Relationship between Shape Retention and X-ray Absorption Value of the Tip of Microcatheters in Neuroendovascular Treatment.

Objective We noticed that the X-ray absorption value of the tip of each microcatheter used for aneurysm treatment varied from product to product. We hypothesized that the differences were caused by variations in the metal's density braid, which could be related to the ability of the tip to retain its shape. Methods The X-ray absorption value of each microcatheter tip was measured. Next, heat forming was performed using a shaping mandrel at 6 mm and 90 degrees to determine whether there was a correlation between the X-ray absorption value and the forming angle. Next, the optimal mandrel angle for forming each microcatheter at 90 degrees was investigated. We also examined the shape retention after 20 times wire insertions into each microcatheter. Conclusion It was found that the higher the X-ray absorption value, the harder it was for the microcatheter to be formed. The mandrel angle required to form 90 degrees was determined by the X-ray absorption value. The higher the X-ray absorption value, the higher the shape retention of the tip shape. The heat formation and shape-retention conditions of the microcatheter tip were correlated with the X-ray absorption value of the metal braid. Even for unknown microcatheters, the optimum shaping conditions can be inferred from the X-ray absorption value.

Hairball-Like Migration of "Onyx Threads" into the Draining Vein during Transarterial Embolization of a Dural Arteriovenous Fistula: A Case Report and Experimental Validation.

Transarterial embolization using Onyx is a well-established treatment for dural arteriovenous fistulas (DAVFs). However, complications can arise when Onyx migrates into the venous side, impairing the draining veins. We encountered a case where Onyx, injected through the arterial side, strayed into the jugular vein, forming a hairball-like structure. Our study aimed to investigate the underlying mechanism of this unusual phenomenon. We postulated that Onyx precipitates into thread-like shapes when passing through extremely narrow openings. To test this, we extruded Onyx from a syringe through a 27-gauge needle into a silicone tube with flowing water. By varying the flow speed, we observed the hardening behavior of Onyx. Under slow flow, the extruded Onyx quickly solidified at the needle tip, forming a round mass. Conversely, high-speed flow resulted in Onyx being dispersed as small pieces. We successfully replicated the formation of "Onyx threads" under continuous slow flow conditions, similar to our case. This phenomenon occurs when Onyx unexpectedly migrates to the draining vein through a tiny opening during transarterial embolization for arteriovenous shunt diseases. Early recognition and appropriate measures are necessary to prevent occlusive complications in the draining veins and the pulmonary system.

Influence of dosing pattern of antipsychotics on treatment outcome of delirium in patients with advanced cancer.

BACKGROUND: Clinical guidelines recommend antipsychotics for the treatment of delirium; however, there has been no confirmed recommendation regarding their administrating patterns. This study aims to investigate whether different dosing patterns of antipsychotics (single or multiple administrations) influence the outcomes of delirium treatment. METHODS: This is a secondary analysis of a prospective observational study involving patients with advanced cancer and delirium receiving antipsychotics. The Delirium Rating Scale Revised-98 was administered at baseline and after 72 h of starting pharmacotherapy. Patients were classified into single administration group (received a single dosage within 24 h before the assessment) and multiple administration group (received more than one dosage). RESULTS: A total of 555 patients (single administration 492 (88.6%); multiple administration 63 (11.4%)) were subjected to analyses. The patients in the multiple administration group were more likely to be male, in psycho-oncology consulting settings, with lower performance status, with hyperactive delirium and with severer delirium symptoms. In the multivariate analysis, single administration was significantly associated with better improvement of delirium (p < 0.01, 95% confidence interval: 1.83-5.87) even after controlling covariates. There were no significant differences in the mean dosages of antipsychotics per day in chlorpromazine equivalent (single administration 116.8 mg/day, multiple administration 123.5 mg/day) and the incidence of adverse events between the two groups. CONCLUSIONS: In this observational study sample, Delirium Rating Scale severity score improvement in single administration was higher than that seen in multiple administration. There was no difference in adverse events between the two groups.

Persistent representation of the environment in the hippocampus.

In the hippocampus, environmental changes elicit rearrangement of active neuronal ensembles or remapping of place cells. However, it remains elusive how the brain ensures a consistent representation of a certain environment itself despite salient events occurring there. Here, we longitudinally tracked calcium dynamics of dorsal hippocampal CA1 neurons in mice subjected to contextual fear conditioning and extinction training. Overall population activities were significantly changed by fear conditioning and were responsive to footshocks and freezing. However, a small subset of neurons, termed environment cells, were consistently active in a specific environment irrespective of experiences. A decoder modeling study showed that these cells, but not place cells, were able to predict the environment to which the mouse was exposed. Environment cells might underlie the constancy of cognition for distinct environments across time and events. Additionally, our study highlights the functional heterogeneity of cells in the hippocampus.

A Novel Approach to Neuroendovascular Treatment Looking Up from the Ascending Aorta Using an Alpha Shape Guiding Catheter.

BACKGROUND: A method of guiding an intermediate catheter from a new alpha-type guiding catheter placed in the ascending aorta to the carotid artery is evaluated in neuroendovascular treatment in challenging anatomic directions of the guiding catheter, such as the bovine aortic arch and type III aortic arch. METHODS: The existing 8-Fr guiding catheter was given a strong bending shape at the tip to make it an alpha type. The total length of the catheter was 85 cm. This guiding catheter was inserted into the ascending aorta to verify whether a 6-Fr intermediate or aspiration catheter could be coaxially guided into the right and left internal carotid arteries. A silicone vascular model was used for evaluation and in actual clinical cases. RESULTS: Creating an alpha shape of the catheter at the aortic arch was very easy. The inner catheter could be easily guided from the brachiocephalic artery to the right common carotid artery by pushing the alpha shape guiding catheter toward the aortic valve. The catheter was easily guided into the left common carotid artery when the α-guide was pulled a little bit backward. The 0.071-inch lumen aspiration catheter reached the bilateral middle cerebral arteries. CONCLUSIONS: The 8-Fr alpha shape guiding catheter quickly guides the inner catheter into the bovine and the type III aortic arch by looking up from the ascending aorta.

A novel remote hands-on training for neuroendovascular-based treatment in the era of the COVID-19 pandemic.

The COVID-19 pandemic has demanded a change in learning modalities, which led us to develop a remote personal training system for clinicians performing neuroendovascular procedures. A portable vascular model designed for practicing catheter navigation guidance, thrombus retrieval, and intracranial aneurysm coil embolisation was established. We created an environment that enabled interactive dialogue and communication across long distances using the Internet. The instructor conducted approximately 2 h of hands-on training with two to four trainees at a time. Despite the restrictions enforced by the Government of Japan due to the COVID-19 pandemic, 17 online hands-on training were successfully conducted throughout Japan over 1 year for a total of 48 trainees. The developed remote training programme, to avoid the aggregation of a large number of trainees at a developed time, proved to be at par with the conventional learning system. The training was well-received since the operation time was longer and the question and answer sessions were more fulfilling compared to the conventional format in which a group of trainees had got a brief opportunity to receive actual hands-on experience.

Usefulness of a Curved Multiple Reconstruction Image for Transarterial Intravenous Coil Embolization of a Dural Arteriovenous Fistula of the Sphenobasal Vein: A Case Report.

Hemorrhagic isolated dural arteriovenous fistulas (DAVFs) are often challenging to treat. Here, we report a case of the lateral cavernous sinus (CS) DAVF successfully treated by transarterial intravenous coil embolization using a curved multiplanar reconstruction (MPR) image assistance. A 54-year-old man presented with a severe headache and was diagnosed with subarachnoid hemorrhage caused by CSDAVF. Angiography indicated that the fistula was fed by branches of the left external carotid artery and drained into cortical veins. There were multiple shunting points at the left sphenobasal vein accompanied by varicose veins. Using curved MPR images, the left accessory meningeal artery was chosen for the endovascular approach into the affected veins, including ruptured varix. The shunt was completely occluded by detachable coils. When the curved MPR image indicates a developing feeding artery and a large shunting point, transarterial intravenous coil embolization becomes a good treatment option for CSDAVF, which has no venous access.

The Impact of Aging on Symptom Prevalence and Management in Terminally ill Patients With Cancer.

CONTEXT: With global population aging, the number of older patients with cancer is increasing. However, few data are available on palliative care for these patients. OBJECTIVES: To evaluate differences in symptom prevalence and the need for medical interventions among patients of different ages in a palliative care unit. METHODS: In this retrospective analysis, a consecutive sample of 1032 terminally ill patients with cancer were categorized into the following age ranges: <70, 70-79, 80-89, and ≥90 years. We evaluated symptom prevalence, the need for palliative medicines, opioid dose on the day before death, and the need for palliative sedation. Trend tests were used to examine whether the prevalence of findings increased or decreased with age. RESULTS: As age increased, significant decreasing trends were observed in the prevalence of pain, dyspnea, fatigue, constipation, nausea, drowsiness, difficulty sleeping, anxiety, and dysuria but not in appetite loss, edema, sputum production, or delirium. As age increased, significant decreasing trends were also observed in the need for opioids, benzodiazepines, antiemetics, and anticholinergics. The median opioid doses in the <70, 70-79, 80-89, and ≥90 years age groups were 118, 72, 48, and 48 mg oral morphine equivalents/day, respectively (P < 0.0001). The need for palliative sedation showed a significant decreasing trend as age increased (P < 0.0001). CONCLUSION: We found age to be inversely related to symptom prevalence and medical interventions among terminally ill patients with cancer, contributing to the understanding of the experience of older patients with cancer.

Safety and Effectiveness of a Modified ASAP Technique during Mechanical Thrombectomy for Acute Ischemic Stroke: Initial Clinical Experience.

OBJECTIVES: For patients with acute ischemic stroke, various endovascular approaches have been reported with high recanalization rates and good clinical outcomes. However, the best technique for the first attempt at mechanical thrombectomy remains a matter of debate. In this study, we evaluated the efficacy of a modified version of a stent-retrieving into an aspiration catheter with a proximal balloon (ASAP) technique. MATERIALS AND METHODS: Modification 1: After stent deployment, the microcatheter was not removed immediately. Modification 2: After the withdrawal of the stent retriever into an aspirator and its removal from the entire system, we focused on the drainage of fluid into a pump. The aspirator was withdrawn slowly until the fluid appeared to be draining continuously into the pump. Before the removal of the aspirator, we performed angiography through the aspirator. We carried out a retrospective analysis of 30 consecutive patients with acute ischemic stroke caused by occlusion of the anterior circulation who were treated with the modified ASAP technique at our institution. RESULTS: A thrombolysis in cerebral infarction score of 2B or 3 was achieved in 29/30 patients (96.7%). The average number of passes was 1.2 ± 0.5. The mean time from puncture to recanalization was 17.6 ± 6.84 min. Twenty-three (76.7%) patients achieved a modified Rankin Scale score of 0-2 at 3 months after the procedure. CONCLUSIONS: We found that the modified ASAP technique yielded fast recanalization, minimal complications, and good clinical outcomes of mechanical thrombectomy in this case series.

Local Balloon-Assisted Navigation of a Microcatheter into an Aneurysm during Intracranial Aneurysmal Coiling: A Dunk Shot Technique.

OBJECTIVES: Various endovascular approaches have been reported for patients with intracranial aneurysms. However, the safety of navigating a microcatheter into the aneurysm remains debatable. In this study, we evaluated a novel method "dunk shot technique," in which a proximal balloon and a local balloon are used for navigation of a microcatheter into an aneurysm under challenging situations. MATERIALS AND METHODS: We have reported two cases of unruptured internal carotid artery-superior hypothalamic artery aneurysm. An 8-F balloon-attached catheter was used as the guiding catheter. A local balloon catheter for neck remodeling and a microcatheter for coil insertion were navigated around the aneurysmal neck region. When it seemed difficult to navigate a microcatheter into an aneurysm, both the guiding balloon and a local balloon catheter were used for assistance. After inflation of the guiding balloon, the local balloon was inflated partially to negotiate the tip of the microcatheter. RESULTS: The uncontrollable tip of the microcatheter could be intentionally moved by the local balloon. CONCLUSIONS: We evaluated the effectiveness of the balloon-assisted technique for the navigation of a microcatheter in cases with challenging anatomy. A little bit of direct effect to the tip of the microcatheter by a local balloon could produce effective outcomes under the proximal flow arrest.

Unruptured Paraclinoid Carotid Aneurysms Occur More Frequently in Younger Ages.

PURPOSE: We investigated the age distribution of cerebral saccular aneurysms in various locations to clarify the differences by location and discuss the mechanism of formation. MATERIALS AND METHODS: We retrospectively assessed clinical material obtained from 1,252 unruptured aneurysms treated with endovascular embolization between 2004 and 2019. Age, sex, laterality, and size were investigated by the location of aneurysms, classified as cavernous internal carotid artery (ICA), paraclinoid ICA, supraclinoid ICA, anterior communicating artery, anterior cerebral artery, middle cerebral artery, basilar artery complex, and posterior inferior cerebellar artery. Paraclinoid aneurysms were subclassified into 3 patterns according to their projecting direction: S-type, with superior protrusion; M-type, with medial protrusion; and P-type, with posteroinferior protrusion. RESULTS: There was no significant difference by location for sex, laterality, and size. The mean age of patients with paraclinoid aneurysms (56.5 years old) was significantly lower than that of other aneurysm patients (64.3 years old). Notably, 40% of the patients with M-type aneurysms were <50 years old. This percentage was significantly higher than that of aneurysms at other locations (P<0.05). CONCLUSION: We found a young female predominance for patients with paraclinoid carotid aneurysms. This study may suggest that congenital factors contribute to paraclinoid aneurysm formation as well acquired factors, such as hemodynamic stress, atherosclerotic wall damage, and local inflammation.

Pull the Trigger Sign: A Novel Method to Identify the Clot Position during Acute Endovascular Thrombectomy.

Objective: Accurately determining the clot position is highly important for immediate recanalization when endovascular mechanical thrombectomy is performed using a stent retriever and aspiration catheter. We describe a new method that facilitates the precise identification of the clot position called pull the trigger sign (PTS). Case Presentation: Selective angiography was performed through a 0.027-inch microcatheter that penetrated the clot into the distal lumen. Although the contrast media highlighted the occluded artery, it often stagnated in the distal artery. It was washed away at a certain point when a stent clot retriever was deployed over the potential clot site. We hypothesized that this point represented the exact position of the clot's proximal end and used in vitro analyses to assess this hypothesis. Briefly, a circulation-enabled silicone vascular model in which colored water was used to simulate stagnation beyond a fake clot was developed and utilized to investigate PTS six times. The rate of identifying PTS in the vascular model was 100%. As hypothesized, stagnant fluid was washed away when the deployed stent reached the clot's proximal position. The clinical efficacy of PTS was also confirmed. Conclusion: PTS was useful in revealing the precise position of clot's proximal end, which enabled safer contact aspiration when using an aspiration catheter. Thus, PTS led to a higher success rate and faster recanalization in the first attempt than conventional methods.

Initial Clinical Experience of Using a Newly Designed Preshaped Microguidewire in Acute Endovascular Thrombectomy.

Mechanical thrombectomy has been widely used for the treatment of acute ischemic stroke. During this procedure, operators must navigate the microcatheter with a microguidewire (MGW) into vessels that cannot be visualized on fluoroscopy as rapidly as possible. In this study, we developed a modified pigtail-shaped MGW (MPMGW) for security and controllability. Moreover, the efficacy of the MPMGW for the treatment of acute ischemic stroke was assessed. The MPMGW was designed using 0.014 MGW. Because we created four MPMGWs during a clinical evaluation before the launch in the market, these wires were used in four consecutive patients with acute ischemic stroke in the single institution. The occluded arteries were the basilar artery (n = 1), middle cerebral arteries (M1 and M2, n = 2), and internal carotid artery (n = 1). All four procedures were conducted without any complications. The procedures included navigating the MGW and passing it through the clot. Complete recanalization was achieved in all cases. The average time between femoral artery puncture and recanalization was 15 min. The use of the preshaped MPMGW in acute thrombectomy was effective in terms of both security of procedure and reduction in recanalization time.

Novel Technique for Detection of Actual Position of Clot During Endovascular Clot Retrieval: Assessment of Microcatheter Withdrawing Angiography.

BACKGROUND: When endovascular clot retrievals are performed using a stent retriever and/or an aspiration catheter, identifying the accurate position of a clot is extremely important for a successful immediate recanalization. Herein, we report a new technique called microcatheter withdrawing angiography, which facilitates the identification of the precise position of a clot. The negative shadow appearance of the clot on angiography was referred to as the actual crab claw sign. METHODS: When a 0.027-inch microcatheter penetrated the clot after inserting a 0.014-inch microwire, selective angiography was conducted using the microcatheter. Simultaneously, the microcatheter was slowly withdrawn with continuous contrast media injection, while the microwire was kept in the distal vessel. The precise position of the clot was found, which was referred to as the actual crab claw sign. Next, we conducted in vitro and in vivo analyses. RESULTS: The actual crab claw sign could be identified in the vascular model and in actual clinical settings. Therefore the sweet spot of the stent retriever could be set over the clot, and an accurate contact aspiration could be performed using an aspirator. CONCLUSIONS: Microcatheter withdrawing angiography can help identify the actual crab claw sign. This technique has a higher success rate and faster recanalization than conventional strategy, particularly in challenging cases of unsuccessful recanalization during the first attempt.

How successful are we in relieving terminal dyspnea in cancer patients? A real-world multicenter prospective observational study.

PURPOSE: Parenteral morphine is widely used for dyspnea of imminently dying cancer patients, but the outcomes to expect over time remain largely unknown. We examined outcomes after the administration of parenteral morphine infusion over 48 h in cancer patients with a poor performance status. METHODS: This was a multicenter prospective observational study. Inclusion criteria were metastatic/locally advanced cancer, ECOG performance status = 3-4, a dyspnea intensity ≥ 2 on a Support Team Assessment Schedule, Japanese version (STAS-J), and receiving specialized palliative care. After initiating parenteral morphine infusion, we measured dyspnea STAS-J as well as Memorial Delirium Assessment Scale (MDAS), item 9, and Communication Capacity Scale (CCS), item 4, every 6 h over 48 h. RESULTS: We enrolled 167 patients (median survival = 4 days). The mean age was 70 years, 80 patients (48%) had lung cancer, and 109 (65%) had lung metastases. The mean STAS-J scores decreased from 3.1 (95% confidence interval (CI) = 3.0-3.2) at the baseline to 2.1 (95%CI = 1.9-2.2) at 6 h, and remained 1.6-1.8 over 12-48 h. The proportion of patients with dyspnea relief (STAS-J ≤ 1) increased to 39% at 6 h, and ranged between 49 and 61% over 12-48 h. In contrast, up to 6.6 and 20% of patients showed hyperactive delirium (MDAS item 9 ≥ 2) and an inability to communicate (CCS item 4 = 3), respectively, over 48 h. CONCLUSIONS: Overall, terminal dyspnea was relatively well controlled with parenteral morphine, though a significant number of patients continued to suffer from dyspnea. Future efforts are needed to improve outcomes following standardized dyspnea treatment using patient-reported outcomes for imminently dying patients.

Variegatic acid from the edible mushroom Tylopilus ballouii inhibits TNF-α production and PKCß1 activity in leukemia cells.

Variegatic acid, isolated from Tylopilus ballouii dry fruiting bodies, is an inhibitor of ß-hexosaminidase release and tumor necrosis factor (TNF)-α secretion from rat basophilic leukemia (RBL-2H3) cells, with IC50 values of 10.4 µM and 16.8 µM, respectively. On the other hand, it inhibits PKCß1 activity with an IC50 value of 36.2 µM.

A Multicenter Cohort Study to Explore Differentiating Factors between Tumor Fever and Infection among Advanced Cancer Patients.

Background: Tumor fever and infection are common febrile etiologies among advanced cancer patients. To date, only few studies have been conducted to differentiate between tumor fever and infections. Objective: This study aimed to identify discriminating factors that provide rapid results and are feasible and minimally invasive for discriminating between tumor fever and infection in advanced cancer patients. Methods: This is a retrospective cohort study. Advanced cancer patients with clinically diagnosed tumor fever or infection, who received medical treatment from palliative care specialists in 10 nationwide Japanese hospitals, were consecutively identified during August 2012 and November 2014. The symptoms, physical findings, blood test results at baseline and during fever, imaging findings, and sociodemographic factors of these patients were retrospectively extracted. Results: Thirty-three patients with tumor fever and 72 patients with infection were identified. Their mean age was 68.8 years, 68 (64.8%) were men, and the median palliative performance status (PPS) was 50. Statistically significant factors predicting tumor fever by logistic regression analysis were as follows: deterioration of PPS (odds ratio, 0.078), shaking chills during fever (0.067), and change from baseline data of neutrophil/lymphocyte ratio of ≥5 (0.14). Conclusions: Shaking chills during fever, and changes from baseline of performance status and white blood cell differentiation can be useful to differentiate between tumor fever and infection among advanced cancer patients. Further confirmatory studies are needed.

Efficacy of Endovascular Proximal Occlusion before Direct Reposition Surgery of Blunt Cervical Fracture with Unilateral Vertebral Injury.

Cerebral infarction related to traumatic vertebral artery (VA) injuries is not common. However, if VA injuries cause ischemic and/or hemorrhage stroke, these subsequent problems can result in severe residual impairment and mortality. Herein, we present five patients with cervical vertebra fractures due to blunt cervical trauma who underwent preoperative endovascular therapy. Between June 2010 and April 2018 in our hospital, five patients with traumatic occlusion of a unilateral VA underwent coil embolization to prevent post-surgical stroke due to reperfusion in the VA. Because of cervical instability or subluxation, all of the patients received endovascular therapy before surgery for their cervical fracture. None of the patients presented with stroke after presurgical embolization and direct surgery. When stagnated blood, including thrombi, in the occluded VA is released during cervical surgery, brain embolism may occur. Therefore, early cerebrovascular vessel assessment and presurgical endovascular treatment must be considered to prevent stroke after direct surgery.

A Novel Technique for Microcatheter Additional Shaping During Intracranial Aneurysmal Coil Embolization: Microcatheter Shaping Cast.

BACKGROUND: When a shaping mandrel is inserted into the tip of a preshaped microcatheter, the existing curve becomes uncertain because the tip is straightened by the inner mandrel. Therefore, we developed a way to perform microcatheter shaping by means of an external cast, which we named "microcatheter shaping cast." TECHNIQUES: A shaping mandrel attached to a microcatheter was used and coiled 4-5 times around a metallic introducer, which was attached using a microguidewire. Then, a stent-like handmade cast was prepared. After the microcatheter tip was inserted into the cast, it was manually bent according to the aneurysmal shape and size. The tip and cast were heated with a hot air gun. We evaluated the relationship between degrees of bending and heating time to achieve appropriate right-angled shaping memory. CONCLUSIONS: The presented microcatheter shaping method should be more useful than conventional internal shaping, especially in cases that require an additional microcatheter shaping or reshaping during aneurysmal coil embolization.

Precautions for using a Filter Protection Device with a Flow Reversal Method during Carotid Artery Stenting: A Case Report on In-Filter Thrombus.

The combination of a flow reversal with two balloons and a filter protection device is one of the safest methods that can be used during carotid artery stenting (CAS). Although major adverse events did not occur under restrict protection, we experienced a case of in-filter thrombus during the procedure. A 68-year-old male presented with temporary right hemiparesis. The radiological examinations revealed 95% stenosis on the origin of the left internal carotid artery (ICA). The patient underwent left CAS of wherein a proximal common carotid artery balloon, an external carotid artery balloon, and a distal ICA filter, with continuous flow reversal to the femoral vein, were used. Although the reversal circulation was established, a massive newly developing thrombus was found in the proximal side of the filter. After an additional systemic heparinization, the thrombus disappeared. The procedure was performed without any complications. Physicians should be aware of the risk of developing intraprocedural thrombosis in a filter protection device. Because the filter protection device is designed for the antegrade flow, it may promote the development of thrombus against the retrograde flow. Thus, the filter protection device should be retrieved first under the flow reversal circumstance to avoid the distal migration of a clot around the filter device.