Comparison of outcomes with/without preoperative embolization for meningiomas with diluted N-butyl-2-cyanoacrylate.

BACKGROUND: Preoperative embolization for meningiomas is controversial regarding its effectiveness in reducing intraoperative blood loss and operative time. In contrast, some reports have documented improved surgical outcomes in large meningiomas. In this study, we retrospectively compared the outcomes of craniotomy for meningiomas with/without preoperative embolization with diluted N-butyl-2-cyanoacrylate (NBCA) primarily in a single institution. METHODS: Data (World Health Organization grade, Simpson grade, maximum tumor diameter, intraoperative bleeding, operative time, history of hypertension, and time from embolization to craniotomy) of patients with initial intracranial meningiomas were compared with or without preoperative embolization from January 2015 to April 2022. RESULTS: The embolization group consisted of 56 patients and the nonembolization group included 76 patients. Diluted NBCA (13% concentration for all patients) was used in 51 of 56 patients (91.1%) who underwent transarterial embolization. Permanent neurological complications occurred in 2 (3.6%) patients. Intraoperative bleeding was significantly lower in the embolization group for a maximum tumor diameter ≥40 mm (155 vs. 305 ml, respectively, p < 0.01). In the nonembolization group, for a maximum tumor diameter ≥30 mm, patients with hypertension had more intraoperative bleeding than non-hypertensive ones. CONCLUSIONS: Despite its limitations, the present results showed that, under certain conditions, preoperative embolization for intracranial meningiomas caused less intraoperative bleeding. The safety of treatment was comparable with that reported in the Japan Registry of NeuroEndovascular Therapy 3 (JR-NET3) with a complication rate of 3.7% for preoperative embolization of meningiomas, despite the treatment focused on the liquid embolization material.

Treatment Outcomes of 94 Cases of Pipeline Embolization Device in a Single Center: Predictive Factors of Incomplete Aneurysm Occlusion.

Objective: This study aimed to report the outcome of an endovascular treatment with a pipeline embolization device (PED) at a single center. We also examined the predictive factors for an incomplete occlusion after the PED placement. Methods: The subjects were 94 patients with 109 aneurysms who underwent the PED placement at our single center from June 2015 to September 2022. As treatment outcomes, we investigated the PED placement success rate, perioperative morbidity and mortality, postoperative cranial nerve improvement rate, and the classification of angiographic result at 6 months after the PED placement. Furthermore, the predictors of an incomplete occlusion were investigated in detail. Results: One hundred nine aneurysms locations were: C1 (9), C2 (30), C3 (15), C4 (53), and C5 (2) in the internal carotid artery segments. Perioperative morbidity, including the asymptomatic ones, occurred in 10 cases (10.6%). Among these 10 cases, the modified Rankin Scale (mRS) improved to preoperative mRS after 90 days in 9 cases except 1 case. On the other hand, no perioperative mortality was observed. The postoperative cranial nerve improvement rate was 84.4%, and 61.7% of patients had a complete occlusion in the follow-up angiography, 6 months after the PED placement. Predictive factors for an incomplete occlusion after the PED placement were the elderly aged 70 years or older (P-value = 0.0214), the elderly aged 75 years or older (P-value = 0.0009), and the use of anticoagulants (P-value = 0.0388) in an univariate analysis. Further, the multivariate analysis revealed that the elderly aged 75 years or older was a predictive factor of an incomplete occlusion in this study. Conclusion: We summarized the outcomes of the PED treatment at our single center. In this study, the elderly aged 75 years or older was a predictive factor of an incomplete occlusion after the PED placement.

Application of the break-even point to express the bone dynamics around implants.

PURPOSE: The aim of this study was to apply the break-even point concept to express the dynamics of bone formation and resorption around implants. METHODS: Published data on new bone and parent bone densities around implants from one human and three dog studies were selected and used for analysis. The break-even point (BEP) of the bone density (BD) was assessed. The BEP is the point at which, in a graph, the lines representing the formation of new bone and resorption of old bone intersect. BEP is expressed in time (x; days) of occurrence and percentage of bone (y; %) at which the break-even point occurs and illustrates the grade of bone modeling. The sooner the occurrence, the faster the bone formation in relation to the resorption of the old bone. RESULTS: In the marrow and cortical compartments, BEP of bone density occurred after 7.9 days (BD% 24.5%) and >30 days, respectively. Different surfaces presented similar BEP, ranging between 9.7 and 11.2 days (BD% 19.1-22.5%). BEP at implants installed in the human maxilla occurred after 29-30.4 days (BD% 28.3-29.6%). CONCLUSION: The present study showed that the parameters used to express the break-even point can provide information on the influence of the model used, surface characteristics, and bone quality on bone modeling/remodeling around implants.

Coil Embolization of Unruptured Distal Anterior Cerebral Artery Aneurysm Using a Marathon Microcatheter.

Marathon is rarely used in coil embolization for an aneurysm; particularly, there have been no reports about distal anterior cerebral artery aneurysms. We have reported a case of successful use of Marathon in coil embolization in case of a distal anterior cerebral artery aneurysm. The patient was an 83-year-old woman. She had undergone coil embolization for an unruptured distal anterior cerebral artery aneurysm, which was discovered by chance. Our initial approach involved the use of a combination of Traxcess and Excelsior SL-10, but the use of SL-10 could not follow Traxcess because the right anterior cerebral artery from the right internal carotid artery had a sharp bifurcation. However, by switching to a combination of TENROU and Marathon, we could access the aneurysm. We thereby decided to continue the use of Marathon in order to complete the coil embolization. In coil embolization for an aneurysm, Marathon was found to be useful, depending on the location of the aneurysm and access route.

Staged strategy using a transcarotid approach for acute tandem occlusions with left common carotid artery origin steno-occlusive lesion.

BACKGROUND: Endovascular treatment for acute tandem occlusion (ATO) of the combination of an ipsilateral extracranial internal carotid artery (ICA) steno-occlusive lesion with concurrent intracranial artery occlusion is challenging. Whether extracranial lesions, especially in cases of the left common carotid artery (LCCA) origin steno-occlusive lesions, should be treated after recanalization of an occluded intracranial artery by mechanical thrombectomy simultaneously in the same session has not been established. We report two cases of successful ATO with LCCA origin steno-occlusive lesions treated by staged retrograde transcarotid LCCA stenting followed emergent mechanical thrombectomy in two sessions because of the tortuous aortic arch. CASE DESCRIPTION: A 61-year-old man with left ICA occlusion and an 82-year-old woman with left middle cerebral artery occlusion underwent emergent mechanical thrombectomy for ATO with LCCA origin stenoocclusive lesions. We achieved recanalization of large vessels, but severe stenosis of LCCAs remained. Because of the tortuous aortic arch, we decided to treat LCCA origin steno-occlusive lesions with staged stenting in the other session followed emergent mechanical thrombectomy. Postoperative courses were uneventful, and their symptoms improved. We performed stenting using a transcarotid approach through CCA cut down for LCCA steno-occlusive lesions without any complications. CONCLUSION: The staged strategy leaving LCCA origin stenosis seems to offer a better strategy than the simultaneous strategy for ATO with LCCA origin steno-occlusive lesions. A retrograde transcarotid approach through CCA cut down is recommended for LCCA stenting.

Successful surgical resection and reconstruction of scrotal elephantiasis.

INTRODUCTION: An enlarged scrotum due to scrotal elephantiasis results in a poor quality of life. This condition is uncommon and challenging to manage for most urologists. We report a case of scrotal elephantiasis treated with resection and scrotal reconstruction. CASE PRESENTATION: A 57-year-old man was referred to our hospital with a 6-year history of scrotal swelling. The scrotum was 20 cm in diameter, stiff, and thick. He was diagnosed with chronic scrotal lymphedema and underwent scrotal resection. The skin and subcutaneous tissues of the scrotum were excised, and the suprapubic skin, which was stretched by the enlarged scrotum, was used for the scrotal reconstruction. The penis was pulled out from this hole in the skin. CONCLUSION: Utilizing suprapubic skin flap for scrotal reconstruction is an effective treatment for scrotal elephantiasis that can result in functionally and cosmetically successful outcomes.

4-Hydroxyl-2-Nonenal Localized Expression Pattern in Retrieved Clots is Associated with Large Artery Atherosclerosis in Stroke Patients.

OBJECTIVES: The relationship between stroke etiology and clot pathology remains controversial. MATERIALS AND METHODS: We performed histological analysis of clots retrieved from 52 acute ischemic stroke patients using hematoxylin and eosin staining and immunohistochemistry (CD42b and oxidative/hypoxic stress markers). The correlations between clot composition and the stroke etiological group (i.e., cardioembolic, cryptogenic, or large artery atherosclerosis) were assessed. RESULTS: Of the 52 clots analyzed, there were no significant differences in histopathologic composition (e.g., white blood cells, red blood cells, fibrin, and platelets) between the 3 etiological groups (P = .92). By contrast, all large artery atherosclerosis clots showed a localized pattern with the oxidative stress marker 4-hydroxyl-2-nonenal (P < .01). From all 52 clots, 4-hydroxyl-2-nonenal expression patterns were localized in 28.8% of clots, diffuse in 57.7% of clots, and no signal in 13.5% of clots. CONCLUSIONS: A localized pattern of 4-hydroxyl-2-nonenal staining may be a novel and effective marker for large artery atherosclerosis (sensitivity 100%, specificity 82%).

[A Case of Primary Mediastinal Seminoma Showing Local Increase in Residual Tumor after Chemotherapy].

A 19-year-old man with abnormal findings on his chest X ray was referred to our hospital. A chest computed tomography scan revealed a 57 mm mass in the anterior mediastinum, and percutaneous needle biopsy was performed. Histopathological diagnosis was pure seminoma. Since the serum alphafetoprotein (AFP) level was normal and no abnormal findings were noted in the testis, the patient was diagnosed with mediastinal seminoma [International Germ Cell Consensus Classification (IGCCC) goodrisk group]. After three cycles of chemotherapy with bleomycin/etoposide/cisplatin [BEP], the tumor decreased in size to 32 mm, and a fluorodeoxyglucose-positron emission tomography scan indicated negative tumor findings. After four months, the residual tumor increased in size to 40 mm without any increase in the tumor marker levels. Surgical resection was performed, and the histopathological finding was only mature teratoma. Six months after the operation, there has been no recurrence.

Other Hospital-onset Acute Ischemic Stroke Due to Large Vessel Occlusion Treated by Mechanical Thrombectomy after Inter-hospital Transfer.

The purpose of this study was to investigate the in-hospital acute ischemic stroke due to large vessel occlusion (LVO) that developed in another thrombectomy-incapable hospital, treated by mechanical thrombectomy after inter-hospital transfer. In eight other hospital-onset LVO patients, clinical characteristics, treatment results, and the timeline of thrombectomy were retrospectively investigated and compared to the results of 17 patients developed LVO at our own hospital and 18 developed in the community. In the analysis of timeline, the mean recognition-to-arrival time in other hospital-onset patients was 169 ± 78 min, significantly longer than for the community-onset patients (79 ± 78 min). Arrival-to-puncture time was 42 ± 19 min, significantly shorter than for the own hospital-onset patients (166 ± 80 min) and the community-onset patients (155 ± 76 min). Recognition-to-puncture times for the other hospital-onset patients, the own hospital-onset patients, and the community-onset patients were 212 ± 74, 166 ± 80, and 216 ± 83 min, respectively, and recognition-to-recanalization times were 285 ± 73, 200 ± 81, and 275 ± 125 min. Both these times were shorter for the own hospital-onset patients. The rates of modified Rankin Scale (mRS) of 0-2 in the three groups were 12%, 30%, and 23%, respectively. The rate of mRS 0-2 was lowest in the other hospital-onset patients. In conclusion, the other hospital-onset patients required additional time for their initial management and inter-hospital transfer although arrival-to-puncture time was shorter. Favorable outcomes were observed less frequently in them. Improving inter-hospital cooperation systems and to educate the medical staff in a thrombectomy-incapable hospital concerning stroke management is important measures for other hospital-onset stroke with LVO.

A thread of hope for successful revascularization for acute embolic basilar artery occlusion due to miserable vertebral artery stump syndrome. A technical report.

Acute basilar artery occlusion (BAO) is associated with major morbidities and a high mortality rate. The prevalence of acute BAO is 10.4% among patients treated with thrombectomy for acute large vessel occlusion. Vertebral artery stump syndrome (VASS) reportedly causes ischemic stroke with tandem occlusions as vertebral artery (VA) origin occlusion and BAO. The pathogenesis of ischemic stroke due to VASS can be attributed to thrombi or emboli. Acute embolic BAO due to VASS accounted for 2 of 25 cases (8.0%) of BAO treated using thrombectomy between April 2014 and May 2019 in our registry. VASS must be considered as one cause of BAO. With the initial Magnetic resonance angiography on arrival, it is difficult to distinguish between BAO due to simple cardiogenic embolus and due to embolus caused by VASS rapidly. In patients suffering from acute embolic BAO due to VASS, the presence of VA origin occlusion makes endovascular therapy (EVT) difficult to perform. Here, we report consecutive cases of thrombectomy for acute embolic BAO due to VASS, showing markedly different outcomes. VA origin occlusion severely limits the technical options for EVT. Visualization or conjecture of the origin of both or dominant VAs conceivably offers the possibility of successful EVT and may allow good outcomes.

A Patient with a Large Aneurysm Complicated by Stenosis of the Internal Carotid Artery Distal to the Aneurysm in Whom Treatment Using a Pipeline Flex Was Performed.

Objective: We report a case of in-stent stenosis as a complication at 6 months after the deployment of Pipeline Flex. This case necessitated retreatment for parent artery occlusion. Case Presentation: A 55-year-old woman with right-side visual disorder was referred to our hospital for the deployment of Pipeline Flex. Cerebral digital subtraction angiography (DSA) demonstrated a large right-side paraclinoid aneurysm in combination with severe internal carotid artery (ICA) stenosis just beyond the aneurysm. We deployed Pipeline Flex under general anesthesia. After deployment, we performed angioplasty through the Pipeline. Six months after deployment, this patient exhibited exacerbation of visual disorder. Follow-up DSA revealed in-stent stenosis at 6 months after the deployment of Pipeline Flex. Therefore, we performed parent artery occlusion. Right-side visual disorder was improved in this patient. Conclusion: If Pipeline is deployed for patients with ICA stenosis just beyond an aneurysm, we need to be aware of in-stent stenosis after deployment.

[A Case of Ureteral Sciatic Hernia Treated with Ureteral Stent].

An 83-year-old woman who was diagnosed with hydronephrosis on the right side was referred to our hospital. An abdominal computed tomography scan failed to reveal the cause of the hydronephrosis due to artifacts caused by her artificial hip joint. A subsequent magnetic resonance imaging scan revealed a ureteral herniation into the sciatic foramen. Retrograde pyelography demonstrated hydronephrosis and dilated ureter loopsthrough the sciatic foramen, known asa "curlicue sign". A ureteral stent was placed on her right side, and the ureter waslinearized. After the stent wasplaced, the hernia wasrepaired and the hydronephrosiswasres olved. The ureteral stent wasremoved 3 monthslater, and relapse of the ureteral sciatic hernia did not occur, even after 18 months.

Catastrophic Multiple Microbleeds Caused by Infective Endocarditis Following Intravenous Thrombolysis and Endovascular Thrombectomy.

Ischemic stroke is one of the most common complications of infective endocarditis (IE). IE must be considered as one of the causes of acute ischemic stroke (AIS) with emergent large vessel occlusion (ELVO), but early diagnosis of IE is difficult. AIS with ELVO must be treated using endovascular thrombectomy (EVT), with or without intravenous thrombolysis (IVT). IVT for AIS due to IE is not well established and remains controversial because of the risk of intracranial hemorrhage. A 42-year-old man suffered from right hemiparesis and disorientation, and AIS with ELVO was diagnosed. EVT with IVT was successfully performed and recanalization was achieved, but catastrophic multiple cerebral microbleeds appeared after treatment. EVT without IVT could be chosen for AIS caused by IE to avoid hemorrhagic complications. Hypointense signal spots on T2*-weighted magnetic resonance imaging (MRI) and susceptibility-weighted MRI could facilitate early diagnosis of IE.

Radiation recall pneumonitis induced by nivolumab in a patient with renal cell carcinoma.

INTRODUCTION: A radiation recall reaction in previously irradiated lungs is known as radiation recall pneumonitis. We encountered a rare case of radiation recall pneumonitis induced by nivolumab 9 months after palliative radiotherapy to the ribs. CASE PRESENTATION: The patient was a 69-year-old woman with renal cell carcinoma. She had received various drugs and palliative irradiation, which was followed by nivolumab treatment, for renal cell carcinoma. Three days after the initial nivolumab administration, she presented with respiratory symptoms. On the basis of chest computed tomography findings, she was diagnosed with nivolumab-induced radiation recall pneumonitis and treated with prednisolone (1 mg/kg). The condition resolved rapidly, and chest computed tomography 4 months after nivolumab cessation revealed interval resolution of the lung consolidation and persistent tumor shrinkage. CONCLUSION: Physicians should consider the risk of radiation recall pneumonitis during treatment with immune checkpoint inhibitors in patients who have received previous thoracic radiotherapy.

Overlapping Stents with Coil Sandwich for Ruptured Blood-blister Aneurysm in a Patient with Ipsilateral Persistent Primitive Trigeminal Artery: A Case Report and Review of Literature.

Ruptured blood-blister aneurysms (RBBAs) of the intracranial internal carotid artery (ICA) are associated with high morbidity and mortality. RBBA has been treated with trapping with high-flow bypass avoiding manipulation of RBBA. In case of the presence of persistent primitive trigeminal artery (PPTA), it is necessary to preserve the antegrade blood flow of PPTA because avoiding ischemic complications. Here, we present a case of RBBA concomitant with ipsilateral PPTA successfully treated with multistaged overlapping braided stents maintaining PPTA flow. A 30-year-old woman suffered from headache and was diagnosed RBBA of the intracranial ICA concomitant with ipsilateral PPTA. A reconstructive endovascular treatment using low-profile visualized intraluminal support (LVIS) stent was performed. However, it has recurred, and RBBA has finally been occluded after overlapping LVIS stents with coil sandwich that is not yet reported in the literature. We report the first case of overlapping LVIS stents with coil sandwich for RBBA.

1O, 20O-diacetyl kamebakaurin protects against acetaminophen-induced hepatotoxicity in mice.

The present study aimed to investigate the protective effects of kamebakaurin (KA) and 1O, 20O-diacetyl kamebakaurin (Ac2KA) on acetaminophen (APAP)-induced hepatotoxicity and compare the hepatoprotective mechanisms of the two chemicals. Seven-week-old male C57BL/6J mice were orally administered KA, Ac2KA, or an ethanol/olive oil emulsion once per day for 7-days. Twenty-four hours after the final administration, the mice were fasted and then intraperitoneally injected with 450 mg/kg APAP or saline. At 16 h after injection, the mice were euthanized and blood samples were collected for plasma analysis. Pretreatment with KA and Ac2KA significantly attenuated APAP-induced hepatic injury. The protective effect of Ac2KA was stronger than that of KA. These two chemicals attenuated oxidative stress, inflammatory cytokine production, c-jun N-terminal kinase activation, and receptor-interacting protein (RIP)-3 activation. Ac2KA also decreased APAP-induced RIP-1 activation and nuclear factor kappa B (NF-κB) p65 translocation. Moreover, Ac2KA repressed mRNA expression of Cyp1a2/2e1 in the liver. Our results showed that KA and Ac2KA exerted protective effects against APAP-induced hepatotoxicity. The responsible mechanisms may be related to the chemicals' antioxidant activity and the inhibition of c-jun N-terminal kinase activation and RIP-3 activation. The effects of Ac2KA included those of KA, as well as RIP-1 inactivation, NF-κB inhibition, and Cyp inhibition.

[Right Essential Renal Hematuria that Can Not Be Coagulated with a Ureteroscope Treated by Hydrogen Peroxide Instillation : A Case Report].

We report a case of right essential renal hematuria treated by hydrogen peroxide instillation. A twentythree-year-old man visited our hospital with gross hematuria, urinary retention and right pelvic pain. Our diagnosis was right renal essential hematuria. A bleeding point was found in the right renal calix using a flexible ureteroscope. Bleeding was prolonged in spite of ureteroscopy and diathermy fulguration. We performed treatment with hydrogen peroxide instillation. The patient made a satisfactory recovery postoperatively, and no complications have been observed. Retrograde hydrogen peroxide instillation therapy is a useful treatment for essential renal hematuria that can not be coagulated with a ureteroscope.

Endovascular Treatment of Idiopathic Intracranial Hypertension with Stenting of the Transverse Sinus Stenosis.

For many years, the pathophysiology of idiopathic intracranial hypertension (IIH) was interpreted as "secondary intracranial hypertension," and IIH was considered to be caused by brain edema due to obstructive sleep apnea. Another theory proposed cerebrospinal fluid (CSF) absorption impairment due to excessive medication with vitamin A derivatives. Other reports pointed out the importance of obesity, which may cause an impairment of intracranial venous drainage due to elevated right atrial pressure. Patients with medically refractory IIH have traditionally undergone a CSF diversion. Venous outlet impairment on IIH has recently been reported as a causative or contributory cause, and thus focused venoplasty of the stenotic sinus with a stent has emerged as a new treatment strategy. We report the cases of two patients who presented with headache and papilledema with IIH. They successfully underwent stent placement at the stenosis of the transverse sinus and experienced complete resolution of symptoms.

Tied Pipeline: A Case of Rare Complication.

A 48-year-old female with a symptomatic giant carotid cavernous aneurysm underwent endovascular treatment with multiple Pipeline Flex embolic devices (PED). The delivery catheter had to take a complicated course of multiple turns to cross the aneurysm, and its loop was tied in the aneurysm. When the catheter was to be withdrawn, it was apparent that the tied catheter had made a tight knot that bound the tail of the previous PED together. We successfully retrieved all of the system including the tied PED, and we used telescoping stents with five PEDs in the next operation. Although this is a rare complication, it is worth noting and checking to make sure that there is no knot before deploying the stent.

Continuous Blood Glucose Monitoring May Detect Carotid Occlusion Intolerance during Carotid Artery Stenting.

BACKGROUND: The frequency of the occurrence of adverse events associated with carotid artery stenting (CAS) is usually low, but serious adverse events such as cerebral hyperperfusion syndrome (CHS) may occur. Real-time monitoring is ideal for the early detection of adverse events during the surgical procedure. This study aimed to evaluate continuous blood glucose (BG) monitoring for the detection of adverse events during CAS. METHODS: Forty patients undergoing scheduled CAS were prospectively enrolled. An artificial pancreas was used for continuous BG monitoring (once per minute), using venous blood extracted at a rate of 2 mL/hr during CAS. The primary endpoint was a correlation between BG change and adverse events. RESULTS: CAS was discontinued in 1 patient, and BG was not measured in 5 patients (12.5%) because of the inability to extract blood. Among 34 evaluable patients, no patient developed CHS, but 3 patients (9%) experienced carotid occlusion intolerance. During CAS, BG was significantly higher in patients with carotid occlusion intolerance (median: 5 mg/dL) than in patients without carotid occlusion intolerance (median: 0 mg/dL) (P = 0.0221). A cutoff BG value ≥4 mg/dL during CAS showed 50% sensitivity and 100% specificity for the detection of carotid occlusion intolerance. There was no significant correlation between BG change and other adverse events. CONCLUSIONS: BG elevation may help detect carotid occlusion intolerance although it is still unknown whether BG monitoring can detect CHS. Further studies should validate that a cutoff BG elevation value of ≥4 mg/dL during CAS indicates carotid occlusion intolerance.