Characterization of carotid plaques using chemical exchange saturation transfer imaging.

PURPOSE: The preoperative assessment of carotid plaques is necessary to render revascularization safe and effective. The aim of this study is to evaluate the usefulness of chemical exchange saturation transfer (CEST)-MRI, particularly amide proton transfer (APT) imaging as a preoperative carotid plaque diagnostic tool. METHODS: We recorded the APT signal intensity on concentration maps of 34 patients scheduled for carotid endarterectomy. Plaques were categorized into group A (APT signal intensity ≥ 1.90 E-04; n = 12) and group B (APT signal intensity < 1.90 E-04; n = 22). Excised plaques were subjected to histopathological assessment and, using the classification promulgated by the American Heart Association, they were classified as intraplaque hemorrhage-positive [type VI-positive (tVI+)] and -negative [no intraplaque hemorrhage (tVI-)]. RESULTS: Of the 34 patients, 22 (64.7%) harbored tVI+- and 12 (35.3%) had tVI- plaques. The median APT signals were significantly higher in tVI+- than tIVI- patients (2.43 E-04 (IQR = 0.98-4.00 E-04) vs 0.54 E-04 (IQR = 0.14-1.09 E-04), p < .001). Histopathologically, the number of patients with tVI+ plaques was significantly greater in group A (100%, n = 12) than group B (45%, n = 22) (p < .01). The number of symptomatic patients or asymptomatic patients with worsening stenosis was also significantly greater in group A than group B (75% vs 36%, p < .01). CONCLUSION: In unstable plaques with intraplaque hemorrhage and in patients with symptoms or progressive stenosis, the ATP signals were significantly elevated. CEST-MRI studies has the potential for the preoperative assessment of the plaques' characteristics.

Fecal Occult Blood Screening before Cardiac Surgery.

BACKGROUND: Concerns of gastrointestinal (GI) bleeding after cardiac surgery are increasing with increased use of antiplatelets and anticoagulants. We investigated the roles of preoperative screening for fecal occult blood by fecal immunochemical test (FIT) widely used to detect GI bleeding and cancer. METHODS: A retrospective review was done in 1,663 consecutive patients undergoing FIT before cardiac surgery between years 2012 and 2020. One or two rounds of FIT were performed 2 to 3 weeks before surgery, when antiplatelets and anticoagulants were not suspended yet. RESULTS: Positive FIT (> 30 µg of hemoglobin/g of feces) was observed in 227 patients (13.7%). Preoperative risk factors for positive FIT included age > 70 years, anticoagulants, and chronic kidney disease. Of those with positive FIT, 180 patients (79%) received preoperative endoscopy, including gastroscopy (n = 139), colonoscopy (n = 9), and both (n = 32), with no findings of bleeding. The most common finding of gastroscopy was atrophic gastritis (36%) while early gastric cancer was detected in 2 patients. The most common finding of colonoscopy was colon polyps (42%) while colorectal cancer was detected in 5 patients. Of 180 FIT-positive patients receiving endoscopy, 8 (4.4%) underwent preoperative GI treatment, while postoperative GI events were documented in 28 (15.6%). Of 1,436 with negative FIT, 21 (1.5%) presented GI complications after surgery. CONCLUSION: Preoperative FIT, which is influenced by anticoagulant use, has little impacts on identification of GI bleeding sites. However, it may be useful to detect GI malignant lesions, potentially impacting operative risks, surgical strategies, and postoperative management.

Comparison between Off-Pump and On-Pump Beating Heart Coronary Artery Bypass Grafting.

BACKGROUND: Although coronary artery bypass grafting (CABG) is performed via three different techniques, conventional, on-pump beating heart CABG (ONBHCAB), or off-pump CABG (OPCAB), data are limited to compare ONBHCAB with OPCAB. METHODS: We retrospectively investigated the postoperative cardiac biomarkers, creatine kinase-MB (CK-MB), and troponin I (cTnI), and early and late outcomes in 806 patients undergoing isolated ONBHCAB or OPCAB between February 2008 and September 2022. To eliminate the bias between different groups, propensity score matching was conducted to validate the findings. RESULTS: After matching, the number of each study group totaled 270 patients. In both complete and matched cohorts, early outcomes, including morbidities and mortalities, were similar. However, cTnI and CK-MB levels were significantly higher after ONBHCAB than after OPCAB with median peak cTnI of 9.85 versus 4.60 ng/mL and median peak CK-MB of 48.45 versus 17.10 ng/mL in the matched cohort, which were quite low, below the threshold for values defining perioperative myocardial infarction. At follow-up of 73 ± 45 months, the overall actuarial survival rates were similar between the ONBHCAB and OPCAB patients (86 vs. 87% at 5 years and 64 vs. 68% at 10 years, respectively, in the matched cohort). CONCLUSION: ONBHCAB may be a comparable alternative to OPCAB with similar early and late outcomes, despite higher elevation of postoperative cardiac biomarkers. ONBHCAB provides more efficient hemodynamic support, providing a better surgical visual field, than OPCAB while reducing the risk of incomplete revascularization.

Outcomes of 881 Consecutive Coronary Artery Bypass Graft Patients Using Heartstring Device.

BACKGROUNDS: One of the strategies to prevent stroke after coronary artery bypass grafting (CABG) may be the use of a device for proximal anastomosis without partial clamp of the ascending aorta. METHODS: We retrospectively investigated early and late outcomes in consecutive 881 patients undergoing isolated CABG using Heartstring for proximal anastomosis from January 2008 to December 2022, to reveal the validity to use it. All patients underwent preoperative imaging workups to evaluate neurovascular atherosclerosis. RESULTS: The mean age of the patients was 68.9 years, 20% were female and 13% had previous history of stroke. CABG was on-pump beating heart (52.2%) or off-pump (47.8%) with a mean number of distal anastomoses of 3.38 ± 0.93, using 1.62 ± 0.53 Heartstring devices under different aortic manipulations. In-hospital mortality was 2.0% and perioperative stroke rate was 0.9%, none of them died during hospital stay. During the follow-up period of 70 ± 47 months, the overall actuarial survival rates were 86 and 66%, and major adverse cardiac and cerebrovascular events (MACCEs)-free rates were 86 and 70% at 5 and 10 years, respectively. On multivariable analysis, risk factors for late death included male, previous history of stroke, postoperative sternomediastinitis, late new-onset stroke, and MACCEs, but did not include the perioperative stroke. CONCLUSION: Low stroke rate, as low as 0.9%, after CABG using Heartstring for proximal anastomosis, although under a variety of aortic manipulations, may contribute to the improved long-term prognosis.

Contributing factors to heparin resistance during cardiopulmonary bypass.

Since the risk factors for heparin resistance (HR) before cardiopulmonary bypass (CPB) have not been fully clarified, this study investigated the contributing factors for HR after the initial unfractionated heparin (UFH) dose of 500 IU/kg. We retrospectively analyzed the data of 371 patients who underwent CPB surgery, with the initial UFH dose of 500 IU/kg, between May 2017 and December 2021. We defined HR as the failure to achieve activated clotting time (ACT) of > 480 s after the initial UFH dose of 500 IU/kg. HR was observed in 36 patients (9.7%) (HR group), while HR was not observed in 335 patients (control group). The HR group included significantly more patients with preoperative use of UFH, with significantly higher white blood cell counts, fibrinogen, fibrinogen degradation products, D-dimer, and C-reactive protein, and lower hemoglobin and albumin. The multivariable logistic regression analysis identified albumin (OR: 3.09, 95% CI 1.3504-7.0845, p = 0.0075) and fibrinogen (OR: 0.99, 95% CI 0.9869-0.9963, p = 0.0003) as independent predictors for HR. Using the Youden index, the cutoffs of albumin and fibrinogen were calculated as 3.8 g/dL and 303 mg/dL, respectively. The receiver operating characteristic curves showed the predictive performance of albumin (area under the curve (AUC): 0.78, sensitivity: 65%, specificity: 81%) and fibrinogen (AUC: 0.77, sensitivity: 56%, specificity: 88%). The incidence of HR after the initial UFH dose of 500 IU/kg was 9.7%. The preoperative albumin < 3.8 g/dL and fibrinogen > 303 mg/dL were independent predictors for HR.

Effectiveness of hinge craniotomy as an alternative to decompressive craniectomy for acute subdural hematoma.

BACKGROUND: Acute subdural hematoma (ASDH) is a life-threatening condition, and hematoma removal is necessary as a lifesaving procedure when the intracranial pressure is highly elevated. However, whether decompressive craniectomy (DC) or conventional craniotomy (CC) is adequate remains unclear. Hinge craniotomy (HC) is a technique that provides expansion potential for decompression while retaining the bone flap. At our institution, HC is the first-line operation instead of DC for traumatic ASDH, and we present the surgical outcomes. METHODS: From January 1, 2017, to December 31, 2022, 372 patients with traumatic ASDH were admitted to our institution, among whom 48 underwent hematoma evacuation during the acute phase. HC was performed in cases where brain swelling was observed intraoperatively. If brain swelling was not observed, CC was selected. DC was performed only when the brain was too swollen to allow replacement of the bone flap. We conducted a retrospective analysis of patient demographics, prognosis, and subsequent cranial procedures for each technique. RESULTS: Of the 48 patients, 2 underwent DC, 23 underwent HC, and 23 underwent CC. The overall mortality rate was 20.8% (10/48) at discharge and 30.0% (12/40) at 6 months. The in-hospital mortality rates for DC, HC, and CC were 100% (2/2), 21.7% (5/23), and 13.0% (3/23), respectively. Primary brain injury was the cause of death in five patients whose brainstem function was lost immediately after surgery. No fatalities were attributed to the progression of postoperative brain herniation. In only one case, the cerebral contusion worsened after the initial surgery, leading to brain herniation and necessitating secondary DC. CONCLUSIONS: The strategy of performing HC as the first-line operation for ASDH did not increase the mortality rate compared with past surgical reports and required secondary DC in only one case.

Posterior cerebral artery involvement in unilateral moyamoya disease is exclusively ipsilateral and influenced by RNF213 mutation gene dose: The SUPRA Japan study: PCA involvement in unilateral moyamoya.

OBJECTIVES: The characteristics and clinical implications of posterior cerebral artery (PCA) involvement in unilateral moyamoya disease (U-MMD), such as laterality, frequency of the RNF213 p.R4810K mutation, and clinical outcomes, have not been well studied. POPULATION AND METHODS: We analyzed a cohort of 93 patients with U-MMD who participated in the SUPRA Japan study. Clinical characteristics and radiological examinations were collected from medical records. The presence of the p.R4810K mutation was determined using a TaqMan assay. The clinical outcome was assessed using the modified Rankin Scale (mRS). Univariate and multivariate logistic regression analyses were performed to assess the associations. RESULTS: Among the patients with U-MMD, PCA involvement was observed in 60.0 % (3/5) of patients with homozygous mutation, 11.3 % (7/62) of those with heterozygous mutation, and 3.8 % (1/26) of those with wild type, showing a significant linear trend (p < 0.001 for trend). PCA involvement was observed exclusively on the same side as the affected anterior circulation. Dyslipidemia and cerebral infarction at initial onset were independently associated with mRS ≥1. Hypertension was associated with mRS ≥1 and it was also linked to infarction at initial onset, suggesting a potential confounding effect. Although PCA involvement showed a trend for higher mRS, it was not statistically significant. CONCLUSIONS: Our findings indicate a gene dose effect of the p.R4810K mutation on PCA involvement, with the homozygous state showing the most significant effect. Both genetic and modifiable factors such as dyslipidemia may influence the progression of U-MMD.

Effects of Fractional Flow Reserve on Coronary Artery Bypass Graft Flow to Left Anterior Descending Artery.

BACKGROUND: The relationships between preoperative fractional flow reserve (FFR) values of the left anterior descending artery (LAD), FFRLAD, and intraoperative transit time flow measurement (TTFM) variables in coronary artery bypass grafting (CABG) remain unclear.Methods and Results: We retrospectively collected data for 74 in situ left internal thoracic artery (LITA) grafts and 27 saphenous vein grafts (SVGs) to the LAD that were shown to be patent on postoperative angiography. Spearman correlation coefficients were determined between FFRLADand TTFM parameters of the LITA graft, as follows: maximum flow (Qmax), -0.22 (P=0.077); minimum flow (Qmin), -0.40 (P=0.014); mean flow (Qm), -0.35 (P=0.039); pulsatility index (PI), 0.33 (P=0.008); diastolic filling (DF): 0.01 (P=0.83); and systolic reverse flow (SRF), 0.37 (P=0.002). Spearman correlation coefficients between FFRLADand TTFM parameters of the SVG to LAD were: Qmax, -0.65 (P=0.004); Qmin, -0.43 (P=0.044); Qm, -0.75 (P=0.001); PI, 0.53 (P=0.033); DF, 0.14 (P=0.48); and SRF, 0.61 (P=0.009). CONCLUSIONS: Both LITA grafts and SVGs to the LAD show negative correlations for FFRLADwith Qminand Qm, but positive correlations for FFRLADwith PI and SFR. These relationships between FFRLADand TTFM variables of CABG grafts to the LAD should be recognized.

Mid-term results of distal anastomosis to the true lumen for chronic type B aortic dissection.

We investigated whether distal anastomosis to the true lumen in open surgical repair of descending aorta for chronic type B aortic dissection improved the long-term outcomes with aortic remodeling. We retrospectively reviewed 71 patients with chronic type B aortic dissection, excluding those with connective tissue disorder, from October 2001 to June 2021. The patients who underwent distal true lumen anastomosis (group T, n = 36) were compared to those with both lumens' anastomosis (group B, n = 35), regarding survival, overall and distal aortic events. The growth rates of the distal aorta (maximum diameter in descending thoracic, suprarenal and infrarenal abdominal aorta) were also investigated. Median age was significantly higher in group T (T; 66 vs B; 60, P = .001). Group T had significantly higher rates of complete and partial thrombosis formation in the false lumen than group B postoperatively (26.9 vs 0%, P = .01 for complete, 65.4 vs 3.9%, P < .0001 for partial, respectively). At median follow-up for 6.8 years of 63 patients (88.7%), survival, overall and distal aortic event-free rates, and the growth rates of the distal aorta were not significantly different between the groups. Distal anastomosis to the true lumen did not improve mid-term survival, aortic event-free rates and the growth rates of the distal aorta compared with that of both lumens for chronic type B aortic dissection.

An imbalance between RAGE/MR/HMGB1 and ATP1α3 is associated with inflammatory changes in rat brain harboring cerebral aneurysms prone to rupture.

BACKGROUND AND PURPOSE: An aneurysmal subarachnoid hemorrhage is a devastating event. To establish an effective therapeutic strategy, its pathogenesis must be clarified, particularly the pathophysiology of brain harboring intracranial aneurysms (IAs). To elucidate the pathology in brain harboring IAs, we examined the significance of the receptor for advanced glycation end-products (RAGE)/mineralocorticoid receptor (MR) pathway and Na+/K+-ATPase (ATP1α3). METHODS: Ten-week-old female rats were subjected to oophorectomy as well as hypertension and hemodynamic changes to induce IAs, and were fed a high-salt diet. Brain damage in these rats was assessed by inflammatory changes in comparison to sham-operated rats fed a standard diet. RESULTS: Six weeks after IA induction (n = 30), irregular morphological changes, i.e., an enlarged vessel diameter and vascular wall, were observed in all of the left posterior cerebral arteries (Lt PCAs) prone to rupture. Approximately 20% of rats had ruptured IAs within 6 weeks. In brain harboring unruptured IAs at the PCA, the mRNA levels of RAGE and MR were higher, and that of ATP1α3 was lower than those in the sham-operated rats (p < 0.05, each). Immunohistochemically, elevated expression of RAGE and MR, and decreased expression of ATP1α3 were observed in the brain parenchyma adjacent to the Lt PCA, resulting in increased Iba-1 and S100B expression that reflected the inflammatory changes. There was no difference between the unruptured and ruptured aneurysm rat groups. Treatment with the MR antagonist esaxerenone abrogated these changes, and led to cerebral and vascular normalization and prolonged subarachnoid hemorrhage-free survival (p < 0.05). CONCLUSIONS: Regulation of the imbalance between the RAGE/MR pathway and ATP1α3 may help attenuate the damage in brain harboring IAs, and further studies are warranted to clarify the significance of the down-regulation of the MR/RAGE pathway and the up-regulation of ATP1α3 for attenuating the pathological changes in brain harboring IAs.

Impact of supra-aortic vessel dissection on the neurological outcome in surgery for acute type A aortic dissection.

We investigated whether supra-aortic vessel (SAV)s dissection is a risk factor for neurological dysfunction (ND) after surgical repair for type A acute aortic dissection (TAAAD). A retrospective review was done in 178 patients with TAAAD undergoing aortic repair between 2015 and 2019, comparing those with SAV dissection to those without it. Preoperatively, 93 patients (54.4%) had SAV dissection. Postoperatively, ND occurred in 26 patients (14.6%), 17 of whom (65.4%) already had been present with preoperative ND. Patients with SAV dissection were more likely to have postoperative ND than those without it (21.5% vs 7.7%; p = 0.02). The severity of preoperative dissection-related stenosis in common carotid artery significantly related to postoperative ND (right; p =0.0071, left; p < 0.0001). Multivariable analysis showed dissection-related stenosis of > 75% in brachiocepharic and left common carotid arteries, and thrombosed false lumen in common carotid arteries were independent risk factors for postoperative ND. However, SAV dissection was not related to new onset of ND. Dissection with stenosis of > 75% in SAVs were significantly decreased after aortic repair and even after ascending aorta/hemiarch replacement. In conclusion, ND after surgical repair for TAAAD is closely related to SAV dissection, especially to stenosis of > 75% and thrombosed false lumen in common carotid arteries. Aortic repair significantly decreased SAV dissection and severity of stenosis.

STING, a cytosolic DNA sensor, plays a critical role in atherogenesis: a link between innate immunity and chronic inflammation caused by lifestyle-related diseases.

AIMS: Lifestyle-related diseases promote atherosclerosis, a chronic inflammatory disease; however, the molecular mechanism remains largely unknown. Endogenous DNA fragments released under over-nutrient condition provoke sterile inflammation through the recognition by DNA sensors. Here, we investigated the role of stimulator of interferon genes (STING), a cytosolic DNA sensor, in atherogenesis. METHODS AND RESULTS: Apolipoprotein E-deficient (Apoe-/-) mice fed a western-type diet (WTD), a hypercholesterolaemic mouse model, showed higher STING expression and markers for DNA damage such as γH2AX, p53, and single-stranded DNA (ssDNA) accumulation in macrophages in the aorta compared with wild-type (WT) mice. The level of cGAMP, a STING agonist, in the aorta was higher in Apoe-/- mice. Genetic deletion of Sting in Apoe-/- mice reduced atherosclerotic lesions in the aortic arch, lipid, and macrophage accumulation in plaques, and inflammatory molecule expression in the aorta compared with the control. Pharmacological blockade of STING using a specific inhibitor, C-176, ameliorated atherogenesis in Apoe-/- mice. In contrast, bone marrow-specific STING expression in Apoe-/- mice stimulated atherogenesis. Expression or deletion of STING did not affect metabolic parameters and blood pressure. In vitro studies revealed that STING activation by cGAMP or mitochondrial DNA accelerated inflammatory molecule expression (e.g. TNF-α or IFN-ß) in mouse and human macrophages. Activation of nuclear factor-κB and TANK binding kinase 1 was involved in STING-associated vascular inflammation and macrophage activation. Furthermore, human atherosclerotic lesions in the carotid arteries expressed STING and cGAMP. CONCLUSION: Stimulator of interferon genes stimulates pro-inflammatory activation of macrophages, leading to the development of atherosclerosis. Stimulator of interferon genes signalling may serve as a potential therapeutic target for atherosclerosis.

[Arteriovenous Malformations(AVM)].

Recently, a KRAS mutation located in the endothelial cells of the nidus in arteriovenous malformations(AVMs)was reported. The findings indicate the possibility of medical therapy against cerebral AVMs; the blockade of RAS-MAPK signaling cascade may stabilize AVM nidus. As for surgical treatment for AVMs, achievement of low morbidity is the most important objective. To achieve this, assessment of blood flow, usage of non-stick bipolar forceps, and 3D simulation prior to operation are important. Assessment of individual cases for surgical treatment leads to low morbidity in surgeries.

[Fundamental Surgical Techniques of Superficial Temporal Artery:Middle Cerebral Artery (STA-MCA) Bypass].

Superficial temporal artery-middle cerebral artery(STA-MCA)bypass surgery is necessary for vascular reconstruction in patients with hemodynamic ischemia, including moyamoya disease and complex aneurysms. This report introduces the fundamental techniques of STA-MCA bypass surgery practiced in my institute. Preoperative and perioperative management is important to minimize complications. During the procedure, the operator should keep a bloodless surgical field to facilitate the bypass. The vascular lumen and intima must be carefully observed during anastomosis, especially in moyamoya cases. In addition, this study emphasizes the importance of off-the-job training using animal or synthetic arteries because this technique includes special movements compared with that of other microsurgical procedures.

[Current Situation of Robot-assisted Cardiac Surgery:Start-up and Ingenuity for Stabilizing Results].

In Japan, the medical fee revision in April 2018 allowed insurance coverage for robot-assisted cardiac surgery for mitral and tricuspid valve plasty. We started robot-assisted mitral valve plasty by da Vinci system in June 2019. The artificial chordae reconstruction by the loop method, which has been our basic surgical technique so far, has also been adopted in robot-assisted cardiac surgery. The author has performed three dimensional( 3D) endoscopic minimally invasive cardiac surgery( MICS), but now focuses on robot-assisted cardiac surgery because of the delicate procedure and good operability. The venous drainage cannulation through the femoral vein is done under fluoroscopy. We use a silicon cylinder, that is elastic and provides a wide field of view, to approach to the papillary muscle. Robot-assisted cardiac surgery, which takes a little longer than through a mid-sternum incision, requires some ingenuity to save time. We also mention cadaver training that had to be experienced abroad, such as robot training with a human body donation that will start soon at our hospital.

Preoperative obliteration of choroidal arteries in the treatment of large hypervascular tumors in the lateral ventricle.

BACKGROUND: Removal of large hypervascular tumors in the lateral ventricle still poses a surgical challenge. These tumors are usually fed from choroidal arteries, and vascular control is typically performed late during the removal. We aimed to evaluate the clinical efficacy of our strategy for persistent preoperative obliteration of feeders from the choroidal arteries to manage large hypervascular tumors in the lateral ventricle. METHODS: We retrospectively analyzed six patients with hypervascular tumors in the lateral ventricle. We first attempted to obstruct feeders using endovascular treatment, and, if unavailable, performed initial microsurgical occlusion through the temporal horn for the staged tumor removal. RESULTS: In all patients, feeder obliteration was successfully performed; the anterior choroidal arteries were occluded by the endovascular treatment and microsurgical occlusion in one and five patients, respectively, while the lateral posterior choroidal arteries were occluded via endovascular treatment in four patients. No patients had permanent symptoms due to feeder obliteration, and tumor devascularization was achieved at the mean rate of 69.9%. During the tumor removal, the mean blood loss volume was 253 ml. No postoperative hemorrhage had occurred, and all patients scored ≤ 2 on the modified Rankin Scale at six months post-removal. CONCLUSIONS: Although further studies are warranted, persistent feeder obliteration of choroidal arteries could be an effective treatment strategy against large hypervascular tumors in the lateral ventricle.

Elevated Urinary Titin and its Associated Clinical Outcomes after Acute Stroke.

INTRODUCTION: Urinary titin is a biomarker of muscle atrophy, which is a serious complication after stroke. However, there are currently no clinical data regarding urinary titin in stroke patients. METHODS: Consecutive stroke patients admitted to the stroke care unit were included. Spot urine samples were collected immediately after admission, and on days 3, 5, and 7. The primary outcome was the trend of urinary titin in patients after acute stroke. The secondary outcomes included the association between the peak urinary titin level and the modified Rankin Scale (mRS) score, the National Institutes of Health Stroke Scale (NIHSS) score, and the Barthel index (BI) upon hospital discharge. Multivariate analysis was adjusted for age, sex, NIHSS at admission, and the peak urinary titin to predict poor outcome (mRS 3-6). RESULTS: Forty-one patients were included (29 male; age, 68 ± 15 years), 29 had ischemic stroke, 8 had intracerebral hemorrhage, and 4 had subarachnoid hemorrhage. The levels of urinary titin on days 1, 3, 5, and 7 were 9.9 (4.7-21.1), 16.2 (8.6-22.0), 8.9 (4.8-15.2), and 8.7 (3.6-16.2) pmol/mg Cr, respectively. The peak urinary titin level was associated with the mRS score (r = 0.55, p < 0.01), the NIHSS score (r = 0.72, p < 0.01), and the BI (r = -0.59, p < 0.01) upon hospital discharge. In multivariate analysis, the peak urinary titin was associated with poor outcome (p = 0.03). CONCLUSIONS: Urinary titin rapidly increased after stroke and was associated with impaired functional outcomes at hospital discharge.

[Mitral Valve Surgery for a Patient with Mediastinal Shift after Left Pneumonectomy:Report of a Case].

A 70-year-old patient who survived about 40 years after left pneumonectomy for tuberculosis visited emergency hospital, because of dyspnea. She received suitable medical therapy for atirial fibrillation and severe mitral regurgitation and hesitated heart surgery because of anxiety for surgical risk. The computed-tomography showed mediastinal shift to left and right lung compensatory expansion. Respiratory function test after treatment of heart failure showed only mild restrictive disorder. And the blood-gas examination in room air was 101 mmHg of Pao2 and 37 mmHg of Paco2. The mitral valve replacement was performed via median sternotomy and using normal cardiopulmonary bypass. And she fully recoverd without any respiratory complications. Mediastinal shift did not obstract the surgical view and establishment of cardiopulmonary bypass in this case. It seemed that the key of surgical successs is the preserved function of healthy residual lung.

Thrombolysis With Alteplase at 0.6 mg/kg for Stroke With Unknown Time of Onset: A Randomized Controlled Trial.

Background and Purpose- We assessed whether lower-dose alteplase at 0.6 mg/kg is efficacious and safe for acute fluid-attenuated inversion recovery-negative stroke with unknown time of onset. Methods- This was an investigator-initiated, multicenter, randomized, open-label, blinded-end point trial. Patients met the standard indication criteria for intravenous thrombolysis other than a time last-known-well >4.5 hours (eg, wake-up stroke). Patients were randomly assigned (1:1) to receive alteplase at 0.6 mg/kg or standard medical treatment if magnetic resonance imaging showed acute ischemic lesion on diffusion-weighted imaging and no marked corresponding hyperintensity on fluid-attenuated inversion recovery. The primary outcome was a favorable outcome (90-day modified Rankin Scale score of 0-1). Results- Following the early stop and positive results of the WAKE-UP trial (Efficacy and Safety of MRI-Based Thrombolysis in Wake-Up Stroke), this trial was prematurely terminated with 131 of the anticipated 300 patients (55 women; mean age, 74.4±12.2 years). Favorable outcome was comparable between the alteplase group (32/68, 47.1%) and the control group (28/58, 48.3%; relative risk [RR], 0.97 [95% CI, 0.68-1.41]; P=0.892). Symptomatic intracranial hemorrhage within 22 to 36 hours occurred in 1/71 and 0/60 (RR, infinity [95% CI, 0.06 to infinity]; P>0.999), respectively. Death at 90 days occurred in 2/71 and 2/60 (RR, 0.85 [95% CI, 0.06-12.58]; P>0.999), respectively. Conclusions- No difference in favorable outcome was seen between alteplase and control groups among patients with ischemic stroke with unknown time of onset. The safety of alteplase at 0.6 mg/kg was comparable to that of standard treatment. Early study termination precludes any definitive conclusions. Registration- URL: https://www.clinicaltrials.gov; Unique identifier: NCT02002325.

Changes in treatment strategy over time for arteriovenous malformation in a Japanese high-volume center.

BACKGROUND: Despite rapid developments in devices used to treat arteriovenous malformation (AVM), a randomised trial of Unruptured Brain Arteriovenous malformations published in 2014 recommended conservative treatment for nonhemorrhagic AVM. The purpose of the current retrospective study was to confirm how AVM treatment in Japan has changed and to assess the safety of treatment for hemorrhagic and nonhemorrhagic AVMs. METHODS: We enrolled 242 consecutive patients with AVM; each patient's treatment was selected and performed at our hospital. The type of onset, Spetzler-Martin (S-M) grade, age, sex, selected treatment, mortality, and morbidity were compared between the first and second periods of our study. RESULTS: In patients with grade I-III AVM, the selected treatment changed between the first and second periods; however, in grade IV and V patients, the selected treatment did not change. Overall, interventions by microsurgery alone decreased (p < 0.001), the proportion of total treatments including microsurgery decreased (p = 0.005), interventions using stereotactic radiosurgery (SRS) alone increased (p = 0.009), and interventions including SRS increased (p = 0.002). Morbidity associated with intervention was 0.92% in the first period and 0% in the second period, and mortality was 0.92% in the first period and 1.67% in the second. CONCLUSIONS: With the development of new devices, the selected treatment was changed in patients with S-M grade I-III AVM, but was not changed in patients with grade IV and V. The complication rate was low and did not change throughout the periods. These findings suggest that the safety of treatment depends on a full understanding of device development and the selection of proper treatment, not on hemorrhagic onset. Further treatment innovations are expected to change the treatment for grade IV and V AVMs.