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Rapid advances in emergent mechanical thrombectomy have resulted in a higher occurrence of arterial perforations during neurointerventions. Here, we report a case of internal carotid artery (ICA) perforation during mechanical thrombectomy in a 78-year-old man with a left middle cerebral artery occlusion. The ICA was perforated by a microcatheter during thrombectomy, forming a direct carotid-cavernous fistula. A two-stage drainer occlusion was conducted because of cortical venous reflex aggravation and ocular symptoms. Here, we report the perforation details and treatment, adding to evidence that ICA perforation with the microcatheter body is a concern during mechanical thrombectomy.

In the selection of thoracic endovascular repair for aortic dissection (AD), it is important to distinguish between the subacute and chronic phases, but there is no reliable way to distinguish between them in patients with unknown onset of AD. The purpose of this study was to assess the diagnostic performance of 2-[18F] fluoro-2-deoxy-d-glucose (18F-FDG)-PET/computed tomography (PET/CT) for discriminating subacute AD from chronic AD.Thirteen patients with AD who were medically treated and followed up for 6 months were studied. 18F-FDG PET/CT images were obtained for each patient in the subacute phase (the first scan) and at 6 months (the second scan) after the onset. Target-to-background ratio (TBR) was measured as the maximum standardized uptake value (SUV) in the dissected aortic wall divided by blood pool SUV.TBR was significantly higher in the first scan (mean ± SD, 1.97 ± 0.32) than in the second scan (1.69 ± 0.29, P = 0.007). The area under the receiver operating characteristic curve of TBR for discriminating subacute AD from chronic AD was 0.76. With a threshold of 1.74, the TBR showed the sensitivity, specificity, and positive and negative predictive value of 85%, 69%, 73%, and 82%, respectively, for the discrimination of subacute AD from chronic AD.Metabolic assessment of dissected aortic wall by 18F-FDG PET/CT is useful in differentiating between subacute and chronic AD and can provide important information in determining the appropriate indication for treatment for patients with AD of unknown onset.

Purpose: Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are recommended based on certain risk factors. The volume of an institution’s treatment experience may be associated with good clinical outcomes. There is a dilemma between the treatment strategy based on risk factors and the experience volume. Therefore, we investigated the clinical outcomes of CAS performed at institutions that selected the treatment strategy based on risk factors and those that performed CAS at the first-line treatment. Materials and Methods: Patients who underwent CAS at 5 institutions were included in this retrospective case-control study. We defined CEA/CAS institutions as those that selected the treatment option based on risk factors, and CAS-first institutions as those that performed CAS as the first-line treatment. We investigated cases of ischemic stroke, hemorrhagic stroke, myocardial infarction, and deaths within 30 days of the intervention between the CEA/CAS- and CAS-first institution groups. One-to-one propensity score matching was performed to compare rates of ischemic and hemorrhagic strokes within 30 days of the intervention. Results: A total of 239 and 302 patients underwent CAS at the CEA/CAS institutions and CAS-first institutions, respectively; ischemic stroke occurred in 12 (5.0%) and 7 patients (2.3%), respectively (p=0.09). No differences in major ischemic strokes (0.8% vs 1.3%; p=0.59), hemorrhagic strokes (0.4% vs 0.3%; p=0.87), or deaths (0.0% vs 0.7%; p=0.21) were observed. Myocardial infarction did not occur in either group. Propensity score analysis showed that ischemic stroke (odds ratio: 1.845, 95% confidence interval: 0.601–5.668, p=0.28) and hemorrhagic stroke (odds ratio: 1.000, 95% confidence interval: 0.0061–16.418, p=1.00) were not significantly associated with either institution group. Conclusions: The CAS-specific treatment strategies for CAS can achieve the same level of outcomes as the treatment strategy based on risk factors. The CAS performed based on risk factors in CEA/CAS institutions and the treatment of more than 30 patients/year/institution in CAS-first institutions were associated with good clinical outcomes.

Here we describe a case of recurrent ischemic strokes due to fragile innominate artery plaque successfully treated using endovascular stent grafting. An 80-year-old man presented with a history of recurrent strokes that were refractory to medical treatment. Computed tomography and magnetic resonance images of the thorax revealed a gross intramural plaque in the innominate artery. He was successfully treated using endovascular stent grafting. An AFX stent graft device was used to prevent further embolic strokes. The AFX stent graft has a unique endoskeleton design with a thin-walled expanded polytetrafluoroethylene fabric-known as active sealing structure-attached to the implant. Postoperatively, the patient has experienced no recurrent strokes in over 2 years of follow-up. The stent grafting procedure could be an optimal treatment option for treating fragile innominate artery plaques.

We herein report a rare case of a patient with a clival diploic vein arteriovenous fistula (AVF) associated with a posterior condylar canal AVF and discuss the radiological features of clival diploic vein AVF during decision-making on treatment strategies. A 69-year-old male patient with one-year history of pulsatile tinnitus was evaluated with magnetic resonance angiography, which revealed a dilated venous structure. Digital subtraction angiography revealed AVFs located in the clivus and posterior condylar canal. The clival diploic vein AVF was fed by the right internal maxillary artery and the petrous branch of middle meningeal artery and shed to the posterior condylar canal only through an intraosseous vein in the jugular tubercle. Although a catheter could not be navigated into the venous pouch in the clivus, the AVFs were successfully obliterated by transvenous embolization of the venous pouch in the posterior condylar canal.

Background The relevance of aortic dissection chronicity to the development of stent graft–induced new entry (SINE) is unknown. Methods This study enrolled 69 patients who underwent thoracic endovascular aortic repair (TEVAR) for chronic aortic dissection from January 2006 to December 2017 and were followed up for ≥6 months. Their medical records were reviewed retrospectively. Patients were stratified according to TEVAR timing into an early group (≤6 months from the onset of aortic dissection) and a late group (>6 months after the onset). The incidence of SINE as well as the interval between TEVAR and the development of SINE was compared between these groups. Results During the follow-up period, SINE occurred in 12% (3/26) and 35% (15/43) of patients in the early and late groups, respectively (P = .029). The interval between TEVAR and SINE development was significantly longer in the late group than the early group (median, 92 days vs 1144 days, respectively; P = .002). According to the multivariate analysis results, the late group (hazard ratio, 3.667; 95% confidence interval, 1.037-12.968; P = .044) and the distal oversizing ratio (hazard ratio, 1.492; 95% confidence interval, 1.071-2.080; P = .018) were the independent predictors for SINE development. Conclusions TEVAR should be performed in the early period of the chronic phase to prevent SINE. Close and lifelong follow-up is mandatory for patients who undergo TEVAR >6 months after onset because SINE can develop several years after TEVAR in those patients.

Progressive aortic enlargement (PAE) is a critical adverse event in patients with medically treated aortic dissection (AD). However, no reliable predictor of the PAE has been established. The purpose of this study was to evaluate the value of 18F-FDG PET/CT for the prediction of PAE in patients with medically treated AD. Sixteen patients with AD who underwent optimal medical therapy were enrolled. 18F-FDG PET/CT examinations were performed in subacute phase (2 weeks–3 months) after the onset of AD. Target-to-background ratio (TBR) was measured as the maximum standardized uptake value (SUV) in the dissected aortic wall divided by blood pool SUV. The relation between TBR and occurrence of PAE (> 10 mm/year) was evaluated. PAE was observed in four patients during the median follow-up period of 24 months. The TBR measured in the 4 patients showing PAE was significantly higher than that in the remaining 12 patients without PAE (2.44 ± 0.56 vs 1.87 ± 0.33, P = 0.025). The area under the receiver operating characteristic curve of TBR for predicting PAE was 0.82. With a threshold of 2.34, the TBR showed the sensitivity, specificity, and positive and negative predictive value of 75%, 92%, 75%, and 92%, respectively, for the prediction of PAE. Higher 18F-FDG uptake in the dissected aortic wall as determined by TBR is associated with increased risk of PAE in patients with medically treated AD. TBR shows good specificity and negative predictive value for predicting PAE.

Various synthetic drugs have appeared over the past years across the world, and phenethylamine derivatives are among them; indeed, aromatic fluoro analogs of methamphetamine and amphetamine have been in the illicit drug market since the early 2000s. Although they are currently widely abused across the world, little information is available on their metabolism and toxicology. Recently, we came across an alleged 2-fluoromethamphetamine (2-FMA) drug abuse case. The urine obtained from the alleged abuser was analyzed as part of a criminal investigation. 2-FMA, 2-fluoroamphetamine (2-FAP) and some related compounds were detected by liquid chromatography–tandem mass spectrometry. In forensic science, both an “unchanged” drug and its metabolite(s) need to be detected in urine to verify the illicit drug use. Notably, the detection of 2-FAP, which is a plausible 2-FMA metabolite, is insufficient as evidence of 2-FMA use because 2-FAP is widely available and may be present as such in taken liquids. In this study, we synthesized analytical standards for N-hydroxy 2-FMA (N-OH-2-FMA) and two diastereomers of 2-fluoroephedrine, which are plausible metabolites of 2-FMA. Using these standards, the urine specimen was found to contain N-OH-2FMA and one diastereomer of 2-fluoroephedrine; moreover, the concentrations of these compounds were successfully determined. The results of our study suggest that N-hydroxylation and aliphatic hydroxylation are the characteristic metabolic pathways of 2-FMA compared with that of methamphetamine. This evidence indicates that both N-OH-2-FMA and 2-fluoroephedrine are plausible candidates as analytical targets for drug-use certification in forensic science.

Background Few reports have focused on chronic subdural hematoma (CSDH) in the very elderly, who have lived beyond average life expectancy. Our aim is to appraise treatment outcomes of burr-hole craniotomy for CSDH in the elderly, focusing on cure, recurrence, and complications. Methods Fifty patients ≤79 years of age (group A) and 73 patients ≥80 years of age (group B) were studied. Recurrence was defined as requiring reoperation for hematoma regrowth or symptomatic failure. A cure was regarded as having been achieved in the absence of hematoma on postoperative computed tomography. Complications were defined as any harmful event related to the treatment procedure for CSDH. Results Cure was documented in 31 patients in group A (63%) and 24 patients in group B (33%) (P = 0.0017). Median intervals to cure were 2.76 and 3.73 months, respectively (P = 0.06). Cumulative cure rates were 51%/76% and 36%/59%, respectively, at the sixth/twelfth postoperative months. Recurrence was documented in 2 patients (4%) and 11 patients (15%), respectively (P = 0.07). Median intervals to recurrence were 0.81 and 1.25 months, respectively (P = 0.049). Cumulative recurrence-free rates were 96%/92% and 87%/75%, respectively, at the third/sixth postoperative months. Complications were observed in 2 patients (4%) and 4 patients (5%), respectively (P = 1.00). Conclusions With advancing age, CSDH might show a greater tendency to recur and a longer time is required to achieve a cure. However, complications developed only in high-risk patients. Thus, surgical treatment for CSDH in elderly patients, even those who have lived beyond life expectancy, might provide acceptably effective results.

The impact of psoas muscle area on overall survival is unknown for older patients undergoing elective thoracic endovascular aortic repair.We retrospectively reviewed 105 patients aged 75 years or more who underwent elective thoracic endovascular aortic repair for descending thoracic aortic aneurysm between January 2010 and December 2019. Psoas muscle area was measured at the L3 level with preoperative computed tomography and adjusted by height squared to derive psoas muscle mass index. The patients were stratified into two groups, sarcopenia and nonsarcopenia. sarcopenia was defined as a psoas muscle mass index less than 5.40 cmTwenty-three patients died during the follow-up period (median, 3 years). Thirty-eight patients (36%) were classified as sarcopenia. The 5-year overall survival rate was 46% (95% confidence interval, 29% to 73%) for sarcopenia and 84% (95% confidence interval, 74% to 94%) for nonsarcopenia. The overall survival was significantly lower in the sarcopenia group than in its matched general population (P = .004), whereas no statistically significant difference in overall survival was found between the nonsarcopenia group and its matched general population (P = .417). Sarcopenia was an independent risk factor for all-cause mortality (adjusted hazard ratio 2.64; 95% confidence interval, 1.02 to 6.82; P = .045).Psoas muscle mass index may be a good predictor of mortality among older patients undergoing elective thoracic endovascular aortic repair for descending thoracic aortic aneurysm.

PurposeWe examined the surgical outcomes at our hospital and considered strategies for improving surgical outcomes for ruptured abdominal aortic aneurysm.MethodsWe examined 95 surgical cases of ruptured abdominal aortic aneurysm performed from January 2009 to December 2020.We examined the preoperative characteristics hospital mortality, postoperative complications and long-term results. Results24 were dead in hospital (hospital mortality 25.2%). The majority of the causes of death were hemorrhage/DIC and intestinal necrosis. 10 cases required preoperative aortic clamp by thoracotomy or insertion of intra-aortic balloon occlusion and 8 of them died. 10 cases required open abdominal management and 5 of them died. Examining the long-term results of the open repair group and the EVAR group, there was no significant difference between the two groups. ConclusionsIn order to improve the surgical outcomes of ruptured abdominal aortic aneurysm, it is necessary to start surgery immediately in a situation where hemodynamics is stable. Whether to select open surgery or EVAR as the surgical method should be selected by each hospital so that it can be started immediately. In order to prevent postoperative intestinal necrosis, it is necessary to consider risk factors of acute compartment syndrome and actively introduce open abdominal management.

Although complications associated with endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms are rarely observed above the diaphragm, they could lead to catastrophic outcomes once they develop. Aortic valve perforation is one of those rare and major adverse events. In this report, we describe a case of an 82-year-old woman who suffered aortic valve perforation during EVAR caused by the wire-push technique. Her hemodynamics became unstable during the procedure and did not improve thereafter. Echocardiography performed 8 days after EVAR revealed aortic valve perforation. Surgical intervention was abandoned because her general condition was poor. The patient died 4 months after EVAR due to heart failure. It should be reminded that inadvertent manipulation of the wire can cause aortic valve perforation even during EVAR.

Objective The efficacy of thoracic endovascular aortic repair (TEVAR) for retrograde type A aortic dissection (r-TAAD) with the entry tear in the descending aorta has not been clarified. Methods The medical records of 31 patients who underwent TEVAR for r-TAAD at three institutions between May 1997 and January 2016 were retrospectively reviewed. Results The mean age of the patients (30 men and 1 woman) was 64 ± 11 years. The entry tear was located in the descending thoracic aorta in all patients. Seven patients (23%) had dissection-related complications. The false lumen of the ascending aorta was patent in 13 patients (42%) and thrombosed in 18 (58%). The maximum diameter of the ascending aorta was 45 ± 4 mm. TEVAR was performed in the acute phase in 24 patients (77%) and in the subacute phase in 7 (23%). Only one patient (3%) died of aortic rupture within 30 days after TEVAR. Early aorta-related adverse events were observed in eight patients (26%), of whom five underwent additional interventions. The mean follow-up period was 99 ± 69 months. There were no late aorta-related deaths, although five patients died of other causes during follow-up. Overall survival rates at 1 year, 5 years, and 10 years were 97%, 93%, and 80%, respectively. Late aorta-related adverse events were observed in seven patients (23%), of whom five underwent additional interventions. Aorta-related event-free survival rates at 1 year, 5 years, and 10 years were 58%, 58%, and 51%, respectively. Conclusions TEVAR for r-TAAD seems promising in terms of survival. However, the incidence of postoperative aorta-related adverse events is not negligible, so careful selection of patients is important. In addition, close follow-up is mandatory after TEVAR to avoid catastrophic consequences.

Treating mycotic aortic aneurysm with thoracic endovascular aortic repair (TEVAR) remains controversial because of sustained infection post-treatment. In this study, an 83-year-old man, who had a ruptured mycotic thoracic aortic aneurysm, underwent salvage TEVAR. However, because an abscess appeared in the aneurysm on follow-up computed tomography, video-assisted thoracoscopic debridement (VATD) followed by continuous drainage was performed next and was successful in eliminating the infection from the abscess. Although frozen elephant trunk and proximal aortic arch repair were further required owing to another pseudoaneurysm, there was no sign of recurrent infection thereafter. The combination of TEVAR and VATD can be effective in treatment of mycotic aortic diseases in selected patients.

Objective The purpose of the present study was to determine the most appropriate timing for thoracic endovascular aortic repair (TEVAR) of type B aortic dissection (TBAD) in terms of remodeling of the aorta. Methods A total of 41 patients who had undergone TEVAR for the treatment of aortic dissection were included in the present study. The patients were divided into two groups: those who had undergone TEVAR in the acute or subacute phase (group A) and those who had undergone TEVAR in the chronic phase (group B). The indications for TEVAR as the treatment of TBAD were the presence of aortic rupture or malperfusion of the aortic branches, a maximum aortic diameter of ≥40 mm on the initial diagnostic computed tomography scan, and/or expansion of the aorta of ≥5 mm within 3 months for acute and subacute TBAD. The indication was a maximum aortic diameter of ≥50 mm or expansion of the aorta of ≥5 mm within 1 year for chronic TBAD. The diameters of the aorta, true lumen, and false lumen were measured at the level of the most dilated part of the descending aorta (level M) and at the diaphragm (level D) on the computed tomography scan obtained before TEVAR and at the 2-year follow-up examination. Results The median interval between TEVAR and the onset of TBAD was 0.2 month (interquartile range, 0.03-0.7 month) in group A (n = 21) and 32 months (interquartile range, 4.7-35.2 months) in group B (n = 20). Except for the aortic diameter at level D in group B, favorable remodeling was obtained at both levels in both groups. The diameter change ratio of the aorta at level D was significantly greater in group A than in group B (P = .02). Receiver operating characteristic curve analysis of the interval for a significant decrease in the aortic diameter at level D yielded 4.2 months as the optimal threshold for performing TEVAR (area under the curve, 0.859; 95% confidence interval, 0.7-1.0). Conclusions TEVAR for TBAD will result in favorable outcomes, irrespective of the timing of the procedure. However, it might be more effective to perform TEVAR within 4.2 months of the onset of TBAD, provided that the TEVAR procedure can be performed safely.

To investigate the effect of alteplase, either combined with stent-retriever thrombectomy or a direct aspiration first pass technique (ADAPT), in patients with large-vessel occlusion stroke. This was a retrospective post hoc analysis of data from The Direct Mechanical Thrombectomy in Acute LVO Stroke (SKIP) study. Patients were divided into two groups according to the first-line thrombectomy technique: stent-retriever and ADAPT. Each group was further divided into two subgroups, namely MT and MT + alteplase. The procedural outcomes, such as first pass effect (FPE) ratio and number of passes, were evaluated. The clinical outcomes included mRS score at 3 months. A total of 180 patients were included (116 in the stent-retriever group and 64 in the ADAPT group). No interaction was detected between the first-line technique and alteplase administration. In the stent-retriever group, after adjusting for factors associated with FPE, the adjusted odds ratio (95% confidence interval) of FPE of the MT + alteplase subgroup versus the MT subgroup was 3.57 (1.5–8.48) and in the ADAPT group it was 1.35 (0.37–4.91). With alteplase, the number of passes decreased with adjusted odds ratios of 0.59 (0.37–0.93) in the stent-retriever group but not in the ADAPT group. In both first-line technique groups, clinical outcomes did not differ between subgroups. In the SKIP study, alteplase administration was associated with increased FPE when combined with stent-retriever thrombectomy, but not with ADAPT. We found no differences in the clinical outcomes.

The effectiveness of endovascular aneurysm repair (EVAR) has been proven, but anatomical limitations, including narrow access route, may obstruct procedure of EVAR and cause serious complications. Parallel placement of Excluder legs (W. L. Gore & Associates, Inc., Newark, DE, USA) was established to treat patients with type IIIb endoleak or those with a narrow aorta, who could not be treated using a standard main body. In this report, we applied this technique in two patients with aortoiliac aneurysms with occlusive lesion.

Background Parent artery occlusion (PAO) is an effective treatment for hemorrhagic diseases associated with the internal carotid artery. There are several reports of long-term cerebral infarction or the formation of de novo cerebral aneurysms following PAO. Materials and methods We retrospectively reviewed these complications in 38 patients who underwent PAO for therapeutic treatment. We investigated perioperative cerebral infarctions, long-term cerebral infarctions, and de novo aneurysms. Results The mean age of the patients was 64.0 years, and 25 patients (65.8%) were female. The causative diseases were unruptured (n = 19; 50.0%) and ruptured (n = 8; 21.1%) aneurysms. PAO was performed after ischemic tolerance was assessed with balloon test occlusion (BTO), and BTO was performed in 34 patients, of whom 25 (73.5%) had ischemic tolerance. Twenty-six patients (68.4%) were treated with PAO alone, eight (23.5%) with low-flow bypass, and six (17.6%) with high-flow bypass. Perioperative complications occurred in five patients (13.2%): two of the 26 patients (7.7%) who underwent scheduled treatment and three of the 12 patients (25.0%) who underwent emergency treatment. One patient (2.6%) had long-term de novo aneurysm, and none developed cerebral infarction. Conclusions These results showed that the assessment of ischemic tolerance by performing BTO and appropriate revascularization in scheduled treatments are important to reduce perioperative and long-term cerebral infarctions. PAO must be performed with greater caution in emergency treatment.

Endoleak is a major complication of endovascular aneurysm repair (EVAR). Type IIIb endoleaks, which are caused by endograft fabric disruption, are relatively rare. Although relining of the previously placed endograft with another main endograft is considered an ideal approach, it is sometimes difficult. The efficacy of parallel placement of Excluder legs has been reported in various settings. Here, we report the successful treatment of a type IIIb endoleak with parallel placement of Excluder legs during EVAR by using an AFX2 device.

Background: While recent randomized clinical trials have shown the efficacy of mechanical thrombectomy for acute large vessel anterior cerebral occlusion, cases in patients with a subarachnoid hemorrhage (SAH) were excluded from the study. Case Description: A 58-year-old man presented with a SAH as a result of a ruptured middle cerebral artery aneurysm. Coil embolization was performed, and a right intracranial angiography showed remnants of an aneurysmal neck. However, the following angiography also revealed a thromboembolic complication that occurred in the same territory as the ruptured aneurysm. The patient underwent a rescue mechanical thrombectomy under the working projection. We deployed a retrieval stent without covering the aneurysmal neck. The occluded vessel was recanalized without any hemorrhagic complication. Due to minimal intracerebral infarction, the patient had good outcomes. Conclusion: Mechanical thrombectomy is a useful option to retrieve a clot from an occluded intracranial vessel located near a ruptured aneurysm. Approaching the clot at the working projection is important to ensure safety in the setting of a ruptured aneurysm.

This study designs and develops a new material measure with a chirp form. Material measures are measurement standards for calibration, verification, and inspection. Since material measures are essential for ensuring the traceability of surface texture instruments, we have been developing a manufacturing system to provide them. ISO 5436-1:2000 contains material measures with sinusoidal wave forms, random wave forms, triangular wave forms, trapezoidal wave forms, cusp forms, rectangular forms, etc. However, ISO 5436-1:2000 does not contain a material measure with a chirp (sweep) form. Therefore, we propose a material measure with a chirp form. Chirp signals are frequently used for various analyses in the fields of mechanical engineering, electrical engineering, physics, and others. The primary purpose of the proposed material measure with a chirp form is to rapidly and simply examine the characteristics and capabilities of implemented Gaussian filters. We designed the surface form of the material measure as a logarithmic chirp form to maximize the utility of the primary purpose in this study. The wavelength of the manufactured chirp form varies logarithmically in the lateral (x) direction. This paper presents the following five points: 1) the design and development of the material measure with a chirp form, 2) the application of the proposed material measure to the examination of the attenuation characteristics of implemented Gaussian filters, 3) the application of the proposed material measure to obtain the deformation of the roughness form due to the implemented Gaussian filters, 4) the application of the proposed material measure to specify the algorithm of the implemented Gaussian filters, and 5) the possibility of another application of the material measure with a chirp form.

Pyrrolidinophenones (PPs) are synthetic cathinones containing a pyrrolidine ring that are used recreationally worldwide. Recently, many studies on the metabolism and cytotoxicity of PPs have been published. Here, we focus on new designer drug containing an indan skeleton, 1-(2,3-dihydro-1H-inden-5-yl)-2-(pyrrolidine-1-yl)butan-1-one (5-PPDI), because there have been no reports to date regarding the metabolism of indan-type cathinones. The identification of 5-PPDI phase I metabolites in human urine enables us to determine whether a person has taken 5-PPDI. This metabolite detection approach plays a very important role in the field of forensic science. We synthesized analytical standards of 5-PPDI and four proposed metabolites. A urine sample was prepared by salting-out assisted liquid-liquid extraction with acetonitrile. Analyses of all standards and the urine sample were performed by liquid chromatography high resolution tandem mass spectrometry. As a result, we were able to detect 5-PPDI and its metabolites in the urine specimen. Two diastereomers of synthesized 1-OH metabolites were successfully separated, and only one diastereomer was observed in the urine specimen. To the best of our knowledge, this is the first report on the stereoselective reduction of PPs in humans. Further, we performed quantitative analyses of 5-PPDI and its metabolites in the urine. We identified three characteristic features of 5-PPDI phase I metabolism: (1) hydroxylation at the indan skeleton, (2) stereoselective reduction of the carbonyl group, and (3) hydroxylation of the indan skeleton possibly proceeding more preferentially than any other metabolization. In addition, several structural isomers and diastereomers of 2'-OH metabolites were detected. Based on these data, we propose phase I metabolic pathways of 5-PPDI, which will be essential in understanding the metabolism of other PPs with an indan skeleton.

The frozen elephant trunk (FET) technique can facilitate the distal anastomosis of total arch replacement (TAR); therefore, the technique is increasingly being used in TAR cases. However, identifying suitable patients remains controversial. This study analyzes the outcome of TAR using FET and clarifies the indications for using FET.Patients who underwent TAR between January 2008 and December 2018 were enrolled and divided into 2 groups: that is, patients treated with conventional TAR (cTAR group, n = 39) and those treated with TAR using FET (TAR-FET group, n = 76). Early and late outcomes were compared.The mean operation time was significantly shorter in the TAR-FET group (447.0 ± 82.1 min) than in the cTAR group (509.4 ± 123.9 min) (P 0.01). Likewise, circulatory arrest time was significantly shorter in the TAR-FET group (29.0 ± 7.8 min) than in the cTAR group (64.2 ± 20.2 min) (P 0.001). Postoperative renal function tended to be preserved in the TAR-FET group. Recurrent nerve palsy was less frequent in the TAR-FET group (9.2%) compared with the cTAR group (25.6%) (P 0.05). Patients with chronic aortic dissection tended to undergo reintervention more frequently following TAR using the FET technique.The FET technique contributed to save operation and circulatory arrest times during TAR and seemed less invasive in terms of renal function and less-frequent recurrent nerve palsy. Considering posttreatment reintervention, however, care should be taken in its application to chronic aortic dissection.

Background: Optic neuropathy due to an aneurysm is relatively rare, with only a few small case series on this topic, and no randomized trials having been published until now. As such, the functional prognosis and treatment for aneurysm-induced optic neuropathy remain controversial. Objective: We quantified optic nerve injuries using an objective index (the visual impairment score) and evaluated prognostic factors of postoperative visual function. Materials and Methods: Of 960 patients treated for an unruptured intracranial aneurysm, 18 (1.9%) patients had optic neuropathy. Visual acuity and visual field were assessed before surgery and 6 months' postoperatively. Cases were classified on the basis of treatment modality (coil embolization or flow alteration [FA]) and prognostic factors of the two treatment groups. Results: Of the 18 patients with an intracranial aneurysm and optic neuropathy, 12 (67%) were treated using coil embolization and 6 (33%) were FA. Visual function improved after surgery in 8 patients (44%), 5 (42%) in the coil embolization group, and 3 (50%) in the FA group. The visual function remained stable after surgery in 6 (33%) patients and worsened in 4 (22%). Patients with an aneurysms

Rationale Bridging therapy with endovascular therapy (EVT) and intravenous thrombolysis (IVT) has been reported to improve outcomes for acute stroke patients with large-vessel occlusion in the anterior circulation. While the IVT may increase the reperfusion rate, the risk of hemorrhagic complications increases. Whether EVT without IVT (direct EVT) is equally effective as bridging therapy in acute stroke remains unclear. Aim This randomized study of endovascular therapy with versus without intravenous tissue plasminogen activator for acute stroke with ICA and M1 occlusion aims to clarify the efficacy and safety of direct EVT compared with bridging therapy. Methods and design This is an investigator-initiated, multicenter, prospective, randomized, open-treatment, blinded-endpoint clinical trial. The target patient number is 200, comprising 100 patients receiving direct EVT and 100 receiving bridging therapy. Study outcome The primary efficacy endpoint is a modified Rankin Scale score of 0–2 at 90 days. Safety outcome measures are any intracranial hemorrhage at 24 h. Discussion This trial may help determine whether direct EVT should be recommended as a routine clinical strategy for ischemic stroke patients within 4.5 h from onset. Direct EVT would then become the choice of therapy in stroke centers with endovascular facilities. Trial registration UMIN000021488.

Introduction: Interhospital transfer to endovascular-capable centers (ECCs) is reported to correlate with worse clinical outcome after endovascular stroke reperfusion therapy (ESRT). The aim of this study was to investigate the relationship between admission mode and functional outcome after ESRT in real clinical setting in Japan. Methods: The RICOVERY study retrospectively registered 575 patients with large vessel occlusion who were admitted to and underwent ESRT at 16 ECCs in Ibaraki prefecture, located just northeast of Tokyo, within 24 hours of onset between January 2015 and December 2017. We extracted patients without in-hospital stroke onset or recurrence and divided them into two groups: those with interhospital transfer (I group) and with direct admission to ECCs (D group). Favorable outcome (FO) was defined as a mRS of 0-2 at discharge. We additionally performed a subgroup analysis with patients with premorbid mRS of 0-2 and who underwent ESRT within 6 hours of onset. Results: A total of 483 patients (198 women, 75±11 years) was included. Intravenous thrombolysis was performed in 289 patients (60%). In the I group (n=69), median baseline NIHSS score was lower (17 vs 19, p=0.025) and the proportion of large-artery atherosclerosis was higher (19% vs 10%, p=0.025) compared with the D group (n=414). The rates of reperfusion (mTICI grade 2b/3) were similarly high in both groups (88% and 86%, respectively). Although median onset-to-puncture time (OPT) was longer in the I group than in the D group (240 min vs 185 min, p=0.01), no significant difference was shown in the rate of FO between the groups (28% vs 36%, p=0.197). In subgroup analysis, baseline NIHSS scores and stroke subtypes were similar between the I group (n=51) and the D group (n=273). Median OPT was longer in the I group than in the D group (220 min vs 160 min, p=0.005) as with the entire study cohort, and the rate of FO in the I group was lower than in the D group (24% vs 43%, p=0.01). After multivariate adjustment, interhospital transfer was a negative predictor of FO (Odds ratio, 0.343; 95% confidence interval, 0.158-0.747). Conclusion: In this Japanese real-world study, interhospital transfer was associated with delays of ESRT and lower chance of FO within a 6-hour time window.

Importance Whether intravenous thrombolysis is needed in combination with mechanical thrombectomy in patients with acute large vessel occlusion stroke is unclear. Objective To examine whether mechanical thrombectomy alone is noninferior to combined intravenous thrombolysis plus mechanical thrombectomy for favorable poststroke outcome. Design, Setting, and Participants Investigator-initiated, multicenter, randomized, open-label, noninferiority clinical trial in 204 patients with acute ischemic stroke due to large vessel occlusion enrolled at 23 hospital networks in Japan from January 1, 2017, to July 31, 2019, with final follow-up on October 31, 2019. Interventions Patients were randomly assigned to mechanical thrombectomy alone (n = 101) or combined intravenous thrombolysis (alteplase at a 0.6-mg/kg dose) plus mechanical thrombectomy (n = 103). Main Outcomes and Measures The primary efficacy end point was a favorable outcome defined as a modified Rankin Scale score (range, 0 [no symptoms] to 6 [death]) of 0 to 2 at 90 days, with a noninferiority margin odds ratio of 0.74, assessed using a 1-sided significance threshold of .025 (97.5% CI). There were 7 prespecified secondary efficacy end points, including mortality by day 90. There were 4 prespecified safety end points, including any intracerebral hemorrhage and symptomatic intracerebral hemorrhage within 36 hours. Results Among 204 patients (median age, 74 years; 62.7% men; median National Institutes of Health Stroke Scale score, 18), all patients completed the trial. Favorable outcome occurred in 60 patients (59.4%) in the mechanical thrombectomy alone group and 59 patients (57.3%) in the combined intravenous thrombolysis plus mechanical thrombectomy group, with no significant between-group difference (difference, 2.1% [1-sided 97.5% CI, −11.4% to ∞]; odds ratio, 1.09 [1-sided 97.5% CI, 0.63 to ∞];P = .18 for noninferiority). Among the 7 secondary efficacy end points and 4 safety end points, 10 were not significantly different, including mortality at 90 days (8 [7.9%] vs 9 [8.7%]; difference, –0.8% [95% CI, –9.5% to 7.8%]; odds ratio, 0.90 [95% CI, 0.33 to 2.43];P > .99). Any intracerebral hemorrhage was observed less frequently in the mechanical thrombectomy alone group than in the combined group (34 [33.7%] vs 52 [50.5%]; difference, –16.8% [95% CI, –32.1% to –1.6%]; odds ratio, 0.50 [95% CI, 0.28 to 0.88];P = .02). Symptomatic intracerebral hemorrhage was not significantly different between groups (6 [5.9%] vs 8 [7.7%]; difference, –1.8% [95% CI, –9.7% to 6.1%]; odds ratio, 0.75 [95% CI, 0.25 to 2.24];P = .78). Conclusions and Relevance Among patients with acute large vessel occlusion stroke, mechanical thrombectomy alone, compared with combined intravenous thrombolysis plus mechanical thrombectomy, failed to demonstrate noninferiority regarding favorable functional outcome. However, the wide confidence intervals around the effect estimate also did not allow a conclusion of inferiority. Trial Registration umin.ac.jp/ctr Identifier:UMIN000021488

We present a retrospective analysis of endovascular treatments for posterior cerebral artery (PCA) aneurysms and discuss the susceptibility of a fetal-type PCA to vascular insufficiency after parent artery occlusion. Among 1207 aneurysms treated with endovascular therapy between March 1997 and March 2013 in our institution, 10 patients (0.8%) presented PCA aneurysms. The principal strategy was to employ selective coil embolization for the aneurysm. However, in certain cases of fusiform or dissecting aneurysms, we performed parent artery occlusion with coils. Clinical and radiological data were collected from hospital charts and evaluated retrospectively. The mean age was 52.7±15.6years (range, 12-65years). Five patients (50%) were admitted with a subarachnoid hemorrhage, and one patient presented with slowly developing paralysis. The remaining four patients were diagnosed incidentally. Five patients underwent selective coil embolization, and five patients underwent parent artery occlusion. All endovascular therapies were successfully performed. However, two patients in the parent artery occlusion group suffered cerebral infarction, and both patients exhibited a fetal-type PCA. The remaining three patients in the parent artery occlusion group exhibited an adult-type PCA and did not suffer a cerebral infarction. Endovascular treatment with either selective coil embolization or parent artery occlusion is safe and effective as the long as the anatomical type of the PCA is considered. Patients with a fetal-type PCA may develop vascular insufficiency upon parent artery occlusion. Neurosurgeons should attempt to preserve the parent artery using a flow-diverting stent or stent-assisted technique for a fetal-type PCA aneurysm.

The present report describes a patient with pseudo-occlusion of the left internal carotid artery accompanied by aortic anomalies consisting of right-sided aortic arch with aberrant left subclavian artery arising from Kommerell’s diverticulum. Initial attempt of carotid artery stenting via the trans-femoral approach was unsuccessful because of low origin of the left common carotid artery. Therefore, carotid artery stenting (CAS) via the trans-brachial approach was successfully performed with distal balloon protection. Eight months later, the patient presented with restenosis of the left internal carotid artery, and CAS via the trans-brachial approach was performed again. CAS via the trans-brachial approach should be considered when standard femoral access is relatively contraindicated due to aortic anomalies consisting of a right-sided aortic arch.

The influences of the average degree of polymerization (Dp), which is derived from Mn and terminal end group, on optical and thermal properties of various refractive indexed transparent polymers were investigated. In this study, we selected the alicyclic compound, Dinorbornane dimethanol (DNDM) homo polymer, because it has been used as a representative monomer in low refractive index polymers for its unique properties. DNDM monomer has a stable amorphous phase and reacts like a polymer. Its unique reaction allows continuous investigation from monomer to polymer. For hydroxy end group and phenolic end group polymers, the refractive index (nd) decreased with increasing Dp, and both converged to same value in the high Dpregion. However, the Abbe number (&nu, d) of a hydroxy end group polymer is not dependent on Dp, and the &nu, d of a phenolic end group polymer is greatly dependent on Dp. As for glass transition temperatures (Tg), both end group series were increased as Dpincreased, and both converged to the same value.

To evaluate the efficacy of thoracic endovascular aortic repair (TEVAR) for ruptured acute type B aortic dissection (r-ATBAD). The study included 18 patients (15 men and 3 women) who underwent TEVAR for r-ATBAD in two institutions between 1997 and 2017. The mean patient age was 74 ± 10 years. The false lumen was patent in 13 patients (72%) and was mostly thrombosed in 5 patients (28%). Three patients had malperfusion of aortic branches. Eight patients (44%) were in circulatory shock. Eleven patients (61%) died during or following TEVAR during admission. The causes of death were aortic rupture (n = 6), sepsis (n = 2), cerebral hypoxia (n = 1), pneumonia (n = 1), and renal failure (n = 1). Statistical analysis showed that dissection extending to the infrarenal level was significantly related to death from aortic rupture (P = 0.013). Early adverse events were observed in 12 patients (67%). One patient died from a non-aorta-related cause (sepsis) after discharge. The overall survival rate at 1 year was 39%. After discharge, an aorta-related adverse event (intimal injury) was observed in one patient. The adverse event-free survival rate at 1 year was 17%. Our results indicate that TEVAR for r-ATBAD is associated with high mortality and morbidity. More advanced strategies may be required to improve the outcome.

A reliable method for structural analysis is crucial for the forensic investigation of new psychoactive substances (NPSs). Towards this end, mass spectrometry is one of the most efficient and facile methods for the identification of NPSs. However, the differentiation among 2-, 3-, and 4-fluoromethcathinones (o-, m-, and p-FMCs), which are ring-fluorinated positional isomers part of the major class of NPSs referred to as synthetic cathinones, remains a challenge. This is mostly due to their similar retention properties and nearly identical full scan mass spectra, which hinder their identification. In this study, we describe a novel and practical method for differentiating the fluorine substitution position on the phenyl ring of FMCs, based on energy-resolved mass spectrometry (ERMS) using an electron ionization-triple quadrupole mass spectrometer. ERMS measurements showed that the three FMC positional isomers exhibited differences in relative abundances of both the fluorophenyl cation (m/z 95) and the fluorobenzoyl cation (m/z 123). The logarithmic plots of the abundance ratio of these two cations (m/z 95 to m/z 123) as a function of the collision energy (CE) followed the order of o-FMC < p-FMC < m-FMC at each CE, which allowed the three isomers to be unambiguously and reliably differentiated. The theoretical dissociation energy calculations confirmed the relationship obtained by ERMS analyses, and additional ERMS measurements of methylmethcathinone positional isomers showed that the differences in abundance among the FMCs were attributed to the differences in their collision-induced dissociation reactivities arising from the halogen-induced resonance effects on the phenyl ring. Moreover, the method for differentiation described herein was successfully applied to the actual samples containing seized drugs. We expect that the described methodology will also contribute significantly to the reliable and accurate structural identification of NPSs in the fields of therapeutic, clinical, and forensic toxicology.

In the 1970s, severe osteoarticular lesion appeared to the patients from a relatively early stage after initiation of dialysis. It was recognized as dialysis osteodystrophy and was an important threat of the patients. The main causes of the lesion were osteitis fibrosa due to secondary hyperparathyroidism and osteomalacia including an aluminum bone disease. But it is now occasional to encounter these typical bone lesion by the development of subsequent active vitamin D preparation, a non-calcium-containing phosphate binder and calcimimetics, and the complete removal of aluminum from the dialysis field. However, ectopic calcification due to aplastic bone disease and the progression of osteoporosis with the aging population are the upcoming problems. To overcome these problems, researches for pathophysiology and mechanism, establishment of the management tools and the development of effective drug are expected.

Introduction: Although endovascular therapy is becoming an alternative to open surgical repair of splenic artery aneurysms (SAAs), reports on the use of stent grafts for SAA repair are limited. We present our experience of endovascular therapy using a stent graft for the treatment of an SAA that had ruptured into the gastric lumen. We also reviewed 18 cases of stent graft repair for SAAs, including the present case. Case Report: A 43-year-old man was admitted due to hematemesis. Endoscopic examination and contrast-enhanced computed tomography (CT) revealed a dissecting SAA that had ruptured into the stomach. Two 10 × 100 mm Viabahn (W.L. Gore, Flagstaff, Arizona) stent grafts were used to exclude the aneurysm. No complications occurred during the procedure. Although postoperative CT showed complete exclusion of the aneurysm, endoscopic examination showed a discharge of purulent matter from the aneurysm. Therefore, surgical debridement and omental implantation were added to avoid stent graft infection. Follow-up CT obtained 1 year later showed the residual aneurysm almost disappeared without any evidence of infection. Literature Review: A literature search in the PubMed database returned 17 cases with sufficient data. Review of these cases, together with the present case, revealed a 100% technical success rate, 11% splenic infarction rate, 94% graft patency rate, and 0% reintervention rate. Conclusion: Endovascular repair of SAAs using stent grafts appears to be safe and effective. In terms of preserving the blood flow and avoiding splenic infarction, it may be superior to coil embolization. Even in a case with aneurysm infection, stent graft repair may be an acceptable method to minimize invasion of concomitant surgical intervention.