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OBJECTIVES: To investigate the relationship between body weight loss and activities of daily living (ADL) 3 months after stroke onset. MATERIALS AND METHODS: This retrospective cohort study included 81 patients at a rehabilitation hospital after receiving acute treatment at our hospital (mean age 70.7 years). Patients were divided into two groups, namely independent and non-independent, based on their ADL 3 months after stroke. Receiver operating characteristic (ROC) curves were constructed with the ADL independence possibility as the objective variable and body weight change rate (%) at 3 months as the explanatory variable. Patients were classified using the weight change rate calculated from the ROC curve and the NIHSS cut-off values, and the ADL independence percentage was compared. RESULTS: The ADL-independent group had significantly lesser body weight loss than the non-independent group (median rate of body weight change: -2.7% vs. -7.2%; p<0.001). The area under the ROC curve was 0.76. The cut-off value was -5.6% for the body weight change rate. When participants with NIHSS ≤ 8 points were selected, the ADL-independent participants' proportion was significantly higher in the body weight loss ≤ -5.6% group than in the > -5.6% group (56.0% vs. 15.4%, p=0.016). However, there was no significant difference in the ADL-independent participants' proportion when those with NIHSS >8 points were selected (p=0.19). CONCLUSIONS: Our findings indicate that weight loss after stroke onset is associated with non-independent ADL at 3 months. Weight maintenance from the onset is important for ADL independence, especially in patients with mild to moderate stroke.

DOI： 10.1016/j.jstrokecerebrovasdis.2022.106573

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DOI： 10.1016/j.clnu.2021.07.009

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BACKGROUND & AIMS: Dysphagia is a common sequela following stroke. Patients with subarachnoid hemorrhage (SAH) often develop atrophy of the temporal muscle, but its clinical significance remains unclear. This study aimed to investigate whether temporal muscle volume (TMV) is related to subsequent oral intake in patients with SAH and evaluate the predictors of temporal muscle atrophy. METHODS: We performed a retrospective analysis of 60 SAH patients receiving enteral nutrition in the acute hospitalization phase at a single center between 2009 and 2019. The TMV was segmented automatically from computed tomography images and measured on admission and at week 2. Patients with a ≥20% TMV reduction were assigned to the atrophy group (n = 24) and those with a <20% TMV reduction were included in the maintenance group (n = 36). The patients' oral intake status was assessed at week 2 using the Food Intake LEVEL Scale (grade of 7-9 considered good ingestion), and the modified Rankin scale (mRS) was used at discharge (grade of 0-2 considered good prognosis). Additional data on age, sex, body mass index, severity of SAH, and protein intake were collected on day 4. RESULTS: The maintenance group had significantly better oral intake and mRS scores compared to the atrophy group. TMV maintenance significantly affected oral intake at week 2 and the mRS score at discharge. Multivariable logistic regression analysis revealed that protein intake on day 4 significantly influenced the maintenance of TMV. CONCLUSIONS: High protein nutrition in the acute stage of SAH contributes to temporal muscle maintenance and improves oral intake.

DOI： 10.1016/j.clnu.2021.01.040

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：The Japan Neurosurgical Society  

Infection is a common complication of stroke and is associated with unfavorable outcomes. Although nutritional intervention reduces the risk of postoperative infection, the impact of specific nutritional products remains unclear. From a hospital management perspective, we aimed to determine whether the provision of specific types of enteral nutrition in acute stroke patients affects infection control and hospital costs. In all, 45 acute hemorrhagic stroke patients receiving enteral nutrition in a single center (April 2017-March 2019) were retrospectively assessed. Patients were divided into two groups according to nutritional interventions: the 1.0-group with general nutrition (1.0 kcal/mL) (24 patients) and the 1.5+α-group with an initial high-protein, whey peptide-digested liquid diet (1.5 kcal/mL), followed by a highly fermentable fiber-containing liquid diet (1.5 kcal/mL initiated after 4 days) (21 patients). Changes in body mass index (BMI), duration of antibiotic use, incidence of postoperative infection, and medical cost were evaluated. Baseline patient characteristics were similar between groups. The mean BMI change was lower in the 1.5+α-group than in the 1.0-group, and the mean duration of antibiotic use throughout hospitalization was 12.8 and 18.3 days, respectively. Antibiotic use in the 1.5+α-group was lesser than that in Japanese patients from other hospitals. The incidence of postoperative infections was lower in the 1.5+α-group. Injection costs for the 1.5+α group (615 USD/patient) were lower than those for the 1.0-group. Enteral nutrition provided to acute stroke patients reduced the risk of hospital infection and medical costs.

DOI： 10.2176/nmc.oa.2020-0350

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Other Link： https://search.jamas.or.jp/link/ui/2022000704

Language：Japanese   Publishing type：Research paper (scientific journal)  

INTRODUCTION: Although arteriovenous fistulas(AVFs)are typically located within the cranium, there are several published reports documenting rare cases of extracranial AVFs between the ascending pharyngeal artery(APA)and the internal jugular vein(IJV). Herein, we report the case of a patient with APA-IJV AVFs who presented with symptoms of lower cranial nerve palsy that was treated with transvenous embolization(TVE). CASE: A 53-year-old man presented with chief complaints of numbness in the left oral cavity and a temple headache. Magnetic resonance angiography showed an abnormal signal in the left jugular bulb. An AVF was suspected; digital subtraction angiography revealed the presence of a shunt from the jugular branch of the APA to the jugular bulb which was accompanied by regurgitation into the inferior petrosal sinus(IPS)and sigmoid sinus(SS). Numbness in the oral cavity was diagnosed as lower cranial nerve palsy associated with increased pressure within the jugular foramen. As the nature of the AVF(single or multi-hole)was uncertain, a therapeutic TVE was planned. Microcatheters were guided into the IPS and SS, and TVE was performed using a double-catheter technique. Regurgitation into the IPS resolved; embolization via the APA was not performed, and symptoms improved postoperatively. CONCLUSIONS: AVFs involving the APA and IJV are identified infrequently and there are only a few published case reports describing this vascular anomaly. Most reported cases were single-hole AVF and were treated with trans-arterial embolization via the APA. As noted in the present case, APA-IJV AVF can also be treated by TVE.

DOI： 10.11477/mf.1436204376

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Language：English   Publisher：The Japanese Society for Neuroendovascular Therapy  

OBJECTIVE: To elucidate the current state of in-hospital acute ischemic stroke under the introduction of acute-phase mechanical thrombectomy. METHODS: The study included 18 consecutive patients with in-hospital cerebral infarction who underwent thrombectomy between April 2014 and March 2020 at St. Marianna University School of Medicine Yokohama City Seibu Hospital. We analyzed the primary disease, department responsible for treatment, modified Rankin Scale (mRS) scores before onset and on discharge, status of onset, treatment course, and so on. RESULTS: The mean age was 79.9 (66-93) years. There were nine females. The admission methods included scheduled admission in 5 patients and non-scheduled admission in 13 patients. The primary diseases consisted of malignant tumors in five patients and heart disease in four patients. The departments responsible for treatment consisted of the Department of Digestive Surgery for six patients and Department of Cardiology for three patients. The mRS score before admission was evaluated as 0-2 in 15 patients and 3-5 in 3 patients. The embolism was evaluated as cardiogenic in 14 patients. Antithrombotic therapy was discontinued before the onset of cerebral infarction in three patients. The mean interval from onset or last well known (LWK) until CT/MRI and puncture was 88.4 and 157.6 minutes. The median Alberta stroke program early CT score (ASPECTS; minimum-maximum) was 8 (2-10). Tissue plasminogen activator (t-PA) was administered to five patients. Concerning the degree of recanalization, the thrombolysis in cerebral infarction (TICI) grade was evaluated as 1 to 2a in 2 patients and 2b to 3 in 16. In the latter, the mean interval from onset or final onset-free confirmation until recanalization was 197.7 minutes. mRS score on discharge was evaluated as 0-2 in four patients, 3-5 in nine, and 6 in five patients. The mortality was related to a primary disease requiring admission in three patients. CONCLUSION: In-hospital onset cerebral infarction was markedly influenced by the primary disease requiring admission. Even when favorable recanalization was achieved, the number of patients with a favorable outcome was small.

DOI： 10.5797/jnet.oa.2020-0171

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Language：Japanese   Publishing type：Research paper (scientific journal)   Publisher：The Japanese Congress of Neurological Surgeons  

Carney complex (CNC) has been defined as “a complex of spotty skin pigmentations, cardiac myxomas, and endocrine overactivity.” It is inherited in an autosomal dominant manner. The incidence of acromegaly has been estimated at less than 15% in patients with CNC. We report a patient with acromegaly who had an overt family history of CNC.

  A 20-year-old woman volunteered to undergo mutation analysis for the <i>PRKAR1A</i> gene that showed mutations its exon 2 in genomic DNA isolated from leukocytes. She manifested spotty skin, labial pigmented lesions on the face, and enlargement of her nose and mandible. Though she was found to have normal levels of growth hormone and insulin-like growth factor-Ⅰ, her oral glucose tolerance test result was abnormal. Magnetic resonance imaging revealed a tiny, minutely enhanced area on the left side in the sella turcica. During the transsphenoidal surgery, degenerated gray-white tissues were observed in the pituitary gland and were extirpated for pathology.

  Immunohistochemical studies of the specimen revealed the typical pattern seen with CNC growth hormone (GH) tumors, displaying the deletion of the <i>PRKAR1A</i> gene. Postoperatively, the results of the oral glucose tolerance test became normal, and no additional treatment was administered.

  Although CNC is a hereditary syndrome of considerable importance to neurosurgeons, many neurosurgeons are not aware of it because of its rarity. Therefore, this report attracts special attention to the importance of clinical and genetic manifestation in CNC patients since they are predisposed to GH adenomas.

DOI： 10.7887/jcns.30.741

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Language：Japanese   Publisher：The Japanese Society on Surgery for Cerebral Stroke  

Background and Purpose: The natural history and therapeutic management of patients with unruptured vertebral dissections presenting with headache remains unclear. We retrospectively assessed 41 consecutive patients treated for unruptured vertebral dissections that presented with headaches.

Methods: We identified 41 patients diagnosed with vertebral artery dissection through magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), and angiography between April 2008 to March 2017 and who experienced only headache at the time of onset. All patients underwent MRI, MRA, or three-dimensional computed tomography (CT) every 1-4 weeks for 3 months, every 1-3 months between 3 and 6 months, every 3-6 months 6 months post-onset, or more often depending on the situation. Clinical characteristics, morphological changes, and treatments were analyzed.

Results: Headaches were posteriorly located in 39 cases, however, there were no specific findings other than location. Primary radiographic investigations showed dilatation in 13 cases, pearl and string signs in 20 cases, and stenosis or occlusion in 8 cases. Following the initial conservative treatment, morphologic changes were improved in 27 cases, dilated and occluded in 8 cases, and remained unchanged in 6 cases. The most morphological changes were seen within 3 months for 35 cases, with a mean time of 1.6 months, however, for 6 cases the mean time was 11.2 months. These 6 patients showed dilation and occlusion as morphological changes. Five of these 6 patients' dissection sites enlarged and 3 underwent surgical treatment at a mean of 7.7 months post-onset. The remaining 2 patients were treated conservatively; their dissection sites healed and decreased. None of the patients experienced bleeding or neurological deficits during follow-up.

Conclusion: Clinicians should monitor patients with unruptured vertebral dissections who present with headache to prevent stroke development. It should be noted that even if the dissection site enlarges without new symptoms, acute intervention is not always required and patients should be treated with careful radiographic follow-up.

DOI： 10.2335/scs.49.42

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OBJECTIVES: This study aimed to examine the effects of protein intake on physical performance in critically ill adult patients admitted to the intensive care unit (ICU). METHODS: This was a retrospective cohort study of adult patients mechanically ventilated over 48 h in the ICU who were classified into two groups based on the amount of protein intake: >1.0 g/kg/d (high-protein group) or <1.0 g/kg/d (low-protein group). After adjustment for possible confounding factors with propensity score matching, we compared muscle strength at the time of ICU discharge and the rate of recovery to independent walking between the two groups. RESULTS: One-to-one propensity score matching created 20 pairs. The high-protein group had significantly higher muscle strength than the low-protein group at the time of discharge from the ICU. In addition, the rate of recovery to independent walking before hospital discharge was higher in the high-protein group than the low-protein group (16 of 20 patients [80%] vs. 8 of 20 patients [40%]; P = 0.032). CONCLUSIONS: Our findings indicate that a sufficient amount of protein intake may lead to a higher rate of recovery to independent walking before discharge from the hospital in critically ill patients admitted to the ICU. This finding is likely related to preserved muscle strength at the time of ICU discharge.

DOI： 10.1016/j.nut.2021.111407

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Language：Japanese   Publisher：The Japan Society of Neurotraumatology  

<i>Objectives:</i> As the incidence of stepladder related fall injury (sLRFI) is increasing in Japan, we retrospectively analyzed our own previous sLRFI cases to investigate the clinical characteristics of sLRFI and to give information about the awareness of stepladder safety and pre­cautions.

<i>Materials and Methods:</i> From April 2009 to March 2019, we treated 8 sLRFI cases at our institution. The frequency of sLRFI cases in acute head trauma, patient’s age, sex, cause of injury, Glasgow Coma Scale (GCS) on admission, type of head injury, extracranial lesions, neurosurgical treatment method and outcomes in each patient were retrospectively reviewed.

<i>Results:</i> During the same period, we treated 989 patients with acute head trauma, and determined the sLRFI frequency to be 0.8%. Patients evaluated in the current analysis included 7 males and 1 female, with ages ranging from 52 to 86 years (mean age of 76 years). Mean GCS on admission was 12 points. Cause of injury were non–occupational falls in 7 patients and occupational in 1. Seven out of 8 patients fell from the top of the stepladders or during straddling the stepladders. Type of head injury included acute epidural hema­toma in 3, acute subdural hematoma in 3, cerebral contusion in 3, traumatic intracerebral hematoma in 1, traumatic subarachnoid hemor­rhage in 5, chronic subdural hematoma in 2, pneumocephalus in 1 and skull fracture in 3. Extracranial lesions included clavicular fracture in 1 patient, rib fracture in 2, hemopneumothorax in 2. Neurosurgical procedures were performed in 6 patients. Evacuation of hematoma via craniotomy was carried out in 4 patient, irrigation of hematoma through a burr hole in 2. At the time of discharge, outcomes based on the Glasgow outcome scale were good recovery in 3, moderately disabled in 3, severely disabled in 1, with death occurring in 1.

<i>Conclusions:</i> Clinical characteristics of sLRFI were evaluated based on our previous cases. The typical patients of sLRFI were male, elderly and non–occupational users. As the trend of stepladder falls has been increasing, preventative strategies should be established to support stepladder safety usage.

DOI： 10.32187/neurotraumatology.43.2_70

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Language：Japanese   Publisher：The Japanese Society for Spine Surgery and Related Research  

We reviewed the surgical outcomes of spinal meningioma. A total of 8 patients (follow-up duration: 1-10 years) with spinal meningioma were treated surgically in our institute over the past 10 years. The localisation of all meningiomas was thoracic. The surgeries consisted of posterior midline skin incision; removal of the meningioma via bilateral laminoplasty (5 cases); hemilaminectomy (2 cases); and bilateral laminectomy, pediculectomy, and facetectomy with posterior fixation (1 case). All meningiomas were completely removed (Simpson grade II). No patients showed neurological deterioration or recurrence. The surgical routes are important in the complete removal of spinal meningiomas.

DOI： 10.34371/jspineres.2020-0702

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Language：Japanese   Publisher：The Japan Society of Neurotraumatology  

<i>Objectives:</i> As traumatic basal ganglia hemorrhage (TBGH) is uncom­mon, we retrospectively analyzed our own previous TBGH cases in order to investigate the clinical characteristics of this rare hemorrhagic lesion.

<i>Materials and methods:</i> From January 2012 to June 2018, we treated 6 TBGH cases at our institution. We reviewed the frequency of TBGH cases in acute head trauma, patient’s age, sex, cause of injury, Glasgow coma scale at the time of admission, TBGH site, associated intracranial lesions, treatment method and outcomes in each patient.

<i>Results:</i> During the same period, we treated 214 patients with acute head trauma, and determined the TBGH frequency to be 2.8%. Patients evaluated in the current analysis included 5 males and 1 female, with ages ranging from 17 to 86 years, (mean age of 43.8 years). Cause of injury included traffic accidents in 3, falls in 2, and falling downstairs in 1 patient. Glasgow coma scale at the time of admission was 15 in 1, and less than 8 in the other 5 patients. TBGH sites included the putamen in 3 and the globus pallidus in 3 patients. Computed tomography detected associated intracranial lesions in all cases, with acute subdural hematoma (aSDH) found in 3, traumatic subarachnoid hemorrhage in 2, skull fracture in 2, and corpus callosum injury in 1 patient. With the exception of 1 case, surgical procedures were performed in all patients. Evacuation of TBGH via craniotomy was carried out in 1 patient, and evacuation of aSDH in 3 patients, and placement of external ventricular drainage and intracranial pressure monitoring in 1 patient. At the time of discharge, outcomes based on the Glasgow outcome scale were moderately disabled in 1, and severely disabled in 3, with death occurring in 2 patients.

<i>Conclusions:</i> Clinical characteristics of TBGH were evaluated based on our previous cases. Although TBGH is uncommon, medical staff need to have a basic knowledge of this traumatic injury.

DOI： 10.32187/neurotraumatology.43.1_23

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Language：Japanese   Publisher：The Japanese Society of Spinal Surgery  

A 63-year-old woman presented with a rare case of both intraspinal and orbital inflammatory pseudotumors (IPT). The former IPT manifested as progressive dysesthesia and pain in her left leg. MRI revealed a mass at L5/S1 with extradural and intradural components, showing low signal on T1 and T2-weighted images and strong homogeneous enhancement on gadolinium diethylenetriamine pentaacetic acid (Gd-DTPA). Intraoperatively, an extradural granulomatous lesion that was slightly adhesive to the dura mater was found and removed. Histological examination of the resected lesions revealed the presence of excessive collagen fibers infiltrated with polyclonal lymphocytes, plasma cells macrophages, and giant cells. Only a small number of IgG4-positive cells were observed. Immunostaining for the epithelial membrane antigen was negative. No malignant cells were detected. The diagnosis was consistent with IPT. Two months after surgery, orbital IPT developed. She was treated with steroids. After one year, no aggravation was observed.

  IPTs usually occur in the lung and the orbit, but rarely in the spine. Although spinal IPTs are typically solitary lesions, we present a case of a patient with multiple IPTs and review the literature.

DOI： 10.2531/spinalsurg.34.302

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Language：Japanese   Publisher：Japanese Society for Clinical Nutrition and Metabolism  

DOI： 10.11244/ejspen.2.2_158

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Language：Japanese   Publisher：Japanese Society for Clinical Nutrition and Metabolism  

<b>Aim:</b> To investigate the optimal acute-phase nutrition protocol by using different enteral formulas in patients with stroke.

<b>Subjects and methods:</b> This single-center retrospective analysis included 51 acute stroke patients who received enteral nutrition according to an early enteral feeding protocol from August 2015 to April 2017. The patients were classified into two groups: the 1.0 kcal group who received a standard 1.0 kcal/mL formula (n = 28 patients) and the 1.5 kcal group who received a 1.5 kcal/mL formula (a high protein peptide-based formula followed by a liquid diet [1.5 kcal/mL] and later switched to partially hydrolyzed guar gum (PHGG]-containing liquid diet; n = 23). Clinical progress and outcomes were retrospectively compared between the groups.

<b>Results:</b> Baseline characteristics were similar between both groups. Compared with the 1.0 kcal group, the 1.5 kcal group had a lower protocol incompletion rate owing to gastrointestinal symptoms and fewer number of days needed to complete the protocol. The 1.5 kcal group also had a lower rate of weight loss. Blood biochemistry results showed improvement in nutritional status and inflammatory status.

<b>Conclusion:</b> The nutritional protocol using a 1.5 kcal/mL high protein peptide-based formula and a 1.5 kcal/mL PHGG-containing liquid diet was more beneficial than that using a 1.0 kcal/mL standard formula in acute stroke patients.

DOI： 10.11244/ejspen.2.2_103

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BACKGROUND: Malignant gliomas are characterized by high invasive ability. In this study, we investigated roles of layilin, a C-type lectin-homologous protein, in the invasive ability of malignant glioma cells. METHODS: Expression of layilin was investigated by western blotting in the malignant glioma cell lines of U251-MG, A172, and T98G and in astrocytes. The effects of layilin-knockdown on the expression and protein levels of snail family transcriptional repressor 1 (SNAI1), a transcriptional factor involved in the acquisition and enhancement of invasive ability in malignant gliomas, and on the expression of its target genes, matrix metalloproteinase 2 (MMP2), MMP9, and collagen type I alpha 1 chain (COL1A1), were investigated by qPCR and/or western blotting. Furthermore, the effects of layilin-knockdown on the expression and protein levels of metastasis associated 1 family member 3 (MTA3), a transcriptional repressor of SNAI1, were also investigated by qPCR and western blotting. Finally, the effects of layilin-knockdown on the invasive ability of the cells were investigated by a wound healing assay. RESULTS: All the tested malignant glioma cells highly expressed layilin, compared to astrocytes, one of representative glial cell types. Layilin-knockdown reduced SNAI1 both at the mRNA and protein levels in A172 cells, and consequently mRNA levels of MMP2, MMP9, and COL1A1 were also reduced. Furthermore, layilin-knockdown increased nuclear protein levels of MTA3 in A172 cells. Notably, layilin-knockdown suppressed the invasive ability of the cells. CONCLUSION: Layilin up-regulates the expression of SNAI1 via down-regulation of MTA3. This process enhances the invasive ability of malignant glioma cells.

DOI： 10.1016/j.brainres.2019.05.034

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Other Link： https://kaken.nii.ac.jp/grant/KAKENHI-PROJECT-19K15752/

Language：Japanese   Publishing type：Research paper (scientific journal)  

OBJECTIVES: Intracranial chordomas are thought to arise from remnants of the notochord and usually occur at the parasellar region. We present a case of a primary intrasellar chondroid chordoma in a patient who was initially diagnosed with a pituitary adenoma. CASE: A 77-year-old woman had a history of two surgeries for a tumor in the sella turcica(17 months after the 1st surgery). On initial MRI, the intrasellar mass showed low signal intensity on T1WI, very high signal intensity on T2WI, and inhomogeneous enhancement. On bone reconstructive CT, the sellar floor was thin, and no abnormalities were observed at the top of the clivus. Transsphenoidal surgery was performed. The pathological diagnosis was pituitary adenoma in both cases. Seventy-two months after the 1st(31 months after the 2nd)surgery, she developed right-sided oculomotor and abducent nerve palsies again. Since recurrence occurred during the relatively short period, the surgical specimens obtained from the 1st and 2nd surgeries were reexamined. Reexamination of the previously obtained specimen demonstrated areas of chondroid tissue that were embedded in a mucoid stroma and tumor cells that were composed of round or pleomorphic nuclei with vacuolated cytoplasm(physaliphorus cells)that were compatible with chondroid chordoma. The third surgery was performed. Postoperatively, her symptoms improved, and cyber knife therapy was administered for the residual part of the tumor. CONCLUSIONS: Although intrasellar chondroid chordomas are extremely rare, they should be considered in the differential diagnosis of tumors located in the sella turcica.

DOI： 10.11477/mf.1436204042

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Language：Japanese   Publisher：Japanese Society for Parenteral and Enteral Nutrition  

DOI： 10.11244/jspen.34.237

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：The Japan Neurosurgical Society  

This study sought to analyze the incidence of contralateral microembolic infarctions (MIs) on diffusion-weighted imaging (DWI) following protected carotid artery stenting (CAS) and compared the difference of risk factors between ipsilateral and contralateral lesions. From April 2010 to March 2017, 147 CASs in 140 patients were performed. All the patients underwent DWI within 1 week before and 24 hrs after the procedures. CAS was successfully completed in 145 (98.6%) of the 147 procedures. Forty-nine (33.8%) patients with new MIs revealed on postprocedural DWI were enrolled. They were divided into ipsilateral and contralateral groups based on the side of the CAS and MIs. The ipsilateral group indicates patients with MIs exclusively on the side of CAS. The contralateral group includes patients with MIs on the opposite side of the CAS or both sides. Patients with MIs at vertebrobasilar territory were excluded. Patient characteristics, morphology of the carotid artery and aortic arch, and procedural data were retrospectively assessed and compared between the two groups. Twenty-two (15.2%) and 14 (9.7%) patients were assigned to the ipsilateral and contralateral groups, respectively. Advanced age, left-sided stenosis, severe aortic arch calcification (AAC) on chest X-ray and contralateral carotid occlusion significantly increased the occurrence of contralateral MIs. On multivariable logistic regression analysis, severe AAC was statistically more frequent in the contralateral group. In the present study, the incidences of contralateral MIs after CAS is relatively not low. Advanced aortic atherosclerosis is statistically predictive for contralateral MIs. AAC on chest X-ray is a useful finding for estimating aortic atherosclerosis in candidates for CAS.

DOI： 10.2176/nmc.oa.2018-0023

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Other Link： https://search.jamas.or.jp/link/ui/2019301726

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OBJECTIVES: Primary meningiomas arising outside the intracranial component are rather rare and have been termed primary extradural meningiomas(PEMs). We present a case of an intraosseous-type PEM occurring at a high convexity location and discuss the clinical characteristics of PEMs. CASE: An 80-year-old woman presented with a soft and painless subcutaneous mass of approximately 10 cm in diameter in the right parietal region, which had appeared 1 year previously. Mild cognitive dysfunction and left hemiparesis were observed upon admission. A skull radiograph and a bone window computed tomography scan revealed an osteolytic lesion at the above-mentioned site. Magnetic resonance imaging indicated that the mass was inhomogeneously enhanced and seemed to extend through the skull defect both intra- and extra-cranially. The preoperative diagnosis was a metastatic skull bone tumor due to the patient's history of breast cancer. During surgery, the tumor was found to be solid and had expanded through both the inner and outer tables of the skull, destroyed the inner table at one location, and perforated into the subdural space via the thinned, but not infiltrated, dura mater. The tumor was removed along with a wide margin of surrounding healthy bone and a cranioplasty was performed using a titanium plate. The histopathological diagnosis was atypical meningioma(World Health Organization grade II). Postoperatively, no adjuvant therapies(radiation and/or chemotherapy)were administered and the patient was reported to be well at 8 months post-surgery with no evidence of tumor recurrence. CONCLUSIONS: Although PEMs are rather rare, clinicians should consider the differential diagnosis of osteolytic skull vault tumors.

DOI： 10.11477/mf.1436203762

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BACKGROUND: A tailor-made treatment is often required in arteriovenous malformations (AVMs) depending on the individual situation. In most cases, treatment strategy is usually determined according to the patient's Spetzler-Martin grade. However, in the present case, we were not able to treat the patient following the usual guidelines because of neurological symptoms and pregnancy. CASE DESCRIPTION: We describe a rare case of a 31-year-old woman in the 15th week of gestation who presented with an AVM in the anterior perforated substance (APS). She suffered a sudden coma and hemiplegia. A computed tomographic scan showed an enhanced mass and a huge hematoma in the basal ganglia and temporal lobe. The hematoma was successfully evacuated in an endoscopic procedure. Angiography showed that a 25-mm nidus in the APS was fed by the anterior choroidal arteries (AChAs) and the lenticulostriate arteries (LSAs). Therefore, we attempted to remove the nidus because the patient became alert with mild aphasia and hemiparesis 10 days after hemorrhage. The feeding arteries were cut under motor evoked potential (MEP) monitoring, and the nidus was totally resected leaving two of four AChAs and a single artery with several LSAs. The postoperative course was uneventful, and she gave birth to a healthy baby by caesarian delivery 122 days after the hemorrhage with only minor sequelae. CONCLUSIONS: Surgical strategy with a device-administered anesthesia are suitable for removing large AVMs even in pregnant women and for the successful outcome of their pregnancies. Even after recovering from a coma and hemiplegia, MEP monitoring is effective for removing large AVMs even when located in the APS.

DOI： 10.4103/sni.sni_220_17

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Language：Japanese   Publisher：Japan Society of Neurosurgical Emergency  

In 228 aneurysm cases, we assessed the relation of ischemic and hemorrhagic complications with age, sex, location, size, ruptured vs. unruptured status, WFNS (World Federation of Neurological Surgeons Committee) grade of ruptured cases and use of neck plasty. Of these 228 cases, 10 had ischemic complications (4.3%) and six had hemorrhagic complications (2.6%). Cases with ischemic complications were significantly correlated with those involving neck plasty. However, no permanent complications were identified. All hemorrhagic complications occurred in cases with ruptured aneurysms. In two cases with hemorrhagic complications, bleeding occurred at the end of coil insertion and the bleeding was stopped with the dilation of the balloon alone, which resulted in good prognosis. Excluding these cases, hemorrhage‒complicated cases tended to have a serious prognosis. Administering argatroban and performing high‒quality endovascular surgery is important for reducing complications. Improvements are also required for reducing the ischemic complications caused by neck plasty. There may be a need to administer dual antiplatelet therapy or perform reinforced heparinization.

DOI： 10.24723/jsne.23.1_45

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OBJECTIVE: Previously, cavernous angiomas(CAs)have been thought to be only congenital in origin. Recently, however, a few cases of de novo CAs have been reported in the literature. We present a case of a de novo CA and discuss the etiology of the newly appeared CA. CASE REPORT: A 29-year-old man was presented to a local clinic because of hypersomnia. MRI demonstrated a heterogeneous mass peripherally located, which was in contact with a developmental venous anomaly(DVA)at the left thalamus. Six years before the presentation, he visited the same clinic because of faintness, and MRI results indicated no abnormality except for the DVA. Three weeks later, he suddenly experienced difficulty in speech, and the MRI revealed an increase in the size of the mass. Subsequently, he was admitted at our institution, and neurological examination revealed aphasia and right hemiparesis. A left carotid angiogram on venous phase showed a narrowing of the DVA, which was seen as it entered the internal cerebral vein. The diagnosis of a de novo CA was made. The mass was completely resected through the transcallosal transventricular approach to avoid injuring the DVA. The DVA could not be found during surgery. The pathological diagnosis was in line with the findings of CA. Postoperatively, the patient continued having difficulty in speech and was transferred to another institution for speech rehabilitation. CONCLUSIONS: Although the association of CA and DVA has been described with increasing frequencies recently, the etiology of de novo CA in the case of this association has been a matter of debate. In the present case, it was speculated that a narrowing of the DVA resulted in increased venous pressure and caused the development of de novo CA.

DOI： 10.11477/mf.1436203503

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BACKGROUND: Recently, it has been reported that hypoxia highly enhances expression of peptidylarginine deiminase (PAD) 4 and production of citrullinated proteins in some tumor cells. However, little is known about malignant gliomas on this issue. Therefore, we here investigated whether expression of PADs was induced by hypoxia and whether PADs citrullinated intracellular proteins if induced using U-251 MG cells of a human malignant glioma cell line. METHODS: Expression of PADs in U-251 MG cells, cultured under hypoxia or normoxia for 24 h, was investigated by quantitative polymerase chain reaction (qPCR). Citrullination of proteins in the cells and the cell lysates incubated for 48 h with or without Ca2+ was detected by western blotting. Citrullinated proteins were identified by mass spectrometry. RESULTS: The mRNA levels of PAD1, 2, 3, and 4 were up-regulated by hypoxia in a hypoxia-inducible factor-1-dependent manner in U-251 MG cells. In spite of the increased expression, intracellular proteins were not citrullinated. However, the induced PADs citrullinated U-251 MG cell-derived proteins when the cells were lysed. Multiple proteins citrullinated by hypoxia-induced PADs were identified. In addition, the extracellular domain of vascular endothelial growth factor receptor 2 was citrullinated by human PAD2 in vitro. CONCLUSION: Our data may contribute to understanding of pathophysiology of malignant gliomas from the aspects of protein citrullination.

DOI： 10.1016/j.bbrc.2016.10.154

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Other Link： https://kaken.nii.ac.jp/grant/KAKENHI-PROJECT-15K15104/

Language：Japanese   Publisher：The Japan Stroke Society  

A 45-year-old woman was presented to our hospital for severe pharyngalgia and neck pain with fever. The CT angiography revealed the presence of the giant extracranial internal carotid artery (ICA) aneurysm at the time of admission. The MRI revealed abnormal intensity suggestive of abscess formation in the pharyngeal area. Endovascular parent artery occlusion was performed on Day 2. Postoperative evaluation was performed by transoral carotid ultrasonography (TOCU) to obtain image guidance for puncture and drainage the abscess. The ICA and the giant aneurysm were completely thrombosed, and the drainage of abscess was performed with high safety on the basis of the TOCU findings. Although endovascular treatment for extracranial infectious ICA aneurysm has not been well established, our case suggests that the treatment with guidance of TOCU appears effective.

DOI： 10.3995/jstroke.10443

DOI： 10.2301/neurosonology.31.134_references_DOI_4Rom7tMM0CIrVGIhspGAzv0vn82

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Other Link： https://search.jamas.or.jp/link/ui/2017264193

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Language：Japanese   Publisher：The Japanese Society on Surgery for Cerebral Stroke  

To determine the predictors of medical complications in aneurysmal subarachnoid hemorrhage during the vasospasm stage, we reviewed the medical complications of 92 patients treated for ruptured cerebral aneurysm at our institutions between January 2010 and December 2014.<br>The 92 patients were divided into medical and non-medical complication groups. Their clinical characteristics were compared, including age, sex, World Federation of Neurological Surgeons (WFNS) grade, vasospasm, medical condition, creatinine (Cr) level, estimated glomerular filtration rate (eGFR), glycemia, cardiothoracic ratio at admission, albumin level, natrium level at onset of medical complication, Cr level 3 days after admission (first period), Cr level at onset of medical complication (second period), eGFR at 3 days after admission (first period), eGFR at onset of medical complication (second period), average intake volume for 3 days (first period), and onset of medical complication (days; second period) after admission by using the Mann-Whitney <i>U</i> test or Fisher test. Univariate and multiple logistic regression analyses were used to determine factors associated with risk of medical complication.<br>The overall rate of medical complication was 26.1% (24/92). The most common medical complication was pulmonary cardiac complication. The Mann-Whitney <i>U</i> test and univariate analyses showed WFNS grade and eGFR (second period) to be significantly higher in the medical complication group than in the non-medical complication group. The independent risk factors of medical complications that were identified in the multiple analyses were WFNS grade and eGFR (second period; odds ratio, 95% confidence interval: 4.9577, 1.6557-15.0264 and 6.6759, 2.2421-19.8780, respectively).<br>We identified WFNS grade and eGFR (second period) as independent risk factors. Under the wrong WFNS grade at admission, extensive care should be taken in the management of the disease. When eGFR is less than that at admission during the vasospasm stage, it may play a predictive role for medical complications.

DOI： 10.2335/scs.45.389

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Other Link： https://search.jamas.or.jp/link/ui/2018027220

Language：Japanese   Publisher：The Japan Stroke Society  

A 25-year-old woman with a right neck swelling visited her local hospital, where paravertebral arteriovenous fistula (PAVF) was diagnosed. The PAVF was fed mainly by the ascending cervical artery and also by the subcutaneous cervical, external cervical, and vertebral arteries, and it drained via multiple fistulas and a varix into the paravertebral venous plexus. Ligation of the main feeding artery and transarterial embolization were performed, but the PAVF recurred, so the patient was referred to our hospital, where angiography revealed multiple high-flow feeding arteries, fistulas, and draining veins. We adopted a bidirectional treatment strategy, combining transarterial and transvenous catheterization and coil embolization. The fistulas were obliterated, and 1-year follow-up angiography showed no signs of recurrence. PAVF is a rare condition involving spinal vascular malformations and for which there is no established treatment strategy. Simultaneous transarterial and transvenous embolization should be considered for PAVF with a complex angioarchitecture.

DOI： 10.3995/jstroke.10421

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Other Link： https://search.jamas.or.jp/link/ui/2017188271

Language：Japanese   Publisher：The Japan Stroke Society  

Purpose: The aim of this study was to examine the relationship between stress index (SI) calculated by dividing blood sugar (BS) concentration by serum potassium (K) level at the time of initial examination and both severity and outcome of subarachnoid hemorrhage (SAH). Methods: We retrospectively analyzed 108 patients with SAH. Severity of SAH was assessed using the World Federation of Neurosurgical Societies (WFNS) classification system. The moderate group included patients with WFNS grade I–III, with all other patients classified into the severe group. Outcomes at the time of discharge were assessed using the Glasgow Outcome Scale. Good outcome group included patients with good recovery or moderate disability, while others were classified to the poor outcome group. Biochemical factors evaluated at the initial examination included K, BS, and SI. Results: BS and SI were significantly higher in the severe group than in the moderate group (p<0.001). These indicators were also significantly higher in the poor outcome group than in the good outcome group (p<0.001). Some patients in the moderate group fell into the poor outcome group. In those patients, SI was significantly high. Conclusion: SI was significantly high in patients with severe SAH and in patients with poor outcome. Patients with high SI who are classified into the moderate group might show poor clinical outcomes.

DOI： 10.3995/jstroke.10406

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Language：Japanese   Publisher：The Japan Society of Neurotraumatology  

<i>Objective:</i> We retrospectively analyzed our own cases of subacute subdural hematoma (SSH) to investigate the clinical characteristics of SSH.

<i>Materials & Methods:</i> From January 2011 to October 2015 we experienced 5 cases with SSH at our institution. Frequency, age, gender, clinical course, radiological find­ings, operative findings and outcomes were reviewed.

<i>Results:</i> During the same period we treated 85 patients with acute subdural hematoma, thus frequency of SSH accounted for 5.9％. The patient’s ages ranged from 45 to 89 years with a mean age of 72 years. There were 2 men and 3 women. The cause of injury was fall on the same level in 4 patients, fall in 1. Glasgow coma scale score on admission was 15 in 4 patients, 14 in 1. Initial comput­erized tomography (CT) scans revealed mixed density subdural hematoma in 2 patients, homogenously high density in 3. The mean maximal thickness of hematoma was 10 mm. Time intervals to worsening were 5 to 13 post­traumatic days with a mean time interval of 9.6 days. Symptomatologically all patients developed contralateral hemiparesis. CT scans on worsening revealed mixed den­sity in 2 patients, iso in 2, low in 1. The mean maximal thickness of hematoma was 13 mm and revealed mass sign and mild midline shift. Magnetic resonance imaging was obtained only in case 3 and demonstrated high signal intensity on T1 weighted images, low signal intensity on T2 weighted images, high signal intensity with the low intensity rim close to the brain surface on diffusion weighted images. All patients underwent craniotomy to evacuate hematoma. Postoperatively 4 patients recovered fully and 1 patient died of pulmonary failure.

<i>Conclusions:</i> Even though subdural hematoma is treated conservatively at acute stage, it should be kept in mind that it may develop at subacute stage and cause neurological deterioration.

DOI： 10.32187/neurotraumatology.39.2_118

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Other Link： http://id.ndl.go.jp/bib/027865199

Language：Japanese   Publisher：The Japan Society of Neurotraumatology  

<i>Background and purposes:</i> We retrospectively reviewed clinical features of chronic subdural hematomas in the patients with hematological diseases.

<i>Methods:</i> A total of 410 patients with chronic subdural hematoma(s) admitted to St. Marianna University Yokohama City Seibu Hospital between 2008 and 2015 were reviewed. Among these patients, 9 corresponding cases were collected.

<i>Results:</i> The average age of the patients was 65.5 years. In three out of 9 patients, preceding head injury was found in the past history. Based on complete blood counts on admission, blood transfusion was needed prior to surgical treatment in order to correct bleeding tendency mostly due to platelets deficiency. Because of cerebral her­niation signs, emergency surgery was necessary in three patients. All under­went common burr hole aspiration surgery under local anesthesia. No surgical complication including postoperative hemorrhages was encountered. Neurological deficits were disappeared immediately after the surgery. However, another surgical treatment was added in 4 patients because of recurrent accumulation of subdural bloody fluid. Although nearly a half of the patients showed good prognosis, coexisting hematological disorders pro­gressed to death within six months after the surgery in four out of 9 patients.

<i>Conclusion:</i> Chronic subdural hematomas are generally recognized as a benign disease having good outcome when appropriate treatments were given. However, as the patients concomitantly having hematological diseases, their prognosis might be pessimistic.

DOI： 10.32187/neurotraumatology.39.2_89

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Other Link： http://id.ndl.go.jp/bib/027865011

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BACKGROUND: Dermoid cysts are non-neoplastic tumors that arise from defects in the separation of the neuroectoderm. Cyst rupture rarely occurs spontaneously and the most common symptom is headache, followed by seizure. Although many cases of ruptured dermoid cysts present with symptoms, reports of cases that are asymptomatic, or where symptoms disappear, are rare. CASE PRESENTATION: We report the case of a 66-year-old Asian man with a history of sudden onset headache who was found to have high amounts of fat material in the subarachnoid space and a fat suppression mass in the left cavernous sinus. He underwent oral steroid therapy. Five days after starting medication his headache symptoms disappeared. Routine neurological imaging was then performed without surgical procedure. Magnetic resonance imaging revealed evidence of the remains of a static lesion 6 months after his first visit. He has remained headache free for 10 months since the initial event. CONCLUSIONS: Although cases of ruptured dermoid cysts presenting with consistent symptoms have been commonly reported, until now there were few reports on asymptomatic cases or cases where symptoms disappeared. We believe that surgical intervention is unnecessary for ruptured dermoid cysts with minimal symptoms.

DOI： 10.1186/s13256-016-1007-3

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<i>Introduction:</i> We retrospectively analyzed surgically treated “talk and deteriorate (T&D)” patients at our institution to find an appropriate management of this potentially preventable poor outcome head injury.

<i>Materials and Methods:</i> From January 1996 to November 2014, a total of 468 patients with mild head injuries (GCS≧13) were admitted to our institution. Among these, 16 patients were identified as T&D. We defined T&D as a patient who utters comprehensible speech at some time after head injury and then deteriorates to a severe state (GCS score 8 or less) within 24 hours after injury. Clinical characteristics of these patients were analyzed.

<i>Results:</i> Of the 16 T&D patients, 10 were men, and 6 were women, aged 16–89 years (mean ± standard deviation (SD) = 65 ± 19). Thirteen patients were injured in non high energy trauma. All deterioration was due to intra-cranial hematomas, mostly acute subdural hematoma. Time interval from accident to deterioration was 1–15 hours (mean ± SD ＝ 4.4 ± 4.0). All patients underwent craniotomy, two of these craniectoy and 5 indwelled intracranial pressure monitoring. Two died and 6 were left in moderate disability or severe disability status. The remaining 8 patients had good outcome.

<i>Conclusion:</i> The most important factors in saving these patients are rapid diagnosis and immediate surgical decompression before irreversible brain damage sets in.

DOI： 10.32187/neurotraumatology.39.1_27

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Other Link： http://id.ndl.go.jp/bib/027688538

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The formation of an intracranial pseudoaneurysm due to a ruptured saccular aneurysm is a rare condition that exhibits characteristic angiographic findings referred to as "ghost aneurysm" or "snowman's head". Currently, no detailed information about the treatment of this condition is available. Clipping has been reported to be more effective and better for removing massive hematomas than endovascular intervention. Moreover, endovascular coil embolization during the acute phase carries a high risk of repeated aneurysm rupture due to the fragility of the pseudoaneurysmal blood clot. Here, we describe three cases of pseudoaneurysm formation following the rupture of an anterior communicating artery aneurysm, and suggest the possibility that ruptured saccular aneurysms with pseudoaneurysm formation can be treated safely and effectively with endovascular coil embolization.

DOI： 10.11477/mf.1436203283

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Introduction: Edaravone (3-methyl-1-phenyl-2-pyrazolin-5-one) of a free radical scavenger has been widely used in treatment of acute ischemic stroke. However, effects of edaravone on hypoxic astrocytes have not been fully understood. Therefore, we investigated the effects by proteomic analysis. Methods: We cultured human astrocytes under hypoxia and normoxia with or without edaravone. Then, we compared protein profiles of the astrocytes using 2-dimensional differential gel electrophoresis (2DDIGE). Further, we identified proteins affected by hypoxia and/or edaravone by mass spectrometry. Results: We detected 507 protein spots by 2D-DIGE. Among them, intensity of 22 spots showed more than 1.5-fold increase or less than 1/1.5-fold decrease with statistical significance (p<0.05) by hypoxia. We were able to identify 6 out of the 22 protein spots (increased: alpha-enolase (ENO1, from 2 spots) and ephrin-B2, decreased: adenosine triphosphate synthase subunit alpha (ATPA), mitochondrial heat shock 70 kDa protein 1A/1B, and ferritin light chain). In addition, in 61 out of the 507 spots, the spot intensity showed more than 1.3-fold increase or less than 1/1.3-fold decrease with statistical significance (p<0.05) by hypoxia. In 9 out of the 61 spots, the hypoxia-induced intensity alteration was suppressed by the simultaneous addition of edaravone. Three out of the 9 protein spots were identified (ENO1, ATPA, and rab-interacting lysosomal protein-like protein 1). Conclusion: Edaravone suppressed a part of molecular responses of human astrocytes to hypoxia. Our data would support use of edaravone in acute ischemic stroke.

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：The Japan Neurosurgical Society  

Anterior communicating artery (ACoA) aneurysms have a complex architecture and many variations, making endovascular therapy more difficult in some cases. The aim of this study was to investigate whether the neck position of an aneurysm was identifiable for determining the immediate angiographic success and procedural complications in the coiling of the ACoA aneurysms. We conducted a retrospective case review of 40 patients with ACoA aneurysms treated by endovascular therapy from 2008 to 2015. The mean age was 66.8 years. Thirty-five aneurysms were ruptured; five were unruptured. For the analysis, the patients were divided into two groups according to the neck position of aneurysms: the true ACoA group, 9 patients with the neck located on the ACoA itself; and the other ACoA group, 31 patients with the neck at the junction of the A1 and A2 portions of an anterior cerebral artery. Morphological characteristics (dome size, dome direction, rate of wide neck, and angulation of aneurysms in relation to the parent artery) were analyzed along with immediate angiographic results, volume embolization ratio (VER), and procedural complications. Small aneurysms with superior dome projection and acute angulation of the aneurysm direction occurred more often in the true ACoA group. The rates of complete obliteration, VER, and procedural complications were 33.3%, 32.3%, and 22.2% in the true ACoA group and 54.8%, 36.3%, and 6.5% in the other ACoA group, respectively. True ACoA aneurysms could present an anatomical difficulty in endovascular coiling. Aneurysmal neck position should be accurately assessed to achieve successful embolization of the ACoA aneurysms.

DOI： 10.2176/nmc.oa.2015-0201

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Other Link： https://search.jamas.or.jp/link/ui/2016275717

Language：Japanese   Publisher：The Japanese Society on Surgery for Cerebral Stroke  

Dural arteriovenous fistulas (DAVFs) are generally present in the transverse-sigmoid sinus as well as the cavernous sinus. To date, endovascular surgery has been mainstream; however, direct surgical treatment seems to be primarily limited to anterior skull base DAVFs. We herein report two cases of non-sinus-type DAVF located in the middle cranial fossa that were successfully treated with direct surgery. Both were symptomatic and angiographically classified as Cognard type IV. The first case was referred to our institution because of recurrence of a left middle fossa DAVF seven years after initial treatment with transarterial coil embolization (TAE). Drainer obliteration was performed using the subtemporal approach. The second case had severe headache with prominent clinical features similar to those of a carotid cavernous sinus fistula. TAE was applied to the branches of the right external carotid artery to reduce the flow rate. Drainer obliteration was performed without difficulty using the conventional frontotemporal approach.<br>The cortical vein-draining DAVF, classified as Cognard type III or type IV, presents a high risk of intracranial hemorrhage. When diagnosed, they should be treated completely, as early as possible. The aforementioned drainer obliteration appeared to be the best way to cure the DAVF. Endovascular surgery before direct surgical treatment was effective to reduce shunt flow and to enable an easy access to the shunt point.

DOI： 10.2335/scs.44.151

DOI： 10.5797/jnet.cr.2021-0021_references_DOI_aOeqscrzwocyUBmlupsoSG4zcAP

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A 79-year-old woman presented with a subarachnoid hemorrhage. Angiography revealed pseudoaneurysm formation due to rupture of a true saccular anterior communicating artery aneurysm. Coil embolization, limited to the true aneurysm, was performed successfully with a favorable clinical outcome. This procedure can be considered as an alternative treatment option for similar aneurysms in cases where surgical clipping is contraindicated.

DOI： 10.1136/neurintsurg-2013-011006.rep

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Language：Japanese   Publisher：The Japan Stroke Society  

We here tried to comprehensively elucidate the effects of edaravone on human brain microvascular endothelial cells (HBMECs) by Two Dimensional Fluorescence Difference Gel Electrophoresis (2D-DIGE). We found 17 proteins, the intensity of which was significantly altered more or less than 1.3 folds on average (p<0.05) by the treatment with edaravone after 4 hours. Functionally, 4 out of the 17 proteins were cytoskeleton proteins themselves or a cytoskeleton-regulating protein. Thus, we next investigated the change of size and shape of the cells, actin network, and the tight junction of HBMEC by immunocytochemistry. We found data would provide fundamental and useful information in the clinical use of edaravone in patients with cerebral vascular diseases.

DOI： 10.3995/jstroke.10300

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Language：Japanese   Publishing type：Research paper (scientific journal)   Publisher：The Japanese Congress of Neurological Surgeons  

A 12-year-old boy with a thalamic anaplastic astrocytoma underwent surgical excision of the tumor and subsequent chemoradiotherapy. Five months later, a growing mass was detected on the scalp. The mass was excised, and the histological examination revealed an astrocytoma identical to the original thalamic tumor. Subcutaneous metastasis of a brain tumor to the scalp is relatively rare. To our knowledge, this is only the second case report of subcutaneous metastasis of anaplastic astrocytoma to the scalp.

DOI： 10.7887/jcns.24.713

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Other Link： https://search.jamas.or.jp/link/ui/2015406169

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We report a case of infected subdural hematoma(ISH). We followed up an 81-year-old man with asymptomatic chronic subdural hematoma(CSDH). After half a year, he came to our hospital because of reduced activities of daily living and a high fever. Although his inflammatory markers were high, various cultures and imaging studies yielded negative results. Right hemiparesis developed 5 days later. Burr-hole surgery was performed to treat the CSDH. The hematoma proved to be mixed with pus, suggesting ISH. The ISH recurred twice despite antibiotic therapy and repeated irrigation. Finally, inflammatory parameters normalized and computed tomography disclosed an organized CSDH. ISH should be suspected in patients with CSDH presenting with high fever.

DOI： 10.7887/jcns.24.246

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Endovascular treatment of wide-necked aneurysms with preservation of the parent artery remains a challenge. The authors describe a novel and simple technique to navigate a balloon or stent-delivery catheter across a wide-necked aneurysm in which previously existing methods could have failed to pass the catheter across the neck of the aneurysm, which we have named "temporary caging" technique. The technical results using this method are presented in 6 cases.

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BACKGROUND: Intracranial vascular complications following radiosurgery are extremely rare. CASE DESCRIPTION: We report a case of stenosis in the internal carotid artery 5 years after gamma knife radiosurgery for a recurrent pituitary adenoma. Percutaneous transluminal angioplasty was performed successfully with anatomical and functional improvement. CONCLUSION: These results suggested the importance of monitoring for arterial stenosis in the long-term follow-up. Moreover, this is the first case of endovascular treatment as an effective therapy for intracranial arterial stenosis due to radiotherapy.

DOI： 10.4103/2152-7806.157795

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BACKGROUND: The anterior interhemispheric approach provides wide exposure of the anatomy around the anterior communicating artery aneurysm. A disadvantage of this approach is that splitting the interhemispheric fissure is a complicated surgical maneuver. One solution is to hold the fissure horizontally in the operation field. Surgical procedures for bicoronal scalp incision and craniotomy are difficult in the horizontal head position. We developed a modified low anterior interhemispheric approach to minimize damage to the frontal lobe and olfactory nerve by rotating the head after opening the dura. METHODS: The head is fixed in a prerotated Sugita head holder in a neutral head position. Bicoronal scalp incision and frontal craniotomy are performed and the head holder is rotated 30 degrees clockwise to allow gravity to retract the right frontal lobe. The surgeon can then move to the right side of the patient to obtain a horizontal operation field parallel to the interhemispheric fissure. RESULTS: This method was used for 12 patients in the past 6 years. All aneurysms were successfully clipped without any complications related to the procedure. Damage to the frontal lobe was avoided and the olfactory nerve was preserved in all the patients. CONCLUSION: Intraoperative head rotation minimizes surgical damage to the neural structures in the anterior interhemispheric approach.

DOI： 10.4103/2152-7806.153705

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：The Japan Neurosurgical Society  

Microvascular decompression (MVD) is a standard surgical procedure for treating vascular compression syndromes. There are two basic ways to perform MVD: interposition using a prosthesis and transposition. With the transposition technique, adhesions and granuloma around the decompression site are avoided, but the required operation is more complex than that for the interposition method. We describe a simple, quick MVD transposition procedure that uses a small "belt" cut from a sheet of 0.3-mm-thick expanded polytetrafluoroethylene membrane. The belt has a hole at the wide end and the other end tapered to a point. The belt is encircled around offending vessels by inserting the pointed end into the hole. The pointed end is then passed through a dural tunnel over the posterior wall of the petrous bone and is tied two or three times. This method avoids the risks involved in handling a surgical needle close to the cranial nerves and vessels.

DOI： 10.2176/nmc.tn2012-0296

DOI： 10.1007/s10143-016-0759-y_references_DOI_M1AE5VuUOJwDQDKbUrpYOQX3JwJ

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A 79-year-old woman presented with a subarachnoid hemorrhage. Angiography revealed pseudoaneurysm formation due to rupture of a true saccular anterior communicating artery aneurysm. Coil embolization, limited to the true aneurysm, was performed successfully with a favorable clinical outcome. This procedure can be considered as an alternative treatment option for similar aneurysms in cases where surgical clipping is contraindicated.

DOI： 10.1136/bcr-2013-011006

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Language：Japanese   Publishing type：Research paper (scientific journal)   Publisher：The Japanese Congress of Neurological Surgeons  

Cerebral vasospasm is a well-documented occurrence of aneurysmal subarachnoid hemorrhage but has not been sufficiently analyzed in cases with arteriovenous malformation. Moreover, cerebral vasospasm following arteriovenous malformation rupture is a rare and critical complication. We describe a case of symptomatic cerebral vasospasm following cerebellar arteriovenous malformation rupture.<br>  An 8-year-old girl presented with deteriorated consciousness. Computed tomography revealed packed intraventricular and diffuse thin subarachnoid hemorrhages due to cerebellar arteriovenous malformation. Immediate endoscopic evacuation of intraventricular hemorrhage was performed. Subsequently, total arteriovenous malformation resection was achieved surgically after preoperative glue embolization. Twelve days posthemorrhage, cerebral angiogram revealed severe vasospasm at both internal carotid arteries. Although emergency intra-arterial fasudil hydrochloride injection and balloon angioplasty resolved the vasospasm successfully, postoperative magnetic resonance imaging showed bifrontal cerebral infarction.<br>  The characteristic features of cerebral vasospasm after arteriovenous malformation rupture are discussed. In the present case, packed intraventricular hemorrhage could strongly affect significant vasospasm. Treatment of patients with intraventricular hemorrhage related to arteriovenous malformations should consider the risk of severe delayed vasospasm.

DOI： 10.7887/jcns.23.909

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Edaravone (3-methyl-1-phenyl-2-pyrazolin-5-one) is a free radical scavenger used for acute ischemic stroke. However, it is not known whether edaravone works only as a free radical scavenger or possess other pharmacological actions. Therefore, we elucidated the effects of edaravone on human brain microvascular endothelial cells (HBMECs) by 2 dimensional fluorescence difference gel electrophoresis (2D-DIGE). We found 38 protein spots the intensity of which was significantly altered 1.3 fold on average (p< 0.05) by the edaravone treatment and successfully identified 17 proteins of those. Four of those 17 proteins were cytoskeleton proteins or cytoskeleton-regulating proteins. Therefore, we subsequently investigated the change of size and shape of the cells, the actin network, and the tight junction of HBMEC by immunocytochemistry. As a result, most edaravone-treated HBMECs became larger and rounder compared with those that were not treated. Furthermore, edaravone-treated HBMECs formed gathering zona occludens (ZO)-1, a tight junction protein, along the junction of the cells. In addition, we found that edaravone suppressed interleukin (IL)-1β-induced secretion of monocyte chemoattractant protein-1 (MCP-1), which was reported to increase cell permeability. We found a novel function of edaravone is the promotion of tight junction formations of vascular endothelial cells partly via the down-regulation of MCP-1 secretion. These data provide fundamental and useful information in the clinical use of edaravone in patients with cerebral vascular diseases.

DOI： 10.1016/j.brainres.2013.08.019

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Other Link： https://kaken.nii.ac.jp/grant/KAKENHI-PROJECT-24790563/

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Intracranial pressure (ICP) monitoring has been used widely for patients with intracranial hypertension. However, the data of mean ICP do not reflect various brain conditions correctly. Therefore, we performed ICP -waveform analysis to assess brain compliance. Data for ICP -waveform analysis were obtained by stereotactic intraventricle puncture. ICP waveform is expressed as a three-phase wave. Analyzed differential waveforms in a water intoxication model and continuous infusion models were evaluated respectively. In the water intoxication models, the second wave (P2) known to reflect compliance is elevated. ICP waveform analysis will be valuable for the assessment of the pathological condition of the brain.

DOI： 10.1007/978-3-7091-1434-6_41

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A 12-year-old boy had been known to have a small swelling in the left high vertex for several years. After a trivial head hit to the site of the swelling, the swelling enlarged gradually. A bone window CT scan showed a lesion having bubble-like lytic change in the left parietal bone. Similar changes, but small, were able to be pointed out in a CT scan taken seven years previously. In the following 13 months CT scans eventually revealed sequential increases to 3.5 cm in diameter. Surgical exploratory resection of the mass was performed. Intraoperatively, partial destruction of the outer skull table and a simple cyst with serous yellowish brown colored fluid were identified. There was no finding adherent to the diploic structure. The bone defect after excision was reconstructed by using a titanium plate. The patient was followed up for 2 years after the surgery. Bone window CT showed bony development of normal appearance. Histological examination showed the cyst wall consisted of fibrous connective tissue but there were neither epithelial nor endothelial cells. The histopathological diagnosis of SBC was most likely. SBC is relatively common in long bones, but rarely in flat bones. Only several cases of the SBC of cranial bone have been reported. Although a craniectomy for total excision followed by cranioplasty by resin was common, in cases of children, cyst removal with titanium plate application would be an alterative. SBC increasing in size after head injury is extremely rare, but clinicians may need to be aware of cystic skull bone tumors increasing in size after head injury.

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Diabetes mellitus in neurosurgical patients is known to be a disease with high risks and severe outcomes. However, the mechanism by which diabetes mellitus induces dysfunction of brain tissue is not well known. The hypothesis of this study was that the damage to brain microvasculature in diabetes mellitus results in impaired compliance of the brain. Pathological changes associated with type II diabetes were investigated using a rat model. Pathophysiological changes in diabetic brain tissue were also investigated to confirm cerebral compliance by analyzing intracranial pressure waveforms. Pathologic findings revealed thickening of the basement membrane and fibrous collagen infiltration into the inner basement membrane of the brain microvasculature in diabetes mellitus. Analysis of intracranial pressure waveforms revealed that the P2 portion increased in diabetic rats compared to the control and was increased further with the increase in intracranial pressure. Analysis of the differential pressure curve, with respect to time, demonstrated that intracranial elasticity showed a concomitant increase. Pathologic findings and intracranial pressure waveforms were consistent with changes in brain microvasculature in diabetes mellitus. The increase of elasticity of brain tissue in diabetes mellitus may exacerbate the damage of intracranial disease.

DOI： 10.1016/j.brainres.2012.03.061

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Intracerebral metastasis in osteosarcoma is extremely rare. A 14-year-old girl who had previously been operated upon for osteosarcoma of the femur presented with seizures and left hemiparesis. A right parietal lesion with calcification and brain oedema was found. After resection of the mass, pathology revealed an osteosarcoma metastasis.

DOI： 10.3109/02688697.2011.581771

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Language：Japanese   Publisher：The Japanese Congress of Neurological Surgeons  

Object: In order to predict the technical difficulties of coil embolization for paraclinoid aneurysms (PC-an), we retrospectively analized our clinical experience. Method: We analyzed 34 patients with 35 PC-an treated with endovascular techniques between 2001 and 2010. These aneurysms were classified into 4 groups on the basis of their projections visualized on angiograms as follows: ventral, 17 ; medial, 7 ; dorsal, 8 and lateral, 3. The size of the aneurysms and the angle of carotid siphon were measured on angiograms for each group. The levels of those aneurysm necks were classified as supraclinoid, clinoid and infraclinoid according to their relation to the anterior clinoid process. Angiographic outcome, volume embolization ratio (VER), number of microcatheters and microguidewires used and duration of endovascular procedure were evaluated for each group. Clinical outcomes were assessed using the Glasgow Outcome Scale (GOS). Result: The mean size of the aneurysms in the ventral, medial, dorsal and lateral groups was 4.1, 5.6, 6.7 and 8.4 mm, respectively. The mean angle of carotid siphon was more acute in the dorsal and lateral groups. The neck level was supraclinoid in 10, clinoid in 14 and infraclinoid in 11. The percentage of dorsal and lateral groups was larger in the supraclinoid level. Endovascular treatment was successfully performed in 91.4% cases with treatment complications including 3 ischemic events. The number of patients with clinical outcomes classified according to the GOS was as follows: good recovery, 31 ; moderately disabled, 2 ; severely disabled, 1 ; vegetative state, 0 and dead, 1. Complete obliteration was achieved in 70.6%, 57.1%, 32.5% and 0% patients in the ventral, medial, dorsal and lateral groups, respectively, and the corresponding VER was 37.6%, 32.3%, 24.8% and 16.4%. The number of microcatheters and microguidewires used was higher in the dorsal and lateral groups than that used in the other 2 groups. The duration of the procedures was also longer in the dorsal and lateral groups. Conclusion: Endovascular treatment is a safe and effective therapeutic alternative for PC-an. However, in dorsal and lateral PC-an, this treatment entails additional difficulties of handling microcatheters and microguidewires because of their anatomical specificity. Therefore, endovascular treatment for these aneurysms is occasionally associated with lower rates of complete obliteration and lower VER than those of ventral and medial PC-an.

DOI： 10.7887/jcns.21.481

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Language：Japanese   Publishing type：Research paper (scientific journal)   Publisher：The Japanese Congress of Neurological Surgeons  

The ultimate purpose of meningioma surgery is to achieve total tumor removal and functional recovery without complications. Various steps are required for successful tumor removal including a thorough preoperative imaging study, preoperative embolization, intraoperative monitoring, suitable positioning and craniotomy, selection of surgical approach and surgical instruments. In order to improve the surgical outcome, we introduce our method to utilize the Sugita multipurpose head frame and rake retractor. Intraoperative head rotation of up to 35 degrees makes the surgical approach less irritable to the brain thanks to the use of gravitational force. Various methods manipulating the rake retractor enable rapid tumor eradication with minimal brain damage.

DOI： 10.7887/jcns.21.931

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：The Japan Neurosurgical Society  

A 22-year-old woman developed an unruptured fusiform aneurysm of the internal carotid artery 7 months after being diagnosed with Wagener's granulomatosis. Intracranial aneurysmal formation is an extremely rare complication of Wegener's granulomatosis. This rare case of intracranial aneurysm was treated by endovascular balloon occlusion.

DOI： 10.2176/nmc.52.216

DOI： 10.3109/14397595.2015.1021950_references_DOI_FV6kbbCxGUQG2r7CIW04vjLyEI2

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Other Link： https://search.jamas.or.jp/link/ui/2013155946

Language：Japanese   Publisher：The Japanese Congress of Neurological Surgeons  

The pterional approach is arguably the most popular surgical approach for neurosurgeons. Therefore, we should understand and experience this approach properly. The other surgical approaches can be learned readily once this approach is mastered. The principle aspect of the pterional approach is an appropriate exposure of the parasellar area without damaging the brain and vessels. There are various surgical options based on the primary disease and patterns of the sylvian veins. We will discuss about methods for widening the pterional approach, including manipulation of the sylvian vein and sphenoparietal sinus, the temporopolar approach, optic unroofing, anterior clinoidectomy, resection of the tuberculum sellae, and section of the dural ring.

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Our patient presented with a mass lesion mimicking a meningioma. The mass was resected, but pathological examination confirmed a foreign body granuloma, which was caused by silk fibres used as tenting sutures 8 years previously. Herein, we describe the case and review the neurosurgical literature on intracranial foreign body granulomas.

DOI： 10.3109/02688697.2011.568641

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Language：Japanese   Publisher：The Japanese Society on Surgery for Cerebral Stroke  

We report a case of sylvian hematoma enlarging 3 days after neck clipping for a ruptured anterior communicating artery aneurysm, in the contralateral sylvian fissure to the operative approach.<br> This 65-year-old man was admitted with sudden loss of consciousness by ambulance. Angiography revealed a saccular aneurysm at the anterior communicating artery complex, measuring 2.3×2.4 mm and pointing inferiorly. The aneurysmal neck was successfully clipped by using the right pterional approach. To minimize predictable vasospasm, the hematoma in the left sylvian stem was removed. Postoperative CT scan showed a considerable decrease in hematoma in the basal cistern, but a slight decrease in the vertical portion of the left sylvian fissure. The patient’s consciousness gradually recovered, but deteriorated again 3 days after the operation. CT scan showed a large high-density area in the sylvian fissure suggesting unexpected enlargement of sylvian hematoma. A left fronto-temporal craniotomy was performed. When the subpial hematoma around the sylvial fissure was removed, a large amount of bloody cerebrospinal fluid (CSF) flowed out. The cavity containing bloody fluid was located in the temporal lobe. Postoperative course was uneventful. He recovered well, but moderate sensory aphasia remained.<br> Sylvian hematoma is rarely associated with ruptured anterior communicating artery aneurysms. Furthermore, there has been no report describing delayed onset sylvian hematoma as far as we are aware. The following mechanism was considered to explain this very rare condition. Removal of subarachnoid hematoma in the left sylvian fissure made a recovery of CSF flow up to the limen insulae, but CSF appeared to be blocked from entering the distal sylvian fissure by the thick subpial sylvian hematoma. Instead of normal CSF flow route, CSF may enter into the weakened subpial space to allow accumulation of bloody CSF in the temporal lobe. Subpial hematoma may act as a one-way valve. <br>

DOI： 10.2335/scs.38.119

DOI： 10.2176/nmc.cr2013-0025_references_DOI_OH1oPU7vPo4IBYCTMjkzCDCMhky

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Language：Japanese   Publishing type：Research paper (scientific journal)   Publisher：The Japanese Congress of Neurological Surgeons  

The pterional approach is arguably the most popular surgical approach for neurosurgeons. Therefore, we should understand and experience this approach properly. The other surgical approaches can be learned readily once this approach is mastered. The principle aspect of the pterional approach is an appropriate exposure of the parasellar area without damaging the brain and vessels. There are various surgical options based on the primary disease and patterns of the sylvian veins. We will discuss about methods for widening the pterional approach, including manipulation of the sylvian vein and sphenoparietal sinus, the temporopolar approach, optic unroofing, anterior clinoidectomy, resection of the tuberculum sellae, and section of the dural ring.

DOI： 10.7887/jcns.19.727

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Other Link： https://search.jamas.or.jp/link/ui/2011007571

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Language：Japanese   Publishing type：Research paper (scientific journal)   Publisher：The Japanese Congress of Neurological Surgeons  

Idiopathic thrombocytopenic purpura (ITP) is the most common autoimmune disease in women of childbearing age group. Although maternal antiplatelet antibodies might cross the placenta, they usually do not cause severe bleeding disturbances in the fetus. Occurrence of fetal intracranial hemorrhage is extremely uncommon. We report a case of a fetus developed intracranial hemorrhage at 34 weeks of gestational age, possibly secondary to maternal ITP. The hemorrhage was intra and periventricular, with the development of posthemorrhagic hydrocephalus. Cesarean section was performed at 35 weeks of gestation because of progression of hydrocephalus. In order to control hydrocephalus, Ommaya's reservoir was placed in the right anterior horn three days after birth, considering the poor general condition of the infant girl. Her level of consciousness suddenly decreased the following day. CT scan showed recurrence of intraventricular hemorrhage. She underwent platelet transfusion and repeated aspiration of bloody cerebrospinal fluid from the reservoir. Following this, her platelet count normalized gradually. Ventriculoperitoneal shunt was carried out successfully 2 months after birth. Thereafter she did not experience any hemorrhagic episodes. The problem of ITP of the mother in relation to pregnancy and its effects on the fetus and the newborn infant are discussed in the present report.

DOI： 10.7887/jcns.18.56_1

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Other Link： https://search.jamas.or.jp/link/ui/2009113188

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Language：Japanese   Publishing type：Research paper (scientific journal)   Publisher：The Japanese Society for Neuroendovascular Therapy  

<b>Objective</b>: Use of a catheter exchange technique for wide-necked large basilar tip aneurysms in which placement of a balloon catheter across the aneurysmal neck is difficult is described.<br><b>Case Report</b>: A 71-year-old woman presenting with severe headache and vomiting was diagnosed with a subarachnoid hemorrhage by CT on admission. Preoperative angiography indicated a large saccular aneurysm at the tip of the basilar artery, and coil embolization was performed. As the broad neck of the aneurysm was located between the basilar and left posterior cerebral arteries, a neck remodelling technique was necessary. However, placement of a balloon catheter was extremely complicated, and endovascular treatment failed, despite the use of different kinds of microguidewires and microcatheters on the first attempt. On the second attempt, a catheter exchange technique was used and the balloon catheter was able to be easily positioned. Successful embolization was achieved using the neck remodelling technique.<br><b>Technique</b>: First, a soft microcatheter was navigated through the basilar artery to the left posterior cerebral artery using a flexible microguidewire. Tips of the microguidewire and microcatheter were advanced to the distal part of the left posterior cerebral artery for stable positioning. The microguidewire was then exchanged for a long microguidewire, which was advanced into the microcatheter. The microcatheter was then removed over the wire. Next, a balloon catheter was advanced over the long microguidewire and positioned. Finary, coil embolization was achieved safely in the aneurysmal sac using the neck remodelling technique.<br><b>Conclusion</b>: A technique to bypass the aneurysmal neck to perform balloon-assisted endovascular treatment of large aneurysms with broad necks in which other methods fail to obtain access distal to the aneurysm was described. For cases in which placement of a balloon catheter is difficult, the catheter exchange technique is considered to be highly effective.

DOI： 10.5797/jnet.2.238

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Other Link： https://search.jamas.or.jp/link/ui/2009159151

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OBJECTIVE: A rare case of ruptured kissing aneurysms on the right internal carotid-posterior communicating artery (ICPCA) and -anterior choroidal artery (ICAchA) is reported. CASE: A 47-year-old female was transferred to our hospital because of subarachnoid hemorrhage (SAH). Cerebral angiography revealed two aneurysms on the right ICPCA and ICAchA. Right frontotemporal craniotomy was performed to obliterate them on the day of admission. Despite the presence of angiographical cleavage, these two aneurysms were attached to each other tightly, and it was extremely difficult to dissect the space between them and premature rupture occurred. A Sugita long straight clip was inserted parallel to internal carotid artery to obliterate the body of ICAchA aneurysm and the neck of ICPCA aneurysm. Another straight clip was applied to the neck of the former aneurysm. Both PCA and AchA could be secured successfully. Postoperatively, although she developed symptomatic vasospasm on the 10th day, she discharged without any neurological deficits 40 days later. CONCLUSIONS: Because of the difficulty in dissection of aneurysms, the operation for kissing aneurysms has been recognized as hazardous and challenging since Jefferson. We emphasize that a clipping technique described above should be kept in mind as a safe value, though meticulous dissection of each aneurysmal neck followed by independent neck clipping is reasonable.

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Language：Japanese   Publishing type：Research paper (scientific journal)   Publisher：The Japanese Congress of Neurological Surgeons  

A 36-year-old woman complained of a sudden headache, right hemiparesis, and visual disturbances. A CT scan showed a subarachnoid hemorrhage and a round, high-density mass near the left crural cistern. The initial cerebral angiogram revealed a large aneurysm in the left P2-3 segment of the posterior cerebral artery (PCA). The patient was treated conservatively. A MRI, taken 11 days after the onset, showed a partially thrombosed large aneurysm. The second angiogram, taken one month after the onset, showed complete occlusion of the aneurysm without visualization of the left distal PCA. The third angiogram, taken two months after the onset, showed recanalization of the distal PCA, and 3D-CT angiogram at two and a half months after the onset showed reappearance of the neck of the aneurysm. To prevent the aneurysm from rerupturing, parent artery occlusion (PAO) of the aneurysm was performed using endovascular surgery. Both the aneurysm and the P2-3 segment of the left PCA were obliterated. However, since collateral circulation through the parietal branches of the middle cerebral artery filled the distal PCA, no severe complications appeared following PAO. The patient was discharged with slight right hemiparesis, but no visual disturbances. Only a few cases have been reported involving the spontaneous disappearance of aneurysms on cerebral angiograms. Even rarer are cases involving the reappearance of aneurysms. In the past, surgical clipping was indicated for the treatment of P2-3 segment aneurysms. Recently, however, PAO has been performed using endovascular techniques. It has been reported PAO using endovascular techniques is a relatively safe treatment for P2-3 segment aneurysms, because the rich collateral blood supply to the PCA provides good ischemic stress tolerance.

DOI： 10.7887/jcns.13.711

DOI： 10.2335/scs.38.52_references_DOI_BZxDfl4psqSAVwvx6wOMXR5gV3I

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Other Link： https://search.jamas.or.jp/link/ui/2005019196