Predictive role of regional thigh tissue oxygen saturation monitoring during cardiopulmonary bypass in lung injury after cardiac surgery.

Acute respiratory distress syndrome (ARDS) is a serious complication following cardiac surgery mainly associated with the use of cardiopulmonary bypass (CPB), which could increase the risk of mortality and morbidity. This study investigated the association of regional oxygen saturation (rSO2) during CPB with postoperative outcomes, including respiratory function. Patients who underwent cardiac surgery with CPB from 2015 to 2019 were included. Near-infrared spectroscopy was used to monitor rSO2 at the forehead, abdomen, and thighs throughout the surgery. Postoperative markers associated with CPB were assessed for correlations with PaO2/FiO2 (P/F) ratios at intensive care unit (ICU) admission. Postoperative lung injury (LI) was defined as moderate or severe ARDS based on the Berlin criteria, and its incidence was 29.9% (20/67). On multiple regression analysis, the following were associated with P/F ratios at ICU admission: vasoactive-inotropic scores at CPB induction (P = 0.03), thigh rSO2 values during CPB (P = 0.04), and body surface area (P < 0.001). A thigh rSO2 of 71% during CPB was significantly predictive of postoperative LI with an area under the curve of 0.71 (P = 0.03), sensitivity of 0.70, and specificity of 0.68. Patients with postoperative LI had longer ventilation time and ICU stays. Thigh rSO2 values during CPB were a potential predictor of postoperative pulmonary outcomes.

Carotid Endarterectomy With Shunt-A Stepwise Surgical Technique Demonstration for Trainees: 2-Dimensional Operative Video.

Carotid endarterectomy (CEA) is a common cerebrovascular surgery and is an effective treatment option for patients with carotid stenosis.1-4 Although the routine or selective use of a shunt is still debatable,5 the CEA technique is generally well-established. We believe that bloodless and "shallow and wide" operative fields make CEA safe and successful. Maintaining a bloodless operative field is highly crucial to prevent postoperative cervical hematoma and damage to anatomic structures, such as the hypoglossal and vagus nerves, because it facilitates their identification. In the cases of CEA, antiplatelet medications are usually continued, and systemic heparinization is performed intraoperatively; therefore, further meticulous hemostasis should be performed than in other neurological surgery cases. The 2-step pull-up technique, which involves pulling up loose connective tissue surrounding the carotid arteries in addition to the carotid sheath, makes the operative field "shallow and wide." This technique allows the internal carotid artery to move from deep to superficial, making CEA feasible, particularly when placing a shunt. This video illustrates the CEA technique used for symptomatic mild carotid stenosis in a 66-year-old man with vulnerable plaques. Evolving carotid artery stenting should facilitate the improvement of the operative technique to increase the safety and accordingly train young surgeons. This video is intended to increase familiarity with CEA because carotid artery stenting decreases CEA indications for carotid stenosis and diminishes proficiency in managing CEA. The patient consented to the publication of his image. Patient consent was obtained to perform the surgery and publish the surgical video.

Midline Suboccipital Unilateral Trans-Cerebellomedullary Fissure Approach for Clipping of Ruptured VA-PICA Aneurysm: Two-Dimensional Operative Video.

The vertebral artery-posterior inferior cerebellar artery (VA-PICA) aneurysm poses a technical challenge for microsurgical clipping due to its anatomical complexity, which requires dissection of lower cranial nerves. Endovascular treatment is regarded as a feasible first-line therapeutic option for VA-PICA aneurysm because it has an acceptable aneurysm occlusion rate and is less invasive. However, microsurgical clipping remains an effective treatment option. We present the case of a 62-year-old man who presented with subarachnoid hemorrhage (SAH) due to a ruptured VA-PICA aneurysm. Neuroradiologic examination revealed a 2-3 mm medially pointing left VA-PICA aneurysm with acute obstructive hydrocephalus due to massive SAH in the posterior cranial fossa. As the patient had acute obstructive hydrocephalus and a relatively small aneurysm, we selected clipping over endovascular treatment. Because the aneurysm was located close to the midline and anterolateral to the medulla oblongata, we approached it from the midline. A midline suboccipital craniotomy, C1 laminectomy, and drilling of the left condylar fossa were performed; a unilateral cerebellomedullary fissure opening was added; and the aneurysm was clipped. Postoperative neuroradiologic examinations revealed complete obliteration of the aneurysm. As shown in this video, unilateral cerebellomedullary fissure opening combined with adequate removal of the condylar fossa provides a wide operative field in the cerebellomedullary cistern while avoiding strong retraction of the cerebellum. We believe that this technique makes VA-PICA aneurysm clipping safe and successful. Patient consent was obtained to perform the surgery and to publish the surgical video (Video 1).

Monitoring of intraoperative femoral oxygenation predicts acute kidney injury after pediatric cardiac surgery.

Cardiopulmonary bypass-associated acute kidney injury (CPB-AKI) is a pediatric cardiac surgery postoperative complication that is associated with a longer duration of mechanical ventilation and length of hospital stay. Identifying an early predictor of CPB-AKI is critical. Near infrared spectroscopy (NIRS), which can provide real-time monitoring of regional tissue oxygen saturation (rSO2) during CPB, may predict CPB-AKI in an early phase of surgical treatment. This study analyzed clinical data from 87 children who underwent an elective surgical repair of ventricular septal defect (VSD) from January 2013 to March 2019. NIRS sensors were placed on the patients' forehead, abdomen, and thighs. The pediatric modified risk, injury, failure, loss, and end-stage (p-RIFLE) score was determined for each patient postoperatively. The incidence of AKI based on the p-RIFLE classification was 11.5% at the end of surgery, 23.0% at 24 h after surgery, and 5.7% at 48 h after surgery. The AKI incidence rate was highest at 24 h after surgery. Multiple regression analysis revealed that femoral oxygenation (rSO2) during CPB, CPB time, oxygen delivery index (DO2i), and lactate at the end of CPB were independent risk factors for AKI. Receiver-operating characteristic curve analysis indicated that femoral oxygenation of 74% or less predicted AKI development within 24 h after surgery. In conclusion, rSO2 measured at the thigh during CPB is highly predictive of CPB-AKI.

An analysis of the demographic history of the risk allele R4810K in RNF213 of moyamoya disease.

BACKGROUND: Ring finger protein 213 (RNF213) is a susceptibility gene of moyamoya disease (MMD). A previous case-control study and a family analysis demonstrated a strong association of the East Asian-specific variant, R4810K (rs112735431), with MMD. Our aim is to uncover evolutionary history of R4810K in East Asian populations. METHODS: The RNF213 locus of 24 MMD patients in Japan were sequenced using targeted-capture sequencing. Based on the sequence data, we conducted population genetic analysis and estimated the age of R4810K using coalescent simulation. RESULTS: The diversity of the RNF213 gene was higher in Africans than non-Africans, which can be explained by bottleneck effect of the out-of-Africa migration. Coalescent simulation showed that the risk variant was born in East Asia 14,500-5100 years ago and came to the Japanese archipelago afterward, probably in the period when the known migration based on archaeological evidences occurred. CONCLUSIONS: Although clinical data show that the symptoms varies, all sequences harboring the risk allele are almost identical with a small number of exceptions, suggesting the MMD phenotypes are unaffected by the variants of this gene and rather would be more affected by environmental factors.

A new targeted capture method using bacterial artificial chromosome (BAC) libraries as baits for sequencing relatively large genes.

To analyze a specific genome region using next-generation sequencing technologies, the enrichment of DNA libraries with targeted capture methods has been standardized. For enrichment of mitochondrial genome, a previous study developed an original targeted capture method that use baits constructed from long-range polymerase chain reaction (PCR) amplicons, common laboratory reagents, and equipment. In this study, a new targeted capture method is presented, that of bacterial artificial chromosome (BAC) double capture (BDC), modifying the previous method, but using BAC libraries as baits for sequencing a relatively large gene. We applied the BDC approach for the 214 kb autosomal region, ring finger protein 213, which is the susceptibility gene of moyamoya disease (MMD). To evaluate the reliability of BDC, cost and data quality were compared with those of a commercial kit. While the ratio of duplicate reads was higher, the cost was less than that of the commercial kit. The data quality was sufficiently the same as that of the kit. Thus, BDC can be an easy, low-cost, and useful method for analyzing individual genome regions with substantial length.

Vaginal Delivery under Epidural Analgesia in Pregnant Women with a Diagnosis of Moyamoya Disease.

BACKGROUND: Moyamoya disease more commonly occurs in young people and women, so patients with this disease may experience pregnancy and delivery. Cesarean section (CS) is often chosen as the mode of delivery for these patients in Japan. No appropriate mode of delivery has yet been established for pregnant women with moyamoya disease in terms of stroke prevention. We have used vaginal delivery under epidural analgesia (EA) in such patients unless CS has been indicated for the maternal or fetal reasons. This study retrospectively analyzed our patients with moyamoya disease who gave birth to confirm the safety of vaginal delivery under EA. METHODS: Twelve consecutive patients diagnosed with moyamoya disease had 14 deliveries at our hospital between September 2004 and January 2013. The incidences of intrapartum stroke were compared between cases of vaginal delivery under EA and CS cases. RESULTS: Ten vaginal deliveries under EA and 4 elective CSs were performed. No intrapartum stroke was observed during either vaginal delivery under EA or CS. Among the patients who underwent vaginal delivery under EA, 1 parturient who experienced 2 deliveries suffered transient ischemic attack during both postpartum periods. All 14 infants were healthy without sequelae. CONCLUSIONS: Vaginal delivery under EA is an option for patients with moyamoya disease, provided that close cooperation with neurosurgeons, obstetricians, and anesthesiologists is assured.

Selecting an appropriate surgical treatment instead of carotid artery stenting alone according to the patient's risk factors contributes to reduced perioperative complications in patients with internal carotid stenosis: a single institutional retrospective analysis.

This retrospective study was aimed to compare the perioperative complications for internal carotid artery stenosis (ICS) in a Japanese single institute between the use of carotid artery stenting (CAS) alone or the use of an appropriate individualized treatment method allowing either carotid endarterectomy (CEA) or CAS based on patient risk factors. Based on the policy at our hospital, only CAS was performed on patients (n = 33) between January 2005 and November 2009. From December 2009 to December 2012, either CEA or CAS (tailored treatment) was selected for patients (n = 61) based on individual patient risk factors. CEA was considered the first-line treatment in all cases. In high-risk CEA cases, CAS was performed instead (n = 11), whereas in low-risk CEA cases, CEA was performed (n = 19). Further, in moderate-risk CEA cases based on own criteria, CAS was considered first, whereas for high-risk CAS cases, CEA was performed (n = 17). For low-risk CAS cases, CAS was performed (n = 9). Perioperative clinical complications (any stroke, myocardial infarction, or death within 30 days) were compared between both periods. Significantly reduced perioperative complications were observed during the tailored period (4/61 sites, 6.6%) as compared with the CAS period (8/33 sites, 24.2%) [Fisher's exact test p = 0.022; odds ratio, 4.56 (CAS/tailored); 95% confidence interval, 1.26-16.5]. Selecting an appropriate individualized treatment method according to patient risk factors, as opposed to adhering to a single treatment approach such as CAS, may contribute to improved overall outcomes in patients with ICS.

Impact of platelet transfusion on survival of patients with intracerebral hemorrhage after administration of anti-platelet agents at a tertiary emergency center.

This study examined the impact of platelet transfusion (PLT) on the survival of intracerebral hemorrhage (ICH) patients who had been administered anti-platelet agents (APA). This retrospective cohort analysis investigated 432 patients (259 men, 60%) who were newly diagnosed with ICH between January 2006 and June 2011 at the tertiary emergency center of Kitasato University Hospital. Median age on arrival was 67.0 years (range, 40-95 years). ICH was subcortical in 72 patients (16.7%), supratentorial in 233 (53.9%), and infratentorial in 133 (30.8%). PLT was performed in 16 patients (3.7%). Within 90 days after admission to the center, 178 patients (41.2%) had died due to ICH. Before the onset of ICH, 66 patients had been prescribed APA because of atherosclerotic diseases. Multivariate regression analysis indicated APA administration was an independent risk factor for death within 7 days (odds ratio, 5.12; P = 0.006) and within 90 days (hazard ratio, 1.87; P = 0.006) after arrival. Regarding the effect of a PLT in ICH patients with APA, no patient with PLT died. PLT had a survival benefit on patients with ICH, according to our analysis. Further prospective analysis is necessary to confirm the effects of PLT on survival in ICH with APA.

A nationwide survey of hypertrophic pachymeningitis in Japan.

OBJECTIVES: To clarify the prevalence, frequent causes and distinct features of hypertrophic pachymeningitis (HP) according to background conditions in a nationwide survey in Japan. METHODS: The study began with a preliminary survey to determine the approximate number of HP patients diagnosed from 1 January 2005 to 31 December 2009, and was followed by a questionnaire survey for clinical and laboratory findings. HP was defined as a condition with thickening of the cranial or spinal dura mater with inflammation, evidenced by MRI or histology. RESULTS: Crude HP prevalence was 0.949/100 000 population. The mean age at onset was 58.3±15.8 years. Among 159 cases for whom detailed data were collated, antineutrophil cytoplasmic antibody (ANCA)-related HP was found in 54 cases (34.0%) and IgG4/multifocal fibrosclerosis (MFS)-related HP in 14 cases (8.8%). Seventy cases (44.0%) were classified as 'idiopathic' and 21 (13.2%) as 'others'. ANCA-related HP cases showed a female preponderance, a higher age of onset, and higher frequencies of otological symptoms and elevated systemic inflammatory biomarkers, but lower frequencies of diplopia compared with idiopathic HP. IgG4/MFS-related HP cases showed a marked male predominance; all had cranial HP while none had isolated spinal HP or decreased sensation. CONCLUSIONS: HP is not extremely rare. ANCA-related HP is the most frequent form, followed by IgG4/MFS-related HP. Both forms have unique features, which may help to differentiate background causes.

[DBS therapy for Parkinson's disease - our approach].

It is controversial whether the STN or the GPi, the main targets of DBS therapy in patients with Parkinson's disease, is the appropriate target. We select GPi-DBS in patients judged by our cognitive function test battery to be at high-risk for cognitive decline after STN-DBS. While DBS surgery is usually performed under local anesthesia for the precise placement of DBS electrodes, general anesthesia might be useful in patients intolerant of long-lasting surgical stress. Our monkey experiments revealed that the most medial part of the STN receives direct input from the limbic cortex, suggesting that the spread of stimulation to these limbic territories may elicit adverse emotional effects. Other monkey experiments on the physiological mechanism of DBS suggest that high-frequency GPi stimulation disrupts information flow through the GPi.

Signal intensity changes for the middle cerebral artery on 3-dimensional time-of-flight magnetic resonance angiography indicate acute hemodynamic changes after carotid endarterectomy.

BACKGROUND: For 3-dimensional time-of-flight magnetic resonance angiography (3D-TOF-MRA), the signal intensity (SI) loss depends on the flow velocity. In this study, we aimed to evaluate whether 3D-TOF-MRA could be used as an alternative to single-photon emission computed tomography (SPECT) for assessing the increase in the regional cerebral blood flow (rCBF) after carotid endarterectomy (CEA). To do this, we compared the SI of the middle cerebral artery (MCA) on magnetic resonance angiography (MRA) and the rCBF on SPECT. METHODS: We enrolled 30 patients with internal carotid artery stenosis. SPECT and MRA were performed before and 3-4 days after CEA. rCBF was assessed using SPECT, and the SI of the MCA was assessed using single-slab 3D-TOF-MRA. Regions of interest were placed in the bilateral middle M1 portions of the MCA on MRA, and their mean SI was measured. The increase ratio of the rCBF on SPECT and the increase ratio of the SI of the MCA on MRA were calculated using the formula: (post-CEA ipsilateral/post-CEA contralateral)/(pre-CEA ipsilateral/pre-CEA contralateral). RESULTS: A significant correlation was observed between the increase ratio of the rCBF on SPECT and the increase ratio of the SI of the MCA on MRA (r=.894, y=.4863+.5184x, P<.001). All values obtained by MRA were greater than or equal to the SPECT values, indicating that MRA tends to overestimate the post-CEA rCBF increase. CONCLUSION: Because MRA identified increased rCBF after CEA, we recommend that patients first be screened using MRA.

Hanging foot switch for bipolar forceps: a device for surgeons operating in the standing position: technical note.

For surgeons operating in the standing position, the manipulation of foot switches involves shifting of the weight to the pivoting leg and the possible loss of contact between the switch and the foot. We solved this problem by changing the position of the switch that operates bipolar forceps. Our novel device is made of aluminum plates. The base plate features a foot strap and a height-adjustable overhang over the switch-operating foot. A commercially-available disc type foot switch is attached to the underside of the overhang in upside-down position, so the switch is operable with the toe. To turn on the switch, the toe is flexed dorsally to push the switch pedal, so the action is limited to the part distal to the metatarsophalangeal joints. Our switch was used in more than 100 consecutive microsurgeries performed by surgeons operating in the standing position. The switch manipulation required no shifting of the weight and was easier and quicker than manipulation of conventionally-placed switches. The surgeons were able to change the foot position freely with the modified switch, thereby avoiding loss of contact with the switch. The modified switch placement reduced physical fatigue in the lower extremities, annoyance related to the manipulation of conventionally-placed switches, and increased the comfort of surgeons operating in the standing position.

Middle fossa approach for total resection of petrous apex cholesterol granulomas: use of vascularized galeofascial flap preventing recurrence.

BACKGROUND: Cholesterol granulomas (CGs) of the petrous apex (PA) are rare, benign, expanding lesions. Surgical treatment is recommended for patients with symptomatic disease; however, the optimal surgical procedure is still controversial due to high recurrence rates. The main treatment strategy is divided into drainage and complete resection. OBJECTIVE: We advocate radical resection of the lesion by the middle fossa approach and reconstruction with a vascularized galeofascial flap. METHODS: A 10-year retrospective case review of 17 patients undergoing surgical treatment of PA CGs between 2000 and 2010 was undertaken. Operative outcomes and surgical complications were analyzed. In addition, our operative method and the related anatomy are described from cadaveric dissections. RESULTS: All but 1 patient was operated on via a middle fossa approach. Using the middle fossa approach, radical resection of all PA CGs was achieved with obliteration of the cyst cavity using a vascularized flap. Important surrounding structures included the internal auditory canal, cochlea, petrous carotid artery, and abducens nerve. There was 1 death caused by internal carotid artery occlusion. No other major complications or cranial nerve deficits occurred postoperatively. Clinical recurrence occurred in 1 patient (5.9%). CONCLUSION: Our technique of radical resection and reconstruction with a vascularized flap has the advantage of being less invasive with less cosmetic deformity and allows preservation of cranial nerve function with a low recurrence rate. Knowledge of the surgical anatomy and the characteristics of CG is prudent because important neurovascular structures may be exposed behind the CG wall due to bony erosion.

Clinicopathological features of human brainstem gliomas.

We describe the clinicopathological features of 25 brainstem gliomas (BSGs). Twenty BSGs located in the pons and were all in children. Four BSGs located in the medulla oblongata were in 2 children and 2 adults. One (in a child) was located in the midbrain. Radiological findings on MR images were low-intensity on T1 weighted images and high-intensity on T2 weighted images. Mean survival when pontine glioma was treated by radiotherapy and/or use of temozolomide was 14 months, although 4 patients (3 cervicomedullary types and one focal type arising from midbrain) are alive. Follow up was from 5 months to 6 years. Histopathological features of 10 cases of the diffuse type were: 4 grade II astrocytomas, 4 grade III astrocytomas, and 2 glioblastomas. MIB-1 index was from 0.8 to 38 %. P53 was positive for 80 % of 15 tumors and there were no negative results. MGMT was positive in 60 % of 15 tumors and negative in 12.4 %. IDH1 was negative in 61.6 %. There was no positive result for IDH1 in this study. Thus, our histopathological results were indicative of high p53 immunoreactivity and no IDH1 immunoreactivity related to secondary malignant change.

Investigation of IgG4-positive cell infiltration in biopsy specimens from cases of hypertrophic pachymeningitis.

This study was an immunohistological study of IgG4-positive cell infiltration in 6 cases of hypertrophic pachymeningitis excluding secondary hypertrophic pachymeningitis caused by infectious diseases such as aspergillosis. The cases included 5 males and 1 female, ranging in age from 36 to 82 years (mean, 55 years). A biopsy was performed in all of the cases for diagnostic purposes, revealing fibrous dural hyperplasia with nonspecific inflammatory cell infiltration histologically. Two of the 6 patients had been treated with steroids before the biopsy, which was taken for poor response to steroid treatment. In these two cases, some IgG-positive cell infiltration of the thickened dura was observed; however, most of the cells were IgG4-negative. In the remaining four cases, many IgG- and IgG4-positive cells infiltrated the thickened dura and the IgG4-positive/IgG-positive cell ratio exceeded 40%. One of these patients was finally diagnosed with IgG4-related sclerosing disease, since he was diagnosed subsequently with retroperitoneal fibrosis. There was no evidence of any other lesions associated with IgG4-related sclerosing disease, other than in the dura. It is not rare for IgG4-positive cells to appear in the dura in cases of hypertrophic pachymeningitis; however, no IgG4-related systemic disease is present in these cases. Hypertrophic pachymeningitis with IgG4-positive cells may have some kind of relation to other systemic autoimmune diseases.

Granulofilamentous meningioma.

A 55-year old female was referred to the Department of Neurosurgery, Kitasato Hospital, because of a hearing impairment. Neuroimaging revealed a typical meningioma attached to the falx in the right frontal region. During surgery, an encapsulated, circumscribed, reddish-gray, slightly hard tumor attached to the falx was completely removed by an interhemispheric approach. On light microscopy, many of the tumor cells contained eosinophilic inclusions with single or multiple vacuoles that displaced the cytoplasm. The nuclei of the tumor cells were eccentric. There were no signs of malignancy in the specimen. Electron microscopy revealed that most of the eosinophilic inclusions were composed of filaments measuring 12 nm in diameter. There have been several reports of benign meningiomas with eosinophilic inclusions composed of intermediate filaments. The microscopic differences between these types of tumor and rhabdoid meningiomas are very subtle, and it is important the two types of tumors are not confused. Benign meningiomas with eosinophilic inclusions comprising intermediate filaments, for example the tumor described in this report, have been diagnosed as granulofilamentous meningiomas, which is a subtype of benign meningioma.

An operation in the park bench position complicated by massive tongue swelling.

This paper presents a case of massive tongue swelling as a complication after an operation in the park bench position. A 43-year-old male who had undergone a resection of a mass in the petrous bone of the clivus showed massive tongue swelling after the surgery in the left park bench position. A direct compression of the bite block caused the swelling of tongue. Tongue swelling may become fatal if it progresses to an airway obstruction; therefore the intraoperative and postoperative management is important.

Pathophysiological evaluation of cerecyte coil embolization for experimental broad neck aneurysms.

Cerecyte second-generation coils feature inner surfaces coated with an absorbable polyglycolic acid (PGA) polymer. Their use is expected to accelerate aneurysm organization, but time course data are limited. The present experimental study was therefore conducted to clarify the processes by pathological examination. Methods. Two types of experimental aneurysms were initially generated in adult mongrel dogs, one bifurcation and another of lateral wall type. Long-term persistence of each was defined by follow-up angiography for more than 1 year. Embolization of the aneurysms was then performed using only cerecyte coils, and follow-up angiography was conducted after 2 and 4 weeks followed by pathological examination. Results. Organization of both types of broad neck aneurysm was apparent 4 weeks after embolization, which is earlier as compared with already reported data for bare coils.

Two cases of nevoid basal cell carcinoma syndrome associated with meningioma caused by a PTCH1 or SUFU germline mutation.

Nevoid basal cell carcinoma syndrome (NBCCS) is an autosomal dominant disorder characterized by developmental defects and tumorigenesis. The gene responsible for NBCCS is PTCH1. The development of meningioma in NBCCS patients is a rare event. Here, we report two cases of NBCCS in which meningiomas did develop. The first patient carried a germline mutation in one allele of PTCH1, c.290dupA (p.N97KfsX43). In addition, the meningioma sample carried a somatic mutation, c.307delG (p.Val103LeufsX15), in the other allele of the same gene, suggesting a second hit. This is the first case of NBCCS-associated meningioma explained by the standard two-hit hypothesis. The second patient had a germline nonsense mutation in the SUFU gene, c.550C>T (p.Q184X). SUFU is located downstream of PTCH1 in the sonic hedgehog signaling pathway. This is the second time a germline mutation in SUFU has been found to cause NBCCS. Together with the previous report describing three cases of non-NBCCS medulloblastoma carrying a germline mutation in this gene, individuals with a SUFU germline mutation are expected to have a markedly high risk of developing medulloblastoma and probably meningioma.