., Analysis of GM3 ganglioside composition in human serum under chronic inflammation conditions reveals that the fatty acid chain length of GM3 ganglioside impacts the inflammatory activation of macrophages via direct modulation of TLR4 signaling.

Objectives Bilateral upper cerebellar hemorrhage is extremely rare clinical entity but relatively known as postoperative neurosurgical complication with as-yet unknown etiology. Here, we report a case of bilateral upper cerebellar hemorrhage due to pial arteriovenous fistula (pAVF) and discuss the possible pathophysiology of this bleeding pattern. Case Description A 4-year-old boy who was previously healthy presented with a sudden onset of headache, vomiting, and gait instability. Computed tomography revealed atypical bleeding in the sulci of bilateral cerebellar hemispheres facing the tentorium. Despite the symmetric distribution of bleeding, T2-weighted magnetic resonance imaging showed flow void adjacent to the lateral margin of bleeding. Diffusion-weighted magnetic resonance imaging showed increased apparent diffusion coefficient value in the hemorrhagic lesion, suggesting vasogenic edema. Vertebral angiogram revealed a pAVF, which was fed by the hemispheric branch of superior cerebellar artery. It drained via the venous varix, inferiorly into the tortuous and engorged inferior hemispheric vein, indicating venous congestion. On the venous phase of vertebral angiogram, the superior vermian vein, which is one of the main drainers of the superior part of the cerebellum, was not opacified. Transarterial n-butyl-2-cyanoacrylate embolization was performed to prevent rebleeding, and the pAVF was treated successfully. The patient's follow-up has been uneventful for 3 years. Conclusions We reported an extremely rare case of cerebellar pAVF presenting as bilateral upper cerebellar hemorrhage. Severe congestion of upper cerebellar veins seemed to be a possible pathophysiology of this specific bleeding pattern.

Background: Management of hemorrhagic moyamoya disease (MMD) is one of the most challenging issues in neurosurgical practice. Recently, surgical revascularization by superficial temporal artery-middle cerebral artery anastomosis was reported to significantly reduce the risk of re-bleeding in hemorrhagic-onset MMD patients in the chronic state, but the optimal treatment strategy in the acute phase of hemorrhagic MMD is undetermined. Thus, we retrospectively analyzed our surgical results for hemorrhagic MMD in the acute stage, focusing on the efficacy of neuro-endoscopic management for hematoma removal. Materials and methods: Among 26 consecutive hemorrhagic MMD patients who were managed at our institution in the acute stage, 8 patients with intracerebral hemorrhage underwent surgical evacuation of the hematoma. All patients were diagnosed with MMD before surgery by magnetic resonance angiography and/or catheter angiography. Results: The initial surgical procedure was neuro-endoscopic hematoma removal in seven patients and microsurgical hematoma removal by craniotomy in one patient. One patient treated by the neuro-endoscopic procedure required subsequent small craniotomy due to difficulty in hemostasis. Satisfactory hematoma evacuation was achieved in all eight patients, as demonstrated by post-operative computed tomography, although one patient who was deeply comatose before surgery died in the early post-operative period. Conclusion: Neuro-endoscopic hematoma removal may be the optimal management method for hemorrhagic MMD in the acute stage in terms of the maximum preservation of pre-existing collateral anastomosis without affecting the potential donor vessels used for future revascularization surgery. Abbreviations: MMD: Moyamoya disease; STA: Superficial temporal artery; MCA: Middle cerebral artery; JAM: Japan Adult Moyamoya; ICH: Intracerebral hemorrhage; IVH: Intraventricular hemorrhage; SAH: Subarachnoid hemorrhage; CT: Computed tomography; TE: Total evacuation; PE: Partial evacuation; SMR: Light mass reduction; MR: Magnetic resonance; mRS: Modified Rankin scale; GCS: Glasgow Coma Scale; ICP: Intracranial pressure.

Background: Definitive treatment of carotid dissection-related strokes is currently unproved. The best endovascular technique in this setting remains to be established. Objective: To report our experience in endovascular treatment of internal carotid artery dissection presenting with acute strokes. Methods: Consecutive patients with acute strokes due to internal carotid artery dissection treated with endovascular therapy at our hospital between January 2008 and July 2019 were included. Patients were assigned to endovascular treatment according to clinical-radiologic mismatch, NIHSS greater than or equal to 5, and within 6 hours after symptom onset. The endovascular technique is described. Intracranial recanalization, carotid dilatation, and clinical outcomes were retrospectively analyzed. Results: Seven patients met the inclusion criteria. The mean age was 55 years; 5 patients (71.4%) were male. 71.4% had tandem occlusion strokes, while 28.6% had hemodynamic strokes. The mean onset-to-puncture time was 3.92 hours. Stent-assisted angioplasty for internal carotid artery was done for 85.7% of patients with a mean of 1.6 deployed stents. Dilatation was successful in 83.3% of them. Successful overall recanalization rate was 85.7%. No major complications were encountered. Minor complications occurred in 42.8% of cases. The mean NIHSS score decreased from 13.7 preoperative to 5 after 3 days. Good functional outcome (mRS 0-2) was found in 85.7% of patients at 3 months. No recurrent strokes identified over an average of 40.86 months follow-up. Conclusion: Our study provides evidence that endovascular therapy for internal carotid artery dissection-related strokes has high rates of reperfusion and favorable outcomes. Stent-assisted angioplasty of carotid dissection is thought to be safe and effective.

Background Although most intracranial aneurysms can be treated with microsurgery or endovascular procedure alone, a subset of aneurysms may require a combined approach. The purpose of this study was to assess the efficacy of endovascular interventions combined with bypass surgery for the treatment of complex intracranial aneurysms. Methods We retrospectively reviewed medical records from a prospectively maintained patient database to identify patients who underwent endovascular treatment of an intracranial aneurysm at our institutes between 2007 and 2017. We recruited patients who received a preplanned combination of endovascular treatment and extracranial-intracranial bypass surgery. Results Forty-four patients (44 aneurysms) were treated with a combined approach. Twenty-four patients presented with subarachnoid hemorrhage. Treatment strategies included endovascular parent artery occlusion with the bypass surgery to restore cerebral blood flow (n = 12), endovascular trapping with bypass surgery to isolate incorporated branches (n = 12), and intra-aneurysmal coil embolization with bypass surgery to isolate incorporated branches (n = 20). During a mean period of 35.6 months, follow-up catheter angiography was performed in 35 of 44 patients (79.5%) and demonstrated complete aneurysm obliteration in 29 patients (82.9%) and bypass patency in 33 (94.3%). The postoperative aneurysm-related mortality and morbidity rates were 6.8% and 13.6%, respectively. Conclusions Combined endovascular and surgical bypass procedures are useful for the treatment of complex intracranial aneurysms when conventional surgical or endovascular techniques are not feasible and show acceptable rates of morbidity and mortality.

Spinal dural arteriovenous fistula (DAVF) occurs at any spinal level, but the clinical characteristics of lumbosacral DAVF have not been well documented. The purpose of this study was to evaluate clinical characteristics of lumbosacral DAVF and compare these features with those in thoracic DAVF.Twenty-five consecutive patients with 16 thoracic and 9 lumbosacral DAVFs were included (mean age, 63.9 years; 20 men). All patients presented with progressive myelopathy. Preoperative and postoperative neurologic deficits were compared between thoracic and lumbosacral DAVF groups. Using magnetic resonance imaging, the extent of T2 high-intensity areas and signal flow voids were documented. Follow-up after surgical interventions ranged from 6 to 96 months (mean, 38.1 months).Preoperatively, patients suffering lumbosacral DAVF tended to be more severely disabled compared with thoracic DAVF patients. Lumbosacral DAVF patients exhibited diminished patellar (P = 0.04) and Achilles tendon reflexes (P0.01), while most thoracic DAVF patients exhibited hyperreflexia. In magnetic resonance imaging, signal flow voids around the spinal cord were evident in only 4 of 9 lumbosacral DAVF patients (P = 0.012). Rather, a serpentine signal flow void of the filum terminale was a hallmark of lumbosacral DAVFs to distinguish them from thoracic DAVFs. In the lumbosacral DAVF group, postoperative improvements were significantly better in micturition function (P = 0.02).In lumbosacral DAVF, postoperative micturition function recovery was superior to thoracic DAVF. Intradural lumbar signal flow void is indicative of lumbosacral DAVF. For appropriate management, it is important to recognize these differences between lumbosacral and thoracic DAVF.

Background Identification of rupture sites in patients with multiple intracranial aneurysms is largely based on aneurysm size, location, and shape. Finding circumferential enhancement along the aneurysm wall (CEAW) on magnetic resonance (MR) vessel wall imaging was recently shown to be indicative of ruptured aneurysm. Objective To investigate the hypothesis that a higher degree of CEAW would identify the site of rupture in patients with multiple aneurysms. Methods We prospectively performed quantitative analysis of CEAW in consecutive patients with both aneurysmal subarachnoid hemorrhage and multiple aneurysms (26 patients with a total of 62 aneurysms), using MR vessel wall imaging. Three-dimensional T1-weighted fast spin-echo sequences were obtained before and after injection of contrast media, and the wall enhancement index (WEI) was calculated. Aneurysm characteristics (size, location, irregular shape, aspect ratio [neck-to-dome length/neck width], and WEI) were compared between ruptured and unruptured aneurysms. Odds ratios with 95% confidence intervals for ruptures were calculated with conditional univariable logistic regression analysis. Analyses were repeated after adjustment for aneurysm size. Results Large aneurysm size, high aspect ratio, WEI (above the median values), and irregular shape were significantly associated with aneurysm rupture. After adjustment for aneurysm size, WEI (adjusted odds ratio: 8.8; 95% confidence interval, 1.1-72.6) as well as irregular shape and aspect ratio showed a strong association with rupture. Conclusion CEAW is associated with rupture of intracranial aneurysm independent of aneurysm size and patient characteristics. Contrast-enhanced MR vessel wall imaging helps to identify the site of rupture in patients with multiple aneurysms.

We report a case of tentorial dural arteriovenous fistula (DAVF) with a severe intracranial hemorrhage occurring after Onyx embolization. A 40-year-old man presented with an asymptomatic tentorial DAVF on angiography. Transarterial embolization with Onyx was performed via the middle meningeal artery, and the cast filled the fistula itself and its proximal draining vein. Postoperative angiography confirmed complete occlusion of the DAVF. A computed tomography scan performed immediately after the procedure demonstrated an acute subdural hematoma with the temporal hemorrhage. Emergency craniotomy revealed continuous arterial bleeding from a viable glomus-like vascular structure around the proximal part of the embolized draining vein, fed by a pial artery arising from the posterior cerebral artery. Pathologic findings suggested diagnosis of vascular malformation extending into the subdural space. Tentorial DAVFs can extend to the subdural space along their drainage route, and may be involved in severe hemorrhagic complications of curative endovascular treatment using Onyx, particularly those with pial arterial supply.

Among brainstem arteriovenous malformations (AVMs), there exist small AVMs predominantly located in the cerebellopontine angle cistern (CPAC) with minimal extension into the pial surface of the brainstem. However, previous studies of CPAC AVMs did not particularly discuss the role of embolization in the treatment of these lesions. This study was conducted to clarify the effectiveness and validity of embolization in the treatment of CPAC AVMs. We retrospectively reviewed five patients with CPAC AVMs who underwent endovascular treatment. These patients were treated with embolization followed by open surgery or gamma knife (GK) radiosurgery. Radiological findings and clinical course for these patients were then assessed. All five patients presented with a hemorrhage. Angiography revealed that the main feeder contained a dilated pontine perforating artery in all cases. Embolization through the dilated pontine perforating artery effectively reduced shunt flow within the nidus or obliterated associated aneurysms. Magnetic resonance imaging showed infarction on the lateral pons in four patients, one of which developed transient mild dizziness and mild ataxia of the right side. Subsequent open surgery was performed in three patients, and GK radiosurgery was performed in two patients without complications. At the end of the follow-up period, all patients demonstrated favorable outcomes. Postoperative rebleeding did not occur in any of the patients. Disappearance of the AVM was confirmed in four patients, except in the one patient treated with GK. Although ischemic complications should be noted, embolization of CPAC AVMs may be an appropriate treatment option to reduce the risk of subsequent surgery or radiosurgery.

Objective: Superficial temporal artery (STA)-middle cerebral artery (MCA) anastomosis is a standard surgical procedure for adult patients with moyamoya disease (MMD) and plays a role in preventing ischemic and/or hemorrhagic stroke. Cerebral hyperperfusion (CHP) syndrome is a potential complication of this procedure that can result in deleterious outcomes, such as delayed intracerebral hemorrhage, but the exact threshold of the pathological increase in postoperative cerebral blood flow (CBF) is unclear. Thus, we analyzed local CBF in the acute stage after revascularization surgery for adult MMD to predict CHP syndrome under modern perioperative management. Materials and Methods: Fifty-nine consecutive adult MMD patients, aged 17–66 years old (mean 43.1), underwent STA-MCA anastomosis with indirect pial synangiosis for 65 affected hemispheres. All patients were perioperatively managed by strict blood pressure control (systolic pressure of 110–130 mm Hg) to prevent CHP syndrome. Local CBF at the site of anastomosis was quantitatively measured using the autoradiographic method by N-isopropyl-p-[123I] iodoamphetamine single-photon emission computed tomography 1 and 7 days after surgery, in addition to the preoperative CBF value at the corresponding area. We defined CHP phenomenon as a local CBF increase over 150% compared to the preoperative value. Then, we investigated the correlation between local hemodynamic change and the development of CHP syndrome. Results: After 65 surgeries, 5 patients developed CHP syndrome, including 2 patients with delayed intracerebral hemorrhage (3.0%), 1 with symptomatic subarachnoid hemorrhage (1.5%), and 2 with focal neurological deterioration without hemorrhage. The CBF increase ratio was significantly higher in patients with CHP syndrome (270.7%) than in patients without CHP syndrome (135.2%, p = 0.003). Based on receiver operating characteristic analysis, the cutoff value for the pathological postoperative CBF increase ratio was 184.5% for CHP syndrome (sensitivity = 83.3%, specificity = 94.2%, area under the curve [AUC] value = 0.825) and 241.3% for hemorrhagic CHP syndrome (sensitivity = 75.0%, specificity = 97.2%, AUC value = 0.742). Conclusion: Quantitative measurement of the local CBF value in the early postoperative period provides essential information to predict CHP syndrome after STA-MCA anastomosis in patients with adult MMD. The pathological threshold of hemorrhagic CHP syndrome was as high as 241.3% by the local CBF increase ratio, but 2 patients (3.0%) developed delayed intracerebral hemorrhage in this series that were managed following the intensive perioperative management protocol. Thus, we recommend routine CBF measurement in the acute stage after direct revascularization surgery for adult MMD and satisfactory blood pressure control to avoid the deleterious effects of CHP.

Background Hemorrhagic presentations are rare in vertebrovertebral arteriovenous fistula (VVAVF). To the best of our knowledge, this is the first report of a patient initially presenting with subarachnoid hemorrhage and progressing to intramedullary hemorrhage. Case Description The authors report on a 59-year-old man with VVAVF who developed massive intramedullary hemorrhage. Twelve months before ictus, the patient presented with subarachnoid hemorrhage. Although we recommended endovascular surgery, the patient refused treatment. Twelve months after the initial attack, the massive intramedullary hemorrhage in cervical spinal cord caused complete spinal cord injury. Emergent endovascular intervention was performed after the intramedullary hemorrhage, but there was no neurologic improvement. Conclusions Identification of this phenomenon is important in VVAVF because intramedullary hemorrhage dramatically degrades patient outcome. Prompt surgical intervention is mandatory for VVAVF cases presenting with subarachnoid hemorrhage.

To date, few studies have investigated whether perinatal factors affect coagulation parameters at birth in preterm and term neonates. We retrospectively investigated coagulation factors on day 1 in 609 consecutive neonates admitted to our neonatal intensive care unit between January 2010 and December 2017. We measured coagulation factors on day 1 using peripheral blood samples. Multivariate analysis revealed that prothrombin time–international normalized ratio correlated with intraventricular hemorrhage (p = 0.000; β = 0.180) and placental abruption (PA; p = 0.000; β = 0.142). Activated partial thromboplastin time (aPTT) correlated with birth weight (BW; p = 0.000; β = − 0.217), gestational age (GA; p = 0.000; β = − 0.282), and PA (p = 0.000; β = 0.181). Fibrinogen concentration was associated with respiratory distress syndrome (p = 0.007; β = − 0.114), pregnancy-induced hypertension (p = 0.000; β = − 0.141), and Apgar score at 1 minute (p = 0.043; β = 0.147). Furthermore, the level of d-dimer inversely correlated with Apgar score at 5 minutes (p = 0.049). Finally, antithrombin III levels positively correlated with GA (p = 0.000) and BW (p = 0.000). Thus, maternal and neonatal complications affect coagulation parameters in preterm and term neonates.

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Background: Transcranial Doppler (TCD) is used to monitor cerebral vasospasm after subarachnoid hemorrhage (SAH), but its diagnostic ability is reported to be limited. Therefore, the purpose of this study was to investigate the relationship between the diagnosability of TCD and the localization of the vasospasm. Methods: This retrospective study included 20 patients who presented with symptomatic vasospasm after SAH. All 20 patients underwent daily TCD examinations and cerebral angiography after the onset of delayed cerebral ischemia. We defined positive findings on TCD as a maximum flow velocity >200 cm/s or as a mean flow velocity >120 cm/s at the horizontal part of the middle cerebral artery (MCA). We also examined the site of vasospasm on cerebral angiography. Results: Fourteen patients had true-positive findings on TCD examination, and cerebral angiography showed diffuse vasospasm involving the horizontal segment of the MCA. However, 6 patients had false-negative findings on TCD examination, and cerebral angiography showed vasospasm localized at the distal part of the MCA (the insular and/or cortical segments). The patients with proximal vasospasm were significantly younger than those with distal vasospasm. Blood flow velocity at initial TCD and the increase in velocity at the onset of vasospasm were lower and smaller, respectively, in the distal vasospasm group. Conclusions: In patients with cerebral vasospasm localized at the distal part of the MCA, flow velocity at the horizontal segment of the MCA did not increase to the level we defined as positive. To avoid such false negatives, a slight increase in velocity on TCD should be considered as positive in distal vasospasm cases, especially in older patients.

Spinal cord intramedullary arteriovenous malformations are rare. For patients suffering from either hemorrhage or myelopathy, surgical or endovascular interventions are indicated. However, complete eradication of the nidus is often difficult because of its intramedullary location and complex angioarchitecture. In this report, we evaluate the feasibility and safety of stereotactic radiosurgery as a treatment modality for intramedullary spinal arteriovenous malformations (AVMs). Between 2010 and 2014, we performed stereotactic radiosurgery to treat four patients with intramedullary AVM and one with spinal arteriovenous metameric syndrome (one woman and four men; age range, 31-66 years). Three patients presented with myelopathy, and two suffered hemorrhages. Nidi were located in the cervical (three cases) and thoracic (two cases) spinal cord regions. Based on the angioarchitecture, surgery and endovascular embolization were indicated. When both modalities were deemed hazardous, radiosurgery using CyberKnife™ was offered. Radiation using marginal doses of 18 Gy was administered in three fractions. The mean follow-up period was 37.2 months (range, 16-62 months). After treatment, two of the three patients with myelopathy experienced either improvement or stabilization of their symptoms and one experienced worsening of dysesthesia. In two patients with hemorrhage, symptoms improved in one and remained stable in the other. No further hemorrhagic episodes were evident during follow-up. Follow-up angiograms showed marked shrinkage of the nidus located in the thoracic spinal cord in one case and angiographic stabilization in the others. As a treatment modality for intramedullary AVMs, CyberKnife™ is safe and can be considered when surgery or endovascular therapy is not indicated. To determine optimum radiation doses and protocols for treating spinal AVMs, further studies with more patients and long-term follow-up are required.

Spinal arteriovenous malformation (AVM) is a broad term that constitutes diverse vascular pathologies. To date, various classification schemes for spinal AVM have been proposed in literature, which helped neurosurgeons understand the pathophysiology of the disease and determine an optimal treatment strategy. To discuss indications and results of surgical and endovascular interventions for spinal AVM, this article refers to the following classification proposed by Anson and Spetzler in 1992: type I, dural arteriovenous fistula (AVF); type II, glomus intramedullary AVM; type III, juvenile malformations; and type IV, perimedullary AVF. In general, complete obliteration of the fistula is a key for better outcome in type I dural and type IV perimedullary AVFs. On the other hand, in type II glomus and type III juvenile malformations, functional preservation, instead of pursuing angiographical cure, is the main goal of the treatment. In such cases, reduction of the shunt flow can alleviate clinical symptoms. Proper management of spinal AVM should start with neurological examination and understanding of angioarchitectures, which provide critical information that guides the indication and modality of intervention. Finally, close collaboration of the microsurgical and endovascular teams are mandatory for successful treatment.

Postoperative meningitis is a serious complication occurring after neurosurgical interventions. However, few investigations have focused specifically on the risk factors that predispose patients to meningitis after major craniotomy. This study identified the risk factors for postoperative meningitis after neurovascular surgery, and investigated the relationship between postoperative meningitis and clinical outcome.A total of 148 consecutive patients with subarachnoid hemorrhage (SAH) who underwent clipping surgery through a pterional approach within 72 h between January 2007 and September 2011 were retrospectively analyzed. The treatment strategy of our hospital for patients with SAH was based on the findings of digital subtraction angiography in the acute phase. Coil embolization was firstly considered, and clipping through craniotomy if indicated was performed as soon as possible. Prophylactic antibiotics were administered before beginning craniotomy and for at least 3 days after. Hydrocortisone was used to prevent hyponatremia if allowed by the medical condition of the patient. Intrathecal administration of nicardipine hydrochloride was given if required for vasospasm treatment. Meningitis was clinically diagnosed from the blood samplings and cerebrospinal fluid (CSF) examinations. Data were collected from the electronic and paper charts. The status of modified Rankin scale (mRS) 0-2 at discharge was defined as favorable outcome.A total of 14 patients (9.5%) had meningitis during this study period. Symptomatic vasospasm was detected in 33 patients (22.3%), and 12 patients (8.1%) had permanent neurological deficits caused by vasospasm. Overall, 109 patients (73.6%) had favorable outcome. The longer duration of drainage placement, presence of CSF leakage, and intrathecal administration of vasodilatory agent showed significantly higher incidence of postoperative meningitis in univariate analysis (p=0.0093, 0.0017, and 0.0090, respectively). The proportion of favorable outcome patients at discharge (mRS 0-2) was significantly lower in patients with postoperative meningitis (35.7%) than in patients without it (77.6%) (p=0.0004). The duration of in-hospital stay was significantly longer in patients with postoperative meningitis (median 58.5, range 28-115 days) than in patients without it (median 38.5, range 19-149 days) (p0.001). Multivariate logistic regression analysis showed that only presence of CSF leakage was associated with postoperative meningitis (p=0.0299).Meningitis after surgery is still a serious complication that requires preventative intervention. The clinical outcome of patients with postoperative meningitis after neurovascular surgery is not still satisfactory.

Background Bypass with parent artery trapping is an alternative treatment method for ruptured internal carotid artery (ICA) aneurysms when clipping or coiling is contraindicated. However, the efficacy and safety of this strategy during the acute stage of subarachnoid hemorrhage (SAH) is undetermined. Methods A retrospective review of 955 consecutive patients presenting SAH between 2006 and 2014 identified 17 patients with ruptured ICA aneurysms treated by bypass with parent artery trapping within 72 hours after the bleeding (bypass group). The 26 cases with ruptured posterior communicating artery aneurysms treated with clipping during the same period were defined as a control group (clipping group). Postoperative cerebral blood flow (CBF) was evaluated by single photon emission computed tomography (SPECT). We analyzed the postoperative hemodynamic status, surgical complications, and the clinical outcomes. Results Postoperative rebleeding did not occur in any of the cases. CBF in the first postoperative week in the bypass group was lower than that in the clipping group ( P = .0165). This CBF decrease improved in the second postoperative week and did not differ from that of the clipping group. The incidence of acute ischemic complications was significantly higher in the bypass group ( P = .0284), but the incidence of delayed cerebral ischemia did not differ between the 2 groups. The incidence of favorable outcomes at 6 months was 82.4% in the bypass group and 81% in the clipping group. Conclusions Although the transient CBF decrease with acute ischemic complications should be noted, acute bypass with parent artery trapping is safe and effective for unclippable/uncoilable ruptured ICA aneurysms.

Background Correct diagnosis of cerebral stroke type, hemorrhagic or ischemic, is essential in the early stage to establish the optimum treatment. The diagnosis is mainly determined based on imaging studies. Other more available diagnostic methods are desirable, such as blood sample examination. Lectin-like oxidized low-density lipoprotein receptor-1 (LOX-1) is very important in vascular dysfunction induced by oxidized low-density lipoprotein, including cell apoptosis. The present study evaluated LOX-1 as a biomarker for cerebral stroke. Subjects and Methods Patients with newly diagnosed stroke were prospectively enrolled between February and July 2014. LOX-1 serum values were measured twice, within 24 hours and 2 months after the onset. Results A total of 16 patients were enrolled; 7 patients with intracerebral hemorrhage (ICH) and 9 patients with cerebral infarction. Median LOX-1 values of patients with ICH and infarction in the acute phase were 1825.8 and 593.9 pg/mL, respectively, significantly higher in patients with ICH than in patients with infarction (P Conclusion LOX-1 serum level has potential as a biomarker of ICH.

Background Varix of the drainage route can spontaneously develop thrombosis and disappear after the treatment of the associated cerebral arteriovenous malformation (AVM). We report a rare case in which a thrombosed cerebral venous varix of the drainage route exhibited growth despite complete resection of the associated cerebral AVM. Case Description A 46-year-old man was diagnosed with an AVM in the left temporal lobe. The AVM was accompanied by a large venous varix in the superficial venous drainage route. Transarterial embolization was performed followed by resection of the nidus. The venous varix in the drainage route was not resected, as it was buried in the temporal lobe of the dominant hemisphere. The venous varix was ligated using a titanium clip and nylon thread. Postoperative angiography confirmed the disappearance of the AVM, and magnetic resonance imaging showed thrombosis of the venous varix. However, follow-up magnetic resonance imaging performed 5 months after surgery showed the enlargement of the thrombosed venous varix and emergence of perilesional cerebral edema. The venous varix was excised by reoperation to prevent further growth. Histopathologic evaluation showed infiltration of macrophages and multinucleated giant cells and proliferation of capillaries vessels within the walls of the varix, particularly around the embolic and ligation materials. Conclusions To the best of our knowledge, this is the first report of the growth of a thrombosed cerebral venous varix after the resection of a cerebral AVM. The possible cause of this rare phenomenon is excessive inflammation with neovascularization within the wall of the venous varix during thrombogenesis, enhanced by reaction against embolic and ligation materials.

The authors report the case of a 70-year-old woman with lumbar spinal epidural arteriovenous fistula (SEDAVF) who experienced subarachnoid hemorrhage (SAH) after a diagnostic lumbar puncture. According to the literature, perimedullary spinal vein enlargement is a hallmark of spinal vascular diseases; however, there are certain cases in which routine sagittal MRI fails to disclose signal flow voids. In such cases, patients may undergo a lumbar tap to investigate the possible causes of spinal inflammatory or demyelinating disease. Recognizing this phenomenon is essential because lumbar puncture of the epidural venous pouch or an enlarged intradural vein in SEDAVF may induce severe SAH. A high clinical index of suspicion can prevent similar cases in lumbar SEDAVF.

Surgical treatments should be considered for vertebral artery fusiform aneurysms, which become symptomatic due to cerebral ischemia or mass effect. Ischemic complication is one of the major problems after surgical or endovascular trapping, which is associated with unfavorable outcomes. The authors present a case with growing vertebral artery (VA) fusiform aneurysm with ischemic onset successfully treated with outflow occlusion with occipital artery-posterior inferior cerebellar artery (OA-PICA) bypass. A 50-year-old woman presented with left PICA territory infarction. Left vertebral angiography (VAG) showed occlusion of the left VA at the proximal V4 segment. Right VAG revealed that the distal part of the left V4 segment with fusiform aneurysmal dilatation was reconstituted through vertebrobasilar junction, and the left PICA was the outlet of the blood flow from the fusiform aneurysm. Although the patient was treated conservatively, enlargement of the left VA fusiform aneurysm was observed 8 months after the initial presentation. Considering the potential risks for future stroke or bleeding, we performed clip occlusion of the origin of the left PICA, which could achieve outflow occlusion of the fusiform aneurysm with preservation of the perforators arising around the aneurysm. We created OA-PICA anastomosis for revascularization of the distal PICA. The postoperative course was uneventful, and the postoperative right VAG revealed occlusion of the fusiform aneurysm. Outflow occlusion instead of trapping is an effective surgical option for VA fusiform aneurysm to achieve obliterate the aneurysm with preservation of the perforator at the blind end.

Cerebral microaneurysms, which are 2 mm or small in size, are a rare cause of subarachnoid hemorrhage (SAH). The authors present 2 cases with ruptured microaneurysms, in which 3-dimensional (3D) fast spin-echo T1 imaging with variable flip angles (CUBE T1) using gadolinium-diethylenetriaminepentaacetic acid (Gd) enhancement was useful in diagnosing the microaneurysms as the source of bleeding. Case 1 was a 61-year-old woman who had an SAH localized to the left Sylvian fissure. A small bulge (1.4 mm) at the bifurcation of left middle cerebral artery (MCA), which was detected by 3D angiography, was well enhanced by CUBE T1 with Gd enhancement. The patient was successfully treated by trapping of the lower division of the left M2 segment with superficial temporal artery-M3 bypass. The intraoperative findings indicated that the microaneurysm at the bifurcation of the left MCA was the ruptured site. Case 2 was a 41-year-old man who had a diffuse SAH. A small bulge (1.5 mm) at the inferolateral wall of the left internal carotid artery (ICA), which was detected by 3D angiography, was well enhanced by CUBE T1 with Gd enhancement. The patient was treated by trapping of the left ICA with external carotid artery-saphenous vein graft-M2 bypass without complications. The intraoperative findings indicated that the microaneurysm at the inferolateral wall of the left ICA was the ruptured site. CUBE T1 with Gd enhancement was useful as an adjunctive tool for the diagnosis of ruptured cerebral microaneurysms. This sequence might enable neurosurgeons to perform curative surgery with certainty for ruptured microaneurysms.

We describe a rare case with partially thrombosed fusiform anterior choroidal artery (AchA) aneurysm successfully treated with therapeutic occlusion of the AchA.A 58-year-old man presented with transient mild hemiparesis of the right side. Magnetic resonance imaging (MRI) showed an ischemic lesion in the posterior limb of the left internal capsule. Digital subtraction angiography (DSA) revealed a left internal carotid artery saccular aneurysm (14.5-mm diameter) arising from the supraclinoid segment. The left AchA was not detected in the initial DSA, and MRI showed the aneurysm to be partially thrombosed. The second DSA performed 2 weeks after the onset showed recanalization of the thrombosed portion of the aneurysm with the left AchA apparently arising from its tip. The aneurysm was diagnosed as a partially thrombosed fusiform AchA aneurysm.Open surgery was performed and a titanium clip was applied to the base of the fusiform aneurysm under motor evoked potential monitoring, which remained unchanged after clipping. Occlusion of the aneurysm was confirmed by Doppler ultrasound and intraoperative fluorescence angiography. Furthermore, Doppler ultrasound and fluorescence angiography showed that the blood flow supplying the pyramidal tract was reconstituted by the retrograde collateral flow from the choroidal segment. The aneurysm was completely obliterated in postoperative DSA, which demonstrated retrograde filling of the AchA through the posterior circulation. The patient manifested transient weakness of the right side postoperatively, which was completely recovered after short-term rehabilitation.This case illustrates the unique clinical course of a rare partially thrombosed fusiform AchA aneurysm, successfully treated with therapeutic clip occlusion of the AchA under the multimodal monitoring.

Background context Spinal arteriovenous metameric syndrome (SAMS) is a subgroup of spinal arteriovenous malformations (AVMs). Most SAMS cases have intra- and extradural AVMs and suffer from hematomyelia, subarachnoid hemorrhage, or venous congestive myelopathy. Purpose To present a rare case of SAMS in which spinal AVMs were exclusively epidural. We reviewed previous literature and evaluated the feasibility of a treatment strategy using endovascular interventions, followed by surgical obliteration. Study design A case report and literature review of SAMS. Methods We report a case of a 15-year-old boy suffering from SAMS in which epidural venous ectasia because of extradural AVMs caused spinal cord compression. Results The patient was successfully treated with multiple sessions of transarterial embolization followed by open surgery. After the treatment, his neurologic deficits resolved. Postoperative angiography confirmed complete obliteration of extradural AVMs. Conclusions Although exclusively epidural spinal AVM is an uncommon type of SAMS, combined endovascular and surgical interventions can be an effective treatment for AVMs to achieve better radiologic outcomes and complete resolution of patient symptoms.

Partial targeted embolization of the ruptured site of cerebral arteriovenous malformations (AVMs) is considered effective to prevent rebleeding. The site of rupture is usually determined by morphological features, such as an intranidal aneurysm or a venous varix; however, the site can be difficult to identify in high-grade AVM with complicated angioarchitecture. The authors present a case of a 36-year-old woman with high-grade AVM presented with repeated hemorrhage. Cerebral angiography showed intranidal aneurysm, which was considered the ruptured site. The T1-weighted imaging with gadolinium enhancement demonstrated linear enhancement along the outer surface of the thickened wall of the intranidal aneurysm, which could be supplementary information to identify the ruptured site. Obliteration of the intranidal aneurysm was successfully achieved by emergent targeted embolization using N-butyl cyanoacrylate. The patient recovered and regained an independent status. The patient underwent volume-staged radiosurgery and experienced no further hemorrhage during the 26 months follow-up. Targeted embolization of the ruptured site is considered effective to prevent rebleeding in high-grade cerebral AVMs. Wall enhancement of the intranidal aneurysm, in addition to the structural characteristics, could be helpful in identifying the site of rupture embedded in the complicated angioarchitecture.

We report a case of a 39-year-old man presenting with a high-grade left parieto-occipital arteriovenous malformation (AVM) complicated by superior sagittal sinus (SSS) stenosis, seven years after the first presentation. Magnetic resonance imaging revealed a newly developed perilesional edema. Venous sinus stenosis acutely progressed to occlusion and induced multiple intracerebral hemorrhages. An emergent balloon venoplasty of the SSS successfully recanalized the thrombosed sinus. Further, multistage transarterial nidus embolization was performed followed by surgical resection, resulting in a complete eradication of the large AVM. The emergence of perilesional edema is a key radiological feature for the early recognition of a newly developed venous drainage route disturbance, which would result in hemorrhagic events. Venous sinus thrombosis is a rare cause of drainage route disturbance in cerebral AVMs. For such cases, the recanalization of venous drainage concomitant with flow reduction by performing transarterial embolization is effective in preventing further hemorrhage, which enables a safe performance of subsequent radical surgery.

OBJECTIVEThe aim of this retrospective multicenter cohort study was to assess the details of the angioarchitecture of arteriovenous fistulas (AVFs) at the craniocervical junction (CCJ) and to determine the associations between the angiographic characteristics and the clinical presentations and outcomes.METHODSThe authors analyzed angiographic and clinical data for patients with CCJ AVFs from 20 participating centers that are members of the Japanese Society for Neuroendovascular Therapy (JSNET). Angiographic findings (feeding artery, location of AV shunt, draining vein) and patient data (age, sex, presentation, treatment modality, outcome) were tabulated and stratified based on the angiographic types of the lesions, as diagnosed by a member of the CCJ AVF study group, which consisted of a panel of 6 neurointerventionalists and 1 spine neurosurgeon.RESULTSThe study included 54 patients (median age 65 years, interquartile range 61–75 years) with a total of 59 lesions. Five angiographic types were found among the 59 lesions: Type 1, dural AVF (22 [37%] of 59); Type 2, radicular AVF (17 [29%] of 59); Type 3, epidural AVF (EDAVF) with pial feeders (8 [14%] of 59); Type 4, EDAVF (6 [10%] of 59); and Type 5, perimedullary AVF (6 [10%] of 59). In almost all lesions (98%), AV shunts were fed by radiculomeningeal arteries from the vertebral artery that drained into intradural or epidural veins through AV shunts on the dura mater, on the spinal nerves, in the epidural space, or on the spinal cord. In more than half of the lesions (63%), the AV shunts were also fed by a spinal pial artery from the anterior spinal artery (ASA) and/or the lateral spinal artery. The data also showed that the angiographic characteristics associated with hemorrhagic presentations—the most common presentation of the lesions (73%)—were the inclusion of the ASA as a feeder, the presence of aneurysmal dilatation on the feeder, and CCJ AVF Type 2 (radicular AVF). Treatment outcomes differed among the angiographic types of the lesions.CONCLUSIONSCraniocervical junction AVFs commonly present with hemorrhage and are frequently fed by both radiculomeningeal and spinal pial arteries. The AV shunt develops along the C-1 or C-2 nerve roots and can be located on the spinal cord, on the spinal nerves, and/or on the inner or outer surface of the dura mater.

OBJECTIVERisk factors for aneurysm rupture have been extensively studied, with several factors showing significant correlations with rupture status. Several studies have shown that aneurysm shape and hemodynamics change after rupture. In the present study the authors investigated a static factor, the bifurcation angle, which does not change after rupture, to understand its effect on aneurysm rupture risk and hemodynamics.METHODSA hospital database was retrospectively reviewed to identify patients with cerebral aneurysms treated surgically or endovascularly in the period between 2008 and 2015. After acquiring 3D rotational angiographic data, 3D stereolithography models were created and computational fluid dynamic analysis was performed using commercially available software. Patient data (age and sex), morphometric factors (aneurysm volume and maximum height, aspect ratio, bifurcation angle, bottleneck ratio, and neck/parent artery ratio), and hemodynamic factors (inflow coefficient and wall shear stress) were statistically compared between ruptured and unruptured groups.RESULTSSeventy-one basilar tip aneurysms were included in this study, 22 ruptured and 49 unruptured. Univariate analysis showed aspect ratio, bifurcation angle, bottleneck ratio, and inflow coefficient were significantly correlated with a ruptured status. Logistic regression analysis showed that aspect ratio and bifurcation angle were significant predictors of a ruptured status. Bifurcation angle was inversely correlated with inflow coefficient (p < 0.0005), which in turn correlated directly with mean (p = 0.028) and maximum (p = 0.014) wall shear stress (WSS) using Pearson's correlation coefficient, whereas aspect ratio was inversely correlated with mean (0.012) and minimum (p = 0.018) WSS.CONCLUSIONSBifurcation angle and aspect ratio are independent predictors for aneurysm rupture. Bifurcation angle, which does not change after rupture, is correlated with hemodynamic factors including inflow coefficient and WSS, as well as rupture status. Aneurysms with the hands-up bifurcation configuration are more prone to rupture than aneurysms with other bifurcation configurations.