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Literature has yet to establish an appropriate treatment strategy for large arteriovenous malformations (AVMs) and AVMs located in eloquent areas. In this study, the treatment outcomes of hypofractionated stereotactic radiotherapy (HSRT) with CyberKnife (CK) for large AVMs and AVMs in eloquent areas were evaluated. This study retrospectively evaluated 38 consecutive patients with AVMs treated with HSRT in the Japanese Red Cross Medical Center between August 2010 and July 2015. Obliteration rates and hemorrhage rates at 3- and 5-years of follow-up were calculated. Factors for hemorrhage and obliteration were analyzed with logistic regression analysis. Fourteen (36.8%) patients had a history of hemorrhage. Twenty (52.6%) AVMs were larger than 10 mL, and 34 (89.5%) AVMs were located in eloquent areas. The majority of the AVMs (84.2%) were classified into high grades (grades 3, 4, and 5) using the Spetzler-Martin grading scale. The median modified radiosurgery-based AVM score was 2.05, and the median Virginia Radiosurgery AVM Score was 3. The mean marginal dose was 24.5 ± 2.5 Gy. Twenty-three and 15 patients received three- and five-fraction stereotactic radiotherapy, respectively. At 3 and 5 years posttreatment, two (2.0%/year) and six (6.7%/year) patients had hemorrhage with obliteration rates of 15.2% and 16.7%, respectively. AVM localization in eloquent areas was a risk factor for obliteration failure. This study revealed that HSRT with CK for large AVMs and AVMs located in eloquent areas contributed to hemorrhage risk reduction and obliteration, at least in the early stages.

Background: Anterior clinoidectomy is an established procedure used to decompress the optic nerve, mobilize the internal carotid artery (ICA), or enlarge the retrocarotid space. However, its use carries the risk of optic nerve injury. In certain surgeries, such as those for internal carotid aneurysms, propose modification to the anterior clinoidectomy for enlarging the retrocarotid space, especially in operations for ICA aneurysms. Methods: After the anterior clinoid process (ACP) is sufficiently exposed, the internal cancellous bone or pneumatization can be removed through a small window created at its lateral edge to reveal the compact bone of the optic canal. Since the compact bone of the inferior surface facing the ICA is absent or very thin, the ACP can be removed by drilling through the anchoring compact bone with the optic canal in direct sight. Results: In 10 consecutive internal carotid aneurysm cases, the ACP was successfully removed without opening of the optic canal to enlarge the retrocarotid space. Conclusions: Anterior clinoidectomy can be performed to enlarge the retrocarotid space without opening the optic canal from outside the dura.

Summary:. Aplasia Cutis Congenita (ACC) in the scalp is a rare congenital malformation. The treatment for ACC with large defects involving the scalp, bone, and the dura is challenging. Local debridement of necrotic tissue is important to prevent lethal complications such as infection and meningitis. However, debridement has the risk of damaging the sagittal sinus or the dura. Recent developments in ultra-high-frequency ultrasound(US) systems provide frequencies of 70 MHz and capability resolution as fine as 30 μm, which could allow precise imaging of small and thin anatomical structures. The study aimed to describe the methods of precise evaluation of the defect in the scalp and safe debridement using ultra-high-frequency US. This is the first report on direct observation of a newborn’s brain using ultra-high-frequency US. The boy was delivered spontaneously with a large defect of the scalp and bone. After 14 days, due to signs of infection, local debridement was performed carefully under ultra-high-frequency US-based evaluation. The dura, the sagittal sinus, and the small anatomical structures such as arachnoid granulations could be observed. Because the brain herniation gradually aggravated, dural reconstruction using fascia lata and scalp reconstruction using transposition flap was performed. Finally, good skin coverage over the defects was obtained. This method minimizes the risk of damaging the sagittal sinus and the brain parenchyma, which may cause fatal complications. Although further clinical investigations will be required to confirm its efficacy, ultra-high-frequency US has the potential to be a useful device for ACC treatment.

Abstract Background Although brain arteriovenous malformations (AVM) usually remain asymptomatic during pregnancy, they can cause intracranial hemorrhage and lead to serious neurological deficits. Nowadays, it is accepted that treatment of a ruptured brain AVM during pregnancy should be based on neurologic, not obstetric, indications. Recently, endovascular treatment has been recognized as a treatment option associated in pregnant patients with brain AVMs. Case presentation A 34-year-old woman presented at 25 weeks of gestation with a history of severe headache followed by severe consciousness disturbance. Brain CT showed a subcortical hematoma in the right occipital lobe along with bilateral intraventricular hematomas. A cerebral angiogram was performed to confirm the diagnosis, which revealed right occipital AVM. At 27 weeks of gestation, endovascular embolization of the AVM was attempted under general anesthesia. The feeding artery and the nidus were simultaneously obliterated by injection of 50 % n-butyl-cyanoacrylate. As a result, the blood flow into the nidus was drastically decreased and the risk of re-bleeding was substantially reduced. At 38 weeks of gestation, elective cesarean section was performed to deliver the baby under combined spinal-epidural anesthesia (CSEA). An infant weighing 3665 g was delivered, with Apgar scores of 8 and 9 at 1 and 5 min, respectively. Postoperative analgesia was provided by a continuous infusion of ropivacaine via the epidural catheter. The infant was confirmed as not having any congenital anomalies. On POD 5, both of the patient and the infant were discharged home without any medical problems. The mother has shown no evidence of re-bleeding from the intracranial lesion since, and the infant is thriving well. Conclusions Endovascular treatment in pregnant women is associated with various unique concerns. However, it can be carried out safely and effectively and is useful not only for saving the mother’s life but also for allowing the pregnancy to continue to term.

Sinking skin flap syndrome (SSFS), also known as syndrome of the trephined, is one of the complications of decompressive craniectomy. The definitive treatment for the condition is cranioplasty, but there are cases where that is not an option. We report a seventy-seven-year-old male patient with disturbance of consciousness after removal of infected bone flap and debridement. The skin showed marked depression and SSFS was diagnosed. The scalp had contracted due to infection and debridement so as to need skin grafting. Cranioplasty with a full-size bone flap was not an option. Reconstruction of the temporal line with autologous rib graft was performed. The patient became alert after the operation. [ABSTRACT FROM AUTHOR]

Recently, the survival of the high-risk population of preterm infants has steadily improved, and the severity of prematurity is a growing threat of gestational-age-related fatal conditions. Posthemorrhagic hydrocephalus (PHH) is the most common but serious neurological complication in premature infants, which can have life-threatening consequences during the acute phase in the neonatal period and life-long psychomotor and cognitive sequelae in their later life. Although neonatologists, pediatric neurologists, and pediatric neurosurgeons have investigated a diversified strategy for several decades, a consensus on the best management of PHH in premature infants still must be reached. Several approaches have tried to reduce the incidence of intraventricular hemorrhage (IVH) and mitigate the effect of IVH-related hydrocephalus. This paper reviews and discusses the clinical feature of PHH in premature infants, general/nonsurgical management of prematurity for IVH prevention, and posthemorrhagic management, and how and when to intervene. [ABSTRACT FROM AUTHOR]

Background: A dissection beginning from a point distal to the endpoint of the carotid endarterectomy (CEA) is called distal carotid artery dissection (CAD), which is known as one of the significant surgical complications of CEA. Case Description: We present a case of distal CAD as a perioperative complication after CEA using indwelling shunt. We estimated this pathophysiology to be caused by the mechanical conflict of the inflated balloon with the elongated styloid process. Conclusion: Since a distal CAD can cause severe, irreversible neurological deficits, preoperative assessment of the styloid process should be routinely performed in CEA. [ABSTRACT FROM AUTHOR]

Background: Cerebellar hemorrhage is rare in children, and its cause is usually vascular disorders such as arteriovenous malformations or hematological disorders. Case Description: A previously healthy 10-year-old girl presented with a loss of consciousness following sudden headache and vomiting. A non-contrast brain computed tomography (CT) scan revealed a massive cerebellar hemorrhage with obstructive hydrocephalus; however, subsequent CT angiography (CTA) showed no vascular abnormalities. An emergency craniotomy was performed to evacuate the hematoma, and histological analysis of the specimen obtained from the tissue surrounding the hematoma revealed a pilocytic astrocytoma (PA). Six months after the ictus, her recovery was scored at 2 on the modified Rankin Scale. Conclusion: PA can be a cause of critical cerebellar hemorrhage. In this case of life-threatening massive hematoma, CTA was useful to exclude a major vascular pathology and to save time. [ABSTRACT FROM AUTHOR]

Interventions to the gut microbiome manipulate the gut–brain axis and could be useful in the treatment of anxiety and depression. In this study, we demonstrated that administration of the bacterium Paraburkholderia sabiae reduces anxiety-like behavior in adult zebrafish. P. sabiae administration increased the diversity of the zebrafish gut microbiome. Linear discriminant analysis Effect Size (LEfSe) analysis revealed that the populations of Actinomycetales including Nocardiaceae, Nocardia, Gordoniaceae, Gordonia, Nakamurellaceae, and Aeromonadaceae were reduced, whereas those of Rhizobiales including Xanthobacteraceae, Bradyrhizobiaceae, Rhodospirillaceae, and Pirellulaceae were increased in the gut microbiome. Functional analysis using Phylogenetic Investigation of Communities by Reconstruction of Unobserved States (PICRUSt2) predicted that P. sabiae administration altered taurine metabolism in the zebrafish gut, and we demonstrated that P. sabiae administration increased the taurine concentration in the brain. Since taurine functions as an antidepressant neurotransmitter in vertebrates, our results suggest that P. sabiae could improve anxiety-like behavior in zebrafish via the gut-brain axis.

Abstract Background Perforation of a duodenal diverticulum is a rare complication that may become fatal with a delay in appropriate treatment. However, the optimal treatment for perforated duodenal diverticulum remains controversial, ranging from conservative therapy to surgery including pancreatoduodenectomy. Case presentation The patient was a 60-year-old woman with no particular medical history who visited our hospital with chief complaints of continuous fever and right dorsal pain. Upon arrival, she had tenderness in the right upper quadrant of the abdomen. Laboratory data showed the elevation of inflammatory markers. Computed tomography revealed free air with abscess formation around the duodenum, which was diagnosed as duodenal perforation with abdominal abscess. We decided on emergent surgery, and we identified the perforation site on the dorsal side of the second portion of the duodenum intraoperatively. However, the inflammation around the perforation site was severe, and it was difficult to perform primary closure or dissection of the perforated diverticulum. Therefore, we finished surgery by placing four indwelling intra-abdominal tubes. Since postoperative day (POD) 1, the elevation of inflammation markers appeared to be uncontrollable, owing to the leakage of bile and pancreatic juice. We decided to perform endoscopic retrograde cholangiopancreatography on POD 2, and inserted endoscopic nasobiliary drainage and nasopancreatic drainage tubes. The patient showed a good postoperative course and was discharged on POD 57. Conclusions Endoscopic nasobiliary and nasopancreatic drainage in combination with surgical drainage may be an effective treatment for perforated duodenal diverticulum.

The cultivation of the cellulolytic bacterium, Clostridium thermocellum, can have cost-effective cellulosic biomass utilizations, such as consolidated bioprocessing, simultaneous biological enzyme production and saccharification. However, these processes require a longer cultivation term of approximately 1 week. We demonstrate that constituents of the C. thermocellum membrane vesicle fraction significantly promoted the growth rate of C. thermocellum. Similarly, cell-free Bacillus subtilis broth was able to increase C. thermocellum growth rate, while several B. subtilis single-gene deletion mutants, e.g., yxeJ, yxeH, ahpC, yxdK, iolF, decreased the growth stimulation ability. Metabolome analysis revealed signal compounds for cell–cell communication in the C. thermocellum membrane vesicle fraction (ethyl 2-decenoate, ethyl 4-decenoate, and 2-dodecenoic acid) and B. subtilis broth (nicotinamide, indole-3-carboxaldehyde, urocanic acid, nopaline, and 6-paradol). These findings suggest that the constituents in membrane vesicles from C. thermocellum and B. subtilis could promote C. thermocellum growth, leading to improved efficiency of cellulosic biomass utilization.