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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.>.

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.

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.