Effectiveness of intraoperative visual evoked potential in avoiding visual deterioration during endonasal transsphenoidal surgery for pituitary tumors.

Postoperative visual function is a major concern in transsphenoidal surgery (TSS). Although several reports have demonstrated the importance of visual evoked potential (VEP) monitoring during TSS, the usefulness of VEP monitoring have been controversial because of its reproducibility. Efficacy of VEP was analyzed in 20 consecutive cases of patients who underwent endoscopic endonasal TSS surgery. We adapted a high-power light-emitting diode stimulator with electroretinography using venous anesthesia. In addition, we used black shield patch and braided codes to obtain reproducible VEP amplitudes. Stable and reproducible VEP waveforms were obtained in 38 of 39 eyes (97.4%) before surgery. Fifteen eyes had deteriorated VEP amplitude during operation, and nine eyes had improved VEP amplitude at the end of surgery, and six eyes had not improved VEP amplitude. But no postoperative visual impairment was observed in all cases by temporary halting the surgical manipulation when the VEP was deteriorated. In conclusion, VEP monitoring could be a warning sign to avoid postoperative visual dysfunction. We recommend VEP as a routine monitoring in TSS.

Iatrogenic Atrial Septal Defect After Percutaneous Mitral Valve Repair With the MitraClip System.

This study examines the incidence of iatrogenic atrial septal defect (iASD) after the MitraClip procedure and its influence on echocardiographic and clinical outcomes. We examined 96 patients who underwent a successful MitraClip procedure and who also had baseline and 1-year postprocedure transthoracic echocardiograms. At 1-year follow-up, iASD were observed in 24% of cases. Compared with the patients without iASD, the patients with iASD had a larger right atrium and greater severity of tricuspid regurgitation (TR) at baseline. After the MitraClip procedure, mitral regurgitation lessened significantly in both groups. Although right atrial area and right ventricular diameters increased significantly in patients with iASD (25.3 ± 8.0 to 28.3 ± 9.5 cm2, 39.7 ± 7.1 to 42.2 ± 8.1 mm, p <0.05 for both comparisons), these variables did not change in patients without iASD. In addition, patients with iASD had worse TR at follow-up. The incidence of stroke was comparable between the 2 groups during 1-year follow-up (4.3% vs 4.1%). However, patients with iASD had a markedly higher re-hospitalization rate for heart failure (26% vs 2.7%, p <0.05). In conclusion, iASD occurred in 24% of patients who underwent the MitraClip therapy and the presence of iASD was associated with right-sided heart enlargement, worse TR, and a higher re-hospitalization rate for heart failure.

Postprocedural Changes of Tricuspid Regurgitation After MitraClip Therapy for Mitral Regurgitation.

The effect of percutaneous mitral valve repair using the MitraClip system on tricuspid regurgitation (TR) has not been well investigated. We retrospectively analyzed 102 consecutive patients who underwent the successful MitraClip procedure, and who also had a preprocedural and 1-year follow-up transthoracic echocardiography. TR severity was graded by standard guideline-recommended criteria. At 1 year after the MitraClip procedure, the degree of TR regressed (at least 1 grade) in 23% of the patients, was unchanged in 62% of the patients, and progressed in 16% of the patients. Compared with patients in the other groups, the patients with TR regression had a greater severity of TR at baseline. The TR regression group showed a significant reduction in the systolic pulmonary artery pressure (sPAP) (49 ± 13 to 37 ± 11 mm Hg, p <0.05), a right-sided cardiac reverse remodeling (right ventricular diameter: 41 ± 7 to 39 ± 7 mm, tricuspid annular diameter: 48 ± 8 to 46 ± 9 mm, both p <0.05), and an increase in the right ventricular fractional area change (38 ± 7 to 40 ± 7%, p <0.05). In the multivariate analysis, the decrease in sPAP was the only independent parameter change associated with TR regression. In conclusion, TR regression was observed in 23% of the patients after the successful MitraClip procedures, and favorable echocardiographic parameter changes were detected in this group. Only a reduction in sPAP was independently associated with TR regression.

Endovascular Therapy for a Post-irradiated Cervical Pseudoaneurysm at the Carotid Stump: A Case Report.

A nearly 80-year-old man with a history of radiotherapy (RT) and total laryngectomy for laryngeal cancer 25 years previously presented with a rapidly growing mass on the right side of his neck. A huge pseudoaneurysm (pseudoAN) was detected at the right carotid bifurcation, though angiography performed four years previously had shown total occlusion of the internal carotid artery. Stent-assisted coil embolization enabled aneurysm sac shrinkage. Clinicians must be aware that the stump of an arterial occlusion associated with RT can change into a pseudoAN over the long term and must provide follow-up in such cases.

Intraoperative Mapping and Monitoring of the Pyramidal Tract Using Endoscopic Depth Electrodes.

OBJECTIVE: To evaluate motor function during neuroendoscopic resectioning of deep-seated brain tumors using endoscopically guided depth electrodes. METHODS: For 12 cases of thalamic tumors, including high-grade gliomas, germinomas, and malignant lymphomas, depth electrodes were inserted using endoscopic guides between the tumor and the pyramidal tract in the thalamus. Motor-evoked potentials (MEPs) were continuously recorded during neuroendoscopic resectioning of the tumors. RESULTS: Monitoring of MEP responses using depth electrodes in all 12 cases was successful. The minimum stimulus intensity threshold required to induce MEP responses was 3 mA. Gross total or subtotal resections were successful with this technique for all patients with glioma. No additional neurologic impairments were found after surgery in any of the cases. CONCLUSIONS: Continuous MEP measurement using depth electrodes can serve as a new monitoring technique for endoscopic resectioning of deep-seated brain tumors.

Mitral annular motion in patients after transcatheter MitraClip and mitral valve surgery.

BACKGROUND: Longitudinal motion of the mitral annulus is an index that reflects left ventricular (LV) function. The aim of this study was to evaluate and compare the effects of transcatheter mitral valve (MV) repair and open heart surgery for mitral regurgitation (MR) on mitral annular motion (MAM). METHODS: We retrospectively analyzed in total 115 patients who underwent isolated transcatheter MV repair using MitraClip (n=50) or surgical MV interventions (n=65, 50 repairs and 15 replacements) for MR. MAM was assessed by two-dimensional B-mode echocardiography in the four- and two-chamber views. MAM was measured before and within 1 month after the mitral procedure. RESULTS: Compared with patients undergoing MV surgery, patients undergoing the MitraClip procedure were older and had more comorbidities. MR grade improved significantly in both groups after MV intervention. MAM decreased significantly in the surgery group (12.0±3.1 to 8.1±2.2 mm, P<.01), whereas MAM did not change in the MitraClip group (8.8±2.6 to 8.6±2.5 mm, P=.59). In multivariate analysis, mitral surgery was associated with a decrease in MAM when compared to the MitraClip procedure. Furthermore, LV ejection fraction (EF) decreased to a greater degree in patients undergoing surgery than those undergoing MitraClip placement (MV surgery; -10.1±7.6% vs MitraClip; -3.0±10.5%, P<.01). CONCLUSIONS: MitraClip therapy does not adversely influence MAM and is associated with less postprocedural EF reduction compared to surgical intervention. Our results suggest that patients with reduced LV systolic function may benefit from the MitraClip procedure compared to mitral surgery.

[Bone Flap Resorption after Cranioplasty in Pediatric Patients:Report of 2 Cases].

Aseptic bone flap resorption, a rare complication after cranioplasty following decompressive craniectomy, is more likely to develop in children. We experienced two cases of aseptic bone flap resorption and identified potential pathophysiological mechanisms through histological findings. In the first case, an 11-year-old girl underwent decompressive craniectomy due to brain swelling with contusion. An autologous bone flap was cryopreserved for four months. Twenty-five months after cranioplasty with autologous bone flap, aseptic bone flap resorption was observed, and cranioplasty was performed with ceramic bone. Most of the histological findings in this case showed mature osseous tissue, while some showed osteoclasts and new bone formation due to endochondral ossification. In the second case, a 10-year-old girl underwent frontal craniectomy and removal of contusional hematoma. Fourteen months after cranioplasty with autologous bone flap, aseptic bone flap resorption was observed, and cranioplasty was performed with ceramic bone paste. The progression of bone flap resorption was not recognized for 12 months. In these cases, new bone formation was not necessarily linked to pathological bone flap resorption. It is supposed that the balance between bone destruction and new bone formation was disrupted by unknown factors.

[Pediatric Iatrogenic Vertebral Arteriovenous Fistula Successfully Treated with Endovascular Treatment:A Case Report].

OBJECT: We report a relatively rare case of pediatric iatrogenic extradural vertebral arteriovenous fistula. CASE: A five-year-old boy with a history of multiple surgeries for Total Anomalous Pulmonary Venous Return(TAPVR)exhibited vascular engorgement of his right neck from about 4 years old. We thought that this was caused by his past operations. He demonstrated swollen blood vessels in the right neck and pulmonary hypertension with increased right heart load. A right extradural vertebral arteriovenous fistula was seen on angiography. A high flow shunt was present at the V1 segment, at the level of the sixth cervical vertebra, and a 12 mm venous pouch was present anterior to the vertebral artery. We recognized the outlet passages of the cranial tract were the vertebral venous plexus, internal jugular vein, and right atrium. We performed endovascular transarterial embolization using a hydrogel coil. As a result, we treated with a high volume embolization ratio. Following treatment, the arteriovenous fistula disappeared while anterograde blood flow of the vertebral artery was preserved. The patient demonstrated no neurological deficits, improved right heart load, and his venous pouch of the neck. He has had no recurrence in the two years after treatment. CONCLUSION: Endovascular surgery is effective and safe for the treatment of iatrogenic vertebral arteriovenous fistula.

Eicosapentaenoic Acid combined with optimal statin therapy improves endothelial dysfunction in patients with coronary artery disease.

PURPOSE: Eicosapentaenoic acid (EPA) has been reported to augment endothelial function and improve clinical outcomes in patients with coronary artery disease (CAD). The purpose of this study was to determine whether EPA could improve residual endothelial dysfunction despite adequate lipid-lowering with statin in CAD patients. METHODS: Eighty patients with established CAD, who had been on statin treatment and had serum low-density lipoprotein cholesterol (LDL-C) levels <100 mg/dl, were randomly assigned to receive either 1,800 mg of EPA daily plus statin (EPA group, n = 40) or statin alone (Control group, n = 40). Lipid profiles and flow-mediated dilation (FMD) were assessed just before and after more than 3 months of treatment in both groups. Only patients who had impaired FMD (<6 %) before randomization were enrolled. RESULTS: After treatment for 5.2 ± 1.7 months, the EPA group showed a significant increase in the serum concentration of EPA and EPA to arachidonic acid (AA) (EPA/AA) ratio (62.5 ± 38.1 to 159.8 ± 53.8 µg/ml, 0.45 ± 0.34 to 1.20 ± 0.55, p < 0.01 for both). In the EPA group, serum triglycerides significantly decreased (150.7 ± 92.9 to 119.3 ± 60.7 mg/dl, p = 0.02), whereas no significant change was seen in the Control group. FMD, the primary study endpoint, showed a significant improvement in the EPA group (2.6 ± 1.6 % to 3.2 ± 1.6%, p = 0.02), whereas no significant change was observed in the Control group (2.7 ± 1.6% to 2.4 ± 1.7 %, p = 0.29). CONCLUSIONS: EPA improved endothelial function and impaired FMD in patients with established CAD who were on optimal statin therapy.

A case of posterior cerebral artery dissection presenting with migraine-like headache and visual field defect: usefulness of fast imaging employing steady-state acquisition (FIESTA) for diagnosis.

We report a 34-year-old woman with sudden onset of unilateral migraine-like headache and right homonymous hemianopsia. Fast imaging employing steady-state acquisition (FIESTA) of the posterior cerebral artery captured an intimal flap and a pseudolumen, leading to a diagnosis of posterior cerebral artery dissection. This case was considered a spontaneous posterior cerebral artery dissection causing migraine-like headache. The treatment of migraine-like headache hinges on correct diagnosis. In this case, FIESTA was very useful in diagnosing an intracranial artery dissection.

Incidence of intracranial arterial dissection in non-emergency outpatients complaining of headache: preliminary investigation with MRI/MRA examinations.

PURPOSE: Headache is recognized as one of the specific signs of intracranial arterial dissection (ICrAD). We clarified the incidence of ICrAD in non-emergency outpatients complaining of headache and the nature of headache observed in case of ICrAD. PATIENT POPULATION AND METHODS: Consecutive non-emergency outpatients coming to the neurological and neurosurgical departments and who underwent MRI and MRA examinations were included in this study. The diagnosis of ICrAD was made when patients met the following two conditions: (1) pearl-and-string sign, pearl sign, or string sign on MRA, and (2) high arterial wall signal on T1 images or intimal flap on T2 images. If possible, cerebral angiography and/or black blood MRI and/or surface-image MRI was also performed in cases meeting these criteria. RESULTS: (1) Headache group (172 patients): severe headache was seen in five patients and headache of sudden onset in three. Arterial dissection was diagnosed in eight patients (4.7%, including seven cases of asymptomatic vertebral dissection and one of basilar dissection). The headache noted in most cases of ICrAD was similar to that experienced in daily life. (2) Non-headache group (201 patients): complaints included vertigo/dizziness in 52 patients, gait disturbance in 28, weakness of the arm or leg in 20, and limb numbness in 18, syncope attack in 14, and others in 69. Arterial dissection was diagnosed in six patients (3.0%, including one case of asymptomatic basilar and two of vertebral artery dissection, symptomatic two vertebral and one basilar dissection). CONCLUSION: We obtained no evidence of significant difference in the incidence of ICrAD in non-emergency outpatients with (4.7%) and without headache (3.0%). The nature of the headache in the cases of ICrAD was similar to that experienced in daily life. ICrAD with nonspecific headache is more common than previously thought.

Therapeutic benefits of angiogenetic gene-modified human mesenchymal stem cells after cerebral ischemia.

Intravenous transplantation of human mesenchymal stem cells (hMSCs) expanded from adult bone marrow ameliorates functional deficits in rat cerebral infarction models. Several hypotheses to account for the therapeutic mechanisms have been suggested, but angiogenesis is thought to be of critical importance. Recently, we have reported the therapeutic benefits of hMSCs which have been transfected with the angiopoietin-1 gene in a rat permanent middle cerebral artery occlusion (MCAO) model. To potentially enhance the therapeutic effects of angiopoietin-1 gene-modified hMSC (Ang-hMSC), we transfected hMSCs with the angiopoietin-1 gene and the VEGF gene, and investigated whether the combination of Ang-1 and VEGF gene-modified hMSCs (Ang-VEGF-hMSC) contribute to functional recovery in a rat MCAO model. We induced MCAO using intraluminal vascular occlusion, and hMSCs, Ang-hMSCs, VEGF-hMSCs or Ang-VEGF-hMSCs were intravenously infused 6 h later. MRI and behavioral analyses revealed that rats receiving Ang-VEGF-hMSCs showed the greatest structural-functional recovery as compared to the other groups. These results suggest that intravenous administration of hMSCs transfected with the angiopoietin-1 and VEGF gene using a fiber-mutant adenovirus vector may represent a new strategy for the treatment of ischemia.

Accuracy of three-dimensional echocardiography in patients with prior anteroseptal myocardial infarction.

BACKGROUND: Echocardiography is the most feasible modality for monitoring cardiac volume and function. However, conventional two-dimensional echocardiography (2DE) is frequently not accurate in measuring cardiac performance in cases of abnormal left ventricular wall motion, because of the geometric assumptions. Quantitative gated scintigraphy and magnetic resonance imaging are reliable modalities, but are expensive and not feasible for repetitive use. Real-time three-dimensional echocardiography (RT3DE) has been proved to be applicable in daily practice. The purpose of this study was to confirm the superiority of RT3DE to 2DE in assessing cardiac volume and function in patients with abnormal wall motion. METHODS: The subjects were 41 patients with old anteroseptal myocardial infarction who underwent left ventricular volume and functional measurement by RT3DE, 2DE, and left ventriculography (LVG). End-diastolic volume (EDV), end-systolic volume (ESV), and ejection fraction (EF) from RT3DE and 2DE were measured and compared with results from LVG. RESULTS: RT3DE correlated well with LVG in measurements of EDV, ESV, and EF (r = 0.815, 0.940, and 0.812, respectively; P < 0.001 each). Likewise, 2DE correlated with LVG, but underestimated left ventricular volume, particularly EDV (r = 0.652, 0.909, and 0.761, respectively; P < 0.001 each). CONCLUSION: Values derived from RT3DE were closer to those from LVG than were values derived from 2DE. RT3DE provides important information on cardiac function in patients with prior anteroseptal myocardial infarction.

Effect of angiotensin converting enzyme inhibitors and beta-blockers on left ventricular remodeling after coronary artery bypass graft surgery.

Preventing left ventricular (LV) remodeling after coronary artery bypass graft surgery (CABG) is important to avoid long-term congestive heart failure. The present study evaluated the effects of angiotensin converting enzyme inhibitors (ACEIs) and beta-blockers on LV remodeling. Twenty-three patients with angina pectoris and 36 with old myocardial infarction underwent CABG. We assessed end diastolic volume index (EDVI), end systolic volume index (ESVI), and ejection fraction (EF) using left ventriculography before and after CABG. Changes in EDVI, ESVI, and EF were studied in the ACEI, beta-blocker, and control groups. Although EDVI was reduced in the ACEI group, ESVI and EF improved only slightly, whereas in the group given beta-blockers, ESVI was reduced, EF improved, and EDVI was minimally reduced. These results indicate that ACEIs and beta-blockers both protect against LV remodeling, although through different mechanisms.

Dot-like hemosiderin deposition on T2*-weighted MR imaging associated with nonhypertensive intracerebral hemorrhage.

BACKGROUND AND PURPOSE: Microangiopathy, a disorder often related to hypertension, is an important cause of deep intracerebral hematoma (ICH). The microangiopathy is associated with dot-like low-intensity spots (a dot-like hemosiderin spot: dotHS) on gradient-echo T2*-weighted MR images that have been histologically diagnosed as old microbleeds. The locations of dotHS are consistent with deep ICH. METHODS: To investigate how dotHS or other risk factors contribute to nonhypertensive deep ICH, the number and location of dotHSs, as well as other risk factors were examined in 213 deep ICH patients (106 males, 107 females, age: 37-94 (65.8 +/- 11.2) years) consecutively admitted to Hakodate Municipal Hospital. Patients were divided into two subgroups according to the presence or absence of hypertension. DotHSs were also divided into deep and subcortical dotHS and investigated independently. Odds ratios (ORs) were estimated from logistic regression analyses. Furthermore, nonhypertensive ICH patients were compared with nonhypertensive healthy volunteers matched for age and sex. RESULTS: No risk factors were identified in the 31 nonhypertensive deep ICH patients that differed from those found in the 182 hypertensive deep ICH patients. Deep dotHS > or = 1 (OR: 25.5; 95% CI: 4.76-137; P = .0002), subcortical dotHS > or = 1 (OR: 9.0; 95% CI: 1.79-44.9; P = .046), diabetes mellitus (OR: 9.0; 95% CI: 1.53-52.3; P = .015), and smoking (OR, 9.6; 95% CI; 1.8-49.8, P = .007) significantly elevated the risk of nonhypertensive ICH, compared to the healthy volunteers. CONCLUSIONS: Our findings suggest that deep and subcortical dotHSs may be risk factors for the development of non-hypertensive deep ICH.

[Study on hemosiderin deposition after intracerebral hemorrhage].

BACKGROUND AND PURPOSE: Hemosiderin degenerated from intracerebral hematoma (ICH) can be visualized as low intensity on gradient-echo T2*-weighted (T2*-w) MRI, which is sensitive for hemosiderin. We studied the factors associated with the hemosiderin deposition on T2*-w MRI after ICH. METHODS: We analyzed T2*-w MRIs in 72 outpatients with past ICH (46 males, 26 females, 28-89 (60.0 +/- 9.8) years old) consecutively came to our hospital. The odds ratio (OR) for the apparent thickness > or = 2.5 mm of low intensity surrounding ICH cavity was estimated, using the time after the onset of ICH (17 weeks - 26 years), and other factors. RESULTS: All of old ICHs were visible as low intensities on T2*-w MRI. Multivariate logistic regression analysis revealed that an elevated ratio of the apparent thickness > or = 2.5 mm of hemosiderin was found for the patients with time > or =5 years between T2*-w MRI and the onset (odds ratio (OR): 0.24, 95% confidence interval (CI): 0.06-0.99), intraventricular or subarachnoid hemorrhage related to ICH (OR: 0.16, 95% CI: 0.03-0.77), and the diameter of ICH > or =2 cm (OR: 33.7, 95% CI: 4.6-245). CONCLUSION: Though small sample size limited the power of analyses, our findings suggest that the amount of hemosiderin deposition after ICH may be associated with the time after the onset, intraventricular or subarachnoid hemorrhage related to ICH, and the diameter of ICH.

[Chiari malformation (type 1) with regeneration of removed C1 lamina after foramen magnum decompression: a case report].

We present the case of a 20-year-old female who underwent foramen magnum decompression and laminectomy of C1-C3 as well as incision of only the outer layer of the dura, for her symptomatic Chiari malformation (type 1) with syringomyelia, at the age of 9 years. She required additional surgery with removal of regenerated bone and dural plasty for the remaining and recurrent stenosis. The remaining stenosis may have been caused by the use of a technique without dural plasty and insufficient decompression of the bony structure. Further, the regeneration of C1 lamina could have been responsible for the recurrent stenosis. Her symptoms, which included gait disturbance, hypesthesia, excessive sweating, and nocturnal enuresis, manifested themselves when she was at the age of 2 years and progressed since that time. These symptoms didn't improve after the first surgery. However, after the second surgery, the gait disturbance and nocturnal enuresis were partially resolved. It is rare for new bone generation to necessitate reoperation. However, it should be noticed that careful follow-up is important after decompressive surgery for Chiari malformation in young patients.

Region filling and object removal by exemplar-based image inpainting.

A new algorithm is proposed for removing large objects from digital images. The challenge is to fill in the hole that is left behind in a visually plausible way. In the past, this problem has been addressed by two classes of algorithms: 1) "texture synthesis" algorithms for generating large image regions from sample textures and 2) "inpainting" techniques for filling in small image gaps. The former has been demonstrated for "textures"--repeating two-dimensional patterns with some stochasticity; the latter focus on linear "structures" which can be thought of as one-dimensional patterns, such as lines and object contours. This paper presents a novel and efficient algorithm that combines the advantages of these two approaches. We first note that exemplar-based texture synthesis contains the essential process required to replicate both texture and structure; the success of structure propagation, however, is highly dependent on the order in which the filling proceeds. We propose a best-first algorithm in which the confidence in the synthesized pixel values is propagated in a manner similar to the propagation of information in inpainting. The actual color values are computed using exemplar-based synthesis. In this paper, the simultaneous propagation of texture and structure information is achieved by a single, efficient algorithm. Computational efficiency is achieved by a block-based sampling process. A number of examples on real and synthetic images demonstrate the effectiveness of our algorithm in removing large occluding objects, as well as thin scratches. Robustness with respect to the shape of the manually selected target region is also demonstrated. Our results compare favorably to those obtained by existing techniques.