Endovascular treatment with an ultra-thin 4-French guiding catheter via the transfemoral and transbrachial routes--technical note

An ultra-thin-walled 4-French catheter was used for angiography and as a guiding catheter for the Tracker-18 microcatheter in patients with intracranial dural arteriovenous fistulas (AVFs), spinal dural AVFs, spinal epidural AVF, meningioma, and acute embolic occlusion of major cerebral vessels. The 4-French guiding catheter was introduced through the transfemoral or transbrachial route. The guiding catheter and the guidewire were advanced to the aortic arch and then turned over just above the aortic valves, and finally the catheter was introduced into the external carotid artery or vertebral artery when the transbrachial approach was selected. Images of the intracranial vessels and spinal dural branches obtained were excellent in all cases. The Tracker-18 could smoothly be advanced to the target artery through the 4-French catheter in all patients. Endovascular treatment with the Tracker-18 can be performed using an ultra-thin 4-French guiding catheter, and safely via the transbrachial route.

Assessment of delayed cerebral vasospasm using intracisternal echography--technical note

BACKGROUND

A new technique using intravascular ultrasound has been used for diagnosis of coronary artery in order to obtain intravascular echo images. In this study, an intracisternally positioned ultrasound catheter was introduced obtaining serial echo images of the first segment (MI) of the middle cerebral artery in order to detect cerebral vasospasm following subarachnoid hemorrhage (SAH).

METHODS

Thirteen patients were admitted to Osaka Neurological Institute with SAH due to ruptured intracranial aneurysm. All patients underwent surgical neck clipping on the day of admission. In each patient, an 8 Fr. ultrasound imaging catheter (Cardiovascular Imaging Systems, Inc. (CVIS), Sunnyvale, CA) was detained intracisternally adjacent to the M1 segment following neck clipping of the aneurysm and placement of cisternal drainage(s) in the prepontine and/or distal portion of the Sylvian fissure. In order to detain the mirro device near the M1 segment, the tip of a 2.0 cm cisternal drainage tube (SILASCON, E-3L-12, Kaneka Medix Co, Osaka, Japan) was attached to the tip of the intravascular ultrasound catheter with 3-0 silk suture. The tip was placed in the prechiasmal cistern.

RESULTS

Angiographic evidence of delayed vasospasm was obtained for three (23.1%) of the 13 patients. In one (33.3%) of the three patients who had angiographic evidence of vasospasm (25% stenosis), decrease in the inner diameter of the M1 segment was detected on the echo images, but in the other two (66.7%), no such decrease was noted on echo images. Angiographically identified vasospasm in the latter patients was associated with only 10% stenosis.

CONCLUSIONS

Intracisternally positioned ultrasound catheter can be used for intermittent measurement of the diameter of a target artery for detection of cerebral vasospasm after SAH.

Anastomosis of occipital artery to posterior cerebral artery with interposition of superficial temporal artery using occipital interhemispheric transtentorial approach: case report

BACKGROUND

Superficial temporal artery (STA)-superior cerebellar artery (SCA) anastomosis, and STA-posterior cerebral artery (PCA) anastomosis are considered suitable as surgical procedures for the treatment of patients with significant stenosis or occlusion in the rostral portion of the basilar artery and patients with significant stenosis or occlusion of the posterior cerebral artery, respectively. However, several authors have reported frequent and serious complications of these surgical procedures, including temporal lobe retraction edema and hematoma. In this study, we introduce a new surgical revascularization using an occipital interhemispheric transtentorial approach for the treatment of severe stenosis of the rostral portion of the basilar artery.

CASE REPORT

A 47-year-old man with hypertension noted the sudden onset of nuchal pain followed by vertigo, diplopia, drunken gait, and motor weakness on his right side. Angiography performed on the day of the onset disclosed severe stenosis of the basilar artery. The stenotic portion extended just distal to the anterior-inferior cerebellar artery (AICA) to just proximal to the SCA, and in addition, a pseudolumen was visualized just distal to the left AICA. The patient underwent right occipital artery (OA) to left PCA anastomosis with interposition of the STA using an occipital interhemispheric transtentorial approach. Marked improvement in dysarthria, diplopia, ataxia gait, and visual disturbance were noted and he was able to walk without aid 3 days after operation. A postoperative angiogram of the right OA obtained 25 days after operation demonstrated visualization of the left PCA via the anastomosed OA and STA graft.

CONCLUSIONS

OA-PCA anastomosis with interposition of STA graft using an occipital interhemispheric transtentorial approach can be substituted for STA-SCA anastomosis and STA-PCA anastomosis for treatment of stenosis/occlusion of the rostral portion of the basilar artery.

Do recently developed techniques for skull base surgery increase the risk of difficult airway management? Assessment of pseudoankylosis of the mandible following surgical manipulation of the temporalis muscle

We report our experience with anesthetic care for six patients with pseudoankylosis of the mandible following neurosurgical procedures, four of whom required fiberoptically guided intubation for anesthesia. We suggest that the development of operative approaches and reconstruction techniques in skull base surgery may increase the risk of difficult airway due to limitation of mouth opening.

Hemodynamic evaluation of spinal arteriovenous malformations before and after embolization--preliminary report

This preliminary study investigated local hemodynamic changes in intramedullary spinal arteriovenous malformation (AVM) before and after embolization. 99mTcO4- was injected into the anterior spinal artery feeding the AVM via a Tracker-10 or MAGIC microcatheter. Time-dependent radioisotope images were sequentially obtained in the anteroposterior plane every 0.2 sec before and just after embolization. Local mean transit time (MTT) was then calculated for both the nidus and draining vein and compared before and after embolization. Prior to embolization, MTTs in the nidus and in the draining vein were 1.84 +/- 0.62 (mean +/- SD) and 2.80 +/- 0.69 sec for the five patients, respectively. MTTs in both the nidus and the draining vein were significantly prolonged after embolization to 3.32 +/- 1.14 and 4.90 +/- 0.93 sec, respectively (p < 0.02 and p < 0.005, respectively). In vivo measurements of local hemodynamic changes in the spinal cord during the treatment of spinal AVMs could be achieved. This method may allow investigation of the hemodynamic mechanisms which induce ischemic symptoms in patients with spinal AVM.

Haemodynamic evaluation of paraparetic transient ischaemic attacks in childhood moyamoya disease

The haemodynamic mechanisms responsible for the appearance of paraparetic transient ischaemic attacks in ten patients with childhood moyamoya disease who subsequently underwent bifrontal omental transplantation were investigated. Cerebral perfusion (CP) was measured with 99mTc-hexamethylene-propyleneamine oxime single photon computed tomography prior to and after administration of acetazolamide. Cerebral perfusion was obtained by dividing radioisotope uptake per pixel in regions of interest by that in cerebellum. Haemodynamic reserve was defined as [CP after acetazolamide--CP before acetazolamide]/CP before acetazolamide x 100. Amounts of CP in the anterior portion of the frontal lobe and in the paracentral lobule were 0.70 +/- 0.04 and 0.74 +/- 0.03, respectively, before appearance of the transient ischaemic attacks. The latter was significantly higher than the former (p < 0.0001). Haemodynamic reserves were -11.1 +/- 2.8 and -9.6 +/- 3.0, respectively, at that time. These two parameters were significantly decreased just after paraparetic transient ischaemic attacks and two parameters in the paracentral lobule were more decreased than those in the anterior portion of the frontal lobe. But these increased again after bifrontal omental transplantation in these two regions. In summary, the watershed region was located anterior to the paracentral lobule before appearance of the transient ischaemic attacks, and widened and moved backward to include the paracentral lobule just before their appearance.

Treatment of type II perimedullary arteriovenous fistulas by intraoperative transvenous embolization: case report

BACKGROUND Perimedullary arteriovenous fistulas (AVFs) are abnormal vascular connections between medullary arteries and veins without an intervening nidus. It is thought to be difficult to treat Type II AVFs which have multiple feeding branches. We performed intraoperative transvenous embolization to treat Type II AVFs. CASE REPORT A 30-year-old man with Type II perimedullary arteriovenous fistulas (AVFs), present at the level of the L-1 vertebral body, underwent surgical and endovascular treatment. The patient displayed slight motor weakness (4/5) and slight hypesthesia in the right lower extremity. Angiograms demonstrated that an anterior spinal artery and posterior spinal arteries were feeding arteries for the perimedullary AVFs. The patient underwent surgical occlusion of the fistulas three times. Fistulas present on the dorsal surface of the spinal cord were occluded with hemoclips, while those located on the ventral and ventolateral aspect of the spinal cord were occluded transvenously with isobuthyl-2-cyanoacrylate (IBCA) during surgery. Total occlusion of the perimedullary AVFs was achieved with these procedures, and no change was noted postsurgically in the patient's symptoms. CONCLUSIONS In summary, Type II perimedullary AVFs are sometimes difficult to treat using either embolization or open surgery. In such cases, both open surgery and intraoperative transvenous embolization should be performed in order to obtain occlusion of multiple fistulas.

Preoperative evaluation for risk of venous air embolism in the sitting position

We report a patient with meningioma and radiological findings of erosive bony change, who developed venous air embolism via the diploic vein in the eroded inner table of the skull during craniotomy in the sitting position. The findings in our case suggest that preoperative radiological imaging evaluation can increase an awareness of the possibility of venous air embolism.

An intra-arterial electrode for intracranial electro-encephalogram recordings

A new method for intracranial monitoring of brain electrical activity by means of an intra-arterial guide wire as electrode is described. We carried out intracranial electro-encephalography (EEG) using an insulated Seeker Lite-10 guide wire 18 times in 14 patients: ten times in 6 patients with cerebral arteriovenous malformation (AVM) before embolization, and another 8 times in 8 patients with epilepsy. In all cases, a 2-5 times stronger high voltage potential EEG compared with scalp EEG could be recorded. In 3 patients with complex partial epilepsy, intra-arterial (IA) EEG was recorded under subdural strip electrode monitoring, and IAEEG at the sphenoidal portion of the middle cerebral artery was compared with subdural electrode recordings. Frequent interictal spike discharges recorded with subdural electrodes in the lesional medial temporal lobe were simultaneously visible on IAEEG recording. This method is equivalent to that using a semi-invasive electrode, but ECoG recording can be performed at angiography. IAEEG is a method of electrode recording that has the possibility of clinical application.

Cerebral revascularization using gracilis muscle transplantation for childhood moyamoya disease

BACKGROUND

Omental transplantation is effective in the management of ischemia in the territories of the anterior and posterior cerebral arteries in childhood moyamoya disease. We introduced a surgical revascularization using gracilis muscle transplantation to these territories.

METHODS

Between January 1991 and May 1993, six children with moyamoya disease, between the age of 3 and 13 years, underwent gracilis muscle transplantation to the territory of either the anterior or the posterior cerebral artery. The mean period of follow-up after surgery was 15.2 months, with a range of 5 to 32 months. Three of the six patients had suffered from frequent transient visual disturbance and were treated with unilateral or bilateral gracilis muscle transplantation to the territory of the posterior cerebral artery. The other three patients had suffered from frequent transient paraparesis, mental retardation, and/or rectal and urinary incontinence, and were treated with gracilis muscle transplantation bilaterally to the territories of the anterior cerebral arteries.

RESULTS

All three patients with gracilis muscle transplantation unilaterally or bilaterally to the occipital lobes manifested complete disappearance of their symptoms. Two of the three patients with gracilis muscle transplantation bilaterally to the frontal lobes also manifested complete disappearance of their symptoms. The remaining patient who underwent the transplantation bilaterally to the frontal lobes, continued to have episodes of transient paraparesis, postsurgically, but the frequency of symptoms was markedly decreased.

CONCLUSIONS

Ischemia in the territories of the anterior and/or posterior cerebral arteries could be overcome with the use of gracilis muscle transplantation in childhood moyamoya disease.

Intraoperative electrophysiologic monitoring of cranial motor nerves in skull base surgery

BACKGROUND

Intraoperative cranial nerve monitoring has been applied for the preservation of nerve function during skull base surgery. However, its usefulness is controversial because clinical results reported are limited.

METHODS

We evaluated the usefulness of intraoperative electrophysiologic monitoring of the third to seventh cranial motor nerves in 15 patients undergoing skull base surgery. Intracranial bipolar electrical stimulation of each nerve was performed, and compound muscle action potentials (CMAP) were recorded from the innervated muscles.

RESULTS

CMAPs were successfully recorded from 23 of the innervated muscles. The loss of the CMAP response during the manipulation of lesions or high stimulus intensity at the end of manipulation seem to be related to the postoperative deficits of nerve function.

CONCLUSIONS

The results suggest that intraoperative electrophysiologic monitoring of cranial motor nerves is useful for prediction of postoperative nerve function.

Percutaneous transluminal angioplasty for severe stenosis of the posterior cerebral artery: case report

The Stealth dilation catheter was used for the intravascular treatment of a patient who had hemodynamically significant stenosis of the posterior cerebral artery and had a history of recurrent transient ischemic attacks associated with right hemiparesis and ipsilateral hemianopia dating from March 1993. Cerebral perfusion studies prior to and after the intravenous administration of acetazolamide demonstrated regions of moderately low perfusion and low hemodynamic reserve in the territories of the left middle and posterior cerebral arteries. Cerebral angiograms demonstrated severe stenosis of the left posterior cerebral artery and occlusions of both middle cerebral arteries, which had leptomeningeal anastomoses with the posterior cerebral arteries. Percutaneous transluminal angioplasty (PTA) was performed using the Stealth catheter on the stenotic segment of the left posterior cerebral artery after left superficial temporal artery-middle cerebral artery anastomosis. The patient manifested marked improvement in her neurologic condition just after PTA, in association with marked increase in cerebral perfusion and hemodynamic reserve in the territories of the left middle and posterior cerebral arteries. We have presented evidence that PTA can be used to treat patients with stenosis of the first segment of the posterior cerebral artery and hemodynamic compromise in the territory that artery supplies.

Traumatic arteriovenous fistula treated by superselective embolisation with microcoils: case report

A 27-year-old man with a traumatic direct dural arteriovenous fistula (DAVF) was treated using embolisation microcoils. He had suffered blunt trauma to the head while drunk and was aware of no neurological deficit. A few days after the accident, however, he noticed a bruit in the right temple. Angiography demonstrated a direct DAVF fed by the right middle meningeal artery and draining into a right temporal dural vein and the ipsilateral cavernous sinus. A Tracker-18 catheter was passed without difficulty through the fistula and the draining vein was then embolised from distal to proximal with microcoils, and finally the fistula was occluded with microcoils, resulting in total obliteration of the fistula. Immediately after the embolisation, the patient could no longer hear the bruit. Thus, when a microcatheter can be introduced into the draining vein, microcoils can be used as emboli in the treatment of direct DAVF.

Total excision of a thalamic arteriovenous malformation using an orbito-fronto-malar approach: case report

A 37-year-old woman was admitted to Osaka Neurological Institute after the sudden onset of left hemiplegia, hemihypesthesia, and ipsilateral hemianopia on February 4, 1992. Computed tomography (CT) disclosed the presence of hemorrhage in the right thalamus extending to the ipsilateral internal capsule. Cerebral angiography after CT scanning disclosed the presence of a cerebral arteriovenous malformation (AVM) fed by copsulothalamic and lateral geniculate body arteries originating from the right anterior choroidal artery. She was operated on with removal of the AVM using a right orbito-fronto-malar approach (OFM approach), which did not require transection of the cerebral parenchyma. The anterior choroidal artery could be followed distally from its origin and small feeding branches originating from the parent artery were easily identified, and the cerebral base could be examined in greater detail than with the conventional frontotemporal approach. The nidus could be excised in its entirety without difficulty. Postoperative angiography confirmed total excision of the AVM. She was transferred to another hospital for rehabilitation on April 13, 1992. Motor strength on the left side had improved to 3/5 by that time. The OFM approach appears to be potentially useful for the resection of inferolateral thalamic AVMs, because it does not require corticotomy and feeding branches can be identified and dealt with prior to other surgical manipulations.

Pituitary adenoma invading the skull base--a strategy for skull base surgery

A strategy for surgical management, including the approach and preoperative evaluation, of pituitary adenoma invading the skull base is described. Preoperative evaluation requires a balloon occlusion test of the internal carotid artery (ICA) to determine tolerance to occlusion. Failure to tolerate occlusion indicates administration of brain protective agents and/or a bypass procedure before tumor removal. The transsphenoidal, pterional, orbitofrontomalar, and infratemporal fossa approaches are all suitable for various tumor locations. A combined orbitofrontomalar and extended frontal approach allows removal of tumor with extensive invasion and is suitable for bypass procedures. Preoperative evaluation of ICA occlusion can prevent development of hemodynamic stroke. We treated five patients with pituitary adenoma invading the skull base, including two primary and three recurrent cases. All symptoms improved, but temporary oculomotor nerve disturbance occurred in three patients and anosmia in one. Reoperations for recurrent pituitary adenomas were effective in reversing the symptoms. No hemodynamic stroke was seen postoperatively. These tumors, except for drug-responsive cases, are indicated for skull base surgery.

Vasculopathy of the anterior choroidal artery following intra-arterial chemotherapy--case report

A 40-year-old male, treated with radiotherapy and supraophthalmic intracarotid artery (ICA) ACNU infusion for glioblastoma in the right occipital lobe, developed cerebral infarction secondary to vasculopathy manifesting as hemiparesis 3 months after a second ICA injection. The initial diagnosis was focal neurotoxicity, but angiography revealed severe vasospasm of the anterior choroidal artery. The symptoms improved gradually with therapy for the vasospasm. Angiography is required to discriminate vasospasm and focal neurotoxicity as a complication of ICA injection of antineoplastic agents.

Cerebellar primary germ-cell tumor in a young boy

Germ cell tumors originating in the posterior fossa are very rare. Described herein is a case of primary germ cell tumor (yolk sac tumor) found in the cerebellar vermis. A 5-year-old boy who complained of headache was admitted. CT and MRI revealed a tumor with diffuse enhancement by contrast medium in the right cerebellar vermis. Total removal was performed and a diagnosis of medulloblastoma or ependymoma was suspected. However, the tumor proved to be a yolk sac tumor with embryonal carcinomatous components from histological findings. Abnormally high levels of alpha-fetoprotein were found in blood and cerebrospinal fluid. Extensive examination indicated that the intracranial lesion had not metastasized from a primary extracranial tumor.

Lateral approach for anterior thoracic spinal lesions

A lateral approach, consisting of a modified transversectomy, hemilaminectomy, and adequate transversectomy with costectomy of 7-8 cm, was used to treat four cases of anterior or anterolateral thoracic lesions, including two cases of thoracic disc herniations, one of thoracic meningioma, and one of hypertrophic pachymeningitis. All patients presented with gait disturbance, but recovered well postoperatively except for one who needed rehabilitation of the lower extremities. This approach provides a greater access to the anterior thoracic canal, and can achieve effective anterior decompression, and a good outcome for thoracic spinal disease if recognized early.

Dural arteriovenous fistula caused by sinus thrombosis--case report

A 58-year-old male with a history of idiopathic sinus thrombosis presented with gradual onset of gait disturbance, dementia, and involuntary movement in the upper extremities. Cerebral angiography demonstrated a dural arteriovenous fistula fed by a falx cerebelli branch originating from the left vertebral artery and draining into the inferior vermian vein, the straight sinus, a cortical vein lying on the inferolateral surface of the left cerebellar hemisphere, the ipsilateral superior petrosal sinus, the sigmoid sinus, and the internal jugular vein. Endovascular embolization under fluoroscopic control resulted in complete disappearance of the involuntary movement. Sinus thrombosis may result in development of dural arteriovenous fistula which can cause life-threatening complications, so aggressive therapy should be considered.

Intravascular treatment of spinal arteriovenous malformations using a microcatheter--with special reference to serial xylocaine tests and intravascular pressure monitoring

Spinal arteriovenous malformations (spinal AVMs) are now treated using microcatheters and various embolic materials. Interventional techniques of this type are thought to be the first choice for treatment of spinal AVMs. In this study, we used the Tracker vascular access system and MAGIC catheter for intravascular treatment of spinal AVMs in order to avoid proximal occlusion. Notably, serial provocation tests using xylocaine (20 mg in bolus) and intermittent intravascular pressure monitoring in the anterior spinal artery were conducted during embolizations of five intramedullary AVMs. We used 150-350 microns polyvinyl alcohol particles (Ivalon) and/or polyvinyl alcohol (PVA) solutions as embolic materials for occlusion of these AVMs. Vital signs and neurologic functions were carefully monitored during and after the procedure. We were able totally to obliterate the nidus or markedly to reduce its size while preserving the anterior spinal artery in each of the patients. The xylocaine test was conducted an average of 2.6 times (2-4 times) during embolization. For the two patients who were treated with Ivalon and PVA solutions, the final provocation test became positive, and the embolization procedure was terminated. On the other hand, the remaining patients had a positive result on first xylocaine test and were treated with Ivalon alone. At the same time, intravascular pressure monitoring was performed via the microcatheter, which was located in the anterior spinal artery. The value of the intravascular systolic pressure prior to embolization was 71.6 +/- 14.1 mm Hg and it gradually increased during the procedure, and reached 99.6 +/- 12.6 mm Hg (90% of the systemic systolic blood pressure) by the conclusion of embolization. Serial xylocaine tests and intravascular pressure monitoring may be useful for the treatment of spinal AVMs fed mainly by the anterior spinal artery, and embolization with liquid embolic material should be terminated when the provocation test becomes positive and intravascular pressure increased to 90% of the systemic blood pressure.

Successful intra-arterial fibrinolysis of the anterior choroidal artery in the acute stage of internal carotid artery occlusion: case report

A 27-year-old man was admitted to our institution with the sudden development of right hemiparesis and dysarthria beginning an hour after the onset of symptoms on August 9, 1992. The patient was found on admission to have right hemiparesis (2/5), hemihypesthesia, hemianopia, dysarthria; he had transient atrial fibrillation. No abnormalities were detected on computed tomography (CT) scans, and cerebral blood flow studies undertaken following conventional CT scans revealed no low flow regions in the left cerebral hemisphere. But cerebral angiography disclosed an occlusion of the left internal carotid artery with well-developed cross-circulation via the anterior communicating artery and embolus lodged at the level of the anterior choroidal artery. Superselective fibrinolysis using Tracker-18 and 420,000 units of urokinase resulting in complete recanalization of the left anterior choroidal artery without distal migration of the embolus. Immediately after the procedure, his neurologic disturbance underwent complete resolution. In summary, fibrinolysis could be performed but limited to anterior choroidal artery in a case with an occlusion of the internal carotid artery with well-developed cross-flow via the anterior communicating artery; the patient's neurologic condition may deteriorate suddenly if fibrinolysis is incomplete and the embolus migrates to the internal carotid artery.

Percutaneous transluminal angioplasty of stenotic primitive hypoglossal artery--case report

A 76-year-old female presented with vertebrobasilar insufficiency due to a severe stenosis of the right primitive hypoglossal artery (an unusual carotid-basilar anastomosis) manifesting as recurrent transient ischemic attacks (TIA) associated with quadriparesis and cerebellar ataxia with vertigo, nausea, and vomiting. She had been treated with 100 mg of aspirin per day, but TIA associated with the same symptoms persisted. Cerebral blood flow (CBF) studies disclosed a region of moderately low flow in the posterior fossa. Cerebral angiography demonstrated that the posterior fossa was supplied via the right primitive hypoglossal artery, which was severely stenotic at its origin. Percutaneous transluminal angioplasty using a Stealth catheter, 3.0-mm diameter and 10-mm long, successfully dilated the stenosis. No TIA occurred postoperatively, and a marked increase in CBF was demonstrated in the posterior fossa.

Percutaneous transluminal angioplasty for acute stroke due to stenosis of major cerebral vessels: report of two cases

The Stealth dilation catheter was introduced for the intravascular treatment of two patients with acute and unstable ischemic stroke due to hemodynamically significant stenosis in the one case of the middle cerebral artery and in the other of the vertebral artery. Cerebral perfusion study on the two cases showed a moderately low flow area in the right cerebral hemisphere and in the left cerebellar hemisphere, respectively. Percutaneous transluminal angioplasty (PTA) using the Stealth catheter was conducted. The two cases showed marked improvement in their neurologic state just after PTA with marked increase in cerebral perfusion in the relevant regions.

[Intraoperative monitoring in patients undergoing surgery of lesions involving the cavernous sinus]

We reviewed the intraoperative monitoring and anesthesia in 45 patients, who had undergone operation of lesions involving the cavernous sinus between September, 1990, and May, 1993. The patient was placed in a 30 degree of head-up position to reduce the bleeding from the cavernous venous plexus. However, air embolism during the operation has not been noted in any patients. In 13 of 45 patients, a transient or permanent internal carotid artery (ICA) occlusion was performed intraoperatively under the brain protection by thiopental and the monitoring of electroencephalograph, somatosensory evoked potentials, local cerebral blood flow, and oxygen saturation of internal jugular vein. There has been no complications related to the ICA occlusion. In 7 patients, intraoperative recordings of evoked extraocular muscle activities were undertaken to monitor ocular motor nerve function. Responses from the inferior rectus muscle to the oculomotor nerve stimulation, and from the lateral rectus muscle to the abducens nerve stimulation, were obtained in 5 patients and 1 patient, respectively. Intraoperative neurophysiological monitoring in the surgery of lesions involving the cavernous sinus is crucial to reduce the surgical complications, and a team approach, including neurosurgeons, anesthesiologists, and medical engineers, is important for the future progress.