Formation of a Large Fusiform Aneurysm near a Medullary Infarction Caused by Dissection of the Posterior Inferior Cerebellar Artery

Infarction of the posterior inferior cerebellar artery (PICA) can lead to ischemic stroke in the lateral medullary oblongata. PICA dissection can also elicit an ischemic event in this region, but its detection on radiological images is difficult because of the small diameter of the vessel. We report a case of Wallenberg syndrome due to PICA dissection in a 48-year-old man, which was difficult to diagnose on first admission. He reported sudden onset of sensory disturbance on the right side of his face, ataxic gait, and headache. Brain magnetic resonance imaging (MRI) revealed a fresh cerebral infarct in the right lateral medulla oblongata. Magnetic resonance angiography (MRA) performed at the time of his admission showed no cerebral vessel abnormalities. An MRI study 18 months after the event revealed a fusiform aneurysm on the lateral medullary segment of the PICA, which was extremely close to the cerebral infarct. We concluded that the infarct was due to PICA dissection because of the sudden onset of symptoms and because the infarcted territory of the occluded penetrating branch of the dissecting aneurysm was consistent with Wallenberg syndrome. The aneurysm was trapped and an occipital artery-PICA bypass was placed. At the latest follow-up, 1 year after the procedure, he had no neurological symptoms. Imaging findings at the time of his first admission indicated that the PICA was intact. However, 18 months later, MRI revealed enlargement of an aneurysm at the site of the dissection. A cerebral infarct with headache may indicate PICA dissection.

Spontaneous middle cerebral artery dissection: a series of six cases and literature review

Middle cerebral artery (MCA) dissection is rare, and various clinical presentations, including hemorrhage, ischemia, or comorbidities, and the changes in imaging findings over time hinder treatment decisions. The European Stroke Organization guidelines exclude MCA dissection. Few cases have been reported with no review of the relevant literature. Therefore, we reviewed the relevant literature and our own experience with non-traumatic MCA dissection cases to determine appropriate treatment strategies. At our institution and affiliated institutions, we encountered six cases of MCA dissection-five with infarction and one with hemorrhage. Two patients underwent revascularization, and one underwent an aneurysmectomy. We reviewed English and Japanese articles in PubMed and Medical Journal Web and summarized the results based on the relationships among age, sex, location, the presence of an aneurysm, the presence of angiography, history, treatment, and mode of onset. The clinical course, changes in imaging, treatment strategies, and prognosis were discussed. Eighty cases were included in the review. Cerebral aneurysms were more common distal to the M2 area (p = 0.00) and were correlated with hemorrhage (p < 0.001). Most hemorrhagic cases with aneurysms were treated surgically, while ischemic cases were treated with antithrombotic agents, and both had a similar neurological prognosis. There were some cases of rebleeding after antithrombotic therapy, especially in older adults.Surgical treatment is recommended in cases of hemorrhage and confirmed aneurysms, particularly for lesions distal to the M2 area. Patients with aneurysm-associated ischemia should be followed up, and antithrombotic treatment should be considered with particular care in older adults.

Distal Endovascular Occlusion for Incomplete Occlusion of Cavernous Carotid Aneurysms after High-flow Bypass and Cervical Internal Carotid Artery Ligation

Internal carotid artery (ICA) ligation for placing a high-flow extracranial-intracranial (EC-IC) bypass is used in patients with aneurysms on the cavernous portion of the ICA. Recanalization and rupture after proximal ICA ligation can occur. We present four patients who underwent endovascular distal ICA occlusion and report our surgical technique and treatment results. We ligated the ICA to place an EC-IC bypass using a radial artery (RA) graft. Failure to obtain spontaneous occlusion in the distal region required endovascular treatment an average of 219 days later. A guide catheter was placed in the common carotid artery, a guide or distal access catheter was introduced in the RA graft from the external carotid artery, and a microcatheter was navigated into the cavernous aneurysm through the RA graft. Using detachable coils, endovascular ICA occlusion was from just distal to the aneurysmal neck to a site proximal to the origin of the ophthalmic artery. Aneurysmal occlusion was completed by endovascular occlusion of the distal ICA. Complications were RA graft stenosis and transient consciousness disturbance due to local subarachnoid hemorrhage. Outpatient follow-up for a mean of 109.5 months revealed no recurrences. Distal occlusion of the ICA through the implanted RA graft is simple and presents a low risk for cerebral infarction due to thrombus formation during the procedure. To treat cavernous carotid aneurysms that do not disappear after placing the EC-IC bypass after ICA ligation at the aneurysmal neck, we offer our procedure as a treatment option.

Characteristics of Ischemic Versus Hemorrhagic Stroke in Patients Receiving Oral Anticoagulants: Results of the PASTA Study

Objective Limited data exist regarding the comparative detailed clinical characteristics of patients with ischemic stroke (IS)/transient ischemic attack (TIA) and intracerebral hemorrhage (ICH) receiving oral anticoagulants (OACs). Methods The prospective analysis of stroke patients taking oral anticoagulants (PASTA) registry, a multicenter registry of 1,043 stroke patients receiving OACs [vitamin K antagonists (VKAs) or non-vitamin K antagonist oral anticoagulant (NOACs)] across 25 medical institutions throughout Japan, was used. Univariate and multivariable analyses were used to analyze differences in clinical characteristics between IS/TIA and ICH patients with atrial fibrillation (AF) who were registered in the PASTA registry. Results There was no significant differences in cardiovascular risk factors, such as hypertension, diabetes mellitus, dyslipidemia, smoking, or alcohol consumption (all p>0.05), between IS/TIA and ICH among both NOAC and VKA users. Cerebral microbleeds (CMBs) [odds ratio (OR), 4.77; p<0.0001] were independently associated with ICH, and high brain natriuretic peptide/N-terminal pro B-type natriuretic peptide levels (OR, 1.89; p=0.0390) were independently associated with IS/TIA among NOAC users. A history of ICH (OR, 13.59; p=0.0279) and the high prothrombin time-international normalized ratio (PT-INR) (OR, 1.17; p<0.0001) were independently associated with ICH, and a history of IS/TIA (OR, 3.37; 95% CI, 1.34-8.49; p=0.0101) and high D-dimer levels (OR, 2.47; 95% CI, 1.05-5.82; p=0.0377) were independently associated with IS/TIA among VKA users. Conclusion The presence of CMBs, a history of stroke, natriuretic peptide and D-dimer levels, and PT-INR may be useful for risk stratification of either IS/TIA or ICH development in patients with AF receiving OACs.

Role of RNF213 polymorphism in defining quasi-moyamoya disease and definitive moyamoya disease

OBJECTIVE

Quasi-moyamoya disease (QMMD) is moyamoya disease (MMD) associated with additional underlying diseases. Although the ring finger protein 213 (RNF213) c.14576G>A mutation is highly correlated with MMD in the Asian population, its relationship to QMMD is unclear. Therefore, in this study the authors sought to investigate the RNF213 c.14576G>A mutation in the genetic diagnosis and classification of QMMD.

METHODS

This case-control study was conducted among four core hospitals. A screening system for the RNF213 c.14576G>A mutation based on high-resolution melting curve analysis was designed. The prevalence of RNF213 c.14576G>A was investigated in 76 patients with MMD and 10 patients with QMMD.

RESULTS

There were no significant differences in age, sex, family history, and mode of onset between the two groups. Underlying diseases presenting in patients with QMMD were hyperthyroidism (n = 6), neurofibromatosis type 1 (n = 2), Sjögren's syndrome (n = 1), and meningitis (n =1). The RNF213 c.14576G>A mutation was found in 64 patients (84.2%) with MMD and 8 patients (80%) with QMMD; no significant difference in mutation frequency was observed between cohorts.

CONCLUSIONS

There are two forms of QMMD, one in which the vascular abnormality is associated with an underlying disease, and the other in which MMD is coincidentally complicated by an unrelated underlying disease. It has been suggested that the presence or absence of the RNF213 c.14576G>A mutation may be useful in distinguishing between these disease types.

High-flow bypass surgery using a radial artery graft for an extracranial internal carotid artery aneurysm: Case reports and literature review

Background:

Extracranial carotid artery aneurysms are rare. Surgery may be difficult when vessels are tortuous and on a high cervical level. We report two patients whose tortuous extracranial internal carotid artery (ICA) aneurysm located on a high cervical level was successfully treated by ICA ligation and a high-flow bypass using a radial artery (RA) graft between the external carotid- and the middle cerebral artery.

Case Description:

(Case 1) A 47-year-old man suffered a recurrent cerebral infarct despite medical treatment. His right extracranial ICA aneurysm measured 33 mm; it was tortuous and located at a high cervical level. We ligated the ICA after placing a high-flow bypass using an RA graft. The aneurysm was not repaired. (Case 2) A 59-year-old woman noticed pulsatile swelling on her left neck. It was due to an extracranial ICA aneurysm that was large (36 mm), tortuous, and located at a high cervical level. We performed ICA ligation after placing a high-flow bypass using an RA graft without direct aneurysmal repair. Six months after the operation she noted a pulsatile bulge on the left oropharynx. We confirmed recurrence of an aneurysm from retrograde blood flow and performed internal trapping by occluding the distal portion of the ICA aneurysm using an intravascular procedure.

Conclusion:

ICA ligation after placing a high-flow bypass with an RA-graft is a technically demanding, but safe procedure to address extracranial ICA aneurysms that are tortuous and located at a high cervical level.

Lesion Trapping with High-Flow Bypass for Ruptured Internal Carotid Artery Blood Blister-Like Aneurysm Has Little Impact on the Anterior Choroidal Artery Flow: Case Series and Literature Review

OBJECTIVE

To examine the relationship between trap location and cerebral infarction in the anterior choroidal artery (AChA) region and associated risks in ruptured internal carotid artery blood blister-like aneurysm (BLA) treatment with high-flow bypass and lesion trapping.

METHODS

We included 26 patients diagnosed with BLAs and treated with high-flow bypass and trapping. We examined clinical characteristics including age, aneurysm trap location, final prognosis, cerebral infarction on postoperative magnetic resonance imaging, and modified Rankin Scale score at discharge. We also searched the literature for similar studies.

RESULTS

The modified Rankin Scale score at discharge was 0-2 in 20 patients, 3-5 in 2 patients, and 6 in 2 patients. In 19/26 patients (73.1%), the trapped segment was between the posterior communicating (PcomA) and the ophthalmic arteries. In 2 patients (7.7%), the trapped segment included the PcomA and the AChA; in 4 patients (15.4%), the trapped segment was within the PcomA. In these patients, the PcomA was occluded, and blood from the high-flow bypass flowed out to the AChA alone. No patient showed cerebral infarction. Our systematic review identified 70 patients. Of all 96 patients, 12 had AChA cerebral infarction; however, the infarction affected the prognosis of only 2 patients.

CONCLUSIONS

When treating BLAs with high-flow bypass and lesion trapping, the frequency of AChA cerebral infarction is low even when the PcomA is occluded, leaving the AChA as the only outflow vessel during high-flow bypass. However, PcomA occlusion may be associated with risks when treating patients with advanced arteriosclerosis near C1-2.

Open surgical embolectomy for cardiogenic cerebral embolism: Technical note and its advantages

BACKGROUND AND IMPORTANCE

In cardiogenic cerebral embolism, early recanalization is the most important factor for good prognosis. However, endovascular thrombectomy often fails to achieve recanalization. We present an open surgical embolectomy technique and discuss its advantages.

CLINICAL PRESENTATION

A 79-year-old woman developed right hemiparesis and severe aphasia. Magnetic resonance imaging revealed an acute cerebral infarction caused by left middle cerebral artery (MCA) occlusion. We attempted endovascular thrombectomy but failed because it was impossible to guide the catheter to the occlusion site. Hence, we converted to open surgical embolectomy. Sylvian fissure was widely opened. After confirming the range of thrombosis using indocyanine green videoangiography (ICGVAG), the proximal and distal arteries were secured, and a temporary clip was placed on the distal M2 to prevent distal thrombosis migration. MCA was cut approximately 3 mm from the bifurcation, and thrombosis was removed using micro-forceps. The proximal clip was simultaneously inserted but was not clamped because the thrombus was extruded by proximal vascular flow. Immediately after removing the thrombus, intense bleeding occurred from the proximal flow. An assistant clamped the proximal artery using the prepared clip, and the incised area of MCA was sutured using 9-0 threads. We finally confirmed blood flow after recanalization using ICGVAG. The time from skin incision to recanalization was 27 min. After the procedure, the patient developed slight aphasia but had no hemiparesis and was later transferred to a rehabilitation hospital.

CONCLUSION

Open surgical embolectomy may be a secondary rescue treatment option in the case of endovascular thrombectomy failure.

Real-world treatment results for ruptured blood-blister aneurysm of the internal carotid artery: analysis of a Japanese nationwide multicenter study

Ruptured blood-blister aneurysm (BBA) of the internal carotid artery (ICA) remains a challenging lesion, even in the age of modern neurosurgery and endovascular treatment. This retrospective multicenter study aimed to investigate the real-world treatment choice and treatment results. We included 182 ruptured BBAs of the ICA treated at 51 neurosurgical centers in Japan between 2013 and 2017. The baseline patient characteristics, radiological features of the aneurysm, treatment modality, details of treatment, complications of treatment, and treatment results were retrospectively collected. The treatment strategy was divided into deconstructive and reconstructive procedures. Primary clinical outcomes were evaluated using the modified Rankin scale (mRS) at final follow-up. Direct surgery was performed in 144 (79%) cases, and the remaining 38 (21%) cases received endovascular treatment. The majority of treatment selections were deconstructive and reconstructive procedures in the direct surgery group and endovascular treatment group, respectively. Overall, favorable clinical outcomes (mRS 0 to 2) were achieved in 66% of cases, and the mortality rate was 15% at the final follow-up (mean 23 months). There was no significant difference in clinical outcome between direct and endovascular treatment groups. Our large nationwide study compared the real-world treatment options for ruptured BBAs and their results. Our findings may offer beneficial information for treatment decision and for future studies investigating ruptured BBAs.

Abstract P659: Pre-Stroke Chads 2 Scores Should Be Associated With Onset Severity and Functional Outcome in Acute Stroke Patients With Atrial Fibrillation During Oral Anticoagulants: A Sub-Analysis of PASTA Registry Study

Background and Purpose: The impact of CHADS 2 score on neurological severity in patients with stroke during oral anticoagulant (OAC) has not yet been elucidated. We investigated the association between pre-stroke CHADS 2 score and severity on admission and functional outcome in acute cardioembolic stroke due to AF during OAC.

Methods: We conducted an investigator-initiated, multicenter, prospective, observational cohort study, PASTA registry. One thousand forty-three patients with transient ischemic attack, ischemic stroke, and ICH who were taking OACs were prospectively enrolled in 25 medical institutions throughout Japan. We compared the clinical characteristics including severity onset and discharge outcome between low CHADS 2 score group (<2), and high CHADS 2 score group (≥2) in patients with cardioembolic stroke due to AF.

Result: A total of 548 patients (237 women; median age 80 [quartiles 74-85] years) were enrolled. Of these, there were 76 patients (14%) in low CHADS 2 group and 472 (86%) in high CHADS 2 score group (Fig A). Along with increase of pre-stroke CHADS 2 score, NIHSS score was gradually increased (Fig B). Low CHADS 2 score group was associate with good outcome than high CHADS 2 group (p<0.001, Fig C). Age (p<0.001), male (p<0.001), pre-stroke CHADS 2 score (p<0.001), and initial NIHSS score (p<0.001) were significantly higher in non-excellent outcome (mRS≥2) group than excellent outcome group (mRS<2). In contrast, creatinine clearance and body weight were higher in excellent outcome group (Both p<0.001). Multivariate logistic regression analysis indicated that high pre-stroke CHADS 2 score independently associated with higher NIHSS score (NIHSS score≥6; OR 1.55, 95%CI 1.02-2.36, p=0.041) and non-excellent outcome (OR 1.94, 95%CI 1.01-3.80, p=0.047).

Conclusion: The present study suggests that the pre-stroke CHADS 2 score should be useful for the prediction of clinical outcomes in patients with cardioembolic stroke due to AF even taking OAC.

Serum Glucose-To-Potassium Ratio as a Prognostic Predictor for Severe Traumatic Brain Injury

BACKGROUND

Initial management of severe traumatic brain injury is important and includes treatment decision-making and prediction of prognosis. We examined whether biomarkers at admission could be useful prognostic predictors. We focused on electrolytes and blood glucose, which can be measured easily at any facility and for which results can be obtained promptly, before those of other biomarkers, such as D-dimer.

METHODS

All trauma patients with head injuries treated at Chiba Hokusoh Hospital between 2014 and 2017 were investigated. Cases of multiple trauma accompanied by fatal trauma, hemorrhagic shock, or cardiopulmonary arrest, and pediatric cases, were excluded from this study. Blood gas data at the initial hospital visit were reviewed retrospectively. A poor outcome was defined as death during hospitalization or a vegetative state due to head injury. Factors related to poor outcomes were analyzed.

RESULTS

Of the 185 male and 79 female patients studied, 34 had poor outcomes. Poor outcome was significantly correlated with potassium (P = 0.003), glucose (P < 0.001), and glucose-to-potassium ratio (P < 0.001) at arrival. The odds ratio was 4.079 for a glucose-to-potassium ratio of ≥50.

CONCLUSIONS

We evaluated blood gas data at the initial hospital visit, as these results can be obtained more quickly than those of other biomarkers assessed previously. Serum glucose-to-potassium ratio at admission may be a potential predictor of prognosis for severe traumatic brain injury.

Radial Artery Graft for Giant Common Carotid Artery Pseudoaneurysm After Carotid Artery Stenting

BACKGROUND

We present a patient who underwent left superior temporal artery (STA)-to-right middle cerebral artery (MCA) bypass using a radial artery (RA) graft with resection of a giant right cervical common carotid artery (CCA) pseudoaneurysm after carotid artery stenting (CAS) and discuss the treatment strategy and surgical procedure in detail.

CASE DESCRIPTION

An 86-year-old male presented with sudden onset of altered consciousness and complete left hemiparesis. Magnetic resonance angiography and catheter angiography of the brain revealed occlusion of the right cervical ICA. Endovascular thrombectomy and stenting of the cervical segment of the ICA were performed. Thirty-two days after CAS, the patient developed a high fever and rapid swelling of the neck. Catheter angiography showed a giant right CCA pseudoaneurysm that had a fistula just proximal to the carotid stent, and the aneurysm extended to the neck entirely. Because of the expanding neck infection, stent placement long lesion, and lack of distal collateral flow on angiography, we performed aneurysm and stent removal and left STA-to-right MCA bypass using an RA graft. The harvested RA graft was anastomosed side to end to both the M2 segment of the right MCA and the left STA. Bypass patency was confirmed before neck exposure. The pseudoaneurysm and proximal portion area of the stent were resected. The patient recovered well postoperatively, and follow-up catheter angiography showed patency of the bypass.

CONCLUSIONS

Left STA-RA-right MCA bypass with aneurysm resection is a good treatment option for giant CCA pseudoaneurysms that occur after CAS.

Abstract WP246: Characteristic of Ischemic Stroke Prior Taking Direct Oral Anticoagulant versus Warfarin Treatment: Results From the PASTA Registry

Background and Purpose: The characteristics of patients with stroke prior receiving direct oral anticoagulant (DOAC) have not been fully clarified. We planned to recruit patients prospectively and to investigate the characteristics and outcomes in stroke patients taking DOAC and warfarin treatment prior to the event.

Methods: The prospective analysis of stroke patients taking anticoagulants (PASTA) registry study is an observational, multicenter, prospective registry of stroke patients receiving OAC. Patient enrollment started in April 2016 at 25 tertiary centers across Japan. We compared clinical characteristics and discharge modified Rankin Scale (mRS) between DOAC-and warfarin-treatment in patients with atrial fibrillation (AF).

Results: A total of 580 patients (231 women; median age 80 [quartiles 73-84] years) were analyzed (Fig. A). Of these, 365 patients (63%) received prior DOAC treatment and the remaining 215 (37%) received prior warfarin treatment (Fig. B and C). There were significant differences in clinical characteristics and outcome between DOAC-and warfarin-treatment prior to the event regarding initial NIHSS score (median [quartiles]: DOAC, 4 [2-16] vs. warfarin, 9 [3-21]; P =0.0001), rate of medium-large size of infarct (DOAC, 202/340 [59%] versus warfarin, 152/203 [75%]; P =0.0003) and the proportion of patients with favorable outcome (mRS, 0-3: DOAC 218/354 [62%] vs. warfarin 108/212 [49%]; P =0.0036). Subclassification according to DOAC dosing revealed patients with low-dose (259/365; 71%) to be older and to have a higher NIHSS score compared with regular dose (low-dose, 5 [2-17] vs. regular-dose, 3 [1-11]; P =0.0023) (Fig. D). Type of DOAC agent did not result in relevant differences in clinical characteristics or outcome (Fig. E).

Conclusions: Our results showed that patients with DOAC treatment before the event showed smaller infarct size, milder initial stroke severity, and favorable outcome compared to patients with warfarin.

Abstract WP418: Characteristic of Intracerebral Hemorrhage Related to Direct Oral Anticoagulant versus Warfarin: Results From the PASTA Registry

Background and Purpose: The characteristics of direct oral anticoagulant (DOAC)-related intracerebral hemorrhage (ICH) have not been fully clarified. We planned to recruit patients prospectively and to investigate the characteristics and outcomes in patients with ICH receiving direct oral anticoagulant (DOAC) and warfarin treatment.

Methods: The prospective analysis of stroke patients taking anticoagulants (PASTA) registry study is an observational, multicenter, prospective registry of stroke patients receiving OAC. Patient enrollment started in April 2016 at 25 tertiary centers across Japan. We compared imaging, clinical characteristics, and discharge modified Rankin Scale (mRS) between DOAC- and warfarin-related ICH patients with atrial fibrillation (AF).

Results: A total of 154 patients (51 women; median age 77 [quartiles 69-87] years) were analyzed. Of these, 111 patients (72%) received prior DOAC treatment and the remaining 43 (28%) received prior warfarin treatment (Fig. A, B and C). There were no relevant differences in clinical and hematoma characteristics between DOAC- and warfarin-related ICH regarding baseline hematoma volume (median [quartiles]: DOAC, 11 [5-23] mL vs. warfarin, 12 [5-30] mL; P =0.95), rate of hematoma expansion (DOAC, 12/111 [11%] vs. warfarin, 4/43 [9%]; P =0.80), rate of subcortical hemorrhage (DOAC, 15/111 [11%] vs. warfarin, 10/43 [9%]; P =0.80) and the proportion of patients with unfavorable outcome (mRS, 4-6: DOAC 76/108 [70%] vs. warfarin 23/38 [61%]; P =0.26). Cerebral microbleeds (CMBs) were detected more frequently in DOAC group than in warfarin (47/76 [62%] vs. 11/32 [34%]; P <0.01). Subgroup analyses showed that type of DOAC agent did not result in relevant differences in imaging characteristics or outcome (Fig. D and E).

Conclusions: Our results showed that there were no significant differences in hematoma characteristics and functional outcome among AF patients with DOAC- or warfarin-related ICH.

Quantitative Comparison of the Intraoperative Utility of Indocyanine Green and Fluorescein Videoangiographies in Cerebrovascular Surgery

BACKGROUND

A quantitative analysis comparing indocyanine green videoangiography (ICG-VAG) and fluorescein videoangiography (FL-VAG) in cerebrovascular surgery has not been reported so far.

OBJECTIVE

To clear the differences of characteristics of ICG-VAG and FL-VAG by quantitative assessment.

METHODS

We prospectively analyzed results from 23 patients (3 males; mean age at surgery: 60.9 years, range: 14-75 years) at our hospital from August 2014 to July 2015. Eighteen patients had cerebral aneurysms for clipping, and 5 had intracranial arterial stenosis for superficial temporal artery (STA)-middle cerebral artery bypass. We imported data from the operative image data, converted by Audio Video Interleave to Aquacosmos as picture fluorescence intensity-analyzing software. Regions of interest were set at the parent artery, dome of aneurysms, and perforating artery in cases of clipping of aneurysms, and setting at 3 points in STA, in case of bypass. The transition of fluorescence intensity at each region of interest was calculated and plotted using Aquacosmos.

RESULTS

Thick-walled artery, such as parent artery ( P = .0017) and STA ( P = .0182), was more significantly visualized by ICG-VAG than FL-VAG, whereas the perforating artery, especially in deep surgical fields, such as anterior communicating artery, internal carotid artery, and basilar artery, was better visualized by FL-VAG than ICG-VAG ( P < .0001).

CONCLUSION

In this quantitative analysis of fluorescence study, ICG-VAG showed greater efficacy than FL-VAG in visualizing relatively thick arteries, such as parent artery and STA. However, FL-VAG has greater efficacy than ICG-VAG in visualizing perforating artery, especially in deep surgical fields with characteristic vessel walls.

Serum Glucose and Potassium Ratio as Risk Factors for Cerebral Vasospasm after Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE

Cerebral vasospasm is associated with poor prognosis in patients with aneurysmal subarachnoid hemorrhage (SAH), and biomarkers for predicting poor prognosis have not yet been established. We attempted to clarify the relationship between serum glucose/potassium ratio and cerebral vasospasm in patients with aneurysmal SAH.

METHODS

We studied 333 of 535 aneurysmal SAH patients treated between 2006 and 2016 (123 males, 210 females; mean age 59.7 years; range 24-93). We retrospectively analyzed the relationship between cerebral vasospasm grade and clinical risk factors, including serum glucose/potassium ratio.

RESULTS

Postoperative angiography revealed cerebral vasospasm in 112 patients (33.6%). Significant correlations existed between the ischemic complication due to cerebral vasospasm and glucose/potassium ratio (P < .0001), glucose (P = .016), and potassium (P = .0017). Serum glucose/potassium ratio was elevated in the cerebral vasospasm grade dependent manner (Spearman's r = 0.1207, P = .0279). According to the Glasgow Outcome Scale (GOS) score at discharge, 185 patients (55.5%) had a poor outcome (GOS scores 1-3). Serum glucose/potassium ratio was significantly correlated between poor outcome (GOS scores 1-3) and age (P < .0001), serum glucose/potassium ratio (P < .0001), glucose (P < .0001), potassium (P = .0004), white blood cell count (P = .0012), and cerebral infarction due to cerebral vasospasm (P < .0001). Multivariate logistic regression analyzes showed significant correlations between cerebral infarction due to cerebral vasospasm and serum glucose/potassium ratio (P = .018), glucose (P = .027), and potassium (P = .052).

CONCLUSIONS

Serum glucose/potassium ratio in cases of aneurysmal SAH was significantly associated with cerebral infarction due to cerebral vasospasm and GOS at discharge. Therefore, this factor was useful to predict prognosis in patients with cerebral vasospasm and aneurysmal SAH.

Efficacy of Thyrotropin-Releasing Hormone Analog for Protracted Disturbance of Consciousness due to Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE

The efficacy of thyrotropin-releasing hormone tartrate (TRH-T) for treating prolonged disturbance of consciousness due to aneurysmal subarachnoid hemorrhage (SAH) remains unclear. The purpose of the present study was to determine whether TRH-T was really effective, and what was the recovery factor when it was valid. This was a retrospective study of a single facility.

METHODS

We treated 208 patients with aneurysmal SAH at our hospital between 2011 and 2017. Among them, we investigated 97 cases in which TRH-T was administered to prolonged disturbance of consciousness. Thirty one patients with Hasegawa dementia rating scale-revised (HDS-R) score less than 20 were included. Patients' HDS-R scores were evaluated 7 days after clipping the aneurysm and 2 days after completing a course of TRH-T treatment. HDS-R score increases of greater than or over equal to 8 and less than 8 were defined as good and poor outcomes, respectively. Outcomes were compared to 11 patients who did not receive TRH-T treatment.

RESULTS

Average initial and post-treatment HDS-R scores were 9 ± 6.6 and 19 ± 9.5, respectively. The good outcome group included 19 patients. Statistically significant differences in HDS-R score changes were observed between the group with initial HDS-R scores of 0-4 and the other groups. Poor outcomes were significantly correlated with age of greater than 60 years and initial HDS-R scores less than oroverequal to 4 points. The improvement in HDS-R score was significantly greater in the TRH-T administration group than the control group.

CONCLUSIONS

TRH-T was effective for treating prolonged disturbance of consciousness due to aneurysmal SAH, especially in young patients with HDS-R scores between 5 and 20.

Embolectomy Through Aneurysm Wall for Iatrogenic Occlusion of M1 Portion During Coil Embolization: Technical Note for Transaneurysmal Embolectomy

OBJECTIVE

We describe the technique for surgical "transaneurysmal" embolectomy in a patient with subarachnoid hemorrhage and multiple cerebral aneurysms who manifested large-vessel occlusion during coil embolization.

METHODS

An 84-year-old woman with subarachnoid hemorrhage and bilateral internal carotid artery (ICA)-posterior communicating artery and bilateral middle cerebral artery aneurysms (MCAs) was admitted to our institution. We performed clipping to the left ICA and MCAs; however, we could not find the rupture point of both aneurysms. We chose to treat 2 aneurysms on the other side by coil embolization. After complete coil embolization of a right ICA aneurysm, angiograms showed occlusion of the right MCA just proximal to an MCA aneurysm. Considering the risk of bleeding of an untreated MCA distal to the occlusion by endovascular thrombectomy, we performed open transaneurysmal embolectomy at the occlusion site and surgical clipping of the MCA. After cutting the aneurysmal wall, we inserted a suction tube into the cut surface of the aneurysm. The clot was gradually and completely pulled through the cut surface of the aneurysm. Finally, the aneurysm was completely clipped with titanium clips to preserve the M1 and M2 branches.

DISCUSSION

Different from usual surgical thrombectomy, suturing the vessel wall is not required for transaneurysmal embolectomy and the area of brain ischemia is confined. Aneurysms with the fragile wall may rupture during clearance of tissue on the aneurysmal surface, and suction may increase vessel damage.

CONCLUSION

Transaneurysmal thrombectomy may be useful and safe for large-vessel occlusion just distal to cerebral aneurysms.

Serum glucose/potassium ratio as a clinical risk factor for aneurysmal subarachnoid hemorrhage

OBJECTIVE

Aneurysmal subarachnoid hemorrhage (SAH) can result in poor outcomes, and biomarkers for predicting poor prognosis have not yet been established. The aim of this study was to clarify the significance of the serum glucose/potassium ratio for predicting the prognosis of aneurysmal SAH.

METHODS

The authors retrospectively reviewed the records of 565 patients with aneurysmal SAH between 2006 and 2016. The patient group comprised 208 men and 357 women (mean age 61.5 years, range 10-95 years). A statistical analysis was conducted of the clinical and laboratory risk factors of poor outcome, including the serum glucose/potassium ratio.

RESULTS

On estimation of the initial assessment using Hunt and Kosnik (H-K) grading, 233 patients (41.2%) were classified as the severe SAH group (H-K Grade IV or V). There were significant correlations between the severe SAH group and serum glucose/potassium ratio (p < 0.0001). Serum glucose/potassium ratio was elevated in an H-K grade-dependent manner (Spearman's r = 0.5374, p < 0.0001). With the estimation of the Glasgow Outcome Scale (GOS) score at discharge, 355 patients (62.8%) were classified as poor outcome (GOS score 1-3). The serum glucose/potassium ratio was elevated in a GOS score at discharge-dependent manner (Spearman's r = 0.4006, p < 0.0001), and was significantly elevated in the poor outcome group compared with the good outcome group (GOS score 4 or 5; p = 0.0245). There were significant correlations between poor outcome and serum glucose/potassium ratio (p < 0.0001), age (p < 0.0001), brain natriuretic peptide levels (p = 0.011), cerebral infarction due to vasospasm (p < 0.0001), and H-K grade (p < 0.0001). Multivariate logistic regression analyses showed significant correlations between poor outcome and serum glucose/potassium ratio (p = 0.009).

CONCLUSIONS

In this study, the serum glucose/potassium ratio of patients with aneurysmal SAH at admission was significantly correlated with H-K grade and GOS score at discharge. Therefore, this ratio was useful for predicting prognosis of aneurysmal SAH, especially in severe cases.

Acute Poststroke Depression Is Associated with Thalamic Lesions and Clinical Outcomes: A Case-Control Study

BACKGROUND

We investigated the role of acute-phase stroke lesions and patient characteristics in poststroke depression (PSD) and its effect on the clinical outcome.

PATIENTS AND METHODS

Five and 30 days after admission, 175 patients self-reported their depressive symptoms on the Patient Health Questionnaire-9. We compared the clinical characteristics and outcomes in patients with (n = 41) and without PSD (n = 134). Stroke severity was assessed with the National Institutes of Health Stroke Scale (NIHSS); the modified Rankin Scale (mRS) was used to determine the functional outcome.

RESULTS

There was no significant difference between patients with and without PSD in the age, gender ratio, lesion side, and the history of hypertension, diabetes mellitus, alcohol and tobacco use, and previous stroke. Thalamic lesions were significantly associated with PSD (P = .03), although there was no significant difference in both the NIHSS score and the final mRS score of patients with thalamic lesions. Backward stepwise logistic regression analysis showed that a higher NIHSS score and thalamic lesions were independent predictors of PSD. Total hospitalization was significantly longer in patients with PSD. At the time of admission, the NIHSS score was significantly higher in patients who developed moderate to severe PSD than in those with mild PSD or without PSD.

CONCLUSIONS

PSD in the acute phase was associated with thalamic lesions and severe stroke. Hospitalization was significantly longer in patients with PSD and their functional disability was more severe, suggesting that PSD played a role in the unsatisfactory results of poststroke rehabilitation.

Environmental and Clinical Risk Factors for Delirium in a Neurosurgical Center: A Prospective Study

BACKGROUND

Few reports of delirium-related risk factors have focused on environmental risk factors and clinical risk factors, such as white matter signal abnormalities on magnetic resonance imaging fluid attenuated inversion recovery images.

METHODS

We prospectively enrolled 253 patients admitted to our neurosurgical center between December 2014 and June 2015 and analyzed 220 patients (100 male patients; mean age, 64.1 years; age range, 17-92 years). An Intensive Care Delirium Screening Checklist score ≥4 points indicated delirium. We evaluated patient factors consisting of baseline characteristics and related factors, such as white matter lesions (WMLs), as well as the surrounding environment.

RESULTS

Delirium occurred in 29/220 cases (13.2%). Regarding baseline characteristics, there were significant statistical correlations between delirium and age (P = 0.0187), Hasegawa Dementia Scale-Revised score (P = 0.0022) on admission, and WMLs (P < 0.0001). WMLs were related to age (P < 0.0001) and atherosclerotic disease (P = 0.004). Regarding related factors, there were significant statistical correlations between delirium and stay in a neurosurgical care unit (P = 0.0245). Multivariate logistic regression analyses showed statistically significant correlations of delirium with WMLs (P < 0.0001) and surrounding patients with delirium (P = 0.026).

CONCLUSIONS

WMLs in patients and the surrounding environment are risk factors for delirium in a neurosurgical center. To prevent delirium, clinicians must recognize risk factors, such as high-grade WMLs, and manage environmental factors.

The Ivy Sign on Fluid Attenuated Inversion Recovery Images Related to Single-Photon Emission Computed Tomography Cerebral Blood Flow in Moyamoya Disease: A Case Report

Moyamoya disease is an idiopathic progressive cerebrovascular steno-occlusive disorder characterized by the formation of numerous collaterals called Moyamoya vessels. Accurate evaluation of vascular status and cerebral blood flow (CBF) is needed for prompt treatment to prevent ischemic and/or hemorrhagic events. The pathogenesis of the ivy sign on fluid attenuated inversion recovery (FLAIR) images of Moyamoya disease patients is unclear. We report a Moyamoya disease case wherein the ivy sign changed in relation to single-photon emission computed tomography (SPECT)-measured CBF during progression and following treatment. A 49-year-old female presented with slight aphasia and right hemiparesis. Magnetic resonance imaging (MRI) diffusionweighted image revealed cerebral infarction in the left frontal lobe. Cerebral angiography images showed bilateral distal internal carotid artery stenosis and Moyamoya vessels. FLAIR images exhibited the ivy sign. We performed superficial temporal arteryâ€" middle cerebral artery (STA-MCA) bypass surgery with encephalogaleosynangiosis (EGS) and encephalomyosynangiosis (EMS) on the left side 6 months after first presentation. After operation, left-side resting CBF gradually improved on SPECT and the ivy sign decreased. On the other hand, right-side CBF gradually deteriorated at rest, and the ivy sign increased. Therefore, we performed STAâˆ'MCA bypass with EGS and EMS on the right side 4 years after first presentation. After the operation, the resting CBF increased and the ivy sign decreased. The FLAIR ivy sign may be a useful indicator of both deterioration and improvement of CBF status without the need for CBF imaging using contrast material.

Intracerebral Hemorrhage Caused by Cerebral Hyperperfusion after Superficial Temporal Artery to Middle Cerebral Artery Bypass for Atherosclerotic Occlusive Cerebrovascular Disease

Few papers have reported detailed accounts of intracerebral hemorrhage caused by cerebral hyperperfusion after superficial temporal artery to middle cerebral artery bypass (STA-MCA) bypass for atherosclerotic occlusive cerebrovascular disease. We report a case of vasogenic edema and subsequent intracerebral hemorrhage caused by the cerebral hyperperfusion syndrome (CHS) after STA-MCA bypass for atherosclerotic occlusive cerebrovascular disease disease without intense postoperative blood pressure control. A 63-year-old man with repeating left hemiparesis underwent magnetic resonance angiography (MRA), which revealed right internal carotid artery (ICA) occlusion. We performed a double bypass superficial temporal artery (STA)–middle cerebral artery (MCA) bypass surgery for the M2 and M3 branches. While the patient’s postoperative course was relatively uneventful, he suffered generalized convulsions, and computed tomography revealed a low area in the right frontal lobe on Day 4 after surgery. We considered this lesion to be pure vasogenic edema caused by cerebral hyperperfusion after revascularization. Intravenous drip infusion of a free radical scavenger (edaravone) and efforts to reduce systolic blood pressure to <120 mmHg were continued. The patient experienced severe left hemiparesis and disturbance of consciousness on Day 8 after surgery, due to intracerebral hemorrhage in the right frontal lobe at the site of the earlier vasogenic edema. Brain edema associated with cerebral hyperperfusion after STA-MCA bypass for atherosclerotic occlusive cerebrovascular disease should be recognized as a risk factor for intracerebral hemorrhage. The development of brain edema associated with CHS after STA-MCA bypass for atherosclerotic occlusive cerebrovascular disease requires not only intensive control of blood pressure, but also consideration of sedation therapy with propofol.

Intraoperative middle cerebral artery pressure measurements during superficial temporal artery to middle cerebral artery bypass procedures in patients with cerebral atherosclerotic disease

OBJECTIVE

No previous study has monitored middle cerebral artery (MCA) pressure during the superficial temporal artery (STA)-MCA bypass procedure for cerebral atherosclerotic disease. In this paper, the authors describe their method of monitoring MCA pressure and report their initial data on intraoperative MCA pressure and its relationship with hemodynamics prior to and after the bypass procedures.

METHODS

The results from a total of 39 revascularization procedures performed between 2004 and 2014 were analyzed. The patient group included 27 men and 12 women, and their mean age at surgery was 67.6 years (range 39–83 years). The authors investigated the MCA pressure via the STA during STA-MCA bypass procedures. After one branch of the STA was anastomosed to the MCA, the other branch was connected to an arterial line, and a clip was placed temporally on the main STA trunk to monitor the pre-anastomosis MCA pressure. Simultaneously, the radial artery (RA) pressure was determined before removing the temporal clip to measure the post-anastomosis MCA pressure. The relationship between MCA pressures and single photon emission computed tomography findings and the risk factors for hyperperfusion after STA-MCA bypass were analyzed.

RESULTS

The MCA/RA (%) pressure was significantly correlated with that of the resting stenotic/normal side cerebral blood flow (CBF) ratio (%) in the linear regression analysis (slope 1.200, r2 = 0.3564, F = 20.49, p < 0.0001). The intraoperative MCA pressure was 39.3% of RA pressure in patients with Powers' Stage 2 cerebral atherosclerotic disease. After 1 branch of the STA was anastomosed, the intraoperative MCA pressure increased to 75.3% of the RA pressure. The rate of increase in pressure was significantly correlated with the increase in the STA diameter in the linear regression analysis (slope 2.59, r2 = 0.205, F = 9.549, p = 0.0038). Hyperperfusion occurred in 2 cases. When mean values for these 2 patients were compared with those for the 37 patients without hyperperfusion, significant differences were found in the stenotic/normal side CBF ratio (p = 0.0001), pre-anastomosis MCA pressure (p = 0.02), rate of increase in pressure (p = 0.02), pre-anastomotic MCA/RA pressure ratio (p = 0.01), vascular reserve (p = 0.0489), and STA diameter (p = 0.0002).

CONCLUSIONS

The measurement of intraoperative MCA pressure may be a useful technique to assess cerebral perfusion and for predicting the risk of hyperperfusion. Monitoring MCA pressure is recommended during STA-MCA bypass procedures for atherosclerotic disease.

Protection Device Made of a Modified Syringe for Muscle Protection During Cranial Perforation: Technical Note

In neurosurgical procedures, avoiding damage of surrounding tissues such as muscle and periosteum during a craniotomy is important for esthetic and other reasons. We devised a protection tool by using an amputated syringe barrel to cover the perforating drill and protect temporal muscle damage. This device made it possible to prevent damage to surrounding tissues, such as the muscle and periosteum, during cranial perforation. This method could be useful as it is cost-effective, simple, and versatile.

Olfactory preservation during anterior interhemispheric approach for anterior skull base lesions: technical note

Anosmia is not a rare complication of surgeries that employ the anterior interhemispheric approach. Here, we present a fibrin-gelatin fixation method that provides reinforcement and moisture to help preserve the olfactory nerve when using the anterior interhemispheric approach and describe the results and outcomes of this technique. We analyze the outcomes with this technique in 45 patients who undergo surgery for aneurysms, brain tumors, or other pathologies via the anterior interhemispheric approach. Anosmia occurred in 4 patients (8.8%); it was transient in 2 (4.4%) and permanent in the remaining 2 (4.4%). Brain tumors clearly attached to the olfactory nerve were resected in the patients with permanent anosmia. We found a significant difference in the presence of anosmia between patients with or without lesions that were attaching the olfactory nerve (p = 0.011). Our results suggested that fibrin-gelatin fixation method can reduce the reported risk of anosmia. However, the possibility of olfactory nerve damage is relatively high when operating on brain tumors attaching olfactory nerve.

Efficacy of tracheostomy for central alveolar hypoventilation syndrome caused by lateral medullary infarction

Central alveolar hypoventilation syndrome (CAHS) is a rare and potentially fatal condition. However, respiratory care for patients with CAHS caused by lateral medullary infarction (CAHS-LMI) remains an important unsolved problem. We describe 2 patients with CAHS-LMI and review the case reports for 17 previously described patients. Patient 1 was a 78-year-old man who was referred to our hospital because of dizziness. After admission, Wallenberg syndrome developed. Magnetic resonance imaging showed left LMI. He had hypercapnia and respiratory acidosis the next afternoon and temporarily received mechanical ventilation. A tracheotomy was performed on the 12th hospital day, and the patient was weaned from the ventilator on the 18th hospital day. Patient 2 was 72-year-old man who was referred to our hospital because of dizziness and gait disturbance. Wallenberg syndrome was diagnosed after admission, and magnetic resonance imaging showed right LMI. His consciousness deteriorated, and hypercapnia developed on the ninth hospital day. The patient received ventilatory support, and a tracheotomy was performed on the 12th hospital day. He was weaned from the ventilator by the 16th hospital day. Consistent with our findings, most previously reported cases of CAHS-LMI were initially associated with mild symptoms, which subsequently worsened. Five of the 19 patients (26.3%) died within 1 month after onset, and 7 patients (36.8%) died within 1 year. Tracheotomy was performed in 12 patients, 2 of whom died 1 month after onset (16.7%); another patient died of chronic renal failure after 2 years. Tracheotomy seemed to be an effective procedure in patients with CAHS-LMI. We speculate that tracheotomy assists alveolar ventilation by reducing dead space ventilation. Closure of the tracheotomy should, therefore, be avoided in patients with CAHS-LMI, even if respiratory status is good.

Hemothorax after the intravenous administration of tissue plasminogen activator in a patient with acute ischemic stroke and rib fractures

A 79-year-old man experienced sudden-onset left hemiparesis and disturbance of consciousness. Diffusion-weighted magnetic resonance imaging showed an acute ischemic stroke in the territory of the right middle cerebral artery. He underwent systemic thrombolysis via the intravenous administration of tissue plasminogen activator (t-PA). Chest radiography and computed tomography performed the following day showed severe hemothorax with atelectasis of the left lung and multiple rib fractures; the initial chest radiogram had revealed rib fractures but we did not recognize them at the time. Conservative treatment with the placement of chest tubes was successful, and the patient recovered without further deterioration. Although systemic thrombolysis with t-PA is an accepted treatment for acute cerebral ischemic stroke, posttreatment intracranial hemorrhage has a negative effect on prognosis. Extracranial bleeding is a rare complication, and our search of the literature found no reports of hemothorax after treatment with t-PA in patients with cerebral ischemic stroke. We have reported a rare case of severe hemothorax after systemic thrombolysis with t-PA. This important complication indicates the need to rule out thoracic trauma with radiography and computed tomography of the chest.

Occlusion of the ascending pharyngeal artery during carotid artery surgery: importance and technique

AIM

In surgeries involving clamping, opening and repairing the carotid artery such as carotid endarterectomy (CEA) and proximal anastomosis at radial artery (RA) grafting, back-bleeding, often due to insufficient occlusion of the ascending pharyngeal artery (APA), must be avoided. In 96% of cases the APA originates at the dorsal side of the external carotid artery, while in 2% each it arises at the carotid bifurcation or the internal carotid artery. We developed a method to prevent back-bleeding from the APA irrespective of its origin.

MATERIAL AND METHODS

For CEA we dissect the internal carotid artery and clamp the APA and the external carotid artery together. For RA grafting we dissect the external carotid artery and if the APA branches directly from this vessel, the APA is clamped directly.

RESULTS

We used our new surgical technique in 54 cases (22 CEA and 32 RA grafts) and encountered no major back-bleeding.

CONCLUSION

We consider this method to be simple and useful for improving the safety and success of carotid artery surgeries.

Fluorescence Angiography with Temporary Occlusion to Confirm the Distal Artery: Technical Notes

Confirming the patency of the proximal parent and distal artery is necessary in cerebral aneurysm surgery. To understand the relationship between the parent and distal arteries of the aneurysm, the blood vessels running through the subarachnoid space should be extensively dissected, which is time consuming. To examine the efficacy of a temporary clip with indocyanine green (ICG) technique, in which the parent artery is temporarily occluded using a temporary clip, an ICG videoangiography (ICGVAG) is performed to clarify the relationship between the distal artery and the proximal parent artery. Three patients with a distal aneurysm. This technique was used to confirm the connection of the parent and the distal artery in distal aneurysms. With regard to middle cerebral artery (MCA), the procedure is conducted as follows. First, the M2 within the Sylvian fissure is investigated to ensure the absence of atherosclerosis and perforators and that this vessel could undergo occlusion by temporary clipping. The subarachnoid space surrounding the distal artery of the lesion site suspected of an existent aneurysm is dissected. The image range of the ICGVAG is set sufficiently wide to accommodate the possibility that the distal artery is not the artery that was anticipated. Subsequently, after the temporary clip occlusion is completed, the ICGVAG is recorded. In the three distal aneurysms, the relationship between the aneurysm, the distal artery, and the parent artery was confirmed. This method was useful, suggesting that unnecessary dissection in the subarachnoid space might be reduced.

Endovascular Repair of a Middle Meningeal Artery Aneurysm after Cranial Surgery

This report describes a case of middle meningeal artery aneurysm caused after cranial surgery. A 55-year-old woman who experienced a ruptured internal carotid artery anterior wall aneurysm was treated by internal carotid artery trapping and high-flow bypass using a radial artery graft. Eight days after surgery, we performed cerebral angiography to confirm patency of the radial artery graft and discovered a middle meningeal artery aneurysm, which was not identified in preoperative angiography. The aneurysm was treated by endovascular embolization using n-butyl cyanoacrylate and complete obliteration was confirmed by angiography. This middle meningeal artery aneurysm was associated with prior surgical procedures, particularly craniotomy or dural tenting sutures. Our study suggests that middle meningeal artery aneurysms can be a rare complication associated with brain surgery. Endovascular embolization using a liquid material may provide an effective and safe treatment for such cases.

Posttraumatic carotid-cavernous fistulae treated by internal carotid artery trapping and high-flow bypass using a radial artery graft--two case reports

Two patients presented with post-traumatic carotid-cavernous sinus fistulae (CCFs) that were successfully treated by high-flow bypass using a radial artery graft after initial unsuccessful attempts at obliteration by intravascular embolization. Case 1 was a 20-year-old man with a CCF detected by magnetic resonance imaging and angiography following an accident. Although the CCF appeared partially occluded by intravascular embolization, serial angiography revealed CCF recurrence. The CCF was trapped by placing a high-flow bypass. Case 2 was a 21-year-old man who presented with bilateral CCFs after sustaining face trauma. The bilateral CCFs were directly treated because of recurrence after balloon occlusion. At present, intravascular surgery is the first treatment choice, but placing a high-flow bypass with trapping of the CCF gained time to treat the CCF and may be useful for treating post-traumatic CCF that cannot be effectively eliminated by intravascular techniques.

Impact of polyunsaturated fatty acid consumption prior to ischemic stroke

OBJECTIVE

The Japanese have higher levels of n-3 polyunsaturated fatty acids (PUFAs) such as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) in their diets. These facts may contribute to the lower rates of atherosclerosis in Japanese. The purposes of this study were to assess the PUFA levels in patients with subtypes of acute ischemic stroke and to assess the relationship between severity and PUFA levels.

MATERIAL AND METHODS

We studied 75 patients with lacunar infarction (LI; n = 25), atherothrombotic infarction (AT; n = 32), and cardiogenic embolism (CE; n = 18). The patients underwent blood examinations in a fasting state next morning of hospitalization, including examination of low-density lipoprotein cholesterol (LDL), high-density lipoprotein cholesterol (HDL), triglyceride (TG), blood glucose, hemoglobin A1c (HbA1c), uric acid, and fatty acid fractions of EPA, DHA, dihomo-γ-linolenic acid (DGLA), and arachidonic acid (AA). We used the modified Rankin Scale (mRS) to assess clinical severity at discharge.

RESULTS

There was no significant difference in the EPA/AA and DHA/AA ratio among the three stroke subgroups, although the DGLA/AA ratio was significantly higher in patients with LI than in patients with CE. Considering the confounding factors, the mRS was negatively correlated with EPA/AA and positively correlated with age, DHA/AA, and blood glucose.

CONCLUSIONS

High EPA/AA ratio was associated with good outcome in ischemic stroke. Our paper suggests that prestroke dietary habits affect the severity in patients with ischemic stroke.

Surgical technique for the prevention of cerebrospinal fluid leakage after bifrontal craniotomy

BACKGROUND

Cerebrospinal fluid leakage and meningitis caused by frontal sinus (FS) exposure are characteristic complications of bifrontal craniotomy used for treating skull base tumors and anterior communicating artery aneurysms. Prevention of these complications is of utmost importance. We describe in detail our procedure for sealing exposed FSs during bifrontal craniotomy and present the results and outcomes of the procedure.

METHODS

A total of 51 consecutive patients who had undergone bifrontal craniotomy for tuberculum sellae meningiomas, craniopharyngiomas, anterior cerebral artery aneurysms, or other frontal skull base lesions at our institute were selected for the study. Our technique for sealing exposed FSs is described below. The mucosa was sterilized using surgical cotton dipped in iodine. After craniotomy, the exposed mucosa was sealed using 7-0 nylon sutures, whereas Gelfoam with fibrin glue was used to ensure watertight closure. The exposed portions of the FSs were covered by bone covers made of internal table bone and sealed. As a final layer, frontal periosteal flaps were sutured to the frontal base dura mater.

RESULTS

Postoperative cerebrospinal fluid leakage or meningitis did not occur in any of our patients.

CONCLUSION

Our results indicate the effectiveness of our technique in the prevention of FS-related postoperative complications.

Perioperative complications of superficial temporal artery to middle cerebral artery bypass for the treatment of complex middle cerebral artery aneurysms

OBJECT

Only a few studies have reported the risk of ischemic complications occurring when superficial temporal artery (STA) to middle cerebral artery (MCA) anastomosis is performed during surgery for complex MCA aneurysms.

SUBJECTS AND METHODS

This is a retrospective study of 10 patients (age 52-73) with MCA aneurysms treated with revascularization surgery. The aneurysms were 10-50mm in size (mean: 21mm). We studied the causes and frequency of ischemic complications by analyzing postoperative magnetic resonance imaging.

RESULTS

Postoperative diffusion-imaging confirmed ischemic complications in six of the 10 patients (in two of the five ruptured aneurysms and in four of the five unruptured). The ischemic complications that observed were infarction of the lenticulostriate artery territory in three cases, cortical infarction in two cases, and cerebral infarction that was likely to be due to cerebral vasospasm in one case. In one case, both cortical infarction and infarction of the lenticulostriate artery territory were observed. The Glasgow Outcome Scale (GOS) scores at the time of discharge indicated good recovery (GR) and moderate disability (MD) in seven cases, severe disability (SD) in two cases, and death (D) in one case.

CONCLUSIONS

The present study suggests the possibility that STA-MCA anastamosis in surgeries for MCA aneurysms can be performed with comparatively better safety. However, the temporary occlusion time with this surgery is longer than that with a temporary clipping for aneurysmal surgery; thus, we believe that adequate countermeasures are required to prevent ischemic complications.

Preoperative embolization of meningiomas with N-butyl cyanoacrylate

Meningiomas are often embolized before their surgical resection to reduce blood loss during surgery. Polyvinyl alcohol (PVA) particles have been the most frequently used material for embolization of meningiomas. We have used n-butyl cyanoacrylate (NBCA) as the first-choice material since 2001. Thirty-one meningiomas were embolized with NBCA. We report the result of embolization of meningiomas with NBCA in comparison with PVA particles.

Dissecting aneurysm of the anterior temporal artery: case report

A 65-year-old woman presented a rare dissecting aneurysm of the anterior temporal artery (ATA) manifesting as headache. Computed tomography and magnetic resonance imaging revealed a mixed-density mass in the horizontal segment of the middle cerebral artery. Emergent angiography demonstrated aneurysmal dilatation and a thrombosed mass in the sylvian fissure. Infectious aneurysm was excluded. She underwent emergent surgery to reduce the risk of repeated infarction and hemorrhage. The distal side of the ATA manifested occlusive changes suggestive of arterial dissection. The proximal side of the ATA was ligated and the lesion was excised. Histological examination confirmed that the aneurysmal dilatation was attributable to arterial dissection due to disruption of the internal elastic lamina. Distal dissecting aneurysms may occur in the absence of infectious disease. We recommend that ruptured distal dissecting aneurysms be treated surgically in the acute stage immediately after detection.

Utility of the orbitocranial approach for clipping of anterior communicating artery aneurysms: significance of dissection of the interhemispheric fissure and the sylvian fissure

OBJECTIVE

To investigate the importance of sufficient dissection of the interhemispheric and sylvian fissures, an orbitocranial approach was used for clipping of ruptured anterior communicating artery aneurysms.

PATIENTS AND METHODS

From January 1998 through March 2009, 41 patients underwent surgery for subarachnoid hemorrhage caused by rupture of an anterior communicating artery aneurysm. Their mean age was 58.4 years, with a range of 37 to 84 years. The preoperative World Federation of Neurosurgical Societies grade was I to III in 32 patients and IV to V in 9 patients. The direction of the aneurysm was upward in 23 patients, forward in 14 patients, and backward in 4 patients. Seven patients had a large aneurysm.

RESULTS

All patients underwent surgery during the acute stage following the subarachnoid hemorrhage (day 0-2). A right orbitocranial approach was used for most patients, but a left orbitocranial approach was used for 9 patients because of the presence of a complicated aneurysm and the positional relationship of the left-right A2 segment. In 12 patients, external decompression was performed. The outcome, using the Glasgow Outcome Scale, was good recovery in 24 patients, moderately disabled in 8 patients, and severely disabled in 4 patients, and 5 patients died. Temporary eye movement disorders developed after surgery in 5 patients but resolved in all patients within 2 months. No patients had olfactory disturbance.

DISCUSSION

Using the orbitocranial approach and sufficient dissection of the interhemispheric and sylvian fissures, we could secure a broad field of vision and surgical field, which contributed to a safe operation. The only postoperative complication caused by the surgical approach was temporary eye movement disorder. Thus, for some patients with aneurysms of the anterior communicating artery, the orbitocranial approach contributes to improved outcomes.

Cerebral artery restenosis following transluminal balloon angioplasty for vasospasm after subarachnoid hemorrhage

Background:

Although percutaneous transluminal angioplasty (PTA) is a widely used less invasive method to treat coronary artery stenosis, 10% of treated patients experience restenosis. Restenosis also occurs in approximately 5% of patients subjected to carotid artery stenting. Animal and human data suggested that restenosis is a response to injury incurred during PTA. As PTA has come into wide use to manage symptomatic cerebral vasospasm after subarachnoid hemorrhage (SAH) we studied the incidence of restenosis after PTA for cerebral vasospasm.

Methods:

Our study population consisted of 32 patients who had undergone PTA. They were followed by cerebral or 3DCT angiography or MRA for 6 126 months post-PTA (mean 48.65 months) to diagnose restenosis of the cerebral artery. We compared the size of the cerebral artery on the PTA and the contralateral side.

Results:

All 32 patients underwent successful PTA of 38 vascular territories and all manifested angiographic improvement of vasospasm. None suffered restenosis during the follow up period.

Conclusion:

PTA resulted in a significant improvement in the vessel diameter in patients with vasospasm after SAH and they did not suffer restenosis in the course of prolonged follow-up.

Rupture of a vertebral artery dissecting aneurysm developing immediately after trapping of a dissecting aneurysm on the contralateral vertebral artery: case report

The development of vertebral artery (VA) dissecting aneurysm after trapping of the contralateral VA is rare, and rupture of angiographically occult VA dissecting aneurysms immediately after trapping is even less common. A 39-year-old man suffered subarachnoid hemorrhage caused by rupture of a left VA dissecting aneurysm. The VA was trapped and the left occipital artery anastomosed to the posterior inferior cerebellar artery. Postoperatively, he suddenly developed apnea and died of rupture of a right VA dissecting aneurysm. Histological examination of the bilateral VAs and the basilar artery disclosed a hematoma between the media and the adventitia. This case further confirms the need for careful preoperative imaging study of the dissection and all segments of the dissected vessel in patients requiring trapping of a VA dissecting aneurysm, as well as preservation of VA anterograde flow.