Temporal Muscle as an Indicator of Sarcopenia is Independently Associated with Hunt and Kosnik Grade on Admission and the Modified Rankin Scale Score at 6 Months of Patients with Subarachnoid Hemorrhage Treated by Endovascular Coiling

Changes in temporal muscle dimensions and their clinical impact in out-of-hospital cardiac arrest survivors

Objective

This study investigates temporal muscle atrophy in out-of-hospital cardiac arrest patients post-resuscitation, seeking associations with neurological outcomes and factors associated with atrophy.

Methods

Using data from six Japanese intensive care units, adult patients' post-resuscitation who underwent head computed tomography scans on admission and two to five days post-admission were assessed. Temporal muscle area, thickness, and density were quantified from a single cross-sectional image. Patients were categorized into 'atrophy' or 'no atrophy' groups based on median daily temporal muscle atrophy rates. The primary outcome was changes in temporal muscle dimensions between admission and follow-up two to five days later. Secondary outcomes included assessing the impact of temporal muscle atrophy on 30-day survival, as well as identifying any clinical factors associated with temporal muscle atrophy.

Results

A total of 185 patients were analyzed. Measurements at follow-up revealed significant decreases in temporal muscle area (214 vs. 191 mm2, p < 0.001), thickness (4.9 vs. 4.7 mm, p < 0.001), and density (46 vs. 44 HU, p < 0.001) compared to those at admission. The median daily rate for temporal muscle area atrophy was 2.0% per day. There was no significant association between temporal muscle atrophy and 30-day survival (hazard ratios, 0.71; 95% CI, 0.41-1.23, p = 0.231). Multivariable logistic regression found no clinical factors significantly associated with temporal muscle atrophy.

Conclusions

Temporal muscle atrophy in post-resuscitation patients occurs rapidly at 2.0% per day. However, there was no significant association with 30-day mortality or any identified clinical factors. Further investigation into its long-term functional implications is warranted.

Neutrophil-to-lymphocyte ratio associated with symptomatic saccular unruptured intracranial aneurysm

BACKGROUND AND PURPOSE

Whether symptomatic unruptured intracranial aneurysms (UIAs) lead to change in circulating inflammation remains unclear. This study aims to evaluate the role of hematological inflammatory indicators in predicting symptomatic UIA.

METHODS

Adult patients diagnosed with saccular intracranial aneurysm from March 2019 to September 2023 were recruited retrospectively. Clinical and laboratory data, including the white blood cells (WBC), neutral counts (NEUT), lymphocyte counts (LYM), and monocyte counts (MONO) of each patient, were collected. The neutrophil-to-lymphocyte ratio (NLR) and lymphocyte-to-monocyte ratio (LMR) were calculated as NLR = NEUT/LYM, LMR = LYM/MONO, SII = PLT*NEUT/LYM. The hematological inflammatory indicators were compared in symptomatic saccular and asymptomatic UIA patients. Multivariable logistic regression analyses were performed to explore the factors predicting symptomatic UIA.

RESULTS

One hundred and fifty UIA patients with a mean age of 58.5 ± 12.4 were included, of which 68% were females. The NLR and LMR were significantly associated with symptomatic UIA, and the association remained in small UIAs (< 7 mm). The multiple logistic regression analysis showed that NLR was independently associated with symptomatic UIA. On ROC curve analysis, the optimal cutoff value of NLR to differentiate symptomatic from asymptomatic was 2.38. In addition, LMR was significantly associated with symptomatic UIA smaller than 7 mm.

CONCLUSION

There was a significant correlation between NLR and symptomatic UIA. The NLR was independently associated with symptomatic UIA.

Initial Temporal Muscle Thickness and Area: Poor Predictors of Neurological Outcome in Aneurysmal Subarachnoid Hemorrhage in a Central European Patient Cohort

The temporalis muscle area (TMA) has been proclaimed as a surrogate parameter for estimating skeletal muscle mass. Pilot studies in Asian populations suggested temporal muscle thickness (TMT) and TMA as prognostic factors for neurological outcomes in aneurysmal subarachnoid hemorrhage (aSAH) patients. This study aimed to validate these findings in a larger European patient cohort. We retrospectively analyzed age, sex, aneurysm location, treatment, World Federation of Neurosurgical Societies (WFNS) grade, Fisher score, and modified Rankin Score (mRS) at six months in patients with aSAH. TMT and TMA measurements were obtained from initial native CT scans. Logistic regression with the dichotomized six-month mRS as the outcome incorporating TMT, weighted average of TMT, or TMA as predictors was performed. Of the included 478 patients, 66% were female, the mean age was 56, and 48% of patients had an mRS of three to six after six months. The mean TMT at the level of the Sylvian fissure was 5.9 (±1.7) mm in males and 4.8 (±1.8) mm in females. The mean TMA was 234.5 (±107.9) mm2 in females and 380 (±134.1) mm2 in males. WFNS grade (p < 0.001), Fisher score (p < 0.001), and age (p < 0.05) correlated significantly with the mRS after six months. No correlation was found between mRS after six months and the TMT at the Sylvian fissure (p = 0.3), the weighted average of TMT (p = 0.1), or the TMA (p = 0.1). In this central European patient cohort of 478 individuals, no significant associations were found between TMT/TMA and neurological outcomes following aSAH. Further prospective studies in diverse patient populations are necessary to determine the prognostic value of TMA and TMT in aSAH patients.

Temporal Muscle Thickness Correlates with Sarcopenia in Parkinson’s Disease

Background: Sarcopenia is characterized by a progressive loss of muscle mass, strength, and function resulting in adverse health outcomes. Current assessment strategies are bothersome and means to simplify the diagnosis are an unmet medical need in Parkinson’s disease (PD). Objective: To evaluate temporal muscle thickness (TMT) obtained on routine cranial MRI as a surrogate marker of sarcopenia in PD patients. Methods: We correlated TMT from axial non-contrast-enhanced T1-weighted sequences of MRI close (±12 months) to an outpatient visit including sarcopenia (EWGSOP1, EWGSOP2, SARC-F), frailty (Fried’s criteria, clinical frailty scale), and disease characteristics of Parkinson’s patients (Hoehn and Yahr-scale, Movement Disorder Society-Unified Parkinson’s Disease Rating Scale, quality of life with the Parkinson’s Disease Questionnaire-8) assessments. Results: Cranial MRI was available in 32 patients with a mean age of 73.56±5.14 years, mean disease duration of 11.46±5.66 years, and median Hoehn and Yahr stage of 2.5. The mean TMT was 7.49±2.76 (7.15) mm. Mean TMT was significantly associated with sarcopenia (EWGSOP2, p = 0.018; EWGSOP1, p = 0.023) and frailty status (physical phenotype; p = 0.045). Moreover, there were significant moderate to strong correlations between TMT measurement and appendicular skeletal muscle mass index (r: 0.437, p = 0.012), as well as handgrip strength (r: 0.561, p <  0.001). Conclusion: Reduced TMT seems to be a promising surrogate marker for sarcopenia (EWGSOP2) and muscle strength in this pilot study in PD patients.

Outcome measures in neurosurgery: Is a unified approach better? A literature review

Background

Accurate assessment and evaluation of health interventions are crucial to evidence-based care. The use of outcome measures in neurosurgery grew with the introduction of the Glasgow Coma Scale. Since then, various outcome measures have appeared, some of which are disease-specific and others more generally. This article aims to address the most widely used outcome measures in three major neurosurgery subspecialties, "vascular, traumatic, and oncologic," focusing on the potential, advantages, and drawbacks of a unified approach to these outcome measures.

Methods

A literature review search was conducted by using PubMed MEDLINE and Google scholar Databases. Data for the three most common outcome measures, The Modified Rankin Scale (mRS), The Glasgow Outcome Scale (GOS), and The Karnofsky Performance Scale (KPS), were extracted and analyzed.

Results

The original objective of establishing a standardized, common language for the accurate categorization, quantification, and evaluation of patients' outcomes has been eroded. The KPS, in particular, may provide a common ground for initiating a unified approach to outcome measures. With clinical testing and modification, it may offer a simple, internationally standardized approach to outcome measures in neurosurgery and elsewhere. Based on our analysis, Karnofsky's Performance Scale may provide a basis of reaching a unified global outcome measure.

Conclusion

Outcome measures in neurosurgery, including mRS, GOS, and KPS, are widely utilized assessment tools for patients' outcomes in various neurosurgical specialties. A unified global measure may offer solutions with ease of use and application; however, there are limitations.

Significance of Temporal Muscle Thickness in Chronic Subdural Hematoma

Background: Reduced temporal muscle thickness (TMT) was verified as an independent negative prognostic parameter for outcome in brain tumor patients. Independent thereof, chronic subdural hematoma (CSDH) is a neurosurgical condition with high recurrence rates and unreliable risk models for poor outcome. Since sarcopenia was associated with poor outcome, we investigated the possible role of TMT and the clinical course of CSDH patients. Methods: This investigation is a single-center retrospective study on patients with CSDH. We analyzed the radiological and clinical data sets of 171 patients with surgically treated CSDH at a University Hospital from 2017 to 2020. Results: Our analysis showed a significant association between low-volume TMT and increased hematoma volume (p < 0.001), poor outcome at discharge (p < 0.001), and reduced performance status at 3 months (p < 0.002). Conclusion: TMT may represent an objective prognostic parameter and assist the identification of vulnerable CSDH patients.

Use of Facial Morphology to Determine Nutritional Status in Older Adults: Opportunities and Challenges

Undiagnosed malnutrition is a significant problem in high-income countries, which can reduce the quality of life of many individuals, particularly of older adults. Moreover, it can also inflate the costs of existing health care systems because of the many metabolic complications that it can cause. The current methods for assessing malnutrition can be cumbersome. A trained practitioner must be present to conduct an assessment, or patients must travel to facilities with specialized equipment to obtain their measurements. Therefore, digital health care is a possible way of closing this gap as it is rapidly gaining traction as a scalable means of improving efficiency in the health care system. It allows for the remote monitoring of nutritional status without requiring the physical presence of practitioners or the use of advanced medical equipment. As such, there is an increasing interest in expanding the range of digital applications to facilitate remote monitoring and management of health issues. In this study, we discuss the feasibility of a novel digital remote method for diagnosing malnutrition using facial morphometrics. Many malnutrition screening assessments include subjective assessments of the head and the face. Facial appearance is often used by clinicians as the first point of qualitative indication of health status. Hence, there may be merit in quantifying these subtle but observable changes using facial morphometrics. Modern advancements in artificial intelligence, data science, sensors, and computing technologies allow facial features to be accurately digitized, which could potentially allow these previously intuitive assessments to be quantified. This study aims to stimulate further discussion and discourse on how this emerging technology can be used to provide real-time access to nutritional status. The use of facial morphometrics extends the use of currently available technology and may provide a scalable, easily deployable solution for nutritional status to be monitored in real time. This will enable clinicians and dietitians to keep track of patients remotely and provide the necessary intervention measures as required, as well as providing health care institutions and policy makers with essential information that can be used to inform and enable targeted public health approaches within affected populations.

Relevance of presenting risks of frailty, sarcopaenia and osteopaenia to outcomes from aneurysmal subarachnoid haemorrhage

INTRODUCTION

Aneurysmal subarachnoid haemorrhage (aSAH) is a condition with significant morbidity and mortality. Traditional markers of aSAH have established their utility in the prediction of aSAH outcomes while frailty markers have been validated in other surgical specialties. We aimed to compare the predictive value of frailty indices and markers of sarcopaenia and osteopaenia, against the traditional markers for aSAH outcomes.

METHODS

An observational study in a tertiary neurosurgical unit on 51 consecutive patients with ruptured aSAH was performed. The best performing marker in predicting the modified Rankin scale (mRS) on discharge was selected and an appropriate threshold for the definition of frail and non-frail was derived. We compared various frailty indices (modified frailty index 11, and 5, and the National Surgical Quality Improvement Program score [NSQIP]) and markers of sarcopaenia and osteopaenia (temporalis [TMT] and zygoma thickness), against traditional markers (age, World Federation of Neurological Surgery and modified Fisher scale [MFS]) for aSAH outcomes. Univariable and multivariable analysis was then performed for various inpatient and long-term outcomes.

RESULTS

TMT was the best performing marker in our cohort with an AUC of 0.82, Somers' D statistic of 0.63 and Tau statistic 0.25. Of the frailty scores, the NSQIP performed the best (AUC 0.69), at levels comparable to traditional markers of aSAH, such as MFS (AUC 0.68). The threshold of 5.5 mm in TMT thickness was found to have a specificity of 0.93, sensitivity of 0.51, positive predictive value of 0.95 and negative predictive value of 0.42. After multivariate analysis, patients with TMT ≥ 5.5 mm (defined as non-frail), were less likely to experience delayed cerebral ischaemia (OR 0.11 [0.01 - 0.93], p = 0.042), any complications (OR 0.20 [0.06 - 0.069], p = 0.011), and had a larger proportion of favourable mRS on discharge (95.0% vs. 58.1%, p = 0.024) and at 3-months (95.0% vs. 64.5%, p = 0.048). However, the gap between unfavourable and favourable mRS was insignificant at the comparison of 1-year outcomes.

CONCLUSION

TMT, as a marker of sarcopaenia, correlated well with the presenting status, and outcomes of aSAH. Frailty, as defined by NSQIP, performed at levels equivalent to aSAH scores of clinical relevance, suggesting that, in patients presenting with acute brain injury, both non-neurological and neurological factors were complementary in the determination of eventual clinical outcomes. Further validation of these markers, in addition to exploration of other relevant frailty indices, may help to better prognosticate aSAH outcomes and allow for a precision medicine approach to decision making and optimization of best outcomes.

Skeletal muscle atrophy and myosteatosis are not related to long-term aneurysmal subarachnoid hemorrhage outcome

The prognosis of aneurysmal subarachnoid hemorrhage (aSAH) is highly variable. This study aims to investigate whether skeletal muscle atrophy and myosteatosis are associated with poor outcome after aSAH. In this study, a cohort of 293 consecutive aSAH-patients admitted during a 4-year period was retrospectively analyzed. Cross-sectional muscle measurements were obtained at the level of the third cervical vertebra. Muscle atrophy was defined by a sex-specific cutoff value. Myosteatosis was defined by a BMI-specific cutoff value. Poor neurological outcome was defined as modified Rankin Scale 4-6 at 2 and 6-month follow-up. Patient survival state was checked until January 2021. Generalized estimating equation was performed to assess the effect of muscle atrophy / myosteatosis on poor neurological outcome after aSAH. Cox regression was performed to analyze the impact of muscle atrophy and myosteatosis on overall survival. The study found that myosteatosis was associated with poor neurological condition (WFNS 4-5) at admission after adjusting for covariates (odds ratio [OR] 2.01; 95%CI 1.05,3.83; P = .03). It was not associated with overall survival (P = .89) or with poor neurological outcomes (P = .18) when adjusted for other prognostic markers. Muscle atrophy was not associated with overall survival (P = .58) or neurological outcome (P = .32) after aSAH. In conclusion, myosteatosis was found to be associated with poor physical condition directly after onset of aSAH. Skeletal muscle atrophy and myosteatosis were however irrelevant to outcome in the Western-European aSAH patient. Future studies are needed to validate these finding.

Temporal Muscle and Stroke-A Narrative Review on Current Meaning and Clinical Applications of Temporal Muscle Thickness, Area, and Volume

BACKGROUND

Evaluating muscle mass and function among stroke patients is important. However, evaluating muscle volume and function is not easy due to the disturbances of consciousness and paresis. Temporal muscle thickness (TMT) has been introduced as a novel surrogate marker for muscle mass, function, and nutritional status. We herein performed a narrative literature review on temporal muscle and stroke to understand the current meaning of TMT in clinical stroke practice.

METHODS

The search was performed in PubMed, last updated in October 2021. Reports on temporal muscle morphomics and stroke-related diseases or clinical entities were collected.

RESULTS

Four studies reported on TMT and subarachnoid hemorrhage, two studies on intracerebral hemorrhage, two studies on ischemic stroke, two studies on standard TMT values, and two studies on nutritional status. TMT was reported as a prognostic factor for several diseases, a surrogate marker for skeletal muscle mass, and an indicator of nutritional status. Computed tomography, magnetic resonance imaging, and ultrasonography were used to measure TMT.

CONCLUSIONS

TMT is gradually being used as a prognostic factor for stroke or a surrogate marker for skeletal muscle mass and nutritional status. The establishment of standard methods to measure TMT and large prospective studies to further investigate the relationship between TMT and diseases are needed.

Sarcopenia in patients with dementia: correlation of temporalis muscle thickness with appendicular muscle mass

Cognitive decline is one of the most relevant signs of sarcopenia; however, it is challenging to perform tests for sarcopenia in patients with dementia. In a recent study, temporalis muscle thickness (TMT), an alternative to appendicular muscle mass (ASM), was found to be a valid index for screening sarcopenia. This study aimed to determine whether TMT correlates with ASM and evaluate the relationship between TMT and cognitive function in dementia patients. We recruited patients with a complaint of memory loss who visited the Memory Clinic of Konkuk University Medical Center between November 2014 and December 2020. Patients with probable Alzheimer's disease (AD) without weakness were included. TMT was measured on axial T1-weighted magnetic resonance (MR) images, perpendicular to the long axis of the temporal muscle, at the orbital roof level. ASM was measured using body dual-energy X-ray absorptiometry (DXA). It was calculated as the sum of lean soft tissue mass in the arms and legs, and the value by ASM divided by height squared was used. Inter-rater reliability and intra-rater reliability were good and excellent, respectively. We found a correlation between TMT and skeletal ASM, which was obtained from cranial MR images and DXA, respectively (r = 0.379, p = 0.001). TMT was negatively correlated with age (r =  - 0.296, p = 0.014) and positively correlated with body mass index (BMI) (r = 0.303, p = 0.012). Additionally, TMT was correlated with MMSE (r = 0.350, p = 0.003). After adjusting for educational years, there was still a correlation between TMT and MMSE (r = 0.256, p = 0.038). This study demonstrated that TMT correlates with ASM and cognitive function in patients with dementia. Measuring TMT using cranial MR images could help diagnose sarcopenia accessibly and assess cognitive function in patients with dementia.

Temporal muscle thickness as a prognostic marker in newly diagnosed glioblastoma patients: translational imaging analysis of the CENTRIC EORTC 26071-22072 and CORE trials

PURPOSE

To investigate the prognostic relevance of temporal muscle thickness (TMT) as a surrogate parameter of skeletal muscle status in patients with newly diagnosed glioblastoma.

METHODS

We assessed TMT in cranial magnetic resonance images (MRI) of 755 patients enrolled in the CENTRIC EORTC 26071-22072 study (n=508) and CORE study (n=247). We used predefined sex-specific TMT cutoff values to categorize "patients at risk of sarcopenia" and "patients with normal muscle status" at baseline. Furthermore, we categorized patients according to the extent of TMT loss over time. Associations with progression-free survival (PFS) and overall survival (OS) were evaluated using the Cox model adjusted for other exploratory variables.

RESULTS

Patients at risk of sarcopenia (CENTRIC; n=158/508, 31.1%; CORE; n=87/247, 35.2%) at baseline had significantly higher risk of progression and death than patients with normal muscle status in both study cohorts (CENTRIC: PFS=HR 0.16, 95% CI: 0.12, 0.21, p<0.001; OS=HR 0.341, 95% CI: 0.27, 0.44, p < 0.001; CORE: PFS=HR 0.29, 95% CI: 0.21, 0.39, p<0.001; OS=HR 0.365, 95% CI: 0.27, 0.49, p<0.001). Similar results were obtained in multivariate Cox models adjusted for other important prognostic parameters. The extent of TMT loss over time showed a significant inverse correlation with median OS times in patients at risk for sarcopenia (CENTRIC: p<0.001, CORE: p=0.005), but not in patients with normal baseline muscle mass (CENTRIC: p=0.538, CORE: p=0.28).

CONCLUSION

TMT identifies ambulatory patients with newly diagnosed glioblastoma at risk for progressive sarcopenia and adverse outcomes. Early intervention may prevent skeletal muscle loss and improve patient outcome.

Deep Learning-Based Functional Independence Measure Score Prediction After Stroke in Kaifukuki (Convalescent) Rehabilitation Ward Annexed to Acute Care Hospital

Introduction

Prediction models of functional independent measure (FIM) score after kaifukuki (convalescent) rehabilitation ward (KRW) are needed to decide the treatment strategies and save medical resources. Statistical models were reported, but their accuracies were not satisfactory. We made such prediction models using the deep learning (DL) framework, Prediction One (Sony Network Communications Inc., Tokyo, Japan).

Methods

Of the 559 consecutive stroke patients, 122 patients were transferred to our KRW. We divided our 122 patients’ data randomly into halves of training and validation datasets. Prediction One made three prediction models from the training dataset using (1) variables at the acute care ward admission, (2) those at the KRW admission, and (3) those combined (1) and (2). The models’ determination coefficients (R²), correlation coefficients (rs), and residuals were calculated using the validation dataset.

Results

Of the 122 patients, the median age was 71, length of stay (LOS) in acute care ward 23 (17-30) days, LOS in KRW 53 days, total FIM scores at the admission of KRW 85, those at discharge 108. The mean FIM gain and FIM efficiency were 19 and 0.417. All patients were discharged home. Model (1), (2), and (3)’s R² were 0.794, 0.970, and 0.972. Their mean residuals between the predicted and actual total FIM scores were -1.56±24.6, -4.49±17.1, and -2.69±15.7.

Conclusion

Our FIM gain and efficiency were better than national averages of FIM gain 17.1 and FIM efficiency 0.187. We made DL-based total FIM score prediction models, and their accuracies were superior to those of previous statistically calculated ones. The DL-based FIM score prediction models would save medical costs and perform efficient stroke and rehabilitation medicine.

A novel radiographic marker of sarcopenia with prognostic value in glioblastoma

OBJECTIVE

Sarcopenia is an important prognostic consideration in surgical oncology that has received relatively little attention in brain tumor patients. Temporal muscle thickness (TMT) has recently been proposed as a novel radiographic marker of sarcopenia that can be efficiently obtained within existing workflows. We investigated the prognostic value of TMT in primary and progressive glioblastoma.

METHODS

TMT measurements were performed on magnetic resonance images of 384 patients undergoing 541 surgeries for glioblastoma. Relationships between TMT and clinical characteristics were examined on bivariate analysis. Optimal TMT cutpoints were established using maximally selected rank statistics. Predictive value of TMT upon postoperative survival (PS) was assessed using Cox proportional hazards regression adjusted for age, sex, Karnofsky performance status (KPS), Stupp protocol completion, extent of resection, and tumor molecular markers.

RESULTS

Average TMT for the primary and progressive glioblastoma cohorts was 9.55 mm and 9.40 mm, respectively. TMT was associated with age (r = -0.14, p = 0.0008), BMI (r = 0.29, p < 0.0001), albumin (r = 0.11, p = 0.0239), and KPS (r = 0.11, p = 0.0101). Optimal TMT cutpoints for the primary and progressive cohorts were ≤ 7.15 mm and ≤ 7.10 mm, respectively. High TMT was associated with increased Stupp protocol completion (p = 0.001). On Cox proportional hazards regression, high TMT predicted increased PS in progressive [HR 0.47 (95% confidence interval (CI)) 0.25-0.90), p = 0.023] but not primary [HR 0.99 (95% CI 0.64-1.51), p = 0.949] glioblastoma.

CONCLUSIONS

TMT correlates with important prognostic variables in glioblastoma and predicts PS in patients with progressive, but not primary, disease. TMT may represent a pragmatic neurosurgical biomarker in glioblastoma that could inform treatment planning and perioperative optimization.

Easily Created Prediction Model Using Automated Artificial Intelligence Framework (Prediction One, Sony Network Communications Inc., Tokyo, Japan) for Subarachnoid Hemorrhage Outcomes Treated by Coiling and Delayed Cerebral Ischemia

Introduction Reliable prediction models of subarachnoid hemorrhage (SAH) outcomes and delayed cerebral ischemia (DCI) are needed to decide the treatment strategy. Automated artificial intelligence (AutoAI) is attractive, but there are few reports on AutoAI-based models for SAH functional outcomes and DCI. We herein made models using an AutoAI framework, Prediction One (Sony Network Communications Inc., Tokyo, Japan), and compared it to other previous statistical prediction scores. Methods We used an open dataset of 298 SAH patients, who were with non-severe neurological grade and treated by coiling. Modified Rankin Scale 0-3 at six months was defined as a favorable functional outcome and DCI occurrence as another outcome. We randomly divided them into a 248-patient training dataset and a 50-patient test dataset. Prediction One made the model using training dataset with 5-fold cross-validation. We evaluated the model using the test dataset and compared the area under the curves (AUCs) of the created models. Those of the modified SAFIRE score and the Fisher computed tomography (CT) scale to predict the outcomes. Results The AUCs of the AutoAI-based models for functional outcome in the training and test dataset were 0.994 and 0.801, and those for the DCI occurrence were 0.969 and 0.650. AUCs for functional outcome calculated using modified SAFIRE score were 0.844 and 0.892. Those for the DCI occurrence calculated using the Fisher CT scale were 0.577 and 0.544. Conclusions We easily and quickly made AutoAI-based prediction models. The models' AUCs were not inferior to the previous prediction models despite the easiness.

Temporal muscle thickness is associated with the severity of dysphagia in patients with acute stroke

BACKGROUND

Post-stroke dysphagia is a common and expensive complication of acute stroke. The relationship between dysphagia and skeletal muscle loss (sarcopenia) has been recently highlighted. This study aimed to determine the relationship between temporal muscle thickness (TMT) measured by head magnetic resonance imaging (MRI) and dysphagia in patients with acute stroke.

METHODS

Seventy participants (43 men and 27 women; mean age, 75.6 ± 12.7 years) were included in this study. TMT was measured by T2-magnetic resonance images within seven days of hospitalization. The severity of dysphagia was assessed using the Functional Oral Intake Scale (FOIS). Participants were classified into three categories according to the severity of dysphagia (severe: FOIS score, 1-3; mild: FOIS score, 4-6; normal: FOIS score, 7). Linear regression analysis was used to determine the independent explanators of dysphagia severity.

RESULTS

Twenty participants (28.6%) had severe dysphagia, 31 participants (44.3%) had mild dysphagia, and 19 participants (27.1%) had normal swallowing function at discharge. The results of the linear regression analysis showed that TMT was a significant explanator of dysphagia severity following stroke, along with age and National Institute of Health Stroke Scale (NIHSS) score (P < 0.05, effect size: f² = 0.72).

CONCLUSIONS

TMT was an independent risk factor for dysphagia in patients with acute stroke. Skeletal muscle loss may be secondarily involved in dysphagia with acute stroke, and measurement of TMT with head MRI is a useful method to assess skeletal muscle loss.

Chronic subdural hematoma in patients over 65 years old: Results of using a postoperative cognitive evaluation to determine whether to permit return to driving

Background:

Chronic subdural hematoma (CSDH) is usually associated with good recovery with burr hole irrigation and postoperative drainage under local anesthesia. In Japan, traffic accidents by the elderly drivers over 65 years old are severely increasing, and there is no consensus on whether or not to return to driving after CSDH treatment. We perform a postoperative cognitive assessment. We retrospectively investigated the return-to-driving rate and associated factors.

Methods:

Of the 45 patients over 65 y.o. and who had usually driven, 30 patients wished to drive again. We performed tests composed of Mini-Mental State Examination (MMSE), line cancellation and line bisection task, Kohs block design test, trail making test (TMT)-A and B, Kana-hiroi test, Rey-Osterrieth complex figure test, and behavioral assessment of the dysexecutive syndrome, in order. When all tests’ scores were better than the cutoff values, we let patients drive again. When some of the scores were worse than the cutoff values, we reevaluated the patients at the outpatient every month. If the patients’ scores could not improve at the outpatient, we recommended them to stop driving.

Results:

Nineteen of 30 patients could return to driving. Worse MMSE, Kohs block design test, TMT-A, TMT-B scores, higher age, dementia, or consciousness disturbance as chief complaints were associated with driving disability.

Conclusion:

CSDH is known as treatable dementia. However, we should perform an objective cognitive assessment before discharge because only 63% of the patients over 65 y.o. who wished to drive could return to driving.

Postsurgical functional outcome prediction model using deep learning framework (Prediction One, Sony Network Communications Inc.) for hypertensive intracerebral hemorrhage

BACKGROUND

Reliable prediction models of intracerebral hemorrhage (ICH) outcomes are needed for decision-making of the treatment. Statistically making such prediction models needs a large number of samples and time-consuming statistical analysis. Deep learning (DL), one of the artificial intelligence, is attractive, but there were no reports on DL-based functional outcome prediction models for ICH outcomes after surgery. We herein made a functional outcome prediction model using DLframework, Prediction One (Sony Network Communications Inc., Tokyo, Japan), and compared it to original ICH score, ICH Grading Scale, and FUNC score.

METHODS

We used 140 consecutive hypertensive ICH patients' data in our hospital between 2012 and 2019. All patients were surgically treated. Modified Rankin Scale 0-3 at 6 months was defined as a favorable outcome. We randomly divided them into 100 patients training dataset and 40 patients validation dataset. Prediction One made the prediction model using the training dataset with 5-fold cross-validation. We calculated area under the curves (AUCs) regarding the outcome using the DL-based model, ICH score, ICH Grading Scale, and FUNC score. The AUCs were compared.

RESULTS

The model made by Prediction One using 64 variables had AUC of 0.997 in the training dataset and that of 0.884 in the validation dataset. These AUCs were superior to those derived from ICH score, ICH Grading Scale, and FUNC score.

CONCLUSION

We easily and quickly made prediction models using Prediction One, even with a small single-center dataset. The accuracy of the DL-based model was superior to those of previous statistically calculated models.

Temporal muscle thickness and area are an independent prognostic factors in patients aged 75 or younger with aneurysmal subarachnoid hemorrhage treated by clipping

BACKGROUND

Skeletal muscle mass is an important factor for various diseases' outcomes. As for its indicators, temporal muscle thickness (TMT) and temporal muscle area (TMA) on the head computed tomography are useful, and TMT and TMA were reported as potential prognostic factors for aneurysmal subarachnoid hemorrhage (SAH). We examined the clinical characteristics, including TMT and TMA, of SAH patients aged 75 or younger.

METHODS

We retrospectively investigated 127 SAH patients with all World Federation of Neurosurgical Societies (WFNS) grades and treated by clipping between 2009 and 2019. Clinical outcome was measured with the modified Rankin Scale (mRS) at 6 months, with favorable outcome defined as mRS 0-2. The associations between the clinical variables and the outcomes were analyzed.

RESULTS

The mean age was 60.6 (32-74) years, and 65% were women. The mean ± standard deviation of WFNS grade was 2.8 ± 1.4. TMT and TMA were larger in the favorable outcome group than the poor one. Multivariate analysis revealed that age, smoking, WFNS grade, and TMT or TMA were associated with favorable outcome. Receiver operating characteristic analysis found that the threshold of TMT was 4.9 mm in female and 6.7 mm in male, and that of TMA was 193 mm2 in female and 333 mm2 in male.

CONCLUSION

The odds ratios for TMT and TMA related to clinical outcome were lower than for smoking and WFNS grade; however, on multivariate analysis they remained independent prognostic factors in SAH patients aged 75 or younger treated by clipping. Further studies are needed to confirm these findings.

Measuring and Monitoring Skeletal Muscle Mass after Stroke: A Review of Current Methods and Clinical Applications

OBJECTIVES

Muscle mass at admission is important to survive stroke, and stroke-induced sarcopenia is a serious problem because of its poor prognosis. Muscle mass measurement and monitoring are essential for appropriate rehabilitation and nutrition management. However, few reviews are available about the muscle mass measurement and monitoring after stroke.

MATERIAL AND METHODS

Several methods are used to assess skeletal muscle mass in stroke, such as computed tomography (CT), ultrasound, bioelectrical impedance analysis, dual-energy X-ray absorptiometry, biomarkers, and anthropometrics. We summarized the current methods and clinical applications in stroke.

RESULTS

In stroke, a head CT is used to estimate muscle mass by measuring the temporal muscle. However, it can be conducted retrospectively due to radiation exposure. After stroke, limb muscle atrophy and diaphragm dysfunction are observed using ultrasound. However, ultrasound requires an understanding of the methods and skill. A bioelectrical impedance analysis can be used to assess muscle mass in patients after a stroke unless they have dynamic fluid changes. Dual-energy X-ray absorptiometry is used for follow-up after hospital discharge. Urinary titin N-fragment and serum C-terminal agrin fragment reflect muscle atrophy after stroke. Anthropometrics may be useful with limited resources.

CONCLUSIONS

We summarized the features of each measurement and proved the recent evidence to properly measure and monitor skeletal muscle mass after stroke.

Standard values for temporal muscle thickness in the Japanese population who undergo brain check-up by magnetic resonance imaging

BACKGROUND

Skeletal muscle mass is an important factor for various diseases' outcomes. The psoas muscle cross-sectional area on the abdominal computed tomography (CT), gait speed, and handgrip strength is used to measure it. However, it is difficult to measure the neurological patients' muscle mass or function because (1) we do not perform abdominal CT. (2) Such patients have impaired consciousness, gait disturbance, paresis, and need of rest. Temporal muscle thickness (TMT) on magnetic resonance imaging (MRI) is now attractive for skeletal muscle volume indicator, but the reference values are not established. We herein investigated the standard value of the Japanese TMT using the brain check-up database by MRI.

METHODS

We retrospectively investigated 360 Japanese individuals from two institutions between 2017 and 2019. We measured TMT on the T1-weighted images in the previously reported way. The associations between TMT and other variables were analyzed.

RESULTS

TMT of 214 women and 146 men, ranging from 35 to 84 years old, was investigated. TMT ranged from 3.69 to 16.90 mm. Mean TMT values were significantly higher in men compared to women except for the over 70-year-old cohort. TMT was correlated to weight and body mass index in both sexes.

CONCLUSION

This is the first retrospective study on the standard TMT values from the Japanese brain check-up database. Our results were just reference values, but these would be useful for further investigation in other neurosurgical and neurological diseases regarding muscle volume or sarcopenia.

High protein intake after subarachnoid hemorrhage improves oral intake and temporal muscle volume

BACKGROUND & AIMS

Dysphagia is a common sequela following stroke. Patients with subarachnoid hemorrhage (SAH) often develop atrophy of the temporal muscle, but its clinical significance remains unclear. This study aimed to investigate whether temporal muscle volume (TMV) is related to subsequent oral intake in patients with SAH and evaluate the predictors of temporal muscle atrophy.

METHODS

We performed a retrospective analysis of 60 SAH patients receiving enteral nutrition in the acute hospitalization phase at a single center between 2009 and 2019. The TMV was segmented automatically from computed tomography images and measured on admission and at week 2. Patients with a ≥20% TMV reduction were assigned to the atrophy group (n = 24) and those with a <20% TMV reduction were included in the maintenance group (n = 36). The patients' oral intake status was assessed at week 2 using the Food Intake LEVEL Scale (grade of 7-9 considered good ingestion), and the modified Rankin scale (mRS) was used at discharge (grade of 0-2 considered good prognosis). Additional data on age, sex, body mass index, severity of SAH, and protein intake were collected on day 4.

RESULTS

The maintenance group had significantly better oral intake and mRS scores compared to the atrophy group. TMV maintenance significantly affected oral intake at week 2 and the mRS score at discharge. Multivariable logistic regression analysis revealed that protein intake on day 4 significantly influenced the maintenance of TMV.

CONCLUSIONS

High protein nutrition in the acute stage of SAH contributes to temporal muscle maintenance and improves oral intake.

Reliability and validity of measuring temporal muscle thickness as the evaluation of sarcopenia risk and the relationship with functional outcome in older patients with acute stroke

BACKGROUND

Pre-stroke sarcopenia associated with poor functional outcomes. However, diagnosis of pre-stroke sarcopenia is often difficult in patients with acute stroke. Thus, we investigated the reliability and validity of measuring temporal muscle thickness (TMT) as an indicator of sarcopenia risk and its relationship with functional outcome in older patients with acute stroke.

METHODS

We conducted a cross-sectional and longitudinal study of the patients with acute elderly stroke in a single neurosurgical hospital. We measured TMT manually using brain computed tomography (CT) by two examiners. Sarcopenia risk, malnutrition risk, inflammation, comorbidities, and modified Rankin Scale (mRS) scores at 3 months after stroke were additionally assessed. Inter-rater reliability of TMT was determined by calculating the intra-class correlation coefficient ([ICC] _2,1). Multiple linear regression analyses was used to determine whether sarcopenia risk was independently associated with TMT, and logistic regression was used to evaluate the relationship between TMT and poor functional outcome (mRS > 3).

RESULTS

A total 289 acute elderly stroke patients (163 men and 126 women; mean age: 76 years) were enrolled in this study. Regarding the reproducibility of TMT, good reliability was found; ICC_2,1 = 0.759 (95 % confidence interval = 0.705-0.804). Multiple linear regression analyses for TMT after adjusting for potential confounders showed that sarcopenia risk was independently associated with TMT in older patients with acute stroke (β = -0.138, p = 0.02). After adjusting for variables, disease severity and comorbidities were the only independent predictors for poor functional outcome, but not TMT.

CONCLUSIONS

TMT measurement using brain CT is a reliable and variable method to evaluate sarcopenia risk, but is not related to functional outcome in older patients with acute stroke.

Easily created prediction model using deep learning software (Prediction One, Sony Network Communications Inc.) for subarachnoid hemorrhage outcomes from small dataset at admission

BACKGROUND

Reliable prediction models of subarachnoid hemorrhage (SAH) outcomes are needed for decision-making of the treatment. SAFIRE score using only four variables is a good prediction scoring system. However, making such prediction models needs a large number of samples and time-consuming statistical analysis. Deep learning (DL), one of the artificial intelligence, is attractive, but there were no reports on prediction models for SAH outcomes using DL. We herein made a prediction model using DL software, Prediction One (Sony Network Communications Inc., Tokyo, Japan) and compared it to SAFIRE score.

METHODS

We used 153 consecutive aneurysmal SAH patients data in our hospital between 2012 and 2019. Modified Rankin Scale (mRS) 0-3 at 6 months was defined as a favorable outcome. We randomly divided them into 102 patients training dataset and 51 patients external validation dataset. Prediction one made the prediction model using the training dataset with internal cross-validation. We used both the created model and SAFIRE score to predict the outcomes using the external validation set. The areas under the curve (AUCs) were compared.

RESULTS

The model made by Prediction One using 28 variables had AUC of 0.848, and its AUC for the validation dataset was 0.953 (95%CI 0.900-1.000). AUCs calculated using SAFIRE score were 0.875 for the training dataset and 0.960 for the validation dataset, respectively.

CONCLUSION

We easily and quickly made prediction models using Prediction One, even with a small single-center dataset. The accuracy of the model was not so inferior to those of previous statistically calculated prediction models.

The dataset on the characteristics of the intracerebral hemorrhage patients treated by endoscopic hematoma removal or craniotomy

These data present the characteristics of 148 intracerebral hemorrhage (ICH) patients surgically treated. We retrospectively collected data from the medical records of Suwa Red Cross Hospital, including neurological and physiological symptoms, laboratory data, radiological data on admission, complication rate, Glasgow Coma Scale scores on admission or postoperative day 7, and modified Rankin Scale scores at 6 months. Our two articles on the endoscopic hematoma removal and craniotomy for ICH were based on these data [1,2]. This dataset includes detailed laboratory data and radiological features, and it would be useful for reference value for other neurosurgeons or further analysis.

Endoscopic hematoma removal of supratentorial intracerebral hemorrhage under local anesthesia reduces operative time compared to craniotomy

The surgical efficacy for supratentorial intracerebral hemorrhage (ICH) remains unknown. We compared the advantages of the widely practiced endoscopic hematoma removal under local anesthesia with that of craniotomy under general anesthesia for ICH. We also focused on our novel operative concept of intentional hematoma leaving technique to avoid further damage to the brain. We retrospectively analyzed 134 consecutive patients (66 endoscopies and 68 craniotomies) who were surgically treated for supratentorial ICH. The characteristics of the 134 patients were as follows: The median (interquartile range) age was 73 (61-82) years. The median Glasgow Coma Scale scores at admission, on day 7, and the median modified Rankin Scale (mRS) score at 6 months were 10 (7-13), 13 (10-14), and 4 (3-5) respectively. The statistical comparison revealed there were no differences in GCS score on day seven between the endoscopy 13 (12-14) and craniotomy group 12 (9-14). No differences were observed in mRS scores at 6 months between the endoscopy 4 (2-5) and craniotomy group 4 (3-5). However, the patients treated with our technique tended to have favorable outcomes. Multivariate analysis revealed the operative time was significantly decreased in the endoscopy group compared to the craniotomy group (p < 0.001).

Temporal muscle thickness and area with various characteristics data of the patients with aneurysmal subarachnoid hemorrhage who underwent endovascular coiling

These data present the characteristics of patients with subarachnoid hemorrhage who underwent endovascular coiling. We retrospectively collected data from the medical records of Iwaki City Medical Center including physiological symptoms, laboratory data, radiological data on admission, and modified Rankin Scale scores at 6 months. Our article entitled “Temporal Muscle as an Indicator of Sarcopenia is Independently Associated with Hunt and Kosnik Grade on Admission and the Modified Rankin Scale at 6 Month of Patients with Subarachnoid Hemorrhage Treated by Endovascular Coiling” was based on these data [1]. We previously reported similar small dataset of elderly patients with subarachnoid hemorrhage who underwent surgical clipping [2], [3]. However, remarkably, this is the largest and the first dataset on temporal muscle thickness or area of patients of all ages with subarachnoid hemorrhage who underwent endovascular coiling, not surgical clipping.