Levetiracetam versus fosphenytoin as a second-line treatment after diazepam for adult convulsive status epilepticus: a multicentre non-inferiority randomised control trial.

OBJECTIVE: Status epilepticus (SE) is an emergency condition for which rapid and secured cessation is crucial. Although fosphenytoin (FPHT) is recommended as a second-line treatment, levetiracetam (LEV) reportedly has similar efficacy, but higher safety. Therefore, we herein compared LEV with FPHT in adult SE. METHODS: We initiated a multicentre randomised control trial in emergency departments with adult patients with convulsive SE. Diazepam was initially administered, followed intravenously by FPHT at 22.5 mg/kg or LEV at 1000-3000 mg. The primary outcome was assigned as the seizure cessation rate within 30 min of the administration of the study drug. RESULTS: A total of 176 adult patients with SE were enrolled (82 FPHT and 94 LEV), and 3 were excluded from the full analysis set. Seizure cessation rates within 30 min were 83.8% (67/80) in the FPHT group and 89.2% (83/93) in the LEV group. The difference in these rates was 5.5% (95% CI -4.7 to 15.7, p=0.29). The non-inferiority of LEV to FPHT was confirmed with p<0.001 by the Farrington-Manning test. No significant differences were observed in the seizure recurrence rate or intubation rate within 24 hours. Serious adverse events developed in three patients in the FPHT group and none in the LEV group (p=0.061). CONCLUSION: The efficacy of LEV was similar to that of FPHT for adult SE following the administration of diazepam. LEV may be recommended as a second-line treatment for SE along with phenytoin/FPHT. TRIAL REGISTRATION NUMBER: jRCTs031190160.

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

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

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

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

Supervised Myoelectrical Hand Gesture Recognition in Post-Acute Stroke Patients with Upper Limb Paresis on Affected and Non-Affected Sides.

In clinical practice, acute post-stroke paresis of the extremities fundamentally complicates timely rehabilitation of motor functions; however, recently, residual and distorted musculoskeletal signals have been used to initiate feedback-driven solutions for establishing motor rehabilitation. Here, we investigate the possibilities of basic hand gesture recognition in acute stroke patients with hand paresis using a novel, acute stroke, four-component multidomain feature set (ASF-4) with feature vector weight additions (ASF-14NP, ASF-24P) and supervised learning algorithms trained only by surface electromyography (sEMG). A total of 19 (65.9 ± 12.4 years old; 12 men, seven women) acute stroke survivors (12.4 ± 6.3 days since onset) with hand paresis (Brunnstrom stage 4 ± 1/4 ± 1, SIAS 3 ± 1/3 ± 2, FMA-UE 40 ± 20) performed 10 repetitive hand movements reflecting basic activities of daily living (ADLs): rest, fist, pinch, wrist flexion, wrist extension, finger spread, and thumb up. Signals were recorded using an eight-channel, portable sEMG device with electrode placement on the forearms and thenar areas of both limbs (four sensors on each extremity). Using data preprocessing, semi-automatic segmentation, and a set of extracted feature vectors, support vector machine (SVM), linear discriminant analysis (LDA), and k-nearest neighbors (k-NN) classifiers for statistical comparison and validity (paired t-tests, p-value < 0.05), we were able to discriminate myoelectrical patterns for each gesture on both paretic and non-paretic sides. Despite any post-stroke conditions, the evaluated total accuracy rate by the 10-fold cross-validation using SVM among four-, five-, six-, and seven-gesture models were 96.62%, 94.20%, 94.45%, and 95.57% for non-paretic and 90.37%, 88.48%, 88.60%, and 89.75% for paretic limbs, respectively. LDA had competitive results using PCA whereas k-NN was a less efficient classifier in gesture prediction. Thus, we demonstrate partial efficacy of the combination of sEMG and supervised learning for upper-limb rehabilitation procedures for early acute stroke motor recovery and various treatment applications.

Exercise training using hybrid assistive limb (HAL) lumbar type for locomotive syndrome: a pilot study.

BACKGROUND: With a rapidly aging population in Japan, locomotive syndrome is becoming an increasingly serious social problem. Exercise therapy using the lumbar type HAL, which is a wearable robot suit that can assist voluntary hip joint motion, would be expected to cause some beneficial effects for people with locomotive syndrome. The purpose of this study was to assess whether the deterioration of low back pain and any other adverse events would occur following HAL exercise therapy. Moreover, the changes of motor ability variables were evaluated. METHODS: We enrolled 33 participants (16 men, 17 women) with locomotive syndrome in this study. They received exercise training (sit-to-stand, lumbar flexion-extension, and gait training) with HAL (in total 12 sessions). We assessed the change of low back pain (lumbar VAS). More than 50% and 25 mm increase compared to baseline was defined as adverse events. One-leg standing time (OLST), 10-m walking test (10MWT), Timed Up and Go test (TUG), 1-min sit-to-stand test (1MSTS), FIM mobility scores and EQ-5D were measured. RESULTS: Of the 33 participants, 32 (16 men, 16 women) (97.0%) completed all 12 exercise training sessions using the lumbar type HAL. One woman aged 82 years withdrew because of right upper limb pain after the second session regardless of the use of HAL. There was no participant who had deterioration of low back pain. Any other adverse events including external injuries and/or falling, skin disorders, uncontrollable cardiovascular or respiratory disorders, and other health disorders directly related to this exercise therapy did not occur. Several outcome measures of motion ability including OLST, TUG and 1MSTS, EQ VAS and lumbar pain improved significantly after this HAL training. CONCLUSIONS: Almost all patients with locomotive syndrome completed this exercise training protocol without any adverse events related to HAL. Furthermore, balance function variables including OLST, TUG and 1MSTS improved after this HAL exercise therapy even though mobility function variables including 10MWT and FIM mobility scores did not show any significant change. These findings suggest that the exercise therapy using the lumbar type HAL would be one of the options for the intervention in locomotive syndrome.

Improving the neurological prognosis following OHCA using real-time evaluation of cerebral tissue oxygenation.

BACKGROUND: The neurological prognosis is poor for patients suffering from out-of-hospital cardiac arrest (OHCA), in the absence of bystander cardio pulmonary resuscitation (CPR), and showing asystole as the initial waveform. However, such patients have the potential of resuming social activity if cerebral tissue oxygen saturation can be preserved. CASE PRESENTATION: We recently encountered a 60-year-old man who had suffered an OHCA in the absence of bystander CPR, and who successfully resumed complete social activity despite initial asystole and requiring at least 75min of chest compressions before return of spontaneous circulation (ROSC). In this case, chest compression was appropriately performed concurrently with real-time evaluation of cerebral tissue oxygenation using near-infrared spectroscopy (NIRS). As a result, the cerebral tissue oxygenation was well maintained, leading to resumption of social activity. CONCLUSIONS: Improved neurological prognoses can be expected if OHCA patients with the potential for social activity resumption are identified, using NIRS, and effective cardiopulmonary and cerebral resuscitation is performed while visually checking CPR quality.

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

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

Neurovascular Unit Protection From Cerebral Ischemia-Reperfusion Injury by Radical-Containing Nanoparticles in Mice.

BACKGROUND AND PURPOSE: Reperfusion therapy by mechanical thrombectomy is used to treat acute ischemic stroke. However, reactive oxygen species generation after reperfusion therapy causes cerebral ischemia-reperfusion injury, which aggravates cerebral infarction. There is limited evidence for clinical efficacy in stroke for antioxidants. Here, we developed a novel core-shell type nanoparticle containing 4-amino-4-hydroxy-2,2,6,6-tetramethylpiperidine-1-oxyl (nitroxide radical-containing nanoparticles [RNPs]) and investigated its ability to scavenge reactive oxygen species and confer neuroprotection. METHODS: C57BL/6J mice underwent transient middle cerebral artery occlusion and then received RNPs (9 mg/kg) through the common carotid artery. Infarction size, neurological scale, and blood-brain barrier damage were visualized by Evans blue extravasation 24 hours after reperfusion. RNP distribution was detected by rhodamine labeling. Blood-brain barrier damage, neuronal apoptosis, and oxidative neuronal cell damage were evaluated in ischemic brains. Multiple free radical-scavenging capacities were analyzed by an electron paramagnetic resonance-based method. RESULTS: RNPs were detected in endothelial cells and around neuronal cells in the ischemic lesion. Infarction size, neurological scale, and Evans blue extravasation were significantly lower after RNP treatment. RNP treatment preserved the endothelium and endothelial tight junctions in the ischemic brain; neuronal apoptosis, O2- production, and gene oxidation were significantly suppressed. Reactive oxygen species scavenging capacities against OH, ROO, and O2- improved by RNP treatment. CONCLUSIONS: An intra-arterial RNP injection after cerebral ischemia-reperfusion injury reduced blood-brain barrier damage and infarction volume by improving multiple reactive oxygen species scavenging capacities. Therefore, RNPs can provide neurovascular unit protection.

Myoblast-mediated gene therapy improves functional collateralization in chronic cerebral hypoperfusion.

BACKGROUND AND PURPOSE: Direct extracranial-intracranial bypass surgery for treatment of cerebral hemodynamic compromise remains hindered by complications but alternative simple and safe indirect revascularization procedures, such as an encephalomyosynangiosis (EMS), lack hemodynamic efficiency. Here, the myoblast-mediated transfer of angiogenic genes presents an approach for induction of therapeutic collateralization. In this study, we tested the effect of myoblast-mediated delivery of vascular endothelial growth factor-A (VEGF) to the muscle/brain interface of an EMS in a model of chronic cerebral hypoperfusion. METHODS: Permanent unilateral internal carotid artery-occlusion was performed in adult C57/BL6 mice with or without (no EMS) surgical grafting of an EMS followed by implantation of monoclonal mouse myoblasts expressing either VEGF164 or an empty vector (EV). Cerebral hemodynamic impairment, transpial collateralization, angiogenesis, mural cell investment, microvascular permeability, and cortical infarction after ipsilateral stroke were assessed by real-time laser speckle blood flow imaging, 2- and 3-dimensional immunofluorescence and MRI. RESULTS: VEGF-expressing myoblasts improved hemodynamic rescue by day 14 (no EMS 37±21%, EV 42±9%, VEGF 48±12%; P<0.05 for VEGF versus no EMS and versus EV), together with the EMS take rate (VEGF 60%, EV 18.2%; P<0.05) and angiogenesis of mature cortical microvessels below the EMS (P<0.05 for VEGF versus EV). Importantly, functional and morphological results were paralleled by a 25% reduction of cortical infarction after experimental stroke on the side of the EMS. CONCLUSIONS: Myoblast-mediated VEGF supplementation at the target site of an EMS could help overcome the clinical dilemma of poor surgical revascularization results and provide protection from ischemic stroke.

Temporal Muscle Swelling after Clipping Surgery with Frontotemporal Craniotomy Is Associated with Immediate Postcraniotomy Headache.

Immediate postcraniotomy headache frequently occurs within the first 48 h after surgery. The mechanisms underlying immediate postcraniotomy headache are not yet fully understood, and effective treatments are not yet established. This study aimed to identify the factors associated with immediate postcraniotomy headache in patients who underwent clipping surgery with frontotemporal craniotomy and to examine the effects of these factors on postcraniotomy headache. A total of 51 patients were included in this study. Immediate postcraniotomy headache was defined as pain with numerical rating scale score ≥4 on postoperative day 7. Sixteen patients (31.4%) had immediate postcraniotomy headache. The headache-positive group had a higher incidence of preoperative analgesic use (50.0% vs. 5.7%, respectively, p < 0.001), increased temporal muscle swelling ratio (137.0%±30.2% vs. 112.5%±30.5%, respectively, p = 0.01), and higher postoperative analgesic use (12.9±5.8 vs. 6.7±5.2, respectively, p < 0.001) than the headache-negative group. The risk factors independently associated with immediate postcraniotomy headache were preoperative analgesic use and temporal muscle swelling by >115.15% compared with the contralateral side in the receiver operating characteristic analysis. Postcraniotomy headache was significantly more common in patients with preoperative analgesic use and temporal muscle swelling than in those without (p < 0.001 and p = 0.002, respectively). Altogether, patients with immediate postcraniotomy headache had greater preoperative analgesic use, greater temporal muscle swelling ratio, and higher postoperative analgesic use than those without. Thus, temporal muscle swelling is a key response to immediate postcraniotomy headache.

Image Quality Evaluation for Brain Soft Tissue in Neuro -endovascular Treatment by Dose-reduction Mode of Dual-axis "Butterfly" Scan.

BACKGROUND AND PURPOSE: Flat-panel cone-beam CT (CBCT) is essential for detecting hemorrhagic complications during neuroendovascular treatments. Despite its superior image quality and trajectory over conventional CBCT (Circular scan), dual-axis butterfly scan incurs a slightly higher radiation dose relative to conventional CBCT. This study evaluates the image quality in dose-reduction mode to uncover the appropriate radiation dose for the butterfly scan. MATERIALS AND METHODS: We prospectively included patients who scheduled neuroendovascular treatment and performed conventional CBCT and dose-reduction mode of the butterfly scan. Two reduced radiation dose modes were utilized for the butterfly scan: medium-dose butterfly scan (70% of the original dose, 45 mGy) or low-dose butterfly scan (50% of the original dose, 30 mGy). The enrolled patients were assigned alternately to receive either the medium-or low-dose butterfly scan. We evaluated and compared artifacts, contrast, and discrimination of the corticomedullary junction between conventional CBCT and one of the dose-reduction modes of the butterfly scan, with a 5-point scale scoring system. RESULTS: Twenty patients were enrolled in each of the medium-and low-dose groups, totaling 40 patients. Compared to conventional CBCT, the medium-dose butterfly group exhibited reduced artifacts, enhanced contrast, and discriminated corticomedullary junction (except in the occipital lobe). While the low-dose butterfly group exhibited markedly reduced artifacts and improved contrast (except in the occipital lobe), a significant improvement in corticomedullary junction discrimination was unobserved. CONCLUSIONS: Even with dose reduction, the specialized trajectory of the butterfly scan enables artifact reduction, contrast improvement, and enhanced corticomedullary junction discrimination. However, the impact of the reduced dose was more noticeable, particularly in the occipital region where susceptibility to bone interference resulted in decreased contrast and compromised corticomedullary junction discrimination. ABBREVIATIONS: AVM=arteriovenous malformation, CBCT=cone-beam CT, CAS=carotid artery stenting, CTDI=CT dose index, DAVF=dural arteriovenous fistula, FD=flow diverter,PTAS=percutaneous transluminal angioplasty and stenting.

Targeted Transarterial Embolization for Treatment of a Symptomatic Venous Varix in the Draining Vein of an Arteriovenous Malformation: Case Report and Literature Review.

BACKGROUND: Venous varices in the draining vein of arteriovenous malformations (AVMs) can result in compression symptoms. This condition is extremely rare, and its treatments and long-term outcomes are unresolved. Herein, we describe the treatment of a thrombosed venous varix in a draining vein and review the relevant literature. PATIENT: The patient presented with progressive right-sided hemiparalysis and aphasia. Magnetic resonance imaging revealed flow void accumulation from the corpus callosum to the left ventricle and a 30-mm mass in the left putamen. The patient underwent targeted transarterial embolization to reduce the blood flow to the venous varix and relieve the neurological symptoms. The patient had recovered completely from the right hemiparesis and aphasia 4 years after treatment, with a modified Rankin Scale score of 0. CONCLUSION: Targeted transarterial embolization for symptomatic venous varix is a palliative treatment that may improve long-term functional outcomes.

Transient Hemichorea-hemiballism Induced by a Combination of Postprandial Hypotension and Severe Stenosis of the Innominate Artery Concomitant with Left Carotid Occlusion.

Hemichorea-hemiballism (HCHB) due to transient ischemic attacks (TIAs) is rare. An 83-year-old woman had repeated episodes of right-sided HCHB for 3 months. Magnetic resonance (MR) angiography demonstrated occlusion of the left carotid and middle cerebral arteries and severe stenosis of the innominate artery, and 24-hour ambulatory blood pressure monitoring showed a blood pressure decrease of >20 mmHg after each meal. We speculated that HCHB developed as TIAs due to hemodynamic failure in the left cerebral hemisphere, caused by a combination of severe stenosis of the innominate artery concomitant with occlusion of the left carotid and middle cerebral arteries as well as postprandial hypotension.

Additional outlet occlusion as an important factor in avoiding retreatment after transvenous embolization for cavernous sinus dural arteriovenous fistulas.

BACKGROUND: Transvenous embolization (TVE), such as selective shunt occlusion, is the first line treatment for cavernous sinus dural arteriovenous fistula (CSDAVF). Despite the favorable outcomes of TVE, some cases necessitating retreatment due to recurrence or incomplete occlusion persist. Given the physical, psychological, and financial burden of multiple treatments, understanding the predictive factors for recurrence, spontaneous occlusion, or retreatment is important. However, few reports have addressed these factors, complicating decision making regarding the need for retreatment. This study analyzed predictive factors for retreatment and spontaneous occlusion to offer new insights into CSDAVF management. METHODS: This retrospective, observational study was conducted in two acute care hospitals. Patients aged 18-100 years undergoing endovascular treatment for CSDAVF from January 2011 to December 2022 were included. RESULTS: Of 65 patients treated with TVE, 29 experienced immediate complete occlusion. Meanwhile, 22 of 36 patients with incomplete occlusion had spontaneous occlusion, and retreatment was performed in 20% of patients. Additional outlet occlusion was negatively associated with retreatment (P=0.046), and it tended to promote spontaneous occlusion (P=0.056). Favorable functional outcomes were observed in all patients, and approximately 94% of patients showed complete occlusion at the latest follow-up. CONCLUSION: TVE is an effective treatment for CSDAVF. Outlet occlusion, when immediate complete occlusion is unattainable, is important to reduce retreatment and promote spontaneous occlusion. Substantially reducing shunt flow, carefully assessing dangerous drainage routes, and closely monitoring the residual shunt are crucial for preventing intracranial hemorrhage when outlet occlusion is performed.

Anatomical Flow Diversion by Hybrid Strategy for Intractable Large Cerebral Aneurysms.

BACKGROUND AND IMPORTANCE: Flow diverters (FDs) provide curative endovascular treatment for wide-necked sidewall aneurysms. The efficacy of FDs for bifurcation or branching sidewall aneurysms is probably limited. We used anatomical flow diversion (AFD) for intractable large cerebral aneurysms. We report our experiences with AFD. METHODS: The concept of AFD is the transformation from the bifurcation or branching sidewall type to the nonbranching sidewall type. Linearization of the parent artery by stenting, intentional branch occlusion, and aneurysmal coil embolization were performed. Furthermore, bypass surgery is performed for patients intolerant to branch occlusions. We evaluated the clinical outcomes of intractable aneurysms treated with AFD. RESULTS: AFD was performed in seven unruptured large aneurysms. Aneurysmal locations were the top of the basilar artery (BA), BA-superior cerebellar artery (SCA), internal carotid artery (IC)-posterior communicating artery (PcomA), and IC terminal. The mean dome diameter was 17.0 ± 4.6 mm. Six patients underwent bypass surgery. The occluded branches were the PCA + SCA, PcomA, and anterior cerebral artery (ACA) A1. An FD was used in three patients and a neck bridge stent in four patients. No intraprocedural complications occurred. Two postprocedural ischemic complications occurred in one patient. Six (86%) patients demonstrated a modified Rankin Scale (mRS) 0 at the 3-month follow-up, and one with an ischemic complication showed an mRS 5. Complete occlusion of all aneurysms was maintained with a median follow-up duration of 60 months. CONCLUSION: AFD is useful for intractable large cerebral aneurysms with high curability, although safety verification is required.

Spontaneous asymptomatic common carotid artery dissection resembling a carotid web: illustrative case.

BACKGROUND: Carotid artery dissection is a common cause of ischemic stroke, predominantly affecting the internal carotid artery, with rare involvement of the common carotid artery (CCA). The limited literature makes diagnosis and management challenging, particularly in asymptomatic patients. In this report, the authors present a unique case of spontaneous, asymptomatic CCA dissection that resembled a carotid web, shedding light on its clinical spectrum and management. OBSERVATIONS: A 70-year-old man was diagnosed with an intimal flap in the left CCA. Although the findings resembled those of a carotid web, cerebral angiography confirmed the presence of an intimal flap and arterial wall irregularities indicative of vascular dissection. Endarterectomy successfully prevented the stroke, and the postoperative recovery was uneventful. Pathological examination confirmed the diagnosis of CCA dissection. LESSONS: Spontaneous CCA dissection, though rare, presents significant diagnostic and therapeutic challenges. Because of morphological similarities, differentiating the diagnosis from a carotid web can be difficult. Available treatment strategies include antiplatelet therapy and surgical intervention. In this case, endarterectomy was chosen to avoid antithrombic treatment in anticipation of further invasive treatments for other conditions. The successful outcome highlights the potential as a treatment option, emphasizing the need for an individualized approach to each patient. https://thejns.org/doi/10.3171/CASE24344.

Endovascular electroencephalography (eEEG) can detect the laterality of epileptogenic foci as accurately as subdural electrodes.

Background: Traditional brain activity monitoring via scalp electroencephalography (EEG) offers limited resolution and is susceptible to artifacts. Endovascular electroencephalography (eEEG) emerged in the 1990s. Despite early successes and potential for detecting epileptiform activity, eEEG has remained clinically unutilized. This study aimed to further test the capabilities of eEEG in detecting lateralized epileptic discharges in animal models. We hypothesized that eEEG would be able to detect lateralization. The purpose of this study was to measure epileptiform discharges with eEEG in animal models with lateralization in epileptogenicity. Materials and methods: We inserted eEEG electrodes into the transverse sinuses of three pigs, and subdural electrodes (SDs) on the surfaces of the left and right hemispheres. We induced epileptogenicity with penicillin in the left brain of pigs F00001 and F00003, and in the right brain of pig F00002. The resulting epileptiform discharges were measured by eEEG electrodes placed in the left and right transverse sinuses, and conducted comparisons with epileptiform discharges from SDs. We also had 12 neurological physicians interpret measurement results from eEEG alone and determine the side (left or right) of epileptogenicity. Results: Three pigs were evaluated for epileptiform discharge detection using eEEG: F00001 (7 months old, 14.0 kg), F00002 (8 months old, 15.6 kg), and F00003 (8 months old, 14.4 kg). The eEEG readings were compared with results from SDs, showing significant alignment across all subjects (p < 0.001). The sensitivity and positive predictive values (PPV) were as follows: F00001 had 0.93 and 0.96, F00002 had 0.99 and 1.00, and F00003 had 0.98 and 0.99. Even though one of the neurological physicians got all sides incorrect, all other assessments were correct. Upon post-experimental dissection, no abnormalities were observed in the brain tissue or in the vascular damage at the site where the eEEG was placed, based on pathological evaluation. Conclusion: With eEEG, lateralization can be determined with high sensitivity (>0.93) and PPV (>0.95) that appear equivalent to those of subdural EEG in the three pigs. This lateralization was also discernible by neurological physicians on visual inspection.

Hidden Bow Hunter's Syndrome Diagnosed Using Dynamic Cerebral Angiography and Successfully Treated with Spinal Surgery: A Case Report and Review of the Literature.

Hidden bow hunter's syndrome (HBHS) is a rare disease in which the vertebral artery (VA) occludes in a neutral position but recanalizes in a particular neck position. We herein report an HBHS case and assess its characteristics through a literature review. A 69-year-old man had repeated posterior-circulation infarcts with right VA occlusion. Cerebral angiography showed that the right VA was recanalized only with neck tilt. Decompression of the VA successfully prevented stroke recurrence. HBHS should be considered in patients with posterior circulation infarction with an occluded VA at its lower vertebral level. Diagnosing this syndrome correctly is important for preventing stroke recurrence.

Sequencing-based study of neural induction of human dental pulp stem cells.

Techniques for triggering neural differentiation of embryonic and induced pluripotent stem cells into neural stem cells and neurons have been established. However, neural induction of mesenchymal stem cells, including dental pulp stem cells (DPSCs), has been assessed primarily based on neural-related gene regulation, and detailed studies into the characteristics and differentiation status of cells are lacking. Therefore, this study was aimed at evaluating the cellular components and differentiation pathways of neural lineage cells obtained via neural induction of human DPSCs. Human DPSCs were induced to neural cells in monolayer culture and examined for gene expression and mechanisms underlying differentiation using microarray-based ingenuity pathway analysis. In addition, the neural lineage cells were subjected to single-cell RNA sequencing (scRNA-seq) to classify cell populations based on gene expression profiles and to elucidate their differentiation pathways. Ingenuity pathway analysis revealed that genes exhibiting marked overexpression, post-neuronal induction, such as FABP7 and ZIC1, were associated with neurogenesis. Furthermore, in canonical pathway analysis, axon guidance signals demonstrated maximum activation. The scRNA-seq and cell type annotations revealed the presence of neural progenitor cells, astrocytes, neurons, and a small number of non-neural lineage cells. Moreover, trajectory and pseudotime analyses demonstrated that the neural progenitor cells initially engendered neurons, which subsequently differentiated into astrocytes. This result indicates that the aforementioned neural induction strategy generated neural stem/progenitor cells from DPSCs, which might differentiate and proliferate to constitute neural lineage cells. Therefore, neural induction of DPSCs may present an alternative approach to pluripotent stem cell-based therapeutic interventions for nervous system disorders.