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Endovascular treatment (EVT) is the main treatment for peripheral artery disease (PAD). Despite advances in device development, the restenosis rate remains high in patients with femoropopliteal lesions (FP). This study aimed to evaluate the effectiveness of exercise training in reducing the 1-year in-stent restenosis rate of bare metal nitinol stents for FPs. This prospective, randomized, open-label, multicenter study was conducted from January 2017 to March 2019. We randomized 44 patients who had claudication with de novo stenosis or occlusion of the FP into an intensive exercise group (n = 22) and non-intensive exercise group (n = 22). Non-intensive exercise was defined as walking for less than 30 min per session, fewer than three times a week. We assessed exercise tolerance using an activity meter at 1, 3, 6, and 12 months, and physiotherapists ensured maintenance of exercise quality every month. The primary endpoint was instant restenosis defined as a peak systolic velocity ratio > 2.5 on duplex ultrasound imaging. Kaplan-Meier analysis was used to evaluate the data. There were no significant differences in background characteristics between the groups. Six patients dropped out of the study within 1 year. In terms of the primary endpoint, intensive exercise significantly improved the patency rate of bare nitinol stents at 12 months. The 1-year freedom from in-stent restenosis rates were 81.3% in the intensive exercise group and 47.6% in the non-intensive exercise group (p = 0.043). No cases of stent fracture were observed in the intensive exercise group. Intensive exercise is safe and reduces in-stent restenosis in FP lesions after endovascular therapy for PAD. Clinical trial registration: University Hospital Medical Information Network Clinical Trials Registry (No. UMIN 000025259)., (© 2022. The Author(s).)

Chronic kidney disease is a prognostic factor for cardiovascular disease. Worsening renal function (WRF), specifically, is an important predictor of mortality in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention (PCI). We evaluate the prognostic impact of mid-term WRF after PCI on future cardiovascular events. We examined the renal function data of 1086 patients in the first year after PCI using the SHINANO 5-year registry. Patients were divided into two groups, mid-term WRF and non-mid-term WRF, and primary outcomes were major adverse cardiovascular events (MACE) and death. Mid-term WRF was defined as an increase in creatinine (≥ 0.3 mg/dL) in the first year after PCI. Mid-term WRF was found in 101 patients (9.3%), and compared to non-mid-term WRF, it significantly increased the incidence of MACE (p < 0.001), and all-cause death (p < 0.001), myocardial infarction (p = 0.001). Furthermore, mid-term WRF patients had higher incidence of future heart failure (p < 0.001) and new-onset atrial fibrillation (p = 0.01). Patients with both mid-term WRF and chronic kidney disease had increased MACE compared to patients with either condition alone (p < 0.001). Similarly, patients with mid-term WRF and acute kidney injury had increased MACE compared to patients with either condition alone (p < 0.001). Multivariate Cox regression analysis revealed mid-term WRF as a strong predictor of MACE (hazard ratio: 2.50, 95% confidence interval 1.57-3.98, p < 0.001). Mid-term WRF after PCI negatively affects MACE, as well as future admission due to heart failure and new-onset atrial fibrillation, chronic kidney disease, and acute kidney injury., (© 2021. The Author(s).)

Objective Despite reports on the effects of ankle-brachial index (ABI) improvement following endovascular therapy (EVT) on the limb prognosis, studies evaluating cardiovascular events are limited. We investigated whether or not ABI improvement 1 year following EVT was associated with cardiovascular events. Methods The I-PAD NAGANO registry is an observational multicenter cohort study that enrolled 337 patients with peripheral artery disease (PAD) who underwent EVT between August 2015 and July 2016. From this cohort, we identified 232 patients whose ABI data 1 year following EVT were available, after excluding patients with critical limb ischemia. We divided the patients into two groups according to the degree of ABI improvement 1 year following EVT (ΔABI) - the ΔABI <0.15 group and the ΔABI ≥0.15 group - and compared the outcomes. The primary endpoint was major adverse cardiovascular events (MACEs), including all - cause death, myocardial infarction (MI), and stroke. The secondary endpoints were major adverse limb events (MALEs), defined as a composite of target lesion revascularization and major amputation, all - cause death, MI, and stroke. The median follow-up period was 3.3 years. Results The incidence of MACEs was significantly higher in the ΔABI <0.15 group than in the ΔABI ≥0.15 group (ΔABI <0.15 vs. ΔABI ≥0.15, 25.8% vs. 11.9%, log-rank p=0.036), as was the incidence of stroke (14.1% vs. 2.2%, log-rank p=0.016). A Cox regression analysis revealed that ΔABI ≥0.15 was significantly associated with fewer MACEs (hazard ratio 0.38, 95% confidence interval 0.17-0.83, p=0.016). Conclusion An increase in ABI ≥0.15 at 1 year following EVT was a predictor of reduced MACEs.

The case was a 76-year-old man with chronic limb-threatening ischemia. Plain old balloon angioplasty (POBA) was performed on the popliteal artery. Subsequently, he suffered from cellulitis around the POBA site, followed by reocclusion. Staphylococcus aureus was detected in a blood culture. After re-revascularization with POBA, both purulent gonitis and an infected popliteal aneurysm were observed to occur. We performed aneurysmectomy and bypass grafting with the saphenous vein and then continued antibiotic therapy. Although treatment consisted of endovascular therapy (EVT) with nothing left behind, management was difficult because of secondary infectious complications. We conclude that prophylactic antibiotics before EVT should be considered in such cases.

Why a catheter can be correctly placed in the ventricle by inserting perpendicular to the frontal bone on the ventricular drainage? We performed a study on the accuracy of a path perpendicular to the skull surface into the anterior horn using computed tomography (CT), and a clinical study. Twenty patients were studied on CT images. Using the curved multi-planar reconstruction method, the curved frontal skull and brain were reconstructed to flat structures, and perpendicular lines were drawn from the flat surface to the foramen of Monro on the reconstructed images. In clinical practice, we made a device which guided a catheter inserting perpendicular to the frontal skull surface, and used it in the ventricular drainage surgery for 148 hydrocephalic patients (158 surgeries). We discovered that the curved surface of the frontal bone around Kocher's point represents the surface of a globe (mean radius, 75.9 ± 4.3 mm) centering on the foramen of Monro. The distribution of points ranged from 13.5-43.5 mm (mean, 43.5 ± 6.1 mm) to the midline, with points appearing more laterally as ventricular size increased. A catheter was placed in the ventricle in 148 surgeries (99.4%), and the catheter reached the ventricle with correct orientation toward the foramen of Monro in 128 (81.0%). The reason why the ventricular insertion perpendicular to the frontal bone surface can provide a consistent path toward the foramen of Monro is that the curved surface of the frontal bone around Kocher's point represents the surface of a globe centered on the foramen of Monro.

Five recent multicenter randomized controlled trials (RCTs) have clearly shown the superiority of mechanical thrombectomy in large vessel occlusion acute ischemic stroke compared to systemic thrombolysis. Although 14 hospitals in Ishikawa prefecture have uninterrupted availability of systemic thrombolysis, mechanical thrombectomy is not available at all of these hospitals. Therefore, we established a Kanazawa mobile embolectomy team (KMET), which could travel to these hospitals and perform the acute reperfusion therapy. In this article, we report early treatment outcomes and validate the effectiveness of a network between affiliated hospitals and KMET. Between January 2014 and December 2015, 48 patients, aged 45-92 years (mean: 73.0 years), underwent acute reperfusion therapy provided by KMET in 10 affiliated hospitals of Kanazawa University Hospital. The pre-treatment NIHSS scores ranged from 5 to 39 (mean: 19.1). ASPECTS+W ranged from 1 to 11 (mean: 7.3). Successful revascularization, defined as thrombolysis in cerebral infarction (TICI) 2b or 3, was achieved in 38/48 cases (80%), and a good outcome, defined as modified Rankin Scale (mRS) score from 0 to 2 at 90 days after the treatment, was achieved in 24/48 cases (50%). There were two cases of intracranial bleeding (4%). Mean time from onset to recanalization was 297 min. These results, which are similar to those of five previous RCTs, suggest that a collaborative network between affiliated hospitals and KMET is effective for acute reperfusion therapy in local areas wherein experienced neuroendovascular specialists are insufficient., Competing Interests: The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices in the article. All authors who are members of The Japan Neurological Society (JNS) have registered online Self-reported COI Disclosure Statement Forms through the website for JNS members.

Acute myocardial infarction (AMI) is rare among women of childbearing age. Spontaneous coronary artery dissection (SCAD), a rare cause of AMI, is the leading cause of pregnancy-associated acute myocardial infarction (PAMI), and is associated with critical complications, including pump failure, ventricular arrhythmias, and sudden death. Optimal treatment strategies for SCAD and PAMI remain unclear. In this report, we describe a case of PAMI due to SCAD presenting as cardiopulmonary arrest. After comprehensive treatment including advanced cardiovascular life support, emergent percutaneous coronary intervention (PCI), therapeutic hypothermia, and emergent Cesarian section for intrauterine fetal death, she survived without neurological sequelae. Intensive medication for pump failure was subsequently required, and she was discharged with adequately controlled heart failure, despite revealing stent lumen obstruction by cardiac computed tomography. On close follow-up for one year, she has remained free of further cardiac events. < Learning objective: Pregnancy-associated acute myocardial infarction (PAMI) is a rare but occasionally complicated event. Spontaneous coronary artery dissection is the principal mechanism of PAMI. The clinical presentation of PAMI can range from asymptomatic to cardiac shock and fatal ventricular fibrillation. We aimed to present a sudden cardiac arrest case due to PAMI. Intensive and comprehensive medical care succeeded in her return to spontaneous circulation and discharge without neurological sequelae.>.

Objective: Opening the temporal part of the choroidal fissure (CF) makes it possible to expose the crural cistern, the ambient cistern, and the medial temporal lobe. We examined the microsurgical anatomy and the surgical indications for use of the trans-CF approach., Methods: The microsurgical anatomy encountered in the trans-CF approach for lesions in and around the ambient cistern was studied in three cadavers. On the basis of these cadaveric studies, the trans-CF approach was used during surgery in three live patients with such lesions., Results: The angiographic "plexal point," which indicates the entrance of the anterior choroidal artery as it enters the temporal horn of the lateral ventricle, was thought to be a key anatomic landmark of the trans-CF approach. A cortical incision for entry into the temporal horn should be made in the inferior temporal gyrus to minimize the potential damage to the optic radiations and to the speech centers. After the CF is opened posteriorly to the plexal point between the tenia fimbria and the choroid plexus, the posterior cerebral artery (PCA) in the ambient cistern can be observed with minimal caudal retraction of the hippocampus. In this study, surgical procedures using the trans-CF approach were successfully performed on patients with high-positioned P2 aneurysms whose PCA ran close to the plexal point or higher, whose medial temporal arteriovenous malformations were fed mainly by the PCA, and whose tentorial hiatus meningiomas protruded into the temporal horn through the CF, with no resulting postoperative visual or memory disturbances., Conclusion: The trans-CF approach is especially useful in surgery for lesions in and around the ambient cistern.

A 37-year-old female with toxemia of pregnancy suffered sudden headache and loss of consciousness on the day following a cesarean delivery. Computed tomography revealed subarachnoid hemorrhage (SAH). Vertebral angiography revealed a fusiform dilatation near the origin of the right superior cerebellar artery (SCA) with distal luminal narrowing. She underwent surgery within 24 hours of the ictus. A SAH clot was carefully removed from the prepontine cistern, and subadventitial discoloration was seen in the wall of the right SCA just distal to the aneurysmal protuberance (rupture site). The dissecting aneurysm was treated with body clipping by directly clipping the rupture site and with additional wrapping of the proximal SCA, including the aneurysmal protuberance and discolored site. The postoperative clinical course was uneventful. Postoperative angiography revealed complete obliteration of the aneurysm and patency of the SCA. Therapeutic intervention should be considered for patients with ruptured dissecting aneurysm who present with recurrent SAH.

Drilling of the skull base bone without damaging the important inside structures and with the correct orientation is very difficult even with the help of the anatomical landmarks. Monitoring of the location and direction of the drill tip and indications of the removed part of the bone during the drilling procedure enhances safety and achieves less invasive neurosurgery. We have developed a novel cranionavigator by combining a high-speed drill with a neurosurgical navigation system. To reduce the positional error to less than 1.5 mm, the position sensor (magnetic field sensor) must be attached 5 cm from the metallic fan portion of the drill and the sensor kept at least 10 cm away from the operating microscope. Simulation studies with the cranionavigator using two dried skulls and three cadaver heads were performed before clinical application. Clinically, this surgical instrument was used in four patients with the skull base tumor. The cranionavigator helped to safely drill the skull base bone in a shorter time by dynamic and real-time display of the precise operating site and extent of bone drilling on the preoperative computed tomography scans or magnetic resonance images. The cranionavigator is a very helpful instrument for skull base surgery in the hands of neurosurgeons with extensive expertise and anatomical knowledge.

To predict the efficacy of anticancer drugs such as ACNU [1-(4-amino-2-methyl-5-pyrimidinyl)-methyl-3-(2-chloroethyl-3-nitrosoure a hydrochloride] and MCNU [1-(2-chloroethyl)-3-(methyl-alpha-D-glucopyranos-6-yl)-1-nitrosou rea] in the treatment of malignant gliomas, the usefulness of the chick embryo assay as a chemosensitivity test was studied. Fifty-seven surgical specimens including benign tumors were examined by this method. All tumor specimens tested could be grafted on the chorioallantoic membrane of chick embryo; the evaluable ratio was 100%. Twenty-one patients with previously untreated malignant glioma could be evaluated to test the predictability of the clinical effects, judged by computed tomography. There were 7 (78%) instances in which the assay response corresponded to a clinical partial response (true-positive). There were 2 (22%) false-positives for the assay, 0 (0%) false-negative and 12 (100%) true-negatives. The over-all predictive accuracy was 90% (19/21). Thus, a high-degree of positive association exists between the chick embryo assay and the clinical outcome. This in vivo assay system for malignant glioma is advantageous for chemosensitivity tests because of its convenience, rapidity, and inexpensiveness.

The neurotoxicity of local administration of nitrosoureas in malignant gliomas was investigated clinicopathologically. Twenty patients were entered into this study: 13 were treated with 1-(4-amino-2-methyl-5-pyrimidinyl)methyl-3-(2-chloroethyl)-3-nitrosourea hydrochloride (ACNU) and 7 with methyl 6-[3-(2-chloroethyl-3-nitrosoureido]-6-deoxy-alpha-D-glucopyranoside (MCNU). On the average, a single dose of 20 mg of ACNU was administered 15 times, for a total dose of 295 mg in each case, while a single dose of 11 mg of MCNU was given 2 times, for a total dose of 24 mg. These nitrosoureas provoked greater toxicity when the administration dose was larger or the indwelling multiperforated Silastic basket was in direct continuity with the ventricle or the basal cistern. Usually ACNU was well tolerated, whereas MCNU induced marked brain edema. Side effects consisted of headache, nuchal stiffness, vomiting, motor weakness, and cranial nerve palsy for ACNU, and headache, vomiting, abnormal respiration, and arrhythmia for MCNU. Pathological changes were represented by capsule formation, spongy degeneration and reactive gliosis of adjacent white matter, occlusion of neighboring arteries, and demyelination of cranial nerves in the patients treated with ACNU, while they were represented by focal brain necrosis in two patients treated with MCNU. The differences in neurotoxity of ACNU and MCNU conceivably derive from the different blood-brain delivery of these drugs.

Centrum medianum (CM) afferent pathways, which are involved in pain sensation, were analyzed using physiological techniques. Thirty-four neurons in the gigantocellular nucleus (nucleus gigantocellularis medullae oblongatae, GC) in cats were recorded intracellularly. Of these, 5 (15%) did not respond to electrical stimulation applied to any of the 4 limbs. Twenty-nine (85%) showed spike potentials that were superimposed on excitatory post-synaptic potentials (EPSPs) with an amplitude of 7.2 mV (n = 101) and a duration of 6.8 ms. The latencies from contra- and ipsilateral forelimb, contra- and ipsilateral hindlimb to the GC were 9.3 (n = 25), 7.2 (n = 23), 12.9 (n = 28), and 10.9 ms (n = 25), respectively. Of these responding neurons, 19 (66%) responded to stimuli to all 4 limbs, 7 (24%) to 3 limbs, 1 (3%) to 2 limbs, and 2 (7%) to 1 limb. These afferent neurons in the GC showed spike potentials without EPSPs after stimulation of the CM in the thalamus. Extracellular activities of 37 CM neurons were also tested. Of these, 4 neurons responded to GC stimulation with a short latency of 1.6 ms. Another 33 responded with a long latency of 6.7, and 11 of them were able to follow GC stimulation of over 200 Hz with a fixed long latency; 22 responded with varying long latencies but were not able to follow stimuli over 15 Hz. Three-quarters of the CM neurons received ipsilateral inputs from the GC, and the other contralateral inputs. Three CM neurons responded to stimulation of the GC in quasi-intracellular records. These findings suggest that some ascending fibers from the GC terminate on CM neurons and play a role in pain sensation.

A case of Nelson's syndrome with an adrenocorticotropic hormone-secreting pituitary chromophobe microadenoma is presented to demonstrate the potential capability of rapid sequential (dynamic) computerized tomography (CT) scanning for the diagnosis of a pituitary microadenoma that was isodense with the adjacent pituitary gland on conventional enhanced CT scanning. The dynamic CT scans showed transient high density in this microadenoma contrasting with the pituitary gland in the early-enhancement phase, and thereafter the contrast density was indistinguishable from that of the pituitary gland in the delayed-enhancement phase. For the detection of pituitary microadenoma, dynamic CT combined with subsequent delayed CT scanning can provide diagnostic and localizing information.

If meningeal hemangiopericytoma could be diagnosed prior to operation, the neurosurgeon might be better prepared to deal with excessive bleeding during the operation. This type of tumor should be completely excised because of the high risk of recurrence and remote metastasis. Computed tomography as well as cerebral angiography would aid in the preoperative diagnosis of hemangiopericytoma. Early detection and periodic observation by computed tomography may minimize the morbidity and mortality associated with late detection.

The plasma volume, central venous pressure and water balance of 24 patients were measured around the 1st and 2nd week after early operations for ruptured aneurysms. All of the patients had been successfully treated by induced hypertension therapy for delayed vasospasm. Plasma volume was measured by the RI method using RISA. The average plasma volume of 16 patients was 58.3 +/- 6.2 ml/kg. This group had 200 ml of 25% albumin every day. It was 48.2 +/- 6.2 ml/kg for 8 patients without albumin administration. The average CVP was 11.3 +/- 2.2 cm on the albumin group. It was 5.3 +/- 1.5 cm on the non-albumin group. The value of plasma volume and CVP was statistically higher in the albumin group than in the non-albumin group. Water balance was positive in about half of the albumin group. It was negative in the non-albumin group. Three patients of the albumin group had pulmonary oedemas and one patient of the non-albumin group had congestive heart failure.

Two cases of Rathke's cleft cyst are presented. The cysts showed as high-density lesions on plain CT with slight enhancement with contrast medium. They appeared as a hyperintense mass in the T 1-weighted magnetic resonance images. Preoperative diagnosis is very important because different sellar cystic lesions require different treatment.