Imaging follow-up strategy after endovascular treatment of Intracranial aneurysms: A literature review and guideline recommendations.

OBJECTIVE: Endovascular coil embolization is the primary treatment modality for intracranial aneurysms. However, its long-term durability remains of concern, with a considerable proportion of cases requiring aneurysm reopening and retreatment. Therefore, establishing optimal follow-up imaging protocols is necessary to ensure a durable occlusion. This study aimed to develop guidelines for follow-up imaging strategies after endovascular treatment of intracranial aneurysms. METHODS: A committee comprising members of the Korean Neuroendovascular Society and other relevant societies was formed. A literature review and analyses of the major published guidelines were conducted to gather evidence. A panel of 40 experts convened to achieve a consensus on the recommendations using the modified Delphi method. RESULTS: The panel members reached the following consensus: 1. Schedule the initial follow-up imaging within 3-6 months of treatment. 2. Noninvasive imaging modalities, such as three-dimensional time-of-flight magnetic resonance angiography (MRA) or contrast-enhanced MRA, are alternatives to digital subtraction angiography (DSA) during the first follow-up. 3. Schedule mid-term follow-up imaging at 1, 2, 4, and 6 years after the initial treatment. 4. If noninvasive imaging reveals unstable changes in the treated aneurysms, DSA should be considered. 5. Consider late-term follow-up imaging every 3-5 years for lifelong monitoring of patients with unstable changes or at high risk of recurrence. CONCLUSIONS: The guidelines aim to provide physicians with the information to make informed decisions and provide patients with high-quality care. However, owing to a lack of specific recommendations and scientific data, these guidelines are based on expert consensus and should be considered in conjunction with individual patient characteristics and circumstances.

TREX2 deficiency suppresses spontaneous and genotoxin-associated mutagenesis.

TREX2, a 3'-5' exonuclease, is a part of the DNA damage tolerance (DDT) pathway that stabilizes replication forks (RFs) by ubiquitinating PCNA along with the ubiquitin E3 ligase RAD18 and other DDT factors. Mismatch repair (MMR) corrects DNA polymerase errors, including base mismatches and slippage. Here we demonstrate that TREX2 deletion reduces mutations in cells upon exposure to genotoxins, including those that cause base lesions and DNA polymerase slippage. Importantly, we show that TREX2 generates most of the spontaneous mutations in MMR-mutant cells derived from mice and people. TREX2-induced mutagenesis is dependent on the nuclease and DNA-binding attributes of TREX2. RAD18 deletion also reduces spontaneous mutations in MMR-mutant cells, albeit to a lesser degree. Inactivation of both MMR and TREX2 additively increases RF stalls, while it decreases DNA breaks, consistent with a synthetic phenotype.

Silent Embolic Infarction after Neuroform Atlas Stent-Assisted Coiling of Unruptured Intracranial Aneurysms.

OBJECTIVE: There is still controversy regarding whether neck remodeling stent affects the occurrence of silent embolic infarction (SEI) after aneurysm coiling. Thus, the aim of the present study is to investigate the incidence of SEI after stent-assisted coiling (SAC) using Neuroform Atlas Stent (NAS) and possible risk factors. This study also includes a comparison with simple coiling group during the same period to estimate the impact of NAS on the occurrence of SEI. METHODS: This study included a total of 96 unruptured intracranial aneurysms in 96 patients treated with SAC using NAS. Correlations of demographic data, aneurysm characteristics, and angiographic parameters with properties of SEI were analyzed. The incidence and characteristics of SEI were investigated in 28 patients who underwent simple coiling during the same period, and the results were compared with the SAC group. RESULTS: In the diffusion-weighted imaging obtained on the 1st day after SAC, a total of 106 SEI lesions were observed in 48 (50%) of 96 patients. Of these 48 patients, 38 (79.2%) had 1-3 lesions. Of 106 lesions, 74 (69.8%) had a diameter less than 3 mm. SEI occurred more frequently in older patients (≥60 years, p=0.013). The volume of SEI was found to be significantly increased in older age (≥60 years, p=0.032), hypertension (p=0.036), and aneurysm size ≥5 mm (p=0.047). The incidence and mean volume of SEI in the SAC group (n=96) were similar to those of the simple coiling group (n=28) during the same period. CONCLUSION: SEIs are common after NAS-assisted coiling. Their incidence in SAC was comparable to that in simple coiling. They occurred more frequently at an older age. Therefore, the use of NAS in the treatment of unruptured intracranial aneurysm does not seem to be associated with an increased risk of thromboembolic events if antiplatelet premedication has been performed well.

Avenanthramide-C Shows Potential to Alleviate Gingival Inflammation and Alveolar Bone Loss in Experimental Periodontitis.

Periodontal disease is a chronic inflammatory disease that leads to the gradual destruction of the supporting structures of the teeth including gums, periodontal ligaments, alveolar bone, and root cementum. Recently, interests in alleviating symptoms of periodontitis (PD) using natural compounds is increasing. Avenanthramide-C (Avn-C) is a polyphenol found only in oats. It is known to exhibit various biological properties. To date, the effect of Avn-C on PD pathogenesis has not been confirmed. Therefore, this study aimed to verify the protective effects of Avn-C on periodontal inflammation and subsequent alveolar bone erosion in vitro and in vivo. Upregulated expression of catabolic factors, such as matrix metalloproteinase 1 (MMP1), MMP3, interleukin (IL)-6, IL-8, and COX2 induced by lipopolysaccharide and proinflammatory cytokines, IL-1ß, and tumor necrosis factor α (TNF-α), was dramatically decreased by Avn-C treatment in human gingival fibroblasts and periodontal ligament cells. Moreover, alveolar bone erosion in the ligature-induced PD mouse model was ameliorated by intra-gingival injection of Avn-C. Molecular mechanism studies revealed that the inhibitory effects of Avn-C on the upregulation of catabolic factors were mediated via ERK (extracellular signal-regulated kinase) and NF-κB pathway that was activated by IL-1ß or p38 MAPK and JNK signaling that was activated by TNF-α, respectively. Based on this study, we recommend that Avn-C may be a new natural compound that can be applied to PD treatment.

Posterior reversible encephalopathy syndrome following uneventful clipping of an unruptured intracranial aneurysm: A case report.

BACKGROUND: Posterior reversible encephalopathy syndrome (PRES) is characterized mainly by occipital and parietal lobe involvement, which can be reversible within a few days. Herein, we report a rare case of PRES that developed after craniotomy for an unruptured intracranial aneurysm (UIA). CASE SUMMARY: A 59-year-old man underwent clipping surgery for the treatment of UIA arising from the left middle cerebral artery. Clipping surgery was performed uneventfully, and he regained consciousness quickly immediately after the surgery. At the 4th hour after surgery, he developed a disorder of consciousness and aphasia. Magnetic resonance imaging revealed cortical and subcortical T2/FLAIR hyperintensities in the parietal, occipital, and frontal lobes ipsilaterally, without restricted diffusion, consistent with unilateral PRES. With conservative treatment, his symptoms and radiological findings almost completely disappeared within weeks. In our case, the important causative factor of PRES was suspected to be a sudden increase in cerebral perfusion pressure associated with temporary M1 occlusion. CONCLUSION: Our unique case highlights that, to our knowledge, this is the second report of PRES developing after craniotomy for the treatment of UIA. Surgeons must keep PRES in mind as one of the causes of perioperative neurological abnormality following clipping of an UIA.

Additional rescue stenting with Neuroform Atlas stents during stent-assisted coiling of saccular aneurysms.

OBJECTIVE: Overlapping stenting is sometimes attempted during endovascular treatment of cerebral aneurysm as a rescue for coil herniation, stent mal-positioning, or in-stent thrombosis. We retrospectively evaluated the efficacy and safety of additional rescue stenting (ARS) in telescoping fashion with Neuroform Atlas stent (NAS) during stent-assisted coiling of saccular aneurysms. METHODS: We collected clinical and radiological data of patients with saccular aneurysms treated with ARS using NASs between March 2018 and December 2021. Y or X-stent-assisted coiling technique was excluded. RESULTS: Eighteen unruptured and 5 ruptured aneurysms in 23 patients were treated with ARS using NASs. Sizes of aneurysms ranged from 2.0 mm to 10.0 mm (mean: 5.0 mm). Immediate angiographic results were complete occlusion in 11 aneurysms, residual neck in 4 aneurysms, and residual sac in 8 aneurysms. Peri-operative morbidity was 4.3 %. Nineteen of 23 patients underwent follow-up conventional angiography (mean, 9.9 months). Results showed progressive occlusion in 10 (52.6 %) cases and asymptomatic in-stent stenosis in 3 (15.8 %) cases. At the end of the observation period (mean, 17.4 months), all 18 patients without subarachnoid hemorrhage had excellent clinical outcomes (mRS of 0), except one (mRS of 1). Of five patients with subarachnoid hemorrhage, four had a favorable outcome (mRS of 0-1), while the other one was dependent (mRS of 4). CONCLUSION: In this report on 23 patients, ARS with NASs for treating saccular aneurysms showed good technical safety with favorable clinical and angiographic outcomes. However, delayed in-stent stenosis was not uncommon. Thus, regular imaging follow-up is required.

The changes of distance between nipples following correction of women pectus excavatum.

The breasts in women pectus excavatum patients frequently appear to be slanting medially along the inclination of the distorted ribs. This study aims to evaluate changes in the distance between the nipples and to find out whether medially slanting breasts are corrected in women pectus excavatum patients following modified Nuss procedure. This case series analysis enrolled 22 young women patients with pectus excavatum between October 2011 and September 2020. We measured all the patients' distances from the sternal midline to the right and left nipples, based on chest computerized tomography. We calculated the distances between nipples as being the sum of the right and left distances. The mean age of patients was 16.50 ± 4.73 years, and the follow-up periods were 35.59 ± 20.23 months. The postoperative Haller indices (2.89 ± 0.43) were significantly lower than the preoperative Haller indices (5.14 ± 1.96) (p = 0.000). The distances between the nipples before and after Nuss procedure were 145.17 ± 17.73 mm and 172.29 ± 19.11 mm, which is a significant increase following surgery. (p = 0.000). Our results demonstrated that skeletal correction with modified Nuss procedure in pectus excavatum increased the distance between nipples, indicating that medially slanting breasts had been corrected.

Concomitant Occurrence of Acute Motor Axonal Neuropathy in Systemic Lupus Erythematosus.

ABSTRACT: Few case reports exist on the association of acute motor axonal neuropathy, a subtype of the Guillain-Barré syndrome (GBS), with systemic lupus erythematosus. Standard therapeutic guidelines for concomitant acute motor axonal neuropathy and systemic lupus erythematosus in the acute phase are not established, and no studies have reported physical medicine and rehabilitation perspective management in the plateau and recovery phases. A 50-yr-old woman with systemic lupus erythematosus presented with upper and lower limb weakness that progressed to an inability to walk. Neurological examination, radiologic evaluation, serologic analysis, and electrodiagnostic study were conducted, and she was diagnosed with acute motor axonal neuropathy. Subsequently, intravenous immunoglobulin therapy was administered. She complained of residual upper and lower extremity weakness and an inability to walk 3 mos after symptom onset. She underwent an intensive inpatient rehabilitation program for 6 wks and showed remarkable recovery in muscle strength and functional status (Berg Balance Scale, modified Barthel index, and Guillain-Barré syndrome disability scale). To our knowledge, this is the first reported case that focused on the functional outcomes after the rehabilitation program in acute motor axonal neuropathy with a history of systemic lupus erythematosus. This case report emphasizes the need for rehabilitation intervention for functional recovery in the plateau and recovery phases.

Erratum: Contralateral Transverse Sinus Occlusion After Treatment of Transverse-Sigmoid Sinus Dural Arteriovenous Fistula: A Case Report.

[This corrects the article on p. 104 in vol. 18, PMID: 35557632.].

Multiscale landscaping of droplet wettability on fibrous layers of facial masks.

Liquid mobility is ubiquitous in nature, with droplets emerging at all size scales, and artificial surfaces have been designed to mimic such mobility over the past few decades. Meanwhile, millimeter-sized droplets are frequently used for wettability characterization, even with facial mask applications, although these applications have a droplet-size target range that spans from millimeters to aerosols measuring less than a few micrometers. Unlike large droplets, microdroplets can interact sensitively with the fibers they contact with and are prone to evaporation. However, wetting behaviors at the single-microfiber level remain poorly understood. Herein, we characterized the wettability of fibrous layers, which revealed that a multiscale landscape of droplets ranged from the millimeter to the micrometer scale. The contact angle (CA) values of small droplets on pristine fibrous media showed sudden decrements, especially on a single microfiber, owing to the lack of air cushions for the tiny droplets. Moreover, droplets easily adhered to the pristine layer during droplet impact tests and then yielding widespread areas of contamination on the microfibers. To resolve this, we carved nanowalls on the pristine fibers by plasma etching, which effectively suppressed such wetting phenomena. Significantly, the resulting topographies of the microfibers managed the dynamic wettability of droplets at the multiscale, which reduced the probability of contamination with impact droplets and suppressed the wetting transition upon evaporation. These findings for the dynamic wettability of fibrous media will be useful in the fight against infectious droplets.

Comparing carotid endarterectomy and carotid artery stenting: retrospective single-center analysis.

BACKGROUND: Extracranial cerebrovascular diseases represent approximately 20% of ischemic stroke cases. Carotid endarterectomy (CEA) was the gold standard procedure for carotid artery stenosis treatment until the introduction of carotid artery stenting (CAS) in the 1980s. While there have been several multicenter randomized trials comparing CEA and CAS, a more efficacious procedure has not been conclusively distinguished. This study reports the results of CAS versus CEA in patients with symptomatic or asymptomatic carotid stenosis and compares them with those from other studies. METHODS: This study is a single-center retrospective study and included patients who underwent CAS and CEA as elective surgery between January 2012 and December 2020. The final analysis included patient baseline characteristics, postoperative complications, and patient outcomes. RESULTS: The 235 patients included were assigned to the CAS (n=128) and CEA (n=107) groups. Within 30 days postoperatively, no significant differences were noted in myocardial infarction [n=1, 0.8% (CAS); n=1, 0.9% (CEA); P=0.899], cerebral infarction [n=4, 3.1% (CAS); n=1, 0.9% (CEA); P=0.247], and patient mortality [n=1, 0.8% (CAS); n=0, 0% (CEA); P=0.247]. CONCLUSIONS: In elective surgery, CAS and CEA had the same effect of preventing cerebral infarction with no difference in postoperative complications.

Stacking ensemble learning model to predict 6-month mortality in ischemic stroke patients.

Patients with acute ischemic stroke can benefit from reperfusion therapy. Nevertheless, there are gray areas where initiation of reperfusion therapy is neither supported nor contraindicated by the current practice guidelines. In these situations, a prediction model for mortality can be beneficial in decision-making. This study aimed to develop a mortality prediction model for acute ischemic stroke patients not receiving reperfusion therapies using a stacking ensemble learning model. The model used an artificial neural network as an ensemble classifier. Seven base classifiers were K-nearest neighbors, support vector machine, extreme gradient boosting, random forest, naive Bayes, artificial neural network, and logistic regression algorithms. From the clinical data in the International Stroke Trial database, we selected a concise set of variables assessable at the presentation. The primary study outcome was all-cause mortality at 6 months. Our stacking ensemble model predicted 6-month mortality with acceptable performance in ischemic stroke patients not receiving reperfusion therapy. The area under the curve of receiver-operating characteristics, accuracy, sensitivity, and specificity of the stacking ensemble classifier on a put-aside validation set were 0.783 (95% confidence interval 0.758-0.808), 71.6% (69.3-74.2), 72.3% (69.2-76.4%), and 70.9% (68.9-74.3%), respectively.

The Addition of ROTEM Parameter Did Not Significantly Improve the Massive Transfusion Prediction in Severe Trauma Patients.

Background: Rotational thrombelastometry (ROTEM) has been used to evaluate the coagulation state, predict transfusion, and optimize hemostatic management in trauma patients. However, there were limited studies on whether the prediction value could be improved by adding the ROTEM parameter to the prediction model for in-hospital mortality and massive transfusion (MT) in trauma patients. Objective: This study assessed whether ROTEM data could improve the MT prediction model. Method: This was a single-center, retrospective study. Patients who presented to the trauma center and underwent ROTEM between 2016 and 2020 were included. The primary and secondary outcomes were massive transfusions and in-hospital mortality, respectively. We constructed two models using multivariate logistic regression with backward conditional stepwise elimination (Model 1: without the ROTEM parameter and Model 2: with the ROTEM parameter). The area under the receiver operating characteristic curve (AUROC) was calculated to assess the predictive ability of the models. Result: In total, 969 patients were included; 196 (20.2%) received MT. The in-hospital mortality rate was 14.1%. For MT, the AUROC was 0.854 (95% confidence interval [CI], 0.825-0.883) and 0.860 (95% CI, 0.832-0.888) for Model 1 and 2, respectively. For in-hospital mortality, the AUROC was 0.886 (95% CI, 0.857-0.915) and 0.889 (95% CI, 0.861-0.918) for models 1 and 2, respectively. The AUROC values for models 1 and 2 were not statistically different for either MT or in-hospital mortality. Conclusion: We found that the addition of the ROTEM parameter did not significantly improve the predictive power of MT and in-hospital mortality in trauma patients.

Wire perforation of the missed tiny aneurysm originating from the fenestrated A1 segment during the endovascular approach.

Vascular anomaly and aneurysmal formation of an anterior communicating artery (ACOM) complex has often been reported. Because of such a complicated relationship between the vascular structure and aneurysms, ACOM aneurysm is one of the most difficult aneurysms to treat among other common anterior circulation aneurysms. We herein report a case of wire perforation of a missed tiny aneurysm arising from the fenestrated A1 segment during the endovascular approach to ACOM aneurysm. Although the fenestration of A1 segment is a rare vascular anomaly, it is likely to accompany saccular type aneurysms in the vicinity of the vascular anomaly. Endovascular treatment for ACOM aneurysm requires more detailed evaluations of the accompanying vascular anomaly and hemodynamics around ACOM to avoid complications.

A Positive Association between the Atherogenic Index of Plasma and White Matter Hyperintensity.

BACKGROUND: White matter hyperintensity (WMH) is a risk factor for dementia and ischemic stroke. The atherogenic index of plasma (AIP) is a simple and cost-effective marker for the prediction of various vascular diseases. In this study, we evaluated the relationship between AIP and WMH in adults without cerebrovascular accidents. METHODS: We analyzed the data of 281 adults, aged ≥26 years, who underwent brain magnetic resonance imaging (MRI) at the health promotion center of an education hospital between January 2014 and December 2018. Participants were divided into three categories according to tertiles of the AIP scores (T1: <0.20; T2: 0.20-0.48; and T3: >0.48). WMH was defined as a modified Fazekas scale score of 1-3 on brain MRI. A cubic spline curve was used to determine the linearity of the relationship between AIP and WMH. Multiple logistic regression analysis was used to evaluate the relationship between the AIP and WMH. RESULTS: The prevalence of WMH was 45.7% in T1, 57.0% in T2, and 66.0% in T3 (T3 vs. T1, P for post-hoc analysis=0.005). The increased odds of WMH were associated with increased AIP. The odds ratio (OR) with a 95% confidence interval (CI) for WMH of T2 and T3 compared with T1 were 1.57 (0.88-2.80) and 2.30 (1.28-4.14), respectively. After adjusting for confounding variables, the OR with a 95% CI for WMH in the T2 and T3 groups vs. the referent T1 were 1.55 (0.76-3.13) and 2.27 (1.06-4.84), respectively. CONCLUSION: AIP is independently and positively associated with WMH in a healthy population.

Contralateral Transverse Sinus Occlusion After Treatment of Transverse-Sigmoid Sinus Dural Arteriovenous Fistula: A Case Report.

A dural arteriovenous fistula (DAVF) is a pathologic arteriovenous shunt located within the dural wall of a venous sinus. In addition, DAVFs are associated with sinus thrombosis. Consequently, sinus occlusion may occur near DAVF lesions, making treatment challenging. However, there are few reports of sinus occlusion unrelated to lesions. In this study, we present a rare case of contralateral transverse sinus occlusion in a patient who underwent endovascular treatment and stereotactic radiosurgery for DAVF in the transverse-sigmoid sinus with ipsilateral sigmoid sinus occlusion.