Combining Laminoplasty With Artificial Disc Replacement for the Treatment of Cervical Spondylotic Myelopathy With Congenital Cervical Stenosis.

BACKGROUND: Cervical spondylotic myelopathy (CSM) is a very common and devastating spinal disease. Congenital cervical stenosis (CCS) is the most common cause. We aimed to elucidate the security, effectivity, and feasibility of surgery combining laminoplasty with artificial disc replacement (ADR) to treat CSM patients with radiculopathy, especially for preserving the range of motion (ROM) of the cervical spine. METHOD: Between August 2008 and April 2019, 39 patients with multiple CSM caused by CCS were enrolled in the present study. All patients received laminoplasty first and then ADR. We used a retrospective collection of data for evaluating the functional and radiologic outcomes, especially regarding preservation of ROM. RESULTS: Each patient underwent at least a 2-year postoperative follow-up. The Japanese Orthopedic Association score showed great improvements at 6 months. The ADR index-level ROM was preserved during follow-up. The subaxial Cobb angle could also be retained in the whole cervical spine, and the spinal canal diameter could be expanded by more than 52.6%. There were no severe complications or side effects, and no patients needed secondary surgery. CONCLUSIONS: We aimed to treat multiple levels of CSM with adequate decompression without too many intervertebral disc replacements. We were able to expand the spinal canal directly for these patients with CCS and needed only 1- or 2-level ADR to treat them with associated radiculopathy. This combined surgical strategy was secure, effective, and was able to preserve the ROM of the cervical spine.

Mangiferin depresses vesicular glutamate release in synaptosomes from the rat cerebral cortex by decreasing synapsin I phosphorylation.

Mangiferin is a glucosyl xanthone that has been shown to be a neuroprotective agent against brain disorders involving excess glutamate. However, the effect of mangiferin on the function of the glutamatergic system has not been investigated. In this study, we used synaptosomes from the rat cerebral cortex to investigate the effect of mangiferin on glutamate release and identify the possible underlying mechanism. We observed that mangiferin produced a concentration-dependent reduction in the release of glutamate elicited by 4-aminopyridine with an IC50 value of 25 µM. Inhibition of glutamate release was blocked by removing extracellular calcium and by treatment with the vacuolar-type H+-ATPase inhibitor bafilomycin A1, which prevents the uptake and storage of glutamate in vesicles. Moreover, we showed that mangiferin decreased the 4-aminopyridine-elicited FM1-43 release and synaptotagmin 1 luminal domain antibody (syt1-L ab) uptake from synaptosomes, which correlated with decreased synaptic vesicle exocytosis. Transmission electron microscopy in synaptosomes also showed that mangiferin attenuated the 4-aminopyridine-elicited decrease in the number of synaptic vesicles. In addition, antagonism of Ca2+/calmodulin-dependent kinase II (CaMKII) and protein kinase A (PKA) counteracted mangiferin's effect on glutamate release. Mangiferin also decreased the phosphorylation of CaMKII, PKA, and synapsin I elicited by 4-aminopyridine treatment. Our data suggest that mangiferin reduces PKA and CaMKII activation and synapsin I phosphorylation, which could decrease synaptic vesicle availability and lead to a subsequent reduction in vesicular glutamate release from synaptosomes.

TCD, a triterpenoid isolated from wild bitter gourd, reduces synaptosomal release of glutamate and protects against kainic acid-induced neuronal death.

3ß,7ß,25-Trihydroxycucurbita-5,23(E)-dien-19-al (TCD) is a triterpenoid isolated from wild bitter gourd that is a common tropical vegetable with neuroprotective effects. Because excessive glutamate release is a major cause of neuronal damage in various neurological disorders, the aims of this study were to examine the effect of TCD on glutamate release in vitro and to examine the effect of TCD in vivo. In rat cerebrocortical synaptosomes, TCD reduced 4-aminopyridine (4-AP)-stimulated glutamate release and Ca2+ concentration elevation, but had no effect on plasma membrane potential. TCD-mediated inhibition of 4-AP-induced glutamate release was dependent on the presence of extracellular calcium; persisted in the presence of the glutamate transporter inhibitor dl-TBOA, P/Q-type Ca2+ channel blocker ω-agatoxin IVA, and intracellular Ca2+-releasing inhibitors dantrolene and CGP37157; and was blocked by the vesicular transporter inhibitor bafilomycin A1 and the N-type Ca2+ channel blocker ω-conotoxin GVIA. Molecular docking studies have demonstrated that TCD binds to N-type Ca2+ channels. TCD-mediated inhibition of 4-AP-induced glutamate release was abolished by the Ca2+-dependent protein kinase C (PKC) inhibitor Go6976, but was unaffected by the Ca2+-independent PKC inhibitor rottlerin. Furthermore, TCD considerably reduced the phosphorylation of PKC, PKCα, and myristoylated alanine-rich C kinase substrate, a major presynaptic substrate for PKC. In a rat model of kainic acid (KA)-induced excitotoxicity, TCD pretreatment substantially attenuated KA-induced neuronal death in the CA3 hippocampal region. These results suggest that TCD inhibits synaptosomal glutamate release by suppressing N-type Ca2+ channels and PKC activity and exerts protective effects against KA-induced excitotoxicity in vivo.

Transfemoral Approach for Intraoperative Angiography in the Prone or Three-quarter Prone Position : A Revisited Protocol for Intracranial Arteriovenous Malformation and Fistula Surgery.

PURPOSE: Among the different arterial accesses, the femoral access is the main approach for intraoperative angiography (IOA) performed in a prone position. Without a standardized protocol, however, the application of prone IOAs in intracranial arteriovenous malformation (AVM) or arteriovenous fistula (AVF) surgery remains limited by its procedural complexity. This study describes the detailed protocol for prone IOA through a transfemoral approach and highlights several refinements in preparing this procedure. METHODS: This study retrospectively reviewed the intracranial or high cervical AVM/AVF surgical cases in which both resection and IOA were performed in the prone or three-quarter prone position. Extended femoral sheath approaches and radiolucent head clamps were used in all cases. An aneurysm clip, serving as a localization landmark in IOA, was routinely placed within the surgical field. The IOA imaging, clinical impact of IOA, and complications related to the procedure were recorded. RESULTS: A total of six AVM and three AVF cases, operated on in the prone (n = 7) or three-quarter prone (n = 2) positions, were included. Multiple vessel injections were required in 66.7% of cases, and IOA was successfully performed in every intended vessel. All IOA images were adequate for interpretation, except for two cases in which the non-radiolucent component of the head clamp obscured the region of interest in the lateral views. Incomplete occlusion was identified in two patients, and the aneurysm clip provided precise guidance in localizing the residual nidus. Final IOA confirmed complete lesion removal in all cases, and there were no IOA-related complications. CONCLUSION: Three key steps in setting-up a prone IOA procedure for intracranial AVM/AVF surgery are proposed: (1) utilize an extended femoral sheath approach, (2) establish a localization landmark with an aneurysm clip and (3) avoid possible image interference from the non-radiolucent component of the head clamp.

Impact of Intraoperative 3-Dimensional Volume-Rendering Rotational Angiography on Clip Repositioning Rates in Aneurysmal Surgery.

OBJECTIVE: Three-dimensional (3D) rotational angiography (RA), a gold standard imaging tool for the evaluation of cerebral aneurysms after clipping, can currently be performed intraoperatively in a hybrid operating room (OR). However, its role in intraoperative aneurysmal surgery is unclear. We aimed to study the value of intraoperative 2-dimensional digital subtraction angiography (2D-DSA) and 3D-RA for the evaluation of aneurysms after clipping, in terms of clip repositioning. METHODS: We included patients with cerebral aneurysms who were treated with microsurgical clipping in a hybrid OR. After aneurysmal clipping and indocyanine green video angiography assessment, intraoperative 2D-DSA and 3D-RA with volume-rendering (VR) images of the clipped aneurysm were obtained. The incidence rate of clip repositioning was determined, and aneurysm-related factors associated with suboptimal clipping that required clip revision after intraoperative angiography evaluation were analyzed. RESULTS: Between September 2016 and August 2017, 24 consecutive patients with 35 aneurysms were treated with microsurgical clipping. A clip repositioning rate of 17.1% was revealed after intraoperative 3D-VR imaging and initial indocyanine green-video angiography. 3D-VR was able to demonstrate all aneurysmal remnants, whereas 2D-DSA helped confirm flow stagnation in compromised vessels. Challenging aneurysms of size >7 mm (P = 0.043) and neck width >4 mm (P = 0.012) were significantly associated with a higher incidence of suboptimal aneurysmal clipping. CONCLUSIONS: A hybrid OR, with angiography facilities for high-resolution 2D-DSA and 3D-VR images, allows neurosurgeons to perform high-quality surgery. The routine use of intraoperative 3D-RA may not be necessary; however, it is invaluable for treating challenging aneurysms.

Rendering a ruptured arteriovenous malformation more susceptible to spontaneous obliteration as a possible treatment strategy for cerebral AVM.

Spontaneous regression of cerebral arteriovenous malformation (AVM) is a rare phenomenon, but its occurrence is an important consideration in treatment planning. A 58-year-old male was found to have a high-flow AVM of Spetzler-Martin Grade III. Before his scheduled treatment, the AVM ruptured with a large parenchymal hemorrhage. Following emergency decompressive surgery, a targeted embolization procedure was performed to obliterate the ruptured weak point and to reduce the shunting flow. The residual AVM became a malformation harboring angio-architectural factors favoring spontaneous obliteration. Together with other favorable clinical factors, including prior parenchymal hemorrhage and neurosurgical intervention, the residual AVM spontaneously regressed in 2 months. This case highlighted a possible treatment strategy in that, for a ruptured AVM in which definite treatment is not possible, an alternative is to treat the AVM into a situation in which as many favorable factors as possible for spontaneous AVM regression are present.

Accurate Localization of Aneurysm Neck Margins in Clipping of a Carotid Cave Aneurysm Using Intraoperative Dual-Volume 3-Dimensional Volume-Rendering Rotational Angiography.

BACKGROUND: Full visualization of the aneurysm neck is usually impossible in a classical pterional craniotomy when a paraclinoid aneurysm is located on the opposite side of the internal carotid artery. Optic nerve (ON) retraction is required for better aneurysmal exposure, but ON injuries may occur. CLINICAL DESCRIPTION: In a case of a 70-year-old female harboring a carotid cave aneurysm, we introduced a new method to delineate better the margins of the aneurysm neck by using intraoperative 3-dimensional (3D) rotational angiography (RA) with dual-volume reconstruction. After complete exposure of the aneurysm, we placed a straight clip adjacent to the aneurysm for localization purposes and performed 3D-RA to locate the distal end of the aneurysm neck relative to the localization clip. With a better anatomic understanding of the neck position, we were able to reduce ON retraction and position the clip across the aneurysm neck more precisely. CONCLUSIONS: With the advantage of a hybrid operating room, we introduced a novel technique to define the margins of the obscured aneurysm neck more clearly by obtaining a 3D-RA dual-volume reconstruction image to locate the aneurysm neck relative to a localization clip. This technique facilitates the clipping procedure and also reduces the risk related to ON retraction during surgical exposure of a paraclinoid aneurysm.

Chronic subdural hematoma: Differences between unilateral and bilateral occurrence.

Chronic subdural hematoma (CSDH) is one of the most common neurological diseases. However, bilateral CSDH is more infrequent than unilateral CSDH, and the clinical and radiological characteristics are not well-defined. We aimed to investigate the clinical and radiological differences between bilateral and unilateral CSDH. A retrospective study was performed on 75 surgically-treated CSDH patients from January 2011 to December 2015. These patients were divided into unilateral and bilateral CSDH groups. The clinical features, radiological findings, surgical outcome, occurrence of postoperative intracranial bleeding, and recurrence were analyzed. 30.7% of patients had bilateral CSDH. The mean age was 79years and 68.8years for the bilateral and unilateral CSDH patients, respectively (p=0.001). The presence of a history of alcohol abuse was 8.7% and 32.7% in the bilateral and unilateral CSDH patients, respectively (p=0.028). The patients with bilateral CSDH were more likely to present with nausea or vomiting (p=0.048). A lesser degree of midline shift on computed tomographic (CT) scan was also observed in the bilateral group (p=0.001). Most patients had a favorable postoperative outcome, even with bilateral CSDH. In this study, we found that the patients with bilateral CSDH were older, had a lower prevalence of a history of alcohol abuse, presented more commonly with nausea or vomiting, and had a lesser degree of midline shift on CT. Burr-hole craniostomy with a closed-drainage system is a feasible and effective surgical technique for the treatment of unilateral or bilateral CSDH.

Regression of moyamoya-associated weak spots on the distal anterior choroidal artery following surgical revascularization.

A 20-year-old female with moyamoya disease presented with acute intraventricular hemorrhage. Cerebral angiography demonstrated that the anterior choroidal artery (AChA) was responsible for the bleeding, but the precise point of rupture was unpredictable, because multiple angiographic weak spots were found on the artery. As direct targeting of the rupture point was unfeasible, we performed encephalo-duro-arterio-synangiosis to decrease the hemodynamic overload on the AChA. This revascularization procedure alone successfully induced the regression of all weak points. In this report, we demonstrated that, when direct targeting of weak points was not feasible, a revascularization procedure was an acceptable alternative.