Akira Sugie

Ultra-Early Induction of Brain Hypothermia for Patients with Poor-Grade Subarachnoid Hemorrhage

The potential of hypothermia in reducing neuronal damage has been demonstrated in various neurological emergencies. However, its safety, feasibility, and potential benefits for poor-grade subarachnoid hemorrhage (SAH) are uncertain. We induced brain hypothermia in 35 patients (14 men and 21 women; mean age 58 ± 12 years; range 25–70 years) with SAH classified in Grade V by the World Federation of Neurosurgical Societies and evaluated the outcome. Hypothermia was induced by surface cooling immediately after diagnosis of SAH and was followed by urgent surgical obliteration of the ruptured aneurysm. The core temperature was maintained at 33°–34°C for at least 48 h; subsequently, patients were rewarmed 1°C per day. Median time from onset to arrival, cerebral angiography, and surgery was 31.5, 88.5, and 174.5 min, respectively. The core temperature (mean ± standard deviation) was 35.8° ± 1.0°C on arrival, 34.8° ± 1.0°C just before surgery, 34.0° ± 0.7°C at the beginning of microsurgery, and 33.7° ± 0.8°C immediately after surgery. Hypothermia was completed in all patients without serious complications over a period of 6–22 days, with a mean of 9.4 days. The Glasgow Outcome Scale assessed at 3 months after onset was as follows: 4 (11.4%), good recovery; 6 (17.1%), moderate disability; 17 (48.6%), severe disability; 4 ( 11.4%), vegetative state; 4(11.4%), death. Poor outcome was mostly related to primary brain damage; cerebral vasospasm occurred in four patients. Ultra-early induction of hypothermia is feasible and possibly beneficial in poor-grade SAH without increasing morbidity and mortality.

Surgical treatment of distal cervical internal carotid artery aneurysm

We report on a 55-year-old male with an internal carotid artery aneurysm at the level of the second cervical vertebra. Since ant-coagulation therapy failed to prevent the ischemic attack, aneurysmectomy with arterial reconstruction was performed. Vertical mandibular osteotomy allowed a wide working space in deep operative field. This technique is considered to be useful in surgery for aneurysms of the extracranial distal internal carotid artery.

Microsurgical Resection of Thoracic Meningioma: 2-Dimensional Operative Video

The primary goal of surgery with spinal meningioma is complete safe tumor removal and decompression of the spinal cord. For the surgical removal of spinal meningioma, internal debulking before dissection of the tumor capsule is essential. Intraoperative ultrasonography to localize the tumor is recommended by some authors, but we use indocyanine green (ICG) videography to visualize the localization of tumor before dural incision. ICG videography allows safe and complete delineation of intradural tumors before dural opening. This technique is quick, cost-effective, and simple to use, especially with its integration into the surgical microscope.  Herein, we present a case of a 54-yr-old female patient presenting with a 1-yr history of numbness of the right lower limb. Neurological examinations demonstrated temperature pain disorder of right lower limb and slight dysuria. Magnetic resonance images demonstrated intradural extramedullary tumor at the level of Th6. Preoperative diagnosis was spinal meningioma.  In this surgical video, we show ICG angiography before dural opening, in addition to the basic surgical procedure of the thoracic meningioma. We believe this operative video will be useful for those in training as well as practicing surgeons. We received written informed consent from the patient for this publication.

Microsurgery of Spinal Dural Arteriovenous Fistula Using Indocyanine Green Video Angiography: 2-Dimensional Operative Video

Spinal dural arteriovenous fistulas (SDAVF) develop by direct abnormal arteriovenous connection between both sides of the spinal dura matter. In this condition, there is no intervening nidus between a meningeal segmental artery and a radiculomedullary vein. Open microsurgery is one of the choices for patients with SDAVF. When the AVF is on the inner dural surface, we can easily block the radiculomedullary vein in a microscopic view. We herein report a 50-yr-old woman who presented with low back pain, was diagnosed with an SDAVF, and underwent surgical treatment under a microscopic view. The spinal angiography demonstrated abnormal arteriovenous connections between intercostal arteries at the level of Th11 to 12 and the intradural radiculomedullary vein. Operative indocyanine green (ICG) microangiography demonstrated the blood flow in meningeal vessels and their anastomoses between both sides of the dural surface. We easily identified the radiculomedullary vein fed by the surrounding meningeal feeding arteries and block completely under a direct microscopic view. We detected the change in hemodynamic during feeder ligation by Flow 800 (Zeiss Penteto Flow 800 microscope; Zeiss Corporation, Tokyo, Japan). After surgery, the patients symptoms disappeared and no recurrence of the disease has been noted in the past 23 mo. We have received the informed consent of this patient for the publication of this case report.

Microsurgical Resection of a Ventral Pontine Cavernoma via Supratrigeminal Zone by Anterior Transpetrosal Approach: 2-Dimensional Operative Video

Brainstem cavernomas with recurrent bleeding and gradual neurological deterioration should be considered an indication for surgical treatment. However, surgery is challenging for cavernous hemangiomas located in the ventral part of the pons. In such cases, safe surgical access to the brainstem is limited and obtaining a good surgical field, regardless of the approach selected, is often difficult. Here, we show a 73-year-old man with a history of 3 episodes of intracranial bleeding associated with a cavernous hemangioma located in the right ventral pons. The hemangioma was removed via the supratrigeminal zone of the brainstem using an anterior transpetrosal approach (ATPA). ATPA was first described in 1985 for upper petroclival lesions by Kawase T.1 This approach requires epidural subtemporal procedures to expose the petrous apex adequately. The petrous apex must be totally resected and the dura of the temporal lobe and posterior fossa is then cut to ligate the superior petrosal sinus and tentorium. In this procedure, the most important things are to preserve the internal carotid artery (C2 segment) and greater superficial petrosal nerve (GSPN). To identify the GSPN, facial nerve integrity monitor (Medtronic Inc, Dublin, Ireland) is very useful. In the extradural bone removal, Sonopet Ultrasonic Aspirator (Stryker Ltd, Portage, Michigan) is a very excellent surgical tool for avoiding the injury of the internal carotid artery. As demonstrated by Cavalcanti DD2, ATPA is particularly useful for accessing lesions located in the upper ventral pons via the supratrigeminal zone because it provides a wide and shallow surgical field above the trigeminal nerve without requiring retraction of the cerebellum. We received written informed consent from the patient for this publication.

Surgical repair of lacerated anterior cerebral artery presented with massive intracerebral hemorrhage.

Objective and Importance:Traumatic intracranial aneurysms present diagnostic and therapeutic challenges. Owing to their fragile nature, endovascular intervention has become the first-line treatment; however, direct surgery has an advantage in certain cases. Clinical Presentation:A 34-year-old man in coma was admitted after a motor vehicle accident. Brain computed tomographic scans revealed deep bifrontal, left intraventricular, and subarachnoid hemorrhages. Three-dimensional computed tomographic angiography and digital subtraction angiography revealed an aneurysm arising from the left pericallosal artery. Intervention:A massive intracerebral hematoma prompted us to perform emergency surgical intervention. We immediately removed the hematoma and extirpated the aneurysm. After hematoma evacuation via the interhemispheric approach, a pulsating red sphere projecting from the pericallosal artery, with no obvious solid wall or neck, was encountered. While retracting the frontal lobe, it suddenly ruptured. Under temporary trapping of the parent artery, the point of bleeding was identified. No aneurysm wall or fibrous tissue was present, whereas a 1.5-mm laceration was observed at the pericallosal artery close to its branching point. The laceration was sutured with 10-0 nylon. Postoperative digital subtraction angiography confirmed patency of the pericallosal artery. Conclusions:Although recent technologic advances of intravascular surgery have enabled successful treatment of traumatic pseudoaneurysms, open surgical intervention still has some advantages of providing definitive hemostasis, allowing for parent artery reconstruction, and facilitating mass reduction. The case in the current study was quite unusual in that angiographic aneurysm had disrupted easily, leaving arterial laceration. This finding implies the probability of unavoidable parent artery occlusion when endovascular treatment is applied.