One-stage Revascularization to the Ipsilateral Middle Cerebral Artery and Contralateral Anterior Cerebral Artery Territories

BACKGROUND

Patients with multiple intracranial atherosclerotic stenoses often present with haemodynamic instability in two remote regions without a reciprocal vascular network. In this situation, revascularisation to each region may be required.

METHODS

In this report, two patients who had coexisting unilateral middle cerebral artery (MCA) and contralateral anterior cerebral artery (ACA) territory ischemia were treated by using ipsilateral superficial temporal artery (STA)-radial artery graft (RAG)-contralateral A3 bypass and ipsilateral STA-MCA bypass in one stage.

RESULTS

Postoperatively, the bypass conduit was well established and the patients' haemodynamic instability was improved.

CONCLUSION

In patients with severe haemodynamic instability in the remote unilateral MCA and contralateral ACA regions, as in our two cases, ipsilateral STA-MCA and ipsilateral STA-RAG-contralateral A3 bypasses in one stage can be a treatment option.

Non‐invasive transcriptomic analysis using mRNAs in skin surface lipids obtained from children with mild‐to‐moderate atopic dermatitis

Background

Specimens for analysing the molecular pathology of skin disease are generally obtained through invasive methods, such as biopsy. However, less burdensome methods are desirable for paediatric patients. We recently established a method that comprehensively analyses RNA present in sebum (skin surface lipid–RNAs: SSL‐RNAs) using a next‐generation sequencer. Using this method, biological information can be obtained from the skin in a completely non‐invasive manner.

Objectives

To verify the applicability of the SSL‐RNA method for analysis of paediatric skin and analyse the molecular pathology of mild‐to‐moderate atopic dermatitis (AD) in children.

Methods

We collected sebum specimens from the whole faces of 23 healthy children and 16 children with mild‐to‐moderate AD (eczema area and severity index (EASI) score: 5.9 ± 2.6) ranging in age from 6 months to 5 years, using an oil‐blotting film. We then extracted SSL‐RNAs from the samples and performed an AmpliSeq transcriptomic analysis.

Results

The expressions of genes related to keratinization (LCE, PSORS1C2, IVL and KRT17), triglyceride synthesis and storage (PLIN2, DGAT2 and CIDEA), wax synthesis (FAR2), ceramide synthesis (GBA2, SMPD3 and SPTLC3), antimicrobial peptides (DEFB1) and intercellular adhesion (CDSN), all of which are related to the skin barrier, are lower in children with AD than in healthy children. The children with AD also have higher expression of CCL17, a Th2‐cytokine and an increased Th2‐immune response as demonstrated by a gene set variation analysis. Moreover, KRT17 and CCL17 expression levels are significantly correlated with the EASI score.

Conclusions

Molecular changes associated with abnormal immune responses and the epidermal barrier in children with mild‐to‐moderate AD can be determined using the SSL‐RNA method. This non‐invasive method could therefore be a useful means for understanding the molecular pathology of paediatric AD.

Social Detachment Influenced Muscle Mass and Strength during the COVID-19 Pandemic in Japanese Community-Dwelling Older Women

Social detachment due to coronavirus disease (COVID-19) has caused a decline in physical activity, leading to sarcopenia and frailty in older adults. This study aimed to compare muscle mass, strength, and function values in older women before and after the first wave of the COVID-19 pandemic (April-May 2020). Furthermore, changes in muscle measures across women who experienced different levels of impact on their social participation due to the COVID-19 pandemic were examined. Muscle mass (total, trunk, and appendicular muscle), grip strength, oral motor skills, social interactions (social network and participation), and social support were assessed in 46 Japanese community-dwelling older women (mean, 77.5 y; range 66-93 y) before and after the first wave of the COVID-19 pandemic. Trunk muscle mass significantly decreased after the first wave of the pandemic. When comparing changed values between the enhanced/maintained and reduced group during the pandemic, significant group difference was observed in trunk muscular mass, grip strength, and oral motor skills. Intriguingly, those who enhanced social participation had a positive change of grip strength values, showing that social participation might influence muscle function during the COVID-19 pandemic.

Superficial temporal artery lengthening technique to prevent postoperative wound complications in direct revascularization to the anterior cerebral artery for Moyamoya disease

BACKGROUND

Neurocognitive dysfunctions or psychomotor symptoms of Moyamoya disease may improve after direct revascularization to the anterior cerebral artery (ACA). However, long-distance harvest of the frontal branch of the superficial temporal artery (STA) is needed to reach the cortical ACA, frequently resulting in postoperative wound complications. To solve this problem, we devised a novel method (STA lengthening technique). In this study, we compared the STA lengthening technique and the conventional method regarding postoperative wound complications.

METHODS

Twenty-five patients who underwent STA-ACA direct bypass from December 2016 to October 2021 were retrospectively reviewed, and postoperative wound complications were recorded. Magnetic resonance angiography was performed to evaluate the patency of the bypass to the ACA and postoperative development of collaterals to the skin flap.

RESULTS

Thirty-eight hemispheres (new method [n = 12] vs. conventional method [n = 26]) were treated. Wound complications occurred in 12 surgeries (46%) of the conventional method, and none (0%) of the new method. The anastomosis with the cortical ACA was patent in all surgeries. Postoperative development of collaterals to the skin flap was confirmed after all surgeries (100%) in the new method, whereas after only five surgeries (20%) in the conventional method.

CONCLUSION

The STA lengthening technique can enable to preserve the collateral circulation to the skin flap postoperatively, resulting in good wound healing.

Expression of CXCL12 in esophageal high grade dysplasia characterized pathologically by lymphocyte accumulation directly under the lesion

Squamous dysplasia of the esophagus is an unequivocal neoplastic alteration of the esophageal squamous epithelium without invasion. Esophageal high grade dysplasia (EHGD) is characterized by >50% epithelial involvement or severe cytological atypia. Frequently, lymphocytes accumulate below EHGD lesions even though there is no invasion. If this lymphocytic accumulation is active, a transmitter should exist between the EHGD cells and the lymphocytes. C-X-C motif chemokine ligand (CXCL) 12, CXCL10 and C-C motif chemokine ligand 18 (CCL18) are all lymphocyte chemoattractants in vivo, but there are no reports on the relationship between these chemokines and EHGDs. In this study, we investigated these chemokines and C-X-C motif chemokine receptor 4 (CXCR4) (receptor for CXCL12) in 30 EHGDs using immunohistochemistry and reverse transcription polymerase chain reaction (RT-PCR). For comparison, we enrolled 30 samples of normal esophageal squamous epithelium (NESE). We confirmed CXCL12 expression (H-score≥50 points) in 70% of EHGD and 0% of NESE samples, CXCL10 expression in 3% of EHGD and 3% of NESE samples, CCL18 expression in 3% of EHGD and 0% of NESE samples, and CXCR4 expression in 53% of EHGD and 0% of NESE samples by immunohistochemistry. EHGD and NESE cases were significantly different in their expressions between the tissue types (CXCL12, p<0.001; CXCR4, p<0.001). We examined CXCL12 and CXCR4 mRNA expressions of 3 representative EHGD samples, each having their respective immunostained areas detected by RT-PCR. Finding CXCL12 expression may indicate that this chemokine plays a part in the lymphocyte accumulation that occurs directly under EHGDs.

Revascularization to the ACA: effectiveness and variation of the STA-RAG-A3 bonnet bypass

BACKGROUND

The effectiveness of bypass surgery in patients with atherothrombotic ischemia in the anterior cerebral artery (ACA) domain remains unclear. In this study, three cases with ischemia in the ACA territory underwent revascularization surgery using superficial temporal artery (STA)-radial artery graft (RAG)-A3 (pericallosal artery) bonnet bypass. Herein, we discuss the effectiveness and variations of this approach.

METHODS

Among 182 consecutive patients with atherothrombotic ischemic stroke admitted to the NTT Medical Center, Tokyo, from April 2017 to May 2021, three patients with hemodynamic insufficiency in the extensive ACA territory beyond the recent infarct area were treated using STA-RAG-A3 bonnet bypass.

RESULTS

One patient with bilateral severe cerebral blood flow (CBF) deficiency required additional A3-A3 and STA-middle cerebral artery single bypass in conjunction with STA-RAG-A3 bypass. There were no complications associated with the surgical procedure. The patients' hemodynamic study results and neurocognitive performances improved dramatically after surgery.

CONCLUSION

Our results suggest the efficacy of STA-RAG-A3 bypass for atherothrombotic ACA ischemia. However, because the number of cases was too small to generalize our results, more cases and thorough pre- and postoperative hemodynamic studies are necessary to prove the validity of the approach.

Vein-related Trigeminal Neuralgia: How to Determine the Treatment Method of the Causative Vein: A Technical Note

Trigeminal neuralgia (TN) is often caused by various vein forms. Herein, we report two cases of vein-related TN. In the first case, the vein of the cerebellopontine fissure (VCPF), along with the thickened surrounding arachnoid, clung to the trigeminal nerve. As the perfusion range of this vein was expected to be wide and its injury might cause extensive venous infarction, the anchor between the trigeminal nerve and the vein was carefully dissected and the vein was successfully transposed. In the second case, the involvement of the vein of the middle cerebellar peduncle (VMCP), which penetrates the nerve bundle of the trigeminal nerve, was suspected. Because vein transposition was impossible, the vein was transected at the nerve penetration site after confirming that there was sufficient collateral venous outflow. The superior petrosal vein and its tributaries are the primary causative veins of vein-related TN, and their contact patterns are infinite. Moreover, their perfusion range and the presence or absence of collateral venous outflow vary from case to case. Therefore, it is necessary to judge the perfusion range as well as collateral venous outflow based on preoperative images and intraoperative findings and to determine the appropriate treatment method for each case.

Relationship of early intensive- or coronary care unit admission and post-discharge performance of activities of daily living in patients with acute decompensated heart failure

Background

The management of acute decompensated heart failure (ADHF) often requires intensive care. However, the effects of early intensive care unit (ICU)/coronary care unit (CCU) admission on activities of daily living (ADL) in ADHF patients have not been precisely evaluated. Thus, we assessed whether early ICU entry can improve post-discharge ADL performance in these patients.

Methods and results

ADHF patients (New York Heart Association I–III) admitted on emergency between April 1, 2014, and December 31, 2018, were selected from the Diagnosis Procedure Combination database and divided into ICU/CCU (ICU) and general ward (GW) groups according to the hospitalization type on admission day 1. The propensity score was calculated to create matched cohorts where treatment assignment (ICU/CCU admission) is independent of measured baseline confounding factors including ADL at admission. The primary outcome was post-ADL defined according to the Barthel index (BI) at discharge. Secondary outcomes included length of stay (LOS) and total hospitalization cost (expense). Overall, 12,231 patients were eligible, and propensity score matching created 2,985 pairs. After matching, post-ADL was significantly higher in the ICU group (GW 71.5±35.3 vs. ICU 78.2±31.2, P&lt;0.001, difference in mean 6.7 (95% CI 5.1–8.4) points). After matching, LOS was significantly shorter and expenses were significantly higher in the ICU group. Subanalyses showed that patients with low ADL at admission (BI&lt;60) mainly benefited from early ICU/CCU entry.

Conclusions

Early ICU/CCU entry was beneficially associated with post-ADL in patients with emergency ADHF admission. ADL at admission might serve as a useful criterion for ICU admission.

Funding Acknowledgement

Type of funding sources: None.

Microsurgical Treatment Strategy of Vertebral Artery Fusiform Aneurysm-From the Standpoint of Hemodynamic Integrity and Perforator Preservation

During treatment of vertebral artery (VA) fusiform aneurysms, it is critical to preserve peripheral perforators and anterograde blood flow of the VA and to reduce hemodynamic load to the contralateral VA. Even in the era of endovascular treatment, there are still many benefits to using microsurgical treatments with appropriate clip application and preservation of the perforators around the aneurysm, in conjunction with various bypass techniques. The ideal microsurgical technique involves reconstructive clipping that obliterates the aneurysm but preserves anterograde blood flow of the VA, followed by isolation of the aneurysm and VA reconstruction. If these two methods are unavailable, proximal clipping of the aneurysm combined with flow-augmentation bypass to the distal branch can be considered as an alternative surgical management. We discuss the microsurgical treatment of unruptured VA fusiform aneurysms in our surgical cases on the basis of a review of the current literature.

Posterior Transposition of the Frontal Bridging Veins Together with Sphenoparietal Sinus: A Simple Technique to Widen the Surgical Corridor During Pterional Clipping of the Anterior Communicating Artery

BACKGROUND

High-positioned and/or superoposteriorly directed anterior communicating artery aneurysms can be treated by direct clipping using the pterional (fronto-temporo-sphenoidal) approach. This procedure, however, requires stronger retraction of the frontal lobe. Hence, preservation of the prominent frontal bridging veins (FBVs) draining into the sphenoparietal sinus (SPS) remains a significant challenge in preventing postoperative venous congestion.

METHODS

We developed a technique to release the tension on the FBVs by pulling them together with the SPS epidurally. In 2 patients, who had presented with high-positioned and/or superoposteriorly directed anterior communicating artery aneurysms, we peeled off the arachnoid surrounding the FBVs and detached it from the brain surface. We further released the veins by moving them posteriorly, together with the SPS epidurally.

RESULTS

Using this technique, we established a wide corridor through a more lateral transsylvian trajectory with effective posterior retraction of the frontal lobe and were successful in clipping and obliterating the aneurysms.

CONCLUSIONS

Open clipping of unruptured intracranial aneurysms requires accuracy to preserve higher brain function. Our technique was successful in both patients, and preserving the FBVs could be useful in the treatment of such aneurysms.

Do Reading and Arithmetic Fluency Share the Same Cognitive Base?

We examined the role of different cognitive-linguistic skills in reading and arithmetic fluency, and whether the effects of these skills are mediated by reading and arithmetic accuracy. One hundred twenty-six English-speaking Grade 1 children (67 females, 59 males; M _age = 6.41 years) were followed from the beginning of Grade 1 (Time 1) to the end of Grade 1 (Time 2). At Time 1, they were assessed on measures of non-verbal IQ, speed of processing, working memory, phonological awareness, rapid automatized naming (RAN), and number sense. At Time 2, they were assessed on measures of reading and arithmetic accuracy as well as on measures of reading and arithmetic fluency. Results of path analysis showed first that when reading and arithmetic fluency were included in the model as separate outcomes, RAN was predictive of both and that speed of processing and working memory were predictive of only arithmetic fluency. Second, RAN, speed of processing, and working memory had both direct and indirect effects (via reading and arithmetic accuracy) on the covariation of reading and arithmetic fluency. Irrespective of how reading and arithmetic fluency were treated in the analyses, the effects of non-verbal IQ, phonological awareness, and number sense were all indirect. Taken together, these findings suggest that reading and arithmetic fluency draw on a broader network of cognitive-linguistic skills, whose effects can sometimes be indirect through reading and arithmetic accuracy.

Transdifferentiation of mantle cell lymphoma into sarcoma with limited neuromuscular differentiation after conventional chemotherapy

We report an exceptionally rare case of mantle cell lymphoma (MCL) that transdifferentiated into sarcoma with limited neuromuscular differentiation. An 81-year-old man with t(11;14)-positive MCL was treated with rituximab and bendamustine and achieved complete remission; however, just 2 months later, the patient developed multiple systemic tumors. Pathologic studies revealed round cell sarcoma expressing synaptophysin, CD56, and myogenin without any B-cell markers. The CCND1 translocation and an identical IGL gene rearrangement were shared by both the MCL and sarcoma. Whole-exome sequencing detected 189 single nucleotide variants (SNVs) in the MCL and 205 SNVs in the sarcoma; 160 SNVs including NSD2, ATM, RB1, and TP53 mutations were shared between MCL and sarcoma cells. An additional PTPN11 mutation was specifically found in the sarcoma. These findings confirmed the shared clonal origin of MCL and sarcoma in this patient and indicated that MCL can transdifferentiate into sarcoma in rare cases.

Anterior transpetrosal resection of the lower ventral pontine cavernous malformation: A technical case report with operative video

Background

Surgical treatment of pontine cavernous malformations (CMs) is challenging due to the anatomical difficulties and potential risks involved. We successfully applied an anterior transpetrosal approach (ATPA) to remove a lower ventral pontine CM, and herein we discuss the outline of our procedure accompanied by a surgical video.

Case Description

A 50-year-old woman presenting with progressively worsening diplopia was urgently admitted to our hospital. Preoperative images showed a lower ventral pontine CM compressing the corticospinal tract posteriorly. Considering the location of the CM, we determined that an ATPA was the appropriate approach to achieve a more anterolateral trajectory. We performed extradural anteromedial petrosectomy and penetrated the brainstem from the point just below the anterior inferior cerebellar artery and above the root exit zone of the abducens nerve, which might be located in the somewhat lowest border of actual maneuverability in the ATPA. Maneuverability through this corridor was sufficient without hindering and darkening the high magnification microscopic view, as demonstrated in our surgical video.

Conclusion

This report demonstrates surgical treatment of a lower ventral pontine CM using the ATPA. The surgical video we present provides information that is useful for understanding this technique's maneuverability and working window.

Management of brain metastasis from eccrine porocarcinoma: illustrative case

BACKGROUND

Eccrine porocarcinoma (EP) is a rare malignant skin neoplasm, and there are still many unknowns regarding its natural history and treatment. Due to its scarcity, associated brain metastasis is a far rarer condition.

OBSERVATIONS

A 71-year-old-woman with a history of EP was diagnosed with brain metastasis. In her clinical course, the patient underwent tumor removal surgery twice and Gamma Knife radiosurgery (GKRS) four times. The tumor showed a good response to radiotherapy. The histopathological findings of the brain tumor were consistent with those of the primary skin tumor.

LESSONS

There are only a few case reports referring to the detailed treatment, especially with GKRS, of brain metastasis from EP. Few reports have presented a detailed histopathological comparison between the primary skin lesion and the metastatic brain lesion. Herein, the authors have described the clinical course, histological features, and results of multidisciplinary treatment for brain metastasis of EP.

Expressions of CXCL12, CXCL10 and CCL18 in Warthin tumors characterized pathologically by having a lymphoid stroma with germinal centers

The Warthin tumor is a benign neoplasm of the salivary glands, histologically, the tumor has an oncocytic epithelial component forming uniform rows of cells surrounded by cystic spaces associated with a lymphoid stroma often showing the presence of germinal centers. The lymphoid stroma is a representative microscopic finding. If this lymphocytic accumulation is active, some sort of transmitter should exist between the Warthin tumor cells and lymphocytes. C-X-C motif chemokine ligand (CXCL12) 12, CXCL10 and C-C motif chemokine ligand 18 (CCL18) are a chemoattractant for lymphocytes in vivo. There is no report on the relationship between these chemokines and Warthin tumors. In this study, we investigated these chemokines expressions in 20 Warthin tumors using immunohistochemistry and reverse transcription polymerase chain reaction (RT-PCR). For comparison, we also enrolled samples of pleomorphic adenoma, which is another benign salivary gland tumor type without prominent lymphocytic infiltration. All Warthin tumors were immunopositive for CXCL12 and CXCL10, and these reactivities were diffuse. Meanwhile, the majority of pleomorphic adenomas were immunonegative for CXCL12 (95%), CXCL10 (80%) and CCL18 (85%). Warthin tumor and pleomorphic adenoma cases were significantly different in these immunostaining expressions (CXCL12, p<0.001; CXCL10, p<0.001; CCL18, p=0.024). We examined CXCL12, CXCL10 and CCL18 mRNA expressions of 3 representative Warthin tumor samples, each having these chemokines immunopositive areas detected by RT-PCR. Finding CXCL12 and CXCL10 expressions indicate that these chemokines may play a part in the formation of a lymphoid stroma within Warthin tumors. In regards to this phenomenon, the participation of CCL18 might be restrictive compared to CXCL12 and CXCL10.

Significant therapeutic effectiveness of durvalumab after chemoradiotherapy for a patient with post-operative recurrent pulmonary pleomorphic carcinoma

Pulmonary pleomorphic carcinoma (PPC) is a poorly differentiated non-small cell lung cancer. Because of its rarity, no standard therapy has been established for advanced disease. We herein report on a 62-year-old man with recurrent post-operative PPC, for whom durvalumab after chemoradiotherapy was effective. He was referred to our hospital because of an abnormal shadow in the right upper lung on chest X-ray. After surgical resection was performed, the imaging and histopathological findings revealed PPC (T4N0M0, stage IIIA) with elevated expression of programmed cell death-ligand 1 (PD-L1). A metastasis was found in the left hemithorax 22 months later, and chemoradiotherapy consisting of 60 Gy of radiation and cisplatin plus tegafur/gimeracil/oteracil potassium was administered. Durvalumab was then begun as consolidation therapy. The efficacy of the treatments has continued for longer than 10 months. This case suggests that multidisciplinary treatment with chemoradiotherapy and consolidation immunotherapy may improve the prognosis of locally advanced PPC.

Developmental Relations Between Home Literacy Environment, Reading Interest, and Reading Skills: Evidence From a 3-Year Longitudinal Study

We examined the bidirectional relations between home literacy environment, reading interest, and children's emergent literacy and reading skills in a sample of 172 English-speaking Canadian children (M_age  = 75.87 months) followed from Grade 1 to Grade 3. Results of cross-lagged analysis revealed that the reading comprehension activities (RCA) at home positively predicted children's reading skills at the end of Grade 2 and the reading skills negatively predicted the RCA in Grade 3. Parent-rated reading interest was bidirectionally related to reading skills, whereas child-rated reading interest was only predicted by earlier reading skills, but not vice versa. These findings suggest that parents are sensitive to their children's reading performance and modify their involvement accordingly.

Acute myeloid leukaemia presenting with ecthyma gangrenosum as the first manifestation: A case report

RATIONALE

Ecthyma gangrenosum (EG) is an uncommon cutaneous infection usually associated with Pseudomonas aeruginosa bacteremia in immunocompromised patients, particularly those with underlying malignant diseases. Despite its rarity, especially in immunocompetent or nondiagnosed immunodeficiency patients, EG can present as the first manifestation of an underlying immunosuppression.

PATIENT CONCERNS

A 42-year-old Japanese man was admitted to our hospital with a 3-day history of a painless red macule on his right forearm and fever.

DIAGNOSES

Blood culture on admission revealed the presence of Pseudomonas aeruginosa, whereas pus culture of the skin lesion showed Pseudomonas aeruginosa and methicillin-susceptible Staphylococcus aureus positivity.

INTERVENTIONS

Additional bone marrow aspirate examination and immunophenotyping were performed to confirm the diagnosis of acute promyelocytic leukaemia with PML-retinoic acid alpha receptor.

OUTCOMES

The patient was successfully treated with a 14-day course of antibiotics, and no evidence of relapse was noted. The patient achieved complete remission after treatment for acute promyelocytic leukaemia.

LESSONS

It should be kept in mind that EG is an important cutaneous infection that is typically associated with P aeruginosa bacteremia and the presence of underlying immunodeficiency, such as acute leukaemia.

Comparison of postoperative temporalis muscle atrophy between the muscle-preserving pterional approach and the mini-pterional approach in the treatment of unruptured intracranial aneurysms

This study aimed to compare the muscle-preserving pterional approach (modified classic pterional approach, mCP) and the mini-pterional approach (mPA) with respect to postoperative temporalis muscle atrophy.From November 2013 to April 2020, 78 patients with unruptured intracranial aneurysm of the anterior circulation underwent surgery using mCP or mPA in our institution. Patients' background characteristics, postoperative complications, and temporalis muscle volume (MV) rates (operative side/healthy side) were retrospectively investigated. In 64 patients (n = 31, mCP group; n = 33, mPA group), excluding 14 patients with missing imaging data from 6 to 24 months after surgery, associations between the MV rate and clinical variables were assessed. A multiple regression model was used to examine the association between the MV rate and the surgical method, which is a predictor of postoperative atrophy.The mCP group had a significantly higher mean MV rate than the mPA group (0.955 ± 0.040 and 0.915 ± 0.070, respectively; p = 0.008). Based on the results of the univariate analysis, a multiple regression model was established using sex, age, follow-up period, and the presence of diabetes in addition to the surgical method. Patients who underwent mCP had a higher MV rate than those who underwent mPA (t value = 2.33, p = 0.023).The present result suggested that mCP has a preventive effect on postoperative temporalis muscle atrophy. However, further studies are needed in order to prove that mCP is also effective in terms of postoperative aesthetic and functional outcomes.