Analysis of Factors Influencing Delayed Presentation in Japanese Patients with Subarachnoid Hemorrhage

OBJECTIVE

Some aneurysmal subarachnoid hemorrhage (SAH) patients are delayed in their presentation. This can cause a washout of the subarachnoid hematoma and a potential misdiagnosis. As a result, they may suffer rerupture of the aneurysm and preventable deterioration. We investigated the factors that influence delayed SAH presentation.

METHODS

Aneurysmal SAH patients treated at 9 stroke centers from 2002 to 2020 were included. Age, gender, pre-SAH modified Rankin scale, World Federation of Neurological Surgeons grade, Fisher group, day of presentation, aneurysm treatment method, past history of cerebral stroke, comorbidity of hypertension and/or diabetes mellitus, and modified Rankin scaleat discharge were assessed retrospectively. We formed 2 groups based on the day of presentation after the onset of SAH: day 0-3 (early) and other (delayed). Logistic regression analyses detected the factors that influenced the day of presentation and outcome for SAH. A P- value <0.05 was considered significant.

RESULTS

Delayed presentation comprised 282 cases (6.3%) of 4507 included cases. Logistic regression analyses showed that patients in an urban area, of male gender, low WFNS grade and low Fisher group correlated significantly with a delayed presentation. But delayed presentation did not influence outcome at discharge.

CONCLUSIONS

Area of residency and gender correlated with delayed presentation after SAH in Japan. Urbanization, male gender, and mild SAH lead patients to delay presentation. The factors underlying these tendencies will be analyzed in a future prospective study.

Real Stiffness and Vividness Reproduction of Anatomic Structures Into the 3D Printed Models Contributes to Improved Simulation and Training in Skull Base Surgery

BACKGROUND

Despite the advancement of 3-dimensional (3D) printing technology with medical application, its neurosurgical utility value has been limited to understanding the anatomy of bones, lesions, and their surroundings in the neurosurgical field.

OBJECTIVE

To develop a 3D printed model simulating the surgical technique applied in skull base surgery (SBS), especially to reproduce visually the surgical field together with the mechanical properties of tissues as perceived by the surgeon through procedures performance on a model.

METHODS

The Young modulus representing the degree of stiffness was measured for the tissues of anesthetized animals and printing materials. The stiffness and vividness of models were adjusted appropriately for each structure. Empty spaces were produced inside the models of brains, venous sinuses, and tumors. The 3D printed models were created in 7 cases of SBS planned patients and were used for surgical simulation.

RESULTS

The Young modulus of pig's brain ranged from 5.56 to 11.01 kPa and goat's brain from 4.51 to 13.69 kPa, and the dura of pig and goat values were 14.00 and 24.62 kPa, respectively. Although the softest printing material had about 20 times of Young modulus compared with animal brain, the hollow structure of brain model gave a soft sensation resembling the real organ and was helpful for bridging the gap between Young moduli values. A dura/tentorium-containing model was practical to simulate the real maneuverability at surgery.

CONCLUSION

The stiffness/vividness modulated 3D printed model provides an advanced realistic environment for training and simulation of a wide range of SBS procedures.

Thromboelastography 6s for assessment of platelet function during coil embolization of unruptured intracranial aneurysms

OBJECTIVES

Methods for assessing platelet function in patients with neurovascular disease remain controversial and poorly studied. This study aimed to assess associations between thromboelastography 6s (TEG6s) measurements and postoperative ischemic complications in patients with unruptured intracranial aneurysms (UIAs) treated by coil embolization.

METHODS

Eighty-four patients with UIAs taking a combined aspirin and clopidogrel protocol were retrospectively reviewed from January 2021 to May 2022. Blood samples were obtained for TEG6s to assess platelet function on the day of coil embolization. To identify acute ischemic complications, diffusion-weighted imaging (DWI) was performed within 24 h after coil embolization. Multivariate logistic regression analysis was conducted to identify potential risk factors for postoperative positive DWI (DWI (+)) lesions.

RESULTS

Forty-three of the 84 patients (51%) with DWI (+) lesions were identified. Compared with patients without DWI (+) lesions, Adenosine diphosphate (ADP)-induced platelet-fibrin clot strength (MA_ADP) was significantly higher (53.6 mm [Interquartile range (IQR): 48.3-58.3 mm] vs 46.7 mm [IQR: 36.8-52.2 mm]; p=0.001) and ADP inhibition rate (ADP%) was significantly lower (19% [IQR: 11-31%] vs 31% [IQR: 21-44%]; p=0.001) in DWI (+) patients. Multivariate analysis identified MA_ADP, ADP%, and procedure time as significant independent predictors of subsequent DWI (+) lesions (odds ratios: 1.07, 0.96, and 1.02, respectively). Based on receiver operating characteristic curve analysis, MA_ADP >50.9 mm and ADP% <28.8% were associated with postoperative DWI (+) lesions in patients undergoing coil embolization for UIAs.

CONCLUSIONS

MA_ADP and ADP% as assessed by TEG6s can offer reliable parameters to predict postoperative ischemic complications after coil embolization of UIAs. Lower MA_ADP values and higher ADP% may decrease the risk of postoperative ischemic complications.

Preoperative assessment of dominant occipital sinus in patients with Chiari malformation type I: anatomical variations and implications for preventing potentially life-threatening surgical complications

OBJECTIVE

The surgical treatment of Chiari malformation type I (CM-I) frequently involves dural incision at the posterior cranial fossa. In cases of persistent patent occipital sinus (OS), the sinus is usually obliterated and divided. However, there are some patients whose OS is prominent and requires crucial modification of the operative planning to avoid potentially life-threatening massive hemorrhage and disturbance of cerebral venous circulation. In the present study, the anatomical variations of the dominant OS in patients with CM-I were analyzed and the authors attempted to develop treatment recommendations for patients with CM-I with dominant OS.

METHODS

The study included 213 patients with CM-I who underwent MR venography (MRV) prior to surgical treatment. OS dominance was assessed using 2D time-of-flight MRV or 3D phase-contrast MRV. Particular attention was paid to the pattern of venous outflow channels. The characteristics of the patients with dominant OS and the surgical outcomes were retrospectively reviewed.

RESULTS

Dominant OS was identified in 7 patients (3.3%). The age in those with dominant OS was significantly younger than in those without (p = 0.0202). The incidence of concurrent scoliosis in the patients with dominant OS was significantly higher than in those without (p = 0.0366). All the dominant OSs were found to be of the oblique type. Unilateral oblique OS (OOS) with normal ipsilateral transverse sinus (TS) and hypoplastic contralateral TS was found in 2 patients (0.9%). The authors found 1 patient each (0.5%) who had unilateral OOS with hypoplastic ipsilateral TS and normal contralateral TS, unilateral OOS with bilateral hypoplastic TSs, and bilateral OOSs with bilateral normal TSs. Bilateral OOSs with bilateral hypoplastic TSs were found in 2 patients (0.9%). All these patients had syringomyelia. Instead of performing Y-shaped dural incision and duraplasty, surgical procedures were modified depending on the types of the OOSs to preserve their venous drainage routes. Although massive bleeding from the dominant OS during dural incision occurred in 1 patient, none suffered neurological deterioration. The syrinx volume decreased in all but 1 of the patients postoperatively.

CONCLUSIONS

Assessment of the venous drainage pattern using MRV is indispensable for safe surgical treatment in patients with CM-I. The surgical procedure should be modified based on the type of dominant OS to minimize the surgical risks.

SARS-CoV-2 Infection upon Leaving the Tokyo 2020 Olympic and Paralympic Games

Objective Just before the Tokyo 2020 Olympic and Paralympic Games in Japan, the number of people infected with coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), started to increase at an unprecedented rate. This study investigated the effectiveness of vaccines in large-scale sporting events under difficult circumstances, such as during adherence to a bubble system and confinement inside the Olympic/Paralympic Village. Methods In collaboration with medical clinics inside and outside the Village, a prospective cohort study was conducted among overseas participants using the results of polymerase chain reaction (PCR) tests for SARS-CoV-2 upon leaving Japan. Results A total of 12,072 foreign participants were enrolled, 13 (0.11%) of whom had a positive PCR test result. None of these cases were broadcasters or members of the press, were tested outside the Olympic Village, or had a history of COVID-19 infection. The effectiveness of full vaccination and vaccination at least once (≥14 days ago) was 74% [95% confidence interval (CI): 6-93%] and 81% (95% CI: 30-95%), respectively. Three breakthrough infections with the Delta variant were observed in 6,485 fully vaccinated participants (0.05%). The positivity rate was 0.09% among adherents to the bubble system and 0.28% among non-adherents, but this difference was not significant. Conclusion These findings indicate that even huge sporting events such as the Olympic and Paralympic Games can proceed while pandemics are ongoing in the host country by combining countermeasures such as vaccination, frequent testing, social distancing, and adherence to a bubble system.

LW-5 DENDRITIC CELL IMMUNOTHERAPY FOR MALIGNANT GLIOMA: RESEARCH HISTORY FOR 25 YEARS AND THE FUTURE PROSPECTS

We started a research of dendritic cell (DC) immunotherapy for malignant glioma in late 1997, and were continuing the clinical study for more than 20 years with making several improvements of methods. The presenter has been participating in this research from its inception, and has continued to conduct research as the life's work. We will present research history and the future prospects. Autologous cultured tumor cells were established from tumor tissue obtained from a surgery of patient with malignant glioma in our hospital. Mature DCs were induced from autologous peripheral blood mononuclear cells (PBMC), and were fused with the established tumor cells. Cell manufacturing performed at a cell processing facility (CPF) maintained and managed by our university. Before 2004, the tumor-fused DCs (TFDC) were co-administrated with rIL-12. Since 2014, TFDCs were stimulated with Poly(I:C) and IL-10-siRNA in order to increase IL-12 secretion levels of them. Since 2014, PBMCs were collected by the apheresis method. Since 2006, the TFDC immunotherapy was combined with temozolomide (TMZ) chemotherapy. 111 cases were enrolled in the clinical study. The TFDC-immunotherapy was combined with the TMZ chemotherapy in 88 cases enrolled after 2006. No serious problem was confirmed in the cell manufacturing. The therapeutic effect in this study will be compared with a historical control that were the cases of malignant glioma treated with a standard therapy at the other affiliated hospitals at the same period. The results will be reported in the presentation. The safety and efficacy of this treatment were confirmed in the previous study. We would like to establish a provision system of the TFDCs by use of our CPF by preparing product uniformity, transport safety, preservation methods, etc., and aim to expand the hospitals that can perform this immunotherapy.

MPC-1 IMMUNOHISTOLOGICAL COMPREHENSIVE ANALYSIS OF ANGIOGENIC FACTORS OTHER THAN VEGF IN GLIOBLASTOMAS IN RELATION TO THE USE OF BEVACIZUMAB

To date, few clinical observations have been reported for changes of alternative angiogenic factors (other than vascular endothelial growth factor [VEGF]) in human gliomas under bevacizumab (Bev). The elucidation of the mechanism of action and resistance is imperative to overcome resistance to Bev and develop a more effective therapy. This study aims to investigate the status and change of alternative angiogenic factors regarding Bev usage.The present study used 56 glioblastoma tissues obtained at 3 different settings: tumors of initial resection (naive Bev group), tumors resected following Bev therapy (effective Bev group), and recurrent tumors after Bev therapy (refractory/autopsied Bev group). The expression of alternative angiogenic factors including basic fibroblast growth factor (bFGF), placental growth factor (PlGF), Angiopoietin1 (Ang-1), Angiopoietin2(Ang-2) and EphrinA2 were investigated via immunohistochemistry. In large tumor vasculature (diameter &gt;15μm), the expression of PlGF was significantly higher in the effective Bev group than naive Bev group. The expression of Ang-2 was persistently suppressed in the refractory/autopsied Bev group. In microtumor vasculature (diameter &lt;15μm), the expression of Ang-2 was higher in the effective group than naive Bev group. The status of PlGF was similar among these three groups.We provide the first clinicopathological evidence of the status of alternative angiogenic pathway after the Bev usage. These in situ observations will help to optimize therapy.

IMT-1 PROS AND CONS OF SURGICAL INTERVENTION FOR DIFFUSE MIDLINE GLIOMA AIMED AT DENDRITIC CELL IMMUNOTHERAPY

Since a diffuse midline glioma (DMG) has no effective therapy, it is an urgent need to develop new therapeutic strategy. We performed immunotherapy using fusions of autologous dendritic cells (DC) with tumor cells in DMG cases in which tumor tissue was collected by surgery aimed at biopsy, and evaluate the effectiveness and examine the pros and cons of surgical intervention against DMG. Among the patients with basal ganglia or brain stem tumors received surgery at our hospital, 5 adult cases of DMG with H3K27M gene mutation were registered. All patients received radiation therapy and temozolomide chemotherapy. 4 cases received bevacizumab chemotherapy when the patients had recurrence or progression of the disease. The tumor-fused DCs (TFDC) were made by DCs induced from autologous peripheral blood mononuclear cells and tumor cells established from surgical specimens. They were injected subcutaneously into the neck 3 ~ 6 times in a 14 ~ 28 day cycle as the immunotherapy. The adverse events, PFS, and OS were evaluated. A transient complication of facial numbness was observed in one case on right after surgery. Although two patients had CR in those therapies, both of them died of disease (OS at 18 and 32 months, respectively). Since the remaining three cases were registered very recently, adverse event or treatment efficacy judgment have not been determined at the time of submission of the abstract. Serious surgical complications have not been observed in the presented cases. Surgery may be acceptable for DMG as long as the surgery is performed by sufficiently experienced surgeon in an appropriate environment. The TFDC immunotherapy, which can be performed only by collecting a small amount of tumor tissue, expects to be a novel treatment for MDG. In this presentation, the pros and cons of surgical intervention aimed at TFDC immunotherapy for DMG will be examined.

MET-4 ANALYSIS OF METASTATIC BRAIN TUMORS DISCOVERED AT THE SAME TIME AS THE PRIMARY LESION

Introduction

Among metastatic brain tumors, especially in cases where the primary tumor and metastatic brain tumor are found at the same time, it is necessary to consider the priority of treatment for intracranial lesions and the means to obtain a definitive diagnosis. In this study, we performed a statistical analysis on the factors affecting mean survival (mOS) in patients with concurrent primary and metastatic brain tumors.

Subjects and Methods

A total of 252 patients with metastatic brain tumors treated at our hospital since 2014 were divided into two groups: simul-meta (58 patients) and non-simul-meta (194 patients). Age, sex, primary tumor, number of tumors, presence or absence of metastasis to other organs, localization of intracranial lesions, presence or absence of carcinomatous meningitis, performance status (PS), details of therapeutic intervention (radiation therapy, chemotherapy, surgery). The background factors between the two groups were analyzed using the chi-square test. Factors affecting mOS were evaluated by univariate analysis with log-rank test and multivariate analysis with Cox proportional hazards test.

Results

In simul-meta and non-simul-meta, mOS was 328 and 295 days, respectively (p=0.864). As a background, lung cancer (76%: 59%; p = 0.02) and surgical intervention group (28%: 11%; p &lt;0.01) were numerous in simul-meta. Good prognostic factors in the simul-meta group extracted by multivariate analysis were surgical intervention and cases of chemotherapy. Chemotherapy cases were stratified into conventional chemotherapy and molecular-targeted drug use, and the prognosis of molecular-targeted cases was better than that of conventional chemotherapy (p=0.01).

Discussion

In patients with concurrent disease, it is important to complete treatment for intracranial lesions, including surgical treatment, and maintain a general condition that allows chemotherapy to be administered. In addition, considering the frequent occurrence of lung cancer, it is necessary to develop a treatment plan with molecular target therapy in mind.

ACT-11 CLINICAL BENEFIT OF ADD-ON BEVACIZUMAB FOR NEWLY DIAGNOSED GLIOBLASTOMA IN ELDERLY PATIENTS WITH UNRESECTABLE AND POOR PERFORMANCE STATUS

Background

Since phase 3 randomized clinical trials failed to show the benefit of bevacizumab(Bev) from the induction therapy, Bev was widely used for the recurrence glioblastoma(GBM) cases. Given that Bev treatment for newly diagnosed GBM(nd-GBM) is permitted only in Japan, we could confirm the appropriate usage and timing of Bev for the GBM patient clinically. Here, we report the clinical benefit of Bev for nd-GBM based on the retrospective cohort study.

Methods

We retrospectively investigated 172 GBM patients who were treated with surgery, radiation therapy(RT) and temozolomide(TMZ) at our hospitals in 2006 to 2020. We classified with and without Bev patients for age, Karnofsky performance status(KPS) and extent of resection(EOR). Kaplan-Meier survival analysis was used to compare median overall survival(mOS) between patients who were treated with Bev simultaneously during Stupp regimen(S-Bev) and without Bev(NS-Bev).

Results

Bev provided prolonged mOS in the elderly(&gt;60 years old)(p&lt;0.01), poor KPS(&lt;70)(p=0.015) and low EOR(&lt;90%)(p&lt;0.01) groups. In addition, mOS was longer in S-Bev compared with NS-Bev in the elderly and low EOR groups, and there was statistically significant difference in low EOR group(p&lt;0.01). S-Bev tended to prolong mOS in elder patients(p=0.06) and NS-Bev tended to prolong in young patients(p=0.31).

Conclusion

Bev therapy commenced simultaneously with concurrent RT and TMZ might contribute to improve mOS for patients with high risk including the elderly, poor KPS and low EOR. Stratification based on risk factors including age and EOR might be effective for patients in whom Bev should be preferentially used as a first-line therapy.

ACT-1 A PROSPECTIVE MULTICENTER PHASE I/IIA STUDY OF PREOPERATIVE NEOADJUVANT BEVACIZUMAB FOR NEWLY DIAGNOSED GLIOBLASTOMA

Background

Preoperative neoadjuvant bevacizumab (neoBev) reduces enhancement and perifocal edema by inhibition of angiogenesis and vascular permeability for glioblastoma (GBM). The aim of this study was to investigate safety and efficacy of neoBev for newly diagnosed GBM through an exploratory prospective multi-center study.

METHODS & PATIENTS

15 patients with newly diagnosed GBM were enrolled in the present study. Eligibility was a patient with a brain tumor representing with ring-shaped enhancement and perifocal edema on magnetic resonance imaging (MRI). Based on neuroimage of typical GBM, neoBev and temozolomide (TMZ) were administered prior to craniotomy. Two weeks after neoBev, the tumor volume on T1-weighted gadolinium enhancement (T1Gd) and fluid attenuated inversion recovery (FLAIR) were assessed. Three to four weeks after neoBev and TMZ administration, patients underwent surgical resection. The primary endpoint was feasibility and safety, and the secondary endpoint was efficacy. Adverse events including systemic toxicity and wound healing delay during radiation (RT), TMZ, and Bev combined therapy were carefully monitored throughout clinical course including extent of resection.

RESULTS

Average of tumor regression rate two weeks after neoBev on T1Gd and FLAIR were 37.0% and 54.0%, respectively. Cerebral blood flow and cerebral blood volume were reduced after neoBev. Patients underwent surgical resection safely without excess blood loss due to less vascular and less degree of brain swelling. Two patients underwent awake surgery without any complications. Postoperative MRI showed that the all tumors were totally removed except one with multiple invasive tumors. Histological diagnosis of all patients was GBM, IDH-1 wild-type. Postoperative course was uneventful without neurological deficit and adverse effects except one postoperative hematoma in the resection cavity and one wound infection due to wound dehiscence.

CONCLUSION

Preoperative neoBev for newly diagnosed GBM might contribute to safe surgery. Clinical outcome of this therapeutics is now currently under investigation.

A novel 3-Fr guiding sheath for transradial access in aneurysm embolization: Technical note

Neurointervention via transradial access (TRA) is challenging when the radial artery is narrow. We performed aneurysm embolization via TRA using a novel 3-Fr guiding sheath (GS) (Axcelguide; Medikit, Tokyo, Japan) with an outer diameter of only 1.76 mm for patients with a radial artery of inner diameter less than 2 mm, and described the whole procedure and pitfalls as a technical note. Here, we present two patients with radial arteries less than 2 mm. One patient had a narrow neck intracranial aneurysm at the bifurcation of the left vertebral artery and posterior inferior cerebellar artery, which was embolized with the primary coiling technique. The other was a patient with a wide-necked extracranial aneurysm in the cavernous portion of the right internal carotid artery, which was embolized with the transcell technique with stent. We utilized a 3-Fr GS, distal access catheter, and a 0.0165-inch microcatheter for coil embolization. All aneurysms were completely occluded, without neurological or puncture site-related complications including subcutaneous hematoma, radial artery occlusion, and vasospasm. This report provides the first description of neurointervention using a 3-Fr GS. The 3-Fr GS contributed to successful completion of TRA aneurysm embolization without neurological or puncture site-related complications in patients with radial arteries narrower than 2 mm. The 3-Fr GS may be useful to accomplish aneurysmal embolization via TRA even in patients with a small radial artery.

BIOM-07. LOW EXPRESSION OF HLA-A AS A NOVEL PROGNOSTIC FACTOR IN GLIOBLASTOMA TREATED WITH TUMOR FUSED DENDRITIC CELL VACCINES

Although immunotherapy has become an attractive approach to cancer treatment in patients with broad types of aggressive tumors, phase III clinical trials of immunotherapy for glioblastoma (GBM) have not achieved extended survival of patients. Dendritic cells perform an essential role in the immune system as antigen-presenting cells and tumor fused dendritic cells (TFDCs) can induce tumor-specific cytotoxic T cells as a cancer vaccine. We have previously described the safety and mechanisms of TFDCs therapy, as well as immunological and clinical responses of patients with GBM, however, there were little known about predictive and prognostic biomarkers specific to TFDCs therapy. In the present study, we investigated the whole transcriptome sequencing of tumor cells, and novel prognostic factors were identified through molecular profiling GBM treated with TFDCs immunotherapy. Fifty-three patients were eligible in this study and 28 samples from patients with newly diagnosed GBM IDH wild-type were included. Of these 28 samples, 15 high-quality RNA samples successfully extracted from tumors were analysed. The samples were divided into two groups based on the median patient's overall survival. Differential expression analyses and enrichment analysis between the two groups were carried out using CLC Genomics Workbench (QIAGEN), and Gene Ontologies (GO) were assigned. A total of 473 differentially expressed genes were detected including 327 enriched GO terms. Fifteen GO terms out of 327 GO terms represented the highest enrichment scores, revealed that five GO terms were associated with the major histocompatibility complex (MHC). The relationship among the MHC, immune-related genes, and clinical outcomes was investigated using the Cox regression model and Kaplan–Meier log-rank test. Low expression of HLA-A in the tumors turned out to be a significantly favorable prognostic impact (p = 0.01). The decreased expression of HLA-A might be a novel prognostic factor in GBM patients treated with TFDCs immunotherapy.

Evaluation of the direct protective effects of Canagliflozin on the Isoproterenol-induced cell injury in rat cardiomyocytes

Background

Sodium-glucose cotransporter-2 (SGLT2) inhibitors are agents that act by inhibiting glucose and sodium reabsorption in the proximal renal tubule which promotes urinary glucose excretion. More recently, significant benefit data of SGLT2 inhibitors in patients with heart failure, independent of the presence of type 2 diabetes has been reported. We have previously demonstrated that Canagliflozin (Cana), a SGLT2 inhibitor, reduced the ventricular effective refractory period in isoproterenol (ISP)-induced myocardial injury rat model accompanied with the suppression of reactive oxygen species and the elevation of ketone bodies, suggesting the effect of Cana on electrical cardiac remodeling. The direct effect of Cana to the cardiomyocytes and its underlying molecular mechanism was remained to be clarified. We therefore established an ISP-induced neonatal rat ventricular cardiomyocyte (NRVCM) in vitro model, pretreated with Cana and/or ketone bodies.

Methods

Primary NRVCM were isolated from Wistar rats, were pretreated by Cana with or without βOHB (the most abundant ketone body in circulation), followed by a stimulation of ISP (10μM). Cells without drug or ketone body pretreatment were used as control. We then analyzed its effect on cell viability, apoptosis, and mitochondrial membrane potential using MTT assay, TUNEL assay, and mitochondrial membrane potential assay, respectively. MTT assay was also performed with or without PI3k inhibitor, LY294002. The end-labeling of DNA fragmentation were labelled with FITC, followed by the nuclei counterstain with DAPI and were observed with confocal microscope. The apoptotic index was defined as the percentage of TUNEL positive cells / total nuclei.

Results

Cana rescued the reduction of NRVCM cell viability induced by ISP stimulation for 24 hours which was inhibited by LY294002 compared to cells without pretreatment. Interestingly, pretreatment of βOHB with or without Cana improved also the NRCVM cell viability whereas there was no significant difference between these two conditions or with cells treated with Cana only, suggesting the direct protective effect of Cana. In 48 hours of ISP stimulation, the apoptotic index intends to decrease in Cana and/or βOHB compared to cells without pretreatment (Figure 1). Although the mitochondrial function was maintained in Cana-pretreated cells compared to cells without pretreatment, there was no significant difference in βOHB-pretreated cells.

Conclusions

Cana has a direct protective effect on cardiomyocytes cell viability, apoptosis as well as the mitochondrial function impaired by ISP through the cell survival signaling PI3K/Akt pathway. This brings a new insight to the therapeutic target of cardiovascular disease.

Funding Acknowledgement

Type of funding sources: None.

Diagnostic performance of intraoperative cone beam computed tomography compared with postoperative magnetic resonance imaging for detecting hemorrhagic transformation after endovascular treatment following large vessel occlusion

OBJECTIVES

Early detection of hemorrhagic transformation (HT) in patients with large vessel occlusion (LVO) after endovascular treatment is important for postoperative patient management. We investigated the diagnostic performance of intraoperative cone beam computed tomography (CBCT) with reference standard magnetic resonance imaging (MRI) for detecting HT.

MATERIALS AND METHODS

Consecutive patients with LVO treated by endovascular treatment who underwent intraoperative CBCT and postoperative MRI were included. Two observers evaluated all images for the presence of HT. Sensitivity and specificity for detecting HT were calculated with MRI as reference standard. The observers classified HT according to the European Cooperative Acute Stroke Study (ECASS). Inter-method and inter-rater agreement for the detection of HT and for the ECASS classification were assessed using kappa or weighted Brennan-Prediger (wBP) statistics.

RESULTS

Images of 106 procedures (94 for anterior circulation) were analyzed. The sensitivity and specificity for detecting HT on CBCT were 0.77 and 0.83, respectively, for all procedures and 0.83 and 0.8, respectively, for anterior circulation. The inter-method agreement for HT detection (κ = 0.63 overall, κ = 0.69 anterior circulation) and ECASS classification (wBP = 0.67 overall, wBP = 0.77 anterior circulation) were substantial. The inter-rater agreement for HT detection (κ = 0.87 overall, κ = 0.85 anterior circulation) and for ECASS classification (wBP = 0.95 overall, wBP = 0.92 anterior circulation) were almost perfect.

CONCLUSIONS

The diagnostic performance of CBCT for the detection of HT in stroke patients treated for LVO was acceptable with excellent inter-rater agreement. Intraoperative CBCT may be useful to trigger early interventions if HT is detected, although detailed classifications of HT may be difficult.

Computational fluid dynamic analysis of the initiation of cerebral aneurysms

OBJECTIVE

Relationships between aneurysm initiation and hemodynamic factors remain unclear since de novo aneurysms are rarely observed. Most previous computational fluid dynamics (CFD) studies have used artificially reproduced vessel geometries before aneurysm initiation for analysis. In this study, the authors investigated the hemodynamic factors related to aneurysm initiation by using angiographic images in patients with cerebral aneurysms taken before and after an aneurysm formation.

METHODS

The authors identified 10 cases of de novo aneurysms in patients who underwent follow-up examinations for existing cerebral aneurysms located at a different vessel. The authors then reconstructed the vessel geometry from the images that were taken before aneurysm initiation. In addition, 34 arterial locations without aneurysms were selected as control cases. Hemodynamic parameters acting on the arterial walls were calculated by CFD analysis.

RESULTS

In all de novo cases, the aneurysmal initiation area corresponded to the highest wall shear stress divergence (WSSD point), which indicated that there was a strong tensile force on the arterial wall at the initiation area. The other previously reported parameters did not show such correlations. Additionally, the pressure loss coefficient (PLc) was statistically significantly higher in the de novo cases (p < 0.01). The blood flow impact on the bifurcation apex, or the secondary flow accompanied by vortices, resulted in high tensile forces and high total pressure loss acting on the vessel wall.

CONCLUSIONS

Aneurysm initiation may be more likely in an area where both tensile forces acting on the vessel wall and total pressure loss are large.

Impact of Neoadjuvant Bevacizumab on Neuroradiographic Response and Histological Findings Related to Tumor Stemness and the Hypoxic Tumor Microenvironment in Glioblastoma: Paired Comparison Between Newly Diagnosed and Recurrent Glioblastomas

Background

Previously, we reported that bevacizumab (Bev) produces histological and neuroradiographic alterations including changes in tumor oxygenation, induction of an immunosupportive tumor microenvironment, and inhibition of stemness. To confirm how those effects vary during Bev therapy, paired samples from the same patients with newly diagnosed glioblastoma (GBM) who received preoperative neoadjuvant Bev (neoBev) were investigated with immunohistochemistry before and after recurrence.

Methods

Eighteen samples from nine patients with newly diagnosed GBM who received preoperative neoBev followed by surgery and chemoradiotherapy and then autopsy or salvage surgery after recurrence were investigated. The expression of carbonic anhydrase 9 (CA9), hypoxia-inducible factor-1 alpha (HIF-1α), nestin, and Forkhead box M1 (FOXM1) was evaluated with immunohistochemistry.

For comparison between neoBev and recurrent tumors, we divided the present cohort into two groups based on neuroradiographic response: good and poor responders (GR and PR, respectively) to Bev were defined by the tumor regression rate on T1-weighted images with gadolinium enhancement (T1Gd) and fluid-attenuated inversion recovery images. Patterns of recurrence after Bev therapy were classified as cT1 flare-up and T2-diffuse/T2-circumscribed. Furthermore, we explored the possibility of utilizing FOXM1 as a biomarker of survival in this cohort.

Results

A characteristic “pseudo-papillary”-like structure containing round-shaped tumor cells clustered adjacent to blood vessels surrounded by spindle-shaped tumor cells was seen only in recurrent tumors. Tumor cells at the outer part of the “pseudo-papillary” structure were CA9-positive (CA9+)/HIF-1α+, whereas cells at the inner part of this structure were CA9−/HIF-1α+ and nestin+/FOXM1+. CA9 and HIF-1α expression was lower in T1Gd-GR and decreased in the “T2-circumscribed/T2-diffuse” pattern compared with the “T1 flare-up” pattern, suggesting that tumor oxygenation was frequently observed in T1Gd-GR in initial tumors and in the “T2-circumscribed/T2-diffuse” pattern in recurrent tumors. FOXM1 low-expression tumors tended to have a better prognosis than that of FOXM1 high-expression tumors.

Conclusion

A “pseudo-papillary” structure was seen in recurrent GBM after anti-vascular endothelial growth factor therapy. Bev may contribute to tumor oxygenation, leading to inhibition of stemness and correlation with a neuroimaging response during Bev therapy. FOXM1 may play a role as a biomarker of survival during Bev therapy.

Effects of different stent wire mesh densities on hemodynamics in aneurysms of different sizes

Background

Intracranial stents are used to treat aneurysms by diverting the blood flow from entering into the aneurysmal dome. Although delayed rupture is rare, clinical outcomes are extremely poor in such cases. Hemodynamics after stent deployment may be related to delayed rupture and a better understanding of the basic characteristics of pressure changes resulting from stent deployment is needed; therefore, this study investigated the relationships between hemodynamics in aneurysms of different sizes treated using stents of different wire mesh densities.

Methods

Using computational fluid dynamics analysis, parameters related to velocity, volume flow rate, pressure, and residual volume inside the aneurysm were evaluated in digital models of 5 basic aneurysms of differing sizes (Small, Medium, Medium-Large, Large, and Giant) and using 6 different types of stent (varying number of wires, stent pitch and wire mesh density) for each aneurysm.

Results

Regardless of the aneurysm size, the velocity inside the aneurysm and the volume flow rate into the aneurysm were observed to continuously decrease up to 89.2% and 78.1%, respectively, with increasing stent mesh density. In terms of pressure, for giant aneurysms, the pressure on the aneurysmal surface elevated to 10.3%, then decreased to 5.1% with increasing stent mesh density. However, in smaller aneurysms, this pressure continuously decreased with increasing stent mesh density. The flow-diverting effect of the stents was limited when a stent with low mesh density (under 20%) was used with a giant aneurysm.

Conclusions

The present results indicate that the selection of appropriate stents according to aneurysm size may contribute to reduced risks of hemodynamic alternations related to stent deployment, which could reduce the incidence of delayed rupture.

Changes in Short-Term Outcomes After Discharge in Patients with Aneurysmal Subarachnoid Hemorrhage: A Multicenter, Prospective, Observational Study

OBJECTIVE

The objective of the study was to clarify the prevalence of and factors associated with changes in patients' outcomes between discharge and 3 months after the onset of aneurysmal subarachnoid hemorrhage (aSAH). Additionally, the World Federation of Neurosurgical Societies (WFNS) and modified WFNS (mWFNS) scales were compared.

METHODS

The data of curatively treated patients with aSAH, collected prospectively in the mWFNS scale study between January 2010 and December 2012, were analyzed retrospectively. The improvement or decline in the modified Rankin Scale (mRS) scores between discharge and 3 months after onset was determined. A multivariable logistic regression analysis was performed to identify factors, such as age and WFNS and mWFNS grades, associated with changes in the outcome.

RESULTS

The mRS scores improved in 28.3% and declined in 2.5% of the patients. WFNS and mWFNS grades Ⅱ-V on admission were significantly associated with improved mRS scores at 3 months after onset. Older age (age: 65-74 years vs. age <65 years, odds ratio: 6.59, 95% confidence interval: 1.28-34.01; age ≥75 years vs. age <65 years, odds ratio: 17.67, 95% confidence interval: 2.11-148.26) and WFNS grade III were significantly associated with a decline in mRS scores at 3 months after onset.

CONCLUSIONS

The optimal timing for postdischarge assessment of outcomes may be at 3 months after onset, especially in older patients with aSAH. The mWFNS scale is presumed to more accurately assess the outcomes of patients with aSAH than the WFNS scale, as demonstrated in this study.

Horizontal stenting via retrograde route for recurrent ruptured posterior communicating artery aneurysm after clipping: A case report and literature review

Treatment of recurrent ruptured aneurysms incorporating a branch vessel arising from the dome is challenging. Here, we attempted horizontal stent-assisted coil embolization via a retrograde route from the contralateral internal carotid artery to treat a small ruptured posterior communicating artery aneurysm incorporating a fetal variant posterior cerebral artery after clipping.

[Surgical Strategy of Benign Skull Base Tumors Based on Membrane Structure]

Meningiomas, schwannomas, and pituitary adenomas are typically benign tumors of intracranial origin, but all of these tumors have a border with the surrounding tissue. The basic structure is a clear "boundary" between the tumor and its surroundings, with a thin membrane layer to create that separation. This layer of membrane is the boundary between the tumor and its surroundings and provides a space for the tumor to grow its cells, and can be viewed as the so-called "tumor capsule. Based on the relationship between the membrane structure of the tumor capsule and the surrounding normal tissues, we perform surgery to reduce surgical complications. We histologically evaluated three types of tumor capsules(meningioma, schwannoma, and pituitary adenoma)and compared the membrane structure of each tumor with that seen in clinical surgery.

A New Approach to Understanding Cancer-Related Fatigue: Leveraging the 3P Model to Facilitate Risk Prediction and Clinical Care

Simple Summary

For the growing number of cancer survivors worldwide, fatigue presents a major hurdle to function and quality of life. Treatment options for cancer-related fatigue are still emerging, and our current understanding of its etiology is limited. In this paper, we describe a new application of a comprehensive model for cancer-related fatigue: the predisposing, precipitating, and perpetuating (3P) factors model. We propose that the 3P model may be leveraged—particularly using metabolomics, the microbiome, and inflammation in conjunction with behavioral science—to better understand the pathophysiology of cancer-related fatigue.

Abstract

A major gap impeding development of new treatments for cancer-related fatigue is an inadequate understanding of the complex biological, clinical, demographic, and lifestyle mechanisms underlying fatigue. In this paper, we describe a new application of a comprehensive model for cancer-related fatigue: the predisposing, precipitating, and perpetuating (3P) factors model. This model framework outlined herein, which incorporates the emerging field of metabolomics, may help to frame a more in-depth analysis of the etiology of cancer-related fatigue as well as a broader and more personalized set of approaches to the clinical treatment of fatigue in oncology care. Included within this review paper is an in-depth description of the proposed biological mechanisms of cancer-related fatigue, as well as a presentation of the 3P model’s application to this phenomenon. We conclude that a clinical focus on organization risk stratification and treatment around the 3P model may be warranted, and future research may benefit from expanding the 3P model to understand fatigue not only in oncology, but also across a variety of chronic conditions.

Japanese Subarachnoid Aneurysm Trial of Neurosurgical Clipping versus Endovascular Coiling in 1863 Patients with Ruptured Intracranial Aneurysms

This is a post hoc multivariate analysis of the modified World Federation of Neurosurgical Societies (WFNS) grading project, multicenter prospective observational study including 38 neurosurgical institutions across Japan. Japan Neurosurgical Society WFNS grading committee conducted a modified WFNS grading project as a nationwide prospective registry study. We investigate the clinical outcome of both surgical and endovascular interventions after aneurysmal subarachnoid hemorrhage (SAH) in Japan. A total of 792 patients received surgical intervention and 417 patients received endovascular treatment. Eight hundred patients were female, and 409 patients were male. The mean age was 61.5 ± 13.7 years. At 3 month follow-up, there was no statistically significant difference in good clinical outcome between surgical (68.2%) and endovascular (60.9%) group (odds ratio, 0.89; 95% confidence interval, 0.68-1.16; p = 0.381). Unfavorable outcome rate was 31.8% (238 patients) in the surgical group and 39.1% (154 patients) in the endovascular group. Male, elderly people, modified Rankin scale condition before onset, high-grade modified WFNS clinical grading scale, intracerebral hematoma, posttreatment normal pressure hydrocephalus, and neurological deficit due to symptomatic vasospasm were risk factors for the clinical outcome. Treatment modality was not a statistical factor for clinical outcomes. Surgical clipping has still a major role in the management of SAH in Japan. The present study was not a randomized controlled study, but clinical outcome is not influenced by treatment modalities.

Improvement of the Japanese healthcare data system for the effective management of patients with COVID-19: A national survey

OBJECTIVE

The burden of data entry in public platforms used for reporting patients with novel coronavirus disease 2019 (COVID-19) is a challenge in the healthcare setting. The key to mitigating the burden of data entry is system integration and elimination of double data entry. In addition, the linkage between public platforms and electronic medical records (EMRs) involves external networks, which are an important target for security management. The purpose of this study was to elucidate the status and challenges of infrastructure for continuous data reporting from hospitals in Japan.

MATERIALS AND METHODS

An online survey of Japanese care delivery institutions was conducted from January 25 to February 22, 2021, to obtain data on the admission of patients with COVID-19, use of information infrastructures, and status of network connections with external organizations. The survey request was distributed to each care delivery institution by Japanese health authorities.

RESULTS

Of the care delivery institutions that responded to the survey, 53.9% treated patients with COVID-19. Of these institutions, 73.3% used EMRs. 57.8% of the EMRs were connected to an external network. The purpose of connecting to the external network was to contribute to regional health information-sharing with other hospitals (22.0%), report online medical insurance claims (27.5%), and conduct intrahospital system maintenance (61.5%). A frequent concern about connecting an EMR to an external network was data leakage.

DISCUSSION

In cases where the frequency of reporting patients with COVID-19 is high, health authorities should provide information regarding anti-data-leakage measures and coordinate frameworks for efficient, sustainable data collection.

CONCLUSIONS

We obtained information on existing infrastructures for patient data sharing among care delivery institutions and public health authorities. Our findings may be referenced by the government to make informed decisions about investments.