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Chronic kidney disease (CKD) is a progressive disease leading to requirement of renal replacement therapy (RRT) over a period of time. Limited availability and high cost of RRT in many countries necessitates the researchers to focus on either prevention or slowing the progression of CKD. High dose probiotics have been hypothesized to metabolize the nitrogenous waste products, thus delaying the requirement of dialysis. The purpose of this short term intervention study was to study the effect of probiotic-prebiotic therapy and diet counseling on nutrition, renal progression, and overall health of CKD patients. Thirty predialysis CKD patients (21 males, 9 females) were included in the study. The diet charts were designed according to the underlying nutritional status and blood parameters. Calorie intake was 30-40 kcal/kg; proteins 0.6-0.8 g/kg (with at least 50% high biological value); potassium 1.5-2 gm./day; and phosphorus

While mechanical thrombectomy is known to be effective for distal medium vessel occlusion (DMVO) as well as large vessel occlusion, tortuous DMVO are predisposed to vessel injury during stent retriever thrombectomy. Furthermore, getting access to the thrombus may be difficult during suction thrombectomy using a dedicated suction catheter. Most studies describe DMVO treatment using stent retrievers and dedicated suction catheters, but there are limited studies reporting DMVO treated with suction thrombectomy using a microcatheter. Herein, we describe three cases of DMVO treated with suction thrombectomy that was performed using a microcatheter and subsequently showed good results. Therefore, suction thrombectomy using a microcatheter is a viable alternative treatment for tortuous DMVO.

This study investigated the potential of phosphodiesterase type 5 (PDE-5) inhibitors, specifically tadalafil, in preventing the delayed cerebral ischemia (DCI) post-rupture of cerebral aneurysms. A total of 19 rabbits were used in this study, divided into different treatment groups, including nimodipine alone, tadalafil alone, and a combination of nimodipine and tadalafil. Both nimodipine and tadalafil showed some impact on reducing endothelial apoptosis in the basilar arteries, although the effects were not statistically significant. Notably, the nimodipine group exhibited significantly lower levels of Bax in the small arterioles compared to the SAH group. These findings suggest that while tadalafil may not directly prevent endothelial cell death like nimodipine, its neuroprotective properties hint at its potential utility in DCI treatment. Further research involving a broader range of apoptosis-related proteins is recommended to enhance our understanding in this area.

Background: Cranial irradiation has well-known long-term side effects, including radiation-induced neoplasms and vasculopathy. This report describes a case of aggressive and rapid-growing multiple meningiomas developed outside the radiation field after the treatment of medulloblastoma., Case Description: A 6-year-old boy underwent surgery (gross total resection) and radiotherapy (19.8 Gy for posterior fossa only) against medulloblastoma in the 4th ventricle. The patient could not receive further craniospinal irradiation because of ventriculoperitoneal shunt-related complications. Eighteen years after the radiotherapy, the first meningioma developed in the right temporal convexity, without recurrence of medulloblastoma. It was left untreated because it was asymptomatic. Three years later, the meningioma grew from 0.6 to 6.3 cm3 in volume and another large meningioma (22.1 cm3) developed in the left temporal convexity with additional small meningioma in the right frontal convexity. The left large temporal meningioma showed aggressive nature invading the adjacent temporal bone and temporalis muscle. It was completely resected and the histology revealed as transitional meningioma with 2% of Ki-67. Another new meningioma was identified on the right cerebellar convexity three years post-craniotomy. Subsequent follow-up indicated a progressive increase in the tumor size and gamma knife radiosurgery was performed with right frontal convexity small meningioma. The patient is currently under ongoing surveillance through follow-up assessments., Conclusions: For patients who received radiotherapy at a young age, clinicians should consider the possibility of secondary neoplasm development even outside the radiation field. Careful imaging follow-up and surgical management are warranted because of the aggressive nature of secondary tumors even though benign in histology.

Objective: To evaluate the feasibility and durability of coil embolization for MCAB aneurysms by analyzing clinical and radiological results., Methods: From January of 2008 to June of 2018, we treated a total of 1785 aneurysms using coil embolization. The aneurysms were treated by both coiling and stent-assisted coiling. Among these cases, 223 MCAB aneurysms were analyzed retrospectively. Clinical and radiological assessments were conducted at admission, after treatment, at discharge, and at last clinical follow-up., Results: Coil embolization was performed on 223 MCAB aneurysms in 217 patients. Peri-procedural ischemic, hemorrhagic, and other complications within 30 days after coil embolization occurred at rates of 8.0 %, 8.0 %, and 2.0 %, respectively, in the ruptured group and at 2.9 %, 1.2 %, and 0 %, respectively, in the unruptured group. The overall morbidity and mortality rates associated with complications were 2.3 % and 2.0 %. The cumulative major recurrence rates were 5.1 % at 12 months, 7.1 % at 18 months, and 11.9 % at three years after coil embolization. The mean follow-up period was 33.27 ± 25.48 months. Independent risk factors for major recurrence after coil embolization for MCAB aneurysms were a ruptured aneurysm, initial incomplete occlusion, the aneurysm size, and the neck size., Conclusion: Coil embolization is a good alternative treatment option for MCAB aneurysms compared to surgical clipping. Considering the risk factors for major recurrence, the follow-up angiography should continue up to three years after coil embolization., Competing Interests: Declaration of competing interest The 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 © 2024. Published by Elsevier Ltd.)

Background and Purpose: Stent-assisted coil embolization of early branch aneurysms of the middle cerebral artery (MCA) can sometimes be challenging due to the small diameter and acute angle of the branches. This study aimed to analyze the treatment results and report the feasibility and outcomes of the distal stenting technique for these aneurysms., Materials and Methods: The distal stenting technique was used for 15 wide-neck MCA aneurysms (females, 10; males, 5; mean age, 65.1 years) originating from the early branch between December 2018 and October 2021. The average sizes of the dome, depth, and neck of the aneurysms were 4.17 mm (range: 2.99-6.21 mm), 2.86 mm (range: 1.82-3.72 mm), and 3.42 mm (range: 2.44-4.32 mm), respectively., Results: The average diameter of the stents was 4.0 mm (3.0 mm, 3; 4.0 mm, 6; 4.5 mm, 6). Stents were successfully deployed in all 15 aneurysms (100%). The average length of the procedure was 69 min (range: 45-117 min). On postoperative angiography, nine (60.0%) aneurysms were completely occluded, four (26.7%) had neck remnants, and two (13.3%) had contrast flow in the sac. During the procedure, vasospasm and thrombus formation occurred in one case each, but no neurological sequelae were observed. On follow-up digital subtraction angiography of the 10 aneurysms after an average of 13.7 months (range: 12-18 months), the branches were well preserved, and neck remnants were noted in four aneurysms (40.0%). No thromboembolic events occurred during the clinical follow-up., Conclusion: The distal stenting technique using an open-cell stent can be a good option for coil embolization of early branch MCA aneurysms., Competing Interests: Declaration of Competing Interest The authors have not declared any competing interests for this article., (Copyright © 2023. Published by Elsevier Masson SAS.)

Background: Contrast-induced encephalopathy (CIE) following endovascular interventions is a rare but serious complication. This study aimed to investigate the risk factors of contrast leakage (CL) and CIE in patients who underwent coil embolization of unruptured intracranial aneurysms (UIAs)., Methods: Patients with UIAs who underwent coil embolization at a single tertiary institute between January 2019 and January 2022 were enrolled retrospectively. CL was defined as cortical or subcortical contrast enhancement with effacement of the cortical sulci. CIE was defined as the new onset of neurological deficits associated with CL. Following the procedure, all patients underwent CT scans, and MRI scans were performed on those with symptoms. Patient and procedural risk factors were investigated., Results: In total, 459 patients were analyzed. The median procedure time and contrast dose were 69 min and 96 mL, respectively. CL was evident in 35 patients. In the multivariate analysis, hypertension, large aneurysm, longer procedure time, and greater contrast dose were associated with CL. CIE was diagnosed in 19 patients, and the risk factors included large aneurysm, longer procedure time, and greater contrast dose. The procedure time was predictive of both CL (P<0.001) and CIE (P=0.01). The optimal cut-off value for procedure time was 81.5 min. All CIE patients recovered completely within 8-96 hours., Conclusions: A large aneurysm and prolonged procedure time may increase the patient's risk of CL and CIE due to increased contrast exposure. Patients who underwent a procedure that exceeded 1.5 hours necessitate post-procedure evaluation and monitoring., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

In this study, we aimed to evaluate the association between general and central obesity, and their changes with risk of knee osteoarthritis (OA) using retrospective cohort data collected from the Korean National Health Insurance Service. We studied 1,139,463 people aged 50 and over who received a health examination in 2009. To evaluate the association between general and/or central obesity and knee OA risk, a Cox proportional hazard models were used. Additionally, we investigate knee OA risk according to the change in obesity status over 2 years for subjects who had undergone health examinations for 2 consecutive years. General obesity without central obesity (HR 1.281, 95% CI 1.270-1.292) and central obesity without general obesity (HR 1.167, 95% CI 1.150-1.184) were associated with increased knee OA risk than the comparison group. Individuals with both general with central obesity had the highest risk (HR 1.418, 95% CI 1.406-1.429). This association was more pronounced in women and younger age group. Remarkably, the remission of general or central obesity over two years was associated with decreased knee OA risk (HR 0.884; 95% CI 0.867-0.902; HR 0.900; 95% CI 0.884-0.916, respectively). The present study found that both general and central obesity were associated with increased risk of knee OA and the risk was highest when the two types of obesity were accompanied. Changes in obesity status have been confirmed to alter the risk of knee OA., (© 2023. The Author(s).)

We aimed to determine whether knee OA is associated with CVD risk and all-cause death and to evaluate whether the association differs by exercise behavior. We used Korea National Health Insurance Service (KNHIS) database and included 201,466 participants (7572 subjects diagnosed with knee OA) who underwent health screening between 2009 and 2015. Those who had been diagnosed with knee OA or CVD before the index year were excluded. Cox proportional hazard models were used after adjusting for sociodemographic and CVD risk factors to evaluate the association between knee OA and CVD risk and all-cause death. Stratification analysis was further performed to determine the effect of exercise behavior on this relationship. During a median follow-up of 7.06 ± 2.24 years, 8743 CVD (2510 MI and 6553 stroke) cases developed. Individuals with knee OA had increased risks of CVD [hazard ratio (HR) 1.26, 95% confidence interval (CI) 1.15-1.38], myocardial infarction (MI) (HR 1.20, 95% CI 1.00-1.44), and stroke (HR 1.29, 95% CI 1.16-1.43) compared with those without knee OA. Those with knee OA who did not exercise had an increased risk of CVD (HR 1.25, 95% CI 1.11-1.40), whereas no significant increased CVD risk was observed in those with knee OA who exercised at least once a week (HR 1.11, 95% CI 0.96-1.28). There was no association between knee osteoarthritis and all-cause death. Knee OA was independently associated with an increased risk of CVD. Lack of exercise might have a synergistic adverse effect on the association between knee OA and CVD., (© 2023. The Author(s).)

Background: Anterior choroidal artery (AchA) aneurysms are usually small in diameter because of the size of the involved artery and are often wide-necked. Coil embolization of AchA aneurysm is thus challenging because of serious risks, such as thromboembolic occlusion of artery and perforation of aneurysm dome. Therefore, aneurysmal neck clipping remains widely performed despite a recent increase in the use of coil embolization for aneurysm treatment. We report the treatment results of AchA aneurysms mostly (92.3%) treated with coil embolization at our institute., Methods: The database and medical records of patients who underwent coil embolization for AchA aneurysms were retrospectively analyzed. The clinical and imaging results and procedure-related complications were investigated after coil embolization performed between January 2006 and March 2022 at our institute., Results: In total, 96 AchA aneurysms comprising 65 unruptured and 31 ruptured aneurysms, including only 1 ruptured aneurysm (1.0%) re-embolized at postoperative day 192 because of coil compaction, were evaluated. After the initial coil embolization, complete occlusion was attained in 41, residual neck in 45, and residual aneurysm in 10 patients. Follow-up radiological studies after 6-174 months were performed for 80 aneurysms. Complete occlusion was noted in 57 patients, residual neck in 22, and residual aneurysm in 1. The dysarthria experienced by one (1.0%) patient was the only symptomatic procedure-related complication. After coil embolization, neither delayed new rupture nor re-rupture was observed., Conclusions: The results of this study demonstrate that coil embolization is a safe and effective treatment option for patients with AchA aneurysms.

Background: Gamma Knife radiosurgery (GKS) is a promising treatment option for meningioma. However, the incidence of peritumoral edema (PTE) following GKS has been reported to be 7%-38%. This study aimed to develop a predictive model for post-GKS PTE using a deep neural network (DNN) algorithm., Methods: Patients treated with GKS for meningioma between November 2012 and February 2020 at a single tertiary center were reviewed. The primary outcome was newly developed or aggravated PTE after GKS. Clinical data, including radiosurgical parameters, were collected, and imaging data obtained at the time of GKS were incorporated into the model using a 50-layered residual neural network, ResNet50. Consequently, the model efficiency was evaluated considering the accuracy and area under the receiver operating curve (AUC) values., Results: A total of 202 patients were included in this study. The median tumor volume was 2.3 mL, and the median prescription dose was 13 Gy. PTE was observed before GKS in 22 patients. Post-GKS PTE was evident in 28 patients (13.9%), which further evolved to radiation necrosis in 5 patients. The accuracy and AUC values of the hybrid data model based on both clinical and imaging data were 0.725 and 0.701, respectively. The performance of the hybrid data model was superior to that of the other models based on clinical or image data only., Conclusions: The DNN-based model using both clinical and imaging data exhibited fair results in predicting post-GKS PTE in meningioma treatment. Predictive models using imaging data may be helpful in prognostic research., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Total knee arthroplasty (TKA) is among the most successful types of surgery for the treatment of knee osteoarthritis (OA). However, nearly 20% of patients report unexpected pain after surgery. Recently, some studies have proposed that pain after TKA is related to pain catastrophizing (PC) and central sensitization (CS). However, there is no study comparing PC and CS for the same patient with knee OA requiring TKA. Thus, the goal of this study was to confirm the association between PC and CS among patients with knee OA awaiting primary TKA. This study was conducted with the clinical data of 153 patients collected between July 2019 and February 2021. Both PC and CS were evaluated with the Pain Catastrophizing Scale (PCS) and the Central Sensitizing Inventory (CSI). Patients with PCS scores higher than 30 were classified as high-level catastrophizing. Patients with CSI scores higher than 40 were classified as central sensitized. The distribution of PC and CS levels was confirmed, and the correlation between PC and CS was analyzed. A significant correlation was found between PCS and CSI scores, with Pearson's correlation coefficient of 0.606. Participants with high-level catastrophizing were 2.07 times more likely to belong to the central sensitized group compared with those who did not show high-level catastrophizing. Participants in the central sensitized group were 3.02 times more likely to belong to the high-level catastrophizing group than those who were not central sensitized. In conclusion, many patients with knee OA awaiting primary TKA had high-level catastrophizing, and a significant association was found between PC and CS. [ Orthopedics . 2022;45(4):197-202.].

Introduction: Sarcopenia, a loss of muscle mass and strength with aging, is associated with various TKA-related complications. In 2020, the AWGS published an undated guideline (AWGS 2019) based on studies from East and Southeast Asia. The purpose of this study was to determine the prevalence of sarcopenia in Asian female patients awaiting primary total knee arthroplasty due to advanced knee osteoarthritis using the updated AWGS criteria., Materials and Methods: The present study included 138 female patients who scheduled for primary TKA with severe osteoarthritis. The included patients were assessed with use of an AWGS 2019 diagnostic criteria based on muscle strength, physical performance, and appendicular skeletal muscle mass. Clinical parameters related to sarcopenia were collected and knee status assessed using the Knee Society scoring system. To better define the association with age, patients were stratified into following four groups: <60, 60-69, 70-79, ≥80. The prevalence of sarcopenia was identified, and the association between sarcopenia and clinical variables was analyzed., Results: The prevalence of sarcopenia and severe sarcopenia in this cohort according to the updated AWGS criteria was 35.5% and 21.7%. Prevalence of sarcopenia and severe sarcopenia significantly increased with advancing age ( p = .003, p = .040, respectively). Although not statistically significant, the proportion of severe sarcopenia among sarcopenia also increased with age. Multivariate logistic regression analysis revealed that lower BMI and lower 25-OH-vitamin D3 level were independent risk factors associated with sarcopenia in women awaiting TKA., Conclusions: In conclusion, our study confirmed that sarcopenia is more prominent amongst female patients awaiting primary TKA than the general population. Therefore, orthopedic surgeons should consider sarcopenia prevention and intervention in this group. Further studies are needed to investigate the effect of TKA on sarcopenia, and the difference of TKA outcomes between groups with or without underlying sarcopenia.

Alzheimer's disease (AD) is a form of dementia characterized by progressive memory decline and cognitive dysfunction. With only one FDA-approved therapy, effective treatment strategies for AD are urgently needed. In this study, we found that microRNA-485-3p (miR-485-3p) was overexpressed in the brain tissues, cerebrospinal fluid, and plasma of patients with AD, and its antisense oligonucleotide (ASO) reduced Aβ plaque accumulation, tau pathology development, neuroinflammation, and cognitive decline in a transgenic mouse model of AD. Mechanistically, miR-485-3p ASO enhanced Aβ clearance via CD36-mediated phagocytosis of Aβ in vitro and in vivo. Furthermore, miR-485-3p ASO administration reduced apoptosis, thereby effectively decreasing truncated tau levels. Moreover, miR-485-3p ASO treatment reduced secretion of proinflammatory cytokines, including IL-1β and TNF-α, and eventually relieved cognitive impairment. Collectively, our findings suggest that miR-485-3p is a useful biomarker of the inflammatory pathophysiology of AD and that miR-485-3p ASO represents a potential therapeutic candidate for managing AD pathology and cognitive decline.

Background: Angiographic outcomes of contact aspiration thrombectomy (CAT), a frontline thrombectomy strategy, can vary depending on balloon guide catheter (BGC) usage, stroke etiology, and occlusion location. The purpose of this study was to analyze conditional outcomes of CAT to determine which result in maximum angiographic benefits., Methods: Patients who received CAT for anterior circulation occlusive stroke between January 2017 and December 2018 were included. Angiographic and clinical outcomes were compared relative to BGC use, stroke etiology, and occlusion location. Multivariable analyses for first-pass reperfusion (FPR) and favorable clinical outcome were performed., Results: Of 160 included patients, the rates of FPR, successful reperfusion after CAT, final successful reperfusion, and favorable clinical outcome were 43.1%, 58.1%, 81.9%, and 60.6%, respectively. BGC use was associated with a higher rate of FPR, successful reperfusion after CAT, a lower rate of distal embolization, and faster reperfusion. Based on subgroup analysis, BGC usage in ICA, MCA M1 occlusion, and cardioembolism were associated with higher FPR, successful reperfusion after CAT, and lower distal embolization. Faster reperfusion was achieved in ICA occlusions and cardioembolisms. BGC usage was an independent predictor of FPR. Favorable clinical outcome was associated with male gender, low initial NIHSS score, fast onset to reperfusion, and FPR., Conclusions: In CAT, BGC usage was associated with better angiographic outcomes, including higher FPR, successful reperfusion after CAT, prevention of distal embolization, and faster reperfusion, especially in proximal occlusions and cardioembolisms. These conditions may play a role in maximizing the benefits of CAT.

Background: In medically refractory vasospasm, invasive intervention may be required. A commonly used approach is intra-arterial (IA) drug infusion. Although calcium channel blockers (CCBs) have been widely applied in this setting, studies comparing their efficacies and durations of action have been few. This study was performed to compare attributes of three CCBs (nicardipine, nimodipine, and verapamil), focusing on duration of the vasodilatory action based on angiography., Methods: Vasospasm was produced in New Zealand white rabbits (N = 22) through experimentally induced subarachnoid hemorrhage and confirmed in each via conventional angiography, grouping them by IA-infused drug. After chemoangioplasty, angiography was performed hourly for 5 h to compare dilated and vasospastic arterial diameters. Drug efficacy, duration of action, and changes in mean arterial pressure (relative to baseline) were analyzed by group., Results: Effective vasodilation was evident in all three groups immediately after IA drug infusion. The vasodilative effects of nimodipine and nicardipine peaked at 1 h and were sustained at 2 h, returning to initial vasospastic states at 3 h. In verapamil recipients, effects were more transient by comparison, entirely dissipating at 1 h. Only the nicardipine group showed a significant 3-h period of lowered blood pressure., Conclusions: Although nimodipine and nicardipine proved longer acting than verapamil in terms of vasodilation, their effects were not sustained beyond 2 h after IA infusion. Further study is required to confirm the vasodilatory duration of IA CCB based on perfusion status, and an effort should be made to find new alternative to extend the duration.

During coil embolization of wide-necked posterior communicating artery (PcomA) aneurysms, stent assistance is sometimes limited if PcomA is acutely angled at its origins from saccular neck. Herein, we present two instances where retrograde stenting was used for coil embolization of PcomA aneurysms. Both procedures involved a contralateral approach via anterior communicating artery (AcomA). To achieve this, the stent-delivery microcatheter was inserted retrograde from contralateral to ipsilateral internal carotid artery (ICA) across AcomA, arriving at ipsilateral PcomA. A separate microcatheter, passed through ipsilateral ICA, was then used to select the aneurysm sac for coil delivery. Coil embolization ultimately took place under protection of a horizontally placed stent extending from PcomA to terminal ICA. Each aneurysm was properly coiled and occluded, without procedural complications. This stenting technique is a reasonable option, offering a means of strategic coil embolization in wide-necked PcomA aneurysms and providing complete neck coverage through contralateral access., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

The crossing Y-stent method is one of the indispensable techniques to achieve sufficient neck coverage during coil embolization of bifurcation aneurysms with a wide neck and/or branch incorporation. However, the inevitable hourglass-like expansion of the second stent at the crossing point can result in insufficient vessel wall apposition, reduced aneurysm neck coverage, delayed endothelialization, and subsequent higher risks of acute or delayed thrombosis. It also interferes with engagement of the microcatheter into the aneurysm after stent installation. We expected to be able to reduce these disadvantages by installing a noncrossing type Y-stent using the Solitaire AB stent, which is fully retrievable with a tapered proximal end. Here we report the techniques and two successful cases.

Objective: As the average life span in modern society continues to increase, much interest is focused on high-risk procedures in elderly patients, including major surgical operations. We investigated the results of endovascular coiling of unruptured intracranial aneurysms (UIA) in patients over 80 years of age., Methods: We retrospectively analyzed 39 patients aged over 80 years who underwent coil embolization for UIA between April 2007 and April 2019 at our hospital., Results: Complete occlusion on digital subtraction angiography (DSA) immediately after surgery was performed in 44 (84.6%) of 52 cases of cerebral aneurysms. Four patients (7.7%) had residual aneurysmal necks, and four (7.7%) had contrast flow in the aneurysmal sac. Follow-up magnetic resonance angiography (mean: 8.2 months) was performed in 37 aneurysms in 24 patients. There was evidence of blood flow in the neck in seven cases (18.9%) and aneurysm in two cases (5.4%). Follow-up DSA (mean: 20.5 months) was performed in 14 aneurysms in 11 patients, and 11 aneurysms (78.6%) had complete occlusion, 1 aneurysm (7.1%) had an aneurysmal neck, and 2 aneurysms (14.3%) had contrast filling into the aneurysmal sac. Coil embolization procedure-related complications occurred in 3 patients (7.7%). Cerebral infarction occurred in 1 (2.6%), arterial dissection in 1 (2.6%), and hypoesthesia in 1 (2.6%)., Conclusions: Active treatment of UIA in elderly patients over 80 years of age through endovascular coil embolization can be considered.

Background: Considering that primary watertight dural closure is not always possible following posterior fossa surgery, several methods of dural reconstruction were proposed to reduce the risk of cerebrospinal fluid (CSF) leakage. This study aimed to evaluate the efficacy of collagen matrix inlay graft compared with other techniques in a propensity score-matched cohort., Methods: Between 2000 and 2019, 176 consecutive patients who underwent posterior fossa surgery were enrolled. Of these, 103 patients underwent dural reconstruction with collagen matrix inlay graft (inlay group). After propensity score matching, 67 pairs were derived. The primary outcome was the development of CSF leakage. Pseudomeningocele and surgical site infection were also investigated., Results: Median follow-up period was 53.9 months. None of the patients in the inlay group had CSF leakage; however, leakage was evident in 5 patients (6.8%) who underwent dural reconstruction without a collagen matrix inlay graft (no-inlay group; P = 0.011). Pseudomeningocele was noted in 1 (1.4%) patient in the no-inlay group, while surgical site infection was noted in 3 (3.0%) patients in the inlay group and 4 (5.5%) patients in the no-inlay group. None of the surgical site infections were related to the use of the inlay graft. After propensity score matching, CSF leakage was still prevalent in the no-inlay group (P = 0.042)., Conclusions: Dural reconstruction using a collagen matrix inlay graft efficiently reduces CSF leakage after posterior fossa surgery and does not increase the risk of postoperative infection and inflammation. It seems to be a feasible option for dural reconstruction., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background and Purpose: As intraarterial thrombectomy (IAT) has been actively practiced, blood biomarkers that can predict outcomes after IAT have drawn attention. Growth differentiation factor-15 (GDF-15) is a stress-responsive cytokine and the levels are increased during inflammation or other pathological conditions of various tissues, including the brain. However, GDF-15 levels have not been reported as a biomarker for IAT outcomes. This study was performed to evaluate whether GDF-15 was related to the extent of brain damage and whether it could predict patient prognosis after IAT., Methods: Patients who showed large arterial occlusion and significant diffusion-perfusion mismatch on imaging underwent IAT. A total of 62 patients who underwent IAT and had blood samples for GDF-15 measurements were enrolled from July 2013 to May 2015. We assessed the infarct severity by consecutive changes on the National Institutes of Health Stroke Scale (NIHSS) during admission and the size of the infarction on brain imaging. Modified Rankin Scale scores (mRS) from 0 to 2 were considered good outcomes, representing functional independence at discharge and three months later., Results: The levels of GDF-15 at the time of admission were significantly correlated with the NIHSS scored at 24 hours (r = 0.306, p = 0.016), three days after IAT (r = 0.261, p = 0.041), and at discharge (r = 0.266, p = 0.037), as well as the infarct size on diffusion-weighted image taken 24 h after IAT (r = 0.452, p = 0.001), but the levels were not correlated with the initial NIHSS or the infarct size before IAT. Multiple logistic regression showed that GDF-15 levels were an independent predictor of functional independence (mRS 0 - 2) at discharge (p = 0.028) and three months after IAT (p = 0.019). Other factors that could predict prognosis were good collateral status on the initial brain angiography and rapid recanalization within six hours from symptom onset., Conclusion: The GDF-15 level at the time of admission showed a significant positive correlation with the severity of cerebral damage and clinical outcome after IAT. This suggests that GDF-15 can provide useful prognostic information for patients who successfully underwent IAT in an emergency setting., Competing Interests: Declaration of Competing Interest The authors have no financial conflicts of interest., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: We report the long-term results of a modified stent-assisted coil embolization technique using the far proximal part of a self-expanding open-cell stent. The technique was used to cover the neck of the aneurysm while simultaneously preserving the branches of the distal internal carotid artery in patients with aneurysms of the posterior communicating (Pcom) and anterior choroidal arteries (AchA)., Methods: We performed a retrospective review of the prospectively maintained databases at two tertiary neurosurgical centers to identify all patients who underwent embolization of Pcom or AchA aneurysms using this technique between January 2014 and July 2019. Postoperative and follow-up clinical and radiological results for initial (n = 16) or re-do (n = 4) embolizations were analyzed., Results: We identified 19 patients with 20 (16 Pcom and 4 AchA) unruptured (n = 19) or ruptured (n = 1) aneurysms. Eighteen among 20 stents (90.0%) were deployed successfully, and complete occlusions were initially attained in 18 aneurysms (90.0%). At follow-up examinations 8 to 56 months later, 6 of 14 aneurysms (42.8%) showed neck remnants. All of the branches were saved and no thromboembolic event, rupture, or sequelae were noted during or after the procedures., Conclusion: These results suggest that this modified stent-assisted technique is a feasible and reasonable alternative to conventional stent deployment for coil embolization of wide-necked sidewall aneurysms in the distal ICA.

Purpose: Total knee arthroplasty (TKA) is a clinically efficacious surgical option for end-stage knee osteoarthritis. However, TKA increases the risk of serious bleeding and blood transfusion. The objective of this study was to evaluate the difference in postoperative blood loss in groups subjected to 3 h of clamping and non-clamping and determine the variations in rate and amount of transfusion after TKA between the two groups., Materials and Methods: Propensity score matching of the group subjected to 3-h drain clamping (43 patients; September 2015 to April 2016) and the control group (43 patients; before initiating the clamping method) was performed in patients undergoing unilateral primary posterior stabilized TKA. The two groups were compared. We measured the total drained blood volume until the drain was removed 48 h after surgery, and we compared the preoperative levels of hemoglobin and hematocrit with levels observed on days 1 and 2 after surgery. We also determined the blood transfusion rate and volume as well as the occurrence of clamping-associated complications., Results: In the group subjected to 3-h drain clamping, the mean volume of total drained blood was significantly lower than in the control group (333.8 ± 190.2 mL vs. 839.9 ± 339.8 mL, P <0.001). There was no significant difference in total blood loss between the two groups (1226.9 ± 488.1 mL vs. 1127.1 ± 424.5 mL, P = 0.315), but the hidden blood loss was significantly higher in the 3-h drain clamping group than in the control group (893.1 ± 487.7 mL vs. 294.7 ± 531.8 mL, P <0.001). Both the transfusion rate and amount in the 3-h drain clamped group were higher than in the control group but were not statistically significant (30.2% vs. 37.2%, P = 0.494 and 269.8 ± 483.8 mL vs. 316.3 ± 158.2 mL, P = 0.648, respectively). No significant differences in complications, including deep vein thrombosis, pulmonary thromboembolism, and oozing, were noted between the two groups (all, P = 1.000)., Conclusions: The 3-h drain clamping method after primary TKA using posterior stabilized implant reduced the loss of postoperative drained blood. However, hidden blood loss was significantly higher in the 3-h drain clamping group; as a result, there were no differences in total blood loss and transfusion rate. The clamping method did not significantly alter the complication rate.

T-cell immunoglobulin and mucin domain-containing molecule 3 (TIM-3), a potential immunotherapeutic target for cancer, has been shown to display diverse characteristics in a context-dependent manner. Thus, it would be useful to delineate the precise functional features of TIM-3 in a given situation. Here, we report that glial TIM-3 shows distinctive properties in the brain tumor microenvironment. TIM-3 was expressed on both growing tumor cells and their surrounding cells including glia and T cells in an orthotopic mouse glioma model. The expression pattern of TIM-3 was distinct from those of other immune checkpoint molecules in tumor-exposed and tumor-infiltrating glia. Comparison of cells from tumor-bearing and contralateral hemispheres of a glioma model showed that TIM-3 expression was lower in tumor-infiltrating CD11b + CD45 mid glial cells but higher in tumor-infiltrating CD8 + T cells. In TIM-3 mutant mice with intracellular signaling defects and Cre-inducible TIM-3 mice, TIM-3 affected the expression of several immune-associated molecules including iNOS and PD-L1 in primary glia-exposed conditioned media (CM) from brain tumors. Further, TIM-3 was cross-regulated by TLR2, but not by TLR4, in brain tumor CM- or Pam 3 CSK 4 -exposed glia. In addition, following exposure to tumor CM, IFNγ production was lower in T cells cocultured with TIM-3-defective glia than with normal glia. Collectively, these findings suggest that glial TIM-3 actively and distinctively responds to brain tumor, and plays specific intracellular and intercellular immunoregulatory roles that might be different from TIM-3 on T cells in the brain tumor microenvironment. SIGNIFICANCE: TIM-3 is typically thought of as a T-cell checkpoint receptor. This study demonstrates a role for TIM-3 in mediating myeloid cell responses in glioblastoma., (©2020 American Association for Cancer Research.)

The LAser raDAR (LADAR) system designed in this study shows a ghost pattern around the object image when operated. The system contains 4 wedge prisms, each with different rotational directions and speeds. Therefore, an efficient and thorough analysis method was established. Ray path analysis was performed, and categorized, for every instantaneous case sampled using a backward ray tracing method. The rays' flux and directions were accumulated according to their path histories. This backward ray tracing was performed repeatedly with different neutral density (ND) filter orientations, until no measurable ghost radiance remained in the field of regard (FOR): a tilt angle of 5°. The ND filter was replaced with a mechanical vignette. Subsequently, the ghost flux was 21% of the total accumulated point cloud, coinciding with the actual measurement of 19%. The final image has significantly improved resolution and shows no ghost reflections where they were previously.

Alzheimer's disease (AD) is an ageing-related neurodegenerative disease characterized and diagnosed by deposition of insoluble amyloid-β (Aβ) plaques in the brain. The plaque accumulation in the brain directly affects reduced levels of Aβ in cerebrospinal fluid (CSF) and blood, as Aβ can freely transport the blood-brain barrier, and clinical investigations have suggested these two biofluids as promising samples for in vitro diagnosis. Given that the human eye structurally resembles the brain and Aβ accumulation often observed in the ocular region of AD patients, in this study, we examined aqueous humor Aβ as another possible surrogate biomarker. First, using the acute Aβ-infused AD mouse model by injecting Aβ to the CSF in intracerebroventricular region of normal ICR mice, we investigated whether Aβ concentration in the aqueous humor in AD models is positively correlated with the concentration in the CSF. Then, we examined the correlation of aqueous humor Aβ levels with increased plaque deposition in the brain and reduced Aβ levels in both CSF and blood in adult and aged 5XFAD Alzheimer transgenic mice. Collectively, the synthetic Aβ injected into CSF immediately migrate to the aqueous humor, however, the age-dependently reducing pattern of Aβ levels in CSF and blood was not observed in the aqueous humor., Competing Interests: The authors have declared that no competing interests exist.

This paper presents the implementation of a pulse-type LAser Detection And Ranging (LADAR) system based on heterodyne detection for long-range measurement. A pulse-type LADAR based on an intensity direct-detection is certainly simple and mature, but it requires a high peak-power laser and a low-noise avalanche photodiode for long-range measurement, which restricts the scope of the application due to the weight, power consumption, and cost of the laser and the photodetector. In this work, heterodyne detection using a PIN photodiode is implemented to increase receiver sensitivity instead of using a low-noise avalanche photodiode. An optical phase-locked loop is adopted to generate an optical local oscillator signal for heterodyne detection. The proposed heterodyne detection scheme achieves a minimum detectable signal level of -52.6 dBm at a bandwidth of 1.2 GHz, and it is adopted in a pulse-type LADAR system for long-range measurement. The pulse-type LADAR system can measure a distance of 2.77 km at a repetition rate of 40 kHz, and it demonstrates great advantages for realizing real-time 3D imaging for long-range measurement with a high frame rate.

Purpose: We report our experience of using stent-retrievers for recurrent cerebral vasospasm (CVS) secondary to aneurysmal subarachnoid hemorrhage (aSAH)., Methods: We performed a retrospective review of our prospectively maintained institutional database to identify all patients with recurrent CVS and treated with stent-retrievers between April 2011 and May 2017. All patients were initially treated with intra-arterial (IA) vasodilators and were subsequently re-treated with stent-retrievers if they developed recurrent vasospasm. Patients were categorized into two groups, those in which IA vasodilators were given again prior to the stent-retriever deployment (VD-first) and those in which the stent-retriever was deployed first and IA vasodilators were given subsequently (SR-first)., Results: We identified 12 patients (7 females, mean age 54.9 years), 5 in the VD-first and 7 in the SR-first cohorts. Stent-retriever lumen dilatation was attempted in 53 segments (VD-first 14, SR-first 39). Stent-retriever deployment was technically feasible in all cases. Vasodilation occurred in 71.4% (10/14 segments) in the VD-first group and 82.1% (32/39 segments) in SR-first group. Additional treatment was required in 5 segments. There was no recurrent vasospasm in the SR-first group; however, 3 patients (60%) in the VD-first group showed recurrent vasospasm. No angiographical abnormality was found at long-term follow-up (7 patients, mean 29.1 months)., Conclusion: The use of stent-retrievers to treat cerebral vasospasm is technically feasible and can cause long-term vasodilatation; however, this effect is maximized if stent-retrievers are used prior to infusion of IA vasodilators.

Introduction: The increasing use of intracranial imaging has led to more frequent diagnoses of arachnoid cysts (ACs). Although ACs are a frequent finding on neuroimaging in children, the prevalence and natural history of these cysts are not well defined. Most ACs may persist and remain asymptomatic throughout life and not require treatment. However, there have been some case reports of ACs that have become larger or smaller over time and, in rare cases, have even spontaneously resolved. It is the authors' practice to recommend serial neuroimaging in patients with asymptomatic sylvian ACs and not offer surgery to patients without symptoms, even in those with a relatively large cyst., Case Report: The present article describes a case involving a 6-year-old boy with a large, asymptomatic AC in the left Sylvian fissure involving the temporo-frontal region, which resolved spontaneously during the 2-year follow-up period after initial diagnosis without any surgical intervention. Currently, at the 7-year follow-up, the patient has remained neurologically intact, attends school, and is symptom-free., Conclusion: Clinicians should be mindful of the possibility of spontaneous regression when encountering patients with asymptomatic and/or incidentally diagnosed sylvian ACs.

Background and Purpose: Aneurysms arising from the proximal A1 segment of the anterior cerebral artery are rare, and their distinctive configurations often pose technical challenges during endovascular embolization. Herein, we present 11 patients with proximal A1 aneurysms requiring a contralateral approach (via the anterior communicating artery) to coil embolization., Materials and Methods: From a prospectively collected data repository, we retrieved records of 11 patients consecutively treated for proximal A1 aneurysms between January 2011 and March 2018. In each instance, coil embolization was performed by the contralateral route. Outcomes were analyzed in terms of morphologic features and clinical status., Results: Aneurysms in all 11 patients were directed posteriorly and were small (<5 mm). A contralateral approach (via the anterior communicating artery) was used after ipsilateral attempts at aneurysm selection failed in each instance, despite using a variety of microcatheters. Single punctures and single guiding catheters sufficed in 9 patients, but 2 patients required dual punctures and 2 guiding catheters. All endovascular treatments ultimately yielded excellent outcomes. Although 1 symptomatic infarct was manifested in the course of ipsilateral treatment, no morbidity or mortality resulted from the contralateral access., Conclusions: Due to angio-anatomic constraints, a contralateral strategy for coil embolization of proximal A1 aneurysms is acceptable if ipsilateral access is technically prohibitive and the vessels (contralateral A1 and anterior communicating artery) are amenable to the passage of microdevices., (© 2018 by American Journal of Neuroradiology.)

We report our initial experience of using a microcatheter for contact aspiration of acute distal occlusions for recanalization. Endovascular technique and a case using Excelsior XT-27 microcatheter are presented. After manual suction within distal middle cerebral artery segments using a 50-ml syringe, instant and complete recanalization was obtained. Microcatheter suction thrombectomy using a 50-ml syringe can be considered a feasible treatment option for acute distal small artery occlusions.

Background: Known facts are that a long period of central catheterization or hemodialysis causes central venous occlusion or stenosis and its further development brings about superior vena cava syndrome. Major symptoms of superior vena cava syndrome include venous congestion caused by the occlusion or stenosis of the central vein in the sites of the head, face, neck, and upper extremity. Clinical manifestations of superior vena cava syndrome are less likely to cause intracranial hypertension, and intracranial venous hypertension does not appear to be a clinical symptom of cavernous sinus-dural arteriovenous fistula., Case Description: A 35-year-old female patient visited our hospital with chief complaints of a 2-week-old headache, chemosis, pulsatile and exophthalmos and the deteriorating ptosis in the right eye. The patient has been on continuous hemodialysis since diagnosis of renal failure due to diabetes for 20 years. Magnetic resonance images led us to a strong suspicion of cavernous sinus-dural arteriovenous fistula. However, an additionally performed digital subtraction angiogram led us to the diagnosis of superior vena cava syndrome of severe stenosis in both brachiocephalic veins. Balloon angioplasty was performed to the narrowed right-side brachiocephalic vein. No more intracranial venous reflux was to be seen in the postballoon angiogram., Conclusions: In our case, the clinical manifestations of superior vena cava syndrome seemed to be cavernous sinus-dural arteriovenous fistula and symptoms disappeared when resolving central vein stenosis. We report a case of superior vena cava syndrome with atypical clinical features., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Stroke is the number one cause of adulthood disability in Korea. Rehabilitation after stroke can minimize functional disability, enhance recovery toward independence, and optimize community reintegration. The inter-departmental stroke meeting (IDSM) is a potential method to improve rehabilitation outcomes in patients with stroke. We aimed to analyze the effect of IDSM on rehabilitation after acute ischemic stroke management., Methods: Medical records of 753 patients with acute ischemic stroke admitted to the neurology department of our medical center between January and December 2014 were reviewed retrospectively. In May 2014, weekly IDSMs were initiated. All physicians responsible for the patient's care reviewed patient treatment, methods of secondary prevention, and future rehabilitation plans., Results: The transfer rate significantly increased after initiation of IDSM (phase 2, 3) and the length of stay (LOS) before transfer to the rehabilitation department decreased significantly from 9.68 ± 8.50 days to 5.75 ± 2.12 days. There was a reduction in the total LOS from 52 ± 28.57 days to 35 ± 27.21 days after IDSMs were introduced. In non-transferred patients also, the total LOS reduced significantly. The transfer rate increased significantly and the LOS before transfer to the rehabilitation department decreased significantly after implementation of IDSM in a subgroup of patients with moderate to severe stroke., Conclusion: The introduction of IDSM was significantly correlated with improvements in transfer rates and reduction of LOS in hospital. This finding shows that IDSMs are an important intervention to improve therapeutic progress and outcomes for patients with stroke., Competing Interests: The authors have no potential conflicts of interest to disclose., (© 2018 The Korean Academy of Medical Sciences.)

Background: The primary objective of the current study was to evaluate the efficacy of a community-based participatory intervention program in improving hepatitis B virus (HBV) screening and vaccination among Korean Americans who were not previously screened., Methods: A cluster randomized trial involving 32 Korean church-based community organizations (1834 participants) was conducted. Sixteen churches were randomly assigned to an HBV screening and vaccination multicomponent intervention condition (972 participants) and 16 were assigned to a general cancer education control condition (862 participants). The main components of the intervention program included interactive group education; patient navigation; and the engagement of health care providers, church leadership, and church members in the medical field. The application of community-based participatory research principles was monitored and evaluated. HBV screening and vaccination rates (self-reported and medical record verification) were assessed at 6-month and 12-month follow-ups, respectively., Results: The results of the current study demonstrated significant efficacy in the HBV screening rate (92.5% in the intervention group vs 5.5% in the control group), 3-series HBV vaccination completion rate (84% in the intervention group vs 17.6% in the control group), and overall screening and vaccination compliance rate (87% in the intervention group vs 3.8% in the control group). Participants in the intervention group were significantly more likely to receive HBV screening (92.5%) compared with those in the control group (5.5%). In multivariate mixed-effect logistic regression analysis, the odds ratio for an intervention effect on HBV screening was 512.3 after adjusting for cluster effect and other demographic variables. With regard to vaccination rates, of the 332 participants who were screened with no immunity in the intervention group, 308 (92.8%) received at least 1 HBV vaccination, 300 (90.4%) received at least 2 shots, and 279 participants (84%) received all 3 shots., Conclusions: A combination of community-based participatory research and a multilevel approach may produce the most optimal results and be essential in producing a considerable effect for enhancing HBV screening and vaccination, particularly for Korean American populations with limited language proficiency and insurance coverage. Cancer 2018;124:973-82. © 2017 American Cancer Society., (© 2017 American Cancer Society.)

Posttraumatic delayed vertebral collapse, known as Kummell's disease, is increasing in number of patients. This disease is already progressive kyphosis due to vertebral collapse at the time of diagnosis and it causes intractable pain or neurologic deficit due to intravertebral instability. Treatment is very difficult after progression of the disease, and the range of treatment, in hospital day, and cost of treatment are both increased. Clinical features, pathogenesis and radiologic findings of these disease groups were reviewed to determine risk factors for delayed vertebral collapse. The purpose of this article is to suggest appropriate treatment before vertebral collapse for patients with osteoporotic vertebral compression fracture who have risk factors for posttraumatic delayed vertebral collapse.

Objectives: Thrombolytic therapy is associated with favorable clinical outcomes after successful and rapid recanalization in patients with acute ischemic stroke. This study aimed to evaluate the cost benefits and clinical outcomes at 1 year after intraarterial thrombectomy (IAT) by the rapidity of the successful recanalization., Materials & Methods: Clinical outcomes of and medical costs incurred by 230 patients with acute ischemic stroke who underwent IAT were compared by the rapidity from symptom onset to successful recanalization (2b/3 thrombolysis in cerebral infarction grade): ≤6-hr ( n  = 143), >6-hr ( n  = 31), and no-recanalization ( n  = 56). Clinical outcomes including functional independence (0-2 modified Rankin Score), mortality, and home-discharge checked at 1 year post-IAT were compared among the three groups. Cost utility was calculated using quality-adjusted life years (QALY) estimated using the EuroQol-5 dimensions-3 levels questionnaire and the fees paid for institutional rehabilitation during the year post-IAT, and, was compared among the groups., Results: Patients in the ≤6-hr group showed higher functional independence (≤6-hr, 70%; >6-hr, 40%; no-recanalization, 6%, p  <   .001) and home-discharge rate (73%, 52%, 21%, and respectively, p  <   .001), and lower mortality (10%, 16%, and 43%, respectively, p  <   .001) at 1 year after IAT than other two groups. The cost utility of the ≤6-hr group was $35,557/QALY higher than that of the >6-hr group, and $27.829/QALY higher than no-recanalization group., Conclusions: Rapid and successful recanalization of the occluded intracranial vessels within 6 hr after the onset of symptoms resulted in markedly higher cost utility and functional independence at 1 year post-IAT.

Background: Korean American women have among the lowest rates of cervical cancer screening in the United States. The authors evaluated a multicomponent intervention combining community education with navigation services to reduce access barriers and increase screening rates in this underserved population. It was hypothesized that cervical cancer screening rates would be higher among women who received the intervention program compared with those in the control program., Methods: Korean American women (N = 705) were recruited from 22 churches. In this matched-pair, group-randomized design, 347 women received the intervention, which consisted of a culturally relevant cancer education program combined with provision of navigation services. The control group (N = 358) received general health education, including information about cervical cancer risk and screening and where to obtain low-cost or no-cost screening. Screening behavior was assessed 12 months after the program., Results: Screening behavior data were obtained from 588 women 12 months after the program. In both site-level and participant-level analyses, the intervention program contributed to significantly higher screening rates compared with the control program (odds ratio [OR], 25.9; 95% confidence interval [CI], 10.1-66.1; P < .001). In sensitivity analysis, the treatment effect remained highly significant (OR, 16.7; 95% CI, 8.1-34.4; P < .001)., Conclusions: A multicomponent intervention combining community cancer education with navigation services yielded significant increases in cervical cancer screening rates among underscreened Korean American women. Community-accessible programs that incorporate cancer education with the delivery of key navigation services can be highly effective in increasing cervical cancer screening rates in this underserved population. Cancer 2017;123:1018-26. © 2016 American Cancer Society., (© 2016 American Cancer Society.)

Objective: To determine whether baseline cerebral atrophy can predict the rate of future chronic subdural hematoma (CSDH) after head trauma and compare indirect markers of brain atrophy with volumetric analysis of computed tomography (CT)., Methods: Single institution case-control study involving 1,476 patients who visited our hospital after head trauma from January 2009 to December 2014. Forty-one patients with delayed CSDH were identified and age, gender matched 41 patients were selected as control group. Both volumetric analyze on CT and Evans index, frontal horn index, bicaudate ratio, sylvian fissure ratio and cortical atrophy scale of 82 patients were estimated by different raters and relationship of those factors with CSDH was analyzed., Results: Every indirect indices except cortical atrophy scale were not enough to give a good estimate of CSDH. Brain atrophy and cortical atrophy scale were predisposing factors of CSDH on multivariate analysis with statistical significance., Conclusion: Brain atrophy was a potential prognostic factor of CSDH after trauma. In practice, patients with a value of cortical atrophy scale over moderate grade needed more attention for CSDH., Competing Interests: The authors have no financial conflicts of interest.