Study of predisposing risk factors and etiology of chronic subdural hematoma in clipped patients of unruptured intracranial aneurysms: An institutional experience

Introduction: Chronic subdural hematoma in clipped patients of unruptured intracranial aneurysms might lead to sudden neurological deterioration and may need emergency evacuation. We studied the effects of various factors in its etiology. Materials and methods: A retrospective study of 91operated clipped patients of unruptured aneurysms in the year 2014-2015 was taken. Various predisposing factors were studied. Results: Goreisan use was not associated with any reduction in post operative CSDH formation. Arachnoidoplasty and reduced post operative dead space contributed in a reduced formation of CSDH. Conclusion: Older male patients with aneurysms who had been treated with anticoagulant drugs should be considered candidates for additive ARP to prevent the development of postoperative CSDH

Computational Fluid Dynamics in Unruptured Intracranial Aneurysms

Introduction and Objective: Intracranial aneurysm, also known as brain aneurysm, is a cerebrovascular disorder in which weakness in the wall of a cerebral artery causes a localized dilation or ballooning of the blood vessel. There is no objective way, device or tools, of predicting rupture of aneurysm so far. Computational fluid dynamics (CFDs) was proposed as a tool to identify the rupture risk. Purpose of study: To reveal the correlation of CFD findings with intraoperative microscopic findings and prove the relevance of CFDin the prediction of rupture risk and in the management of unruptured intracranial aneurysms. Subjects and Methods: A prospective cohort study was conducted inNeurosurgery department of Fujita Health University Banbuntane Hotokukai Hospital, Nagoya, Japanduring a 3?month period in 2018,from January to March, Ten patientswere diagnosed unruptured intracranial aneurysms (UIA). In diagnosis computed tomography (CT) angiogram, CFD and digital subtraction angiogram were included. Intraoperatively microscopic examination of the aneurysm wall was carried out and images recorded. The correlation between microscopic dome morphology and CFD information was performed. Results: Nine cases were found intraoperatively to have a higher risk of rupture based on the thinning of the wall. One cases had an atherosclerotic wall. All cases had low wall shear stress (WSS). In 90 % of cases Low WSS was able to predict the potency rupture risk in the near future. Conclusions: This study of CFD and its correlation with intraoperativefindings of the aneurysm suggested that low WSS of the aneurysm wall is associated with thin wall aneurysm and hence increased risk of aneurysm rupture. Thus CFD can be used to predict the risk of rupture of unruptured aneurysm and for planning of its treatment

Evidence for a Common Founder and Clinical Characteristics of Japanese Families with the MAPT R406W Mutation

Background/Aim: Mutations in MAPT cause frontotemporal dementia with parkinsonism linked to chromosome 17 (FTDP-17). Patients with the MAPT R406W mutation were reported to show phenotypic heterogeneity in different ethnic backgrounds. We here report the clinical and genetic characteristics of Japanese families with the R406W mutation. Methods: We examined the clinical and neuroimaging features of 6 patients from three families with the R406W mutation. We determined the genotypes of intragenic MAPT single-nucleotide polymorphisms (SNPs) and the flanking microsatellite markers to search for a common founder. Results: The initial symptom was memory loss with the average age at onset being 54 years. Anterograde amnesia with episodic memory impairment was the predominant phenotype. Behavioral and personality changes or parkinsonism is not a prominent feature. A brain MRI study revealed marked atrophy of the medial temporal lobe. Genetic analysis of SNPs and microsatellite markers revealed that the affected members of the three families share common genotypes. Conclusion: The findings of the affected members in this study, which corroborate previously reported findings of European families, suggest that the R406W mutation may represent a phenotype of predominant anterograde amnesia in FTLD-17. Our genetic data suggest that a founder effect may account for some families with the R406W mutation

Long term prognosis of ventriculoatrial shunt for idiopathic normal pressure hydrocephalus in the elderly

Objective: A retrospective study was conducted to access the long-term prognosis of inserting the Ventriculoatrial (VA) shunt in the elderly for the idiopathic normal pressure hydrocephalus (iNPH). Material and Methods: Retrospective data is collected from April 2004 to August 2015, and 1065 patients were selected. Patients who underwent surgical examination or surgery in suspected iNPH were included. Tap test is done in all cases and found to be effective for 968 cases and 656 VA shunts for 614 cases. Out of 614 cases there are 440 cases in which patient age were over 75 years. Of these 440 cases only 141 cases were able to observe 03 years or more after the surgery, 37 deaths and 05 cases with survival and unknown prognosis were found among them. So we analyzed this group mainly in 99 cases that the prognosis after 03 years was known. We access the outcome of VA shunt by the modified Rankin scale (mRS), iNPH grading scale (iNPHGS) and complications in the operative 656 cases and in 03 years follow up of 141 patients. Results: Of 141, there are 78 males and 63 females. Age at the time of VA shunt insertion was 81.5±4.1 years and age at final follow-up was 85.2±4.4 years. The proportion of patients who achieved a favorable outcome by complications was 97.9% in 03 years follow-up period and 87.7% in which follow-up is less than 03 years. At the time of VA shunt insertion out of 141, 57 patients lies between 75-79 years, 57 between 80-84, 24 between 85 to 89, and only 03 were found to be 90 years or more. At the time of final follow-up at 03 years, 15 patients lies between 75 to 79 years, 56 between 80 to 84 years, 57 between 85 to 89 years and 23 patents were found to be 90 years or greater. 70 cases or almost 50% exceeded 85 years. At the time of VA shunt 1, 11, 39, 51, 36, 3, 0 patients were in 0 to 6 modified Rankin Scale Score respectively and at 03 years follow-up 8, 19, 32, 29, 9, 2, 37 were in 0 to 6 mRS respectively. Comparison of the study is done with SIPHONI study on VP shunt and LP shunt. Conclusion: Patients suspected of having idiopathic normal pressure hydrocephalus were treated by VA shunt and found no significant difference in serious adverse effects. This study shows that VA shunt is an effective choice for iNPH in the late elderly population, but it needs more randomized control trial to establish its efficacy

High Flow Bypass for Cavernous Carotid Aneurysms

Introduction and objective: High flow extracranial to intracranial (HF EC–IC) cerebral revascularisation may be necessary in the management of complex skull base tumours and intracranial aneurysms. Bypass grafting can be considered high flow when a radial artery or the saphenous vein is interposed between the extracranial carotids arteries and intracranial vessels. The decision as to whether to use a low flow or high flow bypass is determined by the anticipated cerebral blood flow needed and the availability of a supply source. In this study, we have used this method to bypass for two cases of giant aneurysms of the cavernous sinus part of the ICA. Methods: Two cases of giant ICE aneurysm not amenable to clipping or coiling were taken since 2016. Patients were treated in Neurosurgery department of Fujita Health University Banbuntane Hotokukai Hospital, Nagoya, Japan. During bypass surgery, intraoperative methods were used to determine the patency of the graft artery: Doppler sonography and indocyanine green (ICG) Dual-Image Videoangiography (DIVA). Results: Two patients with symptomatic large and giant cavernous carotid aneurysms were evaluated as not amenable for clipping or endovascular treatment due to location and size of the aneurysm and associated high morbidity risk with these treatment options. In both cases radial artery graft was used for high-flow EC-MCA bypass and proximal internal carotid artery was ligated. Additionally, for high-flow bypass was performed superficial temporal artery (STA) to middle cerebral artery (MCA) bypass. DIVA, ICG and Doppler sonography were used multiple times to assess the patency of graft artery. In one case there was not complete ligation of the IC after postop DSA, the next day was performed reintervention to completely ligate IC. Postoperative course was uneventful, there were no mortality or morbidity. Follow-up showed good recovery and postoperative CT and DSA showed complete occlusion of ligated IC and patent functioning arterial graft. Conclusions: Cavernous carotid aneurysms (CCA) are rare and pose considerable challenges in management. A bypass procedure before parent artery occlusion, preferable to reduce the risks of postocclusion stroke. Intraoperative Doppler sonography and DIVA makes it easy to check the patency of the graft. DIVA is superior over Doppler or ICG in terms of better visualization of related anatomical structures

Real-time patency verification during clipping aneurysm and STA-MCA by-pass with dual-image videoangiography

The dual-image videoangiography (DIVA) is a new tool which helps identify ves-sels and surrounding structure. This method is based on use of indocyanine green video angiography (ICG-VA) technology on real time microscopic operative image. In this two case, we report of using DIVA in STA-MCA bypass surgery of 46 years old, female patient of stenosis of right MCA. And using DIVA during clipping ICA paraclinod aneurysm of 35 years old, female. During surgery, it helped in identifying temporal and frontal branches of the STA and there careful selection. After anastomosis, DIVA was used to refine vessel patency and functioning of the anastomosis. DIVA has the potential to replace ICG-VA as a tool for checking the patency of graft during bypass procedures and obliteration of aneurysm along with surgical procedures for AVM and d-AVF. DIVA allows visualization of vessels against a background of normal brain and has better visualization at greater depth and high magnification. This is particularly important during bypass surgery, which very often is performed in deep surgical fields and high magnification

Ischemic Stroke in Acute Decompensated Heart Failure: From the KCHF Registry

[Background] Heart failure (HF) is a known risk factor for ischemic stroke, but data regarding ischemic stroke during hospitalization for acute decompensated HF (ADHF) are limited. [Methods and Results] We analyzed the data from a multicenter registry (Kyoto Congestive Heart Failure [KCHF] Registry) that enrolled 4056 consecutive patients with ADHF in Japan (mean age, 78 years; men, 2238 patients [55%]; acute coronary syndrome [ACS], 239 patients [5.9%]). We investigated the incidence and predictors of ischemic stroke during hospitalization for ADHF. During the hospitalization, 63 patients (1.6%) developed ischemic stroke. The median interval from admission to the onset of ischemic stroke was 7 [interquartile range: 2–14] days, and the most common underlying cause was cardioembolism (64%). Men (OR, 1.87; 95%CI, 1.11–3.24), ACS (OR, 2.31; 95%CI, 1.01–4.93), absence of prior HF hospitalization (OR, 2.21; 95%CI, 1.24–4.21), and high B‐type natriuretic peptide (BNP)/N‐terminal proBNP (NT‐proBNP) levels (above the median) at admission (OR, 3.15; 95%CI, 1.84–5.60) were independently associated with ischemic stroke. In patients without ACS, the independent risk factors for ischemic stroke were fully consistent with those in the main analysis. Higher quartiles of BNP/NT‐proBNP levels were significantly associated with higher incidence of ischemic stroke (P for trend, <0.001). Patients with ischemic stroke showed higher in‐hospital mortality, longer length of hospital stay, and poorer functional status at discharge. [Conclusions] During hospitalization for ADHF, 1.6% of the patients developed ischemic stroke. Men, ACS, absence of prior HF hospitalization, and high BNP/NT‐proBNP levels at admission were independently associated with ischemic stroke

The ability of contemporary cardiologists to judge the ischemic impact of a coronary lesion visually

Background: Landmark trials showed that invasive pressure measurement (Fractional Flow Reserve, FFR) was a better guide to coronary stenting than visual assessment. However, present-day interventionists have benefited from extensive research and personal experience of mapping anatomy to hemodynamics. Aims: To determine if visual assessment of the angiogram performs as well as invasive measurement of coronary physiology. Methods: 25 interventional cardiologists independently visually assessed the single vessel coronary disease of 200 randomized participants in The Objective Randomized Blinded Investigation with optimal medical Therapy of Angioplasty in stable angina trial (ORBITA). They gave a visual prediction of the FFR and Instantaneous Wave-free Ratio (iFR), denoted vFFR and viFR respectively. Each judged each lesion on 2 occasions, so that every lesion had 50 vFFR, and 50 viFR assessments. The group consensus visual estimates (vFFR-group and viFR-group) and individual cardiologists' visual estimates (vFFR-individual and viFR-individual) were tested alongside invasively measured FFR and iFR for their ability to predict the placebo-controlled reduction in stress echo ischemia with stenting. Results: Placebo-controlled ischemia improvement with stenting was predicted by vFFR-group (p < 0.0001) and viFR-group (p < 0.0001), vFFR-individual (p < 0.0001) and viFR-individual (p < 0.0001). There were no significant differences between the predictive performance of the group visual estimates and their invasive counterparts: p = 0.53 for vFFR vs FFR and p = 0.56 for viFR vs iFR. Conclusion: Visual assessment of the angiogram by contemporary experts, provides significant additional information on the amount of ischaemia which can be relieved by placebo-controlled stenting in single vessel coronary artery disease

Isotope production in proton-, deuteron-, and carbon-induced reactions on Nb 93 at 113 MeV/nucleon

Isotope-production cross sections for p-, d-, and C-induced spallation reactions on Nb93 at 113 MeV/nucleon were measured using the inverse-kinematics method employing secondary targets of CH2, CD2, and C. The measured cross sections for Mo90, Nb90, Y86,88 produced by p-induced reactions were found to be consistent with those measured by the conventional activation method. We performed benchmark tests of the reaction models INCL-4.6, JQMD, and JQMD-2.0 implemented in the Particle and Heavy Ion Transport code System (PHITS) and of the nuclear data libraries JENDL-4.0/HE, TENDL-2017, and ENDF/B-VIII.0. The model calculations also showed generally good agreement with the measured isotope-production cross sections for p-, d-, and C-induced reactions. It also turns out that, among the three nuclear data libraries, JENDL-4.0/HE provides the best agreement with the measured data for the p-induced reactions. We compared the present Nb93 data with the Zr93 data, that were measured previously by the same inverse kinematics method (Kawase et al., Prog. Theor. Exp. Phys. 2017, 093D03 (2017)2050-391110.1093/ptep/ptx110), with particular attention to the effect of neutron-shell closure on isotope production in p- and d-induced spallation reactions. The isotopic distributions of the measured production cross sections in the Zr93 data showed noticeable jumps at neutron number N=50 in the isotopic chains of ΔZ=0 and -1, whereas no such jump appeared in isotopic chain of ΔZ=0 in the Nb93 data. From INCL-4.6 + GEM calculations, we found that the jump formed in the evaporation process is smeared out by the intranuclear cascade component in Nb91 produced by the Nb93(p,p2n) and (d,d2n) reactions on Nb93. Moreover, for Nb93, the distribution of the element-production cross sections as a function of the change in proton number ΔZ is shifted to smaller ΔZ than for Zr93, because the excited Nb prefragments generated by the cascade process are more likely to emit protons than the excited Zr prefragments, due to the smaller proton-separation energies of the Nb isotopes