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Background: Dislocation is a major complication of total hip arthroplasty (THA). This study aimed to assess the dislocation rate after THA using the combined strategy of using CT-based navigation, large diameter heads, and posterior soft tissue repair in a large cohort., Methods: We included 1410 patients who had undergone primary cementless THA using the CT-based navigation system. The posterior approach was used by a single surgeon for all patients. The participants included 143 (10.1 %) men and 1267 (89.9 %) women, with a mean age of 65 years. The mean body mass index was 24 kg/m2. Additionally, the incidence rate of postoperative dislocation per year was calculated. The dislocation onset was classified as early when the dislocation occurred within 2 years of the primary THA and late when it occurred more than 2 years after the primary THA. Recurrence and revision rates in patients with dislocations were investigated., Results: The postoperative dislocation rate was 0.56 % (8 patients). The mean time to dislocation onset was 11.2 (0.5-20.0) months postoperatively. All postoperative dislocations occurred in the early phase whereas none in the late phase, showing a significant difference (p < 0.01). Six (0.43 %) patients experienced recurrent dislocations or required revision., Conclusions: THA using the combined strategy resulted in low dislocation rates, especially without late dislocation., Competing Interests: Declaration of competing interest The authors declare that they have no conflict of interest., (Copyright © 2024 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Background: We aimed to quantify the incidence of atrial fibrillation (AF) in patients with cryptogenic stroke globally, as well as separately in patients in and outside of Japan, using an implantable loop recorder from a prospective, observational, Reveal LINQ Registry., Methods and Results: Patients developing cryptogenic stroke and monitored by implantable loop recorder for searching AF were studied. The primary end point was incidence of AF within 36 months after insertion. Secondary end points were recurrent ischemic stroke/transient ischemic attack and AF-related treatment strategies. A total of 271 patients (61.6±14.3 years, 170 men, 60 from Japan) were enrolled from 12 countries. AF was detected in 28.2% at 36 months. The median time from enrollment to AF detection was 7.9 months. During the first 12 months, the AF detection rate slope was relatively steeper in the Japanese subgroup versus non-Japanese patients. However, by 3 years, the cumulative incidence of AF detection did not differ between groups. Age was the only variable associated with AF detection (hazard ratio, 1.05 [95% CI, 1.02-1.07] per year), trending higher in older age groups. Of the 271 patients, 11 (4.1%) developed recurrent ischemic stroke/transient ischemic attack; AF was detected by implantable loop recorder in only 1 of these patients. Patients with detected AF were more commonly taking oral anticoagulation than those without AF at the last follow-up (64.7% versus 25.3%, P <0.001)., Conclusions: The rate of AF detection was similar to other studies in stroke populations monitored by implantable loop recorders, including CRYSTAL-AF (Cryptogenic Stroke and Underlying Atrial Fibrillation), STROKE-AF (Stroke of Unknown Cause and Underlying Atrial Fibrillation) and PER-DIEM (Post-Embolic Rhythm Detection With Implantable Versus External Monitoring). Patients with detected AF more commonly initiated anticoagulation than those without AF.

Purpose: This study aimed to classify medullary bridging vein-draining dural arteriovenous fistulas (MBV-DAVFs) located around the foramen magnum (FM) according to their location and characterize their angioarchitecture and treatment outcomes., Methods: Patients with MBV-DAVFs diagnosed between January 2013 and October 2022 were included. MBV-DAVFs were classified into four groups. Jugular vein-bridging vein (JV-BV) DAVF: located in proximity to jugular fossa, Anterior condylar vein (ACV)-BV DAVF: proximity to anterior condylar canal, Marginal sinus (MS)-BV DAVF: lateral surface of FM and Suboccipital cavernous sinus (SCS)-BV DAVF: proximity to dural penetration of vertebral artery., Results: Twenty patients were included, three JV-BV, four ACV-BV, three MS-BV and ten SCS-BV DAVFs, respectively. All groups showed male predominance. There were significant differences in main feeders between JV (jugular branch of ascending pharyngeal artery) and SCS group (C1 dural branch). Pial feeders from anterior spinal artery (ASA) or lateral spinal artery (LSA) were visualized in four SCS and one MS group. Drainage pattern did not differ between groups. Transarterial embolization (TAE) was performed in three, two, one and two cases and complete obliteration was obtained in 100%, 50%, 100% and 0% in JV, ACS, MS and SCS group, respectively. Successful interventions without major complications were finally obtained in 100%, 75%, 100%, and 40% in JV, ACS, MS and SCS group, respectively., Conclusion: JV-BV DAVFs were successfully treated using TAE alone. SCS-BV DAVFs were mainly fed by small C1 dural branches of vertebral artery often with pial feeders from ASA or LSA, and difficultly treated by TAE alone., (© 2024. The Author(s).)

Periprosthetic joint infection (PJI) is a catastrophic complication after total hip arthroplasty. A new drug-loaded carbon fiber-reinforced polymer (CFRP) prosthesis with a sustained drug-release mechanism is being developed for one-stage surgery. We aimed to examine the diffusion dynamics of vancomycin from vancomycin paste-loaded CFRP implants. The differences in the in vitro diffusion dynamics of vancomycin paste were investigated using the elution test by varying parameters. These included the mixing ratio of vancomycin and distilled water (1:0.8, 1:1.2, and 1:1.4) for vancomycin paste, and hole diameter (1 mm and 2 mm) on the container. The in vivo diffusion dynamics were investigated using a rabbit model with vancomycin-loaded CFRP implants placed subcutaneously. The in vitro experiments showed that the diffusion effect of vancomycin was highest in the parameters of vancomycin paste with distilled water mixed in a ratio of 1:1.4, and with a 2 mm hole diameter. The in vivo experiments revealed diffusion dynamics similar to those observed in the in vitro study. The drug diffusion effect tended to be high for vancomycin paste with a large water ratio, and a large diameter of holes. These results indicate that the drug diffusion dynamics from a CFRP implant with holes can be adjusted by varying the water ratio of the vancomycin paste, and the hole size on the CFRP implant., (© 2023. The Japanese Society for Artificial Organs.)

Background and Purpose: There has been limited literature regarding the bridging veins (BVs) of the medulla oblongata around the foramen magnum (FM). The present study aims to analyze the normal angioarchitecture of the BVs around the FM using slab MIP images of three-dimensional (3D) angiography., Methods: We collected 3D angiography data of posterior fossa veins and analyzed the BVs around the FM using slab MIP images. We analyzed the course, outlet, and number of BVs around the FM. We also examined the detection rate and mean diameter of each BV., Results: Of 57 patients, 55 patients (96%) had any BV. The median number of BVs was two (range: 0-5). The BVs originate from the perimedullary veins and run anterolaterally to join the anterior condylar vein (ACV), inferior petrosal sinus, sigmoid sinus, or jugular bulb, inferolaterally to join the suboccipital cavernous sinus (SCS), laterally or posterolaterally to join the marginal sinus (MS), and posteriorly to join the MS or occipital sinus. We classified BVs into five subtypes according to the draining location: ACV, jugular foramen (JF), MS, SCS, and cerebellomedullary cistern (CMC). ACV, JF, MS, SCS, and CMC BVs were detected in 11 (19%), 18 (32%), 32 (56%), 20 (35%), and 16 (28%) patients, respectively. The mean diameter of the BVs other than CMC was 0.6 mm, and that of CMC BV was 0.8 mm., Conclusion: Using venous data from 3D angiography, we detected FM BVs in most cases, and the BVs were connected in various directions., (© 2023. The Author(s).)

Purpose: Prasugrel is not approved for patients treated with flow diverters, which have a high metal coverage ratio. However, robust antiplatelet therapy with prasugrel may prevent thromboembolic complications. We administered prasugrel and aspirin to all patients treated with flow diverters and reported the safety of the antiplatelet therapy regimen., Methods: This retrospective, single-center study evaluated the angiographic and clinical data of consecutive patients treated with flow diverters for cerebral unruptured aneurysms between June 2020 and May 2022. All patients received dual antiplatelet therapy, including prasugrel and aspirin. The administration of prasugrel ended 3 or 6 months after the procedure, whereas aspirin use continued for at least 12 months. Periprocedural complications (< 30 days post-procedure) and delayed complications (> 30 days post-procedure) were recorded., Results: During the study period, 120 unruptured aneurysms were treated with flow diverters in 110 patients. All patients, except one, survived longer than 12 months after the procedure. The rate of thromboembolic complications was 6.4%, and more than half of the patients had transient symptoms; one (0.9%) had a major ischemic stroke. One patient (0.9%) each had an asymptomatic, small subarachnoid hemorrhage and significant hemorrhagic complications with melena. The rate of permanent neurological deficits was 1.8%, and the mortality rate was 0.9%., Conclusions: Dual antiplatelet therapy comprising routine use of prasugrel and aspirin for flow diverter-implanted patients possibly contributed to a low rate of thromboembolic complications and low risk of hemorrhagic complications., (© 2023. The Author(s).)

A carbon fiber-reinforced polyetheretherketone (CFR/PEEK) hip stem with a special antibiotic elution mechanism is under development to treat periprosthetic joint infection (PJI). The antibiotic elution characteristics of intramedullary implants were experimentally investigated, and the efficacy of revision surgery using a therapeutic stem in treating ovine PJI was examined. To evaluate elution characteristics, the intramedullary vancomycin-loaded CFR/PEEK cylindrical implants were inserted in the distal femur of nine sheep, and the vancomycin elution rate was measured at 2, 7, and 21 days. To evaluate therapeutic efficacy, the PJI model with staphylococcus aureus was attempted to create for five sheep. Moreover, the therapeutic vancomycin-loaded CFR/PEEK stem was implanted during one-stage revision surgery. Three weeks after revision surgery, the treatment efficacy was evaluated based on bacterial cultures and wound findings. In addition, the vancomycin elution rate from the stem was measured. On average, the cylindrical implants eluted approximately 70% vancomycin in 21 days. Of the five sheep attempting to create a PJI model, three were successfully infected with S. aureus as intended for verification of treatment efficacy. In all three joints, negative bacterial cultures and no purulence were observed 3 weeks after revision surgery. The vancomycin elution rates from the stems were >70%. Efficient elution of vancomycin was confirmed by the experimental implant inserted into the bone marrow and the stem in actual PJI treatment. Using a novel therapeutic stem with an antibiotic elution mechanism in one-stage revision surgery, successful treatment was demonstrated in all S. aureus-induced PJIs., (© 2023 Orthopaedic Research Society.)

Objective: LEONIS Mova (SB-KAWASUMI LABORATORIES, Kanagawa, Japan, hereinafter called LEONIS Mova) is a steerable microcatheter (MC) that enables angle adjustment of the catheter tip using a hand-operated dial. LEONIS Mova may be useful for flow diverter placement when access to the distal parent artery with a conventional MC and microguidewire (MGW) is considered difficult or impossible. Here, we report three such cases encountered during flow diverter placement in large and giant internal carotid artery aneurysms., Case Presentation: In Case 1, a strong S-shaped curve was observed in the proximal parent artery of a giant cerebral aneurysm, and the luminal structure of the parent artery was lost within the aneurysm. It was anticipated that the distal side of the parent artery would be difficult to access with conventional MC and MGW. By adjusting the tip of the LEONIS Mova toward the aneurysm outlet beyond the S-shaped curve, it was possible to induce the MGW to secure the distal parent artery easily. In Case 2, the inflow and outflow axes of the parent artery were completely misaligned at the site of the aneurysm, and stenosis was present in the distal parent artery. Firmly bending the catheter tip increased accommodation for the catheter, enabling the induction of an MGW to access the distal parent artery without kicking back. In Case 3, the lesion extended from the cavernous portion to the petrosal portion; however, by adjusting the tip of the LEONIS Mova toward the aneurysm outlet, it was possible to induce the MGW to secure the distal parent artery easily. In each case, the LEONIS Mova enabled more secure and prompt access to the parent artery than anticipated and facilitated flow diverter placement., Conclusion: Encountering difficult-to-access lesions is one reason endovascular treatment may be unsuccessful. The LEONIS Mova is an excellent device that can overcome this obstacle, and its utility in certain applications should be recognized., (©2024 The Japanese Society for Neuroendovascular Therapy.)

Background and Objectives: The differences in clinical outcomes between endovascular coiling (EC) and surgical clipping (SC) in patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) are controversial. Therefore, this study aimed to evaluate whether EC is superior to SC and identify risk factors in patients with poor-grade aSAH., Methods: We used data from the "Predict for Outcome Study of aneurysmal SubArachnoid Hemorrhage." World Federation of Neurological Societies (WFNS) grade III-V aSAH was defined as poor-grade aSAH, and unfavorable clinical outcomes (modified Rankin Scale scores 3-6) were compared between SC and EC after propensity score matching (PSM). In-hospital mortality was similarly evaluated. Predictors of unfavorable clinical outcomes were identified using multivariable analysis., Results: Ultimately, 1326 (SC: 847, EC: 479) and 632 (SC: 316, EC: 316) patients with poor-grade aSAH were included before and after PSM, respectively. Unfavorable clinical outcomes at discharge were significantly different between SC and EC before (72.0% vs 66.2%, P = .026) and after PSM (70.6% vs 63.3%, P = .025). In-hospital mortality was significantly different between groups before PSM (10.5% vs 16.1%, P = .003) but not after PSM (10.4% vs 12.7%, P = .384). Predictors of unfavorable clinical outcomes in both SC and EC were WFNS grade V, older than 70 years, and Fisher computed tomography (CT) grade 4. Predictors of unfavorable clinical outcomes only in SC were WFNS grade IV (odds ratio: 2.46, 95% CI: 1.22-4.97, P = .012) and Fisher CT grade 3 (4.90, 1.42-16.9, P = .012). Predictors of unfavorable clinical outcome only in EC were ages of 50s (3.35, 1.37-8.20, P = .008) and 60s (3.28, 1.43-7.52, P = .005)., Conclusion: EC resulted in significantly more favorable clinical outcomes than SC in patients with poor-grade aSAH, without clear differences in in-hospital mortality. The benefit of EC over SC might be particularly remarkable in patients with WFNS grade IV and Fisher CT grade 3., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Ischemia-induced postoperative scalp necrosis in the superficial temporal artery (STA) region is known to occur after STA-middle cerebral artery anastomoses. However, no reports have evaluated the risk of postoperative scalp necrosis in the occipital artery (OA) region. This study examined the surgical procedures that pose a risk for postoperative scalp necrosis in the OA region following posterior cranial fossa surgery. Patients who underwent initial posterior fossa craniotomy at our institution from 2015 to 2022 were included. Clinical information was collected using medical records. Regarding surgical procedures, we evaluated the incision design and whether a supramuscular scalp flap was prepared. The supramuscular scalp flap was defined as a scalp flap dissected from the sternocleidomastoid and/or splenius capitis muscles. A total of 392 patients were included. Postoperative scalp necrosis occurred in 19 patients (4.8%). There were 296 patients with supramuscular scalp flaps, and supramuscular scalp flaps prepared in all 19 patients with postoperative necrosis. Comparing incision designs among patients with supramuscular scalp flap, a hockey stick-shaped scalp incision caused postoperative necrosis in 14 of 73 patients (19.1%), and the odds of postoperative scalp necrosis were higher with the hockey stick shape than with the retro-auricular C shape (adjusted odds ratio: 12.2, 95% confidence interval: 3.86-38.3, p = 0.00002). In all the cases, ischemia was considered to be the cause of postoperative necrosis. The incidence of postoperative necrosis is particularly high when a hockey stick-shaped scalp incision is combined with a supramuscular scalp flap., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

A bispecific antibody (bsAb) is a class of engineered antibody molecules that simultaneously binds to two different antigens by having two kinds of antigen-binding domains. One of the major obstacles for the bsAb production is the incorrect chain-pairing problem, wherein each heavy and light chain should form pairings with the correct counterpart's chains, but the structural similarity of the incorrect partners also forms the incorrect pairings. This study aimed to demonstrate a bsAb construction method using intein-mediated protein trans-splicing to create IgG-Fab 2 -type bsAbs, which is a modified antibody with a structure in which two additional Fabs are linked to the N-terminus of the heavy chain of an IgG molecule. The chain-paring problem between a heavy chain and a light chain is circumvented by separate expression and purification of the IgG part and the Fab part. We found that the deletion of a possible glycosylation residue improved the reaction yield and side-reaction cleavage in the protein ligation step. The resulting bsAb, IgG-Fab 2 (Her2/CD3), demonstrated target binding activity and cytotoxicity mediated by activated T cells. These results indicate that the use of the protein ligation to produce the IgG-Fab 2 type bsAb will expand the bsAb production method., (© 2023. Springer Nature Limited.)

Objective: This retrospective study aimed to investigate factors associated with inhibition of early aneurysm obliteration after flow diverter (FD) treatment. We also created the early obliteration inhibition (EOI) score for pre-operative evaluation., Methods: We examined 110 cerebral aneurysms in 104 patients who underwent FD treatment. The following parameters were investigated: age, sex, symptoms, aneurysm location and type, maximum aneurysm diameter, parent vessel diameter, neck diameter, and dome-neck ratio. We also noted aneurysm location relative to the curvature of the parent artery and any branches arising from the aneurysm dome. Procedural factors such as FD diameter and length, number of FDs placed, type of FD, and use of adjunctive coiling were also investigated. Aneurysm obliteration was evaluated using digital subtraction angiography 3 months after the procedure. Adequate obliteration was defined as grade C or D on the O'Kelly-Marotta scale., Results: The following factors inhibited early obliteration: 1) extradural location, 2) saccular aneurysm, 3) aneurysm neck located at the outer convexity of the parent artery, and 4) arterial branch arising from the aneurysm dome. Odds ratios were used to create an EOI score. Receiver operating characteristic curve analysis showed that the optimal cut-off EOI score for adequate obliteration was 1.5 (area under the curve, 0.81; 95% confidence interval, 0.73-0.9; sensitivity, 0.9; specificity, 0.57)., Conclusion: The EOI score, which is based on factors that inhibit early obliteration, may predict early treatment outcomes of FD placement., Competing Interests: One of the authors (I.N.) is a technical advisor for the Terumo Corporation and has a financial relationship with the company. The other authors have no conflicts of interest to declare.

Purpose: Optimal size selection is important for successful Woven EndoBridge (WEB) treatment. Conventional recommendations for WEB sizing based on aneurysm width and height sometimes require device exchange. We aimed to design a novel volume-based parameter, the ideal WEB-aneurysm volume (iWAVe) ratio, for optimal WEB sizing., Methods: Consecutive patients who underwent WEB treatment for wide-neck bifurcation aneurysms between January 2021 and May 2022 were retrospectively reviewed. Aneurysm volume was automatically calculated using software. We measured the aneurysm volume based on the expected position of the device within the aneurysm. The WAVe ratio was defined as the ratio of the aneurysm volume to WEB volume. We dichotomized aneurysms treated with a successful sizing or unsuccessful sizing for WEB (successful group and unsuccessful group, respectively)., Results: Thirty-five patients were eligible for study enrollment. Ten patients (28.6%) needed to exchange the WEB on the first attempt and required another WEB on the second attempt resulting in deployment success. Hence, 35 aneurysms were in the successful group and 10 were in the unsuccessful group. The median WAVe ratio was 1.0 (range 0.76-1.31) in the successful group and 1.27 (0.58-1.89) in the unsuccessful group. Using logistic regression, iWAVe ratio was from 0.90-1.16 to secure a >80% probability of success by the 95% lower confidence limit. The sensitivity and specificity of the iWAVe ratio for optimal size selection on the first attempt were 0.60 and 1.00, respectively., Conclusion: Decision-making based on aneurysm width and the iWAVe ratio could promote optimal WEB sizing., Competing Interests: Declaration of Competing Interest Ichiro Nakahara is technical advisor of Terumo corporation. The other authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Objective: The Woven EndoBridge (WEB) was developed to treat wide-neck bifurcation intracranial aneurysms. Occasionally, persistent contrast-filling has been observed in the WEB after treatment. The purpose of our study was to investigate its incidence, predictive factors, and clinical impact., Methods: All patients treated with the WEB between January 2021 and September 2021 at our institute were reviewed. Age, gender, antiplatelet therapy, and angioarchitecture were compared between the persistent-filling group and the no-filling group at the three-month follow-up angiography., Results: We included 20 patients with 20 unruptured aneurysms. Ten of the 20 intracranial aneurysms (50 %) showed contrast-filling in the WEB after three months. Two of the 10 had contrast not only inside, but around the device. Statistically significant differences were observed between the persistent-filling group and the no-filling group in neck size (median: 4.5 mm vs. 3.8 mm), deviation of the aneurysm axis from the inlet flow line where the orifice of the bifurcated arteries overlaps (mean: 15.1° vs. 33.0°), and postoperative dual antiplatelet therapy (DAPT) for at least a month (90 % vs. 20 %). One case had additional coil embolization six months after the WEB implantation. Including this case, one year after the treatment or the re-treatment, the filling in the device had disappeared in nine of 10 cases. No bleeding was observed during the mean follow-up period of 24 months., Conclusion: Persistent contrast-filling was associated with postoperative DAPT for at least a month, a wide neck, and less deviation of the aneurysm axis from the inlet flow line. If the contrast-filling is only within the WEB and not between the aneurysmal wall and the WEB, we are not concerned. To further assess the clinical impact of this phenomenon, long-term follow-up will be needed., Competing Interests: Declaration of Competing Interest The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (Copyright © 2023 Elsevier B.V. All rights reserved.)

This study used a rabbit model to investigate the osteocompatibility of Si 3 N 4 -coated carbon fiber-reinforced polyetheretherketone (CFRP) and hydroxyapatite (HA)-coated CFRP with antibiotics (vancomycin [VCM]) and antithrombotic drugs (polyvinylpyrrolidone [PVP]). HA-coated cylindrical CFRP implants were used as the controls (HA), and HA-coated implants treated with VCM and PVP were prepared (HA-VP) as the test groups; a cylindrical CFRP coated with Si 3 N 4 was also prepared (SiN). Ten implants from each group were randomly inserted into the femoral diaphysis of rabbits. The pull-out test, radiological analysis using micro-computed tomography (µ-CT), and histological analysis were performed. The pull-out strength of the SiN group was lower than that of the HA group. µ-CT analysis revealed that the amount of bone formation around the implant in the SiN group was inferior to that in the HA group. Conversely, the HA-VP group had equivalent pull-out strength and bone formation as analyzed by µ-CT compared to the HA group. In conclusion, the additional surface treatment of the HA-coated CFRP with VCM and PVP provided sufficient bone fixation and formation., (© 2022. The Japanese Society for Artificial Organs.)

Objective: Although a qualitative diagnosis of plaque causing carotid stenosis has been attempted with carotid computed tomography angiography (CaCTA), no clear findings have been reported. We examined the correlation between the plaque CT values and plaque images obtained by magnetic resonance imaging to derive a qualitative diagnosis of the plaque using CaCTA., Methods: Preoperative CaCTA images acquired from patients stented for carotid stenosis were retrospectively analyzed with respect to magnetization-prepared rapid acquisition with gradient echo and time-of-flight magnetic resonance angiography data. Carotid plaques in the stenosed region were quantified in terms of CT density and the plaque/muscle ratio (magnetization-prepared rapid acquisition with gradient echo), and correlations between these 2 features were determined. Plaques were classified as stable or unstable based on the plaque/muscle ratio, with the smallest plaque/muscle ratio observed among plaques positive for intraplaque hemorrhage set as the cutoff value (1.76)., Results: A total of 165 patients (179 plaques) were included. Perioperative complications included minor stroke (n = 3), major stroke (n = 1, fatal), and hyperperfusion (n = 2). The correlation between CT density and the plaque/muscle ratio was nonlinear ( P = 0.0139) and negative ( P < 0.0001). The cutoff point (1.76) corresponded to a CT density of 83 HU, supporting this value as a standard reference for plaque stability., Conclusions: Computed tomography density exhibits a nonlinear ( P = 0.0139) and highly negative correlation ( P < 0.0001) with the plaque/muscle ratio. Our results demonstrate that plaque characteristics can be meaningfully diagnosed based on CaCTA image data., Competing Interests: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Some aneurysmal subarachnoid hemorrhage (SAH) patients are delayed in their presentation. This can cause a washout of the subarachnoid hematoma and a potential misdiagnosis. As a result, they may suffer rerupture of the aneurysm and preventable deterioration. We investigated the factors that influence delayed SAH presentation., Methods: Aneurysmal SAH patients treated at 9 stroke centers from 2002 to 2020 were included. Age, gender, pre-SAH modified Rankin scale, World Federation of Neurological Surgeons grade, Fisher group, day of presentation, aneurysm treatment method, past history of cerebral stroke, comorbidity of hypertension and/or diabetes mellitus, and modified Rankin scaleat discharge were assessed retrospectively. We formed 2 groups based on the day of presentation after the onset of SAH: day 0-3 (early) and other (delayed). Logistic regression analyses detected the factors that influenced the day of presentation and outcome for SAH. A P- value <0.05 was considered significant., Results: Delayed presentation comprised 282 cases (6.3%) of 4507 included cases. Logistic regression analyses showed that patients in an urban area, of male gender, low WFNS grade and low Fisher group correlated significantly with a delayed presentation. But delayed presentation did not influence outcome at discharge., Conclusions: Area of residency and gender correlated with delayed presentation after SAH in Japan. Urbanization, male gender, and mild SAH lead patients to delay presentation. The factors underlying these tendencies will be analyzed in a future prospective study., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Purpose: Bayesian estimation with advanced noise reduction (BEANR) in CT perfusion (CTP) could deliver more reliable cerebral blood flow (CBF) measurements than the commonly used reformulated singular value decomposition (rSVD). We compared the efficacy of CBF measurement by CTP using BEANR and rSVD, evaluating both relative to N-isopropyl-p-[(123) I]- iodoamphetamine ( 123 I-IMP) single-photon emission computed tomography (SPECT) as a reference standard, in patients with cerebrovascular disease., Methods: Thirty-one patients with suspected cerebrovascular disease underwent both CTP on a 320 detector-row CT system and SPECT. We applied rSVD and BEANR in the ischemic and contralateral regions to create CBF maps and calculate CBF ratios from the ischemic side to the healthy contralateral side (CBF index). The analysis involved comparing the CBF index between CTP methods and SPECT using Pearson's correlation and limits of agreement determined with Bland-Altman analyses, before comparing the mean difference in the CBF index between each CTP method and SPECT using the Wilcoxon matched pairs signed-rank test., Results: The CBF indices of BEANR and 123 I-IMP SPECT were significantly and positively correlated (r = 0.55, p < 0.0001), but there was no significant correlation between the rSVD method and SPECT (r = 0.15, p > 0.05). BEANR produced smaller limits of agreement for CBF than rSVD. The mean difference in the CBF index between BEANR and SPECT differed significantly from that between rSVD and SPECT (p < 0.001)., Conclusions: BEANR has a better potential utility for CBF measurement in CTP than rSVD compared to SPECT in patients with cerebrovascular disease., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

The posterior condylar vein is an emissary vein that connects the extracranial and intracranial venous systems through the posterior condylar canal (PCC). Dural arteriovenous fistulas (DAVF) of the PCC are rare, and only seven cases have been reported. Transvenous embolization (TVE) is the first-line treatment for PCC DAVF and is predominantly performed through the internal jugular vein. Herein, we report a case of PCC DAVF treated with TVE through the deep cervical vein. This is the first case report of a PCC DAVF treated with TVE through the deep cervical vein., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objectives: This study aimed to determine the impact of the approval of prothrombin complex concentrates on the treatment of vitamin K antagonist-related intracerebral hemorrhage., Materials and Methods: We retrospectively studied all patients with vitamin K antagonist-related intracerebral hemorrhage treated with prothrombin complex concentrate at our institutes between January 2010 and June 2021. Before approval, prothrombin complex concentrate was administered as either 500 or 1000 IU at the physician's discretion (previous dose group). After approval, we adopted the manufacturer's recommended regimen (recommended dose group). The primary outcome was post-administration international normalized ratio. Secondary outcomes were the amount of prothrombin complex concentrate administered and proportion of post-administration international normalized ratio <1.5, hematoma expansion, thrombotic events within 30 days, modified Rankin scale 0-3 at discharge, and in-hospital mortality., Results: Thirty-two and 19 patients in the previous and recommended dose groups, respectively, were included. The post-administration international normalized ratio significantly differed between groups. The prothrombin complex concentrate dose and proportion of patients achieving post-administration international normalized ratio <1.5 were significantly higher in the recommended dose group than in the previous dose group (1500 IU vs. 500 IU, p<0.001 and 100% vs. 68%, p = 0.008). The proportions of hematoma expansion, thromboembolic events, modified Rankin scale 0-3, and mortality did not differ between groups., Conclusion: After prothrombin complex concentrate approval, prothrombin time-international normalized ratio correction was more effective with a significant increase in the prothrombin complex concentrates dose for vitamin K antagonist-associated intracerebral hemorrhage; however, there was no apparent difference in clinical outcomes., Competing Interests: Declaration of Competing Interest None, (Copyright © 2022 Elsevier Inc. All rights reserved.)

Artificial joints are exposed to loads on a daily basis. Loads on the bone through the artificial joint and the joint's sliding surface shear force may cause implant fixation failure, fatigue fractures, wear of the bearing and foreign body reactions. Artificial joints can experience sudden internal damage, which can be fatal if it occurs during activities performed at high altitudes or in water. The standard design hip prosthesis has a metal femoral stem. Most stem fractures are caused at the proximal one third of the stem by fatigue due to repetitive loading. Femoral stem neck fractures can also occur. To eliminate in vivo prosthesis failures, safety performance preclinical studies evaluate stem body and neck breakage. However, the development of new femoral stems via prototyping and fatigue test verification would require excessive time and money. Therefore, evaluation methods based on numerical analyses, such as finite element analysis (FEA), have been introduced to simulate tests on actual machines. Fatigue strength design verification using FEA can efficiently identify a design that can pass International Organization for Standardization fatigue tests. FEA may also aid with composite implant development by enabling efficient preclinical testing to prove safety using minimal actual fatigue testing. Once a biological safety study of a composite material is performed, a clinical trial can prove its clinical efficacy and safety and device regulatory approval can be requested. This review was created based on a translation of the Japanese review written in the Japanese Journal of Artificial Organs in 2020 (Vol. 49, No. 3, pp. 195-198), with adding some additional contents and references., (© 2022. The Japanese Society for Artificial Organs.)

Objectives: The benefit of mechanical thrombectomy for acute ischemic stroke is highly time dependent. However, time to treatment is longer for in-hospital stroke patients than community-onset stroke patients. This study aimed to clarify the cause of this difference., Methods: A retrospective single-center study was performed to analyze patients with large vessel occlusion who underwent mechanical thrombectomy between January 2017 and December 2019. Patients were divided into in-hospital stroke and community-onset stroke groups. Clinical characteristics and treatment time intervals were compared between groups., Results: One hundred four patients were analyzed: 17 with in-hospital stroke and 87 with community-onset stroke. Patient characteristics did not significantly differ between groups. Median door (stroke recognition)-to-computed tomography time (36 min vs. 14 min, P<0.01) and door-to-puncture time (135 min vs. 117 min, P=0.02) were significantly longer in the in-hospital stroke group than the community-onset stroke group. However, median computed tomography-to-puncture time (104 min vs. 104 min, P=0.47) and puncture-to-reperfusion time (53 min vs. 38 min, P=0.17) did not significantly differ., Conclusions: Longer door-to-puncture time in in-hospital stroke patients was mostly caused by longer door-to-computed tomography time, which is the initial part of the workflow. An in-hospital stroke protocol that places importance on early stroke specialist consultation and prompt transportation to the computed tomography scanner might hasten treatment and improve outcomes in patients with in-hospital stroke., Competing Interests: The authors declare no conflicts of interest.

Purpose: The Flow Re-direction Endoluminal Device (FRED) has recently become available for flow diversion in Japan. We have encountered cases that failed to deploy the FRED. In this study, we report our initial experience with the FRED for cerebral aneurysms and clarify the causes of failed FRED deployment., Methods: A retrospective data analysis was performed to identify patients treated with the FRED between June 2020 and March 2021. Follow-up digital subtraction angiography was performed at 3 and 6 months and assessed using the O'Kelly-Marotta (OKM) grading scale., Results: Thirty-nine aneurysms in 36 patients (average age: 54.4 years) were treated with the FRED. The average sizes of the dome and neck were 9.9 mm and 5.2 mm, respectively. In nine patients, additional coiling was performed. In one patient (2.6%), proximal vessel injury caused direct carotid-cavernous fistula during deployment. Ischaemic complications were encountered in one patient (2.6%) with transient symptoms. Angiographic follow-up at 6 months revealed OKM grade C or D in 86.6% of patients. FRED deployment was successful in 35 (92.1%) procedures. In the failure group, the differences between the FRED and the minimum vessel diameter (P = 0.04) and the rate of the parent vessel having an S-shaped curve (P = 0.04) were greater than those in the success group., Conclusions: Flow diversion using the FRED is effective and safe for treating cerebral aneurysms. The use of the FRED for patients with an S-shaped curve in the parent vessel and oversizing of more than 2 mm should be considered carefully., (© 2021. The Author(s).)

Background: We aimed to clarify the relationship between epicardial adipose tissue (EAT) volume and the presence of severe stenoses (SS) on coronary computed tomography angiography (CTA) for risk stratification of the patients with carotid artery stenoses., Methods: We prospectively performed CTA for 125 consecutive patients (72.4 ± 8.1 years, 85% men) without a history of coronary artery disease (CAD), who were scheduled for carotid artery revascularization from 2014 to 2020. SS was defined as ≥70% luminal stenosis on CTA. EAT was quantified automatically as the total volume of tissue with -190 to -30 HU., Results: Of 125 patients, 76 had SS. Between the patients with and without SS, there were significant differences in coronary artery calcium score (CACS), left ventricular ejection fraction (LVEF), dyslipidemia, and EAT, despite no differences in carotid echocardiography findings. After adjustment for age, gender, and dyslipidemia, EAT was an independent factor associated with SS (p=0.011), as well as CACS and LVEF. The addition of EAT to a baseline model including age, gender, dyslipidemia, LVEF, and CACS achieved both net reclassification improvement (0.505, p=0.003) and integrated discrimination improvement (0.059, p=0.003)., Conclusions: In patients with carotid stenoses, EAT is associated with CAD and is useful for additional risk stratification. Epicardial fat may have a specific role in the development of CAD in patients with suspected systemic atherosclerosis., (Copyright © 2021. Published by Elsevier Ltd.)

Purpose: Although intracranial dural arteriovenous fistula (DAVF) without retrograde leptomeningeal venous drainage (Borden type I) is reported to have a benign nature, no study has prospectively determined its clinical course. Here, we report a 3-year prospective observational study of Borden type I DAVF., Methods: From April 2013 to March 2016, consecutive patients with DAVF were screened at 13 study institutions. We collected data on baseline characteristics, clinical symptoms, angiography, and neuroimaging. Patients with Borden type I DAVF received conservative care while palliative intervention was considered when the neurological symptoms were intolerable, and were followed at 6, 12, 24, and 36 months after inclusion., Results: During the study period, 110 patients with intracranial DAVF were screened and 28 patients with Borden type I DAVF were prospectively followed. None of the patients had conversion to higher type of Borden classification or intracranial hemorrhage during follow-up. Five patients showed spontaneous improvement or disappearance of neurological symptoms (5/28, 17.9%), and 5 patients showed a spontaneous decrease or disappearance of shunt flow on imaging during follow-up (5/28, 17.9%). Stenosis or occlusion of the draining sinuses on initial angiography was significantly associated with shunt flow reduction during follow-up (80.0% vs 21.7%, p = 0.02)., Conclusion: In this 3-year prospective study, patients with Borden type I DAVF showed benign clinical course; none of these patients experienced conversion to higher type of Borden classification or intracranial hemorrhage. The restrictive changes of the draining sinuses at initial diagnosis might be an imaging biomarker for future shunt flow reduction., (© 2021. The Author(s).)

The PulseRider (Cerenovus, Johnson & Johnson Medical Devices, New Brunswick, NJ, USA) is a neck reconstruction device that is used for the treatment of unruptured wide-necked bifurcation aneurysms. Herein, we describe the case of a 51-year-old male patient with a basilar apex aneurysm who was treated with PulseRider but had post-procedural brainstem infarctions caused by one of the proximal markers covering the origin of a perforator. In such cases, repositioning of the PulseRider should be performed to avoid infarctions., (Copyright © 2022 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Recurrent complex middle cerebral artery (MCA) aneurysms after combined clipping and endovascular surgery are challenging, and if conventional techniques are adapted, advanced surgical, endovascular, and a combination of both techniques are often required. For such complex aneurysms, safe and effective straightforward techniques for all neurovascular surgeons are warranted. We describe the details of staged hybrid techniques with straightforward bypass surgery followed by flow diverter deployment in a patient with complex MCA aneurysm., Illustrative Case: A 69-year-old woman presented with left recurrent large MCA aneurysm enlargement 25 years after direct surgery and coil embolization for ruptured aneurysm. The recurrent MCA aneurysm had large and complex morphology and was adhering to the brain tissues. Therefore, it was unsuitable to treat such aneurysm with conventional surgical and endovascular techniques with a high risk of morbidity. We performed (1) M2 ligation following superficial temporal artery-M2 bypass and (2) flow diverter deployment assisted with coil packing in two sessions. Three months after the second session, the aneurysm was completely occluded with endothelialization of the neck. Angiographic findings revealed no recurrence 12 months after the treatment., Conclusions: Staged hybrid techniques with straightforward bypass surgery followed by flow diverter deployment may be a safe and effective treatment for complex recurrent MCA aneurysms., Competing Interests: IN reports grants from Kaneka Medix, Medtronic, and Nipro, consultancy from Kaneka Medix, and Medicos Hirata, outside the submitted work. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Tanabe, Nakahara, Matsumoto, Morioka, Hasebe, Watanabe, Suyama and Kuwahara.)

Purpose: Endovascular treatment of posterior communicating artery aneurysms with fetal-type posterior communicating artery originating from the aneurysm dome is often challenging because, with conventional techniques, dense packing of aneurysms for posterior communicating artery preservation is difficult; moreover, flow-diversion devices are reportedly less effective. Herein, we describe a novel method called the λ stenting technique that involves deploying stents into the internal carotid artery and posterior communicating artery., Methods: Between January 2018 and September 2020, the λ stenting technique was performed to treat eight consecutive cases of aneurysms. All target aneurysms had a wide neck (dome/neck ratio < 2), a fetal-type posterior communicating artery with hypoplastic P1, and a posterior communicating artery originating from the aneurysm dome. The origin of the posterior communicating artery from the aneurysm, relative to the internal carotid artery, was steep (< 90°: V shape)., Results: The maximum aneurysm size was 8.0 ± 1.9 mm (6-12 mm). The average packing density (excluding one regrowth case) was 32.7 ± 4.2% (26.8-39.1%). Initial occlusion was complete occlusion in 6 (75.0%) patients and neck remnants in 2 (25.0%) patients. Follow-up angiography was performed at 18.4 ± 11.6 months (3-38 months). There were no perioperative complications or reinterventions required during the study period., Conclusion: The λ stenting technique enabled dense coil packing and preservation of the posterior communicating artery. This technique enabled safe and stable coil embolization. Thus, it could become an alternative treatment option for this sub-type of intracranial aneurysms., (© 2021. The Author(s).)

Background: Thromboembolic complications (TECs) are frequent during the endovascular treatment of unruptured aneurysms. To prevent TECs, dual antiplatelet therapy using aspirin and clopidogrel is recommended for the perioperative period. In patients with a poor response, clopidogrel is a risk factor for TECs. To prevent TECs, our study assessed the stratified use of prasugrel., Methods: Patients who underwent endovascular therapy for unruptured cerebral aneurysms from April 2017 to August 2019 were enrolled in this clinical study and given premedication with aspirin and clopidogrel for 2 weeks prior to the procedure. P2Y12 reaction units (PRU) were measured using the VerifyNow assay on the day before the procedure (tailored group). In subgroups with PRU <240, the clopidogrel dose was maintained (CPG subgroup). In subgroups with PRU ≥240, clopidogrel was changed to prasugrel (PSG subgroup). We compared the occurrence of TECs with retrospective consecutive cases from January 2015 to March 2017 without PRU assessments (non-tailored group). The frequency of TECs within 30 days was assessed as the primary endpoint., Results: The tailored and non-tailored groups comprised 167 and 50 patients, respectively. TECs occurred in 11 (6.6%) and 8 (16%) patients in the tailored and non-tailored groups (P=0.048), respectively. The HR for TECs was significantly reduced in the tailored group (HR 0.3, 95% CI 0.11 to 0.81); P=0.017) compared with the non-tailored group., Conclusion: The results suggest that tailored dual antiplatelet therapy medication with PRU significantly reduces the frequency of TECs without increasing hemorrhagic complications., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Coronavirus Disease 2019 (COVID-19) has spread worldwide with collateral damage and therefore might affect the behavior of stroke patients with mild symptoms seeking medical attention. Methods: Patients with ischemic stroke who were admitted to hospitals within 7 days of onset were retrospectively registered. The clinical characteristics, including onset-to-door time (ODT), of patients with a transient ischemic attack (TIA)/mild stroke (National Institutes of Health Stroke Scale [NIHSS] score of ≤ 3 on admission) or moderate/severe stroke were compared between those admitted from April 2019 to March 2020 (pre-COVID-19 period) and from April to September 2020 (COVID-19 period). Multivariable regression analysis was performed to identify factors associated with the ODT. Results: Of 1,100 patients (732 men, median age, 73 years), 754 were admitted during the pre-COVID-19 period, and 346 were admitted during the COVID-19 period. The number and proportion of patients with TIA/minor stroke were 464 (61.5%) in the pre-COVID-19 period and 216 (62.4%) during the COVID-19 period. Among patients with TIA/mild stroke, the ODT was longer in patients admitted during the COVID-19 period compared with that of the pre-COVID-19 period (median 864 min vs. 508 min, p = 0.003). Multivariable analysis revealed the COVID-19 period of admission was associated with longer ODT (standardized partial regression coefficient 0.09, p = 0.003) after adjustment for age, sex, route of arrival, NIHSS score on admission, and the presence of hypertension, diabetes mellitus, and wake-up stroke. No significant change in the ODT was seen in patients with moderate/severe stroke. Conclusions: The COVID-19 epidemic might increase the ODT of patients with TIA/mild stroke., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Tanaka, Matsumoto, Nakazawa, Yamada, Sonoda, Nagano, Hatano, Yamasaki, Nakahara and Isobe.)

Background and Purpose: The impact of the paraoxonase-1 (PON1) polymorphism, Q192R, on platelet inhibition in response to clopidogrel remains controversial. We aimed to investigate the association between carrier status of PON1 Q192R and high platelet reactivity (HPR) with clopidogrel in patients undergoing elective neurointervention., Methods: Post-clopidogrel platelet reactivity was measured using a VerifyNow® P2Y12 assay in P2Y12 reaction units (PRU) for consecutive patients before the treatment. Genotype testing was performed for PON1 Q192R and CYP2C19*2 and *3 (no function alleles), and *17. PRU was corrected on the basis of hematocrit. We investigated associations between factors including carrying ≥1 PON1 192R allele and HPR defined as original and corrected PRU ≥208., Results: Of 475 patients (232 men, median age, 68 years), HPR by original and corrected PRU was observed in 259 and 199 patients (54.5% and 41.9%), respectively. Carriers of ≥1 PON1 192R allele more frequently had HPR by original and corrected PRU compared with non-carriers (91.5% vs 85.2%, P = 0.031 and 92.5% vs 85.9%, P = 0.026, respectively). In multivariate analyses, carrying ≥1 PON1 192R allele was associated with HPR by original (odds ratio [OR] 1.96, 95% confidence interval [CI] 1.03-3.76) and corrected PRU (OR 2.34, 95% CI 1.21-4.74) after adjustment for age, sex, treatment with antihypertensive medications, hematocrit, platelet count, total cholesterol, and carrying ≥1 CYP2C19 no function allele., Conclusions: Carrying ≥1 PON1 192R allele is associated with HPR by original and corrected PRU with clopidogrel in patients undergoing elective neurointervention, although alternative results related to other genetic polymorphisms cannot be excluded., Competing Interests: The authors have declared that no competing interests exist.

Introduction: To evaluate the advantages of a carbon fiber-reinforced polyetheretherketone (CFR/PEEK) intramedullary nail on the diagnosis of fracture healing because of its radiolucency, we retrospectively reviewed radiographs and computed tomography (CT) images of trochanteric femoral fractures that underwent internal fixation with the CFR/PEEK intramedullary nail or a traditional metallic intramedullary nail., Methods: Radiographs and CT images from 20 patients with intertrochanteric femoral fractures treated with a CFR/PEEK intramedullary nail and 20 similar patients treated with a metallic intramedullary nail were reviewed. After division of the intertrochanteric region into three zones on anteroposterior and lateral views of the radiographs, the visibilities of the fracture site, fracture line, and bone formation were evaluated in each zone. A three-grade assessment for existence of scattering and effect of scattering on diagnosis of the surrounding bone was performed on three axial slices of the CT images., Results: In the CFR/PEEK group, the fracture site was visible in all zones for all cases except for the posterior zone on the lateral view in one case. In the cranial and middle zones on anteroposterior views and the middle zone on lateral views of the radiographs, the visible fracture site rates in the CFR/PEEK group were significantly higher than those in the metal group. The grades for existence of scattering and effect of scattering on diagnosis of surrounding bone on the CT images were significantly lower in the CFR/PEEK group compared with the metal group., Conclusion: Superior fracture site visibility on radiographs was demonstrated in cases treated with the CFR/PEEK intramedullary nail compared with cases treated with the traditional metallic intramedullary nail, thereby confirming the advantages of the CFR/PEEK intramedullary nail for evaluation of fracture reduction and bone formation. The CFR/PEEK nail evoked little scattering on CT images, leading to higher diagnostic values for the peri-prosthetic cancellous and cortical bone compared with the metallic nail., Competing Interests: Declaration of Competing Interest The authors declare no conflict of interest., (Copyright © 2021. Published by Elsevier Ltd.)

Background: The COVID-19 pandemic led to profound changes in the organization of health care systems worldwide., Aims: We sought to measure the global impact of the COVID-19 pandemic on the volumes for mechanical thrombectomy, stroke, and intracranial hemorrhage hospitalizations over a three-month period at the height of the pandemic (1 March-31 May 2020) compared with two control three-month periods (immediately preceding and one year prior)., Methods: Retrospective, observational, international study, across 6 continents, 40 countries, and 187 comprehensive stroke centers. The diagnoses were identified by their ICD-10 codes and/or classifications in stroke databases at participating centers., Results: The hospitalization volumes for any stroke, intracranial hemorrhage, and mechanical thrombectomy were 26,699, 4002, and 5191 in the three months immediately before versus 21,576, 3540, and 4533 during the first three pandemic months, representing declines of 19.2% (95%CI, -19.7 to -18.7), 11.5% (95%CI, -12.6 to -10.6), and 12.7% (95%CI, -13.6 to -11.8), respectively. The decreases were noted across centers with high, mid, and low COVID-19 hospitalization burden, and also across high, mid, and low volume stroke/mechanical thrombectomy centers. High-volume COVID-19 centers (-20.5%) had greater declines in mechanical thrombectomy volumes than mid- (-10.1%) and low-volume (-8.7%) centers (p < 0.0001). There was a 1.5% stroke rate across 54,366 COVID-19 hospitalizations. SARS-CoV-2 infection was noted in 3.9% (784/20,250) of all stroke admissions., Conclusion: The COVID-19 pandemic was associated with a global decline in the volume of overall stroke hospitalizations, mechanical thrombectomy procedures, and intracranial hemorrhage admission volumes. Despite geographic variations, these volume reductions were observed regardless of COVID-19 hospitalization burden and pre-pandemic stroke/mechanical thrombectomy volumes.

Background: The World Federation of Neurosurgical Societies (WFNS) scale is widely accepted for predicting outcomes for subarachnoid hemorrhage (SAH) patients. However, it is difficult to definitely predict outcomes for the most poor grade, WFNS grade 5. The present study aimed to investigate the prognostic ability of a novel classification using computed tomography perfusion (CTP) findings, called the cortical blood flow insufficiency (CBFI) scores., Methods: CTP was performed on admission for aneurysmal SAH followed by radical treatments within 72 hours of onset. Twenty-four cerebral cortex regions of interest (ROIs) were defined. CBFI was defined as Tmax > 4 s in each ROI, and CBFI scores were calculated based on the total number of ROIs with CBFI. Using the optimal cutoff value based on receiver operating characteristics (ROC) analysis to predict patient functional outcomes, CBFI scores were divided into "high" or "low" CBFI scores. Patient functional outcomes at 90 days were categorized based on modified Rankin Scale scores (0-3, favorable group; 4-6 unfavorable group) (0-4, non-catastrophic group; 5-6, catastrophic group)., Results: Fifty-seven patients were included in this study, of whom 21 (36.8%) and 13 (22.8%) were in the unfavorable and the catastrophic groups, respectively. A factor predicting unfavorable and catastrophic outcomes was CBFI score cutoff value of 7 points (area under the curve, 0.73 and 0.81, respectively). In multivariable logistic regression analysis for unfavorable outcome, high CBFI scores (odds ratio (OR), 8.6; 95% confidence interval (CI), 1.1-65.4; P = 0.04) and WFNS grade 5 (OR, 30.0; 95% CI, 4.5-201.0; P < 0.001) remained as independent predictors, while for catastrophic outcome, high CBFI scores (OR, 25.3; 95% CI, 3.3-194.0; P = 0.002) and age (OR, 1.1; 95% CI, 1.0-1.2; P = 0.02) remained as independent predictors. Conversely, WFNS grade 5 was not an independent predictor of catastrophic outcomes (OR, 3.8; 95% CI, 0.6-24.0; P = 0.15). In high CBFI scores, the OR of the delayed cerebral ischemia (DCI) occurrence was 9.6 (95% CI, 1.5-61.4; P = 0.02) after adjusting for age., Conclusion: High CBFI scores could predict unfavorable and catastrophic outcomes for aneurysmal SAH patients and DCI occurrence.

Objective: Periprocedural thromboembolic events are a serious complication associated with coil embolization of unruptured intracranial aneurysms. However, no established clinical rule for predicting thromboembolic events exists. This study aimed to clarify the significance of adding preoperative clopidogrel response value to clinical factors when predicting the occurrence of thromboembolic events during/after coil embolization and to develop a nomogram for thromboembolic event prediction., Methods: In this prospective, single-center, cohort study, we included 345 patients undergoing elective coil embolization for unruptured intracranial aneurysm. Thromboembolic event was defined as the occurrence of intra-procedural thrombus formation and postprocedural symptomatic cerebral infarction within 7 days. We evaluated preoperative clopidogrel response and patients' clinical information. We developed a patient-clinical-information model for thromboembolic event using multivariate analysis and compared its efficiency with that of patient-clinical-information plus preoperative clopidogrel response model. The predictive performances of the two models were assessed using area under the receiver-operating characteristic curve (AUC-ROC) with bootstrap method and compared using net reclassification improvement (NRI) and integrated discrimination improvement (IDI)., Results: Twenty-eight patients experienced thromboembolic events. The clinical model included age, aneurysm location, aneurysm dome and neck size, and treatment technique. AUC-ROC for the clinical model improved from 0.707 to 0.779 after adding the clopidogrel response value. Significant intergroup differences were noted in NRI (0.617, 95% CI: 0.247-0.987, p < .001) and IDI (0.068, 95% CI: 0.021-0.116, p = .005)., Conclusions: Evaluation of preoperative clopidogrel response in addition to clinical variables improves the prediction accuracy of thromboembolic event occurrence during/after coil embolization of unruptured intracranial aneurysm., Competing Interests: The authors have declared that no competing interests exist.

The efficacy of a computed tomography (CT)-based navigation system to accurately position the stem for intended alignment is unclear. In addition, the influence of stem design on the accuracy of insertion is unknown. We therefore retrospectively compared the accuracy and precision for the intended alignment of two different designs of femoral stem which were implanted with or without the navigation system. Forty-nine total hip arthroplasties (THAs) using a tapered wedge stem and 91 THAs using an anatomic stem were evaluated for the navigation group. Thirty-three THAs using the tapered wedge stem and 15 THAs using the anatomic stem were controls for the non-navigation group. Differences between postoperative measurement and preoperative planning were compared among the groups. In the navigation groups, accuracy (mean absolute difference) and precision (95% limits of agreement) of stem anteversion were 4.3° and ± 10.1° in the tapered wedge stem and 3.1° and ± 6.9° in the anatomic stem. In the non-navigation groups, these were 6.0° and ± 15.2° and 4.8° and ± 12.4°, respectively. The accuracy and precision in the navigation groups were significantly superior to those in the non-navigation group, and those in the anatomic stem group were significantly superior to those in the tapered wedge group. Using the CT-based navigation system, the accuracy and precision for intended stem anteversion were improved. When compared under guidance of navigation system, the accuracy and precision for intended stem anteversion in the anatomic stem were superior to those in the tapered wedge stem.

Mechanical thrombectomy using a retrograde approach is performed for tandem occlusion of the internal carotid artery (ICA). In our patient, a guiding catheter was easily passed by the stenosed lesion despite severe stenosis at the ICA origin. Therefore, we aimed to recanalize the occlusion of the terminal ICA without angioplasty for the stenosed lesion. When contrast was injected, a massive extravasation of contrast from the C2 portion of the ICA was observed. It was speculated that the bleeding was caused by rupture of an aneurysm at that site due to increased intra-arterial pressure caused by the contrast injection to a blind alley, which was created by a wedged guiding catheter at severe stenosis at the ICA origin and the occlusion of the terminal ICA. Our simulation experiment using a silicon vascular model in this situation demonstrated that the elevation of intra-arterial pressure in such blind alley reached over 50, 100, and 200 mmHg by injection of contrast from a microcatheter, a 4-Fr inner catheter, and a 9-Fr balloon-guiding catheter, respectively. When a retrograde approach is planned for tandem occlusion of the ICA, even when the proximal lesion is easily passed, prior angioplasty for the proximal lesion should be considered to avoid wedging by catheter.

Introduction: Heparin-induced thrombocytopenia (HIT) is an immune-mediated complication of heparin exposure. A limited number of studies have reported cerebral venous sinus thrombosis accompanied by heparin-induced thrombocytopenia. Here, we present a case of successful endovascular therapy (EVT) without periprocedural heparinization in this situation., Case Presentation: A 47-year-old woman taking an oral contraceptive was admitted to our hospital with severe headache to be diagnosed as cerebral venous sinus thrombosis. Initially, she got improved by medical treatment with intravenous unfractionated heparin. However, she rapidly developed disturbance of consciousness and right hemiplegia due to cerebral venous sinus thrombosis accompanied by heparin-induced thrombocytopenia on the 14th hospital day. She underwent emergent EVT by immediate conversion of anticoagulation from heparin to argatroban. Despite a large clot burden, sufficient recanalization and anterograde venous drainage were re-established by combined EVT including aspiration, balloon sinoplasty, and local thrombolysis with urokinase infusion. She got improved immediately after the intervention and discharged home without any neurological sequelae after two months., Conclusion: This unique case of cerebral venous sinus thrombosis worsened by occurrence of heparin-induced thrombocytopenia during the treatment finally resulted in excellent outcome highlights effectiveness of emergent endovascular intervention for critical cerebral venous sinus thrombosis resistant to initial medical treatment and of immediate establishment of effective anticoagulant strategy for both of heparin-induced thrombocytopenia and cerebral venous sinus thrombosis. Neuroendovascular therapy for cerebral venous sinus thrombosis using alternative argatroban to heparin for periprocedural anticoagulation might be safe and feasible.

Background: Patency of the middle cerebral artery (MCA) in acute ischemic stroke with internal carotid artery (ICA) occlusions is associated with less severe stroke and favorable outcomes. However, thrombus migration to distal intracranial vessels may lead to unfavorable outcomes. We investigated the influence of thrombus migration on clinical outcomes in patients with ICA occlusions and patent MCA., Materials and Methods: We retrospectively analyzed patients with acute ischemic stroke compromising ICA occlusions and patent MCA who were consecutively admitted to our hospital between January 2006 and March 2016. Thrombus migration was assessed (1) by analyzing the discrepancies in arterial occlusion sites between initial imaging and follow-up imaging and (2) by analyzing how occlusion sites changed during endovascular therapy., Results: Thirty-eight patients (mean age: 74.9 years; 23 men, 15 women, median National Institutes of Health Stroke Scale score = 7.5) with ICA occlusions and patent MCA were ultimately included. We identified 10 patients (26%) with thrombus migration (spontaneous: 3; during endovascular therapy: 7). Patients with thrombus migration had higher rates of unfavorable functional outcomes (modified Rankin Scale scores 3-6 at 90 days) than those without thrombus migration (90% vs. 39%, p < .01). Multivariate analysis showed that thrombus migration was independently related to unfavorable functional outcomes (odds ratio, 42.9; 95% confidence interval, 1.5-1211.0; p = .03)., Conclusion: Thrombus migration in cases of ICA occlusion with patent MCA is associated with poor prognosis. Careful monitoring is required under these conditions even if the initial clinical presentation is mild., Competing Interests: Declaration of Competing Interest Akira Ishii has received lecturing fees from Medtronic. Jun-ichi Kira is supported by grants from JSPS KAKENHI (Grant No.16H02657) and Health and Labor Sciences Research Grants on Intractable Diseases (H29-Nanchitou (Nan)-Ippan-043), and received consultant fees, speaking fees and/or honoraria from Novartis Pharma, Mitsubishi Tanabe Pharma, Boehringer Ingelheim, Teijin Pharma, Takeda Pharmaceutical Company, Otuka Pharmaceutical, Astellas Pharma, Pfizer Japan, Eisai. The other authors have no conflicts to report., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background and Purpose- For patients with large vessel occlusion, neuroimaging biomarkers that evaluate the changes in brain tissue are important for determining the indications for mechanical thrombectomy. In this study, we applied deep learning to derive imaging features from pretreatment diffusion-weighted image data and evaluated the ability of these features in predicting clinical outcomes for patients with large vessel occlusion. Methods- This multicenter retrospective study included patients with anterior circulation large vessel occlusion treated with mechanical thrombectomy between 2013 and 2018. We designed a 2-output deep learning model based on convolutional neural networks (the convolutional neural network model). This model employed encoder-decoder architecture for the ischemic lesion segmentation, which automatically extracted high-level feature maps in its middle layers, and used its information to predict the clinical outcome. Its performance was internally validated with 5-fold cross-validation, externally validated, and the results compared with those from the standard neuroimaging biomarkers Alberta Stroke Program Early CT Score and ischemic core volume. The prediction target was a good clinical outcome, defined as a modified Rankin Scale score at 90-day follow-up of 0 to 2. Results- The derivation cohort included 250 patients, and the validation cohort included 74 patients. The convolutional neural network model showed the highest area under the receiver operating characteristic curve: 0.81±0.06 compared with 0.63±0.05 and 0.64±0.05 for the Alberta Stroke Program Early CT Score and ischemic core volume models, respectively. In the external validation, the area under the curve for the convolutional neural network model was significantly superior to those for the other 2 models. Conclusions- Compared with the standard neuroimaging biomarkers, our deep learning model derived a greater amount of prognostic information from pretreatment neuroimaging data. Although a confirmatory prospective evaluation is needed, the high-level imaging features derived by deep learning may offer an effective prognostic imaging biomarker.

Introduction: We developed a new carbon fiber-reinforced polyetheretherketone (CFR/PEEK) intramedullary nail for proximal femoral fractures. This study aimed to examine the efficacy and safety of the CFR/PEEK intramedullary nail for use in the treatment of patients with proximal femoral fractures., Methods: This multicentre single-arm clinical trial enrolled 20 patients (3 men, 17 women; mean age 85.0 years, range 72-95 years) with proximal femoral fractures treated with the CFR/PEEK intramedullary nail. The follow-up period was >4 months. Primary outcomes were union of the bone fracture, time to bone union, bone nonunion, complications, implant failure, and the reoperation rate. Secondary outcomes were fracture reduction success, and clinical scores using the Harris hip score, Barthel index, Vitality index, Mini-Mental State Examination, and Numerical Rating Scale., Results: Among the 20 patients with proximal femoral fractures treated with CFR/PEEK intramedullary nails, 19 (95%) were confirmed to display bone union within 3.7 months (range 2.8-10.0 months). One patient was diagnosed as having bone nonunion, although the patient did not complain any pain, and there was no radiological evidence of failure after a follow-up period of >18 months. There were no complications (e.g., cut out, infection, hardware failure), and reoperation was not required. Fracture reduction was good and acceptable in all cases, and the mean tip-apex distance was 13.5 mm (range 9.0-19.1 mm). The results indicated that preoperative activity was maintained (preoperative and postoperative Harris hip scores were 73.2 and 71.0 points, respectively; p = 0.61)., Conclusion: There were no adverse reactions or failures related to the CFR/PEEK implant, and it provided satisfactory clinical results and a high union rate. Thus, use of the novel CFR/PEEK intramedullary nail is feasible., Competing Interests: Declaration of Competing Interest The authors, Kazuma Takashima, Ichiro Nakahara, Keisuke Uemura, Hidetoshi Hamada, Wataru Ando, Masaki Takao, and Nobuhiko Sugano, declare no conflict of interest., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background and Purpose: The newly developed ultra-high-resolution CT is equipped with a 0.25-mm detector, which has one-half the conventional section thickness, one-half the in-plane detector element width, and one-half the reconstructed pixel width compared with conventional-detector CT. Thus, the ultra-high-resolution CT scanner should provide better image quality for microvasculature than the conventional-detector CT scanners. This study aimed to determine whether ultra-high-resolution CT produces superior-quality images of the lenticulostriate arteries compared with conventional-detector CT., Materials and Methods: From February 2017 to June 2017, thirteen patients with aneurysms (4 men, 9 women; mean age, 61.2 years) who underwent head CTA with both ultra-high-resolution CT and conventional-detector CT were enrolled. Two board-certified radiologists determined the number of all lenticulostriate arteries on the CTA coronal images of the MCA M1 segment reconstructed from 512 matrixes on conventional-detector CT and 1024 matrixes on ultra-high-resolution CT., Results: There were statistically more lenticulostriate arteries identified on ultra-high-resolution CT (average, 2.85 ± 0.83; 95% CI, 2.509-3.183) than on conventional-detector CT (average, 2.17 ± 0.76; 95% CI, 1.866-2.480) ( P  = .009) in 16 of the total 26 MCA M1 segments., Conclusions: Improvements in lenticulostriate artery visualization were the result of the combined package of the ultra-high-resolution CT scanner plus the ultra-high-resolution scanning protocol, which includes higher radiation doses with lower than the national diagnostic reference levels and stronger adaptive iterative dose-reduction processing. This package for ultra-high-resolution CT is a simple, noninvasive, and easily accessible method to evaluate microvasculature such as the lenticulostriate arteries., (© 2020 by American Journal of Neuroradiology.)