Factors affecting reasonable duration of continuous electrocardiographic monitoring to detect atrial fibrillation in acute ischemic stroke.

BACKGROUND: To examine the reasonable duration of continuous electrocardiographic monitoring (CEM) to detect AF at acute ischemic stroke. MATERIALS AND METHOD: 811 consecutive patients admitted to Tsuruga Municipal Hospital by acute ischemic stroke between April 2013 and December 2021 were enrolled in this study. Excluding 78 patients, 733 patients were analyzed by cluster analysis with SurvCART algorithm, followed by Kaplan-Meier analysis. RESULTS: The analysis provided step graphs for 8 subgroups. The duration of CEM to achieve the sensitivity of 0.8, 0.9, and 0.95 in each could be calculated. The duration of CEM to achieve the sensitivity of 0.8 are 18 days in female patients with heart failure (HF) (subgroup 1), 24 days in male patients with HF (subgroup 2), 22 days in patients without HF with arterial occlusion and pulse rate (PR) more than 91 (subgroup 3), 24 days in patients without HF with occlusion with PR less than 91 (subgroup 4), 18 days in patients without HF without occlusion with lacuna (subgroup 5), 26 days in patients without HF, occlusion, and lacuna, with arterial stenosis (subgroup 6), 15 days in patients without HF, occlusion, lacuna, and stenosis with BMI more than 21%(subgroup 7), and 44 days in patients without HF, occlusion, lacuna, stenosis and with BMI less than 21% (subgroup 8). CONCLUSIONS: Duration of CEM with the sensitivity of 0.8, 0.9, and 0.95 could be determined by presence of HF, female sex, arterial occlusion, PR more than 91/minute, presence of lacuna, presence of stenosis, and BMI more than 21%. (250).

Cross-tissue correlations of genome-wide DNA methylation in Japanese live human brain and blood, saliva, and buccal epithelial tissues.

Neuroepigenetics considers genetic sequences and the interplay with environmental influences to elucidate vulnerability risk for various neurological and psychiatric disorders. However, evaluating DNA methylation of brain tissue is challenging owing to the issue of tissue specificity. Consequently, peripheral surrogate tissues were used, resulting in limited progress compared with other epigenetic studies, such as cancer research. Therefore, we developed databases to establish correlations between the brain and peripheral tissues in the same individuals. Four tissues, resected brain tissue, blood, saliva, and buccal mucosa (buccal), were collected from 19 patients (aged 13-73 years) who underwent neurosurgery. Moreover, their genome-wide DNA methylation was assessed using the Infinium HumanMethylationEPIC BeadChip arrays to determine the cross-tissue correlation of each combination. These correlation analyses were conducted with all methylation sites and with variable CpGs, and with when these were adjusted for cellular proportions. For the averaged data for each CpG across individuals, the saliva-brain correlation (r = 0.90) was higher than that for blood-brain (r = 0.87) and buccal-brain (r = 0.88) comparisons. Among individual CpGs, blood had the highest proportion of CpGs correlated to the brain at nominally significant levels (19.0%), followed by saliva (14.4%) and buccal (9.8%). These results were similar to the previous IMAGE-CpG results; however, cross-database correlations of the correlation coefficients revealed a relatively low (brain vs. blood: r = 0.27, saliva: r = 0.18, and buccal: r = 0.24). To the best of our knowledge, this is the fifth study in the literature initiating the development of databases for correlations between the brain and peripheral tissues in the same individuals. We present the first database developed from an Asian population, specifically Japanese samples (AMAZE-CpG), which would contribute to interpreting individual epigenetic study results from various Asian populations.

Factors affecting global neurocognitive status and frontal executive functions in the early stage after surgical clipping of unruptured anterior circulation aneurysms with respect to keyhole clipping and conventional clipping.

PURPOSE: This study investigated the most significant factor for the preservation of the global neurocognitive status and frontal executive functions in the surgical clipping of unruptured anterior circulation aneurysms, specifically in keyhole and conventional clipping procedures. METHODS: The prospective study that was performed to examine the effects of aneurysm surgery on the patient's global neurocognitive status and frontal executive functions started on April 2016. After exclusion posterior circulation aneurysms, anterior communicating aneurysms treated by interhemispheric approach, giant aneurysms, and paraclinoid aneurysms, 23 patients who were enrolled before May 2017 were treated by conventional clipping, and 18 patients who were enrolled after June 2017 were treated by keyhole clipping. Two patients were excluded from each group due to missing data. Finally, 21 and 16 patients in each group were analyzed, respectively. Three-tesla magnetic resonance imaging was performed before and after surgery to detect the presence of perioperative cerebral infarctions and brain edema. The Mini-Mental State Examination, Frontal Assessment Battery, and Self-Rating Depression Scale scores were obtained before and 1 month after surgery. RESULTS: Logistic regression analyses indicated that anterior communicating and internal carotid artery aneurysms were the most significant factors for poor outcomes and that keyhole clipping for these two types of aneurysm was the most significant factor for the preservation of patient global neurocognitive status. Keyhole clipping was also the most significant factor for the preservation of frontal executive functions in patients. CONCLUSIONS: Keyhole clipping may be more favorable than conventional clipping for the preservation of the global neurocognitive status and frontal executive functions. Moreover, it may be the most effective factor for preservation of global neurocognitive status when it is indicated for anterior communicating or internal carotid artery aneurysms.

A Case of the So-Called Posterior Condylar Canal Dural Arteriovenous Fistula with an Osseous Shunt.

Objective: The authors describe a case of the so-called dural arteriovenous fistula (DAVF) around the posterior condylar canal (PCC). Case Presentation: A 71-year-old woman presented with pulse-synchronous bruit on the left side. Conventional DSA demonstrated the following: There were many feeders, including the ascending pharyngeal artery (APA), the occipital artery (OA), and the vertebral artery (VA), to the DAVF around the PCC. Shunt flow from the posterior condylar vein (PCV) drained the suboccipital cavernous sinus (SCS) and sigmoid sinus (SS), and there was venous reflux into the inferior petrosal sinus (IPS). The patient was diagnosed with PCC DAVF and underwent transvenous embolization (TVE) with coils. Intraoperative 3D-rotational angiography (RA) and axially reconstructed images revealed an osseous shunt within the occipital bone adjacent to the PCC. The arteriovenous (AV) shunt and other symptoms disappeared after occluding the drainage route from the osseous shunt to the PCV. Conclusion: There are only three previous reports of PCC DAVF, being rare. However, no report clearly described the shunt point of PCC DAVF. 3D-RA and axially reconstructed images were useful to find and treat the shunt point.

[Optic Neuropathy Secondary to Compression by the Internal Carotid Artery Concomitant with an Inflammatory Granuloma:A Case Report].

A 77-year-old man presented with a 6-month history of progressive right optic neuropathy secondary to compression by the ipsilateral internal carotid artery(ICA). We performed anterior clinoidectomy and optic canal unroofing. Subsequently, we wrapped the ICA with a polytetrafluoroethylene tape, pulled the vessel laterally, and sutured the tape to the dura mater at the anterior skull base for optimal decompression. An inflammatory mass lesion was observed around the ICA, which led to further compression of the optic nerve. Histopathological examination of the resected specimen showed an inflammatory granuloma. The patient's visual field deficit showed partial improvement postoperatively. Transposition using a tape might be an effective surgical alternative for compressive optic neuropathy.

Deflation of a Rathke cleft cyst triggered rupture of a superior hypophyseal artery aneurysm: a case report.

A 57-year-old woman was diagnosed as a Rathke cleft cyst (RCC). Endoscopic transsphenoidal surgery (TSS) was performed uneventfully. She developed subarachnoid haemorrhage on postoperative day 3. The vessels adhered the cyst had been pulled into the pituitary fossa, causing an aneurysm.

[Vestibular Schwannoma Surgery with Continuous Intraoperative Monitoring of Evoked Facial Nerve Electromyograms].

Preservation of facial nerve function is crucial during vestibular schwannoma surgery. Here, we report the utility of continuous intraoperative monitoring of evoked facial nerve electromyograms(EMGs)for preservation of facial nerve function during vestibular schwannoma surgery. A 64-year-old man presented with left ear hearing disturbance. CT and MRI revealed a tumor mass(4cm)with cyst formation in the left cerebellopontine angle. Microsurgical removal was performed with continuous intraoperative monitoring of evoked facial nerve EMGs. An electrode with Ag wire and absorbable gelatin sponge, which we developed, was used for continuous monitoring. It could be placed and fixed more easily on the root exit zone of the facial nerve than the previously reported electrodes and provide reliable information during surgery. The tumor mass could be removed safely without inducing facial nerve palsy. Continuous intraoperative monitoring of evoked facial nerve EMGs with this newly developed electrode could facilitate successful schwannoma surgery.

Pathological examination of cerebral amyloid angiopathy in patients who underwent removal of lobar hemorrhages.

Cerebral amyloid angiopathy (CAA) is a degenerative disorder characterized by amyloid-ß (Aß) deposition in the brain microvessels. CAA is also known to contribute not only to cortical microbleeds but also lobar hemorrhages. This retrospective study examined CAA pathologically in patients who underwent direct surgeries for lobar hemorrhage. Thirty-three patients with lobar hemorrhage underwent open surgery with biopsy from 2007 to 2016 in our hospital. Cortical tissues over hematomas obtained surgically were pathologically examined using hematoxylin, eosin stain, and anti-Aß antibody to diagnose CAA. We also investigated the advanced degree of CAA and clinical features of each patient with lobar hemorrhage. In the 33 patients, 4 yielded specimens that were insufficient to evaluate CAA pathologically. Twenty-four of the remaining 29 patients (82.8%) were pathologically diagnosed with CAA. The majority of CAA-positive patients had moderate or severe CAA based on a grading scale to estimate the advanced degree of CAA. About half of the CAA-positive patients had hypertension, and four took anticoagulant or antiplatelet agents. In five patients who were not pathologically diagnosed with CAA, one had severe liver function disorder, three had uncontrollable hypertension, and one had no obvious risk factor. Our pathological findings suggest that severe CAA with vasculopathic change markedly contributes to lobar hemorrhage. The coexistence of severe CAA and risk factors such as hypertension, anticoagulants or antiplatelets may readily induce lobar hemorrhage.

Spinal endoscopy combined with selective CT myelography for dural closure of the spinal dural defect with superficial siderosis: technical note.

The authors describe a new procedure to detect the tiny dural hole in patients with superficial siderosis (SS) and CSF leakage using a coronary angioscope system for spinal endoscopy and selective CT myelography using a spinal drainage tube. Under fluoroscopy, surgeons inserted the coronary angioscope into the spinal subarachnoid space, similar to the procedure of spinal drainage, and slowly advanced it to the cervical spine. The angioscope clearly showed the small dural hole and injured arachnoid membrane. One week later, the spinal drainage tube was inserted, and the tip of the drainage tube was located just below the level of the dural defect found by the spinal endoscopic examination. This selective CT myelography clarifies the location of the dural defect. During surgery, the small dural hole could be easily located, and it was securely sutured. It is sometimes difficult to detect the actual location of the small dural hole even with thin-slice MRI or dynamic CT myelography in patients with SS. The use of a coronary angioscope for the spinal endoscopy combined with selective CT myelography may provide an effective examination to assess dural closure of the spinal dural defect with SS in cases without obvious dural defects on conventional imaging.

[Neurosurgical Outcomes of Intradural Extramedullary Spinal Tumors in 97 cases:Siberian Experience].

We retrospectively investigated the clinical presentation and outcome of patients with spinal intradural extramedullary tumors, which had been surgically treated. A total of 97 consecutive patients(32 males and 65 females;mean age, 48 years;range, 17-79 years)underwent surgery between 2004 and 2014 at Irkutsk State Medical Academy and affiliated hospitals. To determine presentation and outcomes associated with these tumors, we evaluated the waiting period before surgery, neurological symptoms including motor, sensory, urinary, and rectal dysfunction, modified McCormick scale, Macnab's outcome assessment of patient satisfaction, surgical procedure, tumor location, and histological diagnosis. The most frequent preoperative symptom was myelopathy(52.6%)at presentation, followed by radiculopathy(20.6%), and a combination of both(26.8%). Surgical intervention produced highly successful results, in which 77 of 97 cases showed neurological improvement. However, the symptoms were not completely reversed, and there was improvement only the equivalent to one grade in the modified McCormick scale for most patients. Surgical outcomes were not influenced by tumor location, extent of lamina resection, or histological diagnosis, but there was a correlation between greater patient improvement and a shorter waiting period before surgery. As such, we recommend early total resection for symptomatic spinal intradural extramedullary tumors.

Evaluation of obliteration of arteriovenous malformations after stereotactic radiosurgery with arterial spin labeling MR imaging.

PURPOSE: Complete obliteration of treated arteriovenous malformations (AVMs) can be diagnosed only by confirming the disappearance of arterio-venous (A-V) shunts with invasive catheter angiography. The authors evaluated whether non-invasive arterial spin labeling (ASL) magnetic resonance (MR) imaging can be used to diagnose the obliteration of AVMs facilitate the diagnosis of AVM obliteration after treatment with stereotactic radiosurgery (SRS). MATERIAL AND METHODS: Seven patients with a cerebral AVM treated by SRS were followed up with ASL images taken with a 3T-MR unit, and received digital subtraction angiography (DSA) after the AVM had disappeared on ASL images. Three patients among the seven received DSA also after the postradiosurgical AVM had disappeared on conventional MR images but A-V shunt was residual on ASL images. Four patients among the seven received contrast-enhanced (CE) MR imaging around the same period as DSA. RESULTS: ASL images could visualize postradiosurgical residual A-V shunts clearly. In all seven patients, DSA after the disappearance of A-V shunts on ASL images demonstrated no evidence of A-V shunts. In all three patients, DSA after the AVM had disappeared on conventional MR images but not on ASL images demonstrated residual A-V shunt. CE MR findings of AVMs treated by SRS did not correspond with DSA findings in three out of four patients. CONCLUSIONS: Findings of radiosurgically treated AVMs on ASL images corresponded with those on DSA. The results of this study suggest that ASL imaging can be utilized to follow up AVMs after SRS and to decide their obliteration facilitate to decide the precise timing of catheter angiography for the final diagnosis of AVM obliteration after SRS.

[Detection of oculomotor nerve compression by 3D-FIESTA MRI in a patient with pituitary apoplexy and diabetes mellitus].

We report the usefulness of 3D-FIESTA magnetic resonance imaging(MRI)for the detection of oculomotor nerve palsy in a case of pituitary apoplexy. A 69-year-old man with diabetes mellitus presented with complete left-side blepharoptosis. Computed tomography of the brain showed an intrasellar mass with hemorrhage. MRI demonstrated a pituitary adenoma with a cyst toward the left cavernous sinus, which was diagnosed as pituitary apoplexy. 3D-FIESTA revealed that the left oculomotor nerve was compressed by the cyst. He underwent trans-sphenoid tumor resection at 5 days after his hospitalization. Post-operative 3D-FIESTA MRI revealed decrease in compression of the left oculomotor nerve by the cyst. His left oculomotor palsy recovered completely within a few months. Oculomotor nerve palsy can occur due to various diseases, and 3D-FIESTA MRI is useful for detection of oculomotor nerve compression, especially in the field of parasellar lesions.

Intraoperative computed tomography for cervicomedullary decompression of foramen magnum stenosis in achondroplasia: two case reports.

The authors report two cases of cervicomedullary decompression of foramen magnum (FM) stenosis in children with achondroplasia using intraoperative computed tomography (iCT). A 14-month-old girl with myelopathy and retarded motor development, and a 10-year-old girl who had already undergone incomplete FM decompression was presented with myelopathy. Both patients underwent decompressive sub-occipitalcraniectomy and C1 laminectomy without duraplasty using iCT. It clearly showed the extent of FM decompression during surgery, which finally enabled sufficient decompression. After the operation, their myelopathy improved. We think that iCT can provide useful information and guidance for sufficient decompression for FM stenosis in children with achondroplasia.

Microsurgical findings of Tolosa-Hunt syndrome.

BACKGROUND: Tolosa-Hunt syndrome (THS), a nonspecific chronic inflammation of the cavernous sinus, is a rarely needed surgical manipulation, even for diagnosis, because corticosteroid therapy is markedly effective against this condition. METHODS: A 59-year-old man presented with left trigeminal neuralgia and right abducens nerve palsy 2 months after the improvement of right oculomotor nerve palsy by corticosteroid therapy. Radiological examinations showed a mass lesion in the left cavernous sinus. The clinical course indicated THS; however, hematological examination showed a positive tuberculous test. We performed a biopsy to rule out tuberculoma in the cavernous sinus. RESULTS: The biopsy was via a left frontotemporal interdural approach. The dura propria over the cavernous sinus was thickened and tightly adhered to the inner layer. The cavernous sinus was occupied by whitish elastic-hard tissue, and it was partially resected through the anterolateral triangle. Histopathological examination showed thick fibrous tissue with numerous degenerated cells and partial inflammatory cell infiltrations without any findings of tuberculoma. The final diagnosis was THS, and corticosteroid therapy was effective despite the chronic fibrous change of the cavernous sinus lesion. CONCLUSIONS: This article presents details of surgical findings of THS that have not been demonstrated in any previous reports.

Measurement and cellular sources of the soluble interleukin-2 receptor in primary central nervous system lymphoma.

The aims of this study were to determine the diagnostic utility of the serum levels of the soluble interleukin 2 receptor (sIL-2R) as a tumor marker of primary central nervous system lymphoma (PCNSL) and to investigate the cellular source of sIL-2R using immunohistochemical staining. The serum sIL-2R levels of 37 samples from suspected PCNSL patients were measured. There were 13 patients with PCNSL and 24 patients with other diseases such as glioma, metastatic tumor, inflammation, or cerebrovascular disease. The serum sIL-2R levels of the PCNSL cases and other brain diseases were 629.5 ± 586.0 U/ml (mean ± SD; range 189-2220 U/ml) and 408.5 ± 250.7 U/ml (160-837 U/ml), respectively. The serum sIL-2R levels of the two groups overlapped, and hence the difference between them was not significant. sIL-2R is the α subunit of IL-2R. It is also known as CD25, and is cleaved from its position in the cell membrane and released into the blood. CD25 expression was immunohistochemically detected in 7 of 11 PCNSL samples. Confocal laser microscopy revealed that CD25 signals were present in atypical cells and mononuclear cells. We concluded that both lymphoma cells and infiltrating T cells express CD25, which is one of the cellular sources of sIL-2R.

Intraoperative and pathological findings of intramedullary amputation neuroma associated with spinal ependymoma.

Amputation neuromas typically arise in injured peripheral nerves; rarely, however, they arise in the spinal cord. We report a rare case of intramedullary amputation neuroma associated with ependymoma in the cervical spinal cord. A 73-year-old woman presented with a 5-year history of progressive gait disturbance. Neurological examination revealed complete motor deficit of her hands and legs. Magnetic resonance imaging of the cervical spine revealed an enhancing mass within the spinal cord at the C6/7 level. The patient underwent C5-C7 laminectomy surgery. During resection of the spinal tumor, we found a whitish string resembling an aberrant nerve root or schwannoma with adhesion to the tumor on the ventral side of the spinal cord. After resecting the tumor, the surgical specimen was cut and separated into a soft greyish tumor (spinal tumor) and the tough whitish string. Histopathological and immunohistochemical examination revealed the former was a spinal ependymoma and the latter was a neuroma. An intramedullary amputation neuroma associated with a spinal ependymoma is rare, and this is the first known case in which intraoprerative findings were clearly shown. Neurosurgeons should be aware that spinal ependymomas might coexist with neuromas.

Clinicopathological features in the recurrence of oligodendroglioma and diffuse astrocytoma.

To investigate whether grade II oligodendroglioma was transformed to glioblastoma or not, histopathological evaluation of recurrent oligodendrogliomal tumors (OG) and diffuse astrocytomas (DA) was performed. The OG group was composed of ten patients with OG, including seven oligodendrogliomas and three oligoastrocytomas. The DA group was composed of ten patients with DA, including eight fibrillary astrocytomas and two gemistocytic astrocytomas. The histopathological parameters of glioblastoma including nuclear atypia, multinucleated giant cells, glomeruloid tufts (GT) as a marker of microvascular proliferation, necrosis, and the Ki-67 staining index were investigated. Evaluation of these parameters was scored as follows: 0, none; 1, sporadic; 2, partial; 3, extensive. There were no cases of transformation to glioblastoma in the OG group. There were five cases of transformation to secondary glioblastoma in the DA group. In recurrent tumors, scores of GT and necrosis in the OG group were significantly lower than those in the DA group (p < 0.005). Nuclear atypia and high proliferative activity (Ki-67 index) were identified in recurrent tumors of the OG group. Our study suggested that the extent of GT and necrosis in recurrent OG was less than that in recurrent DA, and transformation to glioblastoma from oligodendroglial tumor was exceptional.

Glioblastoma with oligodendroglial components: glioblastoma or anaplastic oligodendroglial tumors.

There have been some recent reports about glioblastoma with oligodendroglial (OG) components and malignant glioma with primitive neuroectodermal tumor (PNET)-like components. We investigated whether the presence and extent of OG components and PNET-like components influenced the prognosis in patients with glioblastoma. Eighty-six patients with glioblastoma were divided into an OG group (28 %), which revealed areas with a honeycomb appearance, and a non-OG group (72 %) without a honeycomb appearance. Patients with glioblastoma were also divided into a PNET group (27 %), which revealed areas with PNET-like features defined as neoplastic cells with high N/C ratios and hyperchromatic oval-carrot-shaped nuclei, and lacked the typical honeycomb appearance, and a non-PNET group (73 %) without PNET features. There were no significant differences in overall survival among the OG, the non-OG, the PNET, and the non-PNET groups. Two patients who survived longer than 36 months had both OG and PNET components with 1p or 19q loss of heterozygosity. Perinuclear halo, which is a characteristic feature of oligodendrogliomas, is an artifact of tissue fixation. Therefore, we should not readily use the term glioblastoma with OG components. PNET-like components, which are considered rare in malignant gliomas, may be frequently identified in glioblastomas.

Atypical and ischemic features of embolized meningiomas.

Preoperative embolization (POE) of meningiomas is widely used to facilitate surgical removal and to reduce intraoperative blood loss. The resulting necrosis and enhanced proliferation have been reported to affect subsequent histologic grading. However, there was little concern about ischemic features, for example small cells resembling atypical meningiomas, cytoplasmic vacuoles resembling clear cell meningioma, intercellular discohesion resembling rhabdoid meningioma, and perivascular cuffs resembling papillary meningioma. Therefore, the extent of these ischemic features was scored and Ki-67 staining indices were investigated in a POE group composed of 29 specimens of meningiomas treated with POE and compared with equivalent results for a non-POE group composed of 29 meningiomas that were not treated with POE. Small cells with high N/C ratios, cytoplasmic vacuoles, intercellular discohesion, and perivascular cuffs were significantly increased in the POE group (versus the non-POE group, p < 0.05). There were no significant differences of the Ki-67 index between the POE group (2.2%) and the non-POE group (1.9%) (p = 0.49). Our results suggest that small cell change resulting in necrosis may be followed by POE, and that clear cell-like, rhabdoid cell-like, or pseudopapillary pattern identified in meningiomas may also be induced by POE. Therefore, histological findings and determination of grading should be evaluated cautiously in cases of embolized meningiomas.