Development and validation of a risk scoring model for postoperative adult moyamoya disease

OBJECTIVE The current grading system for moyamoya disease (MMD) is focused on angiographic studies with limited clinical application. The authors aimed to determine relevant factors that may impact postoperative outcome and establish a scoring system to predict the functional outcome. METHODS Adult patients with MMD who underwent treatment between 1998 and 2016 were included. Factors such as age, sex, comorbidity, smoking, MMD family history, initial presentation, multimodal imaging modalities, and types of surgical revascularization were thoroughly reviewed. These factors were analyzed to determine possible risk factors related to unfavorable 6-month postoperative outcomes using the modified Rankin Scale (mRS) (unfavorable: mRS score ≥ 3). A scoring system was developed using these independent risk factors to predict the outcome and validated using prospectively collected data from multiple centers between 2017 and 2018. RESULTS Of 302 patients for whom applications were submitted, 260 patients (321 hemispheres) met the diagnostic criteria. In multivariate analysis, hyperlipidemia, smoking, cerebral infarction on preoperative CT or MRI, and moderately to severely reduced regional cerebrovascular reserve results from Diamox SPECT were significantly related to unfavorable outcome. The authors developed a scoring system and stratified patients into risk groups according to their scores: low-risk (score 0?3), intermediate-risk (score 4?6), and high-risk (score 7?9) groups. This model demonstrated both good discrimination and calibration using C-statistics and the Hosmer-Lemeshow goodness-of-fit test showing 0.812 (95% CI 0.743?0.881) (p = 0.568) for the development and 0.954 (95% CI 0.896?1) (p = 0.097) for the temporal and external validation cohort. CONCLUSIONS The authors’ scoring system is readily adoptable to predict the postoperative outcome for MMD. Their data revealed the importance of smoking and hyperlipidemia, which were the only modifiable factors included in the scoring system. The authors validated their scoring system both internally and externally and maintained good performance, highlighting the system’s generalizability and reliability

Posterior Thoracic Cage Interbody Fusion Offers Solid Bone Fusion with Sagittal Alignment Preservation for De-compression and Fusion Surgery in Lower Thoracic and Thoracolumbar Spine

Objective : It is challenging to make solid fusion by posterior screw fixation and laminectomy with posterolateral fusion (PLF) in thoracic and thoracolumbar (TL) diseases. In this study, we report our experience and follow-up results with a new surgical technique entitled posterior thoracic cage interbody fusion (PTCIF) for thoracic and TL spine in comparison with conventional PLF. Methods : After institutional review board approval, a total of 57 patients who underwent PTCIF (n=30) and conventional PLF (n=27) for decompression and fusion in thoracic and TL spine between 2004 and 2019 were analyzed. Clinical outcomes and radiological parameters, including bone fusion, regional Cobb angle, and proximal junctional Cobb angle, were evaluated. Results : In PTCIF and conventional PLF, the mean age was 61.2 and 58.2 years (p=0.46), and the numbers of levels fused were 2.8 and 3.1 (p=0.46), respectively. Every patient showed functional improvement except one case of PTCIF. Postoperative hematoma as a perioperative complication occurred in one and three cases, respectively. The mean difference in the regional Cobb angle immediately after surgery compared with that of the last follow-up was 1.4 degrees in PTCIF and 7.6 degrees in conventional PLF (p=0.003), respectively. The mean durations of postoperative follow-up were 35.6 months in PTCIF and 37.3 months in conventional PLF (p=0.86). Conclusion : PTCIF is an effective fusion method in decompression and fixation surgery with good clinical outcomes for various spinal diseases in the thoracic and TL spine. It provides more stable bone fusion than conventional PLF by anterior column support

Clinical Interrogation of Mandatory Insertion of Central Venous Catheter for Clipping Surgery of Unruptured Intracranial Aneurysm: A Propensity Score Matched Study

Background and Objective: Microsurgical clipping, along with endovascular treatment, has evolved in the treatment of unruptured intracranial aneurysms (UIA), and these developments have resulted in a reduction of the complication rate. We discuss the need for a central venous catheter (CVC) insertion as an anesthetic preparation for microsurgical clipping. Methods: Between January 2019 and September 2019, 722 patients with UIA were treated at our institution. We excluded patients with a history of endovascular treatment or bypass surgery, recurrent aneurysms after coil embolization, brain tumors, or subarachnoid hemorrhages. A total of 272 patients were enrolled. Eighty-four patients underwent CVC insertion, and 188 patients underwent clipping surgery without CVC insertion. Outcome-related factors were compared between the 2 groups. We performed propensity score matching of the 2 groups to increase comparability. Results: There were no significant differences in outcome, sex, aneurysm location, aneurysm multiplicity, aneurysm size, or comorbid disease between the 2 groups. The mean age at the time of surgery was higher in the non-CVC insertion group than in the CVC insertion group. There were no meaningful differences in primary outcomes, including premature rupture and intraoperative motor evoked potential/somatosensory evoked potential change, and secondary outcomes, including estimated blood loss, duration of intensive care unit stay, duration of hospitalization, and Glasgow Outcome Scale score at discharge. Conclusions: CVC insertion for clipping surgery for UIA is not mandatory. Considering the possible complications associated with CVCs, we cautiously suggest aneurysm surgery with CVC insertion in patients with serious medical comorbidities, aneurysm sizes >10 mm, and difficult proximal parent artery control

A Prognostic Model of Pontine Hemorrhage Based on Hemorrhage Volume and Location

Objective Spontaneous pontine hemorrhages have the highest mortality rate. Posterior pontine hemorrhage has a poor prognosis, although more research is required in this area. Herein, we attempted to determine the prognosis of pontine hemorrhage by schematically illustrating the volume and location and developing a scoring model to predict the relationship between initial hemorrhage characteristics and clinical outcome. Methods This multicenter, retrospective study was conducted between January 2010 and December 2019. We developed a scoring model using computed tomography (5-mm sections) to plot the location and volume of pontine hemorrhages. All hemorrhage volumes were classified as mild (0.5?5 cm3), moderate (5?10 cm3), or severe (10?16 cm3). Results As the pontine hemorrhage volume increased, the Glasgow Coma Scale (GCS) and Eastern Cooperative Oncology Group scores (ECOG) were significantly lower, while the modified Rankin Scale (mRS) was higher (p<0.001). In the mild and moderate groups, the GCS recovered from 11.36 to 12.89 and 4.68 to 7.31 over 24 months, respectively. The mRS improved from 3.25 to 2.82 in the mild hemorrhage group but deteriorated in the moderate hemorrhage group from 4.93 to 5.24 over 24 months. More extensive pontine hemorrhages were associated with shorter life expectancy. The mild, moderate, and severe groups showed 32.79%, 89.29%, and 100% mortality, respectively (p<0.0001). The anterior and posterior hemorrhage groups had 69.44% and 42.86% mortality (p=0.0020), respectively. Conclusion According to our prognosis model, initial hemorrhage volume was the most significantly related neurological outcome. Hemorrhage location showed no relationship with neurological outcome. However, anterior upper pontine hemorrhage volume was correlated with shortened survival time

Reactive Oxygen Species Scavenger in Acute Intracerebral Hemorrhage Patients A Multicenter, Randomized Controlled Trial

Background and Purpose: Patients with intracerebral hemorrhage (ICH) have oxidative stress. Oxidative stress contributes to the development and progression of perihematomal edema (PHE) in brain hemorrhage patients. We hypothesized that reactive oxygen species (ROS) scavengers might have a neuroprotective role in the acute period of patients with ICH. Methods: This prospective, multicenter, single-blind, randomized study was conducted between June 2017 and October 2019. Intracranial bleeding, including spontaneous ICH, secondary ICH due to vascular anomalies, venous thrombosis, neoplasms, or hemorrhagic infarction, were included in our study. These ROS scavengers were given for 14 days with a dose of N-acetylcysteine 2000 mg/d and selenium 1600 mu g/d intravenously. Other patients received a placebo. The primary outcome was hemorrhage and PHE volume changes in 2-week follow-up computed tomography between ROS scavenger versus placebo groups. Results: In total, 448 patients were enrolled with 123 patients remaining after applying the inclusion and exclusion criteria. There were no significant differences in baseline characteristics between the ROS scavenger (n=57) and placebo (n=66) groups. No significant differences in baseline hematoma and PHE volumes were observed but 2 weeks follow-up computed tomography showed significant differences in PHE volume (21.90 +/- 17.63 versus 30.66 +/- 32.35, P<0.01) and PHE ratio (1.19 +/- 0.73 versus 2.05 +/- 1.27, P<0.01). Among clinical factors, time to reach target Richmond Agitation Sedation Scale (5.98 hours [95% CI, 4.82-7.241 versus 8.42 hours], [95% CI, 6.57-10.77], P<0.01) and the length of intensive care unit stays (6.46 days [95% CI, 2.38-10.55 versus 12.66 days], [95% CI, 8.47-16.85], P<0.01) were significantly shortened among patients who received ROS scavengers than among patients who did not receive ROS scavenger. Conclusions: ROS scavenger showed a significantly reduced PHE volume, time to reach target Richmond Agitation Sedation Scale, and shortened length of intensive care unit stay in patients with acute ICH. Early and high doses of ROS scavengers in a combination regimen may have played a key role in obtaining a favorable outcome in our study. Registration: URL: ; Unique identifier: KCT0004628

Upregulation of AQP4 improves blood-brain barrier integrity and perihematomal edema following intracerebral hemorrhage

-------------e-pub(22.1.12 현재)--------- In intracerebral hemorrhage (ICH), delayed secondary neural damages largely occur from perihematomal edema (PHE) resulting from the disruption of the blood-brain barrier (BBB). PHE is often considered the principal cause of morbidity and mortality in patients with ICH. Nevertheless, the main cellular mechanism as well as the specific BBB component involved in the formation of PHE after ICH remains elusive. Herein, we evaluated the role of AQP4, a water channel expressed on the astrocytes of the BBB, in the formation of PHE in ICH. The static and dynamic functions of the BBB were evaluated by analyzing the microstructure and leakage assay. Protein changes in the PHE lesion were analyzed and the control mechanism of AQP4 expression by reactive oxygen species was also investigated. Delayed PHE formation due to BBB disruption after ICH was confirmed by the decreased coverage of multiple BBB components and increased dynamic leakages. Microstructure assay showed that among the BBB components, AQP4 showed a markedly decreased expression in the PHE lesions. The decrease in AQP4 was due to microenvironmental ROS derived from the hemorrhage and was restored by treatment with ROS scavenger. AQP4-deficient mice had significantly larger PHE lesions and unfavorable survival outcomes compared with wild-type mice. Our data identify AQP4 as a specific BBB-modulating target for alleviating PHE in ICH. Further comprehensive studies are needed to form the preclinical basis for the use of AQP4 enhancers as BBB modulators for preventing delayed cerebral edema after ICH