Unexpected abnormal intraoperative neurophysiologic monitoring change by multiple spontaneous intracerebral haemorrhage during endovascular coiling.

We report a patient with multiple angiographically negative intracerebral haemorrhages, which were recognized by significant changes in intraoperative neurophysiologic monitoring during the coil embolization of a left middle cerebral artery aneurysm.

Spontaneous Disappearance of an Arachnoid Cyst after Burr Hole Drainage of Chronic Subdural Hematoma.

It is well known that the presence of arachnoid cysts (ACs) in young patients is a risk factor for developing a chronic subdural hematoma (CSDH) after a minor head injury. Although there have been controversies with the treatment, most authors recommend only draining the CSDH if the AC is asymptomatic. This judgement is based on the facts that this surgical approach has shown good clinical outcomes, and the AC usually remains unchanged after the surgery. Our case demonstrates that the AC of a young patient who developed a CSDH after a minor head injury completely disappeared after a burr hole drainage of the CSDH. Although the chances of an AC disappearing are low, this case shows that an AC might disappear after only draining a CSDH when a rupture of the AC membrane is identified. In such cases, we recommend first draining only the CSDH for the treatment of AC-associated CSDHs.

The RAP Index during Intracranial Pressure Monitoring as a Clinical Guiding for Surgically Treated Aneurysmal Subarachnoid Hemorrhage: Consecutive Series of Single Surgeon.

BACKGROUND: It is well known that assessing the RAP index along with intracranial pressure (ICP) monitoring in traumatic brain injury patients is helpful. We will discuss the usefulness of this assessment tool as a clinical guide for surgically treated poor grade aneurysmal subarachnoid hemorrhage (SAH). METHODS: This retrospective study included 35 patients with aneurysmal SAH who presented with World Federation of Neurosurgical Societies (WFNS) grade V SAH and received surgical treatment from January 2013 to December 2018. Emergency surgical clipping, hematoma removal, extraventricular drainage, and if needed, wide decompressive craniectomy were combined as the proper surgical treatments. Outcomes were assessed based on in-hospital survival and the Glasgow outcome scale score at 14-day follow-up. We compared the mortality rate of two groups of seven patients: ICP monitoring only (n=5) and ICP monitoring combined with the RAP index (n=2). RESULTS: The in-hospital 14-day mortality rate by brain lesion was 48.5% (n=17). Seven patients had real-time ICP monitoring. Before 2018, three of five patients with poor WFNS grade who received real-time ICP monitoring only died. There were no deaths in the group of two patients receiving real-time ICP monitoring and the RAP index. CONCLUSIONS: Our data indicate that combining the RAP index and ICP monitoring can be used as markers for critical intracranial physiological parameters in poor grade WFNS patients.

Contralateral Mechanical Thrombectomy of Partial Deployed Stent Retrieval for Acute Anterior Inferior Cerebellar Artery Occlusion.

BACKGROUND: Acute anterior inferior cerebellar artery (AICA) occlusion is considered an acute ischemic stroke requiring medical treatment without mechanical thrombectomy (MT). There is a procedural risk of parent vessel rupture, but neurologic deficits are not generally severe. Here, we report a case of MT performed using partially deployed stent retrieval for acute AICA occlusion. CASE DESCRIPTION: A 53-year-old male patient presented with acute-onset drowsiness and visual disturbance. The initial National Institutes of Health Stroke Scale score of the patient was 5. Computed tomography angiography showed no definite vascular occlusion, but computed tomography perfusion imaging suggested decreased cerebral blood flow and cerebral blood volume, with an increased mean transit time and time to peak in the left posterior inferior cerebellar artery territory. Conventional angiography showed occlusion of the left proximal AICA and posterior inferior cerebellar artery cortical branches, which were reconstituted by the muscular branches of the left vertebral artery. We decided to perform intra-arterial thrombectomy for proximal left AICA occlusion because the patient's symptoms seemed to be aggravated, and neurologic deficits were not expected. MT was performed using a Trevo stent (Stryker Neurovascular, Fremont, California, USA) in the left proximal AICA via a right vertebral artery approach and resulted in complete recanalization of the occluded AICA. The patient recovered and had an National Institutes of Health Stroke Scale score of 0 at 1 day after MT. CONCLUSIONS: Our case suggests that MT can be performed in a highly selective manner in patients with the occlusion of a posterior circulation branch, such as the AICA, and yield a good clinical outcome.

Predictive value of neurophysiologic monitoring during neurovascular intervention for postoperative new neurologic deficits.

PURPOSE: Forms of intraoperative neurophysiologic monitoring (IONM), including somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs), have been widely used in the field of neurosurgery. This study aimed to evaluate the diagnostic efficacy of IONM in identifying intraoperative events and predicting postoperative neurologic deficits in neurovascular intervention. METHODS: From January 2013 to December 2016, we retrospectively reviewed patients who underwent neurovascular intervention under general anesthesia with the use of IONM. Associations between significant changes in MEPs or SSEPs which were defined as a decrease more than 50% in amplitude and/or an increase more than 10% in latency and any identifiable intraoperative events and/or postoperative neurologic deficits were determined. The sensitivity and specificity values for both MEPs and SSEPs were calculated. RESULTS: In total, 578 patients (175 men and 403 women) were included. Their mean age was 59.5 years. SSEP changes occurred in 1% (n = 6), and MEP changes occurred in 1.2% (n = 7). Four patients suffered postoperative neurologic deficits, and identifiable intraoperative events were observed in seven patients. Both SSEP and MEP changes were significantly associated with identifiable intraoperative events and/or postoperative neurologic deficits (p < 0.001, Fisher's exact test). The calculated sensitivity and specificity of MEP monitoring were 50 and 99.5%, respectively. The sensitivity and specificity of SSEP monitoring were both 100%. CONCLUSION: Intraoperative SSEP monitoring might be a reliable and sensitive method to surveil neurologic complications during neurovascular intervention. Intraoperative MEP monitoring appears to be feasible. However, it is unclear whether MEP monitoring has any additive benefit over SSEP monitoring.

Recurrence of Small Cerebral Aneurysms (< 4 mm) Treated Endovascularly Using Target® Nano™ Coils.

OBJECTIVE: In our series, endovascular coiling with Target® Nano™ coils (Stryker Neurovascular, Fremont, CA, USA) with diameters of 1 or 1.5 mm exhibited favorable technical feasibility in the treatment of small cerebral aneurysms (< 4 mm). However, little is known about the recurrence of small cerebral aneurysms treated using Target® Nano™ coils. We investigated recurrence following the treatment of small cerebral aneurysms using Target® Nano™ coils. MATERIALS AND METHODS: Between January 2012 and November 2013, 143 patients with 148 small cerebral aneurysms (< 4 mm) were included our study. A total of 135 cerebral aneurysms (91.2%) were unruptured; 45 cerebral aneurysms (30.4%) were treated by endovascular coiling using Target® Nano™ coils. Follow-up radiological images were obtained for 132 cerebral aneurysms (89.2%) over a range of 3 to 58 months (mean, 34.3 months; standard deviation, 14.2). RESULTS: In the group treated with Target® Nano™ coils, radiological outcomes revealed complete occlusion in 33 (73.3%), residual necks in eight (17.8%), and residual sacs in four (8.9%) cases. Follow-up radiological outcomes revealed complete occlusion in 35 (77.8%) and residual necks in four (8.9%) cases that exhibited stable coil masses. In the group that was not treated with Target® Nano™ coils, radiological outcomes revealed complete occlusion in 69 (67%), residual necks in 18 (17.5%), and residual sacs in 16 (15.5%) cases. Follow-up radiological outcomes revealed complete occlusion in 87 (84.5%) and residual necks (5.8%) in six cases that exhibited stable coil masses. No significant differences were observed in the radiological outcomes or follow-up radiological outcomes between the two groups. No recurrences or retreatments occurred in our series. CONCLUSION: Endovascular treatment using Target® Nano™ coils may be a robust treatment option for small cerebral aneurysms (< 4 mm).

A novel DHCR7 mutation in a Smith-Lemli-Opitz syndrome infant presenting with neonatal cholestasis.

Smith-Lemli-Opitz syndrome (SLOS) is an autosomal recessive malformation syndrome caused by a defect in cholesterol biosynthesis. The incidence is very low in Asians and only one case has been reported in Korea thus far. Recently, we found an infant with neonatal cholestasis. He had microcephaly, ambiguous genitalia, cleft palate, syndactyly of toes, patent ductus arteriosus and hypertrophic pyloric stenosis. The serum cholesterol was decreased and serum 7-dehydrocholesterol was markedly elevated. Genetic analysis of the DHCR7 gene identified a novel missense mutation (Pro227Ser) as well as a known mutation (Gly303Arg) previously identified in a Japanese patient with SLOS. Although rare in Korea, SLOS should be considered in the differential diagnosis of neonatal cholestasis, especially in patients with multiple congenital anomalies and low serum cholesterol levels.

Inkjet printing of single-walled carbon nanotubes and electrical characterization of the line pattern.

Single-walled carbon nanotubes (SWCNTs) were patterned using inkjet printing. To make the uniform networks of dropped SWCNTs, the effects of substrate heating, surface hydrophilicity of the substrate and the jetting process were investigated. Circuit diagrams including holes, lines and curves were printed on glass and polymer substrates, and the conductive lines were printed on a glass substrate to characterize their electrical properties by I-V curve and impedance measurements. Lines 75 mm long were printed along with the number of overwrites with 150 µm linewidth and width change with five overwrites. As for the results, we confirmed that the dc resistance of the SWCNT line was proportionally changed according to the linewidth and the number of overwrites, and the line feature possessed ohmic characteristics to 2 MHz even after two overwrites.