Postoperative Airway Management after Anterior Cervical Spine Surgery: Retrospective Neurosurgical Multicenter Study.

Airway complications that occur after anterior cervical spine surgery pose a life-threatening risk, which encompasses complications including prolonged intubation, unplanned reintubation, and/or necessity of tracheostomy. The present study aimed to identify the surgical risks associated with postoperative airway complications in neurosurgical training institutes. A retrospective, multicenter, observational review of data from 365 patients, who underwent anterior cervical spine surgery between 2018 and 2022, at three such institutes was carried out. Postoperative airway complication was defined as either the need for prolonged intubation on the day of surgery or the need for unplanned reintubation. The perioperative medical information was obtained from their medical records. The average age of the cohort was over 60 years, with males comprising approximately 70%. Almost all surgeries predominantly involved anterior cervical discectomy and fusion or anterior cervical corpectomy and fusion, with most surgeries occurring at the level of C5/6. In total, 363 of 365 patients (99.5%) were extubated immediately after surgery, and the remaining two patients were kept under intubation because of the risk of airway complications. Of the 363 patients who underwent extubation immediately after surgery, two (0.55%) required reintubation because of postoperative airway complications. Patients who experienced airway complications were notably older and exhibited a significantly lower body mass index. The results of this study suggested that older and frailer individuals are at an elevated risk for postoperative airway complications, with immediate postoperative extubation generally being safe but requiring careful judgment in specific cases.

Influence of surgical position and registration methods on clinical accuracy of navigation systems in brain tumor surgery.

The aim of this study was to evaluate the influence of skin distortion due to surgical positioning on the clinical accuracy of the navigation system. The distance errors were measured in four fiducial markers (anterior, posterior, right, and left of the head) after the registration of the navigation system. The distance errors were compared between the surface-merge registration (SMR) method using preoperative imaging and the automatic intraoperative registration (AIR) method using intraoperative imaging. The comparison of the distance errors were performed in various surgical positions. The AIR method had the significant accuracy in the lateral markers than the SMR method (lateral position, 3.8 mm vs. 8.95 mm; p < 0.0001; prone position, 4.5 mm vs. 13.9 mm; p = 0.0001; 5.2 mm vs. 11.5 mm; p = 0.0070). The smallest distance errors were obtained close to the surgical field in the AIR method (3.25-3.85 mm) and in the forehead in the SMR method (3.3-8.1 mm). The AIR method was accurate and recommended for all the surgical positions if intraoperative imaging was available. The SMR method was only recommended for the supine position, because skin distortion was frequently observed in the lateral region.

Ablation efficacy of 5-aminolevulinic acid-mediated photodynamic therapy on human glioma stem cells.

BACKGROUND: Cancer cells with stem cell-like features are generally more resistant to chemotherapy and radiotherapy than differentiated tumor cells. Thus, these cells tend to increase the propensity for tumor recurrence and metastasis. This study investigated the efficacy of 5-aminolevulinic acid-mediated photodynamic therapy (ALA-PDT) in destructing glioma stem cells (GSCs), including the mesenchymal subtype (MES-GSCs) demonstrated to have the lowest radio- and chemosensitivity. METHODS: Five high-grade glioma (HGG) GSC lines and derived differentiated glioma cell (DGC) lines were examined for protoporphyrin-IX (PpIX) expression using fluorescence-activated cell sorting (FACS) and then assessed for ALA-PDT sensitivity using cell viability assays. MES-GSCs surviving ALA-PDT were then isolated and evaluated for stem cell and mesenchymal marker expression levels (CD44, ALDH1A3, KLF4, nestin) by qRT-PCR. The ability of these surviving cells to form tumors was then examined using colony forming and by xenograft tumor assays in athymic mice. Finally, the relationship between PpIX expression level (high versus low) and ALA-PDT sensitivity was examined by FACS and colony forming assays. RESULTS: ALA-PDT was effective against all GSC lines including MES-GSCs. MES-GSC lines exhibited higher PpIX expression than derived DGCs. Surviving MES-GSCs demonstrated lower stem cell marker expression and tumor forming potential than naive MES-GSCs. Higher PpIX production capacity by MES-GSCs was associated with greater colony forming ability, and ALA-PDT was more effective against MES-GSCs with greater PpIX accumulation. CONCLUSION: ALA-PDT may be clinically effective against HGG by targeting GSCs, including MES-GSCs.

Pineal region pilocytic astrocytoma showing uncommon growth: a case report.

Pineal region pilocytic astrocytomas are extremely rare, and there is limited information about their radiological features. We report the case of a 22-year-old woman with a cystic lesion in the pineal region. In the 2 years after diagnosis, the lesion irregularly extended along the bilateral internal cerebral veins and the inferolateral surface of the corpus callosum. Gross total resection was achieved, and the histopathological study revealed that the lesion was a pilocytic astrocytoma. The lesion exhibited uncommon growth, leading to difficulty in establishing an accurate preoperative diagnosis. It should be noted that pineal region pilocytic astrocytomas can demonstrate atypical appearances.

A Case of Puncture-Site Giant Pseudoaneurysm Following Recanalization Therapy for Acute Ischemic Stroke: Marked Growth and Rupture of a Femoral Artery Pseudoaneurysm.

Objective: We report a case of the marked growth and rupture of a giant femoral artery pseudoaneurysm at the puncture site that developed after recanalization therapy for acute basilar artery occlusion. Case Presentation: A 79-year-old woman developed acute ischemic stroke due to atherosclerotic basilar artery occlusion. Endovascular intervention was performed and recanalization of the affected vessel was achieved. However, she developed brainstem infarction and consciousness disturbance persisted. The femoral access site was treated using a vascular closure device at the end of the procedure. A right femoral artery pseudoaneurysm of approximately 5 cm in size was found 2 weeks after onset during the examination for deep venous thrombosis with right lower extremity edema. Manual compression did not achieve thrombotic occlusion of the aneurysm due to obesity and leg edema. Considering the severe neurological status of the patient, the pseudoaneurysm was followed up without surgical treatment. Dual antiplatelet therapy and direct oral anticoagulant agents were administered. Four weeks after onset, the pseudoaneurysm presented rapid growth, and on the 35th day after onset, it exceeded 15 cm in size and ruptured, causing hemorrhagic shock with massive femoral hematoma. Pseudoaneurysm resection and hematoma removal were performed surgically, and the patient recovered. However, improvement of neurological manifestations was poor and the modified Rankin Scale at 90 days after onset was 5. Conclusion: A case of giant femoral artery pseudoaneurysm following recanalization therapy for acute ischemic stroke was reported. Pseudoaneurysms at the puncture site can rupture after significant growth. Curative treatment is required without delay.

A case report of microvascular decompression for cervical myelopathy and radiculopathy caused by tortuous and abnormal bilateral vertebral artery.

BACKGROUND: Tortuous/abnormal vertebral arteries (VAs) sometimes cause neurovascular compression syndromes (NVCs), such as trigeminal neuralgia, hemifacial spasm, and, rarely, myelopathy/radiculopathy. Abnormalities/tortuosity of the VA at the level of the atlas and axis are of particular note; these may be characterized by a persistent first intersegmental artery (PFIA) and C2 segmental type of VA. Herein, we report a 72-year-old male who presented with cervical myelopathy/radiculopathy due to bilateral tortuosity of the PFIA resulting in spinal cord compression at the craniocervical junction. CASE DESCRIPTION: A 72-year-old male presented with cervical pain when turning his neck and progressive gait disturbance. The neurological examination demonstrated a moderate myeloradicular syndrome (Nurick Grade III). The magnetic resonance revealed compression of the medulla and spinal cord due to tortuosity of both dorsal VA at the C1 vertebral level. The three-dimensional computed tomography angiogram confirmed bilateral PFIA running medially. In addition, the left side of VA forms fenestration. Surgery through a C1 laminectomy and midline small suboccipital craniectomy, both VAs were transposed and tethered to the ipsilateral dura utilizing Aron Alpha and vinyl prostheses. In addition, a large vinyl prosthesis was inserted between both VAs to protect them from contacting the spinal cord. Following this decompressive procedure, the patient's symptoms fully resolved, and he remains asymptomatic 10 years later exhibiting no recurrent vascular pathology. CONCLUSION: Microvascular decompression of anomalous VAs contributing to cord compression at the C1 level was safe and effective in a 72-year-old male.

Other Hospital-onset Acute Ischemic Stroke Due to Large Vessel Occlusion Treated by Mechanical Thrombectomy after Inter-hospital Transfer.

The purpose of this study was to investigate the in-hospital acute ischemic stroke due to large vessel occlusion (LVO) that developed in another thrombectomy-incapable hospital, treated by mechanical thrombectomy after inter-hospital transfer. In eight other hospital-onset LVO patients, clinical characteristics, treatment results, and the timeline of thrombectomy were retrospectively investigated and compared to the results of 17 patients developed LVO at our own hospital and 18 developed in the community. In the analysis of timeline, the mean recognition-to-arrival time in other hospital-onset patients was 169 ± 78 min, significantly longer than for the community-onset patients (79 ± 78 min). Arrival-to-puncture time was 42 ± 19 min, significantly shorter than for the own hospital-onset patients (166 ± 80 min) and the community-onset patients (155 ± 76 min). Recognition-to-puncture times for the other hospital-onset patients, the own hospital-onset patients, and the community-onset patients were 212 ± 74, 166 ± 80, and 216 ± 83 min, respectively, and recognition-to-recanalization times were 285 ± 73, 200 ± 81, and 275 ± 125 min. Both these times were shorter for the own hospital-onset patients. The rates of modified Rankin Scale (mRS) of 0-2 in the three groups were 12%, 30%, and 23%, respectively. The rate of mRS 0-2 was lowest in the other hospital-onset patients. In conclusion, the other hospital-onset patients required additional time for their initial management and inter-hospital transfer although arrival-to-puncture time was shorter. Favorable outcomes were observed less frequently in them. Improving inter-hospital cooperation systems and to educate the medical staff in a thrombectomy-incapable hospital concerning stroke management is important measures for other hospital-onset stroke with LVO.

[The Efficacy of the Emergent Shunt-Clamp System for Secondary Hydrocephalus Associated with Fourth Ventricle Outlet Obstruction Syndrome:A Report of Two Cases].

Endoscopic third ventriculostomy(ETV)is the first-line treatment for fourth ventricle outlet obstruction(FVOO)-associated hydrocephalus. However, because FVOO is difficult to diagnose in the acute stage, ventriculoperitoneal shunt(VPS)is also used. Herein, we report two cases of shunted FVOO resulting in overdrainage or slit ventricle syndrome(SVS)that were treated successfully with the shunt-clamp system. In addition, we discuss the efficacy of the shunt-clamp system for FVOO-associated hydrocephalus. CASE 1:A 79-year-old man complained of severe postural headaches. One year earlier, he underwent VPS for secondary hydrocephalus associated with hemorrhagic cerebellar infarction. CT revealed that the ventricle had become slit-like. Although the shunt valve adjusted the maximum pressure, his complaint and the ventricle shape did not improve. After the on-off valve was inserted in the shunt system and clamped, his symptoms were resolved and the ventricle size was normalized. CASE 2:A 21-year-old man who complained of drowsiness, diplopia, and severe intermittent retroocular pain was admitted to our hospital. One year earlier, he underwent VPS with the shunt-clamp system for a secondary hydrocephalus after surgery for medulloblastoma. CT on admission revealed ventricle dilatation;however, the shape of the ventricle became slit-like 3 days after admission. We made a diagnosis of SVS and planned ETV. Owing to the difficulty in approaching the lateral ventricle, the shunt system was clamped 8 hours before the operation. After confirming ventricle dilatation, ETV was successfully performed. After the operation, the symptoms were resolved, and magnetic resonance imaging confirmed that the ventricle size was normalized.

5-Aminolevulinic acid-mediated photodynamic therapy can target human glioma stem-like cells refractory to antineoplastic agents.

BACKGROUND: Glioblastoma (GBM) is a highly malignant lethal brain cancer. Accumulated evidence suggests that elevated resistance of GBM to both chemo- and radio-therapy is, at least in part, due to the presence of a small population of glioma stem cells (GSC). In the present study, we aimed to determine the sensitivity of GSCs to 5-aminolevulinic acid-mediated photodynamic therapy (ALA-PDT). METHODS: For this purpose, we established GSC-enriched cell cultures (termed glioma stem-like cells or GSLCs) from A172 human GBM cell line. Under our cultivation conditions, GSLCs formed floating spheroid clusters that contained increased population of CD133/Sox2 expressing cells. Firstly, to compare the activity of protoporphyrin IX (PpIX) biosynthesis in the GSLCs and the parental A172 glioma cells, we examined the expression levels of biosynthesis enzymes and transporters for PpIX using qRT-PCR, and investigated the intracellular levels of PpIX with use of flow cytometry analysis. Then, we evaluated the sensitivity of these cells to ALA-PDT in vitro. Finally, to confirm the therapeutic impact of ALA-PDT on GSLCs with more clinically relevant model, we performed the same experiment using three different patient-derived glioma sphere lines, which cultivated them either in stem cell media or under differentiation conditions in the presence of serum. RESULTS AND CONCLUSION: GSLCs expressed higher mRNA levels of PpIX biosynthesis enzymes and its transporters PEPT1/2 and ABCB6, when compared to the parental A172 glioma cells. Consistently, flow cytometry analysis revealed that upon incubation with ALA, GSLCs accumulate a higher level of PpIX. Finally, we showed that GSLCs were more sensitive to ALA-PDT than the original A172 cells, and confirmed that all patient-derived glioma sphere lines also showed significantly increased sensitivity to ALA-PDT if cultivated under the pro-stem cell condition. Our data indicate that ALA-PDT has potential as a novel clinically useful treatment that might eliminate GBM stem cells that are highly resistant to current chemo- and radio-therapy.