Clinical characteristics of aneurysmal subarachnoid haemorrhage complicated by Takotsubo cardiomyopathy resulting in good neurological outcome.

BACKGROUND: Takotsubo cardiomyopathy (TC) is a well-known complication of subarachnoid haemorrhage (SAH), often accompanied by neurogenic myocardial dysfunction. Although TC has been reported to be associated with higher morbidity and mortality among patients with aneurysmal SAH (aSAH), some patients have been reported to recover, the profiles and follow-up outcomes of these survivors remain unclear. MATERIALS AND METHODS: To characterize the profiles of patients with aSAH complicated by TC who experienced favourable outcomes using long-term follow-up data, a consecutive series of patients with aSAH were enrolled and TC diagnosis was based on the revised version of the Mayo Clinic criteria. Clinical outcomes were assessed at 6 months according to modified Rankin Scale scores. RESULTS: Among 165 consecutive patients with aSAH, 15 cases were complicated by TC, corresponding to an occurrence rate of 9.0%. Five patients with aSAH complicated by TC (33.3%) experienced a favourable outcome, and the mean value of systolic blood pressure on arrival was significantly lower than in those who experienced an unfavourable outcome (p = 0.032). CONCLUSION: According to analysis, it is possible cardiac dysfunction with decreased cerebral perfusion pressure and catecholamine toxicity transiently worsens conscious disturbance in aSAH complicated by TC. Therefore, it is important to carefully screen patients with aSAH to identify those complicated by TC, and for close collaboration of the multidisciplinary team to design appropriate treatment strategies.

Intraoperative Integrated Diagnostic System for Malignant Central Nervous System Tumors.

PURPOSE: The 2021 World Health Organization (WHO) classification of central nervous system (CNS) tumors uses an integrated approach involving histopathology and molecular profiling. Because majority of adult malignant brain tumors are gliomas and primary CNS lymphomas (PCNSL), rapid differentiation of these diseases is required for therapeutic decisions. In addition, diffuse gliomas require molecular information on single-nucleotide variants (SNV), such as IDH1/2. Here, we report an intraoperative integrated diagnostic (i-ID) system to classify CNS malignant tumors, which updates legacy frozen-section (FS) diagnosis through incorporation of a qPCR-based genotyping assay. EXPERIMENTAL DESIGN: FS evaluation, including GFAP and CD20 rapid IHC, was performed on adult malignant CNS tumors. PCNSL was diagnosed through positive CD20 and negative GFAP immunostaining. For suspected glioma, genotyping for IDH1/2, TERT SNV, and CDKN2A copy-number alteration was routinely performed, whereas H3F3A and BRAF SNV were assessed for selected cases. i-ID was determined on the basis of the 2021 WHO classification and compared with the permanent integrated diagnosis (p-ID) to assess its reliability. RESULTS: After retrospectively analyzing 153 cases, 101 cases were prospectively examined using the i-ID system. Assessment of IDH1/2, TERT, H3F3AK27M, BRAFV600E, and CDKN2A alterations with i-ID and permanent genomic analysis was concordant in 100%, 100%, 100%, 100%, and 96.4%, respectively. Combination with FS and intraoperative genotyping assay improved diagnostic accuracy in gliomas. Overall, i-ID matched with p-ID in 80/82 (97.6%) patients with glioma and 18/19 (94.7%) with PCNSL. CONCLUSIONS: The i-ID system provides reliable integrated diagnosis of adult malignant CNS tumors.

Renin-angiotensin-aldosterone system inhibitors as a risk factor for chronic subdural hematoma recurrence: A matter of debate.

OBJECTIVES: Chronic subdural hematoma (cSDH) is a common central nervous system condition. Recent reports indicate that cSDH affects long-term prognosis; however, its definitive risk factors remain unknown. An antihypertensive drug, renin-angiotensin-aldosterone system inhibitors (RAASi), can affect vascular permeability and cell proliferation processes, which may suppress the recurrence of cSDH. However, several studies have reported negative results to this effect. Therefore, we aimed to evaluate antihypertensive drugs, including RAASi, as risk factors for recurrent cSDH. MATERIALS AND METHODS: A total of 203 consecutive cases of surgically treated cSDH were retrospectively reviewed. Clinical and radiological parameters were compared between the groups with and without cSDH recurrence to identify risk factors. RESULTS: Of the included cases, 68 (33.5%) used RAASi and 37 (18.2%) developed recurrence within 60 days of surgery. In the multiple logistic regression analysis adjusted by composite risk score, the odds ratios (95% confidence interval) of RAASi, calcium channel blockers, diuretics, ß and α blockers, for the recurrent risk of cSDH after surgery were 2.49 (1.16, 5.42), 1.79 (0.84, 3.82), 1.83 (0.62, 4.87), 0.90 (0.28, 2.44), and 0.96 (0.21, 3.20), respectively. The Cox proportional hazard model also demonstrated that RAASi-use was an independent risk factor for cSDH recurrence. CONCLUSIONS: Present series suggests RAASi-use as a risk factor for cSDH recurrence, although the role of RAASi-use in cSDH remains debatable. Further studies for deeper understanding of the microenvironment of hematoma and the surroundings are preferable. (235 words).

Predictors of Outcomes Six Months after Endovascular Coil Embolization of Poor-Grade Aneurysmal Subarachnoid Hemorrhage.

Objective: To identify factors associated with the outcome and prognosis of coil embolization for poor-grade aneurysmal subarachnoid hemorrhage (aSAH). Methods: We retrospectively reviewed 118 patients with World Federation of Neurosurgical Societies (WFNS) grade IV or V subarachnoid hemorrhage at our institute between January 2010 and December 2020. Outcomes were assessed using modified Rankin Scale (mRS) scores at discharge and at six months after aSAH onset. In addition, patient background, aneurysm characteristics, and treatment outcome were compared between patients showing favorable (mRS scores: 0-2) and unfavorable (mRS scores: 3-6) outcomes at six months. Factors for change of mRS during follow-up were explored, and cut off values were calculated for age using the receiver operating characteristic analysis. Results: Endovascular treatment was performed in 51 of the 118 enrolled patients. Data were analyzed for 43 of these patients who underwent coil embolization of ruptured aneurysms and had complete datasets. The mean age was 61.7 years and 24 (55.8%) patients had WFNS grade V aSAH. Coil embolization-related complications were observed in three patients. There were no treatment-related deaths; however, eight patients (18.6%) died at three months. Multivariate analysis showed that the maximum diameter of the aneurysm (p=0.041) and the postoperative dual antiplatelet therapy (DAPT) (p=0.040) were associated with unfavorable and favorable outcomes, respectively. Older age (p=0.033) was independently associated with mRS score deterioration following discharge. Age 72 years and older was the cut off value for mRS deterioration. Conclusion: Aneurysm size and postoperative DAPT might be associated with outcomes at 6 months. Moreover, we identified older age as an independent factor that influences mRS deterioration following discharge; thus, especially in cases of elderly patients over 72 years of age, it is highly likely that long-term care to prevent disuse and regular follow-up on imaging will be necessary.

Renal Dysfunction is the Strongest Prognostic Factor After Carotid Artery Stenting According to Real-World Data.

PURPOSE: Through the progression of devices, the adaptation of carotid artery stenting (CAS) has been expanded according to the non-inferiority of CAS for carotid endarterectomy reported by several randomized control trials. To maintain favorable outcomes, identifying prognostic factors is essential for optimizing treatment indications and periprocedural management. This study focused on the prognostic factors of CAS using real-world data. METHODS: This retrospective multicenter cohort study aimed to identify the prognostic factors after CAS using real-world data from the stroke registry of Yokohama (STrOke Registry of Yokohama; STORY) from January 1, 2018 to May 31, 2021. Patient characteristics, procedural factors, complications, and prognoses were collected using medical records. RESULTS: Data from 107 patients were enrolled in this study after excluding those with insufficient data (2 cases). The mean participant age was 74.9±8.2 years, and 66 patients (61.7%) were symptomatic. Symptomatic lesions were a significant prognostic factor in the overall analysis (p=0.003). A multivariate analysis showed that the estimated glomerular filtration rate (eGFR) (odds ratio: 1.11, p=0.003) and staged CAS (odds ratio: 38.9, p=0.04) were independent prognostic factors. The odds ratio and relative risk of mRS deterioration when eGFR was under 49 mL/min/1.73 m2 compared with when eGFR was above 49 mL/min/1.73 m2 were 5.2 and 3.74, respectively. CONCLUSIONS: In this real-world multicenter study, we established independent prognostic factors for CAS using high totality data. For patients with symptomatic lesions and low eGFR (≤49 mL/min/1.73 m2), indication for treatment should be considered strictly.

Double Meningioma: A Case of Two Fibrous Meningiomas Coexisting Isolatedly in Meningothelial Meningioma.

Meningiomas are the most common intracranial primary neoplasm in adults, and show various histological subtypes, indicating heterogeneous clinical and molecular genetic characteristics. Different subtypes of meningioma coexisting independently within the main tumor of another different subtype is a quite rare clinical situation. A 69-year-old woman presented with a several- year history of dizziness as a non-specific complaint. Magnetic resonance imaging (MRI) revealed an extra-axial mass lesion in the left parieto-occipital region including two well-demarcated, round mass components. Total resection was performed via left parieto-occipital craniotomy. Two white masses were identified within the main tumor, with neither showing dural attachments. Pathological findings showed the main mass represented meningothelial meningioma and the demarcated mass lesions were both fibrous meningiomas. No transitional features existed between these subtypes. No differences in genetic characteristics were evident between subtypes of meningioma. We have described, apparently for the first time, a case of two fibrous meningiomas coexisting in an isolated manner in meningothelial meningioma with the similar molecular genetic profile.

Frontal Base Endodermal Cyst: A Case Report and Review of Literature.

BACKGROUND: Endodermal cyst (EC) is a rare congenital cyst of endodermal origin, but the pathogenesis of this entity remains uncertain. Supratentorial EC is particularly uncommon, but some cases have been reported. Here, we report a case of supratentorial EC that developed at the frontal base which indicates posttraumatic development rather than a congenital origin. CASE DESCRIPTION: A 65-year-old man who had a history of orbital bone fracture without rhinorrhea sustained in a traffic accident presented with gradually enlarging frontal-base cystic lesions. Multiple cystic lesions were removed via left frontal craniotomy. The cysts showed no communication with the frontal sinus. Histological examination identified EC. Postoperative course was uneventful and no recurrences have been identified as of 2 years later. CONCLUSIONS: According to reported cases, unlike ECs in other intracranial locations, frontal base ECs tend to present at advanced ages. The present case also presented with EC enlargement at an advanced age and two lesions located at the bone hiatus in the frontal base that were presumably caused by trauma. It is possible that sinus communication was repaired as the bone fracture was remodeled, and the remnant sinus epithelial tissues developed into ECs over time. This situation makes it reasonable to presume a posttraumatic rather than a congenital origin. In conclusion, as for frontal base ECs, contrary to the traditional theory, the developmental mechanisms may not necessarily be congenital.

Primary Meningeal Melanocytoma Located in the Craniovertebral Junction: A Case Report and Literature Review.

Primary meningeal melanocytoma is a rare benign tumor in the central nervous system (CNS), comprising less than 0.1% of all intracranial tumors. A 44-year-old man presented with occipital headache, nausea, and vomiting. Computed tomography (CT) and magnetic resonance imaging (MRI) showed a well-defined intradural extramedullary mass lesion at the craniovertebral junction (CVJ). Gross total removal was achieved, and the patient improved symptomatically. The pathologic findings were consistent with meningeal melanocytoma. No tumor recurrence was seen on follow-up MRI two years after surgery. Cases of primary meningeal melanocytoma located at the CVJ are rare. The preoperative differential diagnosis of meningeal melanocytoma from meningioma is sometimes difficult because of their similar appearance on CT and MRI. Complete surgical removal is curative for most cases. We present a case of gross total removal of a meningeal melanocytoma located in the CVJ with references to the literature.

[A Case of Unruptured Cerebral Aneurysm Arising from Duplicate Origin of the Middle Cerebral Artery].

We experienced a case of an unruptured cerebral aneurysm arising from a duplicate origin of the middle cerebral artery(MCA). Initially, we diagnosed the condition as an unruptured aneurysm arising from the internal carotid artery on three-dimensional computed tomography;neck clipping was attempted. However, an unidentified vessel was found around the aneurysmal neck, which could not be easily separated from the aneurysm, making neck clipping difficult. Thus, we only completed coating of the aneurysm without neck clipping. Postoperatively, cerebral angiography showed that the unidentified vessel originated from the internal carotid artery and fused with the MCA horizontal segment. We recognized that the identified vessel was a duplicate origin of the MCA. Few reports on the treatment of an aneurysm arising from a duplicate origin of the MCA are available;there has been no discussion on whether this vessel can be occluded. We assumed that occlusion of the proximal end of the duplicate origin of the MCA together with the aneurysm was unlikely to cause ischemia as the duplicate origin of the MCA fuse with MCA. Coil embolization was performed for the aneurysm, and the duplicate origin was unexpectedly preserved immediately after coil embolization. However, it was not enhanced on cerebral angiography performed after several months, and no cerebral infarction was noted on magnetic resonance imaging. If preservation of the duplicate origin of the MCA is difficult, occlusion of the aneurysm together with the proximal end of the duplicate origin of the MCA can be considered as a surgical strategy.

Suprasellar Benign Chondroma: A Case Report and Literature Review.

Intracranial chondroma is a rare benign tumor comprising only 0.2% of all intracranial tumors. A 27-year-old woman presented with visual dysfunction and headache. Brain computed tomography and magnetic resonance imaging revealed a suprasellar mass lesion with a calcified component. Gross total removal was achieved via a basal interhemispheric approach. Postoperatively, visual function improved to the normal range, and no recurrence was evident 4 years later. Histopathological examination confirmed the diagnosis of benign chondroma. Preoperative differentiation of chondromas from chordomas is clinically important, because of the different treatment and prognostic implications. The only effective treatment for chondroma is total surgical removal. We present a case of gross total resection of a suprasellar chondroma with reference to the literature.

Aortic and Internal Carotid Atherosclerosis in Patients with Carotid Stenosis: Semiautomatic Volumetric Analysis of Low-Attenuation Plaque on Curved Planar Reformations Using MDCT Angiographic Data.

This retrospective study included 65 patients who underwent multidetector computed tomography (MDCT) carotid angiography; 28 patients were <70 years old (group 1), and 37 were ≥70 years old (group 2). Each low-attenuation (<30 Hounsfield units [HU]) plaque volume (LPV) and total uncalcified plaque volume ([TUPV] ≤150 HU) were semiautomatically measured on each aortic arch and internal carotid artery (ICA) curved planar reformations (CPR), using MDCT angiographic data. Correlation coefficients were employed to assess the impact of each plaque volume on various factors including ICA stenosis. The correlations (r > 0.5) were observed between aortic LPV and each ICA stenosis ratio and >30% stenosis in group 1, between aortic TUPV and male gender in group 1, and between ICA-TUPV and each aortic TUPV or the largest plaque thickness in group 2. Marginal correlations were observed between hyperlipidemia and aortic LPV and ICA-TUPV in group 1. There was no association between cerebral infarction and the aortic and ICA plaques. Both the aortic arch and ICA plaque volumes can be measured clinically. The increasing aortic LPV may be a significant factor associated with the development of ICA stenosis in patients younger than 70 years old.

Safety and Efficacy of Preoperative Embolization in Patients with Meningioma.

Preoperative embolization for intracranial meningioma has remained controversial for several decades. In this study, we retrospectively reviewed our experience of embolization using particulate embolic material and coil to clarify the therapeutic efficacy, safety, and risk of complication. Methods We reviewed 69 patients who underwent embolization with particulate embolic material followed by surgical resection. An additional 6 procedures were included for patients in whom recurrence was treated, for a total of 75 procedures of preoperative embolization. We analyzed the following clinical data: age, sex, tumor size pathology, complications related to embolization, and surgeon's opinion on the intraoperative ease of debulking and blood transfusion. Embolization was performed mainly from the branches of the external carotid artery. Results No allogenic blood transfusions were needed for any patients. The surgeon had the opinion that whitening and softening of the tumor allowed for easy debulking during decompression of the tumor in most of the patients. Hemorrhagic complications were seen in two patients after embolization. Emergency tumor removal was performed in both of those patients, and they were recovered well after surgery. Transient cranial nerve palsy was seen in one patient. One ischemic complication and one allergic complication occurred. Conclusion Preoperative embolization could give us an advantage in surgery for meningioma. The procedure reduces intraoperative blood loss and operating time by softening the tumor consistency. However, we must pay attention to the possibility of embolic complications and keep the preparation of emergency craniotomy, particularly in patients with large meningiomas.

Orbital Abducens Nerve Schwannoma: A Case Report and Review of the Literature.

Intraorbital schwannoma is a rare tumor which accounts for about 1-2% of all neoplasms of the orbit. Orbital schwannomas most commonly arise from the sensory branches of the trigeminal nerve. On the other hand, intraorbital abducens nerve schwannomas are extremely rare, with a search of the English literature identifying only four cases of intraorbital abducens nerve schwannoma. This is the 5th reported case of an orbital schwannoma arising from the terminal branch of the abducens nerve to the lateral rectus muscle. We report a case of an intraorbital abducens nerve schwannoma in a 51-year-old man with no signs of neurofibromatosis. The tumor was totally excised with functional preservation of the nerve by a zygomatic approach with lateral orbitotomy. With knowledge of these anatomic features, total removal of the tumor with preservation of the abducens nerve function might be possible.

Evaluation of the vertebrobasilar system in thoracic aortic surgery.

BACKGROUND: We evaluated the probability of vertebrobasilar system malperfusion due to occlusion of the left subclavian artery as assessed by preoperative magnetic resonance angiography in patients scheduled to undergo thoracic aortic surgery. METHODS: (Study 1) From January 2000 through March 2009, we studied variations of vertebral arteries in 301 patients scheduled to undergo thoracic aortic surgery. We classified vertebral artery variations into 3 categories according to the findings on preoperative magnetic resonance angiography: connection type, interrupted right vertebral artery, and interrupted left vertebral artery. (Study 2) From February 2007 through January 2010, we evaluated the cerebral complication in 41 patients who had occlusion of the left subclavian artery with a stent graft. RESULTS: (Study 1) On preoperative magnetic resonance angiography, the vertebral artery was classified as connection type in 247 patients, interrupted right vertebral artery in 34, and interrupted left vertebral artery in 20. (Study 2) We performed subclavian obstruction test, left-right subclavian artery bypass, or left subclavian artery-left common carotid artery bypass to the 3 patients with interrupted right vertebral artery, respectively. Forty patients (98%) out of 41 patients had no complication after occlusion of the left subclavian artery. CONCLUSIONS: Preoperative magnetic resonance angiography is useful for detection of the patients with high risk of vertebrobasilar system malperfusion due to occlusion of the left subclavian artery.

Multiple supra-aortic stenting for Takayasu arteritis: extensive revascularization and two-year follow-up.

A patient with Takayasu arteritis with multiple supra-aortic lesions underwent successful treatment with two-staged stent implantation. Stenotic bilateral common carotid, innominate, and left subclavian arteries were dilated, and no restenosis was observed during the follow-up period of 2 years despite recurrent inflammation. Stenting for supra-aortic vessels in cases of Takayasu arteritis has rarely been reported, and to our knowledge, this is the first report of multiple stent placement for all the supra-aortic branches involved.