Three-dimensional Images Fusion Method Useful for Preoperative Simulation of Clipping Surgery for Cerebral Aneurysms.

This study aimed to introduce a three-dimensional (3D) images fusion method for preoperative simulation of aneurysm clipping. Consecutive unruptured aneurysm cases treated with surgical clipping from March 2021 to October 2023 were included. In all cases, preoperative images of plain computed tomography (CT), CT angiography, magnetic resonance imaging (MRI) 3D fluid-attenuated inversion recovery, 3D heavily T2-weighted images, and 3D rotational angiography were acquired and transported into a commercial software (Ziostation2 Plus, Ziosoft, Inc. Tokyo, Japan). The software provided 3D images of skull, arteries including aneurysms, veins, and brain tissue that were freely rotated, magnified, trimmed, and superimposed. Using the 3D images fusion method, two operators predicted clips to be used in the following surgery. The predicted clips and actually used ones were compared to give agreement scores for the following factors: (1) type of clips (simple or fenestrated), (2) shape of clips (straight, curved, angled, or bayonet), and (3) clipping strategy (single or multiple). The agreement score ranged from 0 to 3 because a score of 1 or 0 was given for agreement or disagreement on each factor. Interoperator reproducibility was also evaluated. During the study period, 44 aneurysms from 37 patients were clipped. All procedures were successfully completed, thanks to the precisely reproduced surgical corridors with the 3D images fusion method. Agreement in clip prediction was good with mean agreement score of 2.4. Interobserver reproducibility was also high with the kappa value of 0.79. The 3D images fusion method was useful for preoperative simulation of aneurysm clipping.

Traumatic middle meningeal arteriovenous fistula presenting with long delayed-onset facial nerve palsy without temporal bone fracture: illustrative case.

BACKGROUND: Traumatic facial nerve palsy (FNP) without temporal bone fracture (TBF) has a delayed onset in some cases; however, long delayed-onset FNP in this setting has not been reported. The middle meningeal vein (MMV) is one of the venous drainage routes from the facial nerve. Herein, the authors describe a rare case of traumatic middle meningeal arteriovenous fistula (MMAVF) presenting with the long delayed-onset FNP without TBF. OBSERVATIONS: A 42-year-old man with pulsatile tinnitus and left FNP was admitted to our hospital 4 weeks after head trauma without TBF. Cerebral angiography revealed an MMAVF between the middle meningeal artery and the MMV on the left side. Seven days after admission, the FNP showed slight improvement, and preoperative angiography revealed decreased shunt flow of the MMAVF. Transarterial coil embolization was successfully performed. Postoperative angiography showed no residual fistula. Two weeks after the procedure, there was complete resolution of the FNP. This clinical course was correlated with the angiographic findings, suggesting that the long delayed-onset FNP was caused by the traumatic MMAVF without TBF. LESSONS: In patients presenting with long delayed-onset FNP after head trauma without TBF, the vascular lesion must be evaluated to exclude MMAVF.

Evaluation of Intra-Aneurysmal Residual Blood Flow with the iMSDE T1-Black Blood Imaging after Flow Diverter Treatment.

Objective: We aimed to evaluate the efficacy of the "improved motion-sensitized driven-equilibrium (iMSDE)"-prepared T1-weighted black blood (T1-BB) MRI for monitoring treatment effect with a flow diverter (FD) for cerebral aneurysms. Methods: Following the exclusion of concomitant coiling and retreatment cases from 60 consecutive cases of cerebral aneurysms treated with FDs at our institution, 32 with imaging data were included in the analysis. Detectability of residual blood flow within the aneurysms was validated as follows: 1) comparison of MRI sequences (iMSDE-prepared T1-BB images, T1-weighted images [ T1WI], and time-of-flight [ TOF]-MRA) in cases of incompletely occluded aneurysms and 2) comparison of angiography and MRI sequences in the same period. Results: 1) The probability of diagnosing intra-aneurysmal blood flow was significantly higher with iMSDE-prepared T1-BB (iMSDE-prepared T1-BB vs. T1WI, p <0.001; iMSDE-prepared T1-BB vs. TOF-MRA, p <0.001). 2) The diagnostic accuracy of residual aneurysmal blood flow was significantly higher with iMSDE-prepared T1-BB than that with T1WI (p = 0.032). Furthermore, in cases of incomplete occlusion, the probability of detecting intra-aneurysmal blood flow was significantly higher with iMSDE-prepared T1-BB (iMSDE-prepared T1-BB vs. T1WI, p <0.001; iMSDE-prepared T1-BB vs. TOF-MRA, p = 0.023). Conclusion: Our results demonstrated that iMSDE-prepared T1-BB could help distinguish between blood flow and thrombus within the aneurysms after FD treatment, especially in the early stages of FD treatment.

Early caffeine therapy on the prevention of severe hyperkalemia in preterm infants.

BACKGROUND: The aim of this study was to evaluate the effect of caffeine therapy in preventing severe hyperkalemia in preterm infants. METHODS: We performed a single-center, retrospective study of preterm infants of 25-29 weeks' gestation admitted in our neonatal intensive care unit from January 2019-August 2020. We divided the infants into two groups: the control group (January 2019-November 2019) and the early caffeine group (December 2019-August 2020). RESULTS: We identified 33 infants (early caffeine, 15; control, 18). Baseline potassium levels were 5.3 and 4.8 mEq/L, respectively (p = 0.274). Severe hyperkalemia (K > 6.5 mEq/L) was observed in 0 (0%) and 7 (39%) (p = 0.009), in the early caffeine group and control group. The linear mixed-effect model confirmed the correlation between caffeine therapy and time from birth for the prediction of potassium levels (p < 0.001). While the potassium levels increased from baseline potassium levels at birth by 0.869 mEq/L at 12 h of birth, 0.884 mEq/L at 18 h of birth, and 0.641 mEq/L at 24 h of birth in the control group, the potassium levels were similar to the baseline levels at 12, 18, and 24 h of life in the early caffeine group. Among the clinical features, only early caffeine therapy was negatively associated with the incidence of hyperkalemia within 72 h of life. CONCLUSION: Early caffeine therapy within a few hours of life effectively prevents the incidence of severe hyperkalemia within the first 72 h of life in preterm infants of 25-29 weeks' gestation. Prophylactic early caffeine therapy can, therefore, be considered in high-risk, preterm infants.

A Unique Technique to Adjust Snare Position for Coil Retrieval in Tortuous Vessel During Aneurysm Coil Embolization: A Technical Case Report.

OBJECTIVE: Although snares are useful devices to retrieve an intravascular foreign body, the control of snares is often difficult. We present a safe and effective technique to adjust snare position in the tortuous vessel for coil retrieval during endovascular coil embolization. METHODS: We describe a case of a protruding coil during coil embolization that was successfully retrieved using a unique technique to adjust snare position and discuss additional intraprocedural bailout strategies for retrieving a coil during endovascular coil embolization. RESULTS: The patient was a 44-year-old female with unruptured right internal carotid artery (ICA) aneurysm that had grown over a 1.5-year period. Coil embolization was performed. After detachment of final coil and microcatheter removal, the final coil protruded into the ICA and floated. Coil retrieval using a snare was attempted, but the snare could not be placed around the coil tail and coil retrieval could not be achieved. The following technique was used to allow adjustment of snare position. First, a microguidewire and a microcatheter were guided into the M2 and M1 segment of the middle cerebral artery as monorail guides of the snare, respectively. Next, the snare was advanced over the microcatheter. Around C2 segment of the ICA, the microcatheter and the snare were manipulated as a unit. Thus, the snare could be placed around the protruding coil tail and the coil was retrieved successfully. CONCLUSIONS: This technique may be widely adapted for various situations when using a snare.

Effects of New-Generation Antiepileptic Drug Prophylaxis on Delayed Neurovascular Events After Aneurysmal Subarachnoid Hemorrhage.

Neuroelectric disruptions such as seizures and cortical spreading depolarization may contribute to the development of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (SAH). However, effects of antiepileptic drug prophylaxis on outcomes remain controversial in SAH. The authors investigated if prophylactic administration of new-generation antiepileptic drugs levetiracetam and perampanel was beneficial against delayed neurovascular events after SAH. This was a retrospective single-center cohort study of 121 consecutive SAH patients including 56 patients of admission World Federation of Neurological Surgeons grades IV - V who underwent aneurysmal obliteration within 72 h post-SAH from 2013 to 2021. Prophylactic antiepileptic drugs differed depending on the study terms: none (2013 - 2015), levetiracetam for patients at high risks of seizures (2016 - 2019), and perampanel for all patients (2020 - 2021). The 3rd term had the lowest occurrence of delayed cerebral microinfarction on diffusion-weighted magnetic resonance imaging, which was related to less development of DCI. Other outcome measures were similar among the 3 terms including incidences of angiographic vasospasm, computed tomography-detectable delayed cerebral infarction, seizures, and 3-month good outcomes (modified Rankin Scale 0 - 2). The present study suggests that prophylactic administration of levetiracetam and perampanel was not associated with worse outcomes and that perampanel may have the potential to reduce DCI by preventing microcirculatory disturbances after SAH. Further studies are warranted to investigate anti-DCI effects of a selective α-amino-3-hydroxy-5-methyl-4-isoxazole propionate receptor antagonist perampanel in SAH patients in a large-scale prospective study.

Folding Deformation of Open-Cell Stents in Carotid Artery Stenting: Report of Three Cases and Review of Literature.

Objective: We describe 3 cases with folding deformation of a PRECISE (Cordis, Miami, FL, USA) stent in carotid artery stenting (CAS). Case Presentations: The 3 cases with cervical carotid stenosis consisted of 3 males around 80 years old and included 2 symptomatic lesions. During CAS, distal embolic protection was established using a Mo.Ma (Medtronic, Minneapolis, MN, USA) along with a filter device in 2 cases and an Optimo (Tokai Medical Products, Aichi, Japan) along with a filter device in 1 case. For the filter device, either FilterWire EZ (Boston Scientific, Natick, MA, USA) or Spider FX (Covidien, Irvine, CA, USA) was employed. In all cases, a PRECISE stent was deployed after pre-dilation performed using a percutaneous transluminal angioplasty (PTA) balloon with the diameter of 2.5 to 3 mm. Post-dilation was performed after the stent deployment using a PTA balloon whose diameter was about 80% of that of the normal distal internal carotid artery. In all cases, cone-beam CT taken after the deployment of a stent showed folding deformation of the stent. In 2 cases, heavily calcified plaque hampered self-expansion of the stent, which resulted in the stent deformation. On the other hand, in the remaining 1 case, a distal shaft of the Mo.Ma caused the stent deformation, which was likely accelerated by head rotation and cervical compression that was performed to resolve difficulties for a filter retrieval device to pass through the stent, and post-dilation after the stenting. Conclusion: Heavily calcified plaque and a distal shaft of a Mo.Ma would result in stent deformation.

Vessel Rupture Complication due to Ballooning of the Distal Segment of a JET 7 Xtra Flex Reperfusion Catheter during Angiogram.

Objective: We present a case of intraprocedural device malfunction related to the JET 7 Xtra Flex reperfusion catheter during mechanical thrombectomy. Case Presentation: A 92-year-old man presented with sudden right hemiparesis with a National Institutes of Health Stroke Scale score of 22. His left middle cerebral artery (M1) was occluded, and emergency mechanical thrombectomy was performed. After partial recanalization was achieved, angiography through a JET 7 Xtra Flex was attempted. After manual injection of contrast media via a 10-mL syringe through the JET 7 Xtra Flex, the catheter moved, jumping forward, and the distal tip of the catheter expanded and ruptured. This resulted in intracranial vessel damage and subsequent patient death. Conclusion: Contrast media must not be injected through the JET 7 Xtra Flex. If contrast media needs to be injected for angiography during mechanical thrombectomy with a reperfusion catheter, it should always be through the guide catheter.

Extreme Prematurity and Pulmonary Outcomes Program in Saitama: Protocol for a Prospective Multicenter Cohort Study in Japan.

BACKGROUND: Because of the improvements in survival rates for preterm infants, not only the rates of bronchopulmonary dysplasia (BPD) but also those of long-term respiratory complications of premature birth are increasing, resulting in financial and health burdens in developed countries. Thus far, the risk factors of respiratory morbidities in extremely preterm infants remain unknown. Furthermore, the definition and the predictive ability of BPD for long-term respiratory outcomes are yet to be determined. OBJECTIVE: The objective of our study, Extreme Prematurity and Pulmonary Outcomes Program in Saitama, is to develop the diagnostic criteria for BPD and to determine the prognostic factors contributing to the long-term pulmonary outcomes manifesting in extremely preterm infants. METHODS: The Extreme Prematurity and Pulmonary Outcomes Program in Saitama is an observational prospective cohort study performed by a consortium of six neonatal intensive care units (NICUs) in Saitama, Japan. The subjects included in this study are infants (from each clinical center) with gestational ages 22 to 27 weeks. The target is 400 subjects. This study aims to determine the definition of BPD and other perinatal factors that accurately predict the long-term pulmonary outcomes in survivors of extreme prematurity. Moreover, the association between BPD and postprematurity respiratory disease will be investigated using generalized linear models. RESULTS: The protocol and consent forms were evaluated and approved on September 5, 2019, by the Ethics Committee of Saitama Medical Center, Saitama Medical University. Enrollment began on April 1, 2020. It is expected to end on March 31, 2023. The follow-up for 1 year corrected age is expected to continue through the middle of 2024. CONCLUSIONS: The Extreme Prematurity and Pulmonary Outcomes Program in Saitama incorporates aspects of neonatal care in secondary- and tertiary-level NICUs to develop existing research studies on the definition of BPD, objective biomarkers, and outcome measures of respiratory morbidity in extremely preterm infants beyond NICU hospitalization, thereby leading to a novel understanding of the nature and natural history of BPD and potential mechanistic and therapeutic targets in at-risk subjects. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/22948.

Effects of Carbon Nanowalls (CNWs) Substrates on Soft Ionization of Low-Molecular-Weight Organic Compoundsin Surface-Assisted Laser Desorption/Ionization Mass Spectrometry (SALDI-MS).

Carbon nanowalls (CNWs), which are vertically oriented multi-layer graphene sheets, were employed in surface-assisted laser desorption/ionization mass spectrometry (SALDI-MS) measurements to detect low-molecular-weight organic compounds. CNWs substrates with widely different wall-to-wall distances from 142 to 467 nm were synthesized using a radical-injection plasma-enhanced chemical vapor deposition (RI-PECVD) system with nanosecond pulse biasing to a sample stage. When survival yield (SY) values of N-benzylpyridinium chloride (N-BP-Cl) were examined, which is commonly used to evaluate desorption/ionization efficiency, a narrower wall-to-wall distance presented a higher SY value. The highest SY value of 0.97 was realized at 4 mJ/cm2 for the highest-density CNWs with a wall-to-wall distance of 142 nm. The laser desorption/ionization effect of arginine, an amino acid, was also investigated. When CNWs with a narrower wall-to-wall distance were used, the signal-to-noise (SN) ratios of the arginine signals were increased, while the intensity ratios of fragment ions to arginine signals were suppressed. Therefore, the CNWs nanostructures are a powerful tool when used as a SALDI substrate for the highly efficient desorption/ionization of low-molecular-weight biomolecules.

A Case of Miyazaki Syndrome Caused by Arachnoid Cyst-Peritoneal Shunt.

BACKGROUND: Miyazaki syndrome is overshunting-associated myelopathy, which is a rare complication of ventriculoperitoneal shunt. We present the first case of Miyazaki syndrome caused by cystoperitoneal (CP) shunt for an arachnoid cyst (AC) in this report. CASE DESCRIPTION: We report a case of a 42-year-old man with 12-year progressive spastic paraplegia, who underwent CP shunt for an AC at the age of 15 years. Although few findings suggested overshunting on symptoms and head computed tomography, contrast-enhanced magnetic resonance imaging revealed the engorgement of the cervical spinal epidural venous plexus compressing the spinal cord. Shunt valve replacement with a pressure-adjustable valve was performed. Postoperatively, the cervical cord compression by the enlarged spinal epidural venous plexus was completely improved, but, possibly due to delayed diagnosis and treatment, the patient's symptoms only partially improved. CONCLUSIONS: When patients with a history of any kind of shunt surgery develop myelopathy, Miyazaki syndrome should be suspected and, for early diagnosis, cervical and/or contrast-enhanced magnetic resonance imaging should be performed.

In-hospital Ischemic Stroke Treated by Mechanical Thrombectomy.

Objective: We investigated in-hospital stroke (IHS) treated by mechanical thrombectomy in comparison with out-of-hospital stroke (OHS) to clarify the points of concern in IHS at our institution. Methods: Between September 2015 and June 2018, 19 patients with IHS who underwent mechanical thrombectomy (IHS group) were enrolled, and compared with 154 patients with OHS (OHS group) regarding patient characteristics, technical results, and outcome. In this study, we set the detection time in the IHS group as patient arrival time, termed "Door" in the OHS group. Results: Cardiology and gastroenterology were the two main admitting departments, including four (21%) patients of IHS group. In all, 15 (79%) patients had atrial fibrillation; however, less than one-third of them was taking anticoagulant drugs at onset. There were only two cases of direct consultation to the stroke specialists, although IHS onset was mainly recognized by nurses. The median age in the IHS group was 81 (interquartile range (IQR), 76-86.5) versus 80 in the OHS group (IQR, 73-85; p = 0.43), and the median initial National Institutes of Health Stroke Scale score was 21 (IQR, 16-23) versus 21 (IQR, 14-26; p = 0.92), respectively. Sex, Alberta Stroke Program Early CT Score, etiology, and occlusion site did not differ between groups. The rate of use of intravenous tissue plasminogen activator (IV-tPA) was 26% in the IHS group versus 49% in the OHS group (p = 0.065). The median time of detection to imaging, detection to needle for IV-tPA, and detection to puncture were 32, 69, and 87 minutes, respectively, in the IHS group, being significantly longer than those in the OHS group (11, 30, and 50 minutes; p <0.01, p <0.01, and p <0.01, respectively). The median time of puncture to reperfusion was 39 minutes, being significantly shorter than that in the OHS group (82 minutes; p <0.01). Successful reperfusion defined as thrombolysis in cerebral infarction (TICI) 2b-3 was obtained in 94.7% of the IHS group versus 83.1% of the OHS group (p = 0.19). A favorable outcome (modified Rankin Scale score 0-2) at 90 days was achieved by 36.8% (IHS) versus 35.1% (OHS) of patients (p = 0.88). The rate of symptomatic procedural complications was 0% (IHS) versus 7.1% (OHS; p = 0.23). The rate of death at 90 days was 15.8% (IHS) versus 12.3% (OHS; p = 0.67). Conclusion: The times of detection to imaging and of detection to puncture in the IHS group were longer than those in the OHS group; however, patients in the IHS group had shorter reperfusion. The outcome of the IHS group did not differ from that of OHS group. Our study suggests that the time course of treatment should be improved and rapid stroke pathways involved in consultation with the stroke specialists for IHS should be organized.

Gene Expression of Osteoblast-like Cells on Carbon-Nanowall as Scaffolds during Incubation with Electrical Stimulation.

Nanostructured cell-culture scaffolds of carbon nanowalls (CNWs) were prepared by changing average wall-to-wall distances either 132 or 220 nm. Osteoblast-like cells (Saos-2) proliferated during 4 day incubation on the wider (220 nm) CNW scaffolds in the presence of electrical stimulation (ES). Differentiation gene expression levels of Runt-related transcription factor 2 (Runx2) and osteocalcin (OC) were suppressed after 10 day incubation, which indicated that the average wall-to-wall distances of the CNW scaffolds affect suppression of Runx2 and OC gene expression. This technique holds promise for controlling the differentiation of osteoblast-like cells.

Effect of early measles vaccination (AIK-C strain) for preterm infants.

BACKGROUND: The level of maternal antibodies decreases more quickly in preterm than term infants, leaving them unprotected against measles. To protect premature infants from measles, an early vaccination trial was investigated. METHODS: Changes in the serum measles neutralization test (NT) antibody titer were examined in 152 infants (average gestational period, 29 weeks; average birthweight, 1203 g). RESULTS: The average antibody titer (2(n)) was 2(3.5) at birth and 2(2.2) at 1-3 months of age, and in all cases, NT antibody titer decreased to <1:4 (150 IU/mL). The AIK-C measles vaccine was given to 17 preterm infants at the age of 6 months, and induced sufficient serological responses without any serious adverse events. NT antibody level did not decay during 12 months after vaccination. CONCLUSION: Early immunization at 6 months of age is effective to protect preterm infants in the outbreak setting.

Bronchopulmonary foregut malformation diagnosed by three-dimensional CT.

A case of bronchopulmonary foregut malformation (BPFM) detected by multislice computed tomography with three-dimensional reconstruction (MSCT/3D) is reported. Concern for aspiration frequently limits the use of radiopaque contrast agents when anomalies of the lung and esophagus are suspected. MSCT/3D may make it possible to assess the communication and spatial relationship of malformed lung and esophagus in the early neonatal period without invasive or contrast radiological procedures such as bronchography or upper gastrointestinal series (UGI).