Upregulation of tandem duplicated BoFLC1 genes is associated with the non-flowering trait in Brassica oleracea var. capitata.

KEY MESSAGE: Tandem duplicated BoFLC1 genes (BoFLC1a and BoFLC1b), which were identified as the candidate causal genes for the non-flowering trait in the cabbage mutant 'nfc', were upregulated during winter in 'nfc'. The non-flowering natural cabbage mutant 'nfc' was discovered from the breeding line 'T15' with normal flowering characteristics. In this study, we investigated the molecular basis underlying the non-flowering trait of 'nfc'. First, 'nfc' was induced to flower using the grafting floral induction method, and three F2 populations were generated. The flowering phenotype of each F2 population was widely distributed with non-flowering individuals appearing in two populations. QTL-seq analysis detected a genomic region associated with flowering date at approximately 51 Mb on chromosome 9 in two of the three F2 populations. Subsequent validation and fine mapping of the candidate genomic region using QTL analysis identified the quantitative trait loci (QTL) at 50,177,696-51,474,818 bp on chromosome 9 covering 241 genes. Additionally, RNA-seq analysis in leaves and shoot apices of 'nfc' and 'T15' plants identified 19 and 15 differentially expressed genes related to flowering time, respectively. Based on these results, we identified tandem duplicated BoFLC1 genes, which are homologs of the floral repressor FLOWERING LOCUS C, as the candidate genes responsible for the non-flowering trait of 'nfc'. We designated the tandem duplicated BoFLC1 genes as BoFLC1a and BoFLC1b. Expression analysis revealed that the expression levels of BoFLC1a and BoFLC1b were downregulated during winter in 'T15' but were upregulated and maintained during winter in 'nfc'. Additionally, the expression level of the floral integrator BoFT was upregulated in the spring in 'T15' but hardly upregulated in 'nfc'. These results suggest that the upregulated levels of BoFLC1a and BoFLC1b contributed to the non-flowering trait of 'nfc'.

Quantitative Analysis of Florigen for the Variability of Floral Induction in Cabbage/Radish Inter-generic Grafting.

Grafting-induced flowering is a key phenomenon to understand systemic floral induction caused by florigen. It can also be used as a breeding technique enabling rapid seed production of crops with long generation times. However, the degree of floral induction in grafted plants is often variable. Moreover, it is difficult in some crop species. Here, we explored the factors promoting variability in the grafting-induced flowering of cabbage (Brassica oleracea L. var. capitata), an important vegetable crop with a long generation time, via the quantitative analysis of florigen accumulation. Significant variability in the flowering response of grafted cabbage was observed when rootstocks of different genotypes were used. As reported previously, B. oleracea rootstocks did not induce the flowering of grafted cabbage plants, but radish (Raphanus sativus L.) rootstocks unstably did, depending on the accessions used. Immunoblotting analysis of the FLOWERING LOCUS T (FT) protein, a main component of florigen, revealed that floral induction was quantitatively correlated with the level of accumulated FT protein in the grafted scion. To identify rootstock factors that cause variability in the floral induction of the grafted scion, we investigated FT protein accumulation and flowering response in grafted scions when the transcription levels of FT and the leaf area of rootstocks were altered by vernalization, daylength and leaf trimming treatments. We concluded that increasing the total amount of FT protein produced in the rootstock is important for the stable floral induction of the grafted cabbage, and this can be accomplished by increasing FT transcription and the leaf area of the rootstock.

Aberrant drainage of posterior condylar emissary vein and abnormal orifice of hypoglossal canal: surgical implications in the transcondylar fossa approach for VA-PICA junction aneurysm.

BACKGROUND: The posterior condylar emissary vein (PCEV) and posterior condylar canal (PCC) are anatomical landmarks for identifying important structures like jugular tubercle and occipital condyle in surgical approach to the foramen magnum and condylar fossa. Several anatomical variations have been described. Drainage into the jugular bulb is found to be commonest. METHOD: A 70-year-old patient with unruptured vertebral artery-posterior inferior cerebellar artery (PICA) junction aneurysm-underwent surgical clipping via transcondylar fossa approach. RESULT: Preoperative computed tomography demonstrated an abnormal communication existed between the left-sided PCC and hypoglossal canal (HC). The PCEV was identified draining into a dilated venous channel/pouch at the "hip" of sigmoid sinus (junction of sigmoid sinus and jugular bulb). Intra-operatively, an occipital artery-PICA bypass was performed. The PCEV was skeletonized, coagulated, and divided to achieve hemostasis. The lateral and cranial drilling around PCC was successful at safeguarding the underlying contents of HC (in medial and caudal extent). CONCLUSION: Preoperative angiography and detailed morphometric analysis of the PCC were helpful in planning surgical approach-identifying and controlling the PCEV, and skeletonization of the PCC without compromising the hypoglossal nerve and anterior condylar emissary vein.

Thrombectomy for acute large vessel occlusion in posterior and anterior circulation: a single institutional retrospective observational study.

PURPOSE: Thrombectomy has been the gold standard therapy for anterior circulation occlusion; however, studies regarding thrombectomy in posterior circulation are lacking. In this study, we compared the efficiency of thrombectomy for acute large vessel occlusion between the posterior and anterior circulation at a single institution. METHODS: We retrospectively analyzed consecutive patients who underwent thrombectomy for acute large vessel occlusion at our institution between August 2014 and April 2021. Differences in the clinical background, time course, and treatment technique and outcomes were evaluated between anterior and posterior circulation occlusions. RESULTS: Overall, 353 patients (225 men and 128 women) were included: 314 patients had anterior circulation occlusion and 39 patients had posterior circulation occlusion. Between the patients with anterior and posterior circulation occlusions, the National Institutes of Health Stroke Scale (NIHSS) score (16 [12-21] vs. 29 [19-34], respectively, p < 0.001), door-to-puncture time (65 [45-99] vs. 99 [51-121] min, respectively, p = 0.018), and mortality (22 [7%] vs. 8 [20.5%] patients, respectively, p = 0.010) were significantly different; however, favorable outcome was not significantly different. CONCLUSION: Higher NIHSS score, delayed treatment, and higher mortality were observed in posterior circulation occlusion than in anterior circulation occlusion; successful reperfusion and favorable outcomes were similar between them. Similar favorable outcomes and reperfusion ratio to the anterior circulation might be achieved also in the posterior circulation; however, delayed treatment and the optimal first-pass strategy might need further improvement.

Preprocedural Prediction of Underlying Atherosclerotic Lesions in Cerebral Large-Vessel Occlusions: Clinical Backgrounds, Radiological Findings, and Treatment Outcomes.

AIMS: Mechanical thrombectomy using a standard device has been effective for acute cerebral large-vessel occlusions, particularly those due to cardiogenic embolism. However, evidence for those with underlying atherosclerotic lesions is lacking. In this study, we evaluated the predictive factors, treatment details, and outcomes of acute cerebral large-vessel occlusions with underlying atherosclerotic lesions in patients who underwent mechanical thrombectomy. METHODS: We retrospectively analyzed consecutive patients with acute large-vessel occlusions who underwent mechanical thrombectomy at our institution between August 2014 and May 2021. Predictive factors of underlying atherosclerotic lesions were evaluated using univariate and multivariate analyses. In addition, treatment details and outcomes were evaluated and compared with those of other etiologies. RESULTS: Among 322 included patients, 202 (62.7%) were males and 65 (20.2%) had underlying atherosclerotic lesions. Multivariate analysis identified dyslipidemia, lack of arterial fibrillation documented on admission, smoking, internal carotid artery lesions, and stenosis ≥ 25% in non-occluded large vessels as predictive factors of underlying atherosclerotic lesions. Regarding treatment for underlying atherosclerotic lesions, the need for percutaneous transluminal angioplasty, stent placement, medical therapy, and longer procedure time were observed, while successful reperfusion rates, favorable outcomes, and mortality rates showed no significant differences with those of other etiologies. CONCLUSION: Coexisting diseases and radiological findings were useful for predicting underlying atherosclerotic lesions. Further understanding these characteristics may lead to the early detection of underlying atherosclerotic lesions, optimal treatment strategies, and better outcomes.

Longitudinal epidemiological study of subjective sleep quality in Japanese adolescents to investigate predictors of poor sleep quality.

To clarify the predictors of poor sleep quality in Japanese adolescents. In 2010, baseline surveys were administered to students at 24 randomly selected schools-10 junior high schools and 14 senior high schools-in Japan. After 2 years, follow-up surveys were administered to the same students. The questionnaires included the following five items: basic attributes, sleep status, lifestyle factors, social relationships, and mental health status. Only participants without "poor sleep quality" at baseline were included for analyses and the incidence proportion of poor sleep quality was calculated by observing the rate of poor sleep quality at follow-up. A total of 3473 students were included for analysis. During the 2 years leading to the follow-up study, the incidence proportion of poor sleep quality was 7.7% among junior high and 6.9% among senior high school students. Multivariate analyses revealed that factors associated with poor sleep quality were poor mental health, no extracurricular learning, and short sleep duration on weekdays in junior high school students and poor mental health, waking up at 7:00 or later on weekdays and short sleep duration on weekdays in senior high school students. In junior high school students, mental health status, extracurricular learning, and sleep duration could be predictors of poor sleep quality, whereas in senior high school students, mental health status, waking time, and sleep duration on weekdays could be predictors. The present findings suggest that sleep health should be promoted among junior and senior high school students. Supplementary Information: The online version contains supplementary material available at 10.1007/s41105-021-00343-8.

A cross-sectional epidemiological study of the relationship between sleep duration, quality, and rhythm and presenteeism in workers.

This study aims to examine the relationship of sleep (sleep duration, sleep quality, and sleep rhythm) with presenteeism in workers while controlling for other confounding factors. A total of 2375 workers of six Japanese companies received self-administered questionnaires from June to November 2018. Information on sleep duration was used to evaluate sleep quantity, the Athens Insomnia Scale (AIS) was used to evaluate sleep quality, and workers' engagement in shift work was used to determine their sleep rhythms. We used the World Health Organization Health and Work Performance Questionnaire to evaluate presenteeism. Information on lifestyle (exercise, smoking, etc.), sex, and age was also collected. We conducted a logistic regression analysis with high absolute/relative presenteeism as an objective variable, sleep duration, AIS, and shift work as dependent variables, and basic attributes and lifestyle factors as adjustment factors. Completed questionnaires were collected from 1992 workers (aged 18-79 years; 25.2% women; response rate: 83.9%). Logistic regression analysis showed that high absolute presenteeism was significantly associated with poor sleep quality (high AIS score; P < 0.001) but not with sleep duration (P = 0.326) and shift work (P = 0.177). High relative absenteeism was significantly associated with poor sleep quality (high AIS score; P = 0.001) but not with sleep duration (P = 0.461) or shift work (P = 0.245). We showed that poor sleep quality is significantly associated with a high level of presenteeism. This suggests focusing on improving sleep quality is important for reducing presenteeism among workers.

A Nationwide Cohort Study of Parasomnias Among Adolescents.

Objective: To elucidate the incidence rates and predictive factors for parasomnias (disorders of arousal, nightmare, and sleep paralysis) in adolescents.Methods: This was a prospective cohort study of high school students. In 2010, we conducted a baseline survey of first-year students enrolled in randomly selected Japanese schools (10 junior high schools and 14 senior high schools); 2 years later, a follow-up survey of the same participants was conducted. A self-administered questionnaire inquiring about parasomnias and lifestyles was provided to the students for both surveys. The incidence of new onset of each parasomnia was determined based on the longitudinal survey data obtained at 2 timepoints (ie, baseline and follow-up), separately for the junior and senior high-school students. Moreover, we performed multivariate analyses to identify the predictive factors for new onset of each parasomnia.Results: 776 junior high school students and 2,697 senior high school students participated in both surveys (total response rate: 61.1%). The incidence rates of disorders of arousal, nightmares, and sleep paralysis during the observation period were 14.0%, 16.2%, and 3.3%, respectively, among junior high school students, and 15.1%, 27.8%, and 6.8%, respectively, among senior high school students. The predictive factors (adjusted odds ratio, P value) for new onset of disorders of arousal were female sex (1.38, .009) and sleep duration of less than 5 hours (1.95, .001). The predictive factors for onset of nightmares were female sex (1.82, < .001), enrollment in senior high school (vs junior high school) (2.14, < .001), poor subjective sleep quality (1.60, .010), and spending less than 2 hours studying after school hours (1.64, .027). The predictive factors for new onset of sleep paralysis were enrollment in senior high school (vs junior high school) (2.39, .002) and poor mental health status (1.98, < .001).Conclusions: Our study results suggest that sleep status, lifestyle, and mental health are predictive factors for new onset of parasomnias in adolescents. These should be key areas of focus in school health services.

A nationwide cross-sectional study of difficulty waking up for school among adolescents.

STUDY OBJECTIVES: To determine the prevalence of and risk-factors for difficulty waking up for school among adolescents. METHODS: We used a self-administered questionnaire (140 junior high schools [JHSs]; 124 senior high schools [SHSs]) selected randomly in 2012 from throughout Japan. RESULTS: Total response rate: 60.7%. Data from 38 494 JHS and 61 556 SHS students were analyzed. The prevalence of at least one instance of school tardiness/absence due to difficulty waking up over a 30-day period was 10.9 (95% confidence-interval:10.5-11.3)%/2.9(2.7-3.1)% for JHS-boys and 7.7(7.3-8.1)%/2.0(1.8-2.2)% for JHS-girls. The prevalence was 15.5(15.1-15.9)%/5.6(5.3-5.9)% for SHS-boys and 14.4(14.0-14.8)%/5.9(5.6-6.2)% for SHS-girls. We used ordinal regression to identify the risk factors associated with the experience of school tardiness/absence. Factors significantly associated with school tardiness in all four groups (JHS boys/girls, SHS boys/girls) were "no-participation-in-club-activities," "early-morning-awakening," "feeling bad throughout a morning," "drinking," and "smoking." Among associated factors, the highest odds ratio was found for monthly smoking-days (none vs. at least one-day or more) for JHS-girls at 5.30(3.57-7.85). Factors significantly associated with school absence in all four groups were "no wishing to go to university," "no participation in club activities," "disorders of initiating and maintaining sleep," "long internet use," "drinking," "smoking," "poor-mental-health" and "feeling bad throughout a morning." Among associated factors, the highest odds ratio was found for monthly smoking-days (none vs. at least one-day or more) for JHS-girls at 4.60(3.45-6.15). CONCLUSIONS: These results suggest that the risk factors for difficulty waking up among adolescents are sleep status, lifestyle, and mental health, which can indicate the presence of an underlying disease.

Management of an Uncommon Complication: Anterior Choroidal Artery Occlusion by Posterior Clinoid Process Detected Through Intraoperative Monitoring After Clipping of Paraclinoid Aneurysm: 2-Dimensional Operative Video.

Despite technological advances in endovascular therapy, surgical clipping of paraclinoid aneurysms remains an indispensable treatment option and has an acceptable profile risk. Intraoperative monitoring of motor and somatosensory evoked potentials has proven to be an effective tool in predicting and preventing postoperative motor deficits during aneurysm clipping.1,2 We describe the case of a 61-yr-old Japanese woman with a history of hypertension and smoking. During follow-up for bilateral aneurysms of ophthalmic segment of the internal carotid artery (ICA), left-sided aneurysm growth was detected. A standard pterional approach with extradural clinoidectomy was used to approach the aneurysm. After clipping, a significant intraprocedural change in motor evoked potential (MEP) amplitude was observed despite native vessel patency was confirmed through micro-Doppler and indocyanine green video angiography.3-5 After extensive dissection of the sylvian fissure and exposure of the communicating segment of ICA, the anterior choroidal artery was found to be compressed and occluded by the posterior clinoid because of an inadvertent shift of the ICA after clip application and removal of brain retractors. Posterior clinoidectomy was performed intradurally with microrongeur and MEP amplitude returned readily to baseline values. Computed tomography (CT) angiogram demonstrated complete exclusion of the aneurysm, and magnetic resonance imaging (MRI) was negative for postoperative ischemic lesions on diffusion weighted images. The patient tolerated the procedure well and was discharged home on postoperative day 3 with modified Rankin Scale (mRS) 0. The patient signed the Institutional Consent Form to undergo the surgical procedure and to allow the use of her images and videos for any type of medical publications.

Psychometric Properties of a New Simplified Scale to Assess the Quality of Workers' Rest and Recreation on Their Days Off.

BACKGROUND: In this study, we developed and tested the validity and reliability of the 12-item Rest and Recreation Quality Scale (RRQ-Scale) for Workers as a new scale capable of conveniently assessing the quality of workers' days off, that is, their rest and recreation. METHODS: Participants included 756 employees (694 men, 62 women, mean age ± SD= 44.7 ± 13.5, age range = 18-81) of 26 manufacturing-related companies located in Oita Prefecture, Japan. We analyzed the factorial validity of the scale's score distribution and its criterion-related validity and reliability (Cronbach's coefficient α), compared to MOS 36-Item Short-Form Health Survey version 2.0 (SF-36v2) and the generalized self-efficacy scale. Participants responded to the 12 questions on 4-point scales; these were summed to calculate the total score (score range: 12-48 points). RESULTS: The smallest and largest mean ± SD of the questions were 2.53 ± 0.89 and 3.21 ± 0.74, respectively, which are within the possible score range (1-4, implying the absence of floor and ceiling effects). A confirmatory factor analysis indicated that the goodness of fit of the higher-order factor analysis model was satisfactory (GFI = 0.955), confirming factorial validity. In addition, consistent with the theoretical predictions, the total score exhibited statistically significant positive correlations with the components of the SF-36v2; physical component summary (PCS): rs = 0.193, P < 0.001, mental component summary (MCS): rs = 0.369, P < 0.001, and role/social Component Summary (RCS): rs = 0.115, P = 0.002. This confirmed criterion-related validity. Further, the overall reliability of the scale was high; α = 0.877. CONCLUSION: In sum, the score distribution, validity, and reliability of the RRQ-Scale for workers were good, indicating a high degree of practicality.

Microsurgical resection of unruptured cerebellar arteriovenous malformation presenting with trigeminal neuralgia.

Cerebellar arteriovenous malformations (AVMs) represent 10%-15% of all intracranial AVMs and are associated with a greater risk for hemorrhagic presentation compared with supratentorial AVMs. When they reach the cerebellopontine angle cistern, neurovascular compression syndromes, including trigeminal neuralgia and hemifacial spasm, can occur. Due to the aggressive natural history of cerebellar AVM, an effective treatment strategy is required. In this video, the authors demonstrate the technical nuances of microsurgical resection of an unruptured cerebellar AVM in a 24-year-old female presenting with trigeminal neuralgia. The patient underwent right retrosigmoid craniotomy and complete resection of the AVM with resolution of trigeminal neuralgia. The video can be found here: https://youtu.be/6GmNjgFQwx8.

Predictor of Visual Impairment Following Paraclinoid Aneurysm Surgery: Special Consideration of Surgical Microanatomy Related to Paraclinoid Structures.

BACKGROUND: Microsurgical clipping with extradural anterior clinoidectomy (EDAC) for paraclinoid aneurysm is an established technique with good angiographic outcomes, although postoperative worsening of visual acuity remains a concern. Multiple reports show visual acuity deteriorating after clipping, yet the cause remains unclear. OBJECTIVE: To analyze results of asymptomatic paraclinoid aneurysm surgeries treated with EDACs, specifically focusing on the microanatomy of paraclinoid structure dissection. This determined the causes of delayed visual impairment and microsurgical indications. METHODS: Results of the treatment with EDAC of 94 patients with cerebral aneurysm and normal preoperative visual acuity but also full visual fields were retrospectively analyzed. RESULTS: The mean aneurysm size was 6.2 (±3.3) mm. Clipping was performed in 87 cases and trapping in 7 cases. Complete angiographic occlusion was observed in 91 patients. In 26 cases, a postoperative visual deficit occurred. A total of 20 cases exhibited partial visual field deficits, including 5 who were asymptomatic. Visual deficits were only detectable by postoperative ophthalmologic testing. Six showed light perception impairment or blinding. Of the 15 patients with symptomatic partial visual field deficits, 5 showed improvement at follow-up. Visual deficits persisted in 22 patients at the last follow-up. Multivariate logistic regression analysis revealed that medial projecting aneurysm (adjusted odds ratio [OR]: 10.43) and the opening of the carotidoculomotor membrane (adjusted OR: 5.19) were significantly related to visual impairment. CONCLUSION: Excess dissection of carotidoculomotor membranes causes postoperative delayed visual worsening. For treating small, asymptomatic paraclinoid aneurysms, carotidoculomotor membranes should not be opened, and microsurgical clipping should not be performed for preoperative asymptomatic medial projecting aneurysms.

Complex Bypass Surgery for Multiple Fusiform Aneurysms, Including a Thrombosed Giant Aneurysm of the Middle Cerebral Artery.

Treatment of complex middle cerebral artery (MCA) aneurysms are challenging; however, an appropriate surgical strategy can ensure favorable outcomes. Notably, a protective bypass strategy is essential to treat complex aneurysms and involves the creation of a bypass channel distal to the aneurysm before repairing it. A protective bypass enables the surgeon to establish adequate distal blood flow during the approach to the aneurysm, as well as during additional revascularization. This Video 1 describes complex bypass surgery that successfully treated multiple fusiform aneurysms, including a thrombosed giant aneurysm of the MCA. A 12-year-old girl presented with a history of chronic headache and incidentally diagnosed multiple fusiform aneurysms along the course of the right internal carotid artery to the MCA, including a thrombosed giant aneurysm of the M2 segment of the MCA (M2) superior trunk. The aneurysms were treated by trapping and excision along with a superficial temporal artery to MCA triple bypass, and an M2-radial artery graft-M2 bypass. The patient developed mild left hemiparesis postoperatively but recovered well and was discharged with a modified Rankin Scale score of 0. The pathophysiology of this patient should be different from common saccular aneurysm because of young age and multiple fusiform shape. Hence continuous follow-up is essential. The next surgical strategy should be reconsidered according to the situation if the recurrence is occurred. This surgical video shows the surgical strategy and stepwise procedure to treat complex aneurysms and will be useful to vascular neurosurgeons to devise a surgical approach utilizing a "protective bypass strategy."

High Cervical Carotid Endarterectomy-Outcome Analysis.

OBJECTIVE: Carotid endarterectomy (CEA) for high cervical internal carotid artery stenosis is considered to be technically demanding because of the difficulty in dissecting the distal end. We report the surgical technique and outcome analysis of CEA for high cervical lesions. METHODS: We retrospectively analyzed the records of 98 patients treated by CEA from December 2013 to June 2018. The plaque positions rostral to the C2 vertebral level was defined as the high cervical lesions (n = 34). The surgical technique is to successfully expose the distal end, as follows: 1) extend the skin incision; 2) expose the great auricular nerve maximally; 3) dissect between the SCM and parotid gland fascia; 4) resect the internal deep cervical lymph nodes; and 5) retract the digastric muscle, hypoglossal nerve, and occipital artery. RESULTS: There were 8 cases (high cervical group, 4 cases; non-high cervical group, 4 cases) of postoperative diffusion-weighted imaging high signal and 6 cases (high cervical group, 3 cases; non-high cervical group, 3 cases) of symptomatic ischemic lesion. Four cases belonged to the technique-related cerebral infarction group and 4 cases to the perioperative-related cerebral infarction (PRCI) group. High cervical lesion is not considered to be a risk factor for either PRCI (P = 0.610) or technique-related cerebral infarction (P = 0.610). The difference of the diastolic blood pressure between the preoperative period and the second postoperative day showed a risk factor of PRCI (P = 0.033). CONCLUSIONS: The surgical outcomes for high cervical lesions are equivalent to that of non-high cervical lesions. Excessive blood pressure management from the early postoperative days is a risk of PRCI.

Surgical microanatomy of the occipital artery for suboccipital muscle dissection and intracranial artery reconstruction.

BACKGROUND: The occipital artery (OA) is an important donor artery for posterior fossa revascularization. Harvesting the OA is difficult in comparison to the superficial temporal artery because the OA runs between suboccipital muscles. Anatomical knowledge of the suboccipital muscles and OA is essential for harvesting the OA during elevation of the splenius capitis muscle (SPL) for reconstruction of the posterior inferior cerebellar artery. We analyzed the running pattern of the OA and its anatomic variations using preoperative and intraoperative findings. METHODS: From April 2012 to March 2018, we surgically treated 162 patients with suboccipital muscle dissection by OA dissection using the lateral suboccipital approach. The running pattern and relationship between the suboccipital muscles and OA were retrospectively analyzed using the operation video and preoperative enhanced computed tomography (CT) images. The anatomic variation in the running pattern of the OA was classified into two types: lateral type, running lateral to the muscle and medial type, running medial to the longissimus capitis muscle (LNG). RESULTS: The medial pattern was observed in 107 (66%) patients and the lateral pattern in 54 (33.3%); 1 (0.6%) patient had the OA running between the LNGs. CONCLUSION: Preoperative CT is effective in determining the running course of the OA, which is important for safely harvesting the OA during SPL elevation. There is a risk of causing OA injury in patients with the lateral pattern. This is the first report showing that the OA rarely runs in between the LNGs.

[Transarterial Embolization of Intraorbital Dural Arteriovenous Fistula:A Case Report].

Intraorbital dural arteriovenous fistula(dAVF)is a very rare disease; therefore, an optimal treatment strategy has not yet been established. Here, we describe a case of successful dAVF treatment by performing transarterial embolization(TAE)with n-butyl-2-cyanoacrylate(NBCA). A 66-year-old male presented with right conjunctival injection, with no history of trauma. Magnetic resonance imaging(MRI)demonstrated a flow void in the right orbit. Digital subtraction angiography(DSA)revealed an AVF fed by a branch of the right ophthalmic artery(OA)and draining into the dilated right superior ophthalmic vein(SOV). A transvenous embolization(TVE)was planned, but it could not be performed because the facial vein was meandering. Hence, TAE with NBCA was performed, and the AVF was successfully occluded by this method. There has been no recurrence of intraorbital dAVF in three months since the treatment. Several recent studies have reported that TAE is an effective treatment for intracranial dAVF. However, there are insufficient reports of TAE with NBCA for intraorbital dAVF treatment. The anatomy of the OA needs to be known for the success of TAE in treating intraorbital dAVF, because TAE is a high-risk treatment. In this paper, we report a case wherein TAE with NBCA was performed for intraorbital dAVF and further review the other treatment options.

Comprehensive analysis of perforator territory infarction on postoperative diffusion-weighted imaging in patients with surgically treated unruptured intracranial saccular aneurysms.

OBJECTIVE: Perforator territory infarction (PTI) is still a major problem needing to be solved to achieve good outcomes in aneurysm surgery. However, details and risk factors of PTI diagnosed on postoperative MRI remain unknown. The authors aimed to investigate the details of PTI on postoperative diffusion-weighted imaging (DWI) in patients with surgically treated unruptured intracranial saccular aneurysms (UISAs). METHODS: The data of 848 patients with 1047 UISAs were retrospectively evaluated. PTI was diagnosed on DWI, which was performed the day after aneurysm surgery. Clinical and radiological characteristics were compared between UISAs with and without PTI. Poor outcome was defined as an increase in 1 or more modified Rankin Scale scores at 12 months after aneurysm surgery. RESULTS: Postoperative DWI was performed in all cases, and it revealed PTI in 56 UISA cases (5.3%). Forty-three PTIs occurred without direct injury and occlusion of perforators (43 of 56, 77%). Poor outcome was more frequently observed in the PTI group (17 of 56, 30%) than the non-PTI group (57 of 1047, 5.4%) (p < 0.0001). Thalamotuberal arteries (p < 0.01), lateral striate arteries (p < 0.01), Heubner's artery (p < 0.01), anterior median commissural artery (p < 0.05), terminal internal carotid artery perforators (p < 0 0.01), and basilar artery perforator (p < 0 0.01) infarctions were related to poor outcome by adjusted residual analysis. On multivariate analysis, statin use (OR 10, 95% CI, 3.3-31; p < 0.0001), specific aneurysm locations (posterior communicating artery [OR 4.1, 95% CI 2.1-8.1; p < 0.0001] and basilar artery [OR 3.1, 95% CI 1.1-8.9; p = 0.031]), larger aneurysm size (OR 1.1, 95% CI 1.1-1.2; p = 0.043), and permanent decrease of motor evoked potential (OR 38, 95% CI 3.1-468; p = 0.0045) were related to PTI. CONCLUSIONS: Despite efforts to avoid PTI, it occurred even without direct injury, occlusion of perforators, or evoked potential abnormality. Therefore, surgical treatment of UISAs, especially with the aforementioned risk factors of PTI, should be more carefully considered. The evaluation of PTI in the territory of the above-mentioned perforators could be useful in helping predict the clinical course in patients after aneurysm surgery.

Preoperative Predictors and Prognosticators After Microsurgical Clipping of Poor-Grade Subarachnoid Hemorrhage: A Retrospective Study.

BACKGROUND: Contrary to expectations, some patients with poor-grade subarachnoid hemorrhage (SAH) show favorable outcomes. However, the factors predictive of good prognosis are unclear. The purposes of this study were to identify factors related to poor-grade SAH and to analyze preoperative prognostic factors. METHODS: We included 186 patients with SAH who underwent surgical clipping or conservative treatment immediately after SAH diagnosis. Physiologic, radiographic, and blood examination data were collected retrospectively. Factors related to poor World Federation of Neurological Societies (WFNS) grade (WFNS IV and V) and poor outcome (modified Rankin Scale scores 3-6) were analyzed. RESULTS: The patients (mean age, 61.6 years) included 134 women (72%). Seventy patients (38.2%) had poor WFNS scores. On multivariate analysis, age ≥70 years (adjusted odds ratio [OR], 3.73), midline shift (OR, 4.89), and the absence of cerebrospinal fluid in the high-convexity cortical sulci (OR, 5.47) and ambient cistern (OR, 4.83) were predictive of poor WFNS scores. Age ≥70 years (OR, 8.36), WFNS grade 5 (OR, 15.35), intracerebral hematoma (OR, 3.32), and Evans index (EI) ≥0.3 (OR, 4.40) were predictive of poor outcome. Body mass index (OR, 0.87), intraventricular hemorrhage (OR, 3.86), glycated hemoglobin level (OR, 2.78), and age ≥70 years (OR, 4.12) were predictive of EI ≥0.3. CONCLUSIONS: Poor outcomes correlated with older age, brain-destructive hemorrhage, and EI ≥0.3. The EI reflects both hydrocephalus and the patient's frailty. Radiographic signs of poor-grade SAH were not correlated with poor outcome, suggesting that early decompressive surgery may improve outcome.

Analysis for risk factors of 12-month neurological worsening in patients with surgically treated small-to-moderate size unruptured intracranial aneurysms.

The risk associated with surgical treatment for small-to-moderate size unruptured intracranial aneurysms (SMUIAs, defined as <15 mm) has not been well characterized. Authors aimed to investigate risk factors for poor outcome in surgical treatment of SMUIAs. The data of prospectively collected 801 consecutive patients harboring 971 surgically treated SMUIAs was evaluated. Neurological worsening (NW) was defined as an increase in 1 or more modified Rankin Scale at 12-month. Clinical and radiological characteristics were compared. Neurological worsening was observed in 45 (4.6%). In multivariate analysis, only perforator territory infarction (PTI) on postoperative diffusion-weighted imaging (odds ratio (OR), 13; 95% confidence interval (CI), 4.9-32, p < 0.0001), and aneurysm locations (paraclinoid (OR, 6.9; 95% CI, 3.1-15, p < 0.0001), basilar artery (OR, 4.5; 95% CI, 1.5-14, p = 0.008), vertebral artery (OR, 11; 95% CI, 3.3-34, p < 0.0001)) were related to neurological worsening. Multivariate analysis showed that statin use (OR, 12; 95% CI, 3.8-39, p < 0.0001) and aneurysm locations (internal carotid artery-posterior communicating artery (OR, 3.9; 95% CI, 1.8-8.2, p < 0.0001) and basilar artery (OR, 6.3; 95% CI, 2.3-17, p = 0.008)), and aneurysm size >10 mm (OR, 5.3; 95% CI, 1.8-15, p = 0.003) were related to PTI. Although all SMUIAs should be carefully considered whether to be treated, those with statins, specific locations, and larger sizes should perhaps be more meticulously contemplated, and neurosurgeons should continue to avoid PTI.