Aneurysmectomy and graft interposition for giant thrombosed proximal internal carotid artery aneurysm: Technical details.

A giant thrombosed extracranial internal carotid artery aneurysm (ECCA) is extremely rare and its treatment is challenging. Despite the advance of endovascular technique, open surgery is still considered a first-line treatment in giant thrombosed ECCA. We describe a case of giant thrombosed ECCA which was successfully treated by aneurysmectomy and graft interposition with the technical details.

Development of a Pedicle Screw Fixation Simulation Model for Surgical Training Using a 3-Dimensional Printer.

OBJECTIVE: Training surgeons in pedicle screw fixation (PSF) techniques during actual surgery is limited because of patient safety, complications, and surgical efficiency issues. Recent technical developments are leading the world to an era of personalized three-dimensional (3D) printing. This study aimed to evaluate the educational effect of using a 3D-printed spine model to train beginners in PSF techniques to improve screw accuracy and procedure time. METHODS: Computed tomography (CT) scan data were used in a 3D printer to produce a life-size lumbar spine replica of L1-3 vertebrae. Four residents performed PSF thrice. Each resident performed 18 screw fixations on both sides (6 screws per trial). The time to complete the procedure and pedicle violation was recorded. RESULTS: The average time for the 3 procedures was 42.1±2.9 minutes, 38.8±3.3 minutes, and 32.1±2.5 minutes, respectively. Furthermore, the average pedicle screw score for the 3 procedures was 13.0±0.8, 14.5±0.6, and 16.0±0.8, respectively. As the trial was repeated, the procedure time decreased and the accuracy of screw fixation tended to be more accurate. CONCLUSIONS: It was possible to decrease the procedure time and increase accuracy through repeated training using the 3D-printed spine model. By implementing a 3Dprinted spine model based on the patient's actual CT data, surgeons can perform simulation surgery before the actual surgery. Therefore, this technology can be useful in educating residents to improve their surgical skills.

The serpentine pattern on MRI as an early prognostic factor after fusion for lumbar spinal stenosis.

This study aimed to determine the relationship between the serpentine pattern nerve roots (SNR) and prognosis after lumbar fusion for lumbar spinal stenosis (LSS) by comparing clinical outcomes in patients with or without a serpentine pattern. LSS patients with neurological symptoms often present with SNRs. Several studies have shown that LLS symptoms are worse in patients with SNRs. However, the relationship between SNR and outcome after spinal fusion surgery has not yet been established. A total of 332 patients who underwent spinal fusion surgery between January 1, 2010, and December 31, 2019, were enrolled. Patients were divided into those with a serpentine pattern (S group) and those without a serpentine pattern (N group). The prognosis of the 2 groups was compared using visual analog scale (VAS), Oswestry disability index, claudication distance, medication dose for leg dysesthesia, and glucose tolerance. A total of 113 patients had a serpentine pattern, while the remaining 219 did not. Symptom duration and presence of diabetes mellitus were significantly different between the 2 groups (N = 25.4, S = 32.6, P < .05). Changes in the VAS score for lower extremity pain between the 2 groups at 1 year after surgery showed that patients without a serpentine pattern had significantly better outcomes than those with a serpentine pattern (N: 2.7 ±â€…1.1 vs S: 4.1 ±â€…1.3; P < .001), despite the score change at 1 month showing no difference (N: 3.5 ±â€…0.9 vs S: 3.8 ±â€…1.0; P = .09). SNRs on MRI are more prevalent in diabetic patients and are a negative prognostic factor in lumbar fusion surgery for LSS. Our insights may help physicians decide the optimal surgical plan and predict the postoperative prognosis of patients with LSS.

Modified Glasgow coma scale for predicting outcome after subarachnoid hemorrhage surgery.

ABSTRACT: There are many grading scales that attempt to predict outcome following aneurysmal subarachnoid hemorrhage (aSAH). Most scales used to assess outcome are based on the neurological status of the patient. Here, we propose a new scale for aSAH patients that combines the Glasgow Coma Scale (GCS) and the modified Fisher scale (mFS).Five hundred ninety-seven patients with aSAH who were treated at our institution between January 2008 and December 2017 were retrospectively analyzed. Initial GCS score, Hunt and Hess scale, World Federation of Neurosurgical Societies scale, mFS, and modified Rankin Scale were obtained by reviewing data. Incidence of vasospasm was investigated. Factors found to be significant on a multivariable regression analysis were used to develop a scale that was compared with other grading systems using the area under the curve (AUC) calculated from receiver operating characteristic curve.The GCS score and mFS were related to outcomes in patients with aSAH. A simple score, which we call the GCS-F score, was calculated using these initial data. The GCS-F score had an AUC of 90.5% for unfavorable outcome prediction, and 88.4% for in-hospital mortality prediction. On the receiver operating characteristic curve analysis for vasospasm, the AUC for World Federation of Neurosurgical Societies, mFS and GCS-F scores were 0.912, 0.704, and 0.936, respectively.A simple arithmetic combination of the GCS score and mFS, the GCS-F score, includes the radiographic status as well as the clinical status of the patient, so that the state of the patient can be known in more detail than other single scales. The GCS-F score may be a useful scale for predicting outcome and the occurrence of vasospasm in patients with aSAH.

Relationship between the atlantodental interval and T1 slope after atlantoaxial fusion in patients with rheumatoid arthritis.

BACKGROUND: Atlantoaxial fusion has been widely used for the treatment of atlantoaxial instability (AAI). However, atlantoaxial fusion sacrifices the motion of atlantoaxial articulation, and postoperative loss of cervical lordosis and aggravation of cervical kyphosis are observed. We investigated various factors under the hypothesis that the atlantodental interval (ADI) and T1 slope may be associated with sagittal alignment after atlantoaxial fusion in patients with rheumatoid arthritis (RA). METHODS: We retrospectively investigated 64 patients with RA who underwent atlantoaxial fusion due to AAI. Radiological factors, including the ADI, T1 slope, Oc-C2 angle, cervical sagittal vertical axis, and C2-C7 angle, were measured before and after surgery. RESULTS: The various factors associated with atlantoaxial fusion before and after surgery were compared according to the upper and lower preoperative ADIs. There was a significant difference in the T1 slope 1 year after surgery (p = 0.044) among the patients with lower preoperative ADI values. The multivariate logistic regression analysis showed that the preoperative ADI (> 7.92 mm) defined in the receiver-operating characteristic curve analysis was an independent predictive factor for the increase in the T1 slope 1 year after atlantoaxial fusion (odds ratio, 4.59; 95% confidence interval, 1.34-15.73; p = 0.015). CONCLUSION: We found an association between the preoperative ADI and difference in the T1 slope after atlantoaxial fusion in the patients with RA. A preoperative ADI (> 7.92 mm) was an independent predictor for the increase in the T1 slope after atlantoaxial fusion. Therefore, performing surgical treatment when the ADI is low would lead to better cervical sagittal alignment.

Effects of Possible Osteoporotic Conditions on the Recurrence of Chronic Subdural Hematoma.

The recurrence rate of chronic subdural hematoma (CSDH) has been reported to range from 2.3 to 33%. As bridging veins are composed of abundant collagen bundles and bone matrix, we aimed to investigate the possible associations between skull Hounsfield unit (HU) values and the recurrence of CSDH. We retrospectively enrolled patients with CSDH who underwent burr hole surgery. The HU values of the frontal skull were measured on brain CT scans. The cumulative hazard for recurrence was estimated according to predictive factors. To identify the independent predictors associated with the recurrence of CSDH, hazard ratios (HRs) were estimated using multivariate Cox regression analysis. A total of 208 consecutive patients who underwent burr hole trephination for CSDH over a 7-years period at a single institution were enrolled in this study. We found that age, greater midline shift (≥10.5 mm), lower skull HU (<769.5), and diabetes were independent predictors for the recurrence of CSDH (HR 1.06, 95% confidence interval [CI] 1.00-1.12, p = 0.042; HR 5.37, 95% CI 1.48-19.46, p = 0.010; HR 6.71, 95% CI 1.84-24.45, p = 0.004; and HR 3.30, 95% CI 1.05-10.43, p = 0.042, respectively). A relationship between possible low bone mineral density (BMD) and CSDH recurrence was observed. In addition, age, greater preoperative midline shift, and diabetes were also identified as predictive factors for recurrence. We expect that our findings may facilitate our understanding of the possible association between CSDH and BMD.

Influence of Triggering Events on the Occurrence of Spontaneous Intracranial Hemorrhage : Comparison of Non-Lesional Spontaneous Intraparenchymal Hemorrhage and Aneurysmal Subarachnoid Hemorrhage.

OBJECTIVE: Spontaneous intracranial hemorrhage is a life-threatening disease, and non-lesional spontaneous intraparenchymal hemorrhage (nIPH) and aneurysmal subarachnoid hemorrhage (aSAH) are the leading causes of spontaneous intracranial hemorrhage. Only a few studies have assessed the association between prior physical activity or triggering events and the occurrence of nIPH or aSAH. The purpose of this study is to investigate the role of specific physical activities and triggering events in the occurrence of nIPH and aSAH. METHODS: We retrospectively reviewed 824 consecutive patients with spontaneous intracranial hemorrhage between January 2010 and December 2018. Among the 824 patients, 132 patients were excluded due to insufficient clinical data and other etiologies of spontaneous intracranial hemorrhage. The medical records of 692 patients were reviewed, and the following parameters were assessed : age, sex, history of hypertension, smoking, history of stroke, use of antiplatelet or anticoagulation agents, season and time of onset, physical activities performed according to the metabolic equivalents, and triggering event at onset. Events that suddenly raised the blood pressure such as sudden postural changes, defecation or urination, sexual intercourse, unexpected emotional stress, sauna bath, and medical examination were defined as triggering events. These clinical data were compared between the nIPH and aSAH groups. RESULTS: Both nIPH and aSAH most commonly occurred during non-strenuous physical activity, and there was no significant difference between the two groups (p=0.524). Thirty-two patients (6.6%) in the nIPH group and 39 patients (8.1%) in the aSAH group experienced triggering events at onset, and there was a significant difference between the two groups (p=0.034). The most common triggering events were defecation or urination in both groups. CONCLUSION: Specific physical activity dose no affect the incidence of nIPH and aSAH. The relationship between the occurrence of intracranial hemorrhage and triggering events is higher in aSAH than nIPH.

Association between cerebral atrophy and osteoporotic vertebral compression fractures.

PURPOSE: Osteoporotic vertebral compression fractures (OVCFs) have a serious impact on people's health and quality of life. The purpose of this study was to analyze brain volume in patients with osteoporosis using brain magnetic resonance imaging (MRI) and to investigate the relationship with osteoporotic vertebral compression fractures. MATERIALS AND METHODS: We included 246 patients with osteoporosis who underwent thoracolumbar radiographs and brain MRI at our hospital. Clinical data on age, sex, bone mineral density, height, weight, osteoporosis medication, hypertension, diabetes, alcohol drinking, and smoking were collected. Intracranial cavity, brain parenchyma, and lateral ventricles volumes were measured using brain MRI with a semiautomated tool. RESULTS: We founded an independent correlation between age and volume percentages of the brain parenchyma and lateral ventricles. We observed a statistically significant decrease in volume percentage of the brain parenchyma and an increase in volume percentage of the lateral ventricles with increasing age. In addition, we confirmed that patients with OVCF showed a significantly lower volume percentage of brain parenchyma than patients without OVCF. CONCLUSION: We observed a significant association between OVCF and volume percentage of brain parenchyma. Degeneration of the brain may lead to a high incidence of falls, and OVCF may occur more frequently in patients with osteoporosis.

Correlation of survivin and B-cell lymphoma 2 expression with pathological malignancy and anti-apoptotic properties of glial cell tumors.

Apoptosis, whose mechanism remains unclear, is regulated by multiple factors. B-cell lymphoma 2 (Bcl-2) is a well-known anti-apoptotic mediator. Survivin is also a recently recognized novel family inhibitor of apoptosis protein, which inhibits apoptosis via a pathway distinct from Bcl-2 family members. Survivin and Bcl-2 are expressed in various types of human cancer. In the present study, survivin and Bcl-2 expression were characterized in glial cell tumors, and the correlation with pathological malignancy and anti-apoptotic properties were investigated. Fifty-eight patients who had undergone surgical resection for glial cell tumors were evaluated. The pathological types of glial cell tumors were categorized according to the World Health Organization classification. Survivin and Bcl-2 expression levels were investigated by western blot analysis, and apoptosis was detected by DNA fragmentation analysis. The anti-apoptotic rate of glial cell tumors was calculated in tumor samples according to the expression of survivin and Bcl-2 or co-expression. Survivin was characterized in 60.3%, and Bcl-2 was expressed in 43.1% of glioma samples. Co-expression of survivin and Bcl-2 was observed in 25.9% of the tumor specimens. Survivin expression in astrocytic tumors was identified to be significantly associated with the pathological grade (P<0.05); however, Bcl-2 was not (P>0.05). Anti-apoptotic rate of glial cell tumors were detected in 91.4, 92.0 and 100% of patients exhibiting survivin, Bcl-2 or co-expression, respectively. However, the difference in anti-apoptotic frequency between the three groups was not identified to be statistically significant (P>0.05). The present study suggests that survivin expression is correlated with pathological grades of gliomas. In addition, the expression of survivin or Bcl-2 exerts potent anti-apoptotic properties in gliomas. Thus, survivin or Bcl-2 may serve as potential targets for inducing the apoptosis of gliomas.