Intramedullary feeder aneurysm of a cervical epidural arteriovenous fistula causing myelopathy: a case report and literature review.

While a craniocervical junction (CCJ) epidural arteriovenous fistula (EDAVF) may present with hemorrhagic myelopathy from an associated feeder aneurysm on rare occasions, non-hemorrhagic myelopathy from such an aneurysm remains unreported. A woman in her late sixties presented with cervical myelopathy due to a non-hemorrhagic intramedullary aneurysm associated with CCJ-EDAVF. The intramedullary aneurysm originated from the spinal pial artery supplied by the anterior spinal artery. Direct surgical fistula coagulation and feeder obliteration resulted in the disappearance of the aneurysm and myelopathy improvement. This report illustrates the first case of a non-hemorrhagic intramedullary aneurysm associated with CCJ-EDAVF successfully treated with direct surgery.

Extradural Anterior Clinoidectomy and Optic Canal Unroofing for Paraclinoid and Basilar Aneurysms: Usefulness of a No-Drill Instrumental Method.

The authors describe extradural anterior clinoidectomy without the use of a high-speed drill or ultrasonic device to clip paraclinoid and basilar aneurysms, which can eliminate potential complications related to traditional power drilling or ultrasonic device use. This method involves four steps: (1) partial osteotomy of the sphenoid wing at the superior orbital fissure (SOF); (2) peeling of the dura propria of the temporal lobe from the inner cavernous membrane of the SOF; (3) isolation and resection of the exposed meningo-orbital band to expose the superolateral aspect of the anterior clinoid process (ACP); and (4) piecemeal rongeuring of ACP and the roof of the optic canal. The entire procedure was performed using surgical instruments, including micro-rongeurs, a fine Kerrison punch, and micro-dissectors. Subsequently, intradural neck clipping was performed. Twenty consecutive patients with paraclinoid and basilar aneurysms successfully underwent clipping after this non-drill extradural clinoidectomy. Minor morbidity was noted in two patients (cerebrospinal fluid leakage in one and transient oculomotor palsy in the other). The non-drill method is a simple, easy, safe, and quick alternative to traditional power drilling in extradural clinoidectomy, and this method can avoid morbidity related to direct mechanical/thermal injury of important neurovascular structures.

Bridging veins and veins of the brainstem in microvascular decompression surgery for trigeminal neuralgia and hemifacial spasm.

OBJECTIVE In microvascular decompression surgery for trigeminal neuralgia and hemifacial spasm, the bridging veins are dissected to provide the surgical corridors, and the veins of the brainstem may be mobilized in cases of venous compression. Strategy and technique in dissecting these veins may affect the surgical outcome. The authors investigated solutions for minimizing venous complications and reviewed the outcome for venous decompression. METHODS The authors retrospectively reviewed their surgical series of microvascular decompression for trigeminal neuralgia and hemifacial spasm in patients treated between 2005 and 2017. Surgical strategies included preservation of the superior petrosal vein and its tributaries, thorough dissection of the arachnoid sleeve that enveloped these veins, cutting of the inferior petrosal vein over the lower cranial nerves, and mobilization or cutting of the veins of the brainstem that compressed the nerve roots. The authors summarized the patient characteristics, operative findings, and postoperative outcomes according to the vascular compression types as follows: artery alone, artery and vein, and vein alone. They analyzed the data using chi-square and 1-way ANOVA tests. RESULTS The cohort was composed of 121 patients with trigeminal neuralgia and 205 patients with hemifacial spasm. The superior petrosal vein and its tributaries were preserved with no serious complications in all patients with trigeminal neuralgia. Venous compression alone and arterial and venous compressions were observed in 4% and 22%, respectively, of the patients with trigeminal neuralgia, and in 1% and 2%, respectively, of those with hemifacial spasm (p < 0.0001). In patients with trigeminal neuralgia, 35% of those with artery and venous compressions and 80% of those with venous compression alone had atypical neuralgia (p = 0.015). The surgical cure and recurrence rates of trigeminal neuralgias with venous compression were 60% and 20%, respectively, and with arterial and venous compressions the rates were 92% and 12%, respectively (p < 0.0001, p = 0.04). In patients with hemifacial spasm who had arterial and venous compressions, their recurrence rate was 60%, and that was significantly higher compared to other compression types (p = 0.0008). CONCLUSIONS Dissection of the arachnoid sleeve that envelops the superior petrosal vein may help to reduce venous complications in surgery for trigeminal neuralgia. Venous compression may correlate with worse prognosis even with thorough decompression, in both trigeminal neuralgia and hemifacial spasm.

Coaxial interleaved stimulation of the thalamus and subthalamus for treatment of Holmes tremor.

Holmes tremor is often treated with multiple deep brain stimulation (DBS) electrodes. The authors describe a novel technique to suppress the tremors by effectively utilizing a single electrode. A 16-year-old boy presented with severe right arm tremor following a midbrain injury. A DBS electrode was implanted into the ventral oralis nucleus of the thalamus (VO) and the subthalamic region. While individual stimulation of each target was ineffective, an interleaved dual stimulation of both targets has been effective for 6 years. Coaxial interleaved stimulation of the VO and the subthalamic region is useful for treating Holmes tremor. The video can be found here: https://youtu.be/tSwGh3vy68c .

Posterior atlantoaxial fusion as treatment option for extracranial vertebral artery dissecting aneurysm: a case report and literature review.

Symptomatic extracranial vertebral artery (VA) dissection may need surgery. We describe such a case successfully treated with atlantoaxial fusion based on its rare dynamic angiographic findings. A 27-year-old woman suffered from repeated brainstem and cerebellar infarctions from a left extracranial VA dissecting aneurysm. Dynamic angiography showed the dissecting aneurysm of the V3 segment in the neutral head position, and deflation of the aneurysm during rightward head rotation. She underwent posterior atlantoaxial fusion, and the lesion was repaired with no subsequent ischemia. Posterior atlantoaxial fusion can be an option for some extracranial VA dissections with preserving its anterograde blood flow.

[Treatment of Non-Traumatic Spinal Epidural Hematoma:A Report of Five Cases and a Systematic Review of the Literature].

Objective:Non-traumatic spinal epidural hematoma(SEH)is relatively rare. We report five cases of SEH, review the relevant literature, and discuss the current treatment strategies for non-traumatic SEH in Japan. Methods:Clinical data of cases with non-traumatic SEH treated at our institute from 2008 to 2015 were retrospectively analyzed. In addition, we identified the relevant literature using the Japan Medical Abstracts Society databases for peer-reviewed articles published from Jan 1, 1995 to Aug 31, 2015. The search terms "spinal", "epidural hematoma", and "non-traumatic OR spontaneous" were used. Treatment strategies were summarized according to the treatment criteria. Results:Five patients(1 man and 4 women;age, 59-86 years;mean age, 74 years)were treated for SEH. Hematomas were located in the cervical(n=1), cervicothoracic(n=2), thoracic(n=1), and thoracolumbar(n=1)regions. All patients suffered sudden neck and/or back pain followed by subsequent neurological deterioration. Four patients were under antithrombotic treatment, and underwent laminectomy and drainage of the hematoma due to severe and progressive neurological deficits. All patients demonstrated significant neurological recovery. Seventy-seven articles from domestic institutes and hospitals were identified. Their criteria for conservative and surgical treatments differed based on the time from the onset and severity. Conclusion:Five cases of non-traumatic SEH were treated successfully. Patients with moderate to severe neurological deficit need timely surgical management, while non-surgical treatment may be indicated in mild deficits. To standardize the optimal treatment for non-traumatic SEH, an appropriate assessment system incorporating the time from onset and severity of neurological impairment should be established.

[A Single-Stage Combined Supra- and Infra-Sellar Approach for Recurrent Large Pituitary Adenomas:Report of Two Cases].

Despite the recent technological advances in operative instruments and development of novel techniques for endoscopic skull-base surgeries, surgical treatment of primary or recurrent large/giant pituitary adenomas remains a challenge. Postoperative hemorrhage from the residual tumor and the associated impairment of the adjacent cranial nerve functions can cause severe morbidity. To manage such operative risks, a combined supra- and infra-sellar approach(CSISA)can be used as a surgical option for difficult-to-resect large/giant pituitary adenomas. We successfully performed a single-stage CSISA in two patients with large recurrent pituitary adenomas with favorable outcomes. Both patients had recurrent adenomas after multiple trans-sphenoidal surgeries and presented with visual impairment due to tumor regrowth. Each tumor had a maximum diameter of more than 4 cm. One tumor extended into the anterior skull base, while the other extended into the supra-sellar region with extremely lateral invasion. The CSISA helped surgeons visualize the tumors and the surrounding structures through a combination of different operative views. Subtotal resection was safely achieved in both cases, with no postoperative hemorrhage and deterioration of visual and pituitary function. The CSISA is useful not only for pituitary adenomas with anterior or lateral extension and multi-lobular growth, but also for certain cases with recurrent large/giant pituitary adenomas.

Intramedullary spinal cord abscess and subsequent granuloma formation: a rare complication of vertebral osteomyelitis detected by diffusion-weighted magnetic resonance imaging.

An intramedullary spinal cord abscess, which is usually associated with discitis, is an uncommon but potentially important complication of vertebral osteomyelitis. The authors describe a rare case of an intramedullary conus medullaris abscess and lumbar osteomyelitis sparing the intervertebral discs and without discitis. The patient also developed a granuloma in the cauda equina during treatment. Diffusion-weighted MRI was useful for differentiating the granulomatous lesion from the relapse of infection. A 65-year-old immunocompetent man with moderately controlled diabetes presented with progressive lowerextremity numbness and weakness with urinary dysfunction. He had progressive paraparesis, bilateral leg paresthesia, and sphincter compromise. Magnetic resonance imaging revealed an intramedullary ring-enhanced lesion, which was hyperintense on diffusion-weighted images. The lesion, an intramedullary spinal cord abscess, was surgically drained. During antibiotic treatment, serial MRI showed an enlarging enhanced lesion in the cauda equina, and a recurrent infection was suspected. A second-look surgery confirmed the formation of a granuloma and the absence of a relapse of the abscess. Although the enhanced lesion increased in size, its intensity on diffusion-weighted images remained unchanged. After 3 months of antibiotic treatment, all enhanced lesions were diminished. An intramedullary spinal cord abscess is a rare but important complication of vertebral osteomyelitis, and it requires immediate treatment. Diffusion-weighted MRI was useful for the initial diagnosis as well as for monitoring treatment efficacy.

Modified Atlantoaxial Arthrodesis Technique for Atlantoaxial Instability via Intraarticular Autografting Using Structural Iliac Bone: Technical Nuances and Case Series.

OBJECTIVE: The present study described a modified technique of atlantoaxial arthrodesis in patients with atlantoaxial instability (AAI) along with the postoperative clinical and radiological results. METHODS: Five patients underwent this method for their AAI concurrent with C1 arch hypoplasia and/or the development of odontoid pannus causing myelopathy. After thorough exposure of the posterior surface of the C1-2 complex, the bilateral C2 nerve roots were sectioned to allow for easier access to the C1/2 facet joints. To prepare a suitable grafting bed, the C1/2 facet capsule was opened, and then the articular cartilaginous and synovial tissues were thoroughly removed. After being properly fashioned to match the gap between the C1/2 facet joint spaces, the structural bone grafts from the iliac crest were directly inserted into the facet joint spaces. To alleviate cord compression caused by concomitant odontoid pannus and/or hypoplastic C1 arch, C1 laminectomy was necessitated in all cases. Subsequently, posterior screw-rod instrumental fixation was conducted. RESULTS: All 5 patients underwent this procedure successfully. Clinical and radiological follow-up data of all patients indicated favorable relief of clinical symptoms and early rigid C1-2 stability. The sequelae of C2 nerve resection were not remarkable. No other neural or vascular damage associated with this technique was observed. CONCLUSIONS: Modified atlantoaxial arthrodesis via intraarticular autografting using the structural iliac bone combined with posterior instrumentation appears to be an efficient alternative treatment method for AAI patients with concurrent pathologies, even when the C1-2 posterior arches are unavailable for the grafting bed.

Two reports of iatrogenic pseudoaneurysms intraoperatively induced by an ultrasonic surgical aspirator: A rare intraoperative complication.

Background: The ultrasonic surgical aspirator is widely used in intracranial tumor resection as this instrument is considered safe. The advantage of an ultrasonic surgical aspirator is that it does not damage vessels or nerves close to the tumor. Therefore, limited information exists regarding intraoperative arterial injury by the ultrasonic surgical aspirator. Case Description: We report two cases. The first case was a 30-year-old woman who underwent surgery for a recurrent craniopharyngioma, and the second was a 50-year-old man who underwent surgery for a meningioma. A craniopharyngioma encased the basilar artery in the former case, and the superior cerebellar artery was encased by a meningioma in the latter. An ultrasonic surgical aspirator was used to resect the tumors in two cases. During surgery, the arteries involved in the tumors were unintentionally injured using an ultrasonic surgical aspirator. Intraoperative hemostasis was achieved for the bleeding from the injured arteries. However, postoperative digital cerebral angiography revealed pseudoaneurysms in the injured arteries. A subarachnoid hemorrhage occurred in the first case. The pseudoaneurysms were managed using endovascular embolization. Conclusion: Intraoperative arterial injury can occur with the application of an ultrasonic surgical aspirator. Neurosurgeons should be cautious when using ultrasonic surgical aspirators to avoid damaging the arteries involved with the tumor.

Erratum to "Crossing double stent retriever technique for refractory terminal internal carotid artery occlusion" [Radiology Case Reports 17 (2022) 1848-1852].

[This corrects the article DOI: 10.1016/j.radcr.2022.03.023.].

Risk of Bone Wax Migration During Retrosigmoid Craniotomy for Microvascular Decompression: Case-Control Study.

BACKGROUND AND OBJECTIVES: Bone wax is a flexible hemostatic agent commonly used for surgery in the posterior cranial fossa to control bleeding from the mastoid emissary vein. A large amount of bone wax can migrate into the sigmoid sinus through the mastoid emissary canal (MEC). We aimed to identify clinical factors related to intraoperative bone wax migration through the MEC during microvascular decompression (MVD) surgery, which may result in sigmoid sinus thrombosis. METHODS: We retrospectively collected the clinical data of patients with trigeminal neuralgia, hemifacial spasm, or trigeminal neuralgia accompanied by painful tic convulsif who underwent MVD. Basic information and the residual width and length (from the bone surface to the sigmoid sinus) of the MEC on computed tomography images were collected. We compared the collected clinical data between 2 groups of cases with and without intraoperative bone wax migration in the sigmoid sinus. RESULTS: Fifty-four cases with intraoperative bone wax migration and 187 patients without migration were enrolled. The t -test revealed significant differences in the width and length of the MEC ( P = .013 and P = .003, respectively). These variables were identified as significant factors in predicting intraoperative bone wax migration using multivariate logistic regression analysis. CONCLUSION: The large size of the MEC may be related to intraoperative bone wax migration into the sigmoid sinus in MVD. Neurosurgeons should be aware of these risks. Bone wax should be applied appropriately and hemostasis should be considered to control bleeding from the mastoid emissary vein in patients with a large MEC.

Lipocalin-type prostaglandin D synthase: a glymphopathy marker in idiopathic hydrocephalus.

Idiopathic normal pressure hydrocephalus in elderly people is considered a form of glymphopathy caused by malfunction of the waste clearance pathway, called the glymphatic system. Tau is a representative waste material similar to amyloid-ß. During neurodegeneration, lipocalin-type prostaglandin D synthase (L-PGDS), a major cerebrospinal fluid (CSF) protein, is reported to act as a chaperone that prevents the neurotoxic aggregation of amyloid-ß. L-PGDS is also a CSF biomarker in idiopathic normal pressure hydrocephalus and significantly correlates with tau concentration, age, and age-related brain white matter changes detected by magnetic resonance imaging. To investigate this glymphopathy, we aimed to analyze white matter changes and contributing factors in vivo and their interactions ex vivo. Cerebrospinal tap tests were performed in 60 patients referred for symptomatic ventriculomegaly. Patients were evaluated using an idiopathic normal pressure hydrocephalus grading scale, mini-mental state examination, frontal assessment battery, and timed up-and-go test. The typical morphological features of high convexity tightness and ventriculomegaly were measured using the callosal angle and Evans index, and parenchymal white matter properties were evaluated with diffusion tensor imaging followed by tract-based spatial statistics. Levels of CSF biomarkers, including tau, amyloid-ß, and L-PGDS, were determined by ELISA, and their interaction, and localization were determined using immunoprecipitation and immunohistochemical analyses. Tract-based spatial statistics for fractional anisotropy revealed clusters that positively correlated with mini-mental state examination, frontal assessment battery, and callosal angle, and clusters that negatively correlated with age, disease duration, idiopathic normal pressure hydrocephalus grading scale, Evans index, and L-PGDS. Other parameters also indicated clusters that correlated with symptoms, microstructural white matter changes, and L-PGDS. Tau co-precipitated with L-PGDS, and colocalization was confirmed in postmortem specimens of neurodegenerative disease obtained from the human Brain Bank. Our study supports the diagnostic value of L-PGDS as a surrogate marker for white matter integrity in idiopathic normal pressure hydrocephalus. These results increase our understanding of the molecular players in the glymphatic system. Moreover, this study indicates the potential utility of enhancing endogenous protective factors to maintain brain homeostasis.

Carotid web arising in the common carotid artery and adjacent to a transverse process of the cervical spine: A case report.

BACKGROUND AND IMPORTANCE: A carotid web (CaW) is an intraluminal membrane-like filling defect typically located in the posterior wall of the proximal internal carotid artery and is increasingly recognized as a potential cause of embolic stroke. We herein reported a case of a CaW that has an unusual location at the CCA; furthermore, an elongated transverse process of the cervical spine was adjacent to the CaW at the CCA. CLINICAL PRESENTATION: An 87-year-old woman with a history of minor stroke underwent thorough radiological examinations of her CCA lesion. Radiological examinations, including duplex ultrasonography, digital subtraction angiography (DSA), computed tomography, and magnetic resonance angiography, revealed that the morphological characteristics of the lesion were compatible with those of a typical CaW except for its location at the CCA. Furthermore, three-dimensional DSA revealed that the lesion was adjacent to the transverse process of the sixth cervical spine (C6), suggesting mechanical damage by the spinal transverse process as a possible pathogenesis of this CaW. CONCLUSION: This is the rare case of a CaW located in the CCA, far from the carotid bulb. Arterial dissection due to mechanical damage by the spinal transverse process may be a possible causative mechanism of the CaW in the present case.

Effects of microvascular decompression on quality-of-life in trigeminal neuralgia patients aged 70 years and older.

Background: Trigeminal neuralgia (TN) occasionally affects older adults, frequently worsens, and becomes refractory to medication. Older adult patients with TN may consider microvascular decompression (MVD) for their treatment. No study examines MVD effects on older adult TN patients' health-related quality of life (HRQoL). The present study evaluates the HRQoL of TN patients aged 70 years and older before and after MVD. Methods: Adult TN patients who underwent MVD evaluated their HRQoL using the 36-Item Short-form (SF-36) Health Survey before and 6 months after MVD. The patients were divided into four groups according to their decade of age. The clinical parameters and operative outcomes were analyzed statistically. The SF-36 physical, mental, and role social component summary scores and eight domain scale scores were analyzed using a twoway repeated-measures analysis of variance (ANOVA) to compare the effects of age group and preoperative and postoperative time points. Results: Among 57 adult patients (34 women, 23 men; mean age, 69 years; range, 30-89 years), 21 patients were in their seventies, and 11 were in their eighties. The SF-36 scores of patients in all age groups improved after MVD. Two-way repeated-measures ANOVA demonstrated a significant age group effect on the physical component summary and its physical functioning domain. A time point effect was significant on all component summaries and domains. There was a significant interaction between age group and time point effects on the bodily pain domain. These results suggested that patients 70 years and older had significant postoperative HRQoL improvement, but their improvement of physical-related HRQoL and multiple physical pain issues were limited. Conclusion: Impaired HRQoL in TN patients aged 70 years and older can improve after MVD. Careful management of multiple comorbidities and surgical risks enables MVD to be an appropriate treatment for older adult patients with refractory TN.

Cone-beam CT-assisted microcatheter tip placement at the shunted pouch entry zone: A technical note for anterior condylar arteriovenous fistula.

Accurate microcatheter placement for anterior condylar arteriovenous fistula (AVF) enables selective transvenous embolization (TVE) and helps to avoid hypoglossal nerve palsy. Anterior condylar AVF has a shunted pouch within the condylar vascular and osseous structures. Detailed anatomical comprehension of the shunted pouch is essential, in addition, we believe that it is important to have a strategy for where in the shunted pouch to start filling with coils. Specifically, we consider that it is important to structurally understand the more upstream location (arterial side) within the shunted pouch (called "shunted pouch entry zone"), guide the microcatheter there, and embolize from that site. Although several studies have discussed the usefulness of intraoperative cone-beam computed tomography (CBCT) for treating anterior condylar AVF, there are no studies which have mentioned the importance of microcatheter position before coil embolization in selective TVE as in this study. Intraoperative localization of the shunted pouch entry zone is often difficult. Herein, the authors report that cone-beam computed tomography (CBCT) can assist accurate microcatheter tip placement at the shunted pouch entry zone before staring embolization. This is the novel application of intraoperative CBCT to treat anterior condylar AVF successfully treated with precise and selective TVE.

Functionality and Usability of the Exoscope in Microvascular Decompression for Hemifacial Spasm and Trigeminal Neuralgia.

BACKGROUND: Studies on the functionality and usability of the exoscope in neurosurgical procedures against surgical microscopes (SMs) are limited. This study aimed to examine the functionality and usability of the exoscope during microvascular decompression (MVD) surgery. METHODS: Seven neurosurgeons evaluated the usefulness of a 4 K, 3-dimension digital exoscope in MVD by answering a questionnaire. The questionnaire inquired about the functionality and usability of the exoscope by utilizing a visual analog scale (VAS; 1-10). A score of 5 on VAS was equivalent to the corresponding quality of the SM. The learning effect of the exoscope was evaluated using mean VAS scores in the first and last 3 cases for each neurosurgeon. RESULTS: The functionality of the exoscope in MVD was superior to that in SM (P < 0.001). In the last 3 surgeries, the mean VAS scores of the exoscope were excellent in terms of ease of arm handling, exchange of surgical instruments, ease of surgical procedure, and intraoperative physical stress. The mean VAS scores of the exoscope in intraoperative asthenopia were significantly higher than those of the SM (P < 0.001). No statistical significance was found in operation time, discharge outcome, and 1-year post-surgery outcome between MVD performed using the exoscope and SM. CONCLUSIONS: Neurosurgeons may experience reduced stress levels during MVD when using the exoscope. As the outcome of MVD using the exoscope did not demonstrate a statistical difference compared with MVD using the SM, the exoscope may prove to be a useful tool for performing MVD.

Acute internal carotid artery occlusion due to dissection of the paraclinoid segment: Diagnostic usefulness of angiographic findings during stent retriever deployment.

Intracranial artery dissection is an uncommon but possible cause of ischemic stroke, and is usually diagnosed based on imaging findings such as mural hematoma and dissection flap. However, it is challenging to recognize the underlying dissection in cases of acute large vessel occlusion. In this report, we present a case of acute internal carotid artery occlusion, in which the underlying dissection of the paraclinoid segment was found during the thrombectomy procedure. Two thrombectomy procedures failed to recanalize the acute internal carotid artery occlusion without removing any clot. Angiography performed during a Trevo stent retriever deployment in the first pass showed obscure contrast defects in the stent strut with temporary flow restoration. In the next pass, the appearance of the contrast defects changed and a parallel linear contrast appeared on the outside of the vessel wall. These angiographic findings were identified as mural hematoma and dissection flap, indicating dissection of the paraclinoid as the cause of the occlusion. During antiplatelet loading and preparation of a dedicated intracranial stent, the Trevo stent retriever was left deployed again at the occlusion site to maintain the blood flow. After permanent stenting with an Enterprise stent, angiography revealed complete recanalization. The patient recovered fully after the procedure. In the present case, stent retriever deployment revealed the hallmarks of dissection on angiography, such as mural hematoma, dissection flap, and temporal morphological changes, by restoring the blood flow temporarily. Such angiographic findings can provide useful information on the occlusion characteristics and real-time feedback for optimal treatment strategy.

Predicting the growth of middle cerebral artery bifurcation aneurysms using differences in the bifurcation angle and inflow coefficient.

OBJECTIVE: Growing intracranial aneurysms (IAs) are prone to rupture. Previous cross-sectional studies using postrupture morphology have shown the morphological or hemodynamic features related to IA rupture. Yet, which morphological or hemodynamic differences of the prerupture status can predict the growth and rupture of smaller IAs remains unknown. The purpose of this longitudinal study was to investigate the effects of morphological features and the hemodynamic environment on the growth of IAs at middle cerebral artery (MCA) bifurcations during the follow-up period. METHODS: One hundred two patients with MCA M1-2 bifurcation saccular IAs who underwent follow-up for more than 2 years at the authors' institutions between 2011 and 2019 were retrospectively identified. During the follow-up period, cases involving growth of MCA IAs were assigned to the event group, and those with MCA IAs unchanged in size were assigned to the control group. The morphological parameters examined were aneurysmal neck length, dome height, aspect ratio and volume, M1 and M2 diameters and their ratio, and angle configurations among M1, M2, and the aneurysm. Hemodynamic parameters were flow rate and wall shear stress in M1, M2, and the aneurysm, including the aneurysmal inflow rate coefficient (AIRC), defined as the ratio of the aneurysmal inflow rate to the M1 flow rate. Those parameters were compared statistically between the two groups. Correlations between morphological and hemodynamic parameters were also examined. RESULTS: Eighty-three of 102 patients were included: 25 with growing MCA IAs (event group) and 58 with stable MCA IAs (control group). The median patient age at initial diagnosis was 66.9 (IQR 59.8-72.3) years. The median follow-up period was 48.5 (IQR 36.5-65.6) months. Both patient age and the AIRC were significant independent predictors of the growth of MCA IAs. Moreover, the AIRC was strongly correlated with sharper bifurcation and inflow angles, as well as wider inclination angles between the M1 and M2 arteries. CONCLUSIONS: The AIRC was a significant independent predictor of the growth of MCA IAs. Sharper bifurcation and inflow angles and wider inclination angles between the M1 and M2 arteries were correlated with the AIRC. MCA IAs with such a bifurcation configuration are more prone to grow and rupture.

Self-reported rate of eating is significantly associated with body mass index in Japanese patients with type 2 diabetes. Japan Diabetes Clinical Data Management Study Group (JDDM26).

We examined whether the rate of eating was associated with the body mass index and glycemic control status in Japanese patients with type 2 diabetes (50% women, mean±SD age 59.4±7.5 years). Rapid eating was significantly associated with body mass index (p=0.047). The body mass index of those who reported eating quickly was 0.8 kg/m² higher than in individuals who reported eating at medium speed even after adjustment for known confounders. No significant association was observed between the rate of eating and HbA(1c). Our findings suggest an association between self-reported rapid eating and an elevated body mass index in patients with type 2 diabetes.