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The perioperative risk of sporadic hemangioblastomas (HBs) and von Hippel-Lindau disease (VHL)-associated hemangioblastomas (VHL-associated HBs) remains unclear due to the rare prevalence of HB. Therefore, this study aimed to clarify risk factors for better surgical management of patients with HBs.A retrospective analysis of surgically treated HB patients registered in the Diagnosis Procedure Combination database of Japan, between 2010 and 2015, was performed. Age, sex, sporadic HBs or VHL-associated HBs, medical history, tumor location, hospital case load, postoperative complications, and Barthel index (BI) deterioration were assessed. We also evaluated the outcomes and factors of perioperative BI deterioration.In total, 676 patients with 609 intracranial lesions, 64 spinal lesions, and 3 with both types were eligible. Among them, 618 and 58 patients had sporadic HBs and VHL-associated HBs, respectively. The rates of perioperative BI deterioration were 12.5% and 12.2% for sporadic HBs and VHL-associated HBs, respectively. Perioperative mortality was 1.8% and 0% for sporadic HBs and VHL-associated HBs, respectively. Male sex, old age, high hospital case load, and medical history of diabetes mellitus were significantly associated with perioperative BI deterioration in all cases and sporadic HBs. Only medical history of diabetes mellitus was a significant risk factor for perioperative BI deterioration in VHL-associated HBs.No differences in perioperative BI deterioration rates between sporadic HBs and VHL-associated HBs were found. However, different risk factors for perioperative BI deterioration were identified. Consideration of these risk factors is recommended in all patients undergoing surgery for HB.

Ion channel expression in glioma

Malignant gliomas are the most common primary central nervous system tumors and their prognosis is very poor. In recent years, ion channels have been demonstrated to play important roles in tumor pathophysiology such as regulation of gene expression, cell migration, and cell proliferation. In this review, we summarize the current knowledge on the role of ion channels on the development and progression of gliomas. Cell volume changes through the regulation of ion flux, accompanied by water flux, are essential for migration and invasion. Signaling pathways affected by ion channel activity play roles in cell survival and cell proliferation. Moreover, ion channels are involved in glioma-related seizures, sensitivity to chemotherapy, and tumor metabolism. Ion channels are potential targets for the treatment of these lethal tumors. Despite our increased understanding of the contributions of ion channels to glioma biology, this field remains poorly studied. This review summarizes the current literature on this important topic.

OBJECTIVE Spinal cord stimulation (SCS) has been considered an ineffective procedure for patients with central poststroke pain (CPSP). However, recent case series that included small numbers of patients reported the possible efficacy of SCS as a treatment of CPSP. This multicenter retrospective study aimed to examine the outcomes of using SCS to treat patients with CPSP and to explore factors related to outcomes. METHODS The authors reviewed the medical records of patients with CPSP who underwent SCS to collect data regarding their background, surgical information, and outcomes of SCS at trial stimulation and last follow-up after long-term implantation in six study centers. Outcomes were evaluated with a pain score for intensity (range 0–10) and the Patient Global Impression of Changes (PGIC) scale. Factors associated with outcomes were explored with univariable and multivariable analyses. RESULTS The authors collected data from a total of 166 patients (mean age 63.4 years; mean pain score at baseline 8.2). Of these patients, 163 underwent trial stimulation. The mean pain score decreased by 42.0%, 104 (64%) patients had ≥ 30% decrease in pain score, and 96 (59%) reported much or very much improved condition on the PGIC scale at trial stimulation. Moreover, 106 (64%) patients underwent long-term implantation of SCS devices. The mean decrease in pain score was 41.4%, 63 (59%) patients continued to show ≥ 30% decrease in pain score at last follow-up, and 60 (56%) reported much or very much improved condition on the PGIC scale at last follow-up (median [range] follow-up period 24 [24–63] months). Eleven device-related complications and 10 permanent explantations were observed. Univariable and multivariable analyses suggested that young age, less sensory disturbance, implantation of cervical leads, treatment of upper-limb pain, and extensive treated regions were associated with satisfactory outcomes at last follow-up after long-term implantation. CONCLUSIONS These findings indicate that SCS may modestly benefit patients with CPSP. SCS has therapeutic potential for patients with intractable CPSP owing to the lower invasiveness of the SCS procedure and refractory nature of CPSP. Nevertheless, trial stimulation is necessary because of the high initial failure rate.

The authors report a rare case of spinal osseous epidural arteriovenous fistula (AVF) with intradural reflux. A 71-year-old lady with a past history of a T12 compression fracture and neurofibromatosis type 1 presented with progressive paraparesis. Magnetic resonance (MR) images of the thoracolumbar spine showed edema of the spinal cord and flow voids. Catheter angiography revealed segmental arteries from T11 to L1 feeding an AVF in the epidural space. The AVF drained not only into the epidural venous plexus but also into the perimedullary veins. Of note, there was an intraosseous drainage route that involved the basivertebral vein of T12. Under the diagnosis of spinal osseous epidural AVF with intradural reflux, surgical interruption of the intradural arterialized draining vein was performed. Spinal osseous epidural AVF with intradural reflux is rare with only four cases reported in the past. We believe that spinal osseous epidural AVF should be recognized as a variant of spinal epidural AVF.

The superficial middle cerebral vein (SMCV) is one of the main factors that can impede a wide opening of the sylvian fissure. To reveal the most efficient SMCV dissection for a wide operative field while preserving the veins in the trans-sylvian approach, we retrospectively investigated the SMCVs through intraoperative video images. We characterized the SMCV as composed of the frontosylvian trunk (FST; receiving frontosylvian veins [FSVs] or parietosylvian veins [PSVs]), the temporosylvian trunk (TST; receiving temporosylvian veins [TSVs]), and the superficial middle cerebral common trunk (SMCCT; receiving both FSV/PSV and TSV), and classified the SMCVs of the 116 patients into 5 types based on the morphological classification of the SMCV. Type A SMCV (60.4%) with the SMCCT anastomosed to the frontal side had few bridging veins (BVs) between the SMCCT and the temporal side during dissection. Type B (7.8%) had the SMCCT with no anastomoses to the frontal side. In Type C (17.2%) consisting of the FST and TST and Type D (12.9%) with a merging of the vein of Trolard and Labbé posteriorly and the SMCVs dividing into the FST and the TST again proximally, there were few BVs between the FST and the TST during dissection. Finally, in Type E (1.7%) showing an undeveloped SMCV, there were no BVs between the frontal and the temporal lobes. Postoperative venous infarction occurred in 2.6%. Morphological classification of the SMCV can inform appropriate dissection line to create a wide operative field while preserving the veins in the trans-sylvian approach.

The medial frontal cortex (MFC) is a part of the medial surface of the frontal lobe situated in the rostral portion of the corpus callosum (CC). In a surgical interhemispheric approach (IHA), the MFC covers the anterior communicating artery (Aco) complex until the final stage of dissection. To clarify the anatomical relationship between the MFC and the Aco complex, and to facilitate orientation in IHA, we analyzed the morphological features of the MFC in number, size, and pattern of gyri from the medial surface of the hemisphere in the subcallosal portion using 53 adult cadaveric hemispheres. The mean width of the MFC excluding cingulate gyrus (MFCexcg) was 20.6 ± as mm in the subcallosal portion. MFCexcg consisting of 2, 3, 4, or 5 gyri were observed in 7.5%, 56.6%, 32.1%, or 3.8% of the hemispheres, respectively. Bilateral MFCexcg consisting of >2 gyri were observed in approximately 85% of the hemispheres. Therefore, in many cases, the dissection performed at 2 cm upward from the base of the straight gyrus (SG) or 3–4 gyri of the MFC is sufficient to safely reach the upper portion of the cistern of lamina terminalis located distal to the Aco complex in IHA. The MFC is a good landmark for intraoperative orientation in IHA.

There are no scoring methods for optimal treatment of patients with aneurysmal subarachnoid hemorrhage (aSAH). We developed a scoring model to predict clinical outcomes according to aSAH risk factors using data from the Japan Stroke Data Bank (JSDB). Of 5344 patients initially registered in the JSDB, 3547 met the inclusion criteria. Patients had been diagnosed with aSAH and treated with surgical clipping or endovascular coiling between 1998 and 2013. We performed multivariate logistic regression for poor outcomes at discharge, indicated by a modified Rankin Scale (mRS) score >2, and in-hospital mortality for both treatment methods. Based on each risk factor, we developed a scoring model assessing its validity using another dataset of our institution. In the surgical clipping group, scoring criteria for aSAH were age >72 years, history of more than once stroke, World Federation of Neurological Societies (WFNS) grades II–V, aneurysmal size >15 mm, and vertebrobasilar artery (VBA) aneurysm location. In the endovascular coiling group, scoring criteria were age >80 years, history of stroke, WFNS grades III–V, computed tomography (CT) Fisher group 4, and aneurysmal location in the middle cerebral artery (MCA) and anterior cerebral artery (ACA). The rates of poor outcome of mRS score >2 in an isolated dataset using these scoring criteria were significantly correlated with our model’s scores, so this scoring model was validated. This scoring model can help in the more objective treatment selection in patients with aSAH.

Each year, the Japan Neurosurgical Society (JNS) reports up-to-date statistics from the Japan Neurosurgical Database regarding case volume, patient demographics, and in-hospital outcomes of the overall cohort and neurosurgical subgroup according to the major classifications of main diagnosis. We hereby report patient demographics, in-hospital mortality, length of hospital stay, purpose of admission, number of medical management, direct surgery, endovascular treatment, and radiosurgery of the patients based on the major classifications and/or main diagnosis registered in 2018 and 2019 in the overall cohort (523283 and 571143 patients, respectively) and neurosurgical subgroup (177184 and 191595 patients, respectively). The patient demographics, disease severity, proportion of purpose of admission (e.g., operation, 33.9-33.5%) and emergent admission (68.4-67.8%), and in-hospital mortality (e.g., cerebrovascular diseases, 6.3-6.5%; brain tumor, 3.1-3%; and neurotrauma, 4.3%) in the overall cohort were comparable between 2018 and 2019. In total, 207783 and 225217 neurosurgical procedures were performed in the neurosurgical subgroup in 2018 and 2019, respectively, of which endovascular treatment comprised 19.1% and 20.3%, respectively. Neurosurgical management of chronic subdural hematoma (19.4-18.9%) and cerebral aneurysm (15.4-14.8%) was most common. Notably, the proportion of management of ischemic stroke/transient ischemic attack, including recombinant tissue plasminogen activator infusion and endovascular acute reperfusion therapy, increased from 7.5% in 2018 to 8.8% in 2019. The JNS statistical update represents a critical resource for the lay public, policy makers, media professionals, neurosurgeons, healthcare administrators, researchers, health advocates, and others seeking the best available data on neurosurgical practice.

Malignant gliomas are the most common primary central nervous system tumors and their prognosis is very poor. In recent years, ion channels have been demonstrated to play important roles in tumor pathophysiology such as regulation of gene expression, cell migration, and cell proliferation. In this review, we summarize the current knowledge on the role of ion channels on the development and progression of gliomas. Cell volume changes through the regulation of ion flux, accompanied by water flux, are essential for migration and invasion. Signaling pathways affected by ion channel activity play roles in cell survival and cell proliferation. Moreover, ion channels are involved in glioma-related seizures, sensitivity to chemotherapy, and tumor metabolism. Ion channels are potential targets for the treatment of these lethal tumors. Despite our increased understanding of the contributions of ion channels to glioma biology, this field remains poorly studied. This review summarizes the current literature on this important topic.

There is currently no precise guide for the treatment and management of elderly patients with aneurysmal subarachnoid hemorrhage (aSAH). Thus, the aim of this study was to clarify the factors of poor outcome and mortality in elderly patients with aSAH.In the modified World Federation of Neurosurgical Societies (mWFNS) scale study, 1124 patients were divided into 2 groups, elderly (age ≥65 years) and non-elderly (age65 years), with aSAH investigated between October 2010 and March 2013 in Japan. The odds ratio (OR) and 95% confidence interval (CI) of each risk factor was calculated through multivariate logistic regression analysis for poor outcomes, as indicated by the modified Rankin Scale (mRS) score ≥3 and mortality at 3 months after onset in each group.Both groups demonstrated that the mWFNS scale was significant as a grade order risk factor for poor outcomes and mortality associated with disease. In the elderly group, risk factors for poor outcomes at 3 months after onset were older age (OR 1.10, 95% CI 1.06-1.14), male sex (OR 2.03, 95% CI 1.10-3.73), and severe cerebral vasospasm category (OR 10.13, 95% CI 4.30-23.87). Risk factors for mortality at 3 months after onset were older age (OR 1.06, 95% CI 1.01-1.11) and severe vasospasm category (OR 2.17, 95% CI 1.00-4.72).The mWFNS scale is a useful prognostic predictor for both non-elderly and elderly patients with aSAH. Elderly male patients with aSAH presenting with severe vasospasm should be managed more carefully.

OBJECTIVE Posterior fossa ependymoma (PF-EPN) was categorized into PF-EPN-A and PF-EPN-B subgroups based on the DNA methylation profiling. PF-EPN-A was reported to have poorer prognosis compared with PF-EPN-B. In this study, we particularly evaluated preoperative imaging to distinguish PF-EPN-A from PF-EPN-B. METHODS Sixteen cases of PF-EPN were treated in our institution from 1999 to 2018. The patients were divided into PF-EPN-A and PF-EPN-B groups based on H3K27me3 immunostaining positivity. We evaluated progression-free survival, overall survival, as well as preoperative magnetic resonance imaging and computed tomography scan images in both groups. Based on T1WI and Gd-T1WI magnetic resonance images, the tumor contrast rate was determined from dividing the volume of gadolinium enhanced tumor by the overall tumor volume. RESULTS Nine cases (4 male, 5 female) were grouped as PF-EPN-A, and 7 (4 male, 3 female) as PF-EPN-B. The median age of PF-EPN-A and PF-EPN-B were 4 and 43 years old, respectively. In the PF-EPN-A group, the progression-free survival median value was 32.6 months, and the overall survival median was 96.9 months. In contrast, PFS in PF-EPN-B did not reach a median value (P < 0.05) and all the patients were alive (P < 0.05) at the end of the study. With imaging, tumor contrast rate in PF-EPN-B was more than 50% and significantly different from PF-EPN-A (P = 0.0294). Calcification was mainly observed in PF-EPN-A, whereas cystic formation was only seen in PF-EPN-B. CONCLUSIONS Contrast rate less than 50%, based on the magnetic resonance images, was characteristic in the PF-EPN-A group. Comparatively, cystic component and absence of calcification were more characteristic in the PF-EPN-B group.

Serum and cerebrospinal fluid (CSF) levels of α-fetoprotein and β-subunit of human chorionic gonadotropin are used as biomarkers for the management of central nervous system (CNS) germ cell tumors (GCTs). However, additional discriminating biomarkers are required. Especially, biomarkers to differentiate non-germinomatous germ cell tumors (NGGCTs) from germinomas are critical, as these have a distinct prognosis. We investigated CSF samples from 12 patients with CNS-GCT patients (8 germinomas and 4 NGGCTs). We analyzed circulating tumor DNA (ctDNA) in CSF to detect mutated genes. We also used liquid chromatography-mass spectrometry to characterize metabolites in CSF. We detected KIT and/or NRAS mutation, known as frequently mutated genes in GCTs, in 3/12 (25%) patients. We also found significant differences in the abundance of 15 metabolites between control and GCT, with unsupervised hierarchical clustering analysis. Metabolites related to the TCA cycle were increased in GCTs. Urea, ornithine, and short-chain acylcarnitines were decreased in GCTs. Moreover, we also detected several metabolites (e.g., betaine, guanidine acetic acid, and 2-aminoheptanoic acid) that displayed significant differences in abundance in patients with germinomas and NGGCTs. Our results suggest that ctDNA and metabolites in CSF can serve as novel biomarkers for CNS-GCTs and can be useful to differentiate germinomas from NGGCTs.

One of the major problems with walking encountered by patients with spastic hemiplegia is diminished toe clearance due to spasticity of their leg muscles. To improve their walking, a specialized robot assist for ankle movements (RE-Gait) has been utilized. The present study examined the neurophysiological effects whether spinal cord reciprocal Ia inhibition (RI) in the leg was altered by using RE-Gait. Sixteen patients with a clinical diagnosis of stroke were divided into the two groups, RE-Gait walking group (Group R) and normal (controlled) walking group (Group C). In each group, they walked on a flat floor for 15 min with or without RE-Gait. The depression of soleus (Sol) H-reflexes conditioned by common peroneal nerve stimuli with the conditioning-test (C-T) intervals of 1, 2, 3, and 4 ms were assessed before and immediately after each walking session. After the intervention, the LSM (SE) of Sol H-reflex amplitude with 1, 2 and 3 ms C-T interval conditions were significantly decreased in group R (1 ms: 88.15 (4.60), 2 ms: 86.37 (4.60), 3 ms: 89.68 (4.62)) compared to group C (1 ms: 105.57 (4.56), 2 ms: 100.89 (4.58), 3 ms: 107.72 (4.58)) [1 ms: p = 0.012, 2 ms: p = 0.035, 3 ms: p = 0.011]. Walking assistive robot that targets ankle movements might be a new rehabilitation tool for regulating spinal cord excitability.

This study aimed to explore the genetic alterations and to identify good responders in the experimental arm in the tumor samples from newly diagnosed glioblastoma (GBM) patients enrolled in JCOG0911; a randomized phase II trial was conducted to compare the efficacy of interferonβ (IFNβ) plus temozolomide (TMZ) with that of TMZ alone. Of 122 tumors, we performed deep targeted sequencing to determine the somatic mutations, copy number variations, and tumor mutation burden; pyrosequencing for O6-methylguanine-DNA methyltransferase (MGMT) promoter methylation; Sanger sequencing for the telomerase reverse transcriptase (TERT) promoter; and microsatellite instability (MSI) testing in 95, 91, 91 and 72 tumors, respectively. We performed a multivariable Cox regression analysis using backward stepwise selection of variables including clinical factors (sex, age, performance status, residual tumor after resection, tumor location) and genetic alterations. Deep sequencing detected an IDH1 mutation in 13 tumors (14%). The MGMT promoter methylation by quantitative pyrosequencing was observed in 41% of the tumors. A mutation in the TERT promoter was observed in 69% of the tumors. While high tumor mutation burden (> 10 mutations per megabase) was seen in four tumors, none of the tumors displayed MSI-high. The clinical and genetic factors considered as independent favorable prognostic factors were gross total resection (hazard ratio [HR]: 0.49, 95% confidence interval, 0.30–0.81, P = 0.0049) and MGMT promoter methylation (HR: 0.43, 0.21–0.88, P = 0.023). However, tumor location at the temporal lobe (HR: 1.90, 1.22–2.95, P = 0.0046) was an independent unfavorable prognostic factor. No predictive factors specific to the TMZ + IFNβ + Radiotherapy (RT) group were found. This additional sub-analytical study of JCOG0911 among patients with newly diagnosed GBM showed that tumor location at the temporal lobe, gross total resection, and MGMT promoter methylation were significant prognostic factors, although no factors specific to IFNβ addition were identified.

This study aimed to compare the functional outcome at discharge for unruptured cerebral aneurysms (UCAs) between surgical clipping and endovascular coiling in total, nonelderly (65 years), and elderly (≥65 years) patients by nonbiased analysis based on a national database in Japan.A total of 15,671 patients with UCA were registered in the Diagnosis Procedure Combination, the nationwide database, from 2010 to 2015 in Japan. The outcome of the Barthel Index (BI) at discharge was investigated, and propensity score-matched analysis was conducted in total, nonelderly, and elderly patient groups.Propensity score-matched analysis found no significant difference for in-hospital mortality between the 2 treatment methods in the total and both age-groups. The rate of morbidity of BI90 at discharge was higher after surgical clipping than after endovascular coiling in the total (4.9% vs. 3.9%; P = 0.040; risk difference, -1.0%; 95% confidence interval, -3.6 to 2.3%) and the elderly age-group (8.1% vs. 5.0%; P0.001; risk difference, -3.1%; -4.8% to 1.5%), however, no significant association between the 2 treatment methods (2.4% vs. 2.6%; P = 0.67; risk difference, 0.22%; -0.79 to 1.22%) was found in the nonelderly group.In elderly patients with UCA, a better outcome at discharge after endovascular coiling was found. However, no significantly different functional outcome at discharge between surgical clipping and endovascular coiling for UCA in nonelderly patients was confirmed by propensity score-matched analysis from a nationwide database in Japan.

Background Cerebral embolism after carotid artery stenting (CAS) is a well-known complication, but cerebral ischemia owing to cerebral vasospasm after CAS is rare and has seldom been reported. We describe a patient with transient ischemic complications owing to reversible cerebral vasospasm of the middle cerebral artery after CAS. Case Description A 74-year-old man presented with right hemiparesis caused by acutely scattered brain infarction in the left cerebral hemisphere. Magnetic resonance angiography showed severe stenosis of the left cervical internal carotid artery origin. CAS under a distal filter protection was performed without any intraprocedural complications, but 12 hours later, the patient had aphasia and Gerstmann syndrome. Urgent magnetic resonance imaging revealed no evidence of an intracranial hemorrhage or new cerebral infarction. However, magnetic resonance angiography showed diffuse vasospasm of the left middle cerebral artery. His symptoms and imaging findings improved gradually with conservative treatment. The patient was discharged without new neurologic deficit or recurrent attack 3 weeks after CAS. Conclusions In a patient with delayed neurologic symptoms after CAS, the possibility of cerebral vasospasm should be kept in mind to select appropriate treatment.

The term "growing teratoma syndrome (GTS)" has been used as follows: patients with germ cell tumor (GCT) who present with enlarging original/metastatic masses during or after appropriate systemic chemotherapy despite normalized serum markers. In other words, the definition of the term GTS is not fully established. We analyzed and reviewed our case series regarding GTS that developed after the treatment of central nervous system (CNS) nongerminoatous germ cell tumors (NGGCTs).Our institutional review board approved this retrospective study. Between 2003 and 2018, we treated 16 patients (16 males; age ranging from 5.4 to 51.9 years, median 13.8) with CNS-NGGCT at our institution. We reviewed those patients and also reviewed the literature about GTS of CNS. We defined primary GTS (p-GTS) as the enlargement of cyst size and/or solid tumor occurred during treatment in the absence of marker elevation, and recurrent GTS (r-GTS) as the enlargement of teratoma after complete response of initial tumors.Among 16 patients with CNS-NGGCT, we surgically confirmed mature/immature teratoma components in 15 patients. Two patients underwent surgical removal of tumor before neoadjuvant therapy, and among the rest 14 patients, 6 developed p-GTS, and 2 patients underwent salvage surgery during chemo-/chemoradiotherapy. Those with histologic diagnosis of immature teratoma during salvage surgery had a shorter interval from the initiation of chemoradiotherapy compared with mature teratoma (P 0.05). One patient developed r-GTS. In the literature review, most of the p-GTS consisted of enlargement with the multicystic component. Histologic diagnosis of immature teratoma during salvage surgery was observed in earlier stages of chemoradiotherapy (P 0.05, log-rank test). Previous history of p-GTS might be a risk factor of r-GTS.The incidence of p-GTS, enlargement of the cystic component during treatment, is not rare. Physicians need to be aware of this important phenomenon.

Background Several recent randomized controlled trials have reported that perioperative complications of carotid artery stenting increase with age, and Japan has the highest proportion of elderly in the world. We retrospectively compared clinical factors, treatment outcomes, and adverse events between younger and elderly carotid artery stenting patients at a single institution in Japan to assess carotid artery stenting safety for the aged population. Methods A total of 150 consecutive patients treated with carotid artery stenting using the dual protection (simultaneous flow reversal and distal filter) and blood aspiration method were enrolled. Patients were classified into an elderly (O) group ≥75 years (54/150, 36.0%) and a younger (Y) group Results The carotid artery stenting procedure was successful in all cases. No major adverse events occurred within 30 days in the Y group, and only one occurred in the O group ( P = 0.348). Visible debris was captured in a significantly greater proportion of O group patients than in Y group patients (33/54 (63.5%) vs. 40/96 (42.1%), P = 0.016), but there was no significant difference in the frequency of hyperintense spots on diffusion-weighted images between Y and O groups (23/96 (24.0%) vs. 16/52 (30.8%), P = 0.435). Conclusions Carotid artery stenting using dual protection and blood aspiration is equally safe for younger and elderly patients.

We analyzed the cell characteristics, neuroprotective, and transplantation effects of human cranial bone-derived mesenchymal stem cells (hcMSCs) in ischemic stroke model rats compared with human iliac bone-derived mesenchymal stem cells (hiMSCs). The expressions of brain-derived neurotrophic factor (BDNF) and vascular endothelial growth factor (VEGF ) as neurotrophic factors were analyzed in both MSCs. hiMSCs or hcMSCs were intravenously administered into ischemic stroke model rats at 3 or 24 h after middle cerebral artery occlusion (MCAO) and neurological function was evaluated. The survival rate of neuroblastoma × glioma hybrid cells (NG108-15) after 3 or 24 h oxidative or inflammatory stress and the neuroprotective effects of hiMSCs or hcMSCs-conditioned medium (CM) on 3 or 24 h oxidative or inflammatory stress-exposed NG108-15 cells were analyzed. The expressions of BDNF and VEGF were higher in hcMSCs than in hiMSCs. hcMSCs transplantation at 3 h after MCAO resulted in significant functional recovery compared with that in the hiMSCs or control group. The survival rate of stress-exposed NG108-15 was lower after 24 h stress than after 3 h stress. The survival rates of NG108-15 cells cultured with hcMSCs-CM after 3 h oxidative or inflammatory stress were significantly higher than in the control group. Our results suggest that hcMSCs transplantation in the early stage of ischemic stroke suppresses the damage of residual nerve cells and leads to functional recovery through the strong expressions of neurotrophic factors. This is the first report demonstrating a functional recovery effect after ischemic stroke following hcMSCs transplantation.

As the global population ages, the incidence of traumatic brain injury (TBI) is increasing. Whereas mild TBI can impair the cognitive function of older adults, the cause and background of mild TBI-induced cognitive impairment remain unclear, and the evaluation of risk factors for cognitive impairment after mild TBI remains open for consideration, especially in the aging population. This study aimed to evaluate the risks associated with cognitive impairment following mild TBI.Between January 2006 and December 2018, a total of 2209 patients with TBI required hospitalization in Shimane Prefectural Central Hospital. Mild TBI was defined as a Japan Coma Scale ≤10 at admission. Patients' cognitive function was measured with the Hasegawa Dementia Rating Scale-Revised or Mini-Mental State Examination at least twice during the patients' hospital stays. The odds ratio (OR) and 95% confidence interval (CI) of each considered risk factor was calculated with multivariable logistic regression analysis after univariate analysis.Among 1674 patients with mild TBI, 172 patients underwent cognitive function examinations, of whom 145 (84.3%) were found to have cognitive impairment at discharge. Significant risk factors for cognitive impairment included age (P = 0.008) and hypertension (P = 0.013) in univariate analysis; and age (OR, 1.04: 95% CI, 1.01-1.07) and hypertension (OR, 5.81: 95% CI, 1.22-27.68) by multivariable analysis.Older patients with hypertension displayed a significantly higher risk for cognitive impairment after even mild TBI. These patients warrant careful management after even mild TBI.

PurposeTo investigate temporal changes in imaging findings of conservatively treated unruptured vertebral basilar artery dissection and its contributing factors.MethodsFifty-three patients who underwent conservative treatment for 64 cases of vertebral basilar artery dissection diagnosed between January 2006 and March 2019 and follow-up of at least 12 months after onset were retrospectively investigated. Statistical analyses of age, sex, medical history, pattern of onset, lesion site, imaging findings and changes over time, regular medication, and outcomes were performed. ResultsChanges in the vascular morphology of the lesion site during the follow-up period were observed in only 23 (43%) patients (median time until change: 19 days). Univariate analysis of factors contributing to morphological changes at the dissection site showed that changes were significantly more likely in younger patients (p = 0.011). Patients taking antiplatelet drugs had a significantly greater rate of deterioration at the dissection site (p = 0.028) than others. On multivariate analysis, age was an independent factor contributing to changes at the dissection site, and taking antiplatelet drugs, particularly clopidogrel, was an independent factor contributing to deterioration. No patient developed intracranial hemorrhage, cerebral infarction, or worsening of neurological symptoms during follow-up.ConclusionsMorphological changes at the dissection site are more likely in younger patients with unruptured vertebral basilar artery dissection and those taking antiplatelet drugs. However, chances of intracranial hemorrhage, cerebral infarction, or worsening of neurological symptoms during conservative therapy are low. Therefore, unruptured vertebral basilar artery dissection may be considered a benign condition.

The simplified 5-factor modified frailty index (mFI-5) is a useful indicator of outcome for patients undergoing surgeries as frailty is considered an important risk factor in elderly patients. However, its usefulness has not been validated based on age groups. Therefore, we aimed to investigate risk factors, including the mFI-5, across age groups for complications and worse outcomes in meningioma surgery using data obtained from the nationwide database in Japan.We extracted data from the nationwide registry database in Japan between 2010 and 2015. Age ( 65, 65-74, and ≥ 75 years), sex, Barthel Index (BI), mFI-5 scores, and complications were evaluated. Multivariate logistic regression analyses identified risk factors for worsening BI scores and complications after surgery across all age groups.Among 8138 included patients, an mFI-5 score ≥ 2 items was a significant risk factor for worsening BI scores in patients aged 65 years (odds ratio: 2.3; 95 % confidence interval: 1.5-3.4), but not in patients aged 65-74 years and those aged ≥ 75 years, contrary to chronological age. Similar results were noted for any complications in patients aged 65 years (2.5; 1.8-3.6) and aged 65-74 years (1.5; 1.1-2.1), but not in patients aged ≥ 75 years.Although the mFI-5 scores could predict the risk of in-hospital worsening outcomes, mortality, and complications, it was more useful in non-elderly patients aged 65 years rather than in elderly patients aged ≥ 75 years, contrary to chronological age. Further prospective studies should be performed in the future to clarify the utility of the mFI-5.

Objective: Various clinical parameters have been reported to be associated with favorable seizure outcomes after vagus nerve stimulation (VNS); however, none of these parameters have been conclusively validated. Here, we evaluated interpersonal communication skills (IPCS) and seizure outcomes in pediatric patients treated with VNS. Methods: We enrolled 31 Japanese pediatric patients (mean ± SD: 9.0 ± 3.4 years old, range: 3–15 years old) who were treated with VNS and had at least 2 years of follow-up. We divided the patients into two groups: a responder group with ≥50% seizure reduction from the average number of seizures 2 months before VNS; and a nonresponder group with

Several intracranial pathologies present as a ring-enhancing lesion on conventional magnetic resonance imaging (MRI), creating diagnostic difficulty. We studied the characteristics of the anatomical border of gadolinium enhancement on T1-weighted imaging (WI) and hypointensity on T2WI to employ a simple technique of histogram-profile analysis of MRI for differentiation of various ring-enhancing intracranial lesions.After approval from the institutional review board, preoperative MRI (T2WI, postcontrast T1WI) scans were analyzed retrospectively in 18 patients with histologically confirmed brain abscess, 66 glioblastomas, 46 brain-metastases, and 16 tumefactive multiple sclerosis (MS). T2WI and postcontrast T1WI were overlapped, and histogram-profile analysis was performed with in-house image-fusion software. The pattern of differential-peaks in histogram-profile was assessed visually. Kaplan-Meier survival analysis incorporating histogram-profile patterns was performed in patients with glioblastoma.The histogram-profile study revealed 4 distinct patterns. Pattern 1 showed no differential T2-hypointensity trough, pattern 2 had T2-hypointensity trough inside, whereas pattern 3 had T2-hypointensity trough overlapping the enhanced margin. Pattern 4 had T2-hypointensity trough immediately external to the enhanced margin. Pattern 1 was specific for tumefactive MS (93.3%), whereas pattern 4 was specific for glioblastoma (40.7%). Pattern 4 glioblastoma was subdivided into rim (T2-hypointensity ≥50% of circumference of contrast-enhanced tumor) and arc (T2-hypointensity50% of circumference of contrast-enhanced tumor). Pattern 4 glioblastoma was further subdivided into group A (edema: T2-hyperintensity ≥50% of circumference of contrast-enhanced tumor) and group B (less edema: T2-hyperintensity50% of circumference of contrast-enhanced tumor). Patients with pattern 3 glioblastoma (37.6%) had better survival compared with others (P = 0.0341) and pattern 4B had decreased survival compared with pattern 4A (P = 0.0001) and others (P = 0.0003).Tumefactive MS and a subset of glioblastomas show specific patterns in histogram-profile analysis. The difference in anatomical border also determines difference in survival in glioblastoma. Histogram-profile analysis is a simple and efficient technique to differentiate these pathologies.

OBJECTIVESpinal dural arteriovenous fistulas (SDAVFs) commonly present with symptoms of myelopathy due to venous congestion in the spinal cord; asymptomatic SDAVFs are rarely encountered. To elucidate the clinical characteristics of asymptomatic SDAVFs, the authors present 5 new cases of asymptomatic SDAVF and report the results of their systematical review of the associated literature.METHODSFive databases were systematically searched for all relevant English-language articles on SDAVFs published from 1990 to 2018. The clinical features and imaging findings of asymptomatic SDAVFs were collected and compared with those of symptomatic SDAVFs.RESULTSTwenty cases, including the 5 cases from the authors’ experience, were found. Asymptomatic SDAVFs were more prevalent in the cervical region (35.0%); cervical lesions account for only 2% of all symptomatic SDAVFs. The affected perimedullary veins tended to drain more cranially (50.0%) than caudally (10.0%). Four cases of asymptomatic SDAVF became symptomatic, 1 case spontaneously disappeared, and the remaining 15 cases were unchanged or surgically treated.CONCLUSIONSThe higher prevalence of asymptomatic SDAVFs in the cervical spine might be a distinct feature of asymptomatic SDAVFs. Given that venous congestion is the pathophysiology of a symptomatic SDAVF, abundant collateral venous pathways and unique flow dynamics of the CSF in the cervical spine might prevent asymptomatic cervical SDAVFs from becoming symptomatic. In cases in which venous congestion is avoidable, not all asymptomatic SDAVFs will become symptomatic.

Background Use of angioscopy to directly observe the stent lumen in the chronic phase after carotid artery stenting (CAS) has not been reported to date. Here we report 3 patients in whom angioscopy helped confirm the stent lumen during retreatment after CAS. Case Description Case 1 required retreatment for stent shortening that occurred 1 month after the first CAS. Preprocedure angioscopy showed the presence of neointima, which could not be revealed by intravascular ultrasound (IVUS). In case 2, which required repeat CAS for distal progressive stenosis of the internal carotid artery, the neointima was observed on the stent surface and was more pronounced on the distal side. In case 3, retreatment was necessary for recurrent ischemic stroke caused by stent restenosis; preprocedure angioscopy showed an unstable plaque, which was not detected as vulnerable by IVUS, protruding into the stent lumen, with partial ulceration and bleeding. Conclusions Compared with IVUS, angioscopy enables a more detailed observation of the stent lumen. Although angioscopy is relatively invasive, its use in evaluating changes in the stent lumen after CAS should be clarified by accumulation of reported cases.

Background Bilateral carotid artery stenting (BCAS) is often performed in two stages (staged BCAS) but it is also an option to be performed in one stage (simultaneous BCAS). To confirm the safety of simultaneous BCAS, we retrospectively analyzed perioperative and postoperative course of simultaneous BCAS compared with staged BCAS. Materials and methods Patients with symptomatic stenosis of ≥50% or asymptomatic stenosis of ≥80% of bilateral carotid arteries underwent BCAS. Procedure time, symptomatic ischemic complications, presence/absence of high-intensity spots on postoperative diffusion-weighted image, duration of postoperative hospital stays and 30 days outcome of patients performed with simultaneous BCAS (group A, 8 patients with 16 stenotic lesions (8 procedures)) were compared with those of staged BCAS (group B, 4 patients with 8 stenotic lesions (8 procedures)). Results In groups A and B, procedure time was 146.0 ± 53.8 and 103.5 ± 39.4 min; intraoperative hypotension was observed in 62.5% and 50.0%; postoperative hypotension occurred in 37.5% and 50.0%; diffusion-weighted image showed high-intensity spots in 37.5% and 12.5%; and duration of postoperative hospital stays was 5.1 ± 1.8 and 5.3 ± 2.3 days. No patients suffered symptomatic ischemic complications. In simultaneous BCAS, there was a tendency that procedure time was longer and high-intensity spots on postoperative diffusion-weighted image was more frequent, but there was no increase in symptomatic ischemic complications and duration of hospital stays compared to staged BCAS. Conclusions Safety of simultaneous BCAS may not be inferior to staged BCAS. In terms of duration of hospital stays, simultaneous BCAS can be superior to staged BCAS for patients with bilateral carotid artery stenosis.

There has never been evidence for aneurysmal subarachnoid hemorrhage (aSAH) by endovascular coiling compared to surgical clipping with all grade. The present study and meta-analysis aimed to clarify the in-hospital mortality and poor outcome in the nationwide databases of patients with all grade aSAH between them. The outcome of modified Rankin scale (mRS) at discharge was investigated according to the comprehensive nationwide database in Japan. The propensity score-matched analysis was conducted among patients with aSAH in this database registered between 2010 and 2015. Meta-analysis of studies was conducted based on the nationwide databases published from 2007 to 2018. According to this propensity score-matched analysis, no significant association for poor outcome of mRS > 2 was shown between surgical clipping and endovascular coiling (47.7% vs 48.3%, p = 0.48). However, significantly lower in-hospital mortality was revealed after surgical clipping than endovascular coiling (7.1% vs 12.2%, p

Background Superior cerebellar artery (SCA) aneurysm arising from the SCA itself is rare, and treatment of this aneurysm is challenging because of the important anatomic structures, such as the perforating arteries to the brainstem and cranial nerves. We describe a successful coil embolization with a Low-profile Visualized Intraluminal Support Junior (LVIS Jr.) stent for the proximal SCA dissecting aneurysm. Case Description A 50-year-old woman presented with right oculomotor nerve palsy and subarachnoid hemorrhage. Cerebral angiography showed a dissecting wide neck aneurysm at the anterior pontomesencephalic segment of the right SCA (diameter 1 mm). The patient was treated with coiling assisted by an LVIS Jr. stent. Postoperative angiography demonstrated a complete embolized aneurysm and parent artery preservation. Conclusions Endovascular treatment assisted with LVIS Jr. stent for proximal SCA dissecting aneurysm arising from small parent artery was safely and effectively feasible.

Background Pial arteriovenous fistulas (PAVFs) are rare, accounting for 1.6%–4.7% of all intracranial vascular malformations. Often diagnosed in childhood, about 30% are associated with hereditary hemorrhagic telangiectasia. A case of PAVF diagnosed soon after birth and given cerebrovascular therapy 4 months after birth is reported. Case Description The patient presented with heart failure immediately after birth. Ultrasonography of the head showed abnormal blood flow in the brain. On digital subtraction angiography performed 4 months after birth, a PAVF with a dural feeder shunt and a giant varix at the posterior temporal part was confirmed. After transarterial embolization (TAE), shunt blood flow disappeared. New shunt flow from the right posterior cerebral artery into the varix was confirmed by magnetic resonance imaging 3 months after the operation. A second TAE procedure using a liquid embolic material was performed and confirmed the complete disappearance of the shunt. Conclusions This report describes a case of infant PAVF with heart failure, a giant varix, hydrocephalus, and intraventricular hemorrhage treated by TAE using platinum coils and liquid embolic material.

Various guidelines regarding surgical site infection (SSI) have recently been established. However, perioperative management of the wound and use of antibiotics have never been standardized completely in departments of neurosurgery in Japan. This survey investigated current perioperative management and administration of surgical antibiotic prophylaxis (SAP) and compared with guidelines intended to reduce SSI associated with neurosurgery in Japan. Questionnaires were distributed to members of the conference on Neurosurgical Techniques and Tools and the Japan Society of Aesthetic Neurosurgery via internet. The questionnaires asked about methods of perioperative management. A total of 255 members returned answers to the questionnaires. The questionnaires revealed that partial or no removal of the hair and hair shampooing at the day before surgery were performed in 96.1% and 88.1% of each institute following the World Health Organization (WHO) guidelines. Use of SAP at just before, during, and after surgery were 65.0%, 86.2%, and 63.0%, respectively. The postoperative period of use of intravenous SAP prolonged beyond 24 h in 80.0% against the recommendation of WHO. Perioperative management of wounds and use of SAP varies in institutes in Japan and some procedures were far different from the WHO guidelines. Japanese neurosurgeons should notice the prolonged SAP and comply with the WHO guidelines.