Recent Trends in the Withdrawal of Life-Sustaining Treatment in Patients with Acute Cerebrovascular Disease : 2017-2021.

OBJECTIVE: The Act on Life-Sustaining Treatment (LST) decisions for end-of-life patients has been effective since February 2018. An increasing number of patients and their families want to withhold or withdraw from LST when medical futility is expected. This study aimed to investigate the status of the Act on LST decisions for patients with acute cerebrovascular disease at a single hospital. METHODS: Between January 2017 and December 2021, 227 patients with acute cerebrovascular diseases, including hemorrhagic stroke (n=184) and ischemic stroke (n=43), died at the hospital. The study period was divided into the periods before and after the Act. RESULTS: The duration of hospitalization decreased after the Act was implemented compared to before (15.9±16.1 vs. 11.2±18.6 days, p=0.127). The rate of obtaining consent for the LST plan tended to increase after the Act (139/183 [76.0%] vs. 27/44 [61.4%], p=0.077). Notably, none of the patients made an LST decision independently. Ventilator withdrawal was more frequently performed after the Act than before (52/183 [28.4%] vs. 0/44 [0%], p<0.001). Conversely, the rate of organ donation decreased after the Act was implemented (5/183 [2.7%] vs. 6/44 [13.6%], p=0.008). Refusal to undergo surgery was more common after the Act was implemented than before (87/149 [58.4%] vs. 15/41 [36.6%], p=0.021) among the 190 patients who required surgery. CONCLUSION: After the Act on LST decisions was implemented, the rate of LST withdrawal increased in patients with acute cerebrovascular disease. However, the decision to withdraw LST was made by the patient's family rather than the patient themselves. After the execution of the Act, we also observed an increased rate of refusal to undergo surgery and a decreased rate of organ donation. The Act on LST decisions may reduce unnecessary treatments that prolong end-of-life processes without a curative effect. However, the widespread application of this law may also reduce beneficial treatments and contribute to a decline in organ donation.

Impact on Endovascular Thrombectomy for Acute Ischemic Stroke of Aortic Arch Calcification on Chest X-ray.

BACKGROUND: Vascular conditions can affect the recanalization rates after endovascular thrombectomy (EVT) for acute ischemic stroke (AIS). Chest radiography can assess the conditions of the aortic arch based on the presence or absence of aortic arch calcification (AoAC). The aim of this study was to investigate the relationship between AoAC on chest radiography and first-pass successful recanalization (modified thrombolysis in cerebral infarction 2b/3 after the first-pass). METHODS: We compared the rate of first-pass successful recanalization between patients with and without AoAC. A total of 193 patients with anterior circulation occlusion who underwent EVT between January 2017 and December 2021 were included. RESULTS: AoAC was observed in 80 (41.5%) patients. Patients with AoAC were older (74.5 ± 7.78 vs. 63.9 ± 12.4 years, p < 0.001), had more EVT attempts (3.04 ± 1.95 vs. 2.01 ± 1.34 times, p < 0.001), and a longer procedural time (71.7 ± 31.2 vs. 48.7 ± 23.1 min, p < 0.001) than those without AoAC. Moreover, Patients with AoAC showed a lower incidence of first-pass successful recanalization (18.8% vs. 47.8%, p < 0.001) and a higher incidence of postprocedural hemorrhage (45.0% vs. 27.7%, p = 0.015) than those without AoAC. On multivariate analysis, AoAC was independently associated with first-pass successful recanalization (odds ratio: 0.239 [0.121-0.475], p < 0.001). CONCLUSIONS: AoAC on chest radiography can be used as a preoperative predictor of successful first-pass recanalization in patients undergoing EVT for AIS.

Epigenetic Regulation of the Expression of T Cell Stimulatory and Inhibitory Factors by Histone H3 Lysine Modification Enzymes and Its Prognostic Roles in Glioblastoma.

BACKGROUND: This study aimed to identify the specific T cell co-stimulatory and co-inhibitory factors that play prognostic roles in patients with glioblastoma. Additionally, the unique histone H3 modification enzymes that regulate the expression levels of these specific co-stimulatory and co-inhibitory factors were investigated. METHODS: The medical records of 84 patients newly diagnosed with glioblastoma at our institution from January 2006 to December 2020 were retrospectively reviewed. Immunohistochemical (IHC) staining for T cell co-stimulatory factors (CD27, CD28, CD137, OX40, and ICOS), T cell co-inhibitory factors (CTLA4, PD1, PD-L1, TIM3, and CD200R), and histone H3 lysine modification enzymes (MLL4, RIZ, EZH1, NSD2, KDM5c, JMJD1a, UTX, and JMJD5) was performed on archived paraffin-embedded tissues obtained by biopsy or resection. Quantitative real time-polymerase chain reaction (qRT-PCR) was performed for specific factors, which demonstrated causal relationships, in order to validate the findings of the IHC examinations. RESULTS: The mean follow-up duration was 27.5 months (range, 4.1-43.5 months). During this period, 76 patients (90.5%) died, and the mean OS was 19.4 months (95% confidence interval, 16.3-20.9 months). Linear positive correlations were observed between the expression levels of CD28 and JMJD1a (R2 linear = 0.982) and those of CD137 and UTX (R2 linear = 1.528). Alternatively, significant negative correlations were observed between the expression levels of CTLA4 and RIZ (R2 linear = -1.746) and those of PD-L1 and EZH1 (R2 linear = -2.118); these relationships were confirmed by qRT-PCR. In the multivariate analysis, increased expression levels of CD28 (P = 0.042), and CD137 (P = 0.009), and decreased expression levels of CTLA4 (P = 0.003), PD-L1 (P = 0.020), and EZH1 (P = 0.040) were significantly associated with longer survival. CONCLUSION: These findings suggest that the expression of certain T cell co-stimulatory factors, such as CD28 and CD 137, and co-inhibitory factors, such as CTLA4 and PD-L1 are associated with prognosis of glioblastoma patients.

Role of Neurosurgeons in the Treatment of Acute Ischemic Stroke in the Emergency Room.

OBJECTIVE: With the recent increase in mechanical thrombectomy (MT) for acute ischemic stroke (AIS), the role of neurosurgeons in AIS treatment has become increasingly important. This study aimed to assess the outcomes of patients with AIS treated by neurosurgeons and neurologists in the emergency room (ER) of a tertiary hospital in South Korea. METHODS: From January 2020 to June 2021, 536 patients with AIS within 24 hours of symptom onset were admitted to our hospital via the ER. Based on the type of doctors who provided initial care for AIS in the ER, patients were divided into two groups : (a) neurosurgeon group (n=119, 22.2%) and (b) neurologist group (n=417, 77.8%). RESULTS: Intravenous tissue plasminogen activator (tPA) was administered in 82 (15.3%) of 536 patients (n=17 [14.3%] in the neurosurgeon group and n=65 [15.6%] in the neurologist group). The door-to-tPA time was not significantly different between both groups (median, 53 minutes; interquartile range [IQR], 45-58 vs. median, 54 minutes; IQR, 46-74; p=0.372). MT was performed in 69 patients (12.9%) (n=25, 36.2% in the neurosurgeon group and n=44, 63.8% in the neurologist group). The neurosurgeon group achieved a shorter door-to-puncture time than the neurologist group (median, 115 minutes; IQR, 107-151 vs. median, 162 minutes; IQR, 117-189; p=0.049). Good clinical outcomes (3-month modified Rankin Scale 0-2) did not differ significantly between the two groups (96/119 [80.7%] vs. 322/417 [77.2%], p=0.454). CONCLUSION: The neurosurgeon group showed similar door-to-treatment time and clinical outcomes to the neurologist group in patients with AIS in the ER. This study suggests that neurosurgeons have comparable abilities to care for patients with AIS in the ER.

Clinical Application of the Association between Genetic Alteration and Intraoperative Fluorescence Activity of 5-Aminolevulinic Acid during the Resection of Brain Metastasis of Lung Adenocarcinoma.

The primary objective of this study was to investigate the association of certain genetic alterations and intraoperative fluorescent activity of 5-aminolevulinic acid (ALA) in brain metastasis (BM) of lung adenocarcinoma. A retrospective cohort study was conducted among 72 patients who underwent surgical resection of BM of lung adenocarcinoma at our institute for five years. Cancer cell infiltration was estimated by the intraoperative fluorescent activity of 5-ALA, and genetic alterations were analyzed by next-generation sequencing (NGS). The sensitivity and specificity for detecting cancer cell infiltration using 5-ALA were 87.5% and 96.4%, respectively. Genes associated with cell cycle regulation (p = 0.003) and cell proliferation (p = 0.044) were significantly associated with positive fluorescence activity of 5-ALA in the adjacent brain tissue. Genetic alterations in cell cycle regulation and cell proliferation were also associated with shorter recurrence-free survival (p = 0.013 and p = 0.042, respectively) and overall survival (p = 0.026 and p = 0.042, respectively) in the multivariate analysis. The results suggest that genetic alterations in cell cycle regulation and cell proliferation are associated with positive fluorescence activity of 5-ALA in the adjacent infiltrative brain tissue and influence the clinical outcome of BM of lung adenocarcinoma.

Diffusion-weighted imaging-positive lesions following endovascular treatment for ruptured and unruptured aneurysms: Its incidence according to antithrombotic drugs.

OBJECTIVE: Microembolic infarcts are frequently observed on diffusion-weighted imaging (DWI) following endovascular treatment. We investigated DWI-positive lesions and symptomatic ischemic complications (SICs) in patients with ruptured and unruptured aneurysms following coiling and the relationship between DWI-positive lesions and antithrombotic drugs. METHODS: Between January 2016 and December 2020, 83 patients underwent DWI within 48 h following endovascular treatment for ruptured (n=30) and unruptured (n=53) aneurysms. RESULTS: The overall rate of DWI-positive lesions was 55.4%. There were no significant differences in the occurrence rate (45.3% vs. 43.3%, p=1.000) and the number of lesions (2.7±4.6 vs. 4.0±5.3, p=0.237) between unruptured and ruptured aneurysms. SIC occurred more frequently in patients with ruptured aneurysms than unruptured ones (20.0% vs. 1.9%, p=0.015). The cutoff value of DWI-positive lesions for predicting SIC was 5 (sensitivity 100%, specificity 78.9%). The procedure time was significantly longer in patients with DWI-positive lesions ≥5 than those with DWI-positive lesions <5 (104.1±43.8 vs. 85.1±30.8 min, p=0.030). Patients with DWI-positive lesions <5 were more frequently observed in the postprocedural heparinization group than in the no heparinization group (85.7% vs. 58.5%, p=0.012). CONCLUSIONS: The incidence of DWI-positive lesions did not differ significantly between the ruptured and unruptured aneurysms. However, SIC occurred more frequently in patients with ruptured aneurysms. Longer procedure time is a risk factor for DWI-positive lesions, and postprocedural heparinization seems to reduce the incidence of DWI-positive lesions.

Association of aortic arch calcification on chest X-ray with procedural thromboembolism after coil embolization of cerebral aneurysm.

Procedural thromboembolism after coil embolization of a cerebral aneurysm can occur because of fragmented atherosclerotic plaques in the aortic arch. The purpose of this study was to investigate the relationship between aortic arch calcification (AoAC) observed using preoperative chest X-ray and procedural thromboembolisms after coil embolization of cerebral aneurysms. Between January 2019 and December 2020, 66 patients underwent coil embolization for cerebral aneurysms at our hospital. AoAC was assessed based on the presence of calcification using a preoperative chest X-ray. A procedural thromboembolism was defined as a new positive lesion on diffusion-weighted imaging within 7 days post-procedure. A procedural thromboembolism occurred in 34 (51.5%) patients. The thromboembolism was associated with AoAC (calcification [52.9%] vs. no calcification [6.3%], p < 0.001), aneurysm type (aneurysm with incorporated branches [63.9%] vs. sidewall aneurysm [36.7%], p = 0.047), and a longer procedural time (100.2 ± 34.1 min vs. 79.7 ± 24.9 min, p = 0.007). Multivariable logistic regression analysis showed that AoAC (adjusted odds ratio [OR], 23.566; adjusted 95% confidence interval [CI], 3.921-141.654; p = 0.001) and aneurysm type (adjusted OR, 5.501; adjusted 95% CI, 1.455-20.799; p = 0.012) were independent risk factors for procedural thromboembolism. AoAC on preoperative chest X-ray was associated with a significant increase in the procedural thromboembolism rate. Our study suggests that a procedural thromboembolism after coil embolization of cerebral aneurysms might result primarily from fragmented atherosclerotic plaques in the aortic arch. Preoperative chest X-ray could be a useful tool to predict the risk of procedural thromboembolisms.

Impact of the Coronavirus Disease Pandemic on Patients with Head Injuries in South Korea.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic is affecting the characteristics of patients with head injuries. This study aimed to evaluate the effect of the COVID-19 pandemic on patients with head injuries at a regional emergency medical center in South Korea. METHODS: From April 2019 to November 2020, 350 patients with head injuries were admitted to our hospital. The study period was divided into the pre-COVID-19 (n=169) and COVID-19 (n=181) eras (10 months each). Patients with severe head injuries requiring surgery (n=74) were categorized into those who underwent surgery (n=41) and those who refused surgery (n=33). RESULTS: Head injuries in pediatric patients (<3 years) were more frequent in the COVID-19 era than in the pre-COVID-19 era (8.8% vs. 3.6%, p=0.048). More patients refused surgery in the COVID-19 era than in the pre-COVID-19 era (57.9% vs. 30.6%, p=0.021). Refusal of surgery was associated with old age (67.7±14.5 vs. 52.4±19.1, p<0.001), marital status (married, 84.8% vs. 61.0%, p=0.037), unemployment (42.4% vs. 68.3%, p=0.034), COVID-19 era (66.7% vs. 39.0%, p=0.021), and lower Glasgow coma scale scores (6.12±3.08 vs. 10.6±3.80, p<0.001). Multivariable logistic regression analysis revealed that refusal of surgery was independently associated with old age (adjusted odds ratio [OR], 1.084; 95% confidence interval [CI], 1.030-1.140; p=0.002), COVID-19 era (adjusted OR, 6.869; 95% CI, 1.624-29.054; p=0.009), and lower Glasgow coma scale scores (adjusted OR, 0.694; 95% CI, 0.568-0.848; p<0.001). CONCLUSION: We observed an increased prevalence of head injuries in pediatric patients (<3 years) during the COVID-19 pandemic. Additionally, among patients with severe head injuries requiring surgery, more patients refused to undergo surgery during the COVID-19 pandemic.

Effect of Antiplatelet Preparation Before Endovascular Thrombectomy for Cerebral Infarction on Procedural Thromboembolism.

AIM: To compare an antiplatelet-preparation group with a no-preparation group to evaluate the effect of the antiplatelet preparation on procedural thromboembolism during endovascular thrombectomy (EVT) with diffusion-weighted imaging (DWI), retrospectively. MATERIAL AND METHODS: From January 2017 to April 2020, EVT was performed in 60 patients with cerebral infarction. Patients were categorized into the antiplatelet-preparation group (n=25) or the no-preparation group (n=35). Procedural thromboembolism was defined as new DWI-positive lesions in other areas of the occluded artery after EVT. RESULTS: The antiplatelet-preparation and no-preparation groups did not differ in the rate of procedural thromboembolism occurrence (6/25 [24.0%] vs. 6/35 [17.1%]; p=0.532). Procedural thromboembolism was associated with age (74.4 ± 6.95 years vs. 65.7 ± 12.9 years; p=0.028), atherosclerotic occlusion (66.7% vs. 29.2%; p=0.022), and procedural time (97.4 ± 45.7 min vs. 60.1 ± 28.8 min; p=0.001). Multivariable logistic regression analysis showed that factors affecting procedural thromboembolism during EVT for cerebral infarction were old age (odds ratio [OR], 1.133; 95% confidence interval [CI], 1.009-1.273; p=0.035), atherosclerotic occlusion (OR, 7.434; 95% CI, 1.272-43.431; p=0.026), and longer procedural time (OR, 1.023; 95% CI, 1.001 - 1.046; p=0.006). CONCLUSION: The antiplatelet preparation had no significant protective effect on procedural thromboembolism during EVT for cerebral infarction. Old age, atherosclerotic occlusion, and longer procedural time were independent risk factors for procedural thromboembolism during EVT for cerebral infarction.

Comparative Analysis of Stroke Patients with and without Sequelae: A Cross-Sectional Analysis Using the KOREA National Health and Nutrition Examination Survey (2016-2019).

(1) Background: We aimed to evaluate the association between sociodemographic factors and mental health problems and the sequelae of stroke in South Korea by analyzing the annual Korea National Health and Nutrition Examination Surveys (KNHANES) conducted from 2016 to 2019. (2) Methods: Data were obtained from 32,379 participants who participated in the KNHANES (2016-2019). A total of 567 participants diagnosed with stroke were included in this study. Patients were divided into two groups based on the presence of sequelae: (a) stroke patients with sequelae (n = 227, 40.0%) and (b) stroke patients without sequelae (n = 340, 60.0%). (3) Results: Compared to stroke patients without sequelae, those with sequelae were significantly associated with sex (male, 61.2% vs. 47.6%, p = 0.002), household income (lower half, 78.9% vs. 67.4%, p = 0.005), owning a house (60.4% vs. 68.5%, p = 0.048), marital status (unmarried, 7.05% vs. 1.76%, p < 0.001), depression (13.2% vs. 7.35%, p = 0.045), suicidal ideation (6.17% vs. 3.24%, p = 0.010), and suicide attempts (2.64% vs. 0.88%, p = 0.012). (4) Conclusions: Our study showed that poor sociodemographic factors and mental health problems were significantly associated with sequelae from stroke. Clinical physicians should therefore carefully screen for depression and suicidality in stroke patients with sequelae, especially in those with poor sociodemographic factors.

Association of Aortic Arch Calcification on Chest X-ray with Procedural Thromboembolism after Mechanical Thrombectomy for Acute Ischemic Stroke.

Background and Objective: Procedural thromboembolism after a mechanical thrombectomy (MT) for an acute ischemic stroke (AIS) has rarely been studied. It may occur from the artery-to-artery embolization of atherosclerotic plaque in the aortic arch. We investigated the relationship between aortic arch calcification (AoAC) on a chest X-ray and procedural thromboembolism on diffusion-weighted imaging (DWI) after an MT. Materials and Methods: From January 2017 to December 2020, 131 patients underwent DWI within two days following an MT for an AIS. Procedural thromboembolism was defined as new DWI-positive lesions in other territories from the occluded artery on DWI within two days after MT. Results: Procedural thromboembolism was observed in 30 (22.9%) patients. Procedural thromboembolism was associated with old age (72.3 ± 9.44 vs. 65.7 ± 12.8 years, p = 0.003), a longer procedural time (77.6 ± 37.6 vs. 60.1 ± 29.7 min, p = 0.024), and AoAC (calcification (73.3%) vs. no calcification (29.7%), p < 0.001). Multivariable logistic regression analysis showed that procedural thromboembolism was independently associated with AoAC (adjusted odds ratio (OR): 6.107, adjusted 95% confidence interval (CI): 2.374-15.705, p < 0.001) and a longer procedural time (adjusted OR: 1.015, adjusted 95% CI: 1.001-1.030, p = 0.031). Conclusions: Procedural thromboembolism after an MT for an AIS was related to AoAC on a chest X-ray and a longer procedural time. Our results suggest that although rapid recanalization is the most crucial goal of an MT for an AIS, the importance of the careful advance of the guiding catheter through the aortic arch should not be underestimated to reduce the risk of procedural thromboembolism, especially in patients with AoAC on a chest X-ray.

Improving Door-To-Puncture Time in Mechanical Thrombectomy with Direct Care from a Neurointerventionalist in the Emergency Department.

OBJECTIVE: A shorter door-to-puncture time is an independent predictor of good clinical outcomes in patients with acute ischemic stroke (AIS) who undergo mechanical thrombectomy (MT). We recently initiated a protocol for direct care from neurointerventionalists (NIs) in the emergency department (ED) rather than from non-NI neurologists for patients with AIS. Our aim was to investigate whether NIs, as the first point-of-care physicians for stroke in the ED, could shorten door-to-puncture time compared to non-NI neurologists. METHODS: From January 2020 to December 2020, 50 patients with AIS underwent MT at our hospital. Patients were divided into 2 groups based on the type of physician who provided initial care for stroke in the ED: (a) NI group (n = 20) and (b) non-NI group (n = 30). The door-to-puncture time was retrospectively analyzed. RESULTS: The NI group had a significantly shorter door-to-puncture time than the non-NI group (135.2 ± 50.0 minutes vs. 167.2 ± 54.3 minutes, P = 0.040). A door-to-puncture time of ≤120 minutes was more frequently achieved in the NI group than in the non-NI group (55.0% vs. 23.3%, P = 0.022). Multivariable logistic regression analysis revealed that a door-to-puncture time of ≤120 minutes was independently associated with the NI group (adjusted odds ratio 4.098, 95% confidence interval 1.085-15.479, P = 0.037). CONCLUSIONS: Our study showed that NIs, as the first point-of-care stroke physicians in the ED, were associated with shorter door-to-puncture times. We suggest that NIs should be at the forefront of care for patients with AIS in the acute setting by performing triage and deciding on and performing MT.

Comparative Analysis of the Patients with Spontaneous Thalamic Hemorrhage with Concurrent Intraventricular Hemorrhage and Those without Intraventricular Hemorrhage.

BACKGROUND: This study aimed to compare the characteristics of patients with spontaneous thalamic hemorrhage (STH) accompanied by intraventricular hemorrhage (IVH) with those of patients without IVH. METHODS: The medical records of consecutive patients with STH admitted to our institute between January 2000 and December 2018 were reviewed retrospectively. The laboratory and radiological results, mortality, and functional recovery were compared between the STH patients with IVH and those without IVH. RESULTS: Among 2,389 patients with spontaneous intracerebral hemorrhage, 233 (9.8%) patients were included in this study. Concurrent IVH was detected in 159 (68.2%) patients with STH, and more frequently in those with body mass index ≥ 25, Glasgow Coma Scale score of 3-8, underlying disease, family history of stoke, posterior/medial/global location of hematoma, ventriculomegaly, large volume of hemorrhage, and midline shift ≥ 5 mm. The 3-month mortality was 25.8% and 8.1% (P = 0.039), the rate of good functional recovery at 6 months was 52.2% and 31.0% (P = 0.040), and incidence of delayed normal pressure hydrocephalus (NPH) at 12 months was 10.8% and 24.5% (P = 0.062) in the STH patients with IVH and those without IVH, respectively. At 12 months, delayed NPH developed in 28 of 47 (59.6%) patients who received external ventricular drainage (EVD)-based treatment, 5 of 45 (11.1%) patients who underwent endoscopic evacuation-based treatment, and 8 of 45 (17.8%) patients who underwent other surgeries. CONCLUSION: Concurrent IVH is strongly associated with mortality in patients with STH. Delayed NPH may develop more frequently in STH patients with IVH who were treated with EVD.

Factors Associated with Procedural Thromboembolisms after Mechanical Thrombectomy for Acute Ischemic Stroke.

Background and objective: Procedural thromboembolisms after mechanical thrombectomy (MT) for acute ischemic stroke has rarely been studied. We retrospectively evaluated factors associated with procedural thromboembolisms after MT using diffusion-weight imaging (DWI) within 2 days of MT. Materials and Methods: From January 2018 to March 2020, 78 patients with acute ischemic stroke who underwent MT were evaluated using DWI. Procedural thromboembolisms were defined as new cerebral infarctions in other territories from the occluded artery on DWI after MT. Results: Procedural thromboembolisms were observed on DWI in 16 patients (20.5%). Procedural thromboembolisms were associated with old age (73.8 ± 8.18 vs. 66.8 ± 11.2 years, p = 0.021), intravenous (IV) thrombolysis (12 out of 16 (75.0%) vs. 25 out of 62 (40.3%), p = 0.023), heparinization (4 out of 16 (25.0%) vs. 37 out of 62 (59.7%), p = 0.023), and longer procedural time (90.9 ± 35.6 vs. 64.4 ± 33.0 min, p = 0.006). Multivariable logistic regression analysis revealed that procedural thromboembolisms were independently associated with procedural time (adjusted odds ratio (OR); 1.020, 95% confidence interval (CI); 1.002-1.039, p = 0.030) and IV thrombolysis (adjusted OR; 4.697, 95% CI; 1.223-18.042, p = 0.024). The cutoff value of procedural time for predicting procedural thromboembolisms was ≥71 min (area under the curve; 0.711, 95% CI; 0.570-0.851, p = 0.010). Conclusions: Procedural thromboembolisms after MT for acute ischemic stroke are significantly associated with longer procedural time and IV thrombolysis. This study suggests that patients with IV thrombolysis and longer procedural time (≥71 min) are at a higher risk of procedural thromboembolisms after MT for acute ischemic stroke.

Intracranial Aneurysms in Young Adult Patients: Surgical and Endovascular Treatment Outcomes.

BACKGROUND: Despite its relative rarity, the potential for loss of productive years makes aneurysmal subarachnoid hemorrhage (SAH) a considerably important entity in young adult patients (20-39 years of age). This study aimed to analyze outcomes of microsurgery (MS) and endovascular treatment (EVT) for saccular intracranial aneurysms (IAs) in young adult patients. METHODS: A total of 276 young adult patients with 315 IAs, treated with MS or EVT between January 2001 and December 2015, were studied. Major recurrence and treatment-related complications were the primary outcome measures. Functional outcomes in patients with SAH were also assessed. RESULTS: Major recurrence occurred in 21 cases (6.7%). Younger age (adjusted hazard ratio [aHR], 3.77; 95% confidence interval [CI], 1.45-9.83; P = 0.007), ruptured IA (aHR, 6.44; 95% CI, 2.09-19.89; P = 0.001), size (aHR, 1.84; 95% CI, 1.06-3.18; P = 0.030), and EVT (aHR, 7.21; 95% CI, 2.44-21.35; P < 0.001) were independently related to major recurrence. Treatment-related complications occurred in 5 cases (1.6%) and did not differ between the MS and EVT groups (P > 0.999). Unfavorable outcomes (modified Rankin scale score ≥2) were identified in 30 patients (19.6%) with SAH, and only Hunt and Hess grade was independently associated with unfavorable functional outcome. CONCLUSIONS: Both MS and EVT are safe for treating IAs in young adult patients. MS showed better durability of treatment and may be preferred over EVT in young patients in view of their longer life expectancy compared with older patients.

A Meta-analysis for Evaluating Efficacy of Neuroendoscopic Surgery versus Craniotomy for Supratentorial Hypertensive Intracerebral Hemorrhage.

OBJECTIVE: Hypertensive intracerebral hemorrhage is a potentially life-threatening neurological deficit with the highest morbidity and mortality. In recent years, neuroendoscopy has been used to treat intracerebral hemorrhages (ICHs). However, the choice of neuroendoscopic surgery or craniotomy for patients with ICHs is controversial. The objective of this meta-analysis was to assess the efficacy of neuroendoscopic surgery compared to craniotomy in patients with supratentorial hypertensive ICH. MATERIALS AND METHODS: A systematic electronic search was performed using online electronic databases such as Pubmed, Embase, and Cochrane library updated on December 2017. The meta-analysis was performed by only including studies designed as randomized controlled trials. RESULTS: Three randomized controlled trials met our inclusion criteria. Pooled analysis of death showed that neuroendoscopic surgery decreased the rate of death compared to craniotomy (RR=0.58, 95% CI: 0.26-1.29; P=0.18). Pooled results of complications showed that neuroendoscopic surgery tended to have fewer complications than craniotomy had (RR=0.37, 95% CI: 0.28-0.49; P < 0.0001). CONCLUSION: Although the presenting analyses suggest that neuroendoscopic surgery should have fewer complications than craniotomy dose, it had no superior advantage in morbidity rate definitely. Therefore, it may be necessary for the neurosurgeons to select best optimal patients for individual treatment.

Modified Arachnoid Plasty Reduces Chronic Subdural Hematoma after Unruptured Aneurysm Clipping : Technical Note.

OBJECTIVE: Chronic subdural hematoma (CSDH) is a rare complication of unruptured intracranial aneurysm (UIA) clipping surgery. To prevent postoperative CSDH by reducing subdural fluid collection, we applied the modified arachnoid plasty (MAP) during the UIA clipping surgery to seal the dissected arachnoid plane. METHODS: This retrospective study included 286 patients enrolled from July 2012 to May 2015. We performed arachnoid plasty in all patients, with MAP used after June 17, 2014. Patients were divided into two groups (non-MAP vs. MAP), and by using uni- and multivariate analyses, baseline characteristics, and relationships with postoperative CSDH between the two groups were analyzed. The degree of preoperative brain atrophy was estimated using the bicaudate ratio (BCR) index. RESULTS: Ten patients (3.5%) among 286 patients had postoperative CSDH after clipping. Nine (3.1%) were in the non-MAP group, and one (0.9%) was in the MAP group. The higher BCR index showed statistical significance with occurrence of postoperative CSDH in both uni- (p=0.018) and multivariate (p=0.012, odds ratio [OR] 8.547, 95% confidence interval [CI] 1.616-45.455) analyses. MAP was associated with a lower risk of postoperative CSDH (p=0.022, OR 0.068, 95% CI 0.007-0.683). CONCLUSION: This study shows that the degree of preoperative brain atrophy is associated with an increased occurrence of CSDH after clipping and that MAP could help reduce the risk of postoperative CSDH after unruptured aneurysm clipping via a lateral supraorbital approach.

Pure Subdural Hemorrhage Caused by Internal Carotid Artery Dorsal Wall Aneurysm Rupture.

A 37-year-old woman was admitted to our hospital with altered mentality. The patient was diagnosed an internal carotid artery (ICA) dorsal wall aneurysm leading to acute subdural hemorrhage (SDH) without occurring subarachnoid hemorrhage and/or internal parenchymal hemorrhage. An aneurysmal neck clipping and hematoma evacuation were performed at once. A pure SDH by ruptured aneurysm is unusual, but it is important to consider it if a SDH patient has no other medical history.

Deep brain stimulation in a dentatorubral-pallidoluyisian atrophy patient with myoclonic dystonia.

We describe a patient with myoclonic dystonia caused by dentatorubral-pallidoluyisian atrophy (DRPLA), which was successfully controlled with bilateral deep brain stimulation (DBS) of the globus pallidus internus (GPi). DRPLA is a rare disease which can progressively cause a loss or degeneration of neurons in the globus pallidus, dentate nucleus, subthalamic nucleus, and red nucleus. This observation is another example of secondary dystonia which can be controlled by GPi-DBS in carefully selected patients.

Coronary heart disease in moyamoya disease: are they concomitant or coincidence?

The purpose of this study was to determine the prevalence and characteristics of symptomatic coronary heart disease (CHD) in patients with moyamoya disease (MMD). This retrospective study evaluated 456 patients who received examination for MMD between 1995 and 2012. We reviewed the patients' medical history and coronary imaging, including conventional coronary angiography and coronary computed tomography angiogram (CTA). Among 456 patients with MMD, 21 (4.6%) patients were found to have symptomatic CHD. Ten patients were treated with coronary artery bypass graft or percutaneous coronary intervention for unstable angina or myocardial infarction. Eleven were treated with medication for stable angina (n = 6) and variant angina with mild degree of stenosis (n = 5).The median age of these patients was 44 yr (range, 27-59). The median Framingham score at diagnosing MMD was < 1% (range, < 1%-16%). The old age was associated with CHD in uni- and multivariate analyses (P = 0.021, OR, 1.053; 95% CI, 1.008-1.110). Considering low age of onset and low stroke risk factor, CHD might be a systemic manifestation that is clinically relevant to MMD.