✓ To evaluate the pathogenetic role of alterations in the physical properties of the arterial wall (the passive component) and of active smooth-muscle contraction (the active component) in the occurrence of chronic vasospasm, the temporal profiles of these events were examined using the canine “two-hemorrhage” model. In the in vivo study, the basilar artery was exposed via the transclival approach on Day 0, 2, 4, 7, or 14. Nicardipine, followed by the protein kinase C inhibitor H-7, then papaverine were administered in a cumulative fashion, and the change in the basilar artery diameter induced by the addition of each agent was recorded angiographically. Drug administration markedly reversed the arterial narrowing caused by chronic vasospasm. When the vasodilatory effect of each agent was compared, the dilation induced by nicardipine or papaverine progressively decreased from Day 2 to Day 7, whereas that induced by H-7 increased. The in vitro experiment using arterial segments excised from the basilar artery revealed a progressive increase in arterial stiffness from Day 2 to Day 7. Also, there was a significant decrease in the initial half-circumference of the arterial segment, which was at its maximum on Days 4 and 7. However, the alteration in the initial half-circumference was considerably less than that in the angiographic diameter following subarachnoid hemorrhage. These data indicate that the augmented spontaneous tonus of the smooth muscle plays the predominant role in the occurrence of chronic vasospasm. Thus, the involvement of the protein kinase C-mediated contractile system is strongly suggested.
Toru Matsui, Hiroyuki Kaizu, Shoichi Iron and Takao Asano
Lipid peroxidation as a possible cause of postischemic injury
Shinichi Yoshida, Satoshi Inoh, Takao Asano, Keiji Sano, Masaru Kubota, Hiroyuki Shimazaki and Nobuo Ueta
✓ The effect of transient bilateral carotid occlusion on levels of free fatty acids, phospholipids, and lipid peroxides in the brain was studied in gerbils. During occlusion, both saturated and polyunsaturated free fatty acids increased strikingly to approximately 11-fold in total by 30 minutes. During recirculation, however, a selectively rapid decrement occurred in arachidonic acid, while saturated fatty acids gradually decreased to their basal levels in 180 minutes. The peroxide level, estimated by a thiobarbituric acid test, did not change during occlusion, but was elevated on reperfusion. Phosphatidylethanolamine content decreased throughout the periods examined. These results do not support a hypothesis that lipid peroxidation is initiated during ischemia by the lack of oxygen at the terminus of the mitochondrial respiratory chain. Instead, it is suggested that severe cerebral ischemia disintegrates membrane phospholipids, probably through activation of hydrolytic enzymes, and that overt peroxidative processes take place during reflow by means of restoration of oxygen supply. The peroxidative reactions may, indeed, cause additional damage during the postischemic phase.
Yuichi Murayama, Soichiro Fujimura, Tomoaki Suzuki and Hiroyuki Takao
The authors reviewed the clinical role of computational fluid dynamics (CFD) in assessing the risk of intracranial aneurysm rupture.
A literature review was performed to identify reports on CFD assessment of aneurysms using PubMed. The usefulness of various hemodynamic parameters, such as wall shear stress (WSS) and the Oscillatory Shear Index (OSI), and their role in aneurysm rupture risk analysis, were analyzed.
The authors identified a total of 258 published articles evaluating rupture risk, growth, and endovascular device assessment. Of these 258 articles, 113 matching for CFD and hemodynamic parameters that contribute to the risk of rupture (such as WSS and OSI) were identified. However, due to a lack of standardized methodology, controversy remains on each parameter’s role.
Although controversy continues to exist on which risk factors contribute to predict aneurysm rupture, CFD can provide additional parameters to assess this rupture risk. This technology can contribute to clinical decision-making or evaluation of efficacy for endovascular methods and devices.
Yuichi Murayama, Takayuki Saguchi, Toshihiro Ishibashi, Masaki Ebara, Hiroyuki Takao, Koreaki Irie, Satoshi Ikeuchi, Hisashi Onoue, Takeki Ogawa and Toshiaki Abe
The purpose of this study was to evaluate initial experiences in a surgical operating room (OR) with a multi-purpose angiography unit, which offers integrated neurosurgical and radiological capabilities.
A specially designed biplane digital subtraction (DS) angiography system was installed in the neurosurgery OR. The new suite, which allows three-dimensional DS angiography with C-arm for computerized tomography and microsurgery capabilities, allows the neurosurgeon to perform a wide range of neurosurgical and endovascular procedures. Three hundred thirty-two procedures were performed in the endovascular OR between November 2003 and March 2005. Patients arriving in the emergency department were transferred to the endovascular OR without delay. The neurovascular team performed diagnostic angiography followed by endovascular interventional procedures or surgery.
The newly designed endovascular OR facilitates safe and systemic treatment of neurovascular disease.
Felicitas J. Detmer, Sara Hadad, Bong Jae Chung, Fernando Mut, Martin Slawski, Norman Juchler, Vartan Kurtcuoglu, Sven Hirsch, Philippe Bijlenga, Yuya Uchiyama, Soichiro Fujimura, Makoto Yamamoto, Yuichi Murayama, Hiroyuki Takao, Timo Koivisto, Juhana Frösen and Juan R. Cebral
Incidental aneurysms pose a challenge for physicians, who need to weigh the rupture risk against the risks associated with treatment and its complications. A statistical model could potentially support such treatment decisions. A recently developed aneurysm rupture probability model performed well in the US data used for model training and in data from two European cohorts for external validation. Because Japanese and Finnish patients are known to have a higher aneurysm rupture risk, the authors’ goals in the present study were to evaluate this model using data from Japanese and Finnish patients and to compare it with new models trained with Finnish and Japanese data.
Patient and image data on 2129 aneurysms in 1472 patients were used. Of these aneurysm cases, 1631 had been collected mainly from US hospitals, 249 from European (other than Finnish) hospitals, 147 from Japanese hospitals, and 102 from Finnish hospitals. Computational fluid dynamics simulations and shape analyses were conducted to quantitatively characterize each aneurysm’s shape and hemodynamics. Next, the previously developed model’s discrimination was evaluated using the Finnish and Japanese data in terms of the area under the receiver operating characteristic curve (AUC). Models with and without interaction terms between patient population and aneurysm characteristics were trained and evaluated including data from all four cohorts obtained by repeatedly randomly splitting the data into training and test data.
The US model’s AUC was reduced to 0.70 and 0.72, respectively, in the Finnish and Japanese data compared to 0.82 and 0.86 in the European and US data. When training the model with Japanese and Finnish data, the average AUC increased only slightly for the Finnish sample (to 0.76 ± 0.16) and Finnish and Japanese cases combined (from 0.74 to 0.75 ± 0.14) and decreased for the Japanese data (to 0.66 ± 0.33). In models including interaction terms, the AUC in the Finnish and Japanese data combined increased significantly to 0.83 ± 0.10.
Developing an aneurysm rupture prediction model that applies to Japanese and Finnish aneurysms requires including data from these two cohorts for model training, as well as interaction terms between patient population and the other variables in the model. When including this information, the performance of such a model with Japanese and Finnish data is close to its performance with US or European data. These results suggest that population-specific differences determine how hemodynamics and shape associate with rupture risk in intracranial aneurysms.
Toru Serizawa, Yoshinori Higuchi, Masaaki Yamamoto, Shigeo Matsunaga, Osamu Nagano, Yasunori Sato, Kyoko Aoyagi, Shoji Yomo, Takao Koiso, Toshinori Hasegawa, Kiyoshi Nakazaki, Akihito Moriki, Takeshi Kondoh, Yasushi Nagatomo, Hisayo Okamoto, Yukihiko Kohda, Hideya Kawai, Satoka Shidoh, Toru Shibazaki, Shinji Onoue, Hiroyuki Kenai, Akira Inoue and Hisae Mori
In order to obtain better local tumor control for large (i.e., > 3 cm in diameter or > 10 cm3 in volume) brain metastases (BMs), 3-stage and 2-stage Gamma Knife surgery (GKS) procedures, rather than a palliative dose of stereotactic radiosurgery, have been proposed. Here, authors conducted a retrospective multi-institutional study to compare treatment results between 3-stage and 2-stage GKS for large BMs.
This retrospective multi-institutional study involved 335 patients from 19 Gamma Knife facilities in Japan. Major inclusion criteria were 1) newly diagnosed BMs, 2) largest tumor volume of 10.0–33.5 cm3, 3) cumulative intracranial tumor volume ≤ 50 cm3, 4) no leptomeningeal dissemination, 5) no more than 10 tumors, and 6) Karnofsky Performance Status 70% or better. Prescription doses were restricted to between 9.0 and 11.0 Gy in 3-stage GKS and between 11.8 and 14.2 Gy in 2-stage GKS. The total treatment interval had to be within 6 weeks, with at least 12 days between procedures. There were 114 cases in the 3-stage group and 221 in the 2-stage group. Because of the disproportion in patient numbers and the pre-GKS clinical factors between these two GKS groups, a case-matched study was performed using the propensity score matching method. Ultimately, 212 patients (106 from each group) were selected for the case-matched study. Overall survival, tumor progression, neurological death, and radiation-related adverse events were analyzed.
In the case-matched cohort, post-GKS median survival time tended to be longer in the 3-stage group (15.9 months) than in the 2-stage group (11.7 months), but the difference was not statistically significant (p = 0.65). The cumulative incidences of tumor progression (21.6% vs 16.7% at 1 year, p = 0.31), neurological death (5.1% vs 6.0% at 1 year, p = 0.58), or serious radiation-related adverse events (3.0% vs 4.0% at 1 year, p = 0.49) did not differ significantly.
This retrospective multi-institutional study showed no differences between 3-stage and 2-stage GKS in terms of overall survival, tumor progression, neurological death, and radiation-related adverse events. Both 3-stage and 2-stage GKS performed according to the aforementioned protocols are good treatment options in selected patients with large BMs.