Updated on 2024/03/26

写真a

 
YOKOYAMA Kinya
 
Organization
Nagoya University Hospital Neurosurgery Assistant Professor
Graduate School
Graduate School of Medicine
Title
Assistant Professor

Degree 1

  1. 博士(医学) ( 2018.4   名古屋大学 ) 

Research Interests 1

  1. cereblovascular disease

 

Papers 54

  1. Effect of thin-split encephalomyosynangiosis on transient neurological events in revascularization surgery for pediatric patients with moyamoya disease.

    Ishii K, Kanamori F, Araki Y, Uda K, Yokoyama K, Mamiya T, Takayanagi K, Goto S, Nishihori M, Izumi T, Saito R

    Journal of neurosurgery. Pediatrics   Vol. 33 ( 1 ) page: 29 - 34   2024.1

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    Language:English   Publisher:Journal of Neurosurgery: Pediatrics  

    OBJECTIVE Transient neurological events (TNEs) are among the most important events after revascularization surgery in pediatric patients with moyamoya disease (MMD). Although hemodynamic changes and crying are representative factors of TNEs, brain compression by encephalomyosynangiosis (EMS) is another important cause of TNEs. Therefore, the authors assumed that making the EMS as thin as possible reduces the frequency of TNEs. However, thin-split EMS can lead to insufficient development of collateral vessels. This study aimed to evaluate the effects of thin-split EMS in combined revascularization surgery on postoperative outcomes in pediatric patients with MMD. METHODS The authors retrospectively included 56 consecutive combined revascularization surgeries in the anterior cerebral circulation in pediatric patients with MMD. These surgeries were classified into the former group and thin-split EMS group. The temporal muscle was halved in the former EMS group and split as thinly as possible in the thin-split EMS group. The authors performed between-group comparisons of postoperative stroke events and TNEs during the acute period and the development of collateral flow and stroke events during the chronic period. RESULTS Former and thin-split EMS procedures were performed in 37 and 19 patients, respectively. TNEs without crying or hemodynamic changes were observed significantly less frequently in the thin-split EMS group than in the former EMS group (0 [0.0%] in the thin-split EMS group vs 9 [24.3%] in the former EMS group, p= 0.021). There were no significant between-group differences in the development of indirect bypass during the chronic period (good: 34 [91.9%] and poor: 3 [8.1%] in the former EMS group vs good: 16 [84.2%] and poor: 3 [15.8%] in the thin-split EMS group; p= 0.397). Additionally, there were no significant between-group differences in the incidence of chronic clinical events, including death or stroke. CONCLUSIONS Thin-split EMS can reduce TNEs that do not accompany crying or hemodynamic changes. Furthermore, the procedure has sufficient prevention effects against stroke events during the chronic postoperative period in pediatric patients with MMD.

    DOI: 10.3171/2023.8.PEDS23295

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  2. Characteristics of donor vessels and cerebral blood flow in the chronic phase after combined revascularization surgery for moyamoya disease

    Mamiya, T; Araki, Y; Taoka, T; Fujita, N; Yokoyama, K; Uda, K; Muraoka, S; Kanamori, F; Takayanagi, K; Ishii, K; Nishihori, M; Izumi, T; Kato, K; Saito, R

    CLINICAL NEUROLOGY AND NEUROSURGERY   Vol. 236   page: 108110   2024.1

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    Language:English   Publisher:Clinical Neurology and Neurosurgery  

    Objective: This study aimed to analyze whether the development of donor vessels after combined revascularization surgery for moyamoya disease (MMD) is related to cerebral blood flow (CBF) changes. Methods: We retrospectively reviewed the charts of 11 adult (12 hemispheres) and 13 pediatric (19 hemispheres) patients who underwent combined revascularization in our department. The total vessel cross-sectional area (TVA) was the sum of the cross-sectional areas of the superficial temporal, middle meningeal, and deep temporal arteries imaged using time-of-flight magnetic resonance angiography. The ipsilateral relative CBF (RCBF) on the brain surface in the craniotomy area was calculated by single-photon emission computed tomography. ΔTVA and ΔRCBF were defined as the preoperative and postoperative ratios of TVA and RCBF, and their correlations were analyzed in adult and pediatric patients. Results: The TVA and RCBF showed a significant increase after surgery, regardless of the age group. However, there was no significant correlation between ΔTVA and ΔRCBF in either the adult or pediatric groups. While the adult group exhibited significantly higher ΔRCBF values compared to the pediatric group (p < 0.01, r = −0.44), the ΔTVA values were higher in the pediatric group compared to the adult group (p = 0.06). Conclusions: In the chronic phase after combined revascularization surgery for MMD, the development of measurable TVA of donor vessels does not necessarily correlate with an increase in CBF around the craniotomy area.

    DOI: 10.1016/j.clineuro.2023.108110

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  3. Higher abundance of Campylobacter in the oral microbiome of Japanese patients with moyamoya disease

    Takayanagi, K; Kanamori, F; Ishii, K; Yokoyama, K; Araki, Y; Sumitomo, M; Maeda, S; Goto, S; Ota, S; Nagata, Y; Nishihori, M; Maesawa, S; Izumi, T; Takasu, S; Saito, R

    SCIENTIFIC REPORTS   Vol. 13 ( 1 ) page: 18545   2023.10

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    Genetic factors alone cannot explain the pathophysiology of moyamoya disease (MMD), and environmental factors such as an immune response are thought to be involved. Oral and gut microbiomes have attracted attention as environmental factors in the pathophysiology of some vascular and autoimmune diseases. However, the relationship between MMD and these microbiomes is yet to be thoroughly investigated. This prospective case–control study aimed to compare the microbiomes of Japanese patients with MMD with those of healthy individuals to identify the specific bacteria involved in MMD. Saliva and fecal samples were collected from 16 patients with MMD who had not undergone revascularization surgery. Fifteen healthy individuals were matched for age, sex, and body mass index. The microbiomes were determined using 16S rRNA sequencing and analyzed using QIIME2. Differentially abundant microbes were identified using LEfSE and ANCOM-BC. In the oral microbiome, the two analytical methods showed that Campylobacter was more abundant in patients with MMD than in healthy individuals. Differences in the gut microbiome were smaller than those in the oral microbiome. In conclusion, the oral microbiome profiles of patients with MMD significantly differ from those of healthy individuals. Campylobacter spp. could be a substantial environmental factor in the pathophysiology of MMD.

    DOI: 10.1038/s41598-023-45755-3

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  4. Transarterial embolization and transvenous embolization for transverse-sigmoid sinus dural arteriovenous fistulas with cortical venous reflux: A comparative study

    Tsukada, T; Izumi, T; Nishihori, M; Araki, Y; Uda, K; Yokoyama, K; Saito, R

    INTERVENTIONAL NEURORADIOLOGY     page: 15910199231195135   2023.8

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    Language:English   Publisher:Interventional Neuroradiology  

    Background: Dural arteriovenous fistulas (DAVFs) with cortical venous reflux (CVR) carry a high risk for neurological sequelae or death. Recently, transverse-sigmoid sinus DAVFs were shown as good indications for transarterial embolization (TAE) with ONYX. Here, we compared the effectiveness and safety of conventional transvenous embolization (TVE) with those of TAE with ONYX for transverse-sigmoid sinus DAVFs with CVR. Methods: Sixty-one patients with transverse-sigmoid sinus DAVFs were treated from April 2013 to May 2020. Among them, 37 patients with CVR were included. Transarterial embolization and TVE were compared in terms of complete occlusion and residual CVR immediately after treatment, complications with worsening modified Rankin Scale (mRS) ≥ 1, amount of contrast media used during treatment, radiation exposure, and surgical procedure time. Results: Ten patients were treated with 10 TAEs using ONYX and 27 patients with 29 TVEs. Transarterial embolization and TVE showed no differences in the overall complete occlusion rate (80% [8/10 patients] vs. 80% [23/27], respectively), whereas the residual rate of existing CVR was 10% (1/10 patient) vs. 3.4% (1/27) in the TAE and TVE groups, respectively. No complications with worsening mRS ≥1 occurred in either group. Among the parameters of amount of contrast media, radiation dose, and operative time, only radiation dose in the TAE group was lower than that in the TVE group (median: 2239 mGy vs. 3268 mGy, respectively; p = 0.07). Conclusion: For transverse-sigmoid sinus DAVFs with CVR, TAE treatment reduced radiation exposure. However, both TAE and TVE achieved high complete occlusion rates and low complication rates.

    DOI: 10.1177/15910199231195135

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  5. Moyamoya disease-specific extracellular vesicle-derived microRNAs in the cerebrospinal fluid revealed by comprehensive expression analysis through microRNA sequencing

    Ota, S; Yokoyama, K; Kanamori, F; Mamiya, T; Uda, K; Araki, Y; Wakabayashi, T; Yoshikawa, K; Saito, R

    ACTA NEUROCHIRURGICA   Vol. 165 ( 8 ) page: 2045 - 2055   2023.8

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    Language:English   Publisher:Acta Neurochirurgica  

    Purpose: To examine the specific changes that occur in the expression levels of extracellular vesicle-derived microRNAs (miRNAs) in intracranial cerebrospinal fluid (CSF) in moyamoya disease. Methods: Patients with arteriosclerotic cerebral ischemia were used as controls to eliminate the effects of cerebral ischemia. Intracranial CSF was collected from moyamoya disease and control patients during bypass surgery. Extracellular vesicles (EVs) were extracted from the CSF. Comprehensive expression analysis of miRNAs extracted from EVs by next-generation sequencing (NGS) and validation by quantitative reverse transcription-polymerase chain reaction (qRT-PCR) was performed. Results: Experiments were conducted on eight cases of moyamoya disease and four control cases. In the comprehensive miRNA expression analysis, 153 miRNAs were upregulated, and 98 miRNAs were downregulated in moyamoya disease compared to the control cases (q-value < 0.05 and |log2 fold change|> 1). qRT-PCR performed on the four most variable miRNAs (hsa-miR-421, hsa-miR-361-5p, hsa-miR-320a, and hsa-miR-29b-3p) associated with vascular lesions among the differentially expressed miRNAs gave the same results as miRNA sequencing. On gene ontology (GO) analysis for the target genes, cytoplasmic stress granule was the most significant GO term. Conclusions: This study is the first comprehensive expression analysis of EV-derived miRNAs in the CSF of moyamoya disease patients using NGS. The miRNAs identified here may be related to the etiology and pathophysiology of moyamoya disease.

    DOI: 10.1007/s00701-023-05579-6

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  6. Long noncoding RNAs: potential targets to increase understanding of moyamoya pathogenesis Response

    Mamiya, T; Kanamori, F; Yokoyama, K

    JOURNAL OF NEUROSURGERY   Vol. 139 ( 2 )   2023.8

  7. Clinical Efficiency of an Artificial Intelligence-Based 3D-Angiography for Visualization of Cerebral Aneurysm: Comparison with the Conventional Method

    Ishikawa, K; Izumi, T; Nishihori, M; Imaizumi, T; Goto, S; Suzuki, K; Yokoyama, K; Kanamori, F; Uda, K; Araki, Y; Saito, R

    CLINICAL NEURORADIOLOGY   Vol. 33 ( 4 ) page: 1143 - 1150   2023.7

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    Purpose: Artificial intelligence (AI)-based three-dimensional angiography (3D-A) was reported to demonstrate visualization of cerebral vasculature equivalent to that of three-dimensional digital subtraction angiography (3D-DSA). However, the applicability and efficacy of the AI-based 3D‑A algorithm have not yet been investigated for 3D-DSA micro imaging. In this study, we evaluated the usefulness of the AI-based 3D‑A in 3D-DSA micro imaging. Materials and Methods: The 3D-DSA micro datasets of 20 consecutive patients with cerebral aneurysm (CA) were reconstructed with 3D-DSA and 3D‑A. Three reviewers compared 3D-DSA and 3D‑A in terms of qualitative parameters (degrees of visualization of CA and the anterior choroidal artery [AChA]) and quantitative parameters (aneurysm diameter, neck diameter, parent vessel diameter, and visible length of AChA). Results: Qualitative evaluation of diagnostic potential revealed that visualization of CA and the proximal to middle parts of the AChA with 3D‑A was equal to that with conventional 3D-DSA; in contrast, visualization of the distal part of the AChA was lower with 3D‑A than with 3D-DSA. Further, regarding quantitative evaluation, the aneurysm diameter, neck diameter, and parent vessel diameter were comparable between 3D‑A and 3D-DSA; in contrast, the visible length of the AChA was lower with 3D‑A than with 3D-DSA. Conclusions: The AI-based 3D‑A technique is feasible and evaluable visualization of cerebral vasculature with respect to quantitative and qualitative parameters in 3D-DSA micro imaging. However, the 3D‑A technique offers lower visualization of such as the distal portion of the AChA than 3D-DSA.

    DOI: 10.1007/s00062-023-01325-8

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  8. Long noncoding RNA profile of the intracranial artery in patients with moyamoya disease.

    Mamiya T, Kanamori F, Yokoyama K, Ota A, Karnan S, Uda K, Araki Y, Maesawa S, Yoshikawa K, Saito R

    Journal of neurosurgery   Vol. 138 ( 3 ) page: 709 - 716   2023.3

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    OBJECTIVE Moyamoya disease (MMD) is a rare cerebrovascular disease characterized by progressive stenosis of the internal carotid artery (ICA) and secondary formation of collateral vessels. Revascularization surgery is performed in patients with MMD to prevent stroke; however, the pathogenesis of MMD remains unknown. Recently, long noncoding RNAs (lncRNAs) have been found to play a key role in gene regulation and are implicated in various vascular diseases. However, the lncRNA expression profile in MMD lesions has not been investigated. In this study the authors aimed to determine the characteristics of lncRNA expression in MMD lesions. METHODS The authors collected microsamples of the middle cerebral artery (MCA) from patients with MMD (n = 21) and patients with control conditions (n = 11) who underwent neurosurgical treatment. Using microarray experiments, the authors compared the profiles of lncRNA expression in the MCAs of the MMD and control patient groups and identified differentially expressed lncRNAs (fold change > 2, q < 0.05). In addition, the neighboring coding genes, whose transcription can be regulated in cis by the identified differentially expressed lncRNAs, were investigated and Gene Ontology (GO) analysis was applied to predict associated biological functions. RESULTS The authors detected 308 differentially expressed lncRNAs (fold change > 2, q < 0.05), including 306 upregulated and 2 downregulated lncRNAs in the MCA from patients with MMD. Regarding the prediction of biological function, GO analyses with possible coding genes whose transcription was regulated in cis by the identified differentially expressed lncRNAs suggested involvement in the antibacterial humoral response, T-cell receptor signaling pathway, positive regulation of cytokine production, and branching involved in blood vessel morphogenesis. CONCLUSIONS The profile of lncRNA expression in MMD lesions was different from that in the normal cerebral artery, and differentially expressed lncRNAs were identified. This study provides new insights into the pathophysiology of MMD.

    DOI: 10.3171/2022.5.JNS22579

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  9. Antiplatelet therapy discontinuation after stent-assisted coil embolization for intracranial aneurysms: a single-center, long-term, retrospective, observational study

    Goto S., Izumi T., Nishihori M., Imai T., Araki Y., Kanamori F., Uda K., Yokoyama K., Saito R.

    Journal of Neurosurgery   Vol. 138 ( 3 ) page: 724 - 731   2023.3

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    OBJECTIVE The protocol for antiplatelet therapy after stent-assisted coil embolization (SACE) for intracranial aneurysms is not well established. In particular, the indications for single antiplatelet therapy (SAPT) discontinuation remain controversial. The authors investigated the long-term outcomes of SAPT discontinuation after SACE among patients at a single institution. METHODS Patients who underwent SACE during the period from 2010 to 2020 and who were followed up for > 1 year were included in this study. The delayed ischemic and hemorrhagic complication rates were examined during follow-up. Moreover, the risk factors of antiplatelet therapy reduction or discontinuation and the outcomes of SAPT discontinuation were examined. RESULTS In total, 240 patients were included in the analysis. The average patient age was 60.3 years, and the average follow-up period was 46.7 months. Nine (3.8%) patients presented with symptomatic delayed ischemic complication, and 3 (1.3%) patients experienced a decline in modified Rankin Scale score. The stent configuration (T- or Y-stent) was the only risk factor associated with delayed ischemic complication (p < 0.001). SAPT was discontinued in 147 (71.7%) of 205 patients who were followed up for > 2 years, and no ischemic complications were observed. CONCLUSIONS It is safe to discontinue SAPT in patients without ischemic complications and with stable intraaneurysmal signals on MRA 2 years after SACE. The T- or Y-stent is a high-risk factor for delayed ischemic complications, and antiplatelet therapy reduction or discontinuation should be cautiously considered.

    DOI: 10.3171/2022.6.JNS22815

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  10. Characteristic image on cerebral angiography in ruptured blood blister-like aneurysms

    Kato Naoki, Izumi Takashi, Nishihori Masahiro, Goto Shunsaku, Araki Yoshio, Yokoyama Kinya, Saito Ryuta

    CLINICAL NEUROLOGY AND NEUROSURGERY   Vol. 225   page: 107583   2023.2

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    Objective: To evaluate the static and dynamic features of blood blister-like aneurysms (BBAs) using cerebral angiography to identify characteristic features to improve the diagnosis of these uncommon aneurysms. Methods: Digital subtraction angiography (DSA) images were compared between patients with BBAs (n = 12, group A) and patients with unruptured paraclinoid aneurysms ≤ 5 mm in size treated by endovascular procedures (n = 12, group B). DSA images were assessed for irregularities in the diameter of the parent artery and delayed inflow and outflow of contrast medium in the aneurysm. Enlargement of the aneurysm and morphological changes from the first assessment were also evaluated in patients with BBAs. Results: Compared to the group B, group A had a higher proportion of irregular vessel diameter (p = 0.013) and the delayed contrast medium outflow (p = 0.014). As well, stagnation of contrast medium along the aneurysm wall was a characteristic finding of BBAs, even for small aneurysms. Conclusion: Irregular morphological features of the parent artery and delayed contrast medium outflow as characteristic findings of ruptured BBAs may improve the diagnosis of these uncommon aneurysms, which remains challenging in practice.

    DOI: 10.1016/j.clineuro.2022.107583

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  11. Four-dimensional digital subtraction angiography for the vascular anatomical diagnosis of dural arteriovenous malformation: Comparison with the conventional method

    Ishikawa Kojiro, Nishihori Masahiro, Izumi Takashi, Oshima Ryosuke, Uemura Takeshi, Kanamori Fumiaki, Uda Kenji, Yokoyama Kinya, Araki Yoshio, Saito Ryuta

    INTERVENTIONAL NEURORADIOLOGY     page: 15910199221145526   2022.12

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    Background: Two-dimensional digital subtraction angiography (2D-DSA) and conventional three-dimensional digital subtraction angiography (3D-DSA) are used for the detailed analysis of dural arteriovenous fistula (DAVF). Recently, four-dimensional digital subtraction angiography (4D-DSA), a novel technology, has been attracting attention. The current study aimed to evaluate the capability of 4D-DSA in assessing anatomical angioarchitecture in DAVF. Methods: In total, 10 consecutive patients with DAVF who underwent 3D-DSA and 4D-DSA at a single institution were included in the analysis. Initially, one-slice multiplanar reconstruction (MPR) images obtained via 4D-DSA and 3D-DSA were compared to investigate the visibility of the feeding artery, fistulous point, and draining vein. Next, 4D-DSA images alone were compared and evaluated with and the MPR images of conventional 3D-DSA in terms of diagnosis of the angioarchitecture. Results: In total, six men and four women (with a mean age of 65.6 ± 10.0 years) were included in the study. The MPR image obtained via 3D-DSA had a significantly better visibility of the feeding artery and fistulous point than that acquired via 4D-DSA (p < 0.05). As for the draining vein, the score was equivalent and not significant. The diagnosis of the vascular architecture of only 4D-DSA images was nearly equivalent to that of MPR images of 3D-DSA. There were no inter-rater differences. Conclusion: The MPR images obtained via 4D-DSA may be slightly inferior to those acquired via 3D-DSA in identifying fine angioarchitecture in DAVF. However, they were comparable in terms of diagnostic accuracy.

    DOI: 10.1177/15910199221145526

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  12. Abnormal foreshortening of a Flow Re-Direction Endoluminal Device caused by in-stent thrombosis immediately after deployment br

    Otsuka Takafumi, Izumi Takashi, Nishihori Masahiro, Tsukada Tetsuya, Goto Shunsaku, Ikezawa Mizuka, Kato Naoki, Nakano Mizuki, Uda Kenji, Yokoyama Kinya, Araki Yoshio, Saito Ryuta

    NAGOYA JOURNAL OF MEDICAL SCIENCE   Vol. 84 ( 4 ) page: 884 - 889   2022.11

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    Thromboembolic complications are a concern in the treatment of cerebral aneurysms using a flow diverter. In this study, we report a case of abnormal foreshortening of a Flow Re-Direction Endoluminal Device (FRED) caused by in-stent thrombosis immediately after its deployment. A 72-year-old woman had a large cavernous carotid aneurysm, which caused ptosis and diplopia. FRED deployment was planned, and dual antiplatelet therapy was initiated 2 weeks before the procedure. Under systemic heparinization, FRED was deployed with local compaction over the aneurysm orifice. Cone-beam computed tomography subsequently revealed slightly poor wall apposition at the proximal side. While the balloon catheter was prepared for angioplasty, the stent became abnormally foreshortened, the proximal side slipped into the aneurysm, and the internal carotid artery became occluded. FRED was removed using a snare wire, and recanalization was obtained. The lumen of the removed FRED was filled with thrombus. The antiplatelet therapy was changed to triple regimen, and a Pipeline Flex embolization device was placed 1 month later. At that time, no thromboembolic complications were noted. It was considered that thrombotic occlusion was followed by foreshortening of FRED on the distal side because of antegrade blood flow. Multiple factors, such as increased mesh density by locally compacted stent deployment, slightly poor wall apposition, clopidogrel resistance, and the dual-layer structure of FRED, may have been involved in thrombus formation.

    DOI: 10.18999/nagjms.84.4.884

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  13. Efficacy of comparing coil behavior and distribution using the silicone aneurysm model: difference of coil distribution in the early filling stage

    Goto Shunsaku, Izumi Takashi, Nishihori Masahiro, Araki Yoshio, Yokoyama Kinya, Uda Kenji, Saito Ryuta

    NAGOYA JOURNAL OF MEDICAL SCIENCE   Vol. 84 ( 4 ) page: 762 - 771   2022.11

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    This study sought to establish an experimental aneurysm model of visualizing coil insertion using radiolucent nylon coils. Moreover, this study aimed to clarify the characteristics and differences of each coil and use them clinically as indices of coil selection. The coil insertion test was performed on the 10 mm spherical silicone aneurysm model filled to a nylon coil volume embolization ratio of 11.8%. Five types of coil were randomly tested six times, and the distribution of the coils was analyzed by fluoroscopy imaging. Indices of “Area (mm2),” “Feret’s diameter (mm),” and “Circularity” were calculated from the fluoroscopic images. Among the indices, only “Area” showed a significant difference between coils (p = 0.002). On multivariate analysis, “Area” of the ED Infini was larger than those of Target XL soft and Galaxy G3 (p = 0.018 and 0.026, respectively). Furthermore, the area of the 360 soft was larger than that of G3 (p = 0.049). Analysis of the correlation between these values and the coil configuration showed that “Area” was negatively correlated with the stock-wire diameter (r = −0.50; p = 0.004) and primary coil configuration (r = −0.65; p < 0.001). When inserting the coils in the early stage, although the difference between each coil is relatively difficult to obtain, knowledge on the proper use of the coils with differences in characteristics can help in selecting the coil most appropriate for the conditions.

    DOI: 10.18999/nagjms.84.4.762

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  14. The usefulness and safety of dexmedetomidine for postoperative sedation in pediatric patients with moyamoya disease

    Kanamori Fumiaki, Araki Yoshio, Yokoyama Kinya, Uda Kenji, Kurimoto Michihiro, Shiba Yoshiki, Mamiya Takashi, Takayanagi Kai, Ishii Kazuki, Nishihori Masahiro, Izumi Takashi, Okamoto Sho, Saito Ryuta

    JOURNAL OF NEUROSURGERY-PEDIATRICS   Vol. 30 ( 3 ) page: 301 - 307   2022.9

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    OBJECTIVE After revascularization surgery in pediatric patients with moyamoya disease (MMD), resting and avoiding crying is important. However, this inaction is often difficult because of pain or anxiety. Dexmedetomidine (DEX), which has sedative and analgesic properties, may be useful in reducing those uncomfortable conditions; however, its common side effects include bradycardia and hypotension, which have a risk of decreasing the cerebral blood flow. The aim of this study was to investigate the efficacy and safety of using DEX for pediatric patients with MMD in the acute period after revascularization surgery. METHODS This retrospective study included pediatric patients with MMD who underwent revascularization surgery. Based on whether DEX was used for light sedation during postoperative days (PODs) 0–1 after extubation, the patients were divided into DEX or control groups. For neurological outcomes, the incidence of symptomatic cerebral infarction and transient neurological events (TNEs) during PODs 0–1 and the entire hospitalization were investigated. In addition, the Richmond Agitation-Sedation Scale (RASS) was used to assess the effect of DEX, and bradycardia and hypotension were evaluated as side effects. RESULTS A total of 84 surgical procedures were included in this study (27 in the DEX group and 57 in the control group). During PODs 0–1, symptomatic infarction was not observed in either group. The incidence of TNEs was almost the same in both groups: 2 (7.4%) of the 27 procedures in the DEX group and 4 (7.0%) of the 57 procedures in the control group (p > 0.99). Moreover, the incidences of symptomatic infarction and TNEs during the entire hospitalization did not differ significantly (symptomatic infarction, p > 0.99; TNEs, p = 0.20). Regarding the DEX effect, the median RASS scores during PODs 0–1 were −1.0 (drowsy) in the DEX group and +1.0 (restless) in the control group, showing a significant difference (p < 0.01). Regarding side effects, bradycardia was observed only in 3 (11.1%) of the 27 procedures in the DEX group (p = 0.03), and hypotension was not observed in any of the cases. CONCLUSIONS In pediatric patients with MMD who are extubated after revascularization surgery, DEX produced appropriate light sedation and analgesia. The risk for symptomatic infarction is almost the same in cases in which DEX is used and those in which it is not; however, neurosurgeons should be cautious of bradycardia and TNEs as potential side effects.

    DOI: 10.3171/2022.6.PEDS2241

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  15. Medical Management of a Mural Thrombus Inducing Repeated Ischemic Strokes in a Patient with Congenital Afibrinogenemia

    Nishihori Masahiro, Araki Yoshio, Suzuki Nobuaki, Tamura Shogo, Hattori Mayo, Izumi Takashi, Goto Shunsaku, Yokoyama Kinya, Uda Kenji, Matsushita Tadashi, Saito Ryuta

    JOURNAL OF STROKE & CEREBROVASCULAR DISEASES   Vol. 31 ( 7 ) page: 106526   2022.7

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    Objectives: Congenital afibrinogenemia is an autosomal recessive inherited disorder that can cause thrombotic as well as hemorrhagic events. We describe a case of repeated mild ischemic strokes due to a mural thrombus in the carotid artery and our medical treatment. Case description: A 49-year-old woman with congenital afibrinogenemia developed two minor ischemic strokes in two months. Clinical images revealed scattered fresh infarcts in the right middle cerebral artery region and mild cervical carotid artery stenosis. The risk for surgical treatment was considered to be extraordinarily high. The patient was treated with 100 mg/day of aspirin and 3 g fibrinogen infusion every two weeks. After the one-year course of medication, the mural thrombus gradually decreased, and there were no bleeding or ischemic stroke events. Conclusion: This case report highlights the successful treatment of an ischemic stroke in a patient with a congenital afibrinogenemia with an antiplatelet agent and fibrinogen replacement. There are no guidelines for managing ischemic stroke in patients with congenital afibrinogenemia, and further studies are needed.

    DOI: 10.1016/j.jstrokecerebrovasdis.2022.106526

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  16. Changes in cerebral blood flow in the postoperative chronic phase after combined cerebral revascularization for moyamoya disease with ischaemic onset

    Araki Yoshio, Mamiya Takashi, Fujita Naotoshi, Uda Kenji, Yokoyama Kinya, Kanamori Fumiaki, Takayanagi Kai, Ishii Kazuki, Nishihori Masahiro, Takeuch Kazuhito, Tanahashi Kuniaki, Nagata Yuichi, Nishimura Yusuke, Tanei Takafumi, Sumitomo Masaki, Okamoto Sho, Izumi Takashi, Kato Katsuhiko, Saito Ryuta

    NEUROSURGICAL REVIEW   Vol. 45 ( 3 ) page: 2471 - 2480   2022.6

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    The purpose of this study was to examine the effects of combined revascularization for ischaemic-onset moyamoya disease (MMD) on cerebral haemodynamics by comparing cerebral blood flow (CBF) during the postoperative chronic phase with preoperative CBF. A retrospective cohort of 24 MMD patients (representing 31 surgeries) who received single photon emission computed tomography (SPECT) before and more than 6 months after surgery was investigated. The CBF value of each vascular territory was extracted from SPECT data, and the value relative to the ipsilateral cerebellar value (relative CBF, or RCBF) was calculated. The correlation between the revascularization effect and the proportional change in RCBF before and after surgery (calculated as post-RCBF/pre-RCBF (“post/pre-RCBF”)) was analysed. Furthermore, the relationships between changes in neurological symptoms and post/pre-RCBF were investigated. Preoperative and postoperative mean RCBF values were 0.92 ± 0.15 and 0.96 ± 0.13 (p = 0.619) in the anterior cerebral artery territory, 0.99 ± 0.17 and 1.01 ± 0.17 (p = 0.598) in the middle cerebral artery territory and 1.15 ± 0.22 and 1.14 ± 0.19 (p = 0.062) in the posterior cerebral artery territory, respectively. No significant correlation was found between the revascularization score and post/pre-RCBF. The revascularization score and post/pre-RCBF were not significant predictors of worsening neurological symptoms postoperatively. No significant change in RCBF was observed in any vascular territory in the chronic phase after revascularization. Combined revascularization may assist in the redirection of blood flow from the internal to the external carotid system and contribute to CBF maintenance.

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  17. Evaluation of the differences in pressure applied to the vessel wall by different types of balloon remodeling microcatheters in an experimental model

    Ikezawa Mizuka, Izumi Takashi, Nishihori Masahiro, Tsukada Tetsuya, Tamari Yosuke, Araki Yoshio, Yokoyama Kinya, Uda Kenji, Goto Shunsaku, Kropp Asuka E., Otsuka Takafumi, Kato Naoki, Nakano Mizuki, Saito Ryuta

    INTERVENTIONAL NEURORADIOLOGY   Vol. 28 ( 3 ) page: 323 - 331   2022.6

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    Background: We examined compliance differences among balloon remodeling microcatheters, which have not been established previously. Methods: Straight and 120° angulated vascular models were created in a 3 mm diameter tube with 3 mm hole (vascular model A), a tube with a 4 mm hole (vascular model B), and a 4 mm diameter tube (vascular model C). We compared the pressure exerted when each balloon was herniated 1 or 2 mm between three compliant balloons (SHOURYU SR, TransForm C, and Scepter C) and four super-compliant balloons (HyperForm, SHOURYU HR, TransForm SC, and Scepter XC). Results: In vascular model A, there was a significant difference in the pressure exerted by compliant balloons and super-compliant balloons in both the straight and angulated models. In the straight model (1 and 2 mm), the lowest pressure was exerted by HyperForm (super-compliant balloons group) and SHOURYU SR (compliant balloons group). The lowest pressure was exerted in the angulated model by HyperForm (super-compliant balloons group) and Scepter C (compliant balloons group). The Scepter balloon exerted higher pressure in the straight model than other balloon remodeling microcatheters but less in the angulated model. In vascular model B, the pressure decreased in all balloons compared with model A. In vascular model C, the pressure increased in all balloons compared with model A. Conclusions: Pressure differed across balloon remodeling microcatheters. In addition, vessel shape and diameter, and hole size, affected the results. Our findings can help select balloon remodeling microcatheters.

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  18. Symptomatic hyperperfusion after combined revascularization surgery in patients with pediatric moyamoya disease: patient series

    Araki Y., Mamiya T., Fujita N., Yokoyama K., Uda K., Kanamori F., Takayanagi K., Ishii K., Nishihori M., Takeuchi K., Tanahashi K., Nagata Y., Nishimura Y., Tanei T., Muraoka S., Izumi T., Kato K., Saito R.

    Journal of Neurosurgery: Case Lessons   Vol. 3 ( 19 )   2022.5

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    BACKGROUND Symptomatic hyperperfusion after cerebral revascularization for pediatric moyamoya disease (MMD) is a rare phenomenon. The authors report a series of patients with this condition. OBSERVATIONS In all three patients in this case series, the combined revascularization was on the left side, the patency of bypass grafts was confirmed after surgery, and focal hyperemia around the anastomotic site was observed on single photon emission computed tomography (SPECT). On the first to eighth days after surgery, all of the patients developed neurological manifestations, including motor aphasia, cheiro-oral syndrome, motor weakness of their right upper limbs, and severe headaches. These symptoms disappeared completely approximately 2 weeks after surgery, and all patients were discharged from the hospital. Quantitative SPECT was performed to determine the proportional change in cerebral blood flow (DRCBF) (to ipsilateral cerebellar ratio (denoted DRCBF) in the region of interest around the anastomoses, and the mean value was 1.34 (range, 1.29–1.41). LESSONS This rare condition, which develops soon after surgery, requires an accurate diagnosis by SPECT. One indicator is that the DRCBF has risen to 1.3 or higher. Subsequently, strategic blood pressure treatment and fluid management could prevent the development of hemorrhagic stroke.

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  19. Risk Factors for Cerebral Infarction Early After Revascularization in Children Younger than 5 Years with Moyamoya Disease

    Araki Yoshio, Uda Kenji, Yokoyama Kinya, Kanamori Fumiaki, Kurimoto Michihiro, Shiba Yoshiki, Mamiya Takashi, Nishihori Masahiro, Takeuchi Kazuhito, Tanahashi Kuniaki, Nagata Yuichi, Nishimura Yusuke, Okamoto Sho, Sumitomo Masaki, Izumi Takashi, Saito Ryuta

    WORLD NEUROSURGERY   Vol. 160   page: E220 - E226   2022.4

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    Objective: Cerebral revascularization is necessary for pediatric patients younger than 5 years with moyamoya disease (MMD). However, they have a high risk of developing cerebral infarction early after surgery. This study aimed to analyze the risk factors for developing cerebral infarction among these patients. Methods: The charts of 21 consecutive patients with MMD (39 surgeries) younger than 5 years who had undergone revascularization at our hospital were retrospectively analyzed. Because cerebral infarction occurring within 1 month after surgery was the primary end point, other clinical information was evaluated, including each surgical procedure. Multivariate analysis of the risk factors for postoperative cerebral infarction was performed. Results: Cerebral infarction occurred after 7 of 39 surgeries (17.9%). Of the 39 surgeries, 23 (59%) included direct and indirect combined revascularization. The incidence of cerebral infarction did not differ significantly between the combined (21.7%) and indirect (12.5%) groups (P = 0.46). Logistic regression showed no association between the revascularization procedure and the occurrence of cerebral infarction after surgery (P = 0.3). However, younger age at surgery was correlated with a higher risk of developing cerebral infarction in the early postoperative period (P = 0.05). Conclusions: No differences were found in the risk of developing cerebral infarction early after surgery as a result of surgical procedures. However, younger patients had higher postoperative risk. Further multicenter research should examine this issue for young pediatric patients with moyamoya at high risk of developing cerebral infarction.

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  20. Challenging direct bypass surgery for very young children with moyamoya disease: technical notes

    Araki Yoshio, Uda Kenji, Yokoyama Kinya, Kanamori Fumiaki, Kurimoto Michihiro, Shiba Yoshiki, Mamiya Takashi, Nishihori Masahiro, Takeuchi Kazuhito, Tanahashi Kuniaki, Nagata Yuichi, Nishimura Yusuke, Okamoto Sho, Sumitomo Masaki, Izumi Takashi, Saito Ryuta

    NEUROSURGICAL REVIEW   Vol. 45 ( 2 ) page: 1799 - 1807   2022.4

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    Cerebral revascularization for moyamoya disease (MMD) is an effective treatment for improving cerebral ischaemia and preventing rebleeding. Although direct bypass surgery is commonly performed on older children and adults, it is challenging in very young children due to the high difficulty level of the procedure. The subjects were MMD patients under 3 years of age on whom surgery was performed by a single surgeon (Y.A.). Preoperative clinical findings, information related to direct bypass surgery, bypass patency, and the incidence of postoperative stroke were investigated. Combined revascularization, including direct bypass surgery, was performed on 3 MMD patients (3 sides) under 3 years of age. The average diameter of the grafts used in direct bypass was 0.8 mm. The average recipient diameter was 0.8 ± 0.17 (range 0.6–1) mm. In all cases, the anastomotic procedure was completed using 11–0 monofilament nylon thread, and patency was confirmed. Direct bypass for MMD patients under 3 years old is technically challenging. However, despite the anatomical differences between very young children and elderly individuals, direct bypass surgery could certainly be completed. In addition, a rapid recovery from cerebral blood flow insufficiency could yield a promising neurological outcome.

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  21. Advantages of petrosectomy for superficial temporal artery to superior cerebellar artery bypass based on three-dimensional distance measurements using cadaver heads

    Uda Kenji, Tanahashi Kuniaki, Mamiya Takashi, Kanamori Fumiaki, Yokoyama Kinya, Nishihori Masahiro, Izumi Takashi, Araki Yoshio, Saito Ryuta

    NEUROSURGICAL REVIEW   Vol. 45 ( 2 ) page: 1617 - 1624   2022.4

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    Superficial temporal artery (STA) to superior cerebellar artery (SCA) bypass is usually performed via the subtemporal approach (StA), anterior transpetrosal approach (ApA), or combined petrosal approach (CpA), but no study has yet reported a quantitative comparison of the operative field size provided by each approach, and the optimal approach is unclear. The objective of this study is to establish evidence for selecting the approach by using cadaver heads to measure the three-dimensional distances that represent the operative field size for STA–SCA bypass. Ten sides of 10 cadaver heads were used to perform the four approaches: StA, ApA with and without zygomatic arch osteotomy (ApA-ZO− and ApA-ZO+), and CpA. For each approach, the major-axis length and the minor-axis length at the anastomosis site (La-A and Li-A), the major-axis length and the minor-axis length at the brain surface (La-B and Li-B), the depth from the brain surface to the anastomosis site (Dp), and the operating angles of the major axis and the minor axis (OAa and OAi) were measured. Shallower Dp and wider operating angle were obtained in the order CpA, ApA-ZO+, ApA-ZO−, and StA. In all parameters, ApA-ZO− extended the operative field more than StA. ApA-ZO+ extended La-B and OAa more than ApA-ZO−, whereas it did not contribute to Dp and OAi. CpA significantly decreased Dp, and widened OAa and OAi more than ApA-ZO+. ApA and CpA greatly expanded the operative field compared with StA. These results provide criteria for selecting the optimal approach for STA-SCA bypass in light of an individual surgeon’s anastomosis skill level.

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  22. Angiographic characteristics of improper watershed shift after STA-MCA bypass in a patient with moyamoya disease: illustrative case

    Kanamori F., Araki Y., Yokoyama K., Uda K., Mamiya T., Nohira S., Takayanagi K., Ishii K., Nishihori M., Izumi T., Saito R.

    Journal of Neurosurgery: Case Lessons   Vol. 3 ( 16 )   2022.4

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    BACKGROUND In patients with moyamoya disease (MMD) who receive superficial temporal artery (STA) to middle cerebral artery (MCA) bypass, hypoperfusion remote from the anastomosis site rarely occurs. Watershed shift due to direct bypass has been proposed as the mechanism; however, no report has confirmed this phenomenon using angiography. OBSERVATIONS A 48-year-old man presented with transient weakness in his left arm. Angiography revealed severe bilateral stenosis of the MCAs and moyamoya vessels. The right anterior cerebral artery (ACA) had short stenosis at A2 but ample blood supply to the cortical area of the right ACA and MCA regions. The patient was diagnosed with MMD and received a single STA-MCA bypass. The next day, he had difficulty communicating, and a cerebral infarction away from the anastomosis site was identified. Perfusion examination revealed hyperperfusion around the direct bypass and hypoperfusion away from the anastomosis site. Angiography revealed bypass patency; however, the original anterograde flow of the right ACA decreased significantly at the stenosed point, indicating an improper watershed shift. LESSONS STA-MCA bypass for patients with MMD can cause an improper watershed shift decreasing cerebral flow. Donor flow should be prepared based on each angiographic characteristic, and the risk of the improper watershed shift should be considered.

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  23. Spatially separate cerebral infarction in the posterior cerebral artery territory after combined revascularization of the middle cerebral artery territory in an adult patient with moyamoya disease and fetal-type posterior communicating artery: illustrative case.

    Araki Y, Yokoyama K, Uda K, Kanamori F, Mamiya T, Takayanagi K, Ishii K, Nishihori M, Takeuchi K, Tanahashi K, Nagata Y, Tanei T, Nishimura Y, Izumi T, Saito R

    Journal of neurosurgery. Case lessons   Vol. 3 ( 12 )   2022.3

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    DOI: 10.3171/CASE21704

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  24. Paradoxical symptomatic cerebral blood flow decreases after combined revascularization surgery for patients with pediatric moyamoya disease: illustrative case.

    Araki Y, Yokoyama K, Uda K, Kanamori F, Kurimoto M, Shiba Y, Mamiya T, Takayanagi K, Ishii K, Nishihori M, Takeuchi K, Tanahashi K, Nagata Y, Nishimura Y, Okamoto S, Sumitomo M, Izumi T, Saito R

    Journal of neurosurgery. Case lessons   Vol. 3 ( 3 )   2022.1

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  25. The preoperative focal cerebral blood flow status may be associated with slow flow in the bypass graft after combined surgery for moyamoya disease.

    Araki Y, Yokoyama K, Uda K, Kanamori F, Mamiya T, Takayanagi K, Ishii K, Shintai K, Nishihori M, Tsukada T, Takeuchi K, Tanahashi K, Nagata Y, Nishimura Y, Tanei T, Nagashima Y, Muraoka S, Izumi T, Seki Y, Saito R

    Surgical neurology international   Vol. 13   page: 511   2022

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    Background: The aim of this study was to investigate the association between early postoperative slow flow in bypass grafts and preoperative focal cerebral blood flow (CBF) in patients who underwent combined surgery for moyamoya disease (MMD). Methods: The subjects were 18 patients (22 surgeries) who underwent single photon emission computed tomography (SPECT) before surgery. The CBF value of the middle cerebral artery territory was extracted from the SPECT data, and the value relative to the ipsilateral cerebellar CBF (relative CBF, or RCBF) was calculated. The association between RCBF and early postoperative slow flow in the bypass graft was investigated. In addition, the correlation between the revascularization effect and preoperative RCBF was analyzed. Results: In four of 22 surgeries (18.2%), slow flow in the bypass graft was identified in the early postoperative period. Preoperative RCBF in the slow flow and patent groups was 0.86 ± 0.15 and 0.87 ± 0.15, respectively, with no significant difference (P = 0.72). The signal intensity of four slow-flowed bypasses was improved in all cases on magnetic resonance angiography images captured during the chronic phase (mean of 3.3 months postoperatively). The revascularization scores were 2 ± 0.82 and 2.1 ± 0.68 in the slow flow and patent groups, respectively, and did not differ significantly (P = 0.78). A significant correlation was not observed between preoperative RCBF and the revascularization effect. Conclusion: No significant association was observed between preoperative RCBF and early postoperative slow flow in bypass grafts in patients with MMD undergoing combined surgery. Given the high rate of improved depiction of slow-flowed bypass in the chronic postoperative phase, the conceptual significance of an opportune surgical intervention is to maintain CBF by supporting the patient's own intracranial-extracranial conversion function.

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  26. Contrast-Enhanced Magnetic Resonance Imaging Suggested a Possibility of Transvenous Embolization in the Superior Petrosal Sinus Dural Arteriovenous Fistula: A Case Report

    Nishihori Masahiro, Izumi Takashi, Tsukada Tetsuya, Kato Yutaka, Uda Kenji, Yokoyama Kinya, Araki Yoshio, Saito Ryuta

    Journal of Neuroendovascular Therapy   Vol. 16 ( 3 ) page: 163 - 169   2022

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    <p><b>Objective</b>: Superior petrosal sinus dural arteriovenous fistula (SPS-DAVF) is a rare subtype of intracranial DAVF that sometimes leads to hemorrhagic symptoms following deep venous drainage. Here we report the case of SPS-DAVF with retrograde venous reflux to the cerebellar vein. Preoperative contrast-enhanced MRI was a decisive factor in a safe and effective treatment.</p><p><b>Case Presentation</b>: A 37-year-old woman was referred to our hospital with abnormal MRI findings, which was performed when she had a mild headache during her check-up. DSA revealed left-sided SPS-DAVF, which was diagnosed as Cognard type IIb. Both CTA and DSA could not detect the whole SPS but only the shunt pouch. Using contrast-enhanced MRI, we were able to visualize the presence of the SPS and its continuity within the shunt pouch. 3D-T1 turbo spin echo (SPACE) showed a low-intensity area in the SPS, which was not seen in the 3D-T1 fast field echo (FFE). During the procedure, there was a point where it was difficult to advance the microcatheter, which coincided with the low-intensity area. We achieved effective transvenous embolization from the occluded venous access by devising a surgical technique.</p><p><b>Conclusion</b>: In addition to the contrast-enhanced 3D-T1 FFE, 3D-T1 SPACE might provide beneficial information for endovascular therapy in the evaluation of venous sinuses, which could not be detected by standard examinations.</p>

    DOI: 10.5797/jnet.cr.2021-0029

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  27. Atypical Incomplete Detachment Following PulseRider Deployment

    Goto Shunsaku, Izumi Takashi, Nishihori Masahiro, Araki Yoshio, Yokoyama Kinya, Uda Kenji, Saito Ryuta

    Journal of Neuroendovascular Therapy   Vol. 16 ( 8 ) page: 409 - 412   2022

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    <p><b>Objective</b>: Owing to the limited time since the introduction of the PulseRider (PR), inconsequential or rare complications that clinicians should be aware of remain unreported yet. Here, we report a rare complication of incomplete detachment.</p><p><b>Case Presentation</b>: A 50-year-old male underwent PR-assisted coil embolization for a basilar tip aneurysm. Coiling was completed, and the detachment procedure was performed using a detachment machine; the success signal was observed. The delivery microcatheter was subsequently advanced back up to the proximal markers, and no reapproximation of the proximal markers, which indicates successful detachment, was observed. However, only one of the proximal markers returned to the microcatheter, and incomplete detachment of only one leg was detected. Ultimately, electrical detachment was not possible, and physical separation by tension was achieved.</p><p><b>Conclusion</b>: Our case report presents a rare case of a detachment problem in the PR. The PR could not be detached, although the signal revealed successful detachment. Therefore, careful withdrawal of the delivery wire by checking not only the proximal markers but also the behavior of the entire PR and coil complex is important.</p>

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  28. Postoperative stroke and neurological outcomes in the early phase after revascularization surgeries for moyamoya disease: an age-stratified comparative analysis

    Araki Yoshio, Yokoyama Kinya, Uda Kenji, Kanamori Fumiaki, Kurimoto Michihiro, Shiba Yoshiki, Mamiya Takashi, Nishihori Masahiro, Izumi Takashi, Sumitomo Masaki, Okamoto Sho, Matsui Kota, Emoto Ryo, Wakabayashi Toshihiko, Matsui Shigeyuki, Natsume Atsushi

    NEUROSURGICAL REVIEW   Vol. 44 ( 5 ) page: 2785 - 2795   2021.10

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    Stroke and neurological outcomes in the early phase following revascularization for moyamoya disease (MMD) may depend on the patient’s age. In this study, an age-stratified comparative analysis was performed to clarify this issue. We reviewed 105 MMD patients who underwent 179 revascularization surgeries. The demographic characteristics were collected in four age groups (≤ 5 and 6–17 years for pediatric patients and 18–49 and ≥ 50 years for adults). Additionally, we assessed the incidence of subsequent stroke and deterioration of modified Rankin Scale (mRS) score. Then, we evaluated predictors of postoperative stroke and mRS deterioration using logistic regression. The mean patient age was 26.2 ± 18.5 years. No significant difference in the incidence of postoperative stroke was observed between age groups; however, the incidence tended to be increased among patients aged ≤ 5 years (17.9%) and patients aged ≥ 50 years (16.7%). Deterioration of mRS scores was significantly associated with ages ≤ 5 years (17.9%) and ≥ 50 years (11.1%). Logistic regression showed that posterior cerebral artery involvement (odds ratio [OR], 4.6) and postoperative transient neurological events (TNEs) (OR, 5.93) were risk factors for postoperative stroke. Age ≤ 5 years (OR, 9.73), postoperative TNEs (OR, 7.38), and postoperative stroke (OR, 49) were identified as predictors of unfavorable neurological outcomes. The novel feature of this comparative analysis by age group is that membership in the early-childhood MMD patient group (under 5 years old) was an independent risk factor for unfavorable short-term neurological outcomes and was mainly associated with the incidence of postoperative severe cerebral infarction.

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  29. Triggering of Carotid Sinus Reflex during Deployment of the Flow-diverter Device

    GOTO Shunsaku, IZUMI Takashi, NISHIHORI Masahiro, TSUKADA Tetsuya, ARAKI Yoshio, UDA Kenji, YOKOYAMA Kinya, SAITO Ryuta

    Neurologia medico-chirurgica   Vol. 61 ( 10 ) page: 583 - 590   2021.10

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    <p>The carotid sinus reflex (CSR) is a rare complication of the Pipeline Embolization Device (PED) deployment. No study has assessed the potential risk factors in a case series. The purpose of this study was to examine CSR triggering during PED deployment. Thirty-seven consecutive patients who underwent PED deployment were included. All procedures were performed under local anesthesia with mild sedation. We retrospectively analyzed patient characteristics, PED deployment time, and vital signs during the procedure. The vital signs included the pulse rate (PR) and systolic blood pressure (SBP) obtained at three timepoints (pre-deployment, during deployment, post-deployment). We examined the triggering of the CSR during PED deployment by comparing the vital signs at the three timepoints. Moreover, risk factors for CSR were analyzed with univariate analysis. The patients’ average age was 66.3 years. The average size of the aneurysm was 18.0 mm. Six patients (16.2%) showed a decline in the SBP or PR defined as CSR. One patient had a transient cardiac arrest and two had severe transient bradycardia. Deployment into the ophthalmic segment of the internal carotid artery (C2 segment) aneurysm (p = 0.022), prolonged PED deployment time more than 14.5 minutes (p = 0.005), and an acute angle of the anterior genu less than 51.5 degrees (p = 0.005) were risk factors in triggering CSR. CSR may be triggered during PED deployment under local anesthesia with mild sedation. Deployment to the C2 segment aneurysm, prolonged PED deployment time, and an acute angle of the anterior genu were associated with CSR triggering.</p>

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  30. Transcriptome-wide analysis of intracranial artery in patients with moyamoya disease showing upregulation of immune response, and downregulation of oxidative phosphorylation and DNA repair

    Kanamori Fumiaki, Yokoyama Kinya, Ota Akinobu, Yoshikawa Kazuhiro, Karnan Sivasundaram, Maruwaka Mikio, Shimizu Kenzo, Ota Shinji, Uda Kenji, Araki Yoshio, Okamoto Sho, Maesawa Satoshi, Wakabayashi Toshihiko, Natsume Atsushi

    NEUROSURGICAL FOCUS   Vol. 51 ( 3 ) page: E3 - 10   2021.9

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    OBJECTIVE Moyamoya disease (MMD) is a rare cerebrovascular disease characterized by progressive occlusion of the internal carotid artery and the secondary formation of collateral vessels. Patients with MMD have ischemic attacks or intracranial bleeding, but the disease pathophysiology remains unknown. In this study, the authors aimed to identify a gene expression profile specific to the intracranial artery in MMD. METHODS This was a single-center, prospectively sampled, retrospective cohort study. Microsamples of the middle cerebral artery (MCA) were collected from patients with MMD (n = 11) and from control patients (n = 9). Using microarray techniques, transcriptome-wide analysis was performed. RESULTS Comparison of MCA gene expression between patients with MMD and control patients detected 62 and 26 genes whose expression was significantly (p < 0.001 and fold change > 2) up or downregulated, respectively, in the MCA of MMD. Gene set enrichment analysis of genes expressed in the MCA of patients with MMD revealed positive correlations with genes involved in antigen processing and presentation, the dendritic cell pathway, cytokine pathway, and interleukin-12 pathway, and negative correlations with genes involved in oxidative phosphorylation and DNA repair. Microarray analysis was validated by quantitative polymerase chain reaction. CONCLUSIONS Transcriptome-wide analysis showed upregulation of genes for immune responses and downregulationof genes for DNA repair and oxidative phosphorylation within the intracranial artery of patients with MMD. These findings may represent clues to the pathophysiology of MMD.

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  31. Indocyanine green emission timing of the recipient artery in revascularization surgery for moyamoya disease

    Kanamori Fumiaki, Araki Yoshio, Yokoyama Kinya, Uda Kenji, Mamiya Takashi, Nishihori Masahiro, Izumi Takashi, Okamoto Sho, Natsume Atsushi

    NAGOYA JOURNAL OF MEDICAL SCIENCE   Vol. 83 ( 3 ) page: 523 - 534   2021.8

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    In superficial temporal artery to middle cerebral artery anastomosis with indirect revascularization for patients with moyamoya disease, the optimal method for selecting the most appropriate cortical artery for the recipient in anastomosis has not been established. We investigated the relationship between the fluorescence emission timing of the recipient artery in the preanastomosis indocyanine green videoangiography and operative outcomes. This retrospective study included 51 surgical revascularization procedures for 39 moyamoya disease patients. The enrolled surgical procedures were classified into three groups based on the fluorescence emission timing of the recipient artery in preanastomosis indocyanine green videoangiography: the EARLIEST, the INTERMEDIATE, and the LATEST. Clinical characteristics and operative outcomes were also collected. The occurrence of white thrombus at the anastomosis site and symptomatic hyperperfusion showed significant differences between the groups classified by the fluorescence emission timing of the recipient artery in preanastomosis indocyanine green videoangiography (white thrombus, p = 0.001; symptomatic hyperperfusion, p = 0.026). The development of white thrombi was significantly higher in the LATEST group, and all symptomatic hyperperfusion was observed in the EARLIEST group. These results indicated that the LATEST group had a significantly higher risk for developing white thrombus, and the EARLIEST group was prone to occur symptomatic hyperperfusion. Selecting the recipient artery based on evaluating the fluorescence emission timing in preanastomosis indocyanine green videoangiography may be useful in reducing perioperative complications.

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  32. Evaluation of the Straightening Phenomenon of Various Types of Coils.

    Ishida M, Izumi T, Araki Y, Nishihori M, Yokoyama K, Uda K, Tsukada T, Wakabayashi T

    Neurologia medico-chirurgica   Vol. 61 ( 6 ) page: 356 - 360   2021.6

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  33. Streak Metal Artifact Reduction Technique in Cone Beam Computed Tomography Images after Endovascular Neurosurgery.

    Otsuka T, Nishihori M, Izumi T, Uemura T, Sakai T, Nakano M, Kato N, Kanamori F, Tsukada T, Uda K, Yokoyama K, Araki Y, Saito R

    Neurologia medico-chirurgica     2021.5

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    <p>Cone beam computed tomography (CBCT) images are degraded by artifacts due to endovascular implants. We evaluated the use of streak metal artifact reduction technique (SMART) in non-contrast CBCT images after endovascular neurosurgery obtained from 148 patients (125 with aneurysm and 23 with dural arteriovenous fistula [dAVF]). Three neurosurgeons evaluated the cistern and brain surface visibility in CBCT images with and without SMART correction based on a 4-point scale (1, excellent; 2, good; 3, limited; and 4, insufficient). Significant improvement in visibility was achieved when the median scores improved from 4 or 3 to 2 or 1 or from 2 to 1. Metal artifact reduction in adjacent slices without metal and new artifacts after SMART correction was also examined. A significant improvement was achieved regarding the visibility of the cistern in 90 (60.8%) images and of the brain surface in 108 (73.0%) images. Metal size (cistern: odds ratio [OR], 0.91 per 1 mm increase; 95% confidence interval [CI], 0.83–0.99), irregular metal shape (cistern: OR, 0.18; 95% CI, 0.05–0.60 and brain surface: OR, 0.15; 95% CI, 0.05–0.45), and infratentorial lesions (cistern: OR, 0.37; 95% CI, 0.14–0.96 and brain surface: OR, 0.30; 95% CI, 0.11–0.80) were negatively correlated with improved visibility. Metal artifact reduction in adjacent slices without metal was obtained in 25.6% and 34.8% of images with aneurysm and dAVF, respectively. New artifacts after SMART correction were found in 4.8% and 13.0% of images with aneurysm and dAVF, respectively. SMART is especially effective for supratentorial small aneurysms.</p>

    DOI: 10.2176/nmc.oa.2021-0014

    PubMed

  34. Effects of aspirin and heparin treatment on perioperative outcomes in patients with Moyamoya disease

    Kanamori Fumiaki, Araki Yoshio, Yokoyama Kinya, Uda Kenji, Mamiya Takashi, Nishihori Masahiro, Izumi Takashi, Okamoto Sho, Natsume Atsushi

    ACTA NEUROCHIRURGICA   Vol. 163 ( 5 ) page: 1485 - 1491   2021.5

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    Background: When superficial temporal artery-middle cerebral artery bypass is combined with indirect methods (e.g., revascularization surgery) to treat Moyamoya disease (MMD), antiplatelet treatment can impact bypass patency, infarction, or hemorrhage complications. Recently, heparin has been proposed as an anticoagulant treatment against white thrombus at the anastomosis site. The study aims to evaluate the effect of aspirin on the perioperative outcomes and investigate the results of heparin treatment for white thrombus. Methods: This retrospective study included 74 procedures of combined revascularization surgery for MMD patients who either received or did not receive aspirin. Perioperative outcomes were compared between the two groups. In addition, the effects of heparin treatment for white thrombus were evaluated. Results: The rate of white thrombus at the anastomosis site was significantly higher in the non-aspirin medication group (univariate: p = 0.032, multivariate: p = 0.044) and, accordingly, initial bypass patency was lower in the non-aspirin medication group (p = 0.049). Of the 17 patients with white thrombus development, five received heparin injections, and all white thrombi disappeared; however, there was one case of epidural hematoma and another of subdural hematoma. The risk of hemorrhagic complications was significantly higher in the surgical procedures that received heparin injections (p = 0.021). Conclusions: In MMD patients who received combined revascularization surgery, aspirin medication lowered the occurrence of white thrombus. Heparin injections help to treat white thrombus but can enhance the risk of hemorrhagic complications.

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  35. Ipsilateral late stroke after revascularization surgery for patients with Moyamoya disease

    Araki Yoshio, Yokoyama Kinya, Uda Kenji, Kanamori Fumiaki, Mamiya Takashi, Nishihori Masahiro, Sumitomo Masaki, Okamoto Sho, Izumi Takashi

    ACTA NEUROCHIRURGICA   Vol. 163 ( 5 ) page: 1493 - 1502   2021.5

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    Background: Ipsilateral late stroke events occurring after cerebral revascularization for Moyamoya disease (MMD) and their risk factors have not been fully investigated. Methods: We retrospectively analyzed 123 patients with MMD who underwent 212 revascularizations. We investigated preoperative demographic data, surgical procedures, and ipsilateral stroke events occurring more than 1 month after surgery. The effect of revascularization and the residual Moyamoya vessel (MMV) score were examined using magnetic resonance angiography (MRA). Then, predictive factors for postoperative late stroke occurrence were evaluated by logistic regression. Results: The mean age was 26 ± 18.4 years (range 1 to 66 years). Ipsilateral late stroke events were present in 11 of 123 (9%) patients. Stroke occurred in 11 out of 212 surgeries (5.2%) on a hemispheric basis. During the 1300.1 hemisphere-years of follow-up more than 1 month after surgery, the annual stroke rate was 0.84%. The postoperative MRA time-of-flight image showed a mean revascularization score of 1.82 ± 0.6 and a mean residual MMV score of 1.91 ± 0.83. Postoperative strokes occurring within 1 month after cerebral revascularization (36.4%, p = 0.0026) and lower revascularization scores (1.82 ± 0.6 vs 2.51 ± 0.59, p = 0.0006) were significant factors related to the presence of ipsilateral late stroke. Logistic regression showed that stroke events within 1 month after revascularization (odds ratio [OR], 9.79; 95% confidence interval [CI], 0.02–0.57; p = 0.0103), low revascularization score (OR, 0.15; 95% CI, 0.001–0.37; p = 0.0069), and high residual MMV score (OR, 16.2; 95% CI, 1.88–187.4; p = 0.0107) were risk factors for ipsilateral stroke more than 1 month after revascularization. Conclusions: MMD patients who have a stroke within 1 month after cerebral revascularization are at high risk for late strokes. Less effective revascularization or remarkable residual MMV are risk factors for late stroke events. Additional revascularization may be considered for patients in such situations. Clinical trial registration: This study was approved by the Bioethics Review Committee of Nagoya University Hospital for the treatment and prognosis of Moyamoya disease (2016-0327).

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  36. Short-segment Internal Trapping for Symptomatic Thrombosed Large Fusiform Vertebral Artery Aneurysms (Bird’s Nest Trapping): A Technical Note

    NISHIHORI Masahiro, IZUMI Takashi, TSUKADA Tetsuya, KROPP Asuka Elisabeth, UDA Kenji, YOKOYAMA Kinya, ARAKI Yoshio, WAKABAYASHI Toshihiko

    Neurologia medico-chirurgica   Vol. 61 ( 4 ) page: 284 - 291   2021.4

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    <p>Internal trapping with coils is an established treatment of symptomatic large non-branching thrombosed fusiform vertebral artery aneurysms (VAA). However, when perforators arise near the aneurysm neck, parent artery occlusion has a high risk of causing medullary infarction. As an alternative treatment, we performed short-segment internal trapping of the artery using n-butyl-2-cyanoacrylate (NBCA) and coils (bird’s nest trapping). Before treatment, perianeurysmal perforators are carefully detected using high-resolution three-dimensional rotational angiography (3DRA). Double microcatheters are advanced to the distal portion of the aneurysm through a balloon guiding catheter where coils are deployed without tight packing. Then, NBCA is injected into the coil mass, taking care to preserve perforators and significant branches. The same maneuver is repeated in the proximal portion of the aneurysm. Coil placement is avoided within the middle of the aneurysm; however, if necessary, only a small number of coils are placed to prevent worsening of mass effect. Two quinquagenarian males presented with a large thrombosed fusiform VAA that caused symptoms due to mass effect. In each case, perforators arose from the parent artery and short-segment internal trapping with NBCA and coils was performed. Symptoms improved after treatment and follow-up imaging confirmed aneurysm shrinkage with no long-time recurrence. In symptomatic large fusiform VAAs where the distance from the lesion to important perforators is extremely short, internal trapping using a combination of NBCA and coils can be more useful than conventional internal trapping.</p>

    DOI: 10.2176/nmc.tn.2020-0329

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  37. Efficacy of Respiratory Control under Local Anesthesia during Endovascular Therapy in the Tortuous Vertebral Artery with the Use of Respiratory Dislocation of the Aortic Arch

    Goto Shunsaku, Izumi Takashi, Nishihori Masahiro, Tsukada Tetsuya, Araki Yoshio, Yokoyama Kinya, Uda Kenji, Ikezawa Mizuka

    Journal of Neuroendovascular Therapy   Vol. 15 ( 3 ) page: 195 - 199   2021

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    <p><b>Purpose:</b> Endovascular therapy (EVT) through the tortuous access route is increasingly performed in neurovascular procedures. In the posterior circulation through the vertebral artery (VA), ischemic complications, including vessel dissection and cerebral vessel infarction, are sometimes observed, especially during navigation of the guiding catheter, because of small vessel diameter and tortuous origin. We describe an adjunctive technique for passing the guiding catheter safely to the tortuous VA and reducing ischemic complication using respiratory displacement of the aortic arch.</p><p><b>Case Presentations:</b> The guidewire is advanced to the origin of the VA until it is caught in the tortuosity. Then we instruct the patient to take a maximum deep inspiration and hold his or her breath. In this manner, the aortic arch and side branches are dislocated to the caudal direction, which reduces the tortuosity of the VA origin and facilitates passage of the guidewire. Here, we discuss three representative cases which demonstrate that our techniques are effective in navigating the catheter to the tortuous VA.</p><p><b>Conclusion:</b> In the EVT of a patient who has a tortuous VA, respiration control under local anesthesia, maximum deep inspiration, and breath holding induce the respiratory dislocation of the aortic arch. This enables safe navigation of the guiding catheter, reduces the likelihood of interruption in blood flow, and helps avoid dissection and ischemic complications during EVT.</p>

    DOI: 10.5797/jnet.tn.2020-0109

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  38. A Case of Two Times Parturition by Caesarean Section after Stent-assisted Coil Embolization for the Ruptured Basilar Trunk Artery Aneurysm

    KATO Naoki, IZUMI Takashi, NISHIHORI Masahiro, TSUKADA Tetsuya, ARAKI Yoshio, YOKOYAMA Kinya, UDA Kenji, MATSUBARA Noriaki, KOKETSU Naoki

    No Kekkannai Chiryo   Vol. 6 ( 1 ) page: 24 - 29   2021

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    <p><b>Objective:</b> With the widespread use of endovascular treatment for cerebral aneurysms, women of childbearing age may also undergo this treatment. We report the case of a patient who underwent stent-assisted coil embolization for a ruptured large basilar artery aneurysm after two successful subsequent childbirths.</p><p><b>Case Presentation:</b> A 27-year-old woman developed a subarachnoid hemorrhage due to a ruptured basilar artery aneurysm (maximum diameter, 24 mm). We performed stent-assisted coil embolization. She became pregnant through in vitro fertilization (IVF) at age 33 years when she was already off the antiplatelet medication. She resumed taking aspirin when she found out that she was pregnant and switched to subcutaneous injection of heparin for 28 weeks. She gave birth by cesarean section at 37 weeks, without complications. She became pregnant through IVF again at age 35 years, received the same antithrombotic treatment, and gave birth without complications.</p><p><b>Conclusion:</b> There are no clear criteria for antithrombotic treatment in pregnant patients after the implantation of a cerebral aneurysm-assisted stent. However, the patient in this reported case passed the perinatal period with antithrombotic therapy without complications.</p>

    DOI: 10.20626/nkc.cr.2020-0019

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  39. Outcomes and Issues of ‘Drip and Go’ as an Inter-Hospital Cooperation System in Mechanical Thrombectomy for Acute Ischemic Stroke

    Nishihori Masahiro, Izumi Takashi, Tsukada Tetsuya, Yokoyama Kinya, Uda Kenji, Araki Yoshio, Wakabayashi Toshihiko

    Journal of Neuroendovascular Therapy   Vol. 15 ( 10 ) page: 629 - 636   2021

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    <p><b>Objective:</b> Mechanical thrombectomy in acute ischemic stroke (AIS) has become popular in recent years. Our affiliated institutes without neuro-endovascular specialists call our department to come to assist and perform thrombectomy (Drip and Go). In this study, the effectiveness of this inter-hospital cooperative system was evaluated.</p><p><b>Methods:</b> Between January 2016 and December 2018, “Drip and Go” was performed in a total of 29 patients (20 males, average age of 75 years) from four hospitals located within a 1-hour drive, that frequently called for AIS assistance. The background and outcomes of such cases were then retrospectively collected and evaluated.</p><p><b>Results:</b> The median National Institutes of Health Stroke Scale (NIHSS) and diffusion-weighed image-Alberta Stroke Programme Early CT Score (DWI-ASPECTS) were 19 and 7, respectively. Gro in puncture was performed in 27 patients (93%) within 6 h of onset. Good reperfusion (thrombolysis in cerebral infarction [TICI] 2b/3) was obtained in 24 patients (82%) with only one patient exhibiting hemorrhagic complication. A total of 12 patients (41%) had a modified Rankin Scale (mRS) score of 0–3 after 90 days or at the time of discharge. Univariate analysis identified a DWI-ASPECTS of 7 or higher as the only significant factor associated with a good neurological prognosis (P <0.05). Neurological prognosis was the most favorable at the furthest hospital where patients had a good DWI-ASPECTS.</p><p><b>Conclusion:</b> By employing a 1-hour arrival time window and proper patient selection, the “Drip and Go” inter-hospital cooperative system can be an alternative approach for covering areas where no neuro-endovascular specialists are available for AIS.</p>

    DOI: 10.5797/jnet.oa.2020-0097

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  40. Levodopa-responsive Parkinsonism Caused by Recurrence of Large Basilar-tip Aneurysm after Stent-assisted Coil Embolization: A Case Report

    NISHIHORI Masahiro, IZUMI Takashi, TSUKADA Tetsuya, ARAKI Yoshio, YOKOYAMA Kinya, UDA Kenji, WAKABAYASHI Toshihiko

    NMC Case Report Journal   Vol. 8 ( 1 ) page: 107 - 111   2021

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    <p>Aneurysms of the large basilar artery (BA) occasionally cause cranial nerve palsy and motor disorder through mass effect. Since 1967, five cases of cerebral aneurysm leading to parkinsonism have been reported. Herein, we describe a rare case of progressive parkinsonism caused by the recurrence of a large aneurysm of the basilar tip after stent-assisted coil embolization. A 66-year-old man visited our hospital with an asymptomatic large aneurysm (maximum diameter, 21 mm) of the BA tip. Magnetic resonance imaging (MRI) revealed no perianeurysmal edema. Coil embolization with a Y-configuration stent with cross-placement was performed. Although thrombus formation occurred and the perforator infarction was complicated, complete occlusion was achieved. Three months later, the patient developed progressive and severe parkinsonism. MRI revealed mild enlargement of the aneurysm and perianeurysmal mesencephalic edema with minor neck recurrence. A trial administration of levodopa and additional stent-assisted coil embolization were performed. Levodopa dramatically improved parkinsonism; thus, the patient's symptoms were controlled by a continuous levodopa regimen. In a large BA-tip aneurysm patient, moderate regrowth and minor neck recurrence occurred after initial treatment, and chronic compression of the midbrain caused secondary parkinsonism. In such cases, it is important to consider levodopa administration and therapeutic strategies to prevent recurrence or regrowth.</p>

    DOI: 10.2176/nmccrj.cr.2020-0023

  41. Evaluation of the Straightening Phenomenon of Various Types of Coils

    ISHIDA Mamoru, IZUMI Takashi, ARAKI Yoshio, NISHIHORI Masahiro, YOKOYAMA Kinya, UDA Kenji, TSUKADA Tetsuya, WAKABAYASHI Toshihiko

    Neurologia medico-chirurgica   Vol. 61 ( 6 ) page: 356 - 360   2021

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    <p>The straightening phenomenon is known as a cause of catheter kickback in the late phase of coil embolization. The mechanism is supposed to be the relative shortage of the stretch resistance (SR) line, and it occurs when a coil is folded too small. Among many SR coils available, there should be a coil-specific tendency to cause this phenomenon. Here, we conducted an in-vitro experiment to know which coil is the most resistant to the straightening phenomenon. We developed an experimental model to reproduce the straightening phenomenon. Five different coils (Axium Prime, ED Coil, Hypersoft, SMART Coil, and Target 360 nano) of the same size (3 mm × 6 cm) were investigated for five times each. Resistance to the straightening phenomenon, which is represented by the insertion length at the onset of the phenomenon, was compared among coil types. The straightening phenomenon was successfully observed in all insertions. Insertion lengths were significantly different among coil types (p = 0.013). The insertion length of ED was the longest (mean ± SD, 27.0 ± 8.3 mm), which means the most resistant to the phenomenon. Axium was second (21.6 ± 7.0 mm), followed by Target (15.8 ± 6.9 mm), Hypersoft (13.8 ± 5.8 mm), and SMART (12.4 ± 4.7 mm). Difference between ED and Hypersoft (p = 0.037) and difference between ED and Smart (p = 0.018) were significant. ED coil was the one with the most resistance to the straightening phenomenon. Selecting the optimal coil is the key to avoid the phenomenon.</p>

    DOI: 10.2176/nmc.oa.2020-0348

  42. Evaluation of the Straightening Phenomenon of Various Types of Coils

    ISHIDA Mamoru, IZUMI Takashi, ARAKI Yoshio, NISHIHORI Masahiro, YOKOYAMA Kinya, UDA Kenji, TSUKADA Tetsuya, WAKABAYASHI Toshihiko

    Neurologia medico-chirurgica     2021

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    <p>The straightening phenomenon is known as a cause of catheter kickback in the late phase of coil embolization. The mechanism is supposed to be the relative shortage of the stretch resistance (SR) line, and it occurs when a coil is folded too small. Among many SR coils available, there should be a coil-specific tendency to cause this phenomenon. Here, we conducted an in-vitro experiment to know which coil is the most resistant to the straightening phenomenon. We developed an experimental model to reproduce the straightening phenomenon. Five different coils (Axium Prime, ED Coil, Hypersoft, SMART Coil, and Target 360 nano) of the same size (3 mm × 6 cm) were investigated for five times each. Resistance to the straightening phenomenon, which is represented by the insertion length at the onset of the phenomenon, was compared among coil types. The straightening phenomenon was successfully observed in all insertions. Insertion lengths were significantly different among coil types (p = 0.013). The insertion length of ED was the longest (mean ± SD, 27.0 ± 8.3 mm), which means the most resistant to the phenomenon. Axium was second (21.6 ± 7.0 mm), followed by Target (15.8 ± 6.9 mm), Hypersoft (13.8 ± 5.8 mm), and SMART (12.4 ± 4.7 mm). Difference between ED and Hypersoft (p = 0.037) and difference between ED and Smart (p = 0.018) were significant. ED coil was the one with the most resistance to the straightening phenomenon. Selecting the optimal coil is the key to avoid the phenomenon.</p>

    DOI: 10.2176/nmc.oa.2020-0348

  43. Evaluation of the straightening phenomenon of various types of coils

    Ishida M., Izumi T., Araki Y., Nishihori M., Yokoyama K., Uda K., Tsukada T., Wakabayashi T.

    Neurologia Medico-Chirurgica   Vol. 61 ( 6 ) page: 356 - 360   2021

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    Language:Japanese   Publisher:Neurologia Medico-Chirurgica  

    The straightening phenomenon is known as a cause of catheter kickback in the late phase of coil embolization. The mechanism is supposed to be the relative shortage of the stretch resistance (SR) line, and it occurs when a coil is folded too small. Among many SR coils available, there should be a coil-specific tendency to cause this phenomenon. Here, we conducted an in-vitro experiment to know which coil is the most resistant to the straightening phenomenon. We developed an experimental model to reproduce the straightening phenomenon. Five different coils (Axium Prime, ED Coil, Hypersoft, SMART Coil, and Target 360 nano) of the same size (3 mm × 6 cm) were investigated for five times each. Resistance to the straightening phenomenon, which is represented by the insertion length at the onset of the phenomenon, was compared among coil types. The straightening phenomenon was successfully observed in all insertions. Insertion lengths were significantly different among coil types (p = 0.013). The insertion length of ED was the longest (mean ± SD, 27.0 ± 8.3 mm), which means the most resistant to the phenomenon. Axium was second (21.6 ± 7.0 mm), followed by Target (15.8 ± 6.9 mm), Hypersoft (13.8 ± 5.8 mm), and SMART (12.4 ± 4.7 mm). Difference between ED and Hypersoft (p = 0.037) and difference between ED and Smart (p = 0.018) were significant. ED coil was the one with the most resistance to the straightening phenomenon. Selecting the optimal coil is the key to avoid the phenomenon.

    DOI: 10.2176/nmc.oa.2020-0348

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  44. An Approach to Superior Petrosal Sinus via Contralateral Superior Petrosal Sinus in a Case of Dural Arteriovenous Fistulas with Difficulty in Access

    SUZUKI Keita, NISHIHORI Masahiro, IZUMI Takashi, SUZUKI Osamu, MUTO Manabu, ARAKI Yoshio, UDA Kenji, YOKOYAMA Kinya, SAITO Ryuta

    No Kekkannai Chiryo   Vol. 6 ( 3 ) page: 161 - 168   2021

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    <p><b>Objective</b>: Herein, we report a case of multiple dural arteriovenous fistulas (DAVFs) in the left superior petrosal sinus (SPS) successfully treated by transvenous embolization via the right SPS.</p><p><b>Case Presentation</b>: A 60-year-old woman was diagnosed with multiple DAVFs with deep venous reflux to evaluate consciousness disturbance. We performed packing of the left transverse sinus, which was chiefly involved in reflux to the straight sinus. However, consciousness continued to be mildly disturbed, and DSA was performed again. A shunt was inserted into the left SPS, and the subsequently occurring deep venous reflux was clearly revealed. Because the ipsilateral transverse sinus and both inferior petrosal sinuses were already occluded and unavailable as access routes, we used the contralateral SPS and both cavernous sinuses to navigate the microcatheter into the shunt. We achieved occlusion of the SPS and stopped the reflux by inserting the intermediate catheter firmly into the bilateral SPS.</p><p><b>Conclusion</b>: An access route through the contralateral SPS might successfully enable transvenous embolization of DAVF cases without an ipsilateral access route.</p>

    DOI: 10.20626/nkc.tn.2021-0009

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  45. A case of internal trapping to a thrombosed giant rapidly growing aneurysm at the posterior cerebral artery

    Otawa Masato, Izumi Takashi, Nishihori Masahiro, Tsukada Tetsuya, Oshima Ryosuke, Kawaguchi Tomomi, Goto Shunsaku, Ikezawa Mizuka, Kropp Asuka Elisabeth, Araki Yoshio, Yokoyama Kinya, Uda Kenji, Wakabayashi Toshihiko

    NAGOYA JOURNAL OF MEDICAL SCIENCE   Vol. 82 ( 3 ) page: 557 - 566   2020.8

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    We describe a case of internal trapping including the vasa vasorum for a thrombosed giant rapidly growing posterior cerebral artery aneurysm and performing a detailed analysis. A 48-year-old woman was followed up in our hospital for a thrombosed large posterior cerebral artery aneurysm located in the P2 segment. She initially presented after experiencing a sudden headache on two occasions. Head computed tomography and magnetic resonance imaging indicated a larger aneurysm than before. Digital subtraction angiography with balloon occlusion test was assessed, and internal trapping was sequentially conducted. We detected that the vasa vasorum originated from the posterior temporal artery. Therefore, we embolized the posterior temporal artery including the vasa vasorum using N-butyl-2-cyanoacrylate and Lipiodol. Next, the anterior temporal artery was embolized with N-butyl-2-cyanoacrylate and Lipiodol, posterior temporal artery P3 segment and the aneurysm and finally the proximal P2 segment were embolized with coils. Final vertebral and internal carotid angiography showed complete obliteration of the aneurysm. On the day after the procedure her paresis worsened and she developed left upper quadrantanopia, however was finally discharged with no hemiparesis. We reported a case of a rapidly growing thrombosed giant posterior cerebral artery aneurysm treated by parent artery occlusion including the vasa vasorum with detailed image analysis.

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  46. A Case of Cerebral Tumor Embolism from Extracardiac Lung Cancer Treated by Mechanical Thrombectomy.

    Oyama T, Asai T, Miyazawa T, Yokoyama K, Kogure Y, Torii A, Kawasaki T, Ohno M, Suzaki N, Kajita Y, Takahashi T

    NMC case report journal   Vol. 7 ( 3 ) page: 101 - 105   2020.7

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    DOI: 10.2176/nmccrj.cr.2019-0205

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  47. Surgical Designs of Revascularization for Moyamoya Disease: 15 Years of Experience in a Single Center

    Araki Yoshio, Uda Kenji, Yokoyama Kinya, Kanamori Fumiaki, Mamiya Takashi, Nishihori Masahiro, Izumi Takashi, Tanahashi Kuniaki, Masaki Sumitomo, Sho Okamoto, Wakabayashi Toshihiko, Natsume Atsushi

    WORLD NEUROSURGERY   Vol. 139   page: E325 - E334   2020.7

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    Objective: Cerebral revascularization surgery has been established as an effective treatment for moyamoya disease. On the other hand, harvesting grafts and tissues to nourish the scalp may increase the risk of postoperative wound-related complications. The purpose of this study was to clarify risk factors for wound-related complications after examining the relationship with the surgical design. Methods: We retrospectively analyzed 115 patients who underwent 197 revascularization procedures between October 2004 and March 2019. The design of the revascularization was classified into 6 types, then further classified according to the number of grafts harvested, resulting in 11 subtypes. Incidences of minor and major wound-related complications for the 11 different surgical designs were assessed. The risk of complications from each design was statistically examined. In addition, the yearly transition rate of complications was also investigated. Results: Wound-related complications occurred in 38 of the 195 operations (19.5%), including 10 major events (26.3%) and 28 minor events (73.7%). Significant differences in the incidence of complications were seen according to surgical design (P < 0.05), with complications significantly more frequent for L(a) double type and L(p) double type and less frequent for L(a) single type and L(p) single type. In addition, significant differences were found in the incidence and degree of complications according to the number of grafts (0–2) (P < 0.05). The incidence of wound-related complications has clearly decreased since 2015. Conclusions: Wound-related complications were more frequent and tended to become more severe with double-bypass procedures but were clearly improved under a plastic surgery approach.

    DOI: 10.1016/j.wneu.2020.03.217

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  48. Brain Compression by Encephalo-Myo-Synangiosis is a Risk Factor for Transient Neurological Deficits After Surgical Revascularization in Pediatric Patients with Moyamoya Disease

    Kanamori Fumiaki, Araki Yoshio, Yokoyama Kinya, Uda Kenji, Nishihori Masahiro, Izumi Takashi, Okamoto Sho, Wakabayashi Toshihiko

    WORLD NEUROSURGERY   Vol. 133   page: E558 - E566   2020.1

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    Objective: In pediatric patients with moyamoya disease, the pathophysiology of transient neurological deficits and the clinical features of perioperative cerebral blood flow (CBF) changes are unclear. The purpose of this study was to investigate the risk factors of postoperative transient neurological deficits and identify predictors of perioperative CBF changes. Methods: This retrospective study included 42 surgical procedures in 28 pediatric patients who underwent surgical revascularization for moyamoya disease, including encephalo-myo-synangiosis (EMS) with or without superficial temporal artery–middle cerebral artery (MCA) anastomosis. Magnetic resonance images and single photon emission computed tomography results were obtained. Brain compression by EMS was also checked in fluid attenuated inversion recovery images. Using single photon emission computed tomography, CBF was measured at each anterior and posterior part of the MCA region. Results: Postoperative transient neurological deficits were observed in 12 (28.6%) out of 42 surgical procedures. Brain compression by EMS was a significant risk for transient neurological deficits (P = 0.009). The postoperative CBF in the anterior region increased in 9 cases (21.4%) and decreased in 10 cases (23.8%); in the posterior region, it increased in 12 cases (28.6%) and decreased in 10 cases (23.8%). Preoperative CBF of the anterior region was significantly related to both perioperative CBF changes in the MCA regions (anterior part, P = 0.004; posterior part, P = 0.025). Conclusions: Brain compression by EMS is a risk factor for postoperative transient neurological deficits in pediatric patients with moyamoya disease, and preoperative CBF of the anterior MCA region could predict perioperative CBF change in the MCA regions.

    DOI: 10.1016/j.wneu.2019.09.093

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  49. Characteristics of Periventricular Anastomosis after Surgical Revascularization in Pediatric Patients with Moyamoya Disease

    Kanamori Fumiaki, Araki Yoshio, Yokoyama Kinya, Uda Kenji, Mamiya Takashi, Wakabayashi Toshihiko, Natsume Atsushi

    Japanese Journal of Neurosurgery   Vol. 29 ( 6 ) page: 442 - 447   2020

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    Language:Japanese   Publisher:The Japanese Congress of Neurological Surgeons  

    <p>  Most pediatric patients with moyamoya disease have cerebral ischemic symptoms. Surgical revascularization is widely performed to improve the ischemic condition. During the treatment or follow-up periods, periventricular anastomosis, which is known to be a risk for intracranial hemorrhage, is sometimes observed. In this study, we analyzed the change of periventricular anastomoses after surgical revascularization in pediatric patients with moyamoya disease.</p><p>  This retrospective study included 60 cases of pediatric (younger than 15 years old) patients with moyamoya disease who underwent surgical revascularization for the middle cerebral artery territory. Periventricular anastomoses were evaluated in the images using magnetic resonance angiography. The changes before surgery and at least 3 months after surgery were compared. Lenticulostriate anastomoses were observed in 26 cases before surgery and 4 cases after surgery. Thalamic anastomoses were observed in 23 cases before surgery and 18 cases after surgery. Choroidal anastomoses were observed in 39 cases before surgery and 17 cases after surgery. The periventricular anastomosis score after surgery was significantly higher in cases that showed stenosis or occlusion of the posterior cerebral artery (p<0.01), especially if thalamic anastomoses remained (p<0.01). In the analysis of 5 cases that showed stenosis or occlusion of the posterior cerebral artery and underwent additional surgical revascularization for the posterior cerebral artery territory, almost all thalamic or choroidal anastomoses decreased after surgery.</p><p>  In pediatric patients with moyamoya disease who show stenosis or occlusion of the posterior cerebral artery, periventricular anastomosis can be prone to remain after surgical revascularization for the middle cerebral artery territory. Surgical revascularization of the posterior cerebral artery territory can contribute to a decrease in periventricular anastomosis.</p>

    DOI: 10.7887/jcns.29.442

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  50. Thrombosis of great vein of Galen caused by Factor XIII concentrate: A case report

    Nakano Mizuki, Araki Yoshio, Kanamori Fumiaki, Uda Kenji, Yokoyama Kinya, Nishihori Masahiro, Izumi Takashi, Yoshimoto Masayuki

    Japanese Journal of Stroke   Vol. 42 ( 3 ) page: 196 - 202   2020

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    <p>We report our experience of great vein of Galen thrombosis after treatment consisted of Factor XIII (F XIII) concentrate. A 76-year-old woman presented with subarachnoid hemorrhage (SAH) caused by ruptured anterior communicating artery aneurysm and was successfully treated with direct surgery. Four days after operation, she was awake but presented with cerebrospinal fluid rhinorrhea and was found to be F XIII deficiency, therefore we performed intravenous injection of F XIII concentrate. Sixteen days after operation, she became drowsy without cerebrovascular spasms and hydrocephalus. CT angiography and digital subtraction angiography demonstrated the obstruction of great vein of Galen. She received the treatment with low-molecular-weight heparin (LMWH) and after that, direct oral anticoagulants (DOAC). The patient responded to the treatment, and followed an uneventful course without developing any hemorrhagic complication. To the best of our knowledge, this is the first case of cerebral venous thrombosis after the treatment of F XIII concentrate. The thrombosis can be attributed to the treatment of F XIII concentrate, and would be better served by treatment with LMWH and DOAC.</p>

    DOI: 10.3995/jstroke.10720

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  51. Intraoperative evaluation of local cerebral hemodynamic change by indocyanine green videoangiography: prediction of incidence and duration of postoperative transient neurological events in patients with moyamoya disease

    Uda Kenji, Araki Yoshio, Muraoka Shinsuke, Ota Shinji, Wada Kentaro, Yokoyama Kinya, Nishihori Masahiro, Izumi Takashi, Okamoto Sho, Wakabayashi Toshihiko

    JOURNAL OF NEUROSURGERY   Vol. 130 ( 4 ) page: 1367 - 1375   2019.4

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    OBJECTIVE Transient neurological events (TNEs) occur frequently in the acute phase after direct bypass surgery for moyamoya disease (MMD), but there is currently no way to predict them. FlowInsight is a specialized software for analyzing indocyanine green (ICG) videoangiography taken with a surgical microscope. The purpose of this study was to investigate whether intraoperative evaluation of local hemodynamic changes around anastomotic sites using FlowInsight could predict the incidence and duration of TNEs. METHODS From patients who were diagnosed with MMD in our hospital between August 2014 and March 2017 and who underwent superficial temporal artery–middle cerebral artery bypass surgery, we investigated 25 hemispheres (in 22 patients) in which intraoperative ICG analysis was performed using FlowInsight. To evaluate the local cerebral hemodynamics before and after anastomosis, regions of interest were set at 3 locations on the brain surface around the anastomotic site, and the mean cerebral blood flow (CBF), mean gradation (Grad), mean transit time (MTT), and mean time to peak (TTP) were calculated from the 3 regions of interest. Furthermore, the change rate in CBF (DCBF [%]) was calculated using the formula (postanastomosis mean CBF - preanastomosis mean CBF)/preanastomosis mean CBF. DGrad (%), DMTT (%), and DTTP (%) were similarly calculated. RESULTS Postoperative stroke without TNE occurred in 2 of the 25 hemispheres. These 2 hemispheres (in 2 patients) were excluded from the study, and data from the remaining 23 hemispheres (in 20 patients) were analyzed. For each parameter (DCBF, DGrad, DMTT, and DTTP) calculated by FlowInsight, the difference between the groups with and without TNEs was significant. The median values for DCBF and DGrad were significantly higher in the TNE group than in the no-TNE group (DCBF 30.13 vs 3.54, p = 0.0106; DGrad 62.05 vs 10.78, p = 0.00435), whereas the median values for DMTT and DTTP were significantly lower in the TNE group (DMTT -16.90 vs -7.393, p = 0.023; DTTP -29.07 vs -7.02, p = 0.00342). Comparison of the area under the curve (AUC) for each parameter showed that DTTP had the highest AUC and was the parameter with the highest diagnostic accuracy (AUC 0.857). The Youden index revealed that the optimal cutoff value of DTTP was -11.61 (sensitivity 77.8%, specificity 71.4%) as a predictor of TNEs. In addition, Spearman’s rank correlation coefficients were calculated, and DCBF, DGrad, DMTT, and DTTP each showed a strong correlation with the duration of TNEs. The larger the change in each parameter, the longer the TNEs persisted. CONCLUSIONS Intraoperative ICG videoangiography findings were correlated with the occurrence and duration of TNEs after direct bypass surgery for MMD. Screening for cases at high risk of TNEs can be achieved by ICG analysis using FlowInsight.

    DOI: 10.3171/2017.10.JNS171523

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  52. Progressive stenosis and radiological findings of vasculitis over the entire internal carotid artery in moyamoya vasculopathy associated with graves' disease: a case report and review of the literature

    Ito Hiroto, Yokoi Syunsuke, Yokoyama Kinya, Asai Takumi, Uda Kenji, Araki Yoshio, Takasu Syuntaro, Kobayashi Rei, Okada Hisashi, Okuda Satoshi

    BMC NEUROLOGY   Vol. 19 ( 1 ) page: 34   2019.3

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    Language:Japanese   Publisher:BMC Neurology  

    Background: Moyamoya vasculopathy (MMV) associated with Graves' disease (GD) is a rare condition resulting in ischemic stroke accompanied by thyrotoxicity. Radiological findings of vasculitis have been reported in the walls of distal internal carotid arteries (ICAs) in these patients; however, no reports have described in detail the processes of progression of the lesions in the proximal ICA. Moreover, treatments to prevent recurrence of ischemic stroke and progression of MMV have not yet been sufficiently elucidated. Case presentation: We report a progressive case of MMV associated with GD and review the literature to clarify relationships among recurrence, progression, thyrotoxicity and treatment. Our patient developed cerebral infarction during thyrotoxicity with no obvious stenosis of ICAs. Five months later, transient ischemic attacks recurred with thyrotoxicity. Antiplatelet therapy and intravenous methylprednisolone stopped the attacks. Stenosis of the left ICA from the proximal to distal portion and champagne bottle neck sign (CBN) were found. She declined any surgery. Afterward, gradual progression with mild thyrotoxicity was observed. Eventually, we found smooth, circumferential, concentric wall thickening with diffuse gadolinium enhancement of the left ICA from the proximal to the distal portion on T1-weighted imaging, suggesting vasculitis radiologically. The clinical and radiological similarities to Takayasu arteritis encouraged us to provide treatment as for vasculitis of medium-to-large vessels. In a euthyroid state and after administration of prednisolone and methotrexate, improved flow in the cerebrovascular arteries on magnetic resonance angiography was observed. Based on our review of the literature, all cases with recurrence or progression were treated with anti-thyroid medication (ATM) alone and accompanied by thyrotoxicity. CBN was observed in all previous cases for which images of the proximal ICA were available. Conclusions: We report the details of progressive stenosis from a very early stage and radiological findings of vasculitis over the entire ICA in MMV associated with GD. Cerebral infarction can occur with no obvious stenosis of the ICA. We treated the patient as per vasculitis of a medium-to-large vessel. Management of GD by ATM alone seems risky in terms of recurrence. Adequate management of GD and possible vasculitis may be important for preventing recurrence and progression.

    DOI: 10.1186/s12883-019-1262-1

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  53. Elevation of Proenkephalin 143-183 in Cerebrospinal Fluid in Moyamoya Disease

    Yokoyama Kinya, Maruwaka Mikio, Yoshikawa Kazuhiro, Araki Yoshio, Okamoto Sho, Sumitomo Masaki, Kawamura Akino, Sakamoto Yusuke, Shimizu Kenzo, Izumi Takashi, Wakabayashi Toshihiko

    WORLD NEUROSURGERY   Vol. 109   page: E446 - E459   2018.1

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    Language:Japanese   Publisher:World Neurosurgery  

    Background In moyamoya disease (MMD), the causes of differences in clinical features between children and adults and of the dramatic temporal changes in moyamoya vessels are poorly understood. We previously discovered elevated levels of m/z 4588 and m/z 4473 peptides in cerebrospinal fluid (CSF) in patients with MMD. This study examined the amino acid sequences of these peptides and quantified in specimens. Methods The m/z 4588 and m/z 4473 peptides in CSF from patients with MMD were purified and concentrated by high-performance liquid chromatography and ultrafiltration. Liquid chromatography coupled with tandem mass spectrometry analysis was performed to identify the amino acid sequences of these peptides. We quantified these peptides in samples using sandwich enzyme-linked immunosorbent assay, and concentrations in CSF were compared between MMD (n = 40, 19 male; median age, 37 years) and non-MMD intracranial disease (n = 40, 19 male; median age, 39 years) as controls. Results These peptides were identified as proenkephalin 143-183 (PENK 143–183). The concentration of PENK 143–183 was significantly greater in patients with MMD (median, 8,270 pmol/L) than control patients (median, 3,760 pmol/L; P < 0.001) and decreased in an age-dependent manner in MMD (r = −0.57; P < 0.001). The area under the receiver operating characteristic curve in children (age <18 years) was 0.885 (95% confidence interval 0.741–1). The correlation between proenkephalin concentration and temporal changes in moyamoya vessels was suggested. Conclusions Proenkephalin 143–183 in CSF may offer a helpful diagnostic biomarker in pediatric MMD. The effect of enkephalin peptides through opioid growth factor receptor or delta opioid receptor might be associated with the pathophysiology of MMD.

    DOI: 10.1016/j.wneu.2017.09.204

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  54. Cortical-Sulcal Hyperintensity in Fluid-attenuated Inversion Recovery Images and Postoperative Transient Neurological Events after Indirect Revascularization Surgery for Moyamoya Disease

    ARAKI Yoshio, OKAMOTO Sho, YOKOYAMA Kinya, OTA Shinji, UDA Kenji, MURAOKA Shinsuke, KANAMORI Fumiaki, NISHIHORI Masahiro, IZUMI Takashi, WAKABAYASHI Toshihiko

    Surgery for Cerebral Stroke   Vol. 46 ( 6 ) page: 439 - 444   2018

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

    Transient neurological events (TNEs) are relatively common phenomena after superficial temporal artery-middle cerebral artery (STA-MCA) bypass for the surgical treatment of moyamoya disease. Cortical-sulcal hyperintensity (CSHI) signs in magnetic resonance imaging (MRI) fluid-attenuated inversion recovery (FLAIR) images during the acute stage after the surgery have also been reported. These symptoms and radiological findings are reportedly correlated; however, few studies have examined these characteristics after indirect vascularization surgery. Therefore, here we retrospectively investigated the incidence and correlation of this issue. The CSHI signs were observed in 10 of 16 hemispheres (62.5%), and TNEs after the surgery were recognized in nine (56.3%). This correlation was statistically significant (p = 0.01). Our findings indicate that CSHI signs are associated with direct and indirect bypass surgery and may be closely related to postoperative TNEs.

    DOI: 10.2335/scs.46.439

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Books 1

  1. Use of embolization for the treatment of dural arteriovenous fistula

    Izumi T., Nishihori M., Tsukada T., Araki Y., Uda K., Yokoyama K.

    Arteriovenous Malformations of the Brain  2020.5  ( ISBN:9781536178920

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    Dural arteriovenous fistula (DAVF) is a relatively rare disease, and often develops pulsatile tinnitus. When accompanied by cerebral cortical venous reflux, patients may present with local neurological symptoms. Recently, transarterial embolization using Onyx is often the first-choice treatment for the patients with DAVF. Transvenous embolization for the affected sinus using platinum coils or liquid embolic material, is applied for cavernous sinus DAVF or transverse sinus/sigmoid sinus dural arteriovenous fistula (Borden type II). Since anatomical knowledge required for embolization is not required in the general practice of treating endovascular diseases, physicians treating dAVF must learn the anatomy of the arteries and veins of the head to increase the safety of embolization.

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MISC 4

  1. Dural Arteriovenous Fistula Mimicking a Brain Tumor on Methionine-positron Emission Tomography: A Case Report

    HANYU Taketo, NISHIHORI Masahiro, IZUMI Takashi, MOTOMURA Kazuya, OHKA Fumiharu, GOTO Shunsaku, ARAKI Yoshio, YOKOYAMA Kinya, UDA Kenji, SAITO Ryuta

    NMC Case Report Journal   Vol. 9 ( 0 ) page: 289 - 294   2022

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    Language:English   Publisher:The Japan Neurosurgical Society  

    <p>In this article, we report a case wherein a brain tumor was suspected based on computed tomography and magnetic resonance imaging findings. We made an initial diagnosis of malignant brain tumor based on methionine-positron emission tomography (PET) findings, but the correct diagnosis was dural arteriovenous fistula (DAVF). The patient was a 45-year-old man with DAVF who developed headache. Methionine-PET imaging showed high methionine uptake in the lesion. Although the tumor was strongly suspected from the findings of methionine-PET, the diagnosis of DAVF could be made correctly only by interpreting digital subtraction angiography and computed tomographic angiography. The findings of methionine-PET, which is considered useful in the diagnosis and denial of brain tumors, made the diagnosis of DAVF more difficult. The increased uptake of methionine-PET in DAVF is an important finding because, to our knowledge, this study is the first to report such finding. The results of this study might be useful for differential diagnoses when the diagnosis is uncertain.</p>

    DOI: 10.2176/jns-nmc.2022-0055

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  2. Management of Asymptomatic Vertebral Artery Injury Caused by a Cervical Pedicle Screw Malposition: Two Case Reports

    OTSUKA Takafumi, IZUMI Takashi, NISHIHORI Masahiro, TSUKADA Tetsuya, ARAKI Yoshio, YOKOYAMA Kinya, UDA Kenji, GOTO Shunsaku, IKEZAWA Mizuka, KATO Naoki, NAKANO Mizuki, SAITO Ryuta

    NMC Case Report Journal   Vol. 8 ( 1 ) page: 713 - 717   2021

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    Language:English   Publisher:The Japan Neurosurgical Society  

    <p>Iatrogenic vertebral artery (VA) injury in cervical fusion is an extremely rare complication but can lead to serious sequelae. We present two successful cases of internal trapping for preventing delayed-onset ischemic stroke after iatrogenic VA stenosis caused by a cervical pedicle screw. A 34-year-old female underwent posterior cervical fusion for C4/C5 dislocation fracture. No neurological deficits were observed after the operation. However, the postoperative images revealed that the left C5 pedicle screw perforated the transverse foramen, and the left VA was suspected to be occluded at the screw insertion site. Before revision surgery, we tried to embolize the injured VA with coils. A microcatheter could be navigated from the ipsilateral VA to the distal of the screw, and internal trapping was performed with coils. Another case is that of a 50-year-old male with cervical spondylosis, who underwent posterior decompression and cervical fusion. The neurological symptoms did not deteriorate after the operation. However, the postoperative computed tomography images revealed the perforation of the right C3 transverse foramen by the pedicle screw. In right vertebral angiography, about 70% stenosis was observed at the screw insertion site. Although revision surgery was not planned due to good stability, we embolized the right VA after balloon occlusion test, to prevent the delayed-onset thromboembolic complications. Both the patients recovered without any neurological deficits. Iatrogenic VA injuries, even if asymptomatic immediately after surgery, can lead to serious sequelae in case of delayed-onset ischemic stroke. Therefore, careful attention should be paid when the screw perforates the transverse foramen.</p>

    DOI: 10.2176/nmccrj.cr.2021-0062

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  3. Levodopa-responsive Parkinsonism Caused by Recurrence of Large Basilar-tip Aneurysm after Stent-assisted Coil Embolization: A Case Report

    NISHIHORI Masahiro, IZUMI Takashi, TSUKADA Tetsuya, ARAKI Yoshio, YOKOYAMA Kinya, UDA Kenji, WAKABAYASHI Toshihiko

    NMC Case Report Journal   Vol. 8 ( 1 ) page: 107 - 111   2021

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    Language:English   Publisher:The Japan Neurosurgical Society  

    <p>Aneurysms of the large basilar artery (BA) occasionally cause cranial nerve palsy and motor disorder through mass effect. Since 1967, five cases of cerebral aneurysm leading to parkinsonism have been reported. Herein, we describe a rare case of progressive parkinsonism caused by the recurrence of a large aneurysm of the basilar tip after stent-assisted coil embolization. A 66-year-old man visited our hospital with an asymptomatic large aneurysm (maximum diameter, 21 mm) of the BA tip. Magnetic resonance imaging (MRI) revealed no perianeurysmal edema. Coil embolization with a Y-configuration stent with cross-placement was performed. Although thrombus formation occurred and the perforator infarction was complicated, complete occlusion was achieved. Three months later, the patient developed progressive and severe parkinsonism. MRI revealed mild enlargement of the aneurysm and perianeurysmal mesencephalic edema with minor neck recurrence. A trial administration of levodopa and additional stent-assisted coil embolization were performed. Levodopa dramatically improved parkinsonism; thus, the patient’s symptoms were controlled by a continuous levodopa regimen. In a large BA-tip aneurysm patient, moderate regrowth and minor neck recurrence occurred after initial treatment, and chronic compression of the midbrain caused secondary parkinsonism. In such cases, it is important to consider levodopa administration and therapeutic strategies to prevent recurrence or regrowth.</p>

    DOI: 10.2176/nmccrj.cr.2020-0023

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  4. Coexistence of a Dural Arteriovenous Fistula and Pial Arteriovenous Malformation Sharing a Common Drainer

    UDA Kenji, IZUMI Takashi, KANAMORI Fumiaki, YOKOYAMA Kinya, TSUKADA Tetsuya, NISHIHORI Masahiro, SHINTAI Kazunori, OKAMOTO Sho, ARAKI Yoshio

    NMC Case Report Journal   Vol. 8 ( 1 ) page: 557 - 563   2021

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    Language:English   Publisher:The Japan Neurosurgical Society  

    <p>In cases of a dural arteriovenous fistula (AVF) with a pial arterial supply, postoperative hemorrhagic complications occur frequently. Six cases in which patients were diagnosed with a coexisting dural AVF and pial arteriovenous malformation (AVM) sharing a common drainer are presented. These cases were initially thought to be dural AVFs with pial arterial supplies, but careful examination of preoperative images showed that a pial AVM coexisted near the dural AVF, and that both shared a common drainer. The coexistence of a pial AVM is difficult to notice during surgery; for this reason, determining the presence of a pial AVM on preoperative imaging is essential to safely treat a dural AVF with a pial arterial supply. The details of each case, specifically, the diagnostic evidence for this condition (coexisting dural AVF and pial AVM sharing a common drainer), as well as imaging findings that should be noted, are presented.</p>

    DOI: 10.2176/nmccrj.cr.2020-0349

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KAKENHI (Grants-in-Aid for Scientific Research) 3

  1. 髄液中EVs由来microRNAの網羅的解析によるもやもや病の病態解明

    Grant number:23K15664  2023.4 - 2025.3

    科学研究費助成事業  若手研究

    横山 欣也

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    Authorship:Principal investigator 

    Grant amount:\4680000 ( Direct Cost: \3600000 、 Indirect Cost:\1080000 )

    もやもや病は頭蓋内に限局する動脈の進行性狭窄を特徴とする原因不明の疾患である。細胞外小胞(EVs)は様々な細胞が分泌する小型の膜小胞で、もやもや病の病変部に接する体液である脳脊髄液中にも存在する。EVsに含まれるマイクロRNA(miRNA)は近年、神経難病におけるバイオマーカーや治療標的として注目されている。今研究で我々は、もやもや病患者髄液中のEVsから抽出したmiRNAの網羅的解析により、もやもや病に特異的なmiRNAを特定しその機能を解明することで、もやもや病のバイオマーカー、病因、そして治療標的の発見を目指す。

  2. もやもや病脳動脈COL15A1発現低下のエピゲノム制御機構と病態生理の解明

    Grant number:22K09254  2022.4 - 2025.3

    科学研究費助成事業  基盤研究(C)

    荒木 芳生, 金森 史哲, 大岡 史治, 横山 欣也

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    Authorship:Coinvestigator(s) 

    研究代表者はこれまで、もやもや病病変部に対する網羅的遺伝子発現解析を行い、もやもや病患者では脳動脈に限局してCOL15A1遺伝子の低発現化が顕著であることを見出した。COL15A1蛋白は動脈組織の重要な構成成分であり、これまでの報告や病変の限局性からエピゲノム機序の存在が予想される。その低発現化は血管内皮や平滑筋細胞の変性、血管新生の促進など、もやもや病の様々な病態を矛盾なく説明し得ると考えた。今研究では、COL15A1遺伝子のエピゲノム制御機構と感受性遺伝子RNF213がそこに及ぼす影響を臨床検体を用いて、低発現となることで脳動脈に与える影響を細胞株や動物モデルを用いて明らかにする。

  3. もやもや病の病変部血管の遺伝子発現解析

    Grant number:20K17961  2020.4 - 2023.3

    科学研究費助成事業  若手研究

    横山 欣也

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    Authorship:Principal investigator 

    Grant amount:\4160000 ( Direct Cost: \3200000 、 Indirect Cost:\960000 )

    もやもや病は頭蓋内動脈の進行性狭窄と血管新生を特徴とする原因不明の疾患である。今までにマイクロアレイをはじめとした病変部の遺伝子発現解析は殆ど行われていないが、我々は既存の試薬キットを用いて、脳表の中大脳動脈から抽出したtotal RNAより増幅compliment DNAを作成し、マイクロアレイによる網羅的な遺伝子発現解析と定量PCRを実施するプロトコールを確立した。今研究の目的は、マイクロアレイを用いて、成人・小児を含めたもやもや病患者の病変部の網羅的な遺伝子発現解析を行い、非もやもや病患者検体との比較により、もやもや病患者の病変部に特異的な発現遺伝子・パスウェイの特定を行うことである。
    今研究期間を通じて、もやもや病患者21名、対照として脳動脈瘤患者5名、てんかん患者6名から脳表の動脈検体を採取、total RNAを抽出し、マイクロアレイによる網羅的転写解析を行った。messenger RNAに対する網羅的解析では免疫応答に関わる遺伝子群がもやもや病において高発現となり、酸化的リン酸化と遺伝子修復に関わる遺伝子群がもやもや病群では低発現となっていた。先行する研究では循環血に対するマイクロアレイや病理所見において免疫応答の関連を示唆する報告がなされていたが、今研究では初めて、もやもや病の病変部である頭蓋内動脈においても同様の変化が遺伝子発現レベルにおいて生じていることが見いだされた。この結果について論文化し発表を行った(Neurosurg Focus.51(3),2021)。またlong non-coding RNAに対する網羅的解析では、ゲノム上で免疫応答や血管形成に関わる遺伝子群の近傍にコードされたlong non-coding RNAが発現変動しており、もやもや病の病態生理においてこれらのlong non-coding RNAの関与が示唆された。この結果についても論文化を行い現在投稿中である。またもやもや病群において、感受性遺伝子とされるRNF213 p.R4810Kの一塩基多型について比較を行った結果についても現在論文化を行い、今後欧文誌への投稿を行う予定である。
    申請において今研究の目的は「マイクロアレイを用いて、成人・小児を含めたもやもや病患者の病変部の網羅的な遺伝子発現解析を行い、非もやもや病患者検体との比較により、もやもや病患者の病変部に特異的な発現遺伝子・パスウェイの特定を行うことである」とした。研究実績の概要に記載したように、研究期間内に実験と解析を行い、論文化し欧文誌に掲載を行うことができた。さらに解析の対象をlong non-coding RNAやRNF213 p.R4810K変異の有無にまで広げるなど研究の進展を見ており、今研究課題は順調に進展していると考えている。
    研究の目的のうち、現在も達成できていないこととして、小児もやもや病患者における解析があげられる。これは対照とする疾患群の年齢分布が比較的高齢であることと、小児もやもや病検体が成人くらべさらに微量であることが原因としてあげられる。対照群の年齢については、てんかん患者の検体の集積を行うことで、また小児もやもや病患者検体に対する網羅的転写解析には、スタートRNA量がマイクロアレイよりも微量から可能である次世代シークエンサーを用いることで可能になると考えている。