Ultra-High-Molecular-Weight Polyethylene Merlon Shape: Novel Fixation of Artificial Bone for Cranioplasty.

BACKGROUND: Cranioplasty is a surgical procedure widely performed for repairing cranial defects caused by external decompression surgery for cerebrovascular disease or traumatic brain injury. We devised a new cranioplasty method using artificial bone made up of ultra-high molecular-weight polyethylene, with serrated wings on the edge. We named this newly designed artificial bone as Merlon shape. OBJECTIVE: To describe our initial experience with the Merlon shape and evaluate its usefulness and safety in cranioplasty. METHODS: The serrated wings of the Merlon shape were preoperatively designed for solid fixation and improving cosmetic results by reducing the thickness of the artificial bone. We evaluated 25 patients who underwent cranioplasty with the Merlon shape between December 2018 and December 2021. The causes of bone defects in these patients (male: 9, female: 16; median age: 62 years) were subarachnoid hemorrhage (n = 14), cerebral infarction (n = 8), and traumatic brain injury (n = 3). RESULTS: There were no postoperative adverse events such as infection, bone resorption, implant exposure, or graft sinking in 24 patients during an average follow-up period of 19 months. One patient experienced acute epidural hemorrhage and required reoperation. CONCLUSION: This is the first report on the use of the ultra-high molecular-weight polyethylene Merlon shape. Our initial 4-year case series showed good outcomes with this method.

Fatal Cerebral Venous Thrombosis in a Pregnant Woman with Inherited Antithrombin Deficiency after BNT162b2 mRNA COVID-19 Vaccination.

Antithrombin deficiency is a high-risk factor for venous thromboembolism during pregnancy, whereas cerebral venous thrombosis is rare. Cerebral venous thrombosis related to coronavirus disease 2019 (COVID-19) vaccines has been reported; however, there are a few reports of cerebral venous thrombosis after a messenger RNA (mRNA) vaccination. A 25-year-old female in her sixth week of pregnancy presented with headache 24 days after BNT162b2 mRNA COVID-19 vaccination. The following day, she presented with altered sensorium and was diagnosed with severe cerebral venous thrombosis. She demonstrated heparin resistance and was found to have an inherited antithrombin deficiency. A heterozygous missense variant in SERPINC1 (c.379T>C, p.Cys127Arg, 'AT Morioka') was detected by DNA analysis. Despite intensive care with unfractionated heparin, antithrombin concentrate, and repeated endovascular treatments, she died on the sixth day of hospitalization. Cerebral venous thrombosis in pregnant women with an antithrombin deficiency can follow a rapid and fatal course. Treatment with unfractionated heparin and antithrombin concentrate may be ineffective in severe cerebral venous thrombosis cases with antithrombin deficiency. Early recognition of antithrombin deficiency and an immediate switch to other anticoagulants may be required. Although the association between cerebral venous thrombosis and the vaccine is uncertain, COVID-19 vaccinations may require careful evaluation for patients with prothrombic factors.

A low score on the National Institutes of Health Stroke Scale with eye movement disorder may indicate a good candidate for acute mechanical thrombectomy for posterior circulation large vessel occlusion: illustrative cases.

BACKGROUND: Basilar artery occlusion (BAO) accounts for 1% of all strokes, and its natural prognosis is extremely poor. There is no consensus on the treatment strategy for mild BAO. OBSERVATIONS: Between August 2015 and May 2021, 429 patients received mechanical thrombectomy (MT) in the authors' hospital. Three patients had a BAO with a National Institutes of Health Stroke Scale (NIHSS) score of ≤6 and showed eye movement disorder as the main symptom. MT immediately improved ocular symptoms in all three cases, and the patients were discharged with a modified Rankin Scale ≤2. LESSONS: Lesions responsible for the eye movement disorder are distributed from the midbrain to the pontine tegmentum. These lesions are supplied by the arteries of the interpeduncular fossa, which is impaired by BAO. Symptoms due to problems with the arteries of the interpeduncular fossa can be rapidly improved by MT, and it is useful for preventing neurological deterioration in mild cases. BAO with a low NIHSS score in the presence of eye movement disorder as the main symptom may be a good indication for MT.

Visual Impairment due to a large paraclinoid aneurysm treated with parent artery occlusion and bypass: A case report.

INTRODUCTION: Paraclinoid internal carotid artery (ICA) aneurysms can sometimes cause visual field disturbances due to their size, and it is challenging to treat either surgically or using endovascular techniques. Flow diverters generally have positive outcomes, but sometimes in symptomatic aneurysms, we see the thrombosed section becomes enlarged. Therefore, optimal treatment strategies are difficult to determine. CASE: A 68-year-old woman presented with a chief complaint of vision loss in the left eye. A large wide-necked saccular aneurysm was found on the left ICA paraclinoid portion. Under general anesthesia, a Pipeline Flex was inserted along with coil embolization. After treatment, the aneurysm showed thrombotic expansion, and the visual impairment worsened. One year later, aneurysm recanalization was evident; therefore, another Pipeline was inserted to overlap the stent. However, her visual impairment worsened again, and parent artery occlusion with high flow bypass was performed 20 months after her first treatment. Two weeks postoperatively, improved peripheral vision was confirmed. Further, no enlargement of the aneurysm was observed using magnetic resonance imaging 6 months later. CONCLUSION: This case examined a symptomatic, large paraclinoid aneurysm in a patient, which continued to enlarge after Pipeline stent placement, but was later treated successfully using direct parent artery occlusion in combination with high-flow bypass.

Association of mitochondrial DNA haplogroup and hearing impairment with aging in Japanese general population of the Iwaki Health Promotion Project.

Age-related hearing loss (ARHL) is a complex multifactorial disorder. Studies in animals, including mitochondria-mutator mice, and in human suggest that oxidative stress and mitochondrial disturbance play an important role in the pathoetiology of ARHL. Mitochondrial DNA (mtDNA) haplogroups are populations with genetically similar traits, and they have been reported to affect the mitochondrial function of oxidative phosphorylation. To gain further insights into the relationships between mitochondrial haplotypes and the susceptibility to cochlear aging, in this study, we aimed to elucidate how the differences in mtDNA haplogroups may affect ARHL development in Japanese general population. We focused on early onset ARHL, as the same mtDNA haplogroup can show either a negative or positive effect on systemic co-morbidities of ARHL that appear later in life. A total of 1167 participants of the Iwaki Health Promotion Project were surveyed in 2014, and 12 major haplotype groups (D4a, D4b, D5, G1, G2, M7a, M7b, A, B4, B5, N9, and F) were selected for the analysis. A total of 698 subjects aged 30 to 65 years were included in the statistical analysis, and the hearing loss group consisted of 112 males (40.3%) and 111 females (26.4%). Multiple logistic regression analysis showed that the male subjects belonging to haplogroup A had a significantly increased risk of hearing loss, whereas the female subjects belonging to haplogroup N9 had a significantly decreased risk of hearing loss. These results suggested that the mtDNA haplogroup may be an indicator for future risk of morbidity associated with ARHL.

Tandem Lesions of the Vertebrobasilar System Treated by Thrombectomy and Vertebral Artery Stenting: A Case Report.

Objective: There are few reports on endovascular treatment of tandem lesions in the posterior circulation and no consensus on treatment strategies has been reached. We report a case of tandem lesions of basilar artery occlusion and vertebral artery stenosis treated by thrombectomy and vertebral artery stenting. Case Presentation: We present the case of a 73-year-old man who developed consciousness disorder and tetraplegia. Head and neck CTA revealed tandem left vertebral artery stenosis and basilar artery occlusion. The patient was treated using a reverse technique, which involves performing thrombectomy first and then vertebral artery stenting, along with Carotid Guardwire PS. Postoperative impairment of consciousness and improvement of tetraplegia were achieved. Conclusion: The reverse technique combined with Carotid Guardwire PS may be a useful treatment strategy for tandem lesions in the posterior circulation.

Use of Contralateral Trans-Anterior Communicating Artery Snare to Rescue Lost Access to a Pipeline Embolization Device Unsheathed in an Aneurysm.

Objective: A pipeline embolization device (PED; Medtronic, Minneapolis, MI, USA) is a new vascular reconstruction device used to treat large internal carotid artery (ICA) aneurysms in Japan. We herein present a PED-related complication and describe its rescue strategy. Rescue therapy using a snare via the posterior communicating artery from the contralateral side has already been reported. However, this is the first report of therapy via the anterior communicating artery (AcomA). Case Presentation: A 49-year-old woman underwent vascular reconstruction with a PED for a large cavernous ICA aneurysm. During the placement of the PED, the proximal side of the PED slipped into the aneurysm. It was impossible to enter the true lumen of the PED from the proximal side because the orifice of the stent faced the aneurysmal wall. Contralateral trans-AcomA access to the PED was obtained through the distal ICA. The microwire from the distal ICA was connected with Goose Neck snares (Medtronic) from the proximal ICA. Pulling the snares to the proximal side, the PED was straightened and distal access was regained. Another PED was deployed such that it overlapped with the first PED to achieve vascular reconstruction. The patient finally recovered from aphasia, but paralysis of the right upper limb remained after rehabilitation. Conclusion: If the stent slips into the aneurysm, distal access through the true stent lumen may be very difficult. We presented a rescue technique for this complication, through the AcomA from the contralateral side.

Effect of Preoperative Administration of Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitor on Carotid Artery Stenting.

BACKGROUND: Perioperative embolic stroke is one of the most serious complications during carotid artery stenting (CAS). Proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i) is a low-density lipoprotein-lowering drug that inhibits proprotein convertase subtilisin/kexin type 9, which normally binds to the low-density lipoprotein cholesterol (LDL-C) receptor. Its combination with statin significantly decreases LDL-C levels. PCSK9i is expected to achieve lower LDL-C levels than single use of statin. This study aimed to investigate whether perioperative PCSK9i administration stabilizes carotid artery plaque and reduces perioperative complications of CAS. METHODS: Nine patients with symptomatic stenosis (North American Symptomatic Carotid Endarterectomy Trial [NASCET] 50%) or asymptomatic stenosis (NASCET ≥ 80%) were included. PCSK9i was administered at least twice (once in 2 weeks) in the outpatient clinic before CAS. Perioperative complications; results from blood tests, magnetic resonance imaging (MRI), magnetic resonance angiography, and carotid ultrasonography (US); and modified Rankin scale score at discharge were assessed. RESULTS: High intensity on diffusion-weighted imaging was not observed in 8 patients. Changes in carotid plaque characteristics were found with MRI and/or carotid US in 7 patients. The plaque to muscle ratio decreased in 3 patients. The carotid plaque became hyperechoic in 2 patients, and the fibrous cap was seen more clearly on carotid US. Two patients had findings of stabilized plaque on MRI and carotid US, which indicates that plaque transformation was more stable. CONCLUSIONS: Lowering LDL-C level could reduce ischemic complications, and low LDL-C level affects plaque stability and antithrombus formation. PCSK9i can possibly stabilize carotid plaque and reduce perioperative complications of CAS.

[Genetic diagnosis for epilepsy].

Very few epilepsy phenotypes have been associated with causative genes; nevertheless, it is becoming possible, for some epilepsy phenotypes, to predict the most efficacious anti-epileptic drugs for patients based on their genetic makeup. The development of individualized medicine based on genetic information and the genetic diagnosis of epilepsy are expected to greatly improve the diagnosis and treatment of epilepsy. We developed DNA array(resequencing-array) for genetic diagnosis of epilepsy, and successfully identified epilepsy mutations in patients. This finding indicates that this DNA array is likely to be a useful tool in clinical settings at least for screening purposes, because it can simultaneously and efficiently detect several gene mutations in a patient.

Surgical treatment of spinal extradural arteriovenous fistula with parenchymal drainage: report on 5 cases.

BACKGROUND AND IMPORTANCE: Spinal extradural arteriovenous fistula (SEDAVF) with parenchymal drainage (type A) is a rare clinical entity that causes venous congestive myelopathy. Treatment includes endovascular and open microsurgical interventions. We reviewed the clinical records of patients treated for a type A SEDAVF to evaluate the feasibility of our treatment strategy. CLINICAL PRESENTATION: Between 2004 and 2010, 5 patients with a type A SEDAVF were treated at our institutes (4 men and 1 woman; mean age, 60 years). We performed endovascular transvenous embolization (TVE) when lesions were accessible transvenously; otherwise, microsurgical perimedullary drainer occlusion was performed. Follow-up ranged from 23 to 94 months (mean, 45.8 months). One patient was treated with TVE, and the remaining 4 were treated with microsurgical drainer occlusion. After a simple intradural drainer occlusion, an epidural venous lake was completely thrombosed in 2 patients. In 1 patient, postoperative angiography revealed that a part of the epidural component had persisted; however, the patient has been asymptomatic. In the remaining case with multiple intradural draining veins, sole drainer occlusion was not sufficient. A second surgery was required to meticulously coagulate the venous lake. As a consequence, parenchymal drainers disappeared. Overall, all patients stabilized or improved neurologically and experienced no recurrence. CONCLUSION: To treat a type A SEDAVF, either TVE or microsurgical intradural drainer occlusion can be used for satisfactory long-term results with minimal surgical risks. For a case with multiple intradural draining veins, detachment of the venous lake should be considered.

A novel prophylactic effect of furosemide treatment on autosomal dominant nocturnal frontal lobe epilepsy (ADNFLE).

The transgenic rat strain S284L-TG harbors the S284L mutant of the neuronal nicotinic acetylcholine receptor alpha4 subunit gene (CHRNA4), which is responsible for human autosomal dominant nocturnal frontal lobe epilepsy (ADNFLE). S284L-TG rats have epileptic seizure phenotypes during slow-wave sleep, similar to those in NFLE. We previously demonstrated that γ-aminobutyric acid (GABA)ergic action of these rats was suppressed before the onset of ADNFLE seizures, and that glutamate release in the epileptic focus lesion was increased at the onset of epilepsy. Here, mRNA analysis revealed that Cl(-)-accumulating Na-K-2Cl cotransporter 1 (NKCC1) levels were increased and Cl(-)-extruding K-Cl cotransporter 1 and 2 (KCC1 and KCC2) levels were decreased at the onset of ADNFLE seizures in S284L-TG rat frontal cortexes, which perturbed the GABAergic inhibitory system. The reversal potentials (EGABA) of GABAA receptor-mediated currents in cortical layer V pyramidal neurons of S284L-TG rats also changed their polarity from hyperpolarization to depolarization, and S284L-TG miniature excitatory postsynaptic currents (mEPSCs), but not miniature inhibitory postsynaptic currents (mIPSCs), significantly increased in both amplitude and frequency. Administration of 25mg/kg/day furosemide before, but not after, the onset of interictal discharges prevented idiopathic epileptic activity, reversed the depolarizing shift of EGABA and increased mEPSC amplitude to normal levels. These data indicate that early treatment with an agent that normalizes pathogenesis has a prophylactic effect on epilepsy. We propose a strategy for prophylactic medication against idiopathic epilepsy through the suppression of epileptogenesis and/or ictogenesis.

A case of autosomal dominant nocturnal frontal lobe epilepsy (ADNFLE) coexisting with pervasive developmental disorder harboring SCN1A mutation in addition to CHRNB2 mutation.

We report a case of autosomal dominant nocturnal frontal lobe epilepsy (ADNFLE) with several characteristics distinct from previously reported cases, in which genetic studies identified mutations in two different genes. This case differed from typical ADNFLE with respect to the following: (1) slightly younger onset and refractory to antiepileptic drugs and (2) borderline intellectual functioning and coexistence of pervasive developmental disorder from infancy. Genetic testing revealed a novel mutation and a silent substitution in SCN1A (c.4285G>T, A1429S and c.4371G>C, silent) in addition to a known mutation in CHRNB2 (c.1200C>G, I312M). SCN1A is a gene that codes for the voltage-dependent sodium channel α1 subunit and has been implicated in generalized epilepsy with febrile seizures plus and severe myoclonic epilepsy in infancy. However, the relation between SCN1A and ADNFLE is unknown. We report the clinical course and symptomatic characteristics of this case although the relationship between ADNFLE mutation and SCN1A mutation remains to be elucidated.

[Personalized medicine for epilepsy based on the pharmacogenomic testing].

Currently a trial-and-error approach is employed to determine the most effective antiepileptic drug (AED) and dosage for a patient, and almost 30% of all patients are resistant to AED therapy. Introduction of personalized medicine for epilepsy based on pharmacogenomic testing is a new avenue for optimizing AED therapy. However, several crucial issues remain to be resolved before this initiative can be fully pursued. This article provides a critical review of the status and perspectives in the development of personalized medicine for epilepsy based on pharmacogenetic variations that may affect efficacy, tolerability, and safety of AEDs, such as variations in the genes encoding drug-metabolizing enzymes (e.g., cytochrome P450), or drug transporters (e.g., MDR1, MRP2).

Repeat stereotactic radiosurgery in the management of brain metastases from non-small cell lung cancer.

Non-small cell lung cancer (NSCLC) is characterized by brain metastases that occur in about 30 to 50% of patients. To control tumor growth potential with maintaining neurocognitive function is important in the recent radiotherapy against brain metastases. From this viewpoint, we investigated the utility of repeat stereotactic radiosurgery (SRS) with a linear accelerator in the management of brain metastases from NSCLC. Between October 1998 and May 2010, 28 patients harboring brain metastases received repeat SRS (20 men and 8 women, with the age ranged from 51 to 79). The total number of SRS sessions ranged from 2 to 5, and the total number of lesions in one patient ranged from 1 to 8. Neurological decline due to uncontrolled brain lesions was identified in 9 of 28 patients after the repeat SRS, while the remaining 19 patients showed no neurological decline. Out of the 28 patients, 18 patients died by July 1, 2010; 12 patients died of active extracranial disease and 6 patients died from progressive brain lesions, considered neurological death. The 2-year and 4-year overall survival rates were 51% and 23%, respectively, and the median survival time was 26 months. In conclusion, repeat SRS is a preferred option to manage brain metastases from NSCLC, leading to a long survival with a decreased neurological decline. Repeat SRS is promising to preserve neurocognition, because the convergent dose distribution decreases the unfavorable influences from radiation on germinal niches, thereby preserving neural stem cells that are responsible for the nervous system repair.

Comparison of large intrasylvian and subpial hematomas caused by rupture of middle cerebral artery aneurysm.

The clinical characteristics of intrasylvian and subpial hematomas caused by rupture of middle cerebral artery (MCA) aneurysm were examined in 86 patients admitted to our department with subarachnoid hemorrhage (SAH) caused by ruptured MCA aneurysms. A retrospective study of 26 patients with a large hematoma associated with SAH treated surgically within 48 hours evaluated clinical grade at admission, secondary development of cerebral swelling, ratio of hematoma removal, and incidence of symptomatic vasospasm. Clinical grade on admission, age, and sex showed no significant differences. Ratio of cerebral swelling against the initial hematoma volume (p = 0.005), and incidence of symptomatic vasospasm (p = 0.041) were significantly lower, and the ratio of hematoma was significantly higher (p = 0.01) in the subpial hematoma group. Removal of hematoma was more difficult and symptomatic vasospasm was more frequent in the intrasylvian hematoma group. The clinical features of subpial and intrasylvian hematomas caused by rupture of MCA aneurysm should be considered for the better management of associated SAH.

Outcome of stereotactic radiosurgery for patients with non-small cell lung cancer metastatic to the brain.

We evaluated the treatment outcome of stereotactic radiosurgery (SRS) alone, allowing for salvage with repeat SRS or fractionated radiotherapy, for managing patients with brain metastases from non-small cell lung cancer (NSCLC). From October 1998 through November 2008, 84 patients with NSCLC metastatic to the brain were treated with linac SRS. The marginal dose of SRS ranged from 12 to 20 Gy. Twenty-one patients underwent salvage radiotherapy and repeat SRS was used for 12. The 1- and 5-year overall survival rates were 38% and 11%, respectively, and the median survival time was 9 months. The 1- and 2-year local control rates were 77% and 52%, respectively, and the median time of local control was 9 months. The most common cause of death was active extracranial disease, and central nervous system (CNS) failure was determined in 16%. Chronic CNS toxicity of grade 4 was observed in 2 patients. Uni- and multivariate analyses revealed that factors significantly affecting overall survival were the presence of active extracranial disease (P < 0.0001 and P = 0.003, respectively), performance status (P = 0.001 and P = 0.009, respectively), and number of brain metastases (P = 0.0003 and P = 0.019, respectively). There were 15 long-term survivors, surviving more than 2 years. A large proportion (87%) had a single brain metastasis initially and few intracranial distant metastases afterwards (20%). SRS alone allowing for salvage radiotherapy was effective for managing brain metastases and avoiding CNS failure from NSCLC. In consideration of appropriate prognostic factors and the so-called oligometastases situation for patient selection, the use of upfront whole brain radiotherapy might improve outcome.

Evolution of vestibular schwannoma after removal of epidermoid cyst of the same location: case report.

A 71-year-old man presented with vestibular schwannoma manifesting as hearing disturbance and truncal ataxia 16 years after removal of a cerebellopontine angle (CPA) epidermoid cyst, and located adjacent to the remnant lesion. The patient first presented with a 6-month history of right trigeminal neuralgia. Neuroimaging demonstrated a right CPA lesion, suggestive of an epidermoid cyst. Right lateral suboccipital craniotomy was performed and the histological diagnosis was epidermoid cyst. A small lesion remained, but the symptoms were relieved. Sixteen years later, the patient presented with right auditory disturbance, vertigo, and truncal ataxia. Magnetic resonance imaging revealed a multiple cystic mass adjacent to the remnant epidermoid cyst in the right CPA. The lesion was removed and the histological diagnosis was vestibular schwannoma associated with the epidermoid cyst. The irritative effect of the remnant epidermoid cyst or surgical procedures may have caused the vestibular schwannoma, but no evidence of the evolution of the different types of tumors was found.

Measurement of the rate of myofibrillar protein degradation using the arteriovenous difference in plasma 3-methylhistidine concentration of rats.

There are several methods for measuring the rate of myofibrillar protein degradation using 3-methylhistidine (3-MeHis) levels in urine, plasma and isolated muscle. However, these methods lack the accuracy of rate measurements. Therefore, it is necessary to develop a new method for determining the rate of myofibrillar protein degradation. We characterized an arteriovenous difference method using 3-MeHis plasma concentration. Rats were fasted overnight and subsequently administered leucine (135 mg/100 g BW) or fed a 20% casein diet. The rate of myofibrillar protein degradation was calculated by multiplying the femoral artery blood flow rate by the arteriovenous difference in 3-MeHis concentrations (vein-artery). The blood was collected from the femoral vein and abdominal aorta. The release of 3-MeHis from hindlimb muscle was significantly suppressed (p<0.05) in rats fed leucine or the 20% casein diet, indicating that myofibrillar protein degradation was suppressed. These results suggest that the evaluation of the rate of myofibrillar protein degradation using the arteriovenous difference method reflects nutritional conditions in a more physiological manner.

Adult traumatic leptomeningeal cyst: case report.

A 60-year-old man presented with a traumatic leptomeningeal cyst manifesting as local tenderness in the right parietal region and local headache 2 years after head injury. Magnetic resonance imaging showed a small arachnoid cyst under bone defect. Dural and bone plasty were performed. Intraoperative examination found small and round defects of the dura and bone. Progressive headache was relieved after the surgery. This rare case of adult posttraumatic leptomeningeal cyst occurred within an unusually short period after trauma, and was associated with a small and round bone defect and small dural defect usually characteristic of congenital arachnoid cyst.

Ruptured pseudoaneurysm following Gamma Knife surgery for a vestibular schwannoma.

A 75-year-old woman underwent Gamma Knife surgery (GKS) for a vestibular schwannoma. Eight years after GKS, she suffered sudden onset of headache. Computed tomography revealed diffuse subarachnoid hemorrhage around the cisterns of the posterior fossa. Right vertebral artery angiography showed an aneurysm arising from the lateral pontomedullary segment of the left anterior inferior cerebellar artery. The aneurysm was not located at a branching site. Trapping of the distal anterior inferior cerebellar artery aneurysm was performed, and the aneurysm was removed. The pathological features of this aneurysm are discussed. This aneurysm was diagnosed as a pseudoaneurysm pathologically. This is the first report of aneurysm formation with pathological findings following GKS for a vestibular schwannoma.