Perspective Chapter: Role of Direct Surgery for Recurrent Aneurysms after Endovascular Treatment

Treatment strategies for cerebral aneurysms have changed dramatically in recent years with advances in endovascular therapy. Advances in devices, endovascular surgeons’ skills, and diagnostic modalities have improved the results of endovascular treatment, making it a safer and more reliable treatment option. On the other hand, we are encountering an increasing number of cases of postoperative recurrence. Direct surgery has a specific role in treating these recurrent cases, and it has become essential to establish a decision-making method and surgical technique for treating these cases. In this chapter, I will discuss the treatment options for recurrent cerebral aneurysms after endovascular treatment and the practical application of directclipping and bypass surgery

Nationwide survey on quasi-moyamoya disease in Japan

Objectives: Moyamoya disease (MMD) is a unique occlusive disease of the bilateral internal carotid arteries with moyamoya vessels. Inherited or acquired disorders and conditions may present in conjunction with MMD. This condition is known as quasi-moyamoya disease. To identify the clinical features of quasi-MMD in Japan, a nationwide survey was conducted. Patients and methods: A questionnaire was mailed directly to 241 departments that had acknowledged treating quasi-MMD patients in the primary survey. We ascertained the sex, age, family history, clinical manifestation, radiological findings, treatments, course of the disease, and daily activity of the patients. Results: A total of 114 departments replied to the questionnaire. The data of 108 patients (66 female and 42 male; female to male ratio 1.57) were registered and analyzed. Mean age was 30.6 years old, with a peak in children. Seven patients (7 %) exhibited familial MMD. The initial clinical manifestation was motor weakness, followed by transient ischemic attack and headache. Their imaging study type included ischemic type in 64 patients (63.4 %), bleeding type in seven (6.9 %), and normal in 27 (26.7 %). Stenoocclusive lesion was seen in the internal carotid artery in more than half of the patients. Development of moyamoya vessels was mild in approximately 40 % of the patients. Almost all cases were accompanied by cerebral hypoperfusion. About half of them were unilateral lesion. Vascular reconstruction was employed for the approximately 60 % patients. The prognosis did not change significantly. Conclusion: Clinical features of quasi-MMD were revealed in the nationwide study. In quasi-MMD, unilateral lesion is dominant, and the development of moyamoya vessels and intracranial hemorrhage are less dominant

Three-dimensional 4K resolution video microscope in an orbitozygomatic approach for skull base tumor

Background: The authors propose that the newly developed three-dimensional 4K resolution (3D-4K) video microscope, Orbeye™, can be a user-friendly alternative tool for performing orbitozygomatic craniotomy and tumor removal. It was officially approved in Japan in October 2017.Case description: A 38-year-old, otherwise healthy, woman presented with left impaired visual acuity, motor aphasia, headache, and vomiting. Magnetic resonance imaging (MRI) revealed the presence of a large left sphenoid ridge meningioma with marked perifocal edema and mass effect. Using Orbeye™, en bloc orbitozygomatic craniotomy and skull base tumor removal were safely performed. It enabled us to perform the procedure, and to share the operative image owing to the realistic 3D perception of the operative field, its excellent illumination, and viewing angle. Especially, the lower viewing angle appeared to be extremely difficult to obtain using conventional methods. The patient resumed her daily life, and a postoperative MRI showed total removal of the tumor.Conclusions: Orbeye™ has overcome shortcomings of the operative microscope. It has a user-friendly design, and surgeons’ intraoperative fatigue and stress appear to be decreased. It is useful for observers to understand the skull base technical nuances using the 3D-4K image

Do neutrophil extracellular traps implicate in atheromatous plaques from carotid endarterectomy? Re-analyzes of cDNA microarray data by surgeons

BackgroundCarotid artery stenosis is the cause of 15% of strokes. Neutrophil extracellular traps (NETs) and peptidyl arginine deiminase 4 (PAD4) are believed to be involved in thrombosis. This pilot study described the differential expression profile of NETs between atheromatous plaques and surrounding tissues.MethodsMicroarray datasets of carotid plaques were obtained from Gene Expression Omnibus. The normalized data were processed into comma-separated value matrix files using spreadsheet software. Analyzes of microarray data were conducted using integrated differential expression and pathway analysis.ResultThe clustering results illustrated that the classifications of plaque and control had reasonable biological validity. Pathway analysis revealed the relevance of immune response, cell signaling, and other pathways. Differentially expressed genes were detected between carotid plaques and control specimens. However, enrichment analyzes did not reveal a difference in PAD4 expression between the groups and that NET implication was only found in one cDNA microarray dataset.DiscussionThis pilot study does not necessarily dismiss the possibility of a relationship between NETs and atherothrombotic stroke. Gene expression could differ between endothelial cells and atheromas, and further studies are needed

Extremely Rare Breakdown of the Moyamoya Vessels Resulting in Intraventricular Hemorrhage after Direct Bypass Surgery in a Pediatric Patient with Moyamoya Disease

Revascularization surgery is established for both ischemic and hemorrhagic moyamoya disease (MMD), although hemorrhagic complication is a serious problem especially in adult MMD patients showing postoperative hyperperfusion. Herein, we present an extremely rare case with pediatric MMD showing intraventricular hemorrhage the day following direct bypass surgery, possibly due to a breakdown of the terminal branch of well-developed perforators working as moyamoya vessels. Clinicians should consider this rare complication after bypass surgery for MMD regardless of preoperative hemodynamics or patient age

Perfusion abnormality in neuronal intranuclear inclusion disease with stroke-like episode: A case report

Neuronal intranuclear inclusion disease (NIID) is a slowly progressive neurodegenerative disease. Some patients with NIID occasionally present with acute symptoms. However, its mechanism remains unclear. We report a patient with NIID who presented with a stroke-like episode. Arterial spin labeling magnetic resonance imaging revealed hypoperfusion in the focal cerebral region at the onset while no apparent arterial occlusion was observed. The abnormal perfusion area was normalized 6 days after admission. Therefore, the perfusion abnormality was likely the main cause of acute neurologic deficits in NIID. NIID should be considered in the differential diagnosis of stroke mimics

A score using left ventricular diastolic dysfunction to predict 90-day mortality in acute ischemic stroke: The DONE score

Purpose: The aim of this study was to identify whether diastolic dysfunction predicts death at 90 days after acute ischemic stroke.Methods: We retrospectively analyzed patients with ischemic stroke. All patients underwent transthoracic echocardiography to evaluate systolic function and diastolic function by means of assessing ejection fraction and septal E/e’.We evaluated the initial National Institute of Health Stroke Scale (NIHSS) score,arterial occlusion, and laboratory data. We used multivariate regression models to identify independent predictors of 90-day mortality. Results: Among 1208 patients, the overall 90-day mortality rate was 8%. In multivariate logistic regression analysis, a higher initial NIHSS score,plasma D-dimer level and E/e’ and occlusion of internal carotid artery or basilar artery were independent predictors of 90-day mortality.The DONE score derived from these valuables showed good discrimination with area under the curve (AUC) value of 0.82 (95% confidence interval [CI],0.78?0.87) to predict 90-day mortality. The DONE score also predicted poor outcome (modified Rankin scale score, 4?6) at 90 days (AUC, 0.82;95% CI 0.80?0.85). Conclusions: Higher E/e’ indicating diastolic dysfunction,may be associated with 90-day mortality in patients with acute ischemic stroke. The DONE score could readily predict poor outcome after acute ischemic stroke

MAP Kinase Pathways in Brain Endothelial Cells and Crosstalk with Pericytes and Astrocytes Mediate Contrast-Induced Blood–Brain Barrier Disruption

Neurointervention with contrast media (CM) has rapidly increased, but the impact of CM extravasation and the related side effects remain controversial. This study investigated the effect of CM on blood–brain barrier (BBB) integrity. We established in vitro BBB models using primary cultures of rat BBB-related cells. To assess the effects of CM on BBB functions, we evaluated transendothelial electrical resistance, permeability, and tight junction (TJ) protein expression using immunohistochemistry (IHC) and Western blotting. To investigate the mechanism of iopamidol-induced barrier dysfunction, the role of mitogen-activated protein (MAP) kinases in brain endothelial cells was examined. We assessed the effect of conditioned medium derived from astrocytes and pericytes under iopamidol treatment. Short-term iopamidol exposure on the luminal side induced transient, while on the abluminal side caused persistent BBB dysfunction. IHC and immunoblotting revealed CM decreased the expression of TJ proteins. Iopamidol-induced barrier dysfunction was improved via the regulation of MAP kinase pathways. Conditioned medium from CM-exposed pericytes or astrocytes lacks the ability to enhance barrier function. CM may cause BBB dysfunction. MAP kinase pathways in brain endothelial cells and the interactions of astrocytes and pericytes mediate iopamidol-induced barrier dysfunction. CM extravasation may have negative effects on clinical outcomes in patients

A Case of Neurofibromatosis Type 1 Complicated with Repeated Intracerebral Hemorrhage due to Quasi-Moyamoya Disease

Moyamoya disease (MMD) is a unique occlusive disease of the bilateral internal carotid arteries with moyamoya vessels. Inherited or acquired disorders and conditions may present in conjunction with MMD. This condition is known as quasi-MMD. We report a case of quasi-MMD complicated with repeated intracerebral hemorrhage during long-term follow-up for cerebral ischemia. A 35-year-old woman who had a diagnosis of neurofibromatosis type 1 visited our hospital because of incidentally found cerebral infarction. Angiography showed occlusive changes in the distal portion of the bilateral internal carotid artery and multiple massive collateral arteries from occluded internal carotid artery. Because revascularization from external carotid artery systems developed, she was treated conservatively and followed annually with radiologic study. During follow-up, she suffered from minor intracerebral hemorrhages. At the age of 55 years, she died of massive intracerebral hemorrhages. Although the intracerebral hemorrhage is not common in quasi-MMD, it has a potential to be fatal. Long-term follow-up with radiologic study and proper surgical treatment is required

Association between serum calcium levels and prognosis, hematoma volume, and onset of cerebral hemorrhage in patients undergoing hemodialysis

Background: High serum calcium levels should be avoided in patients on hemodialysis (HD) because they can induce cardiovascular diseases and worsen the patient\u27s prognosis. In contrast, low serum calcium levels worsen the prognosis of patients with cerebral hemorrhage in the general population. So far, whether serum calcium levels in patients on HD are associated with cerebral hemorrhage remains unknown. This study aimed to reveal the association between serum calcium and cerebral hemorrhage in patients on HD, including in-hospital death, volume of hematoma, and onset of cerebral hemorrhage. Methods: This cross-sectional case-control study included 99 patients on HD with cerebral hemorrhage at a single center between July 1, 2007 and December 31, 2017. Controls included 339 patients on HD at a single HD center between July 1, 2011 and June 30, 2012. Data on serum calcium level, patient demographics, and comorbid conditions were collected, and associations between cerebral hemorrhage and subsequent death were evaluated by multivariate logistic regression analysis. Further, the association of these backgrounds and hematoma volume was evaluated by multiple regression analysis. Results: Of the 99 patients, 32 (32%) died from cerebral hemorrhage. The corrected serum calcium level (odds ratio [OR], 2.49; 95% confidence interval [CI], 1.43-4.35; P < 0.001) and antiplatelet drug use (OR, 3.95; 95% CI, 1.50-10.4; P = 0.005)had significant effects on the prognosis. Moreover, the corrected serum calcium (P = 0.003) and antiplatelet drug use (P = 0.01) were significantly correlated with hematoma volume. In the patients, the corrected serum calcium level (OR, 1.54; 95% CI, 1.07-2.22; P = 0.02) was associated with the onset of cerebral hemorrhage, as was pre-hemodialysis systolic blood pressure (per 10 mmHg) (OR, 1.40; 95% CI, 1.23-1.59; P < 0.001). Conclusions: Although the precise mechanisms remain unknown, a high serum calcium level is associated with cerebral hemorrhage in patients on HD. Thus, we should pay attentions to a patient\u27s calcium level