Comparison of protein digestibility of human milk and infant formula using the INFOGEST method under infant digestion conditions.

Many improvements have been made to bring infant formula (IF) closer to human milk (HM) regarding its nutritional and biological properties. Nevertheless, the protein components of HM and IF are still different, which may affect their digestibility. This study aimed to evaluate and compare the protein digestibility of HM and IF using the infant INFOGEST digestion method. Pooled HM and a commercial IF were subjected to the infant INFOGEST method, which simulates the physiological digestion conditions of infants, with multiple directions, i.e. the curd state, gel images of SDS-PAGE, molecular weight distribution, free amino acid concentrations and in vitro protein digestion rate. HM underwent proteolysis before digestion and tended to have a higher protein digestion rate with finer curds during gastric digestion, than the IF. However, multifaceted analyses showed that the protein digestibility of HM and IF was not significantly different after gastrointestinal digestion. In conclusion, the infant INFOGEST method showed that the digestibility of HM and IF proteins differed to some extent before digestion and after gastric digestion, but not at the end of gastrointestinal digestion. The findings of this study will contribute to the refinement of IF with better protein digestibility in infant stomach.

Tuberculum meningioma with recovery of glaucoma-like visual field defects after chiasmal decompression: a case report.

BACKGROUND: To report a case of tuberculum meningioma with recovery of glaucoma-like visual field defects after chiasmal decompression. CASE PRESENTATION: A 39-year-old woman presenting with headache was found to have bilateral arcuate retinal nerve fiber layer (RNFL) thinning on optical coherence tomography (OCT) with a corresponding arcuate scotomas consistent with glaucomatous change. However a suprasellar tumor compressing the anterior chiasm from below was found on magnetic resonance imaging of the brain. After resection of the mass, which was diagnosed as meningothelial meningioma by the pathological examination, the glaucoma-like visual field defects resolved despite the RNFL thinning on the OCT showing no improvement. CONCLUSIONS: Chiasmal compression may mimic glaucoma and produce arcuate scotoma rather than temporal visual field loss. There is a possibility that the development of chiasmal compression somehow converted preperimetric glaucoma into a more advanced form accompanied by visual field defects and that the glaucoma reverted to the preperimetric state after chiasmal decompression.

Internal carotid artery-persistent primitive anterior choroidal artery aneurysms: report of two cases and literature review.

PURPOSE: Persistent primitive anterior choroidal artery (PPAChA) is a rare vascular anomaly. The clinical course of internal carotid artery (ICA)-PPAChA aneurysms has not been well described. CASE REPORTS: We report two patients with an ICA-PPChA aneurysm and summarize previously reported cases. RESULTS: Including our two, a total of 10 patients with an ICA-PPAChA aneurysm have been reported. Data were not described for one. Among the remaining nine, five patients (56%) experienced aneurysmal rupture. Five patients underwent surgical clipping and four underwent endovascular coiling. The procedure was completed in all but one patient who had a tiny branch artery adherent to the aneurysm; this patient was converted from clipping to aneurysm coating with a cotton sheet. Among the other eight patients, one who underwent coiling experienced an internal capsule infarction. The remaining seven had a satisfactory postoperative course; however, an asymptomatic occlusion of the PPAChA at its origin was noted on postoperative angiography in one. CONCLUSION: PPChA is associated with a high incidence of aneurysm formation and rupture. During treatment of ICA-PPAChA aneurysms, obstruction of the PPAChA and any surrounding perforating arteries should be avoided to prevent ischemic stroke.

Replaced posterior cerebral artery.

PURPOSE: Replaced posterior cerebral artery (PCA), defined as a hyperplastic anterior choroidal artery (AChA) supplying all branches of the PCA, is an extremely rare anatomical variation. To the best of our knowledge, there are only a few reports of replaced PCA. METHODS: Herein, we report a case of replaced PCA diagnosed by digital subtraction angiography. RESULTS: A 76-year-old woman visited a neurosurgical clinic because of headache and vertigo. Magnetic resonance imaging and magnetic resonance angiography incidentally revealed a left internal carotid artery aneurysm. She was referred to our hospital for further examination and treatment of the unruptured intracranial aneurysm. Left internal carotid angiography revealed a paraclinoid aneurysm. We also incidentally found an anomalous hyperplastic AChA distal to the aneurysm. This hyperplastic AChA supplied not only the AChA territory but also the entire PCA territory. No vessels that could be a normal AChA or posterior communicating artery were identified along the left internal carotid artery. Vertebral angiography demonstrated that the left PCA was not visualized. With these findings, we diagnosed anomalous hyperplastic AChoA in this case as replaced PCA. CONCLUSION: Careful imaging assessment is important to identify replaced PCA. Both direct findings of a hyperplastic AChA course and perfusion territory and indirect findings of the absence of the original PCA are useful in the diagnosis of replaced PCA.

Dysplastic aberrant left subclavian artery originating from a thoracic intersegmental artery associated with a right aortic arch.

PURPOSE: A right aortic arch (RAA) is a rare vascular anomaly that often coexists with an aberrant left subclavian artery (ALSA). Due to the rarity of RAA, the development of an ALSA is not well understood. METHOD: We describe a case in which a 58-year-old man who was scheduled to undergo posterior decompression and fusion surgery for thoracic ossification of the posterior longitudinal ligament from Th1 to Th3 was found to have a RAA and an ALSA. RESULTS: Preoperative computed tomography angiography demonstrated a RAA and an ALSA. The ALSA was extremely tortuous and ran in the paraspinal muscles behind the thoracic laminae, which meant it was in the surgical field. The ALSA arose from the descending aorta and bifurcated into the left segmental arteries of Th1 and Th2, and also bifurcated into the left vertebral artery, which had a normal subsequent course. The dysplastic ALSA was considered to have developed from the thoracic intersegmental artery. Based on preoperative examination findings, we performed spinal surgery without vessel injury. CONCLUSION: We report a rare case of a dysplastic ALSA that developed from the thoracic intersegmental artery with a RAA. The knowledge of this anomaly provides safety in spinal surgery of the cervicothoracic junction.

[Surgical Techniques for Microvascular Decompression in Hemifacial Spasm].

This study discusses the key microvascular decompression(MVD)techniques for the treatment of hemifacial spasm(HFS). The author's experience is based on their institution's cases, highlighting three critical techniques. (1)Vertebral artery(VA)repositioning: Repositioning the VA is essential in challenging cases. This article focuses on the relocation of the proximal portion of the VA and the importance of careful dissection. (2)Relocating vessels compressing the peripheral branches of the facial nerve: HFS can result from nerve compression at various locations, including the cisternal portion. This study addressed cisternal compression and considered the nearby nerves. (3)Considering the perforating branches during repositioning, cases may involve complex branching of the perforating arteries. This paper describes an approach that carefully repositions the vessels without damaging the perforating branches. The results from 100 VA-involved cases showed excellent outcomes, with 91.2% of patients experiencing T0(excellent)results. This study emphasized the need to adapt the surgical approach to each unique case to ensure the safety and effectiveness of MVD. This study provides insights into the critical MVD techniques for HFS, emphasizing the importance of continuous experience and knowledge accumulation. These techniques can be learned by other neurosurgeons, thereby expanding the availability of safe and successful MVD procedures for HFS.

Proximal migration of a tapered open-cell stent after carotid artery stenting for restenosis following endarterectomy.

OBJECTIVES: Stent migration is an uncommon but serious complication of carotid artery stenting. Shortening and migration of closed-cell stents after carotid artery stenting has been reported, but migration of open-cell stents is extremely rare. MATERIALS AND METHODS: Herein, we report a case of proximal migration of a tapered-design open-cell stent after carotid artery stenting for restenosis following endarterectomy for radiation-induced stenosis. RESULTS: A 70-year-old man with a history of radiation therapy for tongue cancer approximately 10 years earlier was diagnosed with transient ischemic attack owing to severe stenosis of the right cervical internal carotid artery and was referred to our hospital. We performed carotid endarterectomy with a patch graft; 6 months later, restenosis was observed. Therefore, we performed carotid artery stenting with a self-expandable tapered-design open-cell stent. On the second day after the procedure, asymptomatic downward migration of the stent was detected. During the 3-year follow-up period after stent placement, no restenosis or further stent migration was observed. CONCLUSIONS: This report provides evidence that migration of implanted carotid stents can occur even with an open-cell stents. In particular, to our knowledge, there are no reports describing migration of tapered-design open-cell stents in the early postoperative period.

Complete duplication of the posterior cerebral artery.

PURPOSE: Variations of the posterior cerebral artery (PCA) are rare, excluding aplasia or hypoplasia of the P1 segment. To the best of our knowledge, there are few reports of complete duplication of the PCA. METHODS: Herein, we report a case of complete duplication of the PCA diagnosed by 1.5 T magnetic resonance angiography. RESULTS: A 55-year-old woman visited our hospital for cerebrovascular disease screening. Magnetic resonance angiography revealed two right PCAs with similar diameters. One PCA originated as the P1 segment of the PCA branching from the basilar artery, and the other was the fetal-type posterior communicating artery (PCoA) branching from the internal carotid artery (ICA). Neither PCA supplied the right anterior choroidal artery (AChA) territory. Bilateral PCoAs branched from the same position as each ICA, respectively. The right AChA branched from the ICA distal to the PCoA branching position. CONCLUSION: Careful imaging assessment is important for identifying complete duplication of the PCA. In addition to the direct findings of AChA identification, the indirect findings of the PCoA branching position and that the PCAs did not supply the AChA territory were also useful for diagnosis in this case.

Posterior inferior cerebellar artery originating from the posterior meningeal artery mimicking dural arteriovenous fistula.

PURPOSE: Many variations in the origin of the posterior inferior cerebellar artery (PICA) have been reported. To our knowledge, only one case of a PICA originating from the posterior meningeal artery (PMA) has been reported. METHODS: We describe a case with a PICA that was supplied retrograde from the distal segment of the PMA, mimicking a dural arteriovenous fistula on magnetic resonance angiography (MRA). RESULTS: A 31-year-old man was admitted to our hospital with a sudden occipital headache and nausea. MRA showed a hyperplastic left PMA, continuing to an abnormal vessel that was suspicious for venous drainage. Digital subtraction angiography revealed the left PMA originated from the extradural segment of the vertebral artery and then connected to the left PICA near the torcula. The cortical segment of the PICA flowed retrograde, which appeared as venous reflux on MRA. A second PICA originated from the extradural segment of the left vertebral artery and perfused the tonsillomedullary and televelotonsillar segment of the left PICA territory. CONCLUSION: We present an anatomical variant of the PICA mimicking a dural arteriovenous fistula. Digital subtraction angiography is useful for diagnosis of the cortical segment of the PICA flowing retrograde from the distal segment of the PMA because signal intensity in MRA of retrograde flow tends to decrease and diagnosis may be difficult. During endovascular treatment and open surgery, we should note that ischemic complications may occur due to the potential anastomosing channels between cerebral and dural arteries.

Extremely long posterior cerebral artery P1 segment.

PURPOSE: Excluding aplasia and hypoplasia of the P1 segment of the posterior cerebral artery (PCA), anatomical variations in the PCA are rare. To our best knowledge, there are few reports of an extremely long P1 segment of the PCA. METHODS: Herein, we report a rare case of an extremely long P1 segment of the PCA, which was diagnosed by 1.5-T magnetic resonance angiography (MRA). RESULTS: A 96-year-old woman was transferred by ambulance to our hospital with impaired consciousness. Her symptom improved, and magnetic resonance imaging showed no significant findings. MRA revealed an extremely long P1 segment of the left PCA. The length of the P1 segment of the left PCA was 27.3 mm. The left posterior communicating artery (PCoA) was 20.9 mm, which is not considered long. The left anterior choroidal artery branched from the internal carotid artery distal to the PCoA branching position. Basilar artery fenestration was also incidentally identified. CONCLUSION: Careful imaging assessment was important for identifying the extremely long P1 segment of the PCA in the present case. This rare anatomical variation can also be confirmed by 1.5-T MRA.

Time Courses of Gastric Volume and Content after Different Types of Casein Ingestion in Healthy Men: A Randomized Crossover Study.

BACKGROUND: Few studies have evaluated differences in the curd-forming ability of casein on gastric volume and content directly after ingestion in humans. OBJECTIVES: This study evaluated the time course of gastric volume and curd conditions in the stomach after protein ingestion. METHODS: This was an open-labeled, randomized crossover trial. Ten healthy men [age: 33.4 ± 7.3 y; BMI (kg/m2): 21.9 ± 0.9] received 350 g of 3 isonitrogenous and isocaloric protein drinks containing 30 g micellar casein (MCN), sodium caseinate (SCN), or whey protein concentrate (WPC). The gastric antrum cross-sectional area (CSA) and curd in the stomach were measured using ultrasonography within 5 h after ingestion. The differences between test foods were tested using the MIXED model and post hoc tests using Fisher's protected least significant difference. RESULTS: The incremental AUC of the gastric antrum CSA after MCN ingestion was 1.3-fold and 1.5-fold higher than that after the ingestion of SCN and WPC, respectively (both P < 0.05), but not different between SCN and WPC. The number of participants with curds ≥20 mm with a high echogenicity clot observed in the stomach within 5 h after MCN ingestion was significantly greater than that after the ingestion of other proteins (n = 9 for MCN, n = 2 for SCN, and n = 0 for WPC; bothP < 0.01). The regression line slopes on total plasma amino acid concentration and gastric antrum CSA were significantly different between the participants with and without curds. CONCLUSIONS: In contrast to SCN and WPC, MCN ingestion resulted in slow kinetics of gastric antrum CSA. Differences in curd formation of casein in the stomach affect gastric emptying and plasma amino acid absorption kinetics after ingestion in healthy men. This trial was registered at University Hospital Medical Information Network Clinical Trials Registry as UMIN000038388 (https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000043746).

Large vessel occlusions requiring repeated mechanical thrombectomy caused by silent myocardial infarction in a young adult.

OBJECTIVES: Silent myocardial ischemia, defined as objective evidence of myocardial ischemia without symptoms, is associated with ischemic stroke. Nevertheless, silent myocardial infarction is a rare cause of ischemic stroke, especially in young adults with no medical history. MATERIALS AND METHODS: Herein, we report a young adult patient with acute ischemic stroke treated with repeated mechanical thrombectomy for recurrent large vessel occlusions caused by left ventricular thrombus following a silent myocardial infarction. RESULTS: A 40-year-old man was transferred by ambulance to our hospital because of a generalized seizure. He was diagnosed with cerebral infarction and left middle cerebral artery occlusion. We performed intravenous thrombolysis and mechanical thrombectomy. Recanalization was achieved and his symptoms gradually improved. However, the day after treatment he developed bilateral cerebellar infarction and basilar artery occlusion. We performed a second mechanical thrombectomy and recanalization was achieved. Transthoracic echocardiography revealed a mobile left ventricular thrombus. Although he had no previous chest symptomatic episodes, cardiac examination confirmed myocardial infarction of unknown onset. He was diagnosed with acute ischemic stroke with large vessel occlusions caused by left ventricular thrombus following a silent myocardial infarction. Anticoagulation therapy reduced the amount of thrombus. At 1-year follow-up, he had not experienced any recurrences or symptoms. CONCLUSIONS: Silent myocardial infarction should be considered a cause of ischemic stroke in young adults, even without any vascular risk factors. Recurrent large vessel occlusion may occur in patients with left ventricular thrombus, and repeated mechanical thrombectomy should be considered for treatment.

Persistent trigeminal artery variant associated with ipsilateral hypoplasia of the internal carotid artery.

A persistent trigeminal artery is the most common persistent carotid-vertebrobasilar anastomosis, while persistent trigeminal artery variants involve termination at the cerebellar artery without connecting to the basilar artery. Internal carotid artery hyperplasia is also a rare congenital anomaly. To the best of our knowledge, there are no reports of persistent trigeminal artery variant associated with ipsilateral hypoplasia of the internal carotid artery. Herein, we report a case of a 44 year-old woman who visited a neurosurgical clinic because of chronic headaches. Magnetic resonance angiography showed impaired delineation of the left internal carotid artery, and she was referred to our hospital for catheter angiography. Angiogram revealed left internal carotid artery hypoplasia and a left persistent trigeminal artery variant that terminated at the left anterior inferior cerebellar artery. Computed tomography bone images showed a narrow left carotid canal. We diagnosed congenital hypoplasia of the left internal carotid artery concomitant with ipsilateral persistent trigeminal artery variant. Careful imaging assessment is important for identifying persistent trigeminal artery variant when associated with ipsilateral internal carotid artery hypoplasia.

Aberrant right subclavian artery with right type 1 proatlantal artery and segmental dysplasia of the right internal carotid artery: a case report.

PURPOSE: We present a case of an aberrant right subclavian artery (ARSA) with extremely rare vascular anomalies. CASE REPORT: A 69-year-old woman was suspected to have right internal carotid artery (ICA) stenosis. Computed tomography angiography demonstrated an ARSA and hypoplasia of the right ICA. The proximal segment of the right vertebral artery (VA) was aplasia, and a right type 1 proatlantal artery (PA) arose from the right common carotid artery. Cerebral angiography demonstrated segmental dysplasia of the right ICA. The ascending intrapetrous segment and the ascending foramen lacerum-horizontal intracavernous segment of the right ICA demonstrated hypoplasia. The collateral pathways promoted reconstitution of each of the distal segments. Left internal carotid angiography demonstrated anterior communicating artery aneurysm and sufficient cross flow to the contralateral middle cerebral artery via the AcomA. DISCUSSION: A type 1 PA with an ARSA may result in the regression of the right dorsal aorta with persistence of the first cervical intersegmental artery. Although there are few findings of a relationship between an ARSA and intracranial artery anomalies, a developmental error of the right dorsal aorta may cause such complex vascular anomalies. CONCLUSION: Knowledge of anatomical variations in patients with ARSA is useful when performing angiography or endovascular therapy, as well as during clinical follow-up.

[Emergency Superficial Temporal Artery-Middle Cerebral Artery Bypass for Atherosclerotic Ischemic Stroke].

Endovascular recanalization is the primary strategy for the treatment of acute embolic stroke. However, atherosclerotic occlusions are often challenging to recanalize, and only medical therapy can be performed. In these cases, even the best medical treatment may not be effective, and the cerebral infarction progressively worsens. We believe that an emergency superficial temporal artery-middle cerebral artery(STA-MCA)bypass could be effective in these situations, after careful case selection. We use the following eligibility criteria: (1)atherosclerotic infarction; (2)cerebral ischemia with blood flow < 70% of the contralateral side; (3)progressively worsening symptoms or widening of the subcortical infarction despite medical treatment; and(4)surgery availability < 72 h from symptom onset. Among the 35 patients who underwent urgent STA-MCA bypass from 2014 to 2020, 27(77.1%)gained gait independence, and the National Institutes of Health Stroke Scale(NIHSS)scores improved from a preoperative median of 8 to 3 at discharge. The modified Rankin score(mRS)improved from a preoperative median of 5 to 2 at discharge. No intracerebral hemorrhages occurred due to hyper-perfusion syndrome. When we match it with other reports, this emergency surgery allows 76-90% of patients with progressive stroke to achieve gait independency.

[What are the Indications and Points of Anterior Cervical Decompression Surgery?]

Anterior cervical foraminotomy is a motion-preserving and precise decompressing surgery with minimal bone removal. As preserving the motion segment and maximizing decompression are contradictory concepts, proficiency is needed to balance these requirements. Anatomical knowledge and good intraoperative orientation are essential to reach the nerve roots accurately in a narrow surgical field.

Multidisciplinary attentive treatment for patients with chronic disorders of consciousness following severe traumatic brain injury in the NASVA of Japan.

Primary Objective: The aim of this study was to demonstrate the clinical outcomes of long-term multidisciplinary attentive treatment (MAT) in patients with chronic disorders of consciousness (DOC) due to severe traumatic brain injury (TBI) following automotive accidents.Research Design: Five hundred and ten patients (mean age: 40.4 years) were enrolled in this retrospective study.Methods and Procedures: Patients were provided MAT for one to several years in the eight medical facilities of the National Agency for Automotive Safety and Victims' Aid (NASVA) in Japan. Clinical status for consciousness, communication, and activities of daily living were evaluated using the NASVA grading system.Outcomes and results: Following MAT, NASVA scores at discharge were significantly improved compared to those at admission in every patient subgroup including sex, age, NASVA score, and association with/without hypoxic encephalopathy at admission. Younger age, shorter interval between injury and admission, and better neurocognitive function at admission were found to be significant and independent factors for a good prognosis.Conclusions: MAT can partially improve the cognitive and physical abilities of patients with chronic DOC. From the perspective of not only restoring a patient's daily life, but also reducing the caregiver's burden, this type of treatment program warrants more public attention.

[Preventing Crying after Revascularization Surgery in Pediatric Patients with Moyamoya Disease:Sedation with Dexmedetomidine].

BACKGROUND: Hyperventilation is a well-known risk factor of ischemic events in pediatric patients with moyamoya disease. For young children, it is important to avoid crying to prevent ischemic events because of their unstable postoperative hemodynamics. To prevent crying in pediatric patients, we used dexmedetomidine(DEX)for sedation immediately after revascularization surgery. OBJECTIVE: We investigated the effects of postoperative DEX use on hemodynamic changes and the avoidance of crying and hypocapnia in pediatric patients with moyamoya disease. CASE: Ten consecutive patients(5 boys and 5 girls)who underwent surgical revascularization were enrolled, and 16 hemispheres(8 boys and 8 girls)were sedated with DEX postoperatively between August 2011 and August 2016. METHODS: During extubation after revascularization, DEX was started at 0.4µg/kg/hr under spontaneous breathing and its dose was increased depending on the degree of consciousness, to maintain sedation of at least 3 on the Ramsay scale. DEX administration was terminated the next morning. RESULTS: Sedation was maintained well in all patients without hypocapnia, and no ischemic complications were observed. One patient cried and needed additional intravenous DEX injections and was immediately re-sedated;no hypocapnia developed. Respiratory depression did not occur and changes in respiratory rate and decreases in SpO2 were not observed. No significant changes in systolic blood pressure and heart rate were observed. CONCLUSION: Dexmedetomidine is safe and useful for postoperative sedation in children with moyamoya disease.

[Investigation of Repeatability of Residual Urine Volume Measurement for Lower Urinary Tract Disorder in Patients with Lumbar Degenerative Disorders].

STUDY DESIGN: prospective study OBJECTIVE:To evaluate repeatability of residual urine(RU)volume measurement(RUM)in patients with lumbar degenerative disorders. SUMMARY OF BACKGROUND DATA: RUM by abdominal echo is a non-invasive modality to evaluate lower urinary tract disorder(LUTD), repeatability of which is not found in urological disorders. Additionally, its repeatability has not been confirmed in spinal disorders. The authors examined repeatability of RUM for evaluation of LUTD in patients with lumbar degenerative disorders. METHODS: Thirty-four patients with lumbar degenerative disorders and 7 normal adult volunteers entered our study. RUM was performed at least twice(two to seven times; average 3.6 times). According to urological guidelines, RU over 50 cc is defined as abnormal. Thirty-four patients were divided into two groups:the U+group with lower urinary tract lesion(16 patients)and the U-group without such a lesion(18 patients). RESULTS: In normal adult volunteers:In all volunteers, there was no abnormal RU. Repeatability of RUM was 100%. Average RU volume was 1.6 cc. In patients with lumbar degenerative disorders:Repeatability of RUM was 94.4% in the U-group(average RU volume was 35.2 cc)and 50% in the U+group(average RU volume was 50.1 cc). In all patients with lumbar degenerative disorders, repeatability of RUM was 73.5%(average RU volume was 43.0 cc). CONCLUSIONS: Repeatability of RUM in patients with lumbar degenerative disorders was 73.5%. Especially, in patients without lower urinary tract lesion, high repeatability of RUM was confirmed. According to the present study, RUM seemed to be a dependable modality to evaluate LUTD in patients with lumbar degenerative disorders.