Cortical Distribution of Fragile Periventricular Anastomotic Collateral Vessels in Moyamoya Disease: An Exploratory Cross-Sectional Study of Japanese Patients with Moyamoya Disease

BACKGROUND AND PURPOSE:Collateral vessels in Moyamoya disease represent potential sources of bleeding. To test whether these cortical distributions vary among subtypes, we investigated cortical terminations using both standardized MR imaging and MRA.MATERIALS AND METHODS:Patients with Moyamoya disease who underwent MR imaging with MRA in our institution were enrolled in this study. MRA was spatially normalized to the Montreal Neurological Institute space; then, collateral vessels were measured on MRA and classified into 3 types of anastomosis according to the parent artery: lenticulostriate, thalamic, and choroidal. We also obtained the coordinates of collateral vessel outflow to the cortex. Differences in cortical terminations were compared among the 3 types of anastomosis.RESULTS:We investigated 219 patients with Moyamoya disease, and a total of 190 collateral vessels (lenticulostriate anastomosis, n = 72; thalamic anastomosis, n = 21; choroidal anastomosis, n = 97) in 46 patients met the inclusion criteria. We classified the distribution patterns of collateral anastomosis as follows: lenticulostriate collaterals outflowing anteriorly (P < .001; 95% CI, 67.0–87.0) and medially (P < .001; 95% CI, 11.0–24.0) more frequently than choroidal collaterals; lenticulostriate collaterals outflowing anteriorly more frequently than thalamic collaterals (P < .001; 95% CI, 34.0–68.0); and choroidal collaterals outflowing posteriorly more frequently than thalamic collaterals (P < .001; 95% CI, 14.0–34.0). Lenticulostriate anastomoses outflowed to the superior or inferior frontal sulcus and interhemispheric fissure. Thalamic anastomoses outflowed to the insular cortex and cortex around the central sulcus. Choroidal anastomoses outflowed to the cortex posterior to the central sulcus and the insular cortex.CONCLUSIONS:Cortical distribution patterns appear to differ markedly among the 3 types of collaterals.

Collateral vessels in Moyamoya disease develop as the disease progresses.¹ Lenticulostriate arteries (LSAs), perforators from the posterior communicating artery (PcomA), and anterior and posterior choroidal arteries (choAs) are representative collateral vessels that supply the cortex.^2-4 Development of such collateral vessels represents a risk factor for intracerebral hemorrhage,^3,5-7 and these vessels have frequently been considered as the vessels responsible for bleeding in recent reports.^8-10 These collateral vessels connect with medullary arteries near the lateral ventricle and thus supply the cortex via the medullary arteries.^3,4 However, no reports have addressed the cortical distributions of these collateral vessels.Bypass surgery reduces the risk of rebleeding in patients with hemorrhagic onset of Moyamoya disease^7,11-13 and also shrinks collateral vessels in Moyamoya disease.^7,12,14,15 Augmentation of cerebral blood flow via bypass seems to decrease the necessity for development of collateral flow and shrinks existing collaterals.¹⁵ To shrink risky collateral vessels effectively and prevent hemorrhage, well-designed and planned bypass surgeries may be required.¹⁶ Comprehension of the nature and cortical distribution of collateral vessels may thus be clinically useful.MRA performed using a 3T scanner has proved useful for detecting the abnormally extended collateral vessels in Moyamoya disease.² We investigated the cortical distribution of collateral vessels using 3T MR imaging and MRA to clarify whether cortical distributions vary among anastomotic subtypes and to better understand collateral networks.     

Comparison of completed and attempted suicide in Akita, Japan

To determine the factors underlying suicide in Akita prefecture, a questionnaire survey was conducted among members of the Akita Prefectural Medical Association (APMA), regarding suicide cases they attended. During the investigation period (1 July 2001-30 June 2002), the total number of suicide cases was 243 (138 completed, 105 attempted). Significant differences were identified between completed and attempted suicide groups in terms of gender, age distribution, and suicidal methods. Specifically, in the completed suicide group, the number of male completers exceeded that of female completers, the number of middle-aged or elderly completers was high, and the majority of completed suicide cases involved hanging as the suicide method. Conversely, in the attempted suicide group, the number of female attempters exceeded that of male attempters, younger attempters were frequent, hanging was rare, and drug overdose or cutting was common. In addition, the number of cases involving a history of previous suicide attempts was significantly higher in the attempted suicide group than in the completed suicide group. The results of the present study support the concept that the completed and attempted suicide groups are essentially of a different nature. Furthermore, the number of cases involving a history of previous suicide attempts was found to be significantly lower in the completed suicide group than in the attempted suicide group. This result indicates the difficulty in decreasing the number of completed suicides by simply providing intervention and care for individuals who have attempted suicide.     

Association between Angiotensin-Converting Enzyme Inhibitors and Post-Stroke Aspiration Pneumonia

Background: Previous small studies conducted around 2000 suggested an association between the use of angiotensin-converting enzyme inhibitors (ACEIs) and a reduction in post-stroke aspiration pneumonia (AP) in Japan. However, it is unclear whether receiving ACEIs can reduce post-stroke AP in the current clinical environment, where stroke management has been improved. This study aimed to re-evaluate the preventive effect of ACEIs on post-stroke AP, compared with that of angiotensin II receptor blockers (ARBs). Methods: Using the Japanese Diagnosis Procedure Combination database, we identified patients who were hospitalized for stroke and developed AP during hospitalization from July 2010 to December 2016. After applying the exclusion criteria, we performed 1:1 propensity score matching between patients receiving ACEIs and those receiving ARBs after discharge. The outcomes were 14-day, 30-day, and 90-day readmission for post-stroke AP among patients with stroke who had AP during their initial hospitalization. Cox regression was performed to analyze these readmissions. Results: In total, 35,586 eligible patients were identified. Of these patients, 5846 (16%) received ACEIs. Propensity score matching created 5789 pairs. No significant difference was seen in 14-day readmission (0.7% versus 0.8%), 30-day readmission (1.3% versus 1.3%), or 90-day readmission (2.4% versus 2.6%) between the ARB and ACEI groups. The hazard ratio of the ACEI group compared with the ARB group was not significant (1.21; 95% confidence interval: 0.98-1.48). Conclusions: In this retrospective nationwide study, ACEIs could not be concluded to have a preventive effect on post-stroke AP in the current clinical environment.     

Isolated cortical tuber in an infant with genetically confirmed tuberous sclerosis complex 1 presenting with symptomatic West syndrome

Tuberous sclerosis complex (TSC) is an autosomal dominant hereditary disorder caused by mutations in either TSC1 on chromosome 16 or TSC2 on chromosome 9, clinically characterized mainly by facial angiofibroma, epilepsy, and intellectual disability. Cortical dysplasias, subependymal nodules, and subependymal giant cell astrocytoma are characteristic central nervous system lesions among 11 major features in the current clinical diagnostic criteria for TSC. We encountered an unusual case of genetically confirmed TSC1 presenting with symptomatic West syndrome due to an isolated cortical dysplasia in the left occipital lobe of a six‐month‐old male infant who did not meet the clinical diagnostic criteria for TSC. The patient underwent left occipital lesionectomy at age 11 months and has been seizure‐free for nearly six years since then. Histological examination of the resection specimen revealed cortical neuronal dyslamination with abundant dysmorphic neurons and ballooned cells, consistent with focal cortical dysplasia (FCD) type IIb. However, the lesion was also accompanied by unusual features, including marked calcifications, dense fibrillary gliosis containing abundant Rosenthal fibers, CD34‐positive glial cells with abundant long processes confined to the dysplastic cortex, and multiple nodular lesions occupying the underlying white matter, consisting exclusively of ballooned cell and/or balloon‐like astrocytes with focal calcifications. Genetic testing for TSC1 and TSC2 using the patient's peripheral blood revealed a germline heterozygous mutation in exon 7 (NM_000368.5: c.526dupT, p.Tyr176fs) in TSC1. Isolated FCD with unusual features such as calcification, dense fibrillary gliosis, Rosenthal fibers and/or subependymal nodule‐like lesions in the white matter may indicate the possibility of a cortical tuber even without a clinical diagnosis of TSC. Identification of such histopathological findings has significant implications for early and accurate diagnosis and treatment of TSC, and is likely to serve as an important supplementary feature for the current clinical diagnostic criteria for TSC.     

Do scalp-recorded slow potentials during neuro-feedback training reflect the cortical activity?

Objective

Neuro-feedback (NFB) training by the self-regulation of slow potentials (SPs) <0.5?Hz recorded from the vertex scalp has been applied for seizure suppression in patients with epilepsy. However, SP is highly susceptible to artifact contamination, such as the galvanic skin response (GSR). This study aimed to evaluate the correlation between SPs recorded from the scalp and intracranial electroencephalography (EEG) by event-related coherence analysis.

Intraoperative dorsal language network mapping by using single‐pulse electrical stimulation

The preservation of language function during brain surgery still poses a challenge. No intraoperative methods have been established to monitor the language network reliably. We aimed to establish intraoperative language network monitoring by means of cortico‐cortical evoked potentials (CCEPs). Subjects were six patients with tumors located close to the arcuate fasciculus (AF) in the language‐dominant left hemisphere. Under general anesthesia, the anterior perisylvian language area (AL) was first defined by the CCEP connectivity patterns between the ventrolateral frontal and temporoparietal area, and also by presurgical neuroimaging findings. We then monitored the integrity of the language network by stimulating AL and by recording CCEPs from the posterior perisylvian language area (PL) consecutively during both general anesthesia and awake condition. High‐frequency electrical stimulation (ES) performed during awake craniotomy confirmed language function at AL in all six patients. Despite an amplitude decline (≤32%) in two patients, CCEP monitoring successfully prevented persistent language impairment. After tumor removal, single‐pulse ES was applied to the white matter tract beneath the floor of the removal cavity in five patients, in order to trace its connections into the language cortices. In three patients in whom high‐frequency ES of the white matter produced naming impairment, this “eloquent” subcortical site directly connected AL and PL, judging from the latencies and distributions of cortico‐ and subcortico‐cortical evoked potentials. In conclusion, this study provided the direct evidence that AL, PL, and AF constitute the dorsal language network. Intraoperative CCEP monitoring is clinically useful for evaluating the integrity of the language network. Hum Brain Mapp 35:4345–4361, 2014. © 2014 Wiley Periodicals, Inc .     

Prevalence of Depressive Symptoms and Related Factors in Japanese Employees as Measured by the Center for Epidemiologic Studies Depression Scale (CES-D)

This study aimed to examine the prevalence of depressive symptoms and related factors in Japan. For this purpose, a questionnaire including the Center for Epidemiologic Studies Depression Scale (CES-D) was administered to employees from Akita prefecture, Japan. The cutoff point for CES-D scores was 16 or above (high scorers). We analyzed the results of this survey in order to identify relationships between the prevalence of high scores on the CES-D, sociodemographic status, and employment-related variables. In total, 2,220 employees—of whom 1,069 were men and 1,151, women—satisfactorily responded, and their responses indicated that 45.0 % (41.4 % for men, 48.2 % for women) had high scores on the CES-D. The identified sociodemographic and occupation-related factors from the binomial multivariate logistic regression for high scorers were as follows: a high risk of depression was associated with being women, short and/or long sleep durations, the occasional consumption of alcohol in men, and professional work and over 8 h of work per day in women. Older age groups and non-smoking women were associated with a lower risk. These results can be used in the future as CES-D benchmark values, and might be useful in predicting the occurrence of depressive disorders.     

Fluid control in elderly patients with nocturia

Objectives:   To investigate the pathophysiology of nocturnal polyuria associated with aging.
Methods:   Fifty patients (mean age 67.7 years, range 50–87) with nocturia were recruited for this prospective study. Patients were classified into nocturnal polyuria (NP) and non-nocturnal polyuria (non-NP) groups based on records of their frequency-volume charts. A hypertonic saline infusion test was carried out to evaluate individual osmotic and volume control.
Results:   In the NP group, there was a significantly increased nocturnal diuretic rate compared with the daytime diuretic rate. In the non-NP group, there was a significantly decreased nocturnal diuretic rate compared with the daytime rate. There was also a positive correlation between systolic blood pressure and nocturnal diuretic rate, and a negative correlation between systolic blood pressure and daytime diuretic rate in those with NP, but no correlation in those without NP. Thus, a close relationship between diuretic rates and systolic blood pressure was seen in NP patients. Moreover, a slight overall shift upward from the physiological range of plasma osmolality relative to arginine vasopressin after hypertonic saline loading was seen in those with NP compared with those without. An altered circadian rhythm was also seen in diurnal plasma arginine vasopressin levels in patients with and without NP.
Conclusions:   Patients with nocturnal polyuria are likely to have a more hypervolemic or vasoconstrictive condition. It is considered that non-osmotic control takes on a greater meaning in patients with nocturnal polyuria, though osmotic control contributes less to diuresis within the physiological plasma osmolality range with aging.