Development and Validation of Scoring Indication of Surgical Clipping and Endovascular Coiling for Aneurysmal Subarachnoid Hemorrhage from the Post Hoc Analysis of Japan Stroke Data Bank

There are no scoring methods for optimal treatment of patients with aneurysmal subarachnoid hemorrhage (aSAH). We developed a scoring model to predict clinical outcomes according to aSAH risk factors using data from the Japan Stroke Data Bank (JSDB). Of 5344 patients initially registered in the JSDB, 3547 met the inclusion criteria. Patients had been diagnosed with aSAH and treated with surgical clipping or endovascular coiling between 1998 and 2013. We performed multivariate logistic regression for poor outcomes at discharge, indicated by a modified Rankin Scale (mRS) score >2, and in-hospital mortality for both treatment methods. Based on each risk factor, we developed a scoring model assessing its validity using another dataset of our institution. In the surgical clipping group, scoring criteria for aSAH were age >72 years, history of more than once stroke, World Federation of Neurological Societies (WFNS) grades II–V, aneurysmal size >15 mm, and vertebrobasilar artery (VBA) aneurysm location. In the endovascular coiling group, scoring criteria were age >80 years, history of stroke, WFNS grades III–V, computed tomography (CT) Fisher group 4, and aneurysmal location in the middle cerebral artery (MCA) and anterior cerebral artery (ACA). The rates of poor outcome of mRS score >2 in an isolated dataset using these scoring criteria were significantly correlated with our model’s scores, so this scoring model was validated. This scoring model can help in the more objective treatment selection in patients with aSAH.     

Clinical psychological tests useful for differentiating depressive state with Alzheimer's disease from major depression of the elderly

Background:  A depressive state with Alzheimer's disease (AD) is difficult to differentiate from major depression (MD) in many cases. The purpose of this study was to identify differences between the two disorders using a battery of clinically available psychological tests.
Methods:  We evaluated depression and apathy using the Geriatric Depression Scale consisting of 30 items (GDS30) and Apathy Scale in 38 patients with AD and 31 with MD who were diagnosed based on clinical symptoms and radiological findings. In addition, the Cornel Medical Index (CMI) was employed to compare the psychological features of the two disorders.
Results:  In AD patients, the Apathy Scale score was greater than the GDS30 score, suggesting a strong tendency toward apathy. There was a significant difference in the GDS30/Apathy Scale score ratio between the two groups ( P  < 0.05, OR: 3.11). When examining the downstream mental items of the CMI, the values of tension-category parameters were significantly greater in AD patients, whereas those of depression-category parameters were significantly higher in MD patients. In individual patients, we compared the scores for the two categories, and there was a marked difference ( P  < 0.001, OR: 10.6).
Conclusion:  These results suggest that the GDS30, Apathy Scale, and CMI are useful for differentiating MD from AD and evaluating their psychological features.     

Conduction Delay in Right Ventricle as a Marker for Identifying High‐Risk Patients With Brugada Syndrome

Conduction Delay as a Marker for Brugada Syndrome. Objectives: To evaluate the significance of conduction delay (CD) in the right ventricle (RV) in Brugada syndrome (BS) as a marker for risk stratification of sudden death. Methods: Twenty‐five patients with BS (7 with documented ventricular fibrillation (VF), 8 with syncope, and 10 without symptoms) and 10 control subjects were paced from the RV apex using 8 beats of drive pacing and a single extra‐stimulus. CDs in the right ventricular outflow tract (RVOT) (CD‐RV) and in the lateral left ventricle (L‐LV) (CD‐LV), and the local electrogram durations at a single extra‐stimulus in RVOT (D‐RV) and L‐LV (D‐LV) were calculated. We also evaluated changes in 12‐lead ECG parameters in 16 patients with BS after pilsicainide challenge test (Pilsicainide‐test). Results: Maximal CD‐RV and maximal D‐RV were significantly larger than maximal CD‐LV and maximal D‐LV in BS (26 ± 10 and 105 ± 15 vs 20 ± 6 and 92 ± 15 ms, P < 0.05, respectively). Maximal CD‐RV and maximal D‐RV in patients with documented VF were the largest among the 3 groups. There was a significant positive correlation between maximal CD‐RV or maximal D‐RV and changes in QRS duration in leads V2 and V5 and in S wave duration in lead II and V5 after Pilsicainide‐test (CD‐RV; r = 0.54, 0.51, 0.56, and 0.53: D‐RV; r = 0.55, 0.5, 0.57, and 0.53, P < 0.05, respectively). In control subjects, there were no significant differences. Conclusions: CD in RV was a useful marker for identifying high‐risk patients with BS. CD in the RV, especially in the RVOT epicardium, may be related to arrhythmias in BS. (J Cardiovasc Electrophysiol, Vol. 21, pp. 688‐696, June 2010)     

Classification of delusions in Alzheimer's disease and their neural correlates

Background: Previous findings on neural correlates of delusion in Alzheimer's disease (AD) have been inconsistent because of methodological issues, such as treating multiple delusions as a single entity. In this retrospective study, we classified AD delusions and investigated their neural correlates by using single‐photon emission computed tomography data. Methods: We selected AD patients with delusions from our consecutive outpatients from 2004 to 2010. In this study, eight types of delusions were evaluated with Neuropsychiatric Inventory and classified by factor analysis. Twenty‐five of the patients also had single‐photon emission computed tomography data, which we used to assess the relationships between cerebral regions of hypoperfusion and hyperperfusion and each classified delusion. The relations were assessed using Statistical Parametric Mapping with normalization to the white matter cerebral blood flow. Results: The delusions were classified into three factors. Factor 1 consisted of a belief that his/her house is not his/her home, phantom boarder symptom, delusion of abandonment, and belief that one's spouse or others are not who they claim to be. Factor 1 was related to hypoperfusion in the right temporal pole and hyperperfusion in the medial frontal and precentral regions. Factor 2 consisted of delusion relating to the television and delusion of persecution. Factor 2 was related to hypoperfusion in the precuneus and hyperperfusion in the insula and thalamus. Factor 3 consisted of delusion of abandonment and delusional jealousy. Factor 3 was related to hypoperfusion in the right inferior temporal and frontal regions and hyperperfusion in the middle frontal gyrus, insula and posterior cingulate gyrus. Delusion of theft was not included in any factors, and it was related to hypoperfusion in the bilateral thalami and left posterior cingulate gyrus and hyperperfusion in the left inferior frontal regions and anterior cingulate gyrus. Conclusions: Delusions in AD were classifiable, and each classified delusion was related to different neural networks.     

Early infarction detected by diffusion-weighted imaging in patients with subarachnoid hemorrhage

Purpose

Early infarction that occurs at the time of initial subarachnoid hemorrhage (SAH) due to rupture of an aneurysm is a poorly understood phenomenon. We investigate the frequency of early infarction using diffusion-weighted images (DWI) at the time of admission. We then discuss the pathogenesis of infarction.

Materials and methods

This study included 85 SAH patients who underwent serial DWI on admission. Early infarction detected by DWI and clinical features were investigated retrospectively.

Results

The overall incidence of DWI-detected early infarction at the time of SAH onset was 8% (7 of 85 cases). In all seven patients, early infarctions were asymptomatic on admission. Types of early infarction seen on DWI included infarcts occurring in the territory of the vessel harboring a ruptured aneurysm (solitary, three cases) and infarcts occurring outside the territory of the vessel (multiple, two cases; solitary, two cases). Six of seven patients eventually developed delayed ischemic neurological deficit (DIND) and computed tomography (CT)-detected and DWI-detected delayed extensive infarction. Four of seven patients with early infarction had an unfavorable outcome. The occurrence of DWI-detected early infarction on admission was significantly correlated with delayed angiographic vasospasm, DIND, CT-detected delayed infarction, DWI-detected delayed infarction, and unfavorable outcome.

Conclusions

In the present study, DWI-detected early infarction at the time of SAH onset was correlated with the occurrence of delayed extensive ischemic lesions. We believe that performing DWI at the time of admission is useful for evaluating the primary ischemic insult, which might play an important role in the pathogenesis of early brain injury and delayed vasospasm-related complications.     

Sensor Mechanism and Afferent Signal Transduction of the Urinary Bladder: Special Focus on transient receptor potential Ion Channels

In the urine storage phase, mechanical stretch stimulates bladder afferents. These urinary bladder afferent sensory nerves consist of small diameter Aδ‐ and C‐fibers running in the hypogastic and pelvic nerves. Neuroanatomical studies have revealed a complex neuronal network within the bladder wall. The exact mechanisms that underline mechano‐sensory transduction in bladder afferent terminals remain ambiguous; however, a wide range of ion channels (e.g. TTX‐resistant Na⁺ channels, Kv channels and hyperpolarization‐activated cyclic nucleotidegated cation channels, degenerin/epithelial Na+ channel), and receptors (e.g. TRPV1, TRPM8, TRPA1, P2X2/3, etc.) have been identified at bladder afferent terminals and have implicated in the generation and modulation of afferent signals, which are elcited by a wide range of bladder stimulations including physiological bladder filling, noxious distension, cold, chemical irritation and inflammation. The mammalian transient receptor potential (TRP) family consists of 28 channels that can be subdivided into six different classes: TRPV (Vanilloid), TRPC (Canonical), TRPM (Melastatin), TRPP (Polycystin), TRPML (Mucolipin), and TRPA (Ankyrin). TRP channels are activated by a diversity of physical (voltage, heat, cold, mechanical stress) or chemical (pH, osmolality) stimuli and by binding of specific ligands, enabling them to act as multifunctional sensors at the cellular level. TRPV1, TRPV2, TRPV4, TRPM8, and TRPA1 have been described in different parts of the urogenital tract. Although only TRPV1 among TRPs has been extensively studied so far, more evidence is slowly accumulating about the role of other TRP channels, ion channels, and receptors in the pathophysiology of the urogenital tract, and may provide a new strategy for the treatment of bladder dysfunction.     

Peptidylarginine Deiminase 4 as a Possible Biomarker of Plaque Instability in Carotid Artery Stenosis

Background and purposeNeutrophil extracellular traps (NETs) exhibit pro-inflammatory and pro-thrombotic properties. However, they have only been reported as important regulators in atherosclerosis, especially in atherothrombosis. We investigated the presence of NETs and plaque instability in patients with carotid artery stenosis.Material and methodsA total of 39 consecutive patients with carotid artery stenosis were evaluated. All patients underwent carotid artery stenting (CAS) with dual protection (simultaneous flow reversal + distal filter) and blood aspiration as a method of distal embolism prevention. Local arterial blood was aspirated at the stent site and peptidylarginine deiminase 4 (PAD4), which is essential for the formation of NETs, was measured. The relationships between PAD4 and the patient profile, blood examination and plaque data were investigated.ResultsThe mean value of PAD4 in local arterial blood in CAS was 0.5 ng/ml. Bivariate analysis demonstrated that PAD4 was associated with the neutrophil to lymphocyte ratio (p = 0.007), high-density lipoprotein (p = 0.02), triglycerides to high-density lipoprotein ratio (p = 0.007), ulceration (p = 0.02) and plaque contrast enhancement on T1 black blood imaging (p = 0.03). In multiple linear regression analyses, PAD4 was correlated with the neutrophil to lymphocyte ratio (p = 0.01) and ulceration (p = 0.01, cut-off value: 0.49 odds ratio: 19.3).ConclusionsPAD4, representative of the presence of NETs, was high in carotid plaques with unstable features. The neutrophil to lymphocyte ratio in peripheral blood was suggested to be a biomarker of vulnerable plaques. Elucidating the role of NETs may aid in clarifying factors that promote the instability of carotid plaques.     

Newly developed electromagnetic tracked flexible neuroendoscope

Flexible endoscopes can be used in areas that are difficult to approach using rigid endoscopes. No current real-time navigation systems identify the tip of the flexible neuroendoscope. We have developed a flexible neuroendoscope mounted with a magnetic field sensor tip position-tracking system and evaluated the accuracy of this magnetic field neuronavigation system. Based on an existing flexible neuroendoscope, we created a prototype with a built-in magnetic field sensor in the tip. A magnetic field measurement device provides a magnetic field with a working volume of 500 × 500 × 500 mm in front of the device. The device consists of a flat field generator that creates a pulsed magnetic field, connected to a system control unit that interfaces with a computer. The magnetic field sensor (1.8 × 9 mm) was sealed in a site 0.9 mm from the endoscope tip. Accuracy of neuroendoscope tracking was measured using a three-dimensional coordinate-measuring machine that measures the position of objects along 3 axes, with an error of about 3 μm. The accuracy for this neuroendoscope with built-in magnetic field sensor was root mean square error of 1.2 mm and standard deviation of 0.5 mm. This magnetic field neuronavigation system enables real-time tracking of the tip of the flexible neuroendoscope. Application of this flexible neuroendoscope to intraoperative navigation appears promising, and may provide new advantages for minimally invasive endoscopic surgery.