Angiographic Evaluation of the Feeding Artery in Skull Base Meningioma

To identify the characteristics of feeding arteries in skull base meningioma including location and prevalence, we evaluated the distributions and types of feeding arteries in skull base meningioma by cerebral angiography and assessed relationships to tumor attachment. We enrolled patients with skull base meningioma who underwent MRI and cerebral digital subtraction angiography (DSA), from September 2015 to October 2022. Subjects comprised 115 patients (32 males, 83 females; mean age, 52.7) with 117 meningiomas, showing tumor attachments around the "cavernous sinus to the upper part of the clivus" (Area 1), "lower part of the clivus to foramen magnum" (Area 2), and "tentorium around the petrous bone" (Area 3). Frequent arteries, such as the dorsal meningeal artery (DMA), the ascending pharyngeal artery (APA), the tentorial artery (TA), and the petrosal branch (PB) of the middle meningeal artery (MMA) were analyzed in terms of their associations with tumor attachment to Areas 1-3. Meningiomas with the DMA as a feeding artery correlated with tumor attachment to Area 1 (p < 0.001). Meningiomas with the APA correlated with tumor attachment to Area 2 (p < 0.001). Meningiomas with the TA correlated with tumor attachment to Area 3 (p < 0.001). The PB correlated with Area 3 (p < 0.05). Our study founded that visualization of these arteries correlated well with specific areas. These arteries were also the main feeders in each type of skull base meningioma.

Deep Learning-based Angiogram Generation Model for Cerebral Angiography without Misregistration Artifacts

Background Digital subtraction angiography (DSA) generates an image by subtracting a mask image from a dynamic angiogram. However, patient movement-caused misregistration artifacts can result in unclear DSA images that interrupt procedures. Purpose To train and to validate a deep learning (DL)-based model to produce DSA-like cerebral angiograms directly from dynamic angiograms and then quantitatively and visually evaluate these angiograms for clinical usefulness. Materials and Methods A retrospective model development and validation study was conducted on dynamic and DSA image pairs consecutively collected from January 2019 through April 2019. Angiograms showing misregistration were first separated per patient by two radiologists and sorted into the misregistration test data set. Nonmisregistration angiograms were divided into development and external test data sets at a ratio of 8:1 per patient. The development data set was divided into training and validation data sets at ratio of 3:1 per patient. The DL model was created by using the training data set, tuned with the validation data set, and then evaluated quantitatively with the external test data set and visually with the misregistration test data set. Quantitative evaluations used the peak signal-to-noise ratio (PSNR) and the structural similarity (SSIM) with mixed liner models. Visual evaluation was conducted by using a numerical rating scale. Results The training, validation, nonmisregistration test, and misregistration test data sets included 10 751, 2784, 1346, and 711 paired images collected from 40 patients (mean age, 62 years ± 11 [standard deviation]; 33 women). In the quantitative evaluation, DL-generated angiograms showed a mean PSNR value of 40.2 dB ± 4.05 and a mean SSIM value of 0.97 ± 0.02, indicating high coincidence with the paired DSA images. In the visual evaluation, the median ratings of the DL-generated angiograms were similar to or better than those of the original DSA images for all 24 sequences. Conclusion The deep learning-based model provided clinically useful cerebral angiograms free from clinically significant artifacts directly from dynamic angiograms. Published under a CC BY 4.0 license. Supplemental material is available for this article.

Incidental finding of neurosyphilis with intracranial hemorrhage and cerebral infarction: A case report

Syphilis has recently increased in prevalence in Japan. Neurosyphilis is a special pathological condition of syphilis well known to cause cerebral vasculitis and ischemic stroke. Neurosyphilis in the meningovascular stage rarely causes caliber irregularity of the cerebral blood vessels or cerebral hemorrhage. We describe the case of a 49-year-old Japanese man with neurosyphilis. Cerebral hemorrhage, multiple cerebral infarctions, and caliber irregularity of the cerebral blood vessels were observed, the patient underwent surgery for cerebral hemorrhage on the day of admission, all of which were suspected to be caused by syphilis. He was started on an antibacterial treatment of penicillin on the day of admission and was diagnosed with neurosyphilis the following week based on his serum and spinal fluid test results. His condition improved, and he was transferred to another hospital after 4 weeks of treatment consisting of 3 weeks of infusion treatment with benzylpenicillin followed by oral treatment with amoxicillin. To the best of our knowledge, this is a rare case of neurosyphilis in conjunction with cerebral hemorrhage and cerebral infarction. Clinicians should consider syphilis in the differential diagnosis of cerebral hemorrhage and cerebral infarction and test patients for sexually transmitted diseases, in addition to cerebrospinal fluid testing, when cerebral hemorrhage occurs with an unknown cause. This is especially pertinent when patients present with cerebral infarction or caliber irregularity of the cerebral blood vessels.

Quantitative Analysis of Near-Infrared Indocyanine Green Videoangiography for Predicting Functional Outcomes After Spinal Intramedullary Ependymoma Resection

BACKGROUND

One of the most critical steps in surgery for spinal intramedullary ependymomas is the resection of small feeding arteries from the anterior spinal artery with anatomical preservation of the normal circulation of the ventral spinal cord.

OBJECTIVE

To quantitatively analyze the microcirculation of the ventral spinal cord by near-infrared indocyanine green videoangiography (ICG-VA) after the spinal intramedullary ependymoma resection.

METHODS

This retrospective study included 12 patients (7 male and 5 female; average age 55.2 years, range 36-79 years). Patients' neurological conditions were assessed based on the modified McCormick functional schema of grade 1 (neurologically normal) to 5 (severe deficit). Postoperative functional assessment was conducted at least 3 months after surgery. Quantitative analysis of vascular flow dynamics was carried out following spinal intramedullary ependymoma resection. Fluorescence intensities were measured and the indocyanine green (ICG) intensity-time curves were analyzed and compared with the functional outcomes after surgery.

RESULTS

Microscopically total or subtotal resection of the intramedullary ependymoma was achieved in all cases. Average peak time on ICG-VA was significantly shorter in the postoperative functional grade 1 to 2 group than in the postoperative functional grade 3 to 5 group, but there was no significant difference in average peak intensity between the 2 groups. Postoperative functional grade and the peak time of ICG, but not peak intensity, appeared correlated.

CONCLUSION

To the best of our knowledge, this is the first report showing that quantitative analysis of ICG-VA may predict functional outcomes after spinal intramedullary ependymoma resection.

Low recurrence after Simpson grade II resection of spinal benign meningiomas in a single-institute 10-year retrospective study

The objective of this study was to more fully understand the optimal neurosurgical strategy for spinal benign meningiomas from a medium to long-term perspective. This retrospective study included a cohort of 35 patients with a diagnosis of spinal meningioma who were first operated at our institute over the past 10 years and followed-up for at least 2 years after surgery. The inclusion criterion for the study was the pathological diagnosis finally verified as benign meningioma of World Health Organization (WHO) grade 1. The average follow-up duration after surgery was 61.0 months. The location of the spinal meningioma was classified into ventral or dorsal type based on the operative video record and the preoperative MR images. The extent of resection of the spinal meningioma was carefully determined based on the Simpson grade. The average neurological condition was significantly improved at the final follow-up. Simpson grade I or II resection was achieved in 31 of 35 cases (88.6%). No Simpson grade I or II cases showed local recurrence during follow-up. Tumor recurrence was noted in 2 of 4 cases of Simpson grade IV resection. One case has been followed-up without any re-operation because of no neurological deterioration, and the other case underwent stereotactic radiosurgery. This study suggested that meticulous Simpson grade II resection of spinal benign meningiomas of WHO grade 1 may be good enough from a medium to long-term follow-up perspective, though longer follow-up is absolutely necessary.

Challenges in a population-based registry of cardiovascular disease in Shiga, Japan

Background

Stroke and cardiovascular disease are one of the leading causes of death and disability in Japan. In order to investigate current burden, we conduct a population-based registry of cardiovascular disease in Shiga Prefecture, Japan since 2012. We will demonstrate challenges in conduct of the registry study.

Methods

In 2012, we established the Shiga Stroke Registry (SSR), a multicenter population-based registry study designed to build a complete information system for the management of stroke in Shiga Prefecture, Japan. The registry uses local monitoring, combined with remote data collection and quality control systems, to create an integrated surveillance system among a network of all acute care hospitals with neurology/neurosurgery facilities and smaller hospitals with rehabilitation facilities in the region. In 2019, study name has changed to Shiga Stroke and Heart Attack Registry (SSHR) and additional registration of coronary heart disease and aortic disease have started. Each case is reviewed and adjudicated by 2 or more specialists.

Results

In the financial year of 2018 (from April to March), a total of 4809 stroke cases were identified. From December 2018 to April 2019, a total of 515 coronary heart and aortic diseases were identified. A total 10 nurses work full-time for the registry and it takes average of 1 hour to collect information for each patient. Challenges in conduct of the cardiovascular registry involve regulatory and ethical approval, funding, associations with local hospitals, non-standardized hospital diagnosis, staff training for comprehensive data collection including pathophysiology, examination and treatment, and quality control of data collection.

Conclusions

SSHR is a population-based registry of wide range of stroke and cardiovascular disease in Shiga Prefecture, Japan. In order to keep quality of the data, we put a lot of efforts on staff training and quality control.

Key messages

Population-based registry of wide range of stroke and cardiovascular disease in Shiga, Japan. In order to keep quality of the data, we put a lot of efforts on staff training and quality control.

Usefulness of the anterior transpetrosal approach for pontine cavernous malformations

Surgical resection of pontine cavernous malformation remains a particularly formidable challenge. We report the surgical outcome of eight cases with pontine cavernous malformations operated using the anterior transpetrosal approach. All cases presented with neurological deficits caused by hemorrhage before surgery. Gross-total removal was achieved in all cases without any postoperative complication such as worsening of facial nerve palsy, ocular movement disorder, or hemiplegia. A small incision of the pons with multidirectional dissection is the most important factor for minimizing postoperative neurological deficits, so resection of a pontine cavernous malformation via this approach can be an alternative better option.

The video can be found here: https://youtu.be/2Q2CUhBbo28.

Association between excessive supraventricular ectopy and subclinical cerebrovascular disease: a population-based study

BACKGROUND AND PURPOSE

The association between an increased supraventricular ectopic beat (SVEB) and subclinical cerebrovascular disease remains unclear. Given the emerging concept that an increased SVEB is a marker of atrial cardiomyopathy or atherosclerosis burden, we sought to determine whether excessive supraventricular ectopic activity (ESVEA) is associated with a higher burden of subclinical cerebrovascular disease in the middle-aged to older cohort with neither apparent stroke nor atrial fibrillation.

METHODS

We conducted a cross-sectional population-based study of 462 men (mean age, 68.1 years) who underwent 24-h Holter electrocardiography and brain magnetic resonance imaging. ESVEA was defined as the presence of >10 SVEBs/h. Subclinical cerebrovascular diseases were defined as silent brain infarct (SBI), white matter hyperintensity (WMH) and intracranial atherosclerotic stenosis (ICAS). The association of ESVEA with the presence of subclinical cerebrovascular diseases was adjusted for potential confounding covariates.

RESULTS

A total of 88 (19.0%) participants had ESVEA and 81 (17.5%), 91 (19.7%) and 109 (23.6%) had SBI, WMH and ICAS, respectively. In multivariable-adjusted Poisson regression with robust error variance, ESVEA was associated with the presence of WMH (relative risk, 1.58; 95% confidence interval, 1.06-2.36) and ICAS (relative risk, 1.49; 95% confidence interval, 1.02-2.18), but not with that of SBI (relative risk, 1.32; 95% confidence interval, 0.86-2.01). These associations were consistent when the graded distributions of subclinical cerebrovascular diseases were applied as outcomes in ordinal logistic regression.

CONCLUSIONS

The ESVEA was independently associated with higher burdens of WMH and ICAS. This suggests that increased SVEBs might improve risk stratification of individuals at high risk of subclinical cerebrovascular disease and consequently apparent ischaemic stroke.

Anterior and Posterior Segmental Decompression and Fusion for Severely Localized Ossification of the Posterior Longitudinal Ligament of the Cervical Spine: Technical Note

The surgical strategy for severely localized ossification of the posterior longitudinal ligament (OPLL) of the cervical spine is still not straightforward. We describe the surgical technique of extended anterior cervical discectomy and fusion (ACDF) with partial resection of OPLL followed by posterior cervical segmental decompression and fusion (PCDF). This study investigated five patients with severely localized OPLL with an occupying ratio more than 60%. Extended ACDF comprising a modified technique with a trans-unco-discal approach and partial oblique corpectomy was first attempted to achieve neural decompression of the spinal cord and nerve roots at the most prominent level of the OPLL. The OPLL was partially resected to reduce the axial occupying ratio or ensure that the OPLL did not exceed the imaginary line between the midpoint between C2 and C7 on sagittal images. PCDF was then performed to achieve satisfactory decompression of neural elements and cervical stability. One patient underwent one-stage surgery and the remaining four patients underwent two-stage surgery. No patients received spinal cerebrospinal fluid (CSF) drainage and demonstrated CSF leakage after surgery. All patients showed acceptable or satisfactory functional recovery. No instrumentation-related complications were encountered. Radiological analysis demonstrated that all except one patient (OPLL associated with ankylosing spinal hyperostosis) revealed improvements in local angle, C2–7 angle and cervical tilt angle. This anterior and posterior segmental decompression and fusion for severely localized OPLL of the cervical spine remains technically demanding in some parts, but can offer satisfactory decompression of neural elements and stabilization of the cervical spine when applied appropriately.

Spheno-Orbital Meningioma: Surgical Outcomes and Management of Recurrence

OBJECTIVE

Spheno-orbital meningioma (SOM) is a rare intracranial tumor that arises at the sphenoid wing, extends into the orbit, and is associated with hyperostosis of the sphenoid bone. These tumors often invade important neurovascular structures around the orbital apex, superior orbital fissure, and cavernous sinus. Aggressive tumor removal could achieve acceptable control; however, residual tumor can regrow. In this article, our surgical management and long-term outcomes are described.

METHODS

Retrospectively, 12 patients with SOM who were treated surgically over a 21-year period were included. The clinical features and long-term tumor control were evaluated.

RESULTS

Participants comprised 12 patients (5 men and 7 women). Mean follow-up was 74.4 months (range, 10-262 months). Ten patients (83%) were identified as World Health Organization grade 1 (WHO-I), and 2 patients (17%) were identified as WHO grade 2 (WHO-II). We encountered 4 recurrences, 2 of which needed additional surgeries. One patient with WHO-I (10%) experienced recurrence 10 years after the initial surgery and required a second surgery. Two patients with WHO-I (20%) showed slight regrowth of residual tumor around the superior orbital fissure; nevertheless, additive therapy was not recommended. Despite radical tumor resection, including eyeball and adjunctive radiotherapy for 1 patient with WHO-II, tumor recurrence in the posterior fossa was documented 19 years after the initial aggressive surgery.

CONCLUSIONS

SOM follows a relatively benign clinical course given the invasive radiologic findings. Abnormal bone resection is paramount to prevent early-stage recurrence. Although intradural residual tumor might regrow, additional surgery could achieve reasonable long-term tumor control with better outcome.

Work-related psychosocial factors and metabolic syndrome onset among workers: a systematic review and meta-analysis

BACKGROUND

Work-related psychosocial factors have been associated with metabolic syndrome. However, no systematic reviews or meta-analyses have evaluated this association.

METHODS

A systematic literature search was conducted, using PubMed, Embase, PsycINFO, PsycARTICLES and the Japan Medical Abstracts Society. Eligible studies included those that examined the previously mentioned association; had a longitudinal or prospective cohort design; were conducted among workers; provided sufficient data for calculating odds ratios, relative risks or hazard ratios with 95% confidence intervals; were original articles in English or Japanese; and were published no later than 2016. Study characteristics, exposure and outcome variables and association measures of studies were extracted by the investigators independently.

RESULTS

Among 4,664 identified studies, 8 were eligible for review and meta-analysis. The pooled risk of adverse work-related stress on metabolic syndrome onset was significant and positive (RR = 1.47; 95% CI, 1.22-1.78). Sensitivity analyses limiting only the effects of job strain and shift work also indicated a significant positive relationship (RR = 1.75; 95% CI, 1.09-2.79; and RR = 1.59; 95% CI, 1.00-2.54, P = 0.049 respectively).

CONCLUSION

This study reveals a strong positive association between work-related psychosocial factors and an elevated risk of metabolic syndrome onset. The effects of job strain and shift work on metabolic syndrome appear to be significant.

Sex-specific relevance of diabetes to occlusive vascular and other mortality: a collaborative meta-analysis of individual data from 980 793 adults from 68 prospective studies

BACKGROUND

Several studies have shown that diabetes confers a higher relative risk of vascular mortality among women than among men, but whether this increased relative risk in women exists across age groups and within defined levels of other risk factors is uncertain. We aimed to determine whether differences in established risk factors, such as blood pressure, BMI, smoking, and cholesterol, explain the higher relative risks of vascular mortality among women than among men.

METHODS

In our meta-analysis, we obtained individual participant-level data from studies included in the Prospective Studies Collaboration and the Asia Pacific Cohort Studies Collaboration that had obtained baseline information on age, sex, diabetes, total cholesterol, blood pressure, tobacco use, height, and weight. Data on causes of death were obtained from medical death certificates. We used Cox regression models to assess the relevance of diabetes (any type) to occlusive vascular mortality (ischaemic heart disease, ischaemic stroke, or other atherosclerotic deaths) by age, sex, and other major vascular risk factors, and to assess whether the associations of blood pressure, total cholesterol, and body-mass index (BMI) to occlusive vascular mortality are modified by diabetes.

RESULTS

Individual participant-level data were analysed from 980 793 adults. During 9·8 million person-years of follow-up, among participants aged between 35 and 89 years, 19 686 (25·6%) of 76 965 deaths were attributed to occlusive vascular disease. After controlling for major vascular risk factors, diabetes roughly doubled occlusive vascular mortality risk among men (death rate ratio [RR] 2·10, 95% CI 1·97-2·24) and tripled risk among women (3·00, 2·71-3·33; χ2 test for heterogeneity p<0·0001). For both sexes combined, the occlusive vascular death RRs were higher in younger individuals (aged 35-59 years: 2·60, 2·30-2·94) than in older individuals (aged 70-89 years: 2·01, 1·85-2·19; p=0·0001 for trend across age groups), and, across age groups, the death RRs were higher among women than among men. Therefore, women aged 35-59 years had the highest death RR across all age and sex groups (5·55, 4·15-7·44). However, since underlying confounder-adjusted occlusive vascular mortality rates at any age were higher in men than in women, the adjusted absolute excess occlusive vascular mortality associated with diabetes was similar for men and women. At ages 35-59 years, the excess absolute risk was 0·05% (95% CI 0·03-0·07) per year in women compared with 0·08% (0·05-0·10) per year in men; the corresponding excess at ages 70-89 years was 1·08% (0·84-1·32) per year in women and 0·91% (0·77-1·05) per year in men. Total cholesterol, blood pressure, and BMI each showed continuous log-linear associations with occlusive vascular mortality that were similar among individuals with and without diabetes across both sexes.

INTERPRETATION

Independent of other major vascular risk factors, diabetes substantially increased vascular risk in both men and women. Lifestyle changes to reduce smoking and obesity and use of cost-effective drugs that target major vascular risks (eg, statins and antihypertensive drugs) are important in both men and women with diabetes, but might not reduce the relative excess risk of occlusive vascular disease in women with diabetes, which remains unexplained.

FUNDING

UK Medical Research Council, British Heart Foundation, Cancer Research UK, European Union BIOMED programme, and National Institute on Aging (US National Institutes of Health).

Image-guided Spine Stabilization for Traumatic Or Osteoporotic Spine Injury: Radiological Accuracy and Neurological Outcome

Significant progress has been made in image-guided surgery (IGS) over the last few decades. IGS can be effectively applied to spinal instrumentation surgery. In the present study, we focused our attention on the feasibility and safety of image-guided spine stabilization for traumatic or osteoporotic spine injury. The IGS spine fixation with or without minimally invasive surgery (MIS) techniques such as percutaneous screw placement, balloon kyphoplasty (BKP), or vertebroplasty (VP) were accomplished in 80 patients with traumatic or osteoprotic spine injury between 2007 and 2015. The injured vertebral levels included the following: cervical spine, 41; thoracic spine, 22; and lumbar spine, 17. Neurological condition before and after surgery was assessed using the American Spinal Injury Association Impairment Scale (AIS). A total of 419 pedicle, lateral mass, or laminar screws were placed, and 399 screws (95.2%) were found to be placed correctly based on postoperative computed tomography scan. Although 20 screws (4.8%) were found to be unexpectedly placed incorrectly, no neural or vascular complications closely associated with screw placement were encountered. Neurological outcomes appeared to be acceptable or successful based on AIS. The IGS is a promising technique that can improve the accuracy of screw placement and reduce potential injury to critical neurovascular structures. The integration of MIS and IGS has proved feasible and safe in the treatment of traumatic or osteoporotic spine injury, although a thorough knowledge of surgical anatomy, spine biomechanics, and basic technique remain the most essential aspects for a successful surgery.

Depression but not anxiety predicts recurrent cerebrovascular events

OBJECTIVES

Depression and anxiety after stroke occur frequently and have been suggested to have negative influence on functional outcomes. However, the effect of emotional symptoms on stroke recurrence is uncertain. The aim of this study was to define the effect of emotional symptoms on recurrent cerebrovascular events in patients with ischemic stroke.

MATERIALS AND METHODS

This was a hospital-based cohort study including patients with ischemic stroke who participated in a Community Stroke Care Program that provided secondary stroke prevention strategies during 6 months transition period after discharge. We examined the association between depression and anxiety and the risk of recurrent cerebrovascular events using logistic regression model. Depression and anxiety were defined as a score of 7 or more in Hospital Anxiety and Depression Scale at 2 weeks after discharge. Recurrent cerebrovascular events comprised any recurrent stroke and transient ischemic attack (TIA) occurring during 6 months after discharge.

RESULTS

Among 182 patients, 29 (15.9%) were depressed and 41 (22.5%) had anxiety symptoms. During the follow-up period, 9 patients experienced recurrent cerebrovascular events (5 of stroke and 4 of TIA). Depression was associated with recurrent cerebrovascular events at 6 months after adjustment for age, sex, and stroke severity (OR 5.22, 95% CI 1.08-25.12; P = 0.04), whereas anxiety was not (OR 0.98, 95% CI 0.2-4.92; P = 0.982).

CONCLUSIONS

Depression occurring early after stroke was associated with the increased risk of recurrent cerebrovascular events in ischemic stroke survivors. Care plan to detect and manage depression should be implemented to prevent recurrent stroke.

A minimum 2-year comparative study of autologous cancellous bone grafting versus beta-tricalcium phosphate in anterior cervical discectomy and fusion using a rectangular titanium stand-alone cage

Although titanium stand-alone cages are commonly used in anterior cervical discectomy and fusion (ACDF), there are several concerns such as cage subsidence after surgery. The efficacy of β-tricalcium phosphate (β-TCP) granules as a packing material in 1- or 2-level ACDF using a rectangular titanium stand-alone cage is not fully understood. The purpose of this study is to investigate the validity of rectangular titanium stand-alone cages in 1- and 2-level ACDF with β-TCP. This retrospective study included 55 consecutive patients who underwent ACDF with autologous iliac cancellous bone grafting and 45 consecutive patients with β-TCP grafting. All patients completed at least 2-year postoperative follow-up. Univariate and multivariate analyses were performed to examine the associations between study variables and nonunion after surgery. Significant neurological recovery after surgery was obtained in both groups. Cage subsidence was noted in 14 of 72 cages (19.4 %) in the autograft group and 12 of 64 cages (18.8 %) in the β-TCP group. A total of 66 cages (91.7 %) in the autograft group showed osseous or partial union, and 58 cages (90.6 %) in the β-TCP group showed osseous or partial union by 2 years after surgery. There were no significant differences in cage subsidence and the bony fusion rate between the two groups. Multivariate analysis using a logistic regression model showed that fusion level at C6/7, 2-level fusion, and cage subsidence of grades 2-3 were significantly associated with nonunion at 2 years after surgery. Although an acceptable surgical outcome with negligible complication appears to justify the use of rectangular titanium stand-alone cages in 1- and 2-level ACDF with β-TCP, cage subsidence after surgery needs to be avoided to achieve acceptable bony fusion at the fused segments. Fusion level at C6/7 or 2-level fusion may be another risk factor of nonunion.

Posterolateral approach for spinal intradural meningioma with ventral attachment

Background:

Spinal meningioma with ventral attachment is a challenging pathology. Several technical modifications have been proposed to secure safe and precise resection of these tumors.

Materials and Methods:

This retrospective study focused on the precise and safe surgery of spinal meningiomas with strictly ventral attachment of cervical or thoracic spine. The surgical technique included a lateral oblique position for the patient, laminectomy with unilateral medial facetectomy on the tumor side, and spinal cord rotation with the dentate ligament. The neurological status of patients was assessed using the modified McCormick functional schema (mMFS) and sensory pain scale (SPS) before and at least 3 months after surgery. Patients were followed-up for a mean of 23.7 months. Tumor removal was graded using the Simpson grade for removal of meningiomas, and the extent of excision was confirmed using early postoperative magnetic resonance imaging.

Results:

Simpson grade 1 or 2 resections were achieved in all cases. No major surgery-related complications were encountered, postoperatively. The mean mMFS score before surgery was 3.1, improving significantly to 1.7 after surgery (P < 0.05). The mean SPS score before surgery was 2.4, improving significantly to 1.6 after surgery (P < 0.05).

Conclusions:

This surgical technique offers a posterolateral surgical corridor to the ventral canal of both cervical and thoracic spine. The present preliminary analysis suggests that functional outcomes were satisfactory with minimal surgery-related complications, although considerable surgical experience is needed to achieve a high level of surgical confidence.

Higher mortality in patients with right hemispheric intracerebral haemorrhage: INTERACT1 and 2

BACKGROUND AND PURPOSE

Controversy exists over the prognostic significance of the affected hemisphere in stroke. We aimed to determine the relationship between laterality of acute intracerebral haemorrhage (ICH) and poor clinical outcomes.

METHODS

A subsidiary analysis of the INTERACT Pilot and INTERACT2 studies--randomised controlled trials of patients with spontaneous acute ICH with elevated systolic blood pressure (BP), randomly assigned to intensive (target systolic BP <140 mm Hg) or guideline-based (<180 mm Hg) BP management. Outcomes were the combined and separate end points of death and major disability (modified Rankin scale (mRS) scores of 3-6, 6 and 3-5, respectively) at 90 days.

RESULTS

A total of 2708 patients had supratentorial/hemispheric ICH and information on mRS at 90 days. Patients with right hemispheric ICH (1327, 49%) had a higher risk of death at 90 days compared to those with left hemispheric ICH after adjustment for potential confounding variables (OR, 1.77 (95% CI 1.33 to 2.37)). There were no differences between patients with right and left hemispheric ICH regarding the combined end point of death or major disability or major disability in the multivariable-adjusted models (1.07 (0.89 to 1.29) and 0.85 (0.72 to 1.01), respectively).

CONCLUSIONS

Right hemispheric lesion was associated with increased risk of death in patients with acute ICH. The laterality of the ICH does not appear to affect the level of disability in survivors.

TRIAL REGISTRATION NUMBER

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00226096 and NCT00716079.

Prediction of the efficacy of surgical intervention in patients with cervical myelopathy by using diffusion tensor 3T-magnetic resonance imaging parameters

Background:

The clinical significance of diffusion tensor (DT) magnetic resonance imaging (MRI) parameters was analyzed to predict postoperative functional recovery in patients with cervical myelopathy.

Materials and Methods:

Sixteen patients with cervical myelopathy caused by cervical spondylosis, disk herniation or ossification of the posterior longitudinal ligament who underwent surgical intervention in our institute were enrolled in this retrospective study. There were 7 men and 9 women, with a mean age of 62.8 years. Clinical assessment was done before surgery and at least 3 months after surgery. All patients underwent whole-body 3.0-Tesla MRI before surgery. DT images (DTIs) were obtained using a single-shot fast spin-echo-based sequence. Mean values of mean diffusivity (MD) and fractional anisotropy (FA) at 6 disk levels of the cervical spine were measured using manual setting of regions of interest. The MD and FA values at the most compressed part were analyzed. Absolute MD and FA values at the most compressed spinal level in patients were transformed into the normalized values with a z-score analysis.

Results:

MD-z may decrease with the severity of cervical myelopathy. Receiver operating characteristic analysis of MD-z and FA-z suggested that both MD-z and FA-z have clinical validity for predicting the efficacy of surgical intervention, but MD-z was considered to be the most appropriate value to predict the efficacy of surgery.

Conclusions:

DTIs may be a promising modality to predict functional recovery after surgery. MD changes may reflect spinal cord condition and its reversibility.

Qualitative analysis of spinal intramedullary lesions using PET/CT

OBJECT Although the usefulness of PET for brain lesions has been established, few reports have examined the use of PET for spinal intramedullary lesions. This study investigated the diagnostic utility of PET/CT for spinal intramedullary lesions. METHODS l-[methyl-¹¹C]-methionine (MET)- or [¹⁸F]-fluorodeoxyglucose (FDG)-PET/CT was performed in 26 patients with spinal intramedullary lesions. The region of interest (ROI) within the spinal cord parenchyma was placed manually in the axial plane. Maximum pixel counts in the ROIs were normalized to the maximum standardized uptake value (SUV_max) using subject body weight. For FDG-PET the SUV_max was corrected for lean body mass (SUL_max) to exclude any influence of the patient's body shape. Each SUV was analyzed based on histopathological results after surgery. The diagnostic validity of the SUV was further compared with the tumor proliferation index using the MIB-1 monoclonal antibody (MIB-1 index). RESULTS A total of 16 patients underwent both FDG-PET and MET-PET, and the remaining 10 patients underwent either FDG-PET or MET-PET. Pathological diagnoses included high-grade malignancy such as glioblastoma multiforme, anaplastic astrocytoma, or anaplastic ependymoma in 5 patients; low-grade malignancy such as hemangioblastoma, diffuse astrocytoma, or ependymoma in 12 patients; and nonneoplastic lesion including cavernous malformation in 9 patients. Both FDG and MET accumulated significantly in high-grade malignancy, and the SUL_max and SUV_max correlated with the tumor proliferation index. Therapeutic response after chemotherapy or radiation in high-grade malignancy was well monitored. However, a significant difference in SUL_max and SUV_max for FDG-PET and MET-PET was not evident between low-grade malignancy and nonneoplastic lesions. CONCLUSIONS Spinal PET/CT using FDG or MET for spinal intramedullary lesions appears useful and practical, particularly for tumors with high-grade malignancy. Differentiation of tumors with low-grade malignancy from nonneoplastic lesions may still prove difficult. Further technological refinement, including the selection of radiotracer or analysis evaluation methods, is needed.

Effects of blood pressure lowering on cardiovascular risk according to baseline body-mass index: a meta-analysis of randomised trials

BACKGROUND

The cardiovascular benefits of blood pressure lowering in obese people compared with people of normal weight might depend on choice of drug. We compared the effects of blood pressure-lowering regimens on cardiovascular risk in groups of patients categorised by baseline body-mass index (BMI).

METHODS

We used individual patient data from trials included in the Blood Pressure Lowering Treatment Trialists' Collaboration to compare the effects of different classes of blood pressure-lowering regimens for the primary outcome of total major cardiovascular events (stroke, coronary heart disease, heart failure, and cardiovascular death). We used meta-analyses and meta-regressions to assess interactions between treatment and BMI when fitted as either a categorical variable (<25 kg/m(2), 25 to <30 kg/m(2), and ≥30 kg/m(2)) or a continuous variable.

FINDINGS

Analyses were based on 135,715 individuals from 22 trials who had 14,353 major cardiovascular events. None of the six primary comparisons showed evidence that protection varied by drug class across the three BMI groups (all p for trend >0·20). When analysed as a continuous variable, angiotensin-converting-enzyme inhibitors gave slightly greater protection for each 5 kg/m(2) higher BMI than did calcium antagonists (hazard ratio 0·93, 95% CI 0·89-0·98; p=0·004) or diuretics (0·93, 0·89-0·98; p=0·002). The meta-regressions showed no relation between BMI category and the risk reduction for a given fall in systolic blood pressure. By contrast with a previous report, we noted no relation between BMI and the efficacy of calcium antagonists compared with diuretics.

INTERPRETATION

We found little evidence that selection of a particular class of blood pressure-lowering drug will lead to substantially different outcomes for individuals who are obese compared with those who are lean.

FUNDING

None.

Six-axis multi-anvil press for high-pressure, high-temperature neutron diffraction experiments

We developed a six-axis multi-anvil press, ATSUHIME, for high-pressure and high-temperature in situ time-of-flight neutron powder diffraction experiments. The press has six orthogonally oriented hydraulic rams that operate individually to compress a cubic sample assembly. Experiments indicate that the press can generate pressures up to 9.3 GPa and temperatures up to 2000 K using a 6-6-type cell assembly, with available sample volume of about 50 mm(3). Using a 6-8-type cell assembly, the available conditions expand to 16 GPa and 1273 K. Because the six-axis press has no guide blocks, there is sufficient space around the sample to use the aperture for diffraction and place an incident slit, radial collimators, and a neutron imaging camera close to the sample. Combination of the six-axis press and the collimation devices realized high-quality diffraction pattern with no contamination from the heater or the sample container surrounding the sample. This press constitutes a new tool for using neutron diffraction to study the structures of crystals and liquids under high pressures and temperatures.

Surgical management of solitary nerve sheath tumors of the cervical spine: a retrospective case analysis based on tumor location and extension

Complete resection of spinal nerve sheath tumors (NSTs) does not always result in significant neurological deficit. The purpose of this retrospective case analysis was to discuss the optimal surgical strategy for spinal NST of the cervical spine. Twenty-four patients who underwent surgery for solitary cervical NST over the past decade were included in this retrospective study. Patients with neurofibromatosis or schwannomatosis were excluded. Seventeen of the 24 cases (70.8%) showed extradural dumbbell extension, most frequently at the C1 or C2 vertebral level. Neurological condition was assessed using the modified McCormick functional schema and sensory pain scale. Total removal of the tumor was achieved in 20 of 24 cases (83.3%). Staged surgery using combined anterior and posterior approaches was applied for 2 of 17 cases with extradural dumbbell extension. Tumor involvement with nerve root fibers critical for upper extremity function (C5–C8) was recognized in 6 of 24 cases (25.0%), with complete resection in all 6 cases. Final assessment of neurological function revealed satisfactory or acceptable recovery in all 6 patients. Spinal NSTs with extradural dumbbell extension are a common condition in the cervical spine. Complete removal of spinal NST of the cervical spine may carry a risk of permanent neurological deficit, but such sequelae appeared to be the exception in the present case analysis. A radical and safe surgical strategy, including staged surgery combining anterior and posterior approaches, should be tailored to the individual case.

Surgical management of spinal meningiomas: A retrospective case analysis based on preoperative surgical grade

Background:

Although spinal meningiomas respond favorably to surgical excision, their surgical management is impacted by several factors. This study utilized a surgery-based grading system to discuss the optimal surgical strategy.

Methods:

Twenty-three consecutive patients who underwent surgery for spinal meningiomas were included in this retrospective study. The patients’ neurological condition was assessed using the modified McCormick functional schema (mMFS) and sensory pain scale (SPS), and tumor removal was assessed using Simpson grade. Major factors contributing to surgical difficulty included; tumor size, extent/severity of cord compression, location of tumor attachment, spinal level, and anatomical relationships plus tumor extending in a dumbbell shape and local postoperative recurrence.

Results:

Fifteen cases were classified as ventral attachment (65.2%). There were two dumbbell-shaped tumors and three local recurrences at the primary site. Simpson grade 1 or 2 resections were performed in 18 of 20 cases (90%) with preoperative surgical grades 0 to 3. Simpson grade 4 resections were achieved in all three cases with preoperative surgical grades 4 to 5. Overall neurological assessment after surgery revealed the satisfactory or acceptable recovery on mMFS and SPS analysis.

Conclusions:

Lower preoperative grade yielded better results, while the higher the preoperative grade, the more likely tumor was insufficiently removed. A preoperative surgical grading system appeared to be helpful when considering the surgical strategy. Ventral meningiomas could be safely resected via the posterolateral or lateral approach using technical modifications. Recurrent tumors, especially with ventral attachment, were hard to resolve, and primary surgery appears to be important.

Abstract 180: The Relation of Timing and Degree of Blood Pressure Control with Hematoma Growth - Secondary Analysis of The Interact2 Trial

Background: Acute blood pressure (BP) lowering therapy has shown clinical benefit in patients with acute intracerebral hemorrhage (ICH), but the effect of timing and degree of BP control on ICH growth has received less study.

Methods: Among the INTERACT2 participants (N=2839) with acute ICH allocated either to intensive BP lowering therapy (IT, systolic target <140mmHg) or standard BP treatment (ST), CT brain imaging at baseline and 24 hours were centrally analysed in a subset of 491 (34%) in the IT and 473 (34%) in the ST groups.

Results: Absolute mean ICH growth was lower in patients reaching BP target in <1h from randomization (1.7ml), as compared to those reaching target in 1-6h (4.2ml), and >6h (4.6ml, p=0.04). Hematoma growth was particularly high (14.4ml, 95%CI:10.0-18.8) in patients admitted with systolic BP>160mmHg who achieved <10mmHg systolic BP lowering over 24h, as compared to those achieving 10-20mmHg (3.7ml, 95%CI:0.3-7.1) or 20-30mmHg BP reduction (2.7ml, 95%CI:1.1-4.3); p<0.01). Patients maintaining target BP at 0-2 measurements over 24h had higher absolute volume increase (3.6ml; 95%CI:1.8-5.4) as compared to those who maintained target BP over 3-4 (1.6ml, 95%CI:-0.3-3.5), or 5-8 measurements (0.4ml, 95%CI:-1.7-2.4; p=0.01).

Conclusion: These findings suggest that early and sustained BP control have favorable effects on hematoma growth. This reinforces the principle for patients with acute ICH to receive BP lowering therapy as early as possible and to achieve a lower level of systolic BP for the most favorable outcome.

Effects of low estimated glomerular filtration rate on outcomes after stroke: a hospital-based stroke registry in China

BACKGROUND AND PURPOSE

As uncertainty persists over the prognostic significance of low estimated glomerular filtration rate (eGFR) in acute stroke, the effects of low eGFR on death/disability amongst participants with acute stroke in China were determined.

METHODS

Nanjing First Hospital stroke registry was a prospective cohort study of stroke patients. Patients with acute stroke (brain infarction, intracerebral hemorrhage or subarachnoid hemorrhage) within 7 days of onset were recruited consecutively from 2004 to 2008. Baseline eGFR was estimated using the Chronic Kidney Disease Epidemiology Collaboration equation. Outcomes were death/disability, defined by scores 3-6 on the modified Rankin Scale at 90 days.

RESULTS

A total of 1909 participants were included in the present analyses. Of them, 112 (5.9%) had baseline moderate to severe decrease in eGFR (G3b-4) and increasing risk of higher National Institutes of Health Stroke Scale (NIHSS) scores. Low eGFR was associated with increasing risk of death/disability at 90 days [G3b-4, odds ratio 2.58 (95% confidence interval 1.71-3.91); G3a, 1.86 (1.35-2.56); G2, 1.21 (0.96-1.52); P trend <0.001). However, the association was not statistically significant after adjustment for demographic and clinical factors including NIHSS scores.

CONCLUSIONS

There were no appreciable effects of low eGFR on death/disability at 90 days independent of other prognostic factors in Chinese patients with acute stroke.

Intraoperative assessment of spinal vascular flow in the surgery of spinal intramedullary tumors using indocyanine green videoangiography

Background:

The authors demonstrate the utility of indocyanine green videoangiography (ICG-VA) for intraoperative vascular flow assessment in the surgery of a variety of spinal intramedullary tumors to achieve an additional level of safety as well as precision with the surgical procedure.

Methods:

Fourteen patients with spinal intramedullary tumors (nine cervical and five thoracic) operated on between August 2011 and April 2013 were included in the present study. A fluorescence surgical microscope was used to perform ICG-VA after standard exposure of the lesion to assess the dynamic flow of the spinal microvasculature.

Results:

Twenty-seven ICG-VA injections were performed in 14 cases. Pathological diagnosis of the tumors included ependymoa, astrocytoma, cavernous malformation, or hemagioblastoma. There were no complications or side-effects related to ICG-VA. Intraoperative ICG-VA provided dynamic flow images of the spinal microvasculature in accordance with the progress of surgical procedures. Angiographic images could be divided into arterial, capillary, and venous phases. All angiographic images were well integrated into the microscopic view. The utility of ICG-VA could be summarized into three categories: (1) Localization of normal spinal arteries and veins, (2) assessment of posterior spinal venous circulation, and (3) differentiation of feeding arteries, tumor, and draining veins.

Conclusions:

Intraoperative vascular flow assessment using ICG-VA was easy, repeatable, and practical without any significant procedure-related risks. ICG-VA can be used for careful analysis of spinal microvascular flow or anatomical orientation, which is necessary to ensure safe and precise resection of spinal intramedullary tumors.

Impact of antihypertensive medication adherence on blood pressure control in hypertension: the COMFORT study

BACKGROUND

It has not been fully elucidated whether antihypertensive medication adherence affects blood pressure (BP) control in hypertension cases.

AIM

To investigate the association of adherence to antihypertensive drug regimens and BP control using data from the Combination Pill of Losartan Potassium and Hydrochlorothiazide for Improvement of Medication Compliance Trial (COMFORT) study.

DESIGN

An observational analysis from a randomized controlled trial.

METHODS

A total of 203 hypertensive subjects were randomly assigned to a daily regimen of a combination pill (losartan 50 mg/hydrochlorothiazide 12.5 mg) or two pills, an angiotensin II receptor blocker and a thiazide diuretic. Medication adherence calculated based on pill counts and BPs was evaluated at 1, 3 and 6 months after randomization.

RESULTS

The subjects were divided into three groups according to their adherence, i.e. relatively low-adherence (<90%; n = 19), moderate-adherence (90-99%; n = 71) and high-adherence (100%; n = 113) groups. Clinical characteristics of the subjects including BP, sex, randomized treatments and past medical history did not differ significantly among the three groups. Achieved follow-up BPs over the 6-month treatment period, which were adjusted for age, sex, baseline BP and randomized treatment, were significantly higher in the low-adherence group (135/78 mmHg) compared with the high-adherence (130/74 mmHg; P = 0.02/0.02) and the moderate-adherence (128/74 mmHg; P = 0.003/0.02) groups.

CONCLUSION

Low adherence to an antihypertensive-drug regimen was associated with poor BP control.

Formation of NaCl-type monodeuteride LaD by the disproportionation reaction of LaD2

Previous x-ray diffraction measurements revealed the pressure-induced decomposition of an fcc LaH2.3 into H-rich and H-poor fcc phases around 11 GPa. The present neutron diffraction measurements on LaD2 confirm the formation of NaCl-type LaD as a counterpart of the D-rich LaD2+δ by disproportionation. First-principles enthalpy and lattice dynamic calculations demonstrate that the NaCl-type LaH is stabilized at high pressures and can be recovered at ambient conditions. Finding the NaCl-type LaH will pave the way for investigations on the site-dependent nature of hydrogen-metal interactions.

Reduction of insulin signaling upregulates angiopoietin-like protein 4 through elevated free fatty acids in diabetic mice

BACKGROUND

Angiopoietin-like protein 4 (Angptl4) is thought to cause an increase in serum triglyceride levels. In the present study, we elucidated Angptl4 expression in the mouse models of type 1 and type 2 diabetes mellitus, and investigated the possible mechanisms involved.

METHODS

Type 1 diabetes was induced in C57BL/6 J mice by treating them with streptozotocin (STZ). Type 2 diabetes was induced by feeding the mice a high-fat diet (HFD) for 18 weeks.

RESULTS

The levels of Angptl4 mRNA expression in liver, white adipose tissue (WAT), and brown adipose tissue (BAT) were found to increase in the STZ diabetic mice relative to control mice. This effect was attenuated by insulin administration. In the HFD diabetic mice, the Angptl4 mRNA expression levels were increased in liver, WAT, and BAT. Treatment with metformin for 4 weeks attenuated the increased levels of Angptl4 mRNA. Fatty acids (FAs) such as palmitate and linoleate induced Angptl4 mRNA expression in H4IIE hepatoma cells and 3T3-L1 adipocytes. Treatment with insulin but not metformin attenuated FA-induced Angptl4 mRNA expression in H4IIE. Both insulin and metformin did not influence the effect of FAs in 3T3-L1 cells.

CONCLUSION

These observations demonstrated that Angptl4 mRNA expression was increased through the elevated free FAs in diabetic mice.

Trends in prevalence of Alzheimer's disease and vascular dementia in a Japanese community: the Hisayama Study

OBJECTIVE

To examine secular trends in the prevalence of Alzheimer's disease (AD) and vascular dementia (VD) in a general Japanese population.

METHOD

Four cross-sectional examinations were conducted among residents of a Japanese community aged >or=65 in 1985, 1992, 1998 and 2005.

RESULTS

The age- and sex-adjusted prevalence of all-cause dementia significantly increased with time (6.0% in 1985, 4.4% in 1992, 5.3% in 1998 and 8.3% in 2005; P for trend = 0.002). A similar trend was observed for AD (1.1%, 1.3%, 2.3% and 3.8% respectively; P for trend < 0.001), while the age- and sex-adjusted prevalence of VD and other/unclassified dementia showed J-shaped patterns (for VD: 2.3%, 1.5%, 1.5% and 2.5%, respectively, P for trend = 0.82; for other/unclassified dementia: 2.6%, 1.7%, 1.5% and 2.0%, P for trend = 0.26). The prevalence of AD was likely to increase with time from 1985 to 2005 among subjects aged 75 or older. The ratio of the prevalence of VD to that of AD decreased with time (2.1 in 1985, 1.2 in 1992, 0.7 in 1998 and 0.7 in 2005).

CONCLUSION

Our findings suggest that the prevalence of all-cause dementia and AD significantly increased over the past two decades in the general Japanese population.