Does childhood maltreatment affect hikikomori via traits of modern-type depression?

BACKGROUND: In the 1990s, the concepts of hikikomori and modern-type depression (MTD) emerged in Japan. Hikikomori is a condition of social avoidance or isolation, characterized by staying at home and being physically isolated for at least six months. MTD is characterized by depressive symptoms-mainly in stressful work or school situations during adolescence and early adulthood-which tend to rapidly reduce or disappear after leaving the stressful situation. We hypothesized that childhood maltreatment can form MTD traits that lead to hikikomori. METHODS: As a first step, we conducted a multigroup path analysis between childhood maltreatment, MTD traits, and physical isolation in the hikikomori group. This study utilized the nine-item Patient Health Questionnaire (PHQ-9), Home Environment Questionnaire (HEQ), 22-item Tarumi Modern-Type Depressive Trait Scale (TACS-22), 25-item Hikikomori Questionnaire (HQ-25), and Hamilton Depression Rating Scale (HDRS). The HQ-25 contains three factors: physical isolation, lack of socialization, and lack of emotional support. RESULTS: The hikikomori group included 92 patients and the control group comprised 137 healthy individuals. All total and subscale scores of PHQ-9, HEQ, TACS-22, HQ-25, and HDRS were significantly higher in the hikikomori group than in the control group. The risk model of childhood maltreatment for physical isolation via MTD traits obtained good fit with a goodness-of-fit index of.982. LIMITATIONS: The study's limitations were its sample selection bias, cross-sectional design, and use of self-report scales. CONCLUSIONS: Our findings support the hypothesis that childhood maltreatment is an important risk factor for hikikomori via MTD traits.

[Posterior Fossa Anatomy for Microvascular Decompression Surgery].

In most microvascular decompression surgeries, surgical maneuvers are performed within normal anatomical structures without any neoplasms. Thus, detailed anatomical knowledge is essential to perform safe and efficient procedures. "Rule of 3" by Rhoton AL Jr. is helpful for understanding not only the anatomy of the posterior fossa but also the three neurovascular compression syndromes. The cerebellar arteries and posterior fossa veins have substantial variability, but a basic understanding of their typical patterns is useful to explore individual cases. To use adequate surgical approaches through the cerebellar tentorial or petrosal surface in individual trigeminal neuralgia surgeries, anatomical knowledge of the bridging veins on the tentorial(the bridging veins into the tentorial sinus)and petrosal surfaces(the superior petrosal vein)is crucial. Fissure openings help to minimize cerebellar retraction, similarly to the sylvian fissure dissection in supratentorial surgeries.

Development of depression assessment tools using humanoid robots -Can tele-operated robots talk with depressive persons like humans?

BACKGROUND: Depression is a common mental disorder and causes significant social loss. Early intervention for depression is important. Nonetheless, depressed patients tend to conceal their symptoms from others based on shame and stigma, thus hesitate to visit psychiatrists especially during early phase. We hypothesize that application of humanoid robots would be a novel solution. Depressed patients may feel more comfortable talking with such robots than humans. METHODS: We recruited 13 patients with major depressive disorder (MDD) and 27 healthy volunteers as controls. Participants took both tele-operated humanoid robot and human interviews to evaluate severity of depression using the Hamilton Depression Rating Scale (HDRS). In addition, participants completed a self-administered questionnaire asking about their impressions of the robot interview. RESULTS: Confidence interval and t-test analysis have revealed that the HDRS scores are equally reliable between robot and human interviews. No significant differences were observed between the two interviews regarding "nervousness about the interview" and "hesitancy to talk about depressed moods and suicidal ideation." Compared to human interviews, robot interviews yielded significantly lower scores on shame-related factors especially among patients with MDD. LIMITATION: Small sample size, and the evaluator is male only. CONCLUSIONS: This is the first report to show the reliability of tele-operated humanoid robot interviews for assessment of depression. Robot interviews are potentially equally reliable as human interviews. Robot interviews are suggested to be more appropriate in assessing shame-related suppressed emotions and hidden thoughts of depressed patients in clinical practice, which may reduce the stigma associated with depression.

Telovelar/Transcerebellomedullary Fissure Approach: Giant Distal Posterior Inferior Cerebellar Artery Aneurysm, Epidermoid Cyst, and Brainstem Cavernoma: 2-Dimensional Operative Video.

INDICATIONS CORRIDOR AND LIMITS OF EXPOSURE: The telovelar or transcerebellomedullary fissure approach can provide wide exposure of the cerebellomedullary fissure and fourth ventricle by separating the natural plane between the medulla and cerebellum. 1-5. ANATOMIC ESSENTIALS NEED FOR PREOPERATIVE PLANNING AND ASSESSMENT: The cerebellar tonsil is attached to the adjacent cerebellum only by the tonsillar peduncle at its superolateral edge. 2 The posterior inferior cerebellar artery (PICA) runs in the cerebellomedullary fissure, usually making its caudal and cranial loops. 6,7. ESSENTIALS STEPS OF THE PROCEDURE: After widely opening the foramen magnum, the tonsil is gently elevated by shearing the tela choroidea up to the lateral recess from the taenia, where the vein of the inferior cerebellar peduncle courses. 8,9. PITFALLS/AVOIDANCE OF COMPLICATIONS: The developed occipital sinus, posterior condylar vein, and anomalies of the vertebral artery and PICA origin can obstruct the exposure. Detailed neuromonitoring is essential for accomplishing the procedure safely. 10,11. VARIANTS AND INDICATIONS FOR THEIR USE: This exposure can be extended to the lower cerebellopontine angle and can also be applied to the dorsal brainstem surgery. 2,12 The patients consented to the procedure and to the publication of their images.Image Credits: Department of Neurosurgery, Tokyo Medical University logo used by permission. Image at 0:10, 1:02, 2:46, 6:22, and 7:10 from Matsushima and Kohno, 1 used by permission from Medical View Co., Ltd.Right image at 0:14 and also upper image at 0:46, image at 1:26, and for left and lower right images at 1:54 from Matsushima et al, 2 by permission from Journal of Neurosurgery Publishing Group (JNSPG). Left image at 0:14, from Matsushima et al, 4 used by permission from the Congress of Neurological Surgeons. Lower image at 0:46 reprinted from Matsushima et al, 9 by permission from Elsevier. Left image at 1:06 from Matsushima et al, 8 used by permission from the Congress of Neurological Surgeons.Image at top right at 1:54 from Lister et al, 6 used by permission from the Congress of Neurological Surgeons. Image in center at 6:56 from Matsushima et al, 11 used by permission from Springer Nature. Image at right at 6:56 from Matsushima et al, 10 used by permission from JNSPG. Images at 9:48, by year: 1982 article screenshot and figure from Matsushima et al, 4 by permission from the Congress of Neurological Surgeons; 1992: article title screenshot from Matsushima et al, 3 by permission from the Congress of Neurological Surgeons; 1996: used with permission of McGraw-Hill Health Professions Division, from Microsurgical Anatomy of the Fourth Ventrical, Matshushiam T and Rhoton AL Jr, in Neurosurgery , eds Wilkins and Rengachary, vol 1, 1996, permission conveyed through Copyright Clearance Center, Inc.; 2000: article title screenshot from Mussi et al, 5 reused with permission from JNSPG; 2001: article title screenshot from Matsushima, Transcerebellomedullary fissure approach with special reference to methods of dissecting the fissure, J Neurosurg , vol 91, 2001, p. 257-264, by permission from JNSPG; 2021: article title screenshot from Matsushima et al, 12 by permission from Springer Nature. Images at 11:05 from Inoue T et al, "Surgical approach to the mesencephalic vascular malformation" [in Japanese], Surg Cereb Stroke , vol 26, 1998, p 288-289, by permission from the Japanese Society on Surgery for Cerebral Stroke. Cadaveric image at 11:56 from Matsushima T et al, "Exposure of the wide interior of the fourth ventricle without splitting the vermis: importance of cutting procedures for the tela choroidea" Neurosurg Rev , vol 35, 2012, p 563-571, used with permission from Springer Nature.

Psychological Traits of Patients With Depression Comorbid With Chronic Pain: Are Complaint and Competitive Tendency Related to Pain?

BACKGROUND: Modern-Type Depression (MTD) is a category of depression that has been studied mainly in Japan; however, no study has attempted to determine its relation to chronic pain. AIM: To determine possible associations between psychological traits related to MTD and the chronic pain of patients at psychiatric clinics. METHOD: Two hundred and twenty-one first time patients who visited the psychiatric clinic at a Japanese university medical center or an associated clinic were enrolled. The Hamilton Depression Rating Scale was used to measure depressive symptoms. The 22-item Tarumi's Modern-Type Depression Trait Scale (TACS-22), Achievement Motive, and 20-item Toronto Alexithymia Scale were used to assess psychological traits related to depression and chronic pain. The clinical diagnosis of each patient was confirmed by use of the Structured Clinical Interview for DSM-IV Axis I Disorders, administered by experienced specialists. The medians of the psychological traits identified were compared between patients with or without chronic pain. Analysis was also done of patients with Major Depressive Disorder (MDD). RESULT: Of the 221 patients, 139 had chronic pain. Patients with chronic pain had more severe depressive symptoms, Alexithymia, and high scores for the complaint trait of MTD. Seventy-three of the 221 patients met the criteria for MDD (53 had chronic pain). Patients with MDD comorbid with chronic pain had a higher competitive achievement score, severe depression, and difficulty identifying feelings. CONCLUSION: Complaint and competitive traits were shown to be related to chronic pain in psychiatric settings. Further study will allow us to design multidimensional approach for patients suffering from depression.

Evolution of microneurosurgical anatomy with special reference to the history of anatomy, surgical anatomy, and microsurgery: historical overview.

This article reviews the evolution of microneurosurgical anatomy (MNA) with special reference to the development of anatomy, surgical anatomy, and microsurgery. Anatomy can be said to have started in the ancient Greek era with the work of Hippocrates, Galen, and others as part of the pursuit of natural science. In the sixteenth century, Vesalius made a great contribution in reviving Galenian knowledge while adding new knowledge of human anatomy. Also in the sixteenth century, Ambroise Paré can be said to have started modern surgery. As surgery developed, more detailed anatomical knowledge became necessary for treating complicated diseases. Many noted surgeons at the time were also anatomists eager to spread anatomical knowledge in order to enhance surgical practice. Thus, surgery and anatomy developed together, with advances in each benefiting the other. The concept of surgical anatomy evolved in the eighteenth century and became especially popular in the nineteenth century. In the twentieth century, microsurgery was introduced in various surgical fields, starting with Carl O. Nylen in otology. It flourished and became popularized in the second half of the century, especially in the field of neurosurgery, following Jacobson and Suarez's success in microvascular anastomosis in animals and subsequent clinical application as developed by M.G. Yasargil and others. Knowledge of surgical anatomy as seen under the operating microscope became important for surgeons to perform microneurosurgical procedures accurately and safely, which led to the fuller development of MNA as conducted by many neurosurgeons, among whom A.L. Rhoton, Jr. might be mentioned as representative.

Evandro Pinto da Luz de Oliveira, MD, PhD (November 8, 1945-February 11, 2021): A Giant of Microneurosurgery and Neuroanatomy.

Dr Evandro de Oliveira, one of the most acclaimed and recognized names in neurosurgery, anywhere in the world, tragically left us on February 11, 2021, at the age of 75. The Rhoton Society submits an account of Dr Evandro de Oliveira's life with highlights of his personal journey, and his special contributions to the fields of microneurosurgery and neuroanatomy.

Microvascular Decompression for Trigeminal Neuralgia: A Prospective, Multicenter Study.

BACKGROUND: Microvascular decompression (MVD) is the most effective procedure for the long-term management of trigeminal neuralgia (TGN). However, retrospective and single-center studies are inherently biased, and there are currently no prospective, multicenter studies. OBJECTIVE: To evaluate the short- and long-term outcomes and complications in patients with TGN who underwent MVD at specialized Japanese institutions. METHODS: We enrolled patients with TGN who underwent MVD between April 2012 and March 2015. We recorded their facial pain grade and complications at 7 d (short term), 1 yr (mid-term), and 3 yr (long term) postoperatively. RESULTS: There were 166 patients, comprising 60 men and 106 women (mean age 62.7 yr). Furthermore, 105 patients were aged over 60 yr. We conducted neuromonitoring in 84.3% of the cases. The complete pain relief, mortality, and complication rates at the short-term follow-up were 78.9%, 0%, and 16.3%, respectively. Overall, 155 patients (93.4%) completed the long-term follow-up, with the complete pain relief and complication rates of 80.0% and 5.2%, respectively. CONCLUSION: In the hands of experienced neurosurgeons, MVD for TGN can achieve high long-term curative effects. In addition, complications are uncommon and usually transient. Our results indicate that MVD is an effective and safe treatment for patients with TGN, including elderly patients.

Prospective, Multicenter Clinical Study of Microvascular Decompression for Hemifacial Spasm.

BACKGROUND: Microvascular decompression (MVD) is the most effective procedure for hemifacial spasm (HFS). MVD results from nonspecialized or low-volume institutes are not always reliable. Most studies on MVD for HFS are retrospective and single centered; to the best of our knowledge, no prospective, multicenter studies exist. OBJECTIVE: To evaluate short- and long-term outcomes and complications in patients who underwent MVD for HFS in specialized Japanese institutions, in this multicenter, prospective, cohort study. METHODS: Included patients had undergone MVD for HFS in study centers between April 2012 and March 2015. Patients' postoperative grade of involuntary movements and complications were recorded postoperatively at 7 d (short-term) and at 1 (mid-term) and 3 (long-term) yr. RESULTS: A total of 486 patients (150 men, 336 women; mean age 53.9 yr with 181 patients over 60 yr) were enrolled during the study period. Neuromonitoring was used in 96.3% of the cases. The complete cure rate of symptom relief, mortality rate, and complication rate at short-term follow-up were 70.6%, 0%, and 15%, respectively. The long-term follow-up was completed by 463 patients (95.3%); the complete cure rate of symptom relief and complication rate were 87.1% and 3.0%, respectively. CONCLUSION: Our study revealed that under expert guidance and intraoperative neuromonitoring, the long-term curative effect rate of MVD for HFS is high, while complications are uncommon and usually transient. Our results indicate that MVD is an effective and safe treatment for patients with HFS, including elderly patients.

Blood metabolic signatures of hikikomori, pathological social withdrawal.

Background: A severe form of pathological social withdrawal, 'hikikomori,' has been acknowledged in Japan, spreading worldwide, and becoming a global health issue. The pathophysiology of hikikomori has not been clarified, and its biological traits remain unexplored. Methods: Drug-free patients with hikikomori (n = 42) and healthy controls (n = 41) were recruited. Psychological assessments for the severity of hikikomori and depression were conducted. Blood biochemical tests and plasma metabolome analysis were performed. Based on the integrated information, machine-learning models were created to discriminate cases of hikikomori from healthy controls, predict hikikomori severity, stratify the cases, and identify metabolic signatures that contribute to each model. Results: Long-chain acylcarnitine levels were remarkably higher in patients with hikikomori; bilirubin, arginine, ornithine, and serum arginase were significantly different in male patients with hikikomori. The discriminative random forest model was highly performant, exhibiting an area under the ROC curve of 0.854 (confidential interval = 0.648-1.000). To predict hikikomori severity, a partial least squares PLS-regression model was successfully created with high linearity and practical accuracy. In addition, blood serum uric acid and plasma cholesterol esters contributed to the stratification of cases. Conclusions: These findings reveal the blood metabolic signatures of hikikomori, which are key to elucidating the pathophysiology of hikikomori and also useful as an index for monitoring the treatment course for rehabilitation.

Evolution of cerebellomedullary fissure opening: its effects on posterior fossa surgeries from the fourth ventricle to the brainstem.

Surgical approaches to the fourth ventricle and its surrounding brainstem regions have changed significantly in the previous 30 years, after the establishment of cerebellomedullary fissure (CMF) opening. With the development of CMF opening techniques, CMF opening surgeries have become widely used for the treatment of various pathologies and have contributed to the improvement of surgical results in posterior fossa surgeries. We here review the historical progress of CMF opening surgeries to help the future progression of neurosurgical treatments. The authors studied the available literature to clarify how CMF opening surgeries have developed and progressed, and how much the idea and development of CMF opening techniques have affected the advancement of posterior fossa surgeries. With the establishment of angiography, anatomical studies on CMF in the 1960s were performed mainly to clarify vascular anatomy on radiological images. After reporting the microsurgical anatomy of CMF in a cadaveric study in 1982, one of the authors (T.M.) first proposed the clinical usefulness of CMF opening in 1992. This new method enabled wide exposure of the fourth ventricle without causing vermian splitting syndrome, and it took the place of the standard approach instead of the conventional transvermian approach. Several authors reported their experiences using this method from the end of the twentieth century to the early twenty-first century, and the naming of the approach, "telovelar approach" by Mussi and Rhoton in 2000 contributed to the global spread of CMF opening surgeries. The approach has become widely applied not only for tumors but also for vascular and brainstem lesions, and has assisted in the development of their surgical treatments, and brought up the idea of various fissure dissection in the posterior fossa. Studies of microsurgical anatomy of the fourth ventricle, including the CMF, has led to new surgical approaches represented by the transCMF/telovelar approach. The CMF opening method caused a revolution in posterior fossa surgeries. The idea was developed based on the experience gained while dissecting the CMF (the roof of the fourth ventricle) in the laboratory. Anatomical studies using cadaveric specimens, particularly their dissection by surgeons themselves, together with a deep understanding of brain anatomy are essential for further advancements in neurosurgical treatments.

Study of the Anatomical Features of the Offending Arteries Involved in Glossopharyngeal Neuralgia.

BACKGROUND: The anatomic features of the posterior inferior cerebellar arteries (PICAs) and the anterior inferior cerebellar arteries (AICAs) as offending arteries involved in glossopharyngeal neuralgia (GPN) are important to dictate the best surgical approach. OBJECTIVE: To study and classify the anatomic features of the offending arteries. METHODS: All clinical data and surgical videos from 18 GPN cases that were surgically treated during the past 10 yr were retrospectively reviewed. RESULTS: Among these 18 patients, the offending arteries involved were the PICA in 12 (66.7%), AICA in 4 (22.2%), and both PICA and AICA in 2 (11.1%). The PICA were then classified into the following groups based on their anatomic features: type I: the PICA formed an upward loop at the level of the glossopharyngeal nerve and passed between the glossopharyngeal and vestibulocochlear nerves; type II: the PICA formed an upward loop at the level of the glossopharyngeal nerve and passed between the glossopharyngeal and vagus nerves or between the rootlets of the vagus nerve; and type III: the PICA passed between the glossopharyngeal and vestibulocochlear nerves without forming a loop. The AICA had only one running pattern. CONCLUSION: The offending arteries involved in GPN, mainly the PICA and/or AICA, were classified into 4 different types based on their anatomic features.

Prosthesis Used in Microvascular Decompressions: A Multicenter Survey in Japan Focusing on Adverse Events.

OBJECTIVE: To investigate the characteristics of materials used as prostheses for microvascular decompression surgery (MVDs) in Japan and their possible adverse events (AEs) to determine preferable materials for MVDs. METHODS: A questionnaire was sent to all members of the Japanese Society for MVDs, and answers were obtained from 59 institutions. RESULTS: Among a total of 2789 MVDs, 1088 operations for trigeminal neuralgia, 1670 for hemifacial spasm, and 31 others, including 117 reoperations, were performed between April 2011 and March 2014. Nonabsorbable material was used in 96.5% of MVDs, including polytetrafluoroethylene (PTFE) (80.5%), polyurethane (11.9%), expanded PTFE (2.1%), and silk thread (1.47%). The use of absorbable materials, including fibrin glue (87.5%), cellulose (13.5%), gelatin (4,77%), and collagen (1.76%), was reported. The major combinations were PTFE with fibrin glue (58.7%) followed by PTFE alone (7.60%). Eighty-eight AEs in 85 (3.2%) cases were reported among 2672 first operations. AEs included 51 central nervous system dysfunctions, 15 wound infections/dehiscence, and 10 others, which were presumed to be related to the intraoperative procedure. Among relatively high-, moderate-, and low-volume centers, there were no significant differences in the frequency of AEs (P = 0.077). Tissue-prosthesis adhesion and/or granuloma formation were reported in 13 cases of 117 reoperations. The incidence of adhesion-related recurrence was 11.1% of all reoperations. CONCLUSIONS: The number of AEs was quite low in this survey, and intradural use of any prosthesis reported in this paper might be justified; however, further development of easily handled and less-adhesive prosthesis materials is awaited.

Microsurgical Anatomy of the Jugular Process as an Anatomical Landmark to Access the Jugular Foramen: A Cadaveric and Radiological Study.

BACKGROUND: The jugular process forms the posteroinferior surface of the jugular foramen and is an important structure for surgical approaches to the foramen. However, its morphological features have not been well described in modern texts. OBJECTIVE: To elucidate the microsurgical anatomy of the jugular process and examine its morphological features. METHODS: Five adult cadaveric specimens were dissected in a cadaveric study, and computed tomography data from 31 heads (62 sides) were examined using OsiriX (Pixmeo SARL, Bernex, Switzerland) to elucidate the morphological features of the jugular process. RESULTS: The cadaveric study showed that it has a close relationship with the sigmoid sinus, jugular bulb, rectus capitis lateralis, lateral atlanto-occipital ligament, and lateral and posterior condylar veins. The radiographic study showed that 9/62 sigmoid sinuses protruded inferiorly into the jugular process and that in 5/62 sides, this process was pneumatized. At the entry of the jugular foramen, if the temporal bone has a bulb-type jugular bulb, and if surgery concerns the right side of the head, the superior surface of the jugular process is more likely to be steep. CONCLUSION: The jugular process forms the posteroinferior border of the jugular foramen. Resection of the jugular process is a critical step for opening the jugular foramen from the posterior and lateral aspects. Understanding the morphological features of the jugular process, and preoperative and radiographical examination of this process thus help skull base surgeons to access the jugular foramen.

The history of Rhoton's Lab.

The work performed in Dr. Rhoton's Lab, represented by over 500 publications on microneurosurgical anatomy, greatly contributed to improving the level of neurosurgical treatment throughout the world. The authors reviewed the development and activities of the Lab over 40 years. Dr. Albert L. Rhoton Jr., the founder of, and leader in, this field, displayed great creativity and ingenuity during his life. He devoted himself to perfecting his study methodology, employing high-definition photos and slides to enhance the quality of his published papers. He dedicated his life to the education of neurosurgeons. His "lab team," which included microneuroanatomy research fellows, medical illustrators, lab directors, and secretaries, worked together under his leadership to develop the methods and techniques of anatomical study to complete over 160 microneurosurgical anatomy projects. The medical illustrators adapted computer technologies and integrated art and science in the field of microneurosurgical anatomy. Dr. Rhoton's fellows established methods of injecting colors and pursued a series of projects to innovate surgical approaches and instruments over a 40-year period. They also continued to help Dr. Rhoton to conduct international educational activities after returning to their home countries. Rhoton's Lab became a world-renowned anatomical lab as well as a microsurgical training center and generated the knowledge necessary to perform accurate, gentle, and safe surgery for the sake of patients.

Albert L. Rhoton Jr., MD: His Philosophy and Education of Neurosurgeons.

Dr. Rhoton's key philosophies included "Keep working hard.", "Make surgery more accurate, gentle and safe", "We want perfect anatomical dissections, because we want perfect surgical operations", "Competence without compassion is worthless. Compassion without competence is meaningless", "Neurosurgeons share a great professional gift; our lives have yielded an opportunity to help mankind in a unique and exciting way" and "There is no finish line for this effort". His words reveal his passion for microneurosurgery and infinite love for humankind. Although his reknown rested on his reputation as a researcher, Dr. Rhoton was also a devoted educator. The principal aim behind the enormous amount of work he performed was that of educating neurosurgeons worldwide, so that they could be better surgeons. His work included: (1) numerous dissection courses, (2) numerous lectures and publications including about 160 original papers (3) the textbook "RHOTON" and Rhoton Collection (4) the education of 119 research fellows. The projects directed in his lab, produced the international dissemination of neuroanatomical knowledge. The ultimate goal of his microsurgical research was to improve the care of patients with neurosurgical diseases around the world. The technical contributions and humble character of Dr. Rhoton should be remembered as we care for patients.

The microneurosurgical anatomy legacy of Albert L. Rhoton Jr., MD: an analysis of transition and evolution over 50 years.

The authors chronologically categorized the 160 original articles written by Dr. Rhoton and his fellows to show why they selected their themes and how they carried out their projects. The authors note that as neurosurgery progresses and new techniques and approaches are developed, accurate and safe treatment will depend upon continued clarification of microsurgical anatomy.