Assessing the Adequacy of Superficial Temporal Artery Blood Flow in Korean Patients Undergoing STA-MCA Anastomosis

OBJECTIVE

Superficial temporal artery (STA)-middle cerebral artery (MCA) anastomosis is conducted for flow augmentation. In this study, we measured the STA cut flow of a Korean population and evaluated the relationship between STA cut flow and long-term patency of the bypass.

METHODS

A retrospective study was conducted. Intraoperative measurement of STA flow was conducted using a microvascular flow meter on patients who underwent STA-MCA. After cutting the distal end, the STA flow rate was measured with no resistance and recorded. After finishing anastomosis, STA flow was measured and recorded. The cut flow index was calculated by dividing post anastomosis flow by cut flow in intracranial atherosclerotic stenosis patients.

RESULTS

The median STA cut flow was 35.0 mL/min and the post anastomosis flow was 24.0 mL/min. The cut flow of STA decreased with aging (p=0.027) and increased with diameter (p=0.004). The cut flow showed no correlation with history of hypertension or diabetes mellitus (p=0.713 and p=0.786), but did correlate a positively with history of hyperlipidemia (p=0.004). There were no statistical differences in cut flow, STA diameter, and post anastomosis flow between the frontal and parietal branches (p=0.081, p=0.853, and p=0.990, respectively).

CONCLUSION

The median STA cut flow of a Korean population was 35 mL/min. Upon reviewing previous articles, it appears that there are differences in the STA cut flow between Western and Asian patients.

Early Detection of hyperemia with Magnetic Resonance Fluid Attenuation Inversion Recovery Imaging after Superficial Temporal Artery to Middle Cerebral Artery Anastomosis

Objective

Cerebral hyperperfusion syndrome(CHS) manifests as a collection of symptoms brought on by heightened focal cerebral blood flow, afflicting nearly 30% of patients who have undergone superficial temporal artery(STA)-middle cerebral artery(MCA) anastomosis. The aim of this study was to investigate whether the amalgamation of magnetic resonance imaging(MRI) fluid-attenuated inversion recovery(FLAIR) and apparent diffusion coefficient(ADC) imaging via MRI can discern cerebral hyperemia after STA-MCA anastomosis surgery.

Methods

A retrospective study was performed of patients who underwent STA-MCA anastomosis due to Moyamoya disease or atherosclerotic steno-occlusive disease. A protocol aimed at preventing CHS was instituted, leveraging the use of MRI FLAIR. Patients underwent MRI diffusion with FLAIR imaging 24 h after STA-MCA anastomosis. A high signal on FLAIR images signified the presence of hyperemia at the bypass site, triggering a protocol of hyperemia care. All patients underwent hemodynamic evaluations, including perfusion MRI, single-photon emission computed tomography(SPECT), and digital subtraction angiography, both before and after the surgery. If a high signal intensity is observed on MRI FLAIR within 24 hours of the surgery, a repeat MRI is performed to confirm the presence of hyperemia. Patients with confirmed hyperemia are managed according to a protocol aimed at preventing further progression.

Results

Out of a total of 162 patients, 24 individuals(comprising 16 women and 8 men) exhibited hyperemia on their MRI FLAIR scans following the procedure. SPECT was conducted on 23 patients, and 11 of them yielded positive results. All 24 patients underwent perfusion MRI, but 9 of them showed no significant findings. Among the patients, 10 displayed elevations in both cerebral blood flow(CBF) and cerebral blood volume(CBV), 3 only showed elevation in CBF, and 2 only showed elevation in CBV. Follow-up MRI FLAIR scans conducted 6 months later on these patients revealed complete normalization of the previously observed high signal intensity, with no evidence of ischemic injury.

Conclusion

The study determined that the use of MRI FLAIR and ADC mapping is a competent means of early detection of hyperemia after STA-MCA anastomosis surgery. The protocol established can be adopted by other neurosurgical institutions to enhance patient outcomes and mitigate the hazard of permanent cerebral injury caused by cerebral hyperemia.

Potential impact of high-density lipoprotein cholesterol in the postoperative outcomes of chronic subdural hematoma patients: multi-institutional study in Korea

BACKGROUND

Chronic subdural hematoma (CSDH) is a common clinical situation in neurosurgical practice, but the optimal treatment option is controversial. This study aimed to evaluate the effect of cholesterol-lowering medications on and how they affected the prognoses of CSDH patients.

METHODS

In this multi-institutional observational study performed in Korea, data from recently treated CSDH patients were gathered from 5 hospitals. A total of 462 patients were collected from March 2010 to June 2021. Patient clinical characteristics, history of underlying diseases and their treatments, radiologic features, and surgical outcomes were analyzed.

RESULTS

Seventy-five patients experienced recurrences, and 62 had reoperations after the initial burr hole surgery. Among these, 15 patients with recurrences and 12 with reoperations were taking cholesterol-lowering medications. However, the use of medications did not significantly affect recurrence or reoperation rates (P = 0.350, P = 0.336, respectively). When analyzed by type of medication, no clinically relevant differences in total cholesterol (TC), triglyceride (TG), or low-density lipoprotein cholesterol (LDL-C) levels were identified. The combination of a statin drug and ezetimibe significantly elevated high-density lipoprotein cholesterol (HDL-C) levels (P = 0.004). TC, LDL-C, and TG levels did not significantly affect patient prognoses. However, HDL-C levels and recurrence (odds ratio (OR) = 0.96; 95% confidence interval (CI): 0.94-0.99; p = 0.010) were negatively correlated. An HDL-C level of 42.50 mg/dL was identified as the threshold for recurrence and reoperation.

CONCLUSIONS

In this study, using cholesterol-lowering medications did not significantly impact the prognosis of patients who underwent surgical management for a chronic subdural hematoma. However, the findings showed that the higher the HDL-C level, the lower the probability of recurrence and reoperation.

Balancing Bleeding Risk and Thromboembolic Complications in Elderly Chronic Subdural Hematoma Patients Undergoing Burr Hole Trephination : A Multicenter Retrospective Cohort Study and Literature Review

OBJECTIVE

Chronic subdural hematoma (CSDH) patients using antithrombotic agents (AT) at high risk for cardiovascular disease are increasing. The authors aimed to analyze the factors influencing outcome by targeting patients using AT and to establish a desirable treatment strategy.

METHODS

A retrospective analysis was performed on data from 462 patients who underwent burr hole trephination (BHT) surgery for CSDH at five hospitals from March 2010 to June 2021. Outcomes included incidence of postoperative acute bleeding, recurrence rate, and morbidity or mortality rate. Patients were divided into the following four groups based on their history of AT use : no AT. Only antiplatelet agents (AP), only anticoagulants (AC), both of AP and AC. In addition, a concurrent literature review was conducted alongside our cohort study.

RESULTS

Of 462 patients, 119 (119/462, 25.76%) were using AT. AP prescription did not significantly delay surgery (p=0.318), but AC prescription led to a significant increase in the time interval from admission to operation (p=0.048). After BHT, AP or AC intake significantly increased the period required for an in-dwelling drain (p=0.026 and p=0.037). The use of AC was significantly related to acute bleeding (p=0.044), while the use of AP was not (p=0.808). Use of AP or AC had no significant effect on CSDH recurrence (p=0.517 and p=1.000) or reoperation (p=0.924 and p=1.000). Morbidity was not statistically correlated with use of either AP or AC (p=0.795 and p=0.557, respectively), and there was no significant correlation with mortality for use of these medications (p=0.470 and p=1.000).

CONCLUSION

Elderly CSDH patients may benefit from maintenance of AT therapy during BHT due to reduced thromboembolic risk. However, the use of AC necessitates individualized due to potential postoperative bleeding. Careful post-operative monitoring could mitigate prognosis and recurrence impacts.

Progressive postoperative slippage of titanium aneurysm clip confirmed by follow-up radiographic imaging studies and by reoperation: a case report

We report a case of postoperative slippage of a titanium clip that was used for a small ruptured anterior communicating artery aneurysm. Clipping was successful with no remnant in the initial operation. Progressive slippage of the clip was observed in follow-up brain computed tomography angiography studies. Digital subtraction angiography confirmed this finding. Reoperation was performed 19 days after the initial craniotomy. The clinical course after reoperation was uneventful.

Outcomes and complications of cerebral aneurysms operated on by eyebrow incision according to aneurysm type and location

OBJECTIVE

Trans-eyebrow supraorbital aneurysmal neck clipping, also known as keyhole surgery, have many advantages of minimal invasive surgery. However, there are few studies on whether there is a difference in keyhole surgery according to the location of the aneurysm, and how the complications after keyhole approach differ from the conventional approach. The authors investigated the surgical outcome of keyhole aneurysmal surgery for clarify the characteristics of keyhole surgery.

METHODS

A retrospective study was performed with review of medical records and images of patients with anterior circulation aneurysm undergoing aneurysmal clipping with keyhole surgery. The patient's clinical condition, imaging, surgical condition, and outcome were investigated.

RESULTS

As a result of analysis about the location of the aneurysm, middle cerebral artery (MCA) aneurysm group had a longer operation time than internal carotid artery and anterior cerebral artery aneurysm groups, but there was no significant difference in complication rate. The olfactory dysfunction occurred more than that of conventional surgery and occurred less in MCA aneurysm group than others. Scalp sensory change in the surgical site was more common in patients with unruptured aneurysms.

CONCLUSION

By accurately investigating the frequency and severity of complications associated with trans-eyebrow aneurysmal neck clipping surgery, it can help to select a surgical approach considering risk versus benefit. In addition, patient's satisfaction can be increased by providing information to patients and caregivers in advance about the outcome of this approach and the anticipated complications.

Early Restoration of Hypoperfusion Confirmed by Perfusion Magnetic Resonance Image after Emergency Superficial Temporal Artery to Middle Cerebral Artery Anastomosis

Objective

Emergency superficial temporal artery to middle cerebral artery (STA-MCA) anastomosis in patients with large vessel occlusion who fails mechanical thrombectomy or does not become an indication due to over the time window can be done as an alternative for blood flow restoration. The authors planned this study to quantitatively measure the degree of improvement in cerebral perfusion flow using perfusion magnetic resonance imaging (MRI) after bypass surgery and to find out what factors are related to the outcome of the bypass surgery.

Methods

For a total of 107 patients who underwent emergent STA-MCA bypass surgery with large vessel occlusion, the National Institute of Health stroke scale (NIHSS), modified Rankin score (mRS), infarction volume, and hypoperfusion area volume was calculated, the duration between symptom onset and reperfusion time, occlusion site and infarction type were analyzed. After emergency STA-MCA bypass, hypoperfusion area volume at post-operative 7 days was calculated and analyzed compared with pre-operative hypoperfusion area volume. The factors affecting the improvement of mRS were analyzed. The clinical status of patients who underwent emergency bypass was investigated by mRS and NIHSS before and after surgery, and changes in infarct volume, extent, degree of collateral circulation, and hypoperfusion area volume were measured using MRI and digital subtraction angiography (DSA).

Results

The preoperative infarction volume was median 10 mL and the hypoperfusion area volume was median 101 mL. NIHSS was a median of 8 points, and the last normal to operation time was a median of 60.7 hours. STA patency was fair in 97.1% of patients at 6 months follow-up DSA and recanalization of the occluded vessel was confirmed at 26.5% of patients. Infarction volume significantly influenced the improvement of mRS (p=0.010) but preoperative hypoperfusion volume was not significantly influenced (p=0.192), and the infarction type showed marginal significance (p=0.0508). Preoperative NIHSS, initial mRS, occlusion vessel type, and last normal to operation time did not influence the improvement of mRS (p=0.272, 0.941, 0.354, and 0.391).

Conclusion

In a patient who had an acute cerebral infarction due to large vessel occlusion with large ischemic penumbra but was unable to perform mechanical thrombectomy, STA-MCA bypass could be performed. By using time-to-peak images of perfusion MRI, it is possible to quickly and easily confirm that the brain tissue at risk is preserved and that the ischemic penumbra is recovered to a normal blood flow state.

Effects of an Infection Control Protocol for Coronavirus Disease in Emergency Mechanical Thrombectomy

Objective

Since the outbreak of the coronavirus disease 2019 (COVID-19) pandemic, neurointerventionists have been increasingly concerned regarding the prevention of infection and time delay in performing emergency thrombectomy procedures in patients with acute stroke. This study aimed to analyze the effects of changes in mechanical thrombectomy protocol before and after the COVID-19 pandemic on procedure time and patient outcomes and to identify factors that significantly impact procedure time.

Methods

The last-normal-to-door, first-abnormal-to-door, door-to-imaging, door-to-puncture, and puncture-to-recanalization times of 88 patients (45 treated with conventional pre-COVID-19 protocol and 43 with COVID-19 protection protocol) were retrospectively analyzed. The recanalization time, success rate of mechanical thrombectomy, and modified Rankin score of patients at discharge were assessed. A multivariate analysis was conducted to identify variables that significantly influenced the time delay in the door-to-puncture time and total procedure time.

Results

The door-to-imaging time significantly increased under the COVID-19 protection protocol (p=0.0257) compared to that with the conventional pre-COVID-19 protocol. This increase was even more pronounced in patients who were suspected to be COVID-19-positive than in those who were negative. The door-to-puncture time showed no statistical difference between the conventional and COVID-19 protocol groups (p=0.5042). However, in the multivariate analysis, the last-normal-to-door time and door-to-imaging time were shown to affect the door-to-puncture time (p=0.0068 and 0.0097). The total procedure time was affected by the occlusion site, last-normal-to-door time, door-to-imaging time, and type of anesthesia (p=0.0001, 0.0231, 0.0103, and 0.0207, respectively).

Conclusion

The COVID-19 protection protocol significantly impacted the door-to-imaging time. Shortening the door-to-imaging time and performing the procedure under local anesthesia, if possible, may be required to reduce the door-to-puncture and door-to-recanalization times. The effect of various aspects of the protection protocol on emergency thrombectomy should be further studied.

Selection of an Appropriate Surgical Method for the Management of Chronic Subdural Hematoma in a Patient with Poor Physical Status

Physical status is an important factor to consider when treating patients with chronic subdural hematomas. Surgical treatment of chronic subdural hematoma is mainly by burr hole trephination. However, operative methods must be selected after careful consideration of mortality, morbidity, and recurrence rates. In the case presented here, a chronic subdural hematoma was noted in a 65-year-old patient with several comorbidities; therefore, minimally invasive burr hole trephination was performed. After thrice repetition of the burr hole trephination procedure, a craniectomy for hematoma removal and middle meningeal artery embolization was finally conducted, followed by cranioplasty to treat a subsequent epidural hemorrhage. In the case discussed here, we review the options for the treatment of chronic subdural hematoma and evaluate the factors that should be considered in determining the appropriate surgical course. Despite poor patient physical status, minimally invasive operation may not always be the best option. If the patient is at high risk for recurrent subdural hematoma, craniotomy with hematoma removal may be a better choice.

Abstract TP51: Comparison of Recanalization Rate Between Intravenous Actilyse and Intravenous Actilyse With Mechanical Thrombectomy in Larger Artery Occlusion Ischemic Stroke Patients

Background and Purpose: According to the guidelines for acute ischemic stroke treatment, intravenous tissue plasminogen activator (IV-tPA) administration is the first line treatment and intraarterial thrombolysis (IA-Tx) with retrieval stent is regarded as additional treatment. But recanalization rate of large artery intracranial occlusion disease (LAICOD) after IV-tPA is very low and inconsistent according to the reports. Authors tried to find out the early recanalization rate of IV-tPA in patients with LAICOD.

Methods: 278 with anterior circulation occlusion patients were included in this analysis. Brain CT-angiography (CTA) was an initial imaging study and acute stroke MRI was following after the IV-tPA. Recanalization rate was studied with initial CTA and followed MRA image. And other clinical outcomes were compared with IV-tPA, IA-Tx or perfusion/diffusion-mismatching (P/D-mismatching) or not.

Results: The overall recanalization rate of LAICOD after IV-tPA was 15.5% (43/278), 86.0% (86/100) in patients treated with IA-Tx after IV-tPA, and 78.7% (48/61) in IA-Tx without IV-tPA. In patients who underwent IA-Tx after IV-tPA, P/D-mismatching patients showed higher recanalization rate (88.2% = 67/76 vs. 66.7% = 16/27, p = 0.020), and higher incidence of favorable outcomes (63.2% = 48/76 vs. 12.5% = 3/27, p = 0.000) compared to P/D-matching patients.

Conclusion: This study suggests that recanalization rate after IV-tPA for the patients with acute ischemic stroke due to LAICOD is very low and IV-tPA before IA-Tx does not significantly influence on the neurologic outcomes and complication rates. Bridging treatment is effective, for stroke patient management, but authors would like to propose that IA-Tx might be applied as the first therapy option, just like in the management of acute myocardial infarction patients.

Injectable hydrogels based on MPEG–PCL–RGD and BMSCs for bone tissue engineering

The aim of this study was to investigate the osteogenic potential of BMSCs seeded on RGD-conjugated methoxy polyethylene glycol-polycaprolactone (MP–RGD) in vitro and in vivo.

Hemifacial Spasm Caused by a Vein: A Case Report

Hemifacial spasm (HFS) caused by a venous offender is rare, and its clinical course and optimal surgical strategy are unclear. A case of 57-year-old male who had an HFS caused by a venous offender is described in this report. Frontalis, orbicularis oculi, orbicularis oris, and mentalis muscles were involved while his platysma muscle showed no spasm. He was treated successfully with microvascular decompression using Teflon felt and 12 months outcome was excellent without any complications. Lateral spread response was not observed in the facial electromyography during the whole operation. Adequate visualization of the facial nerve root exit zone and meticulous exploration for offenders are necessary to avoid surgical failure and reoperation.

Determining the Lower Limit of Cerebral Perfusion Pressure in Patients Undergoing Decompressive Craniectomy Following Traumatic Brain Injury

BACKGROUND

In patients with severe traumatic brain injury (TBI), maintaining systolic blood pressure >90 mm Hg, intracranial pressure (ICP) <20 mm Hg and cerebral perfusion pressure (CPP) >60-70 mm Hg is recommended to improve clinical outcomes. A recommended CPP value for patients treated with decompressive craniectomy (DC) has not been clearly studied. We aimed to determine whether the targeted CPP can be lowered in patients treated with DC.

METHODS

This retrospective analysis included 191 patients who underwent DC for TBI. All patients were monitored for ICP and blood pressure during and after DC. CPP was calculated every 2 hours after DC. Patient outcomes were evaluated 6 months after initial treatment.

RESULTS

Mean patient age was 50.8 years (median 52 years), and 79.1% of patients were male. Initial Glasgow Coma Scale score was 6.2 (median 6). Comparing clinical outcome based on postoperative ICP >25 mm Hg and <25 mm Hg, Extended Glasgow Outcome Scale score was 1.4 (>25 mm Hg) and 4.9 (<25 mm Hg) (P = 0.000). In patients maintained at ICP <25 mm Hg, mortality was increased significantly with CPP between 35 mmHg and 30 mm Hg (χ², P = 0.029 vs. P = 0.062).

CONCLUSIONS

Patients with TBI who underwent DC with postoperative ICP maintained <25 mm Hg and CPP >35 mm Hg may have similar mortality as patients with CPP >60-70 mm Hg who did not undergo DC. For patients with TBI who undergo DC, targeted CPP might be lowered to 35 mm Hg if ICP is maintained <25 mm Hg.

Cross-transfusion of postshock mesenteric lymph provokes acute lung injury

OBJECTIVE

Substantial investigation has implicated mesenteric lymph as the mechanistic link between gut ischemia/reperfusion (I/R) and distant organ injury. Specifically, lymph diversion prevents acute lung injury (ALI) in vitro, and bioactive lipids and proteins isolated from postshock mesenteric lymph (PSML) maintain bioactivity in vitro. However, Koch's postulates remain to be satisfied via direct cross-transfusion into a naïve animal. We therefore hypothesized that real time cross-transfusion of postshock mesenteric lymph provokes acute lung injury.

METHODS

One set of Sprague-Dawley rats (lymph donors) was anesthetized, with the mesenteric lymph ducts cannulated and exteriorized to drain freely into a siliconates plastic cup; concurrently, a second group of rats ( lymph recipients) was anesthetized, with a cannula inserted into the animal's right internal jugular vein. Blood was removed from the donor rats to induce hemorrhagic shock (MAP of 35 mmHg × 45 min). The recipient rats were positioned 10 cm below the plastic cup, which emptied into the jugular vein cannula. Thus, mesenteric lymph from the shocked donor rat was delivered to the recipient rat at the rate generated during shock and the subsequent 3 h of resuscitation.

RESULTS

Neutrophil (PMN) accumulation in the lungs was substantially elevated in the postshock lymph cross-transfusion group compared to both sham lymph cross-transfusion and instrumented control (MPO: 9.42 ± 1.55 versus 2.81 ± 0.82 U/mg lung tissue in postshock versus sham lymph cross-transfusion, n = 6 in each group, P = 0.02). Additionally, cross-transfusion of PSML induced oxidative stress in the lung (0.21 ± 0.03 versus 0.10 ± 0.01 micromoles MDA per mg lung tissue in lymph cross-transfusion versus instrumented control, n = 6 in each group, P = 0.046). Furthermore, transfusion of PSML provoked lung injury (BAL protein 0.77 ± 0.18 versus 0.15 ± 0.02 mg/mL protein in BALF, postshock versus sham lymph cross-transfusion, n = 6 in each group, P = 0.004).

CONCLUSION

Cross-transfusion of PSML into a naïve animal leads to PMN accumulation and provokes ALI. These data provide evidence that postshock agents released into mesenteric lymph are capable of provoking distant organ injury.

Sorafenib combined with carboplatin/paclitaxel for advanced non-small cell lung cancer: A phase I subset analysis

7194

Background: The EGFR is often overexpressed in advanced non-small-cell lung cancer (NSCLC) - a solid tumor associated with a poor prognosis. Oncogenic k-ras mutations and raised serum VEGF predict poor outcome in NSCLC. In vitro targets of sorafenib include Raf, which is downstream of EGFR and k-ras. Sorafenib also targets the VEGFR-2/-3 tyrosine kinases, involved in tumor angiogenesis. Preclinically, sorafenib targets the tumor and tumor endothelium to inhibit tumor growth. Methods: This subanalysis of a Phase I trial with a Phase II expansion in NSCLC was performed to evaluate the safety (adverse events graded by NCI-CTC 2.0) and preliminary anti-tumor activity (response by RECIST, PFS, TTP) of oral sorafenib combined with carboplatin/paclitaxel in 15 patients with advanced, progressive NSCLC. Carboplatin (AUC 6)/paclitaxel (225 mg/m2) was administered on Day 1, and sorafenib (100, 200, or 400 mg bid) on Days 2–18 of each 21-day treatment cycle. Results: Drug-related adverse events were reported by 73% (11/15) of patients, but were mostly grade 1–2 (53%) in severity; none was grade 4. The most common drug-related events at any grade were dermatologic (Hand-foot skin reaction [20%]; rash [60%]), and gastrointestinal (diarrhea [20%]; anorexia [13%]). There were no drug-related cardiovascular adverse events. Three patients reported grade 1–2 drug-related bleeding events (epistaxis n = 2; other n = 1). Of the 14 evaluable patients, four (29%) had a confirmed PR as best response, seven (50%) had SD, and three (21%) had PD. Therefore, the disease control rate (objective response plus SD) was 79%. Duration of response was 25 weeks. Median PFS was 34 weeks. Discussion: This sorafenib combination was well tolerated and showed promising preliminary anti-tumor activity in patients with advanced, progressive NSCLC.

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Induction of T lymphocyte apoptosis by treatment with glycyrrhizin

The effect of glycyrrhizin (GL), a Chinese herbal drug extracted from licolice roots, on murine lymphocytes for inducing apoptotic cell death was studied. Addition of GL (25-400 micrograms/ml) to cultured splenocytes and thymocytes from BALB/c mice definitely promoted DNA fragmentation. A single injection of GL (100 micrograms/mouse) into BALB/c mice did not cause any detectable DNA fragmentation or cell death of splenocytes and thymocytes. Cytofluorometric analysis of these cells, however, demonstrated a reduction in mitochondrial transmembrane potentials (delta psi m). Repeated injections of GL (100 micrograms/mouse/day) into mice for 7 days actually resulted in induction of low grade DNA fragmentation selectively in splenocytes. Cell population analysis of viable lymphocytes suggested that both CD4+ Th lymphocytes and CD8+ Tc lymphocytes may have been relatively more sensitive than B220+ B lymphocytes for the apoptotic cell death. We concluded from these results that GL acts as a rather selective inducer of mature T lymphocyte apoptosis with a reduction in delta psi m potentially preceding lymphocyte death.