Comparison of the Clinical Outcome of Carotid Artery Stenting Between Institutions With a Treatment Strategy Based on Risk Factors and Those With First-Line Treatment.

PURPOSE: Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are recommended based on certain risk factors. The volume of an institution's treatment experience may be associated with good clinical outcomes. There is a dilemma between the treatment strategy based on risk factors and the experience volume. Therefore, we investigated the clinical outcomes of CAS performed at institutions that selected the treatment strategy based on risk factors and those that performed CAS at the first-line treatment. MATERIALS AND METHODS: Patients who underwent CAS at 5 institutions were included in this retrospective case-control study. We defined CEA/CAS institutions as those that selected the treatment option based on risk factors, and CAS-first institutions as those that performed CAS as the first-line treatment. We investigated cases of ischemic stroke, hemorrhagic stroke, myocardial infarction, and deaths within 30 days of the intervention between the CEA/CAS- and CAS-first institution groups. One-to-one propensity score matching was performed to compare rates of ischemic and hemorrhagic strokes within 30 days of the intervention. RESULTS: A total of 239 and 302 patients underwent CAS at the CEA/CAS institutions and CAS-first institutions, respectively; ischemic stroke occurred in 12 (5.0%) and 7 patients (2.3%), respectively (p=0.09). No differences in major ischemic strokes (0.8% vs 1.3%; p=0.59), hemorrhagic strokes (0.4% vs 0.3%; p=0.87), or deaths (0.0% vs 0.7%; p=0.21) were observed. Myocardial infarction did not occur in either group. Propensity score analysis showed that ischemic stroke (odds ratio: 1.845, 95% confidence interval: 0.601-5.668, p=0.28) and hemorrhagic stroke (odds ratio: 1.000, 95% confidence interval: 0.0061-16.418, p=1.00) were not significantly associated with either institution group. CONCLUSIONS: The CAS-specific treatment strategies for CAS can achieve the same level of outcomes as the treatment strategy based on risk factors. The CAS performed based on risk factors in CEA/CAS institutions and the treatment of more than 30 patients/year/institution in CAS-first institutions were associated with good clinical outcomes.

Development of cortical microvascularization in Moyamoya disease using the maximum intensity projection method from three-dimensional rotational angiography.

BACKGROUND: Neurosurgeons often experience increased cortical microvascularization in Moyamoya disease (MMD). However, there are no previous reports that radiologically evaluated preoperative cortical microvascularization. We investigated the development of cortical microvascularization and clinical characteristics of MMD using the maximum intensity projection (MIP) method. METHODS: We enrolled 64 patients at our institution, including patients with MMD (n = 26), intracranial atherosclerotic disease (ICAD; n = 18), and unruptured cerebral aneurysms (n = 20) as the control group. All patients underwent three-dimensional rotational angiography (3D-RA). The 3D-RA images were reconstructed using partial MIP images. Cortical microvascularization was defined as the vessels that branched off from the cerebral arteries and were classified as grade 0-2 depending on their development. RESULTS: Cortical microvascularization observed in patients with MMD was classified into grade 0 (n = 4, 8.9%), grade 1 (n = 17, 37.8%), and grade 2 (n = 24, 53.3%). The development of cortical microvascularization was more common in the MMD group than in the other groups. The inter-rater reliability measured using weighted kappa was 0.68 (95% confidence interval = 0.56-0.80). There were no significant differences in cortical microvascularization according to the onset type and hemispheres. Cortical microvascularization correlated with periventricular anastomosis. Most patients with Suzuki classifications 2-5 developed cortical microvascularization. CONCLUSION: Cortical microvascularization was characteristic of patients with MMD. These findings developed in the early stages of MMD and may act as a bridge to the development of periventricular anastomosis.

Middle meningeal artery embolization for pediatric chronic subdural hematoma under anticoagulant therapy with ventricular assist device: a case report.

INTRODUCTION: Recently, the efficacy of middle meningeal artery (MMA) embolization for chronic subdural hematoma (cSDH) in the elderly has been reported. However, no previous reports of MMA embolization for cSDH in children with ventricular assist devices (VAD) have been published. Here, we report a case of MMA embolization for cSDH in a child with VAD. CASE: A 15-month-old female was diagnosed with dilated cardiomyopathy at 7 months old. Soon, a VAD was inserted, and anticoagulant and antiplatelet therapy was started. Bilateral cSDH was observed at 15 months, and, 2 months later, an acute exacerbation of the right cSDH necessitated intracerebral hemorrhage removal. Afterwards, increased intracranial pressure occurred due to a contralateral subdural hematoma but, 4 months after intracerebral hemorrhage removal, CT showed new hemorrhaging in the left cSDH. MMA embolization was then conducted to prevent rebleeding in the hematoma. Selective angiography of the left MMA demonstrated stains of hematoma capsules from the frontal and parietal branches, which were embolized using liquid embolic material. During the procedure, the material migrated into the intracranial vessels via an undetected transdural anastomosis. Postoperatively, no new neurological abnormalities, including hemiparesis, were observed. Two months later, CT showed a decrease in hematoma size. CONCLUSION: MMA embolization for cSDH in pediatric patients with VAD may be effective, if vigilance is maintained against transdural anastomoses.

Highly sensitive detection of sodium in aqueous solutions using laser-induced breakdown spectroscopy with liquid sheet jets.

Laser-induced breakdown spectroscopy (LIBS) combined with liquid jets was applied to the detection of trace sodium (Na) in aqueous solutions. The sensitivities of two types of liquid jets were compared: a liquid cylindrical jet with a diameter of 500 µm and a liquid sheet jet with a thickness of 20 µm. Compared with the cylindrical jet, the liquid sheet jet effectively reduced the splash from the laser-irradiated surface and produced long-lived luminous plasma. The limit of detection (LOD) of Na was determined to be 0.57 µg/L for the sheet jet and 10.5 µg/L for the cylindrical jet. The LOD obtained for the sheet jet was comparable to those obtained for commercially available inductively coupled plasma emission spectrometers.

[A Case of Transverse Colon Cancer with Metastatic Recurrence in Bilateral Inguinal Lymph Nodes].

A woman in the 60s. She was referred to our hospital because the fecal occult blood test was positive. Colonoscopy was performed. Cancer is found in the transverse colon. There were no metastases in the lungs and liver. Laparoscopic left hemicolectomy was performed. Histopathological examination was adenocarcinoma(tub1>tub2>muc), pT1b, pN2, ly2, v1, pPM0, pDM0, pRM0, budding(0, Grade 1), fStage Ⅲb. After postoperative adjuvant chemotherapy, she visited an outpatient clinic 8 months after surgery with a complaint of swelling of both inguinal lymph nodes. The swollen inguinal lymph node was relatively soft and there was no evidence of infection. A biopsy of the bilateral lymph nodes was performed. Histopathological examination revealed adenocarcinoma containing mucus components. These findings were consistent with histological findings in transverse colon cancer. Based on these results, we diagnosed metastatic recurrence from transverse colon cancer to both inguinal lymph nodes.

[Disseminated Bone Marrow Carcinomatosis from Colon Cancer-A Case Report].

A 77‒year‒old man came to our hospital with complaints of abdominal pain and difficulty to defecate. Abdominal CT scan showed an abnormal region in the ascending colon, which was suspected to be an ascending colon cancer. D‒dimer was remarkably high, and the platelet count was 63,000/µL; these results suggested disseminated intravascular coagulation caused by tumor activation. After he was admitted, we performed a contrast enhanced CT, and found no signs of remote metastasis. We decided to resect the tumor without colonoscopy examination in order to release the DIC state. After the surgery, the platelet count did not increase, and leukopenia was observed. We conducted a bone marrow biopsy, and made a diagnosis of disseminated carcinomatosis from colon cancer. The patient's condition did not improve, and he died on day 42 after admission. Pathological autopsy was performed and several minimal remote metastases were found throughout the body.

[Resection of a Desmoid Tumor Originated from Greater Omentum with No History of Open Surgery].

Here we report a case of a 41-year-old male patient who underwent resection of a desmoid tumor originating from the greater omentum with no history of open surgery. An elastic hard mass was palpated in the left upper abdomen, but there were no abnormalities on serum chemical tests, including tumor markers. Computed tomography showed a parenchymal tumor located near the descending colon. Integrated positron-emission tomography and computed tomography revealed moderate accumulation of tracer in the tumor. An intra-abdominal malignant mesenchymoma was suspected and surgery was performed. The tumor was located in the anterior portion of the greater omentum. It partially invaded the diaphragm, and the affected regions were concurrently resected. The resected specimen measured 80 mm at longest diameter. The cut surface was grayish white and parenchymal. The histopathological findings showed the atypical spindle shaped tumor cells grown with collagen fiber progression. Immunohistochemical staining for ß-catenin showed strong staining in the nuclei and cytoplasm of tumor cells. The patient was diagnosed with desmoid tumor originating from the greater omentum. The desmoid tumor with no history of open surgery was rare. We report this rare case, along with a discussion of the literature.

[Tumor Embolisms from Colon Cancer Detected on Transcatheter Examination-A Case Report].

A 58-year-old woman underwent surgery and systemic chemotherapy(FOLFIRI plus panitumumab)for ascending colon cancer with multiple lymph node and liver metastases; the preoperative Virchow lymph node aspiration cytology showed adenocarcinoma.After 4 courses of chemotherapy, contrast-enhanced CT showed an embolus in the left subclavian vein.An anticoagulation therapy was started, but the embolus tended to increase.Three months later, the patient developed dyspnea and was diagnosed with pulmonary artery thromboembolism and superior vena cava thrombosis.Transcatheter examination was performed because of the anticoagulation-resistant embolism, and the biopsy revealed tumor embolism due to colon cancer.She died of respiratory failure 10 days after the biopsy.The tumor directly infiltrating the vein because of left subclavian lymph node metastases might have resulted from increased tumor emboli.Although cases of tumor emboli infiltrating the veins and developing from lymph node metastases are rare, a transcatheter biopsy may help to detect them.

[Cognitive Dysfunction in Children who Underwent Surgery after a Traumatic Brain Injury:A Single Institute Investigation].

The cognitive function of children who underwent surgical therapy after a traumatic brain injury is poorly studied. In this study, we investigated the characteristics of 27 children who received surgical therapy at our institution. The children were between 1 and 16 years of age, of which 15 had cognitive dysfunction. Their Glasgow Coma Scale score at the acute stage of dysfunction was worse than in children who did not have cognitive dysfunction. Acute subdural hematoma was more frequent in the cognitive dysfunction group. Moreover, all children in this group showed brain injury by imaging analysis. Differences in imaging characteristics and the association with cognitive dysfunction could not be readily associated with a specific injury. Memory and verbal disorder were the most common cognitive dysfunctions:these symptoms were present among children of all ages;conversely, behavior disorder, impaired attention, and infeasibility were limited to the children under 9 years of age. Since the immature brain is developing, the acquisition of new abilities may be blocked by the injury;thus, we speculate that brain injury at a younger age causes greater cognitive dysfunction.

[A Case of Nephrotic Syndrome Induced by FOLFIRI plus Ramucirumab for Metastatic Descending Colon Cancer].

We report a case of multiple lung metastases of RAS mutant type descending colon cancer with development of nephrotic syndrome after the introduction of FOLFIRI plus ramucirumab(RAM). A female patient in her 50s underwent adjuvant chemotherapy with capecitabine and oxaliplatin after primary tumor and partial lung resection. For recurrent multiple lung metastases, 4 years of capecitabine and bevacizumab therapy was administered. FOLFIRI plus RAM therapy was introduced because of tumor progression. After treatment, the patient showed increased urine protein content, decreased serum albumin levels, marked hypertension, and increased edema, and was diagnosed with nephrotic syndrome. The patient's condition improved with prednisolone, additional doses of antihypertensive, and diuretics. Even in cases where it is possible to control proteinuria during bevacizumab administration, it is necessary to keep in mind that RAM administration as second-line therapy may cause nephrotic syndrome.

[A Case of Cecal Cancer Complicated with Intussusception Treated Laparoscopically].

A 75-year-old woman presented with the chief complaint of right lower abdominal pain. There was mild tenderness in the lower right abdomen and a mass was palpated. There were no peritoneal irritation symptoms. A CT examination was performed. The ascending colon was invaginated with a part of the cecum and ileum. Wall thickening was observed in the advanced part. Colon cancer was suspected. The preoperative diagnosis was considered to be an intussusception with cecal cancer at the advanced part. A laparoscopic ileocecal resection was performed. The intraoperative findings were as follows. The tumor was invading the ascending colon, but it was possible to restore it by pressing on the developed part with forceps. The pathological diagnosis was Type 2, muc>tub1, pT4aN0M0, pStageⅡb. The postoperative course was good. Water intake was started on the next day, meals were started from the second day, and the patient was discharged on the 9th day after the operation. Cecal cancer complicated with intussusception is a relatively rare disease. We report a case that was laparoscopically operable.

[A Case of Stevens-Johnson Syndrome Induced by Chemotherapy for Metastatic Colon Cancer].

A 78-year-old woman had a semicircular ulcerative lesion of AV 7 cm, as detected using colonoscopy, and pathologic examination based on a biopsy showed well-differentiated adenocarcinoma. On contrast-enhanced CT of the liver, a number of nodular lesions that seemed to be liver metastases were observed. It was decided to administer chemotherapy containing mFOLFOX6 plus panitumumab. Bilateral hemorrhage of the ocular conjunctiva and eyelid edema were observed from the 4th day of chemotherapy. Edema of the lips, epidermolysis, and erythema appeared in addition to vision impairment. We diagnosed her with SJS based on these symptoms. We also administered steroid pulse therapy. Eyelid edema improved, and vision impairment improved 24 hours after the initiation of treatment. For severe cases with visual impairment, systemic administration of corticosteroids is recommended. In this case, administering steroid pulse therapy from an early stage resulted in improvement without sequelae.

[Dissecting Internal Carotid Aneurysm Causing Epistaxis:A Case Report].

We report a rare case of a ruptured dissecting internal carotid aneurysm caused epistaxis without a history of trauma or infection. An 89-year-old woman experienced epistaxis and suffered from hemorrhagic shock at her previous hospital. Head computed tomography(CT)images revealed a ruptured internal carotid aneurysm protruding into the Onodi cell, the most posterior ethmoidal sinus, which extends superolaterally to the sphenoid sinus. Cerebral angiography demonstrated a multilobular-shaped dissecting aneurysm with a maximal diameter of 6.7mm at the cavernous portion of the internal carotid artery(ICA). Overlapping stenting was performed to prevent recanalization. However, a fatal subarachnoid hemorrhage occurred 2 days after the procedure due to the progression of the dissection to the intracranial ICA. The anatomical characteristics of the ethmoidal sinus could be associated with the occurrence of epistaxis. A ruptured small ICA aneurysm with an Onodi cell might cause epistaxis without a history of trauma or infection.

[A Case of an Elderly with Locoregional Recurrence of ER-Negative HER2-Positive Breast Cancer Successfully Treated with Local Therapy].

An 80-year-old woman who received on anticoagulant therapy for atrial fibrillation was diagnosed with ER-negative HER2-positive breast cancer(cT4bcN1M0, Stage ⅢB). She underwent mastectomy with skin graft and lymphadenectomy, but was evaluated to be too old for standard chemotherapy and HER2-directed therapy. Four months after the operation, she was diagnosed with regional lymph node metastasis and underwent radiotherapy. Moreover, 9 months later, other recurrent sites were revealed in the parasternal lymph node and thoracic wall without distant metastasis. Radiotherapy could be performed around these secondary recurrent sites while avoiding overlap. After 2 years, solitary contralateral axillary lymph node metastasis was diagnosed by PET-CT. She underwent Lt axillary lymphadenectomy. The intrinsic breast cancer subtype did not change. Patient performance status was kept to achieve a good quality of daily life. Eight months later, she diagnosed with primary pancreatic cancer and received 13 cycles of chemotherapy until her death from pancreatic cancer 14 months later. During chemotherapy, no recurrence of breast cancer was observed.

[A Case of Extended Mediastinal and Retroperitoneal Emphysema after Transanal Local Excision of an Early Lower Rectal Adenocarcinoma].

We observed a case of a large collection of mediastinal and retroperitoneal emphysema, which developed after a transanal local excision for an early lower rectal carcinoma and was treated conservatively. An 80's female patient presented with a chief complaint of bowel difficulty, which was diagnosed as mucosal prolapse syndrome with anal sphincter dysfunction. Endoscopic colonoscopy showed full circumferential proliferation of the mucosal membrane including a semicircular protruding lesion, on the upper side of the dentate line. Biopsy revealed findings indicative of an adenocarcinoma(tub1/pap), Group 4. After a sufficient informed consent was taken, a transanal local excision under spinal anesthesia was conducted discontinuously over half of the circumference. The patient underwent partial-thickness excision, partially full-thickness, and the defects are closed as much as possible. A fever of 38 degrees Celsius was recognized on the 1st postoperative day, and a CT scan, on the 2nd postoperative day, showed a large collection of retroperitoneal and mediastinal emphysema tracking upwards to the nasopharynx. Since fever was the only subjective symptom present, antibiotic therapy under fasting was chosen. The mediastinal emphysema had mostly resolved by the 10th postoperative day. Even though standard transanal excision is not a treatment under air supply there is a risk leading mediastinal and retroperitoneal emphysema.

Early retreatment after surgical clipping of ruptured intracranial aneurysms.

BACKGROUND: Although a rerupture after surgical clipping of ruptured intracranial aneurysms is rare, it is associated with high morbidity and mortality. The causes for retreatment and rupture after surgical clipping are not clearly defined. METHODS: From a prospectively maintained database of 244 patients who had undergone surgical clipping of ruptured intracranial aneurysms, we selected patients who experienced retreatment or rerupture within 30 days after surgical clipping. Aneurysm occlusions were examined by microvascular Doppler ultrasonography and indocyanine green video-angiography. Indications for retreatment included rerupture and partial occlusion. We analyzed the characteristics and causes of early retreatment. RESULTS: Six patients (2.5%, 95% CI 0.9 to 5.3%) were retreated within 30 days after surgical clipping, including two patients (0.8%, 95% CI 0.1 to 2.9%) who experienced a rerupture. The retreated aneurysms were found in the anterior communicating artery (AcomA) (n = 5) and basilar artery (n = 1). Retreatment of the AcomA (7.5%) was performed significantly more frequently than that of other arteries (0.56%) (p < 0.01). A laterally projected AcomA aneurysm (17.4%) was more frequently retreated than were other aneurysm types (2.3%). Cases of laterally projecting AcomA aneurysms tended to result from an incomplete clip placed using a pterional approach from the opposite side of the aneurysm projection. CONCLUSIONS: Despite developments, the rates of retreatment and rerupture after surgical clipping remain similar to those reported previously. Retreatment of the AcomA was significantly more frequent than was retreatment of other arteries. Patients underwent retreatment more frequently when they were originally treated for lateral type aneurysms using a pterional approach from the opposite side of the aneurysm projection. The treatment method and evaluation modalities should be considered carefully for AcomA aneurysms in particular.

[A Case of Advanced Transverse Colon Cancer with Relapse behind the Rectum after Laparoscopic-Assisted Resection].

A 60's male patient underwent laparoscopic left hemicolectomy with D3 lymph node dissection for transverse colon cancer. Adjuvant chemotherapy with tegafur-uracil and leucovorin was administered.Thirty -four months later, MRI scan revealed a mass with sacrum invasion.Radiation therapy(39 Gy/13 Fr)was performed followed by chemotherapy(modified oxaliplatin, leucovorin, and 5-fluorouracil plus bevacizumab).Two weeks after the completion of radiation therapy, staging laparoscopy and tissue biopsy was performed in the hard tumor, which was located at the caudal end of the incisional scar of the retroperitoneum, in front of the sacrum.The pathological diagnosis revealed metastasis from transverse colon cancer.Radiographic examination showed partial response to radiochemotherapy, and buttock pain decreased.CT review before pain developed showed a small tumor located mainly in the mesorectum slightly adjacent to the sacrum, suggesting the implantation of cancer cells to the stripped plane behind the mesorectum during the surgery.

Mechanism of dynamic plasma motion in internal modification of glass by fs-laser pulses at high pulse repetition rate.

Evolution of free-electron density in internal modification of glass by fs-laser pulses at high pulse repetition rates is simulated based on rate equation model, which is coupled with thermal conduction model in order to incorporate the effect of thermal ionization. Model shows that highly absorbing small plasma generated near the geometrical focus moves toward the laser source periodically to cover the region, which is much larger than focus volume. The simulated results agree qualitatively with dynamic motion of plasma produced in internal modification of borosilicate glass by fs-laser pulses at 1 MHz through the observation using high-speed video camera. The paper also reveals the physical mechanism of the internal modification of glass when heat accumulation is significant.

Target geometry and rigidity determines laser-induced cavitation bubble transport and nanoparticle productivity - a high-speed videography study.

Laser-induced cavitation has mostly been studied in bulk liquid or at a two-dimensional wall, although target shapes for the particle synthesis may strongly affect bubble dynamics and interfere with particle productivity. We investigated the dynamics of the cavitation bubble induced by pulsed-laser ablation in liquid for different target geometries with high-speed laser microsecond videography and focus on the collapse behaviour. This method enables us observations in a high time resolution (intervals of 1 µs) and single-pulse experiments. Further, we analyzed the nanoparticle productivity, the sizes of the synthesized nanoparticles and the evolution of the bubble volume for each different target shape and geometry. For the ablation of metal (Ag, Cu, Ni) wire tips a springboard-like behaviour after the first collapse is observed which can be correlated with vertical projectile motion. Its turbulent friction in the liquid causes a very efficient transport and movement of the bubble and ablated material into the bulk liquid and prevents particle redeposition. This effect is influenced by the degree of freedom of the wire as well as the material properties and dimensions, especially the Young's modulus. The most efficient and largest bubble movement away from the wire was observed for a thin (500 µm) silver wire with velocities up to 19.8 m s(-1) and for materials with a small Young's modulus and flexural rigidity. We suggest that these observations may contribute to upscaling strategies and increase of particle yield towards large synthesis of colloids based on targets that may continuously be fed.

[Dural Arteriovenous Fistula with Acute Visual Loss Manifestation:A Case Report].

In this report, we are describing a rare case of dural arteriovenous fistula(DAVF)followed by an isolated symptom of bilateral visual acuity disturbance. The patient was a 67-year-old man suffering from progressive bilateral visual acuity disturbance. Angiography revealed a diffuse arteriovenous fistula in the left transverse-sigmoid sinus affected by severe venous congestion. Visual acuity disturbance is likely to have been caused by increased intracranial pressure(IICP). Venous congestion as well as visual acuity were gradually improved following three transarterial embolizations. It is possible that a gradual progression of the clinical condition has caused only visual acuity disturbance without any other IICP symptoms, which is similar to pseudotumor cerebri. Should an unexplained visual acuity loss occur, the case should be investigated by considering DAVF.