Hirohiko Arimoto

Decompressive craniectomy after intravenous tissue plasminogen activator administration for stroke

OBJECTIVE Intravenous tissue plasminogen activator (IV tPA) is an approved treatment for acute ischemic stroke. However, the effects of decompressive craniectomy (DC) after IV tPA administration for ischemic stroke are still largely unknown. The aim of this study was to investigate the safety and outcomes of DC after IV tPA administration. METHODS We retrospectively reviewed patients who underwent DC for malignant hemispheric infarction. We compared 20 patients who underwent DC after IV tPA administration with another 20 patients who underwent DC without prior IV tPA administration. RESULTS The patient characteristics did not differ between the DC patients with and without prior IV tPA administration. New intracranial bleeding or worsening of pre-existing ICH occurred in two patients (10%) in each group. Furthermore, the rates of an mRS score of 4-6, 5 or 6, and 6 did not differ significantly between the two groups. CONCLUSION DC may be a safe and useful surgical procedure for space-occupying edema after IV tPA administration for acute stroke.

Effects of intravenous infusion of hydrogen-rich fluid combined with intra-cisternal infusion of magnesium sulfate in severe aneurysmal subarachnoid hemorrhage: study protocol for a randomized controlled trial

BackgroundThe failures of recent studies intended to prevent cerebral vasospasm have moved the focus of research into delayed cerebral ischemia away from cerebral artery constriction towards other mechanisms. Recent accumulating evidence has suggested that early brain injury is also involved in the development of delayed cerebral ischemia, and that hydrogen can prevent early brain injury. Therefore, we have established a combination therapy of intravenous hydrogen infusion and intra-cisternal magnesium sulfate infusion for the treatment of both early brain injury and cerebral vasospasm. The present randomized controlled clinical trial is designed to investigate the effects of this novel therapeutic strategy on the occurrence of cerebral vasospasm, delayed cerebral ischemia, and clinical outcomes after high-grade subarachnoid hemorrhage.MethodsThis study is a randomized, double-blind, placebo-controlled design to be conducted in two hospitals. A total of 450 patients with high-grade subarachnoid hemorrhage will be randomized to one of three arms: (i) Mg + H2 group, (ii) Mg group, and (iii) control group. Patients who are assigned to the Mg + H2 group will receive intra-cisternal magnesium sulfate infusion (2.5 mmol/L) at 20 mL/h for 14 days and intravenous hydrogen-rich fluid infusion (200 mL) twice a day for 14 days. Patients who are assigned to the Mg group will receive intra-cisternal magnesium sulfate infusion (2.5 mmol/L) at 20 mL/h for 14 days and intravenous normal glucose-electrolyte solution (200 mL) without added hydrogen twice a day for 14 days. Patients who are assigned to the control group will receive intra-cisternal Ringer solution without magnesium sulfate at 20 mL/h for 14 days and intravenous normal glucose-electrolyte solution (200 mL) without added hydrogen twice a day for 14 days. Primary outcome measures will be occurrence of delayed cerebral ischemia and cerebral vasospasm. Secondary outcome measures will be modified Rankin scale score at 3, 6, and 12 months and biochemical markers.DiscussionThe present protocol for a randomized, placebo-controlled study of intravenous hydrogen therapy with intra-cisternal magnesium infusion is expected to establish the efficacy and safety of this therapeutic strategy.Trial registrationUMIN-CTR: UMIN000014696

Usefulness of an ultrasonic scalpel to harvest and skeletonize the superficial temporal artery for extracranial-intracranial bypass surgery.

OBJECTIVE A new method to harvest and skeletonize the superficial temporal artery (STA) using an ultrasonic scalpel is presented. The technique is simple and safe, and reduces bleeding. We also investigated histopathological changes in donor vessels and whether it is possible to shorten the time needed for STA harvesting using the ultrasonic scalpel. METHODS Between January 1, 2005, and December 31, 2007, 31 consecutive patients underwent STA and middle cerebral artery anastomosis surgery in our hospital. All patients underwent harvesting of both the frontal and parietal branches of the STA. STA harvesting using an ultrasonic scalpel was performed in 18 of the 31 patients. We compared the time needed for STA harvesting by dividing patients into 2 groups: a non–ultrasonic scalpel group and an ultrasonic scalpel group. We also examined the histopathological changes by application of ultrasonic waves on the STA in the 6 most recent patients. RESULTS The mean time needed for STA harvesting was 84.2 ± 14.1 minutes for the non–ultrasonic scalpel group and 55.1 ± 15.2 minutes for the ultrasonic scalpel group. The ultrasonic scalpel group showed a significantly shorter harvesting time than the non–ultrasonic scalpel group (P < 0.01). No histopathological change was observed in any layers of the STA. CONCLUSION Our data suggest that STA harvesting with the ultrasonic scalpel may be useful for STA–middle cerebral artery anastomosis surgery.

Usefulness of preoperative three-dimensional computed tomographic angiography with two-dimensional computed tomographic imaging for rupture point detection of middle cerebral artery aneurysms.

OBJECTIVE We report the technique of three-dimensional computed tomographic (CT) angiography with a two-dimensional CT image aiding in the early operation of ruptured middle cerebral artery aneurysms. This combined image allows the prediction of the rupture point in the aneurysm and may reduce the risk of rupture during early clipping surgery. METHODS The findings for 14 patients with 14 middle cerebral artery ruptured aneurysms who underwent subsequent early clipping were analyzed. The average aneurysm size was 8.5 mm, and there were two large and one giant aneurysms. CT examinations were performed by means of a multidetector CT scanner (Aquilion M16; Toshiba Medical Systems, Tokyo, Japan) and reconstructed with a workstation (ZIO M900 QUADRA; Amin Co., Ltd., Tokyo, Japan). We constructed an operating view through three-dimensional CT angiography for a lateral transsylvian approach with a two-dimensional CT image (nonshaded volume-rendering image), which was perpendicular to the direction of the surgical approach. Using this combined image, we predicted the rupture point of the aneurysm and successfully performed clipping surgery through a lateral transsylvian approach. Rupture points were confirmed at the time of surgery. Rupture points of 13 out of 14 aneurysms appeared as we expected, but one differed; all aneurysms were successfully clipped. Thirteen of the 14 patients could be clipped without rupture at surgery, but the remaining patient experienced rupture just after craniotomy. CONCLUSION The combination of three-dimensional CT angiography and two-dimensional CT images may help improve the surgical outcome by indicating aneurysmal rupture points, leading to the prevention of rupture.

Feasibility of the combination of 3D CTA and 2D CT imaging guidance for clipping microsurgery of anterior communicating artery aneurysm

Abstract Objective. We report the technique of three-dimensional computed tomography angiography (3D CTA) + two-dimensional computed tomographic (2D CT) imaging as an adjunct in early surgery for a ruptured anterior communicating artery (ACoA) aneurysm by adopting an anterior interhemispheric approach. These combined imaging modalities provide accurate intraoperative anatomical information. Methods. To produce images for an anterior interhemispheric approach, 3D CTA + 2D coronal CT images, which are perpendicular to the direction of the surgical approach at three levels (brain surface, genu of the corpus callosum and aneurysm neck), were constructed. We also produced two 3D CTA + 2D CT images of the lamina terminalis, with a horizontal 10-degree difference, to clarify the vascular architecture around the aneurysm stereotactically, as well as the dissection point and direction to open the lamina terminalis. Furthermore, we produced a 3D CTA + 2D sagittal CT image at the midline, which allowed us to understand the anatomical architecture of the aneurysm, planum sphenoidale and tuberculum sellae. In addition, four different 3D CTA aneurysm images were produced for deciding the clip size preoperatively. Results. The imaging findings in 28 patients with 28 ACoA aneurysms facilitated early clipping. Based on these 3D CTA + 2D CT images, we conducted aneurysm surgery, and successfully performed neck clipping via an anterior interhemispheric approach. Conclusion. The combination of 3D CTA and 2D CT images is a feasible and useful method of image guidance for ACoA aneurysm microsurgery.

Effectiveness of 7-day versus weekday-only rehabilitation for stroke patients in an acute-care hospital: a retrospective cohort study

Abstract Purpose: Early rehabilitation is widely recommended for acute-stroke patients. We tested the hypothesis that the functional prognosis of stroke patients receiving daily early rehabilitation in a clinical practice setting is generally better than that of patients receiving rehabilitation only on weekdays. Materials and methods: We analyzed hospitalized patients who experienced either cerebral infarctions or cerebral hemorrhages and subsequently underwent rehabilitation at our hospital between October 2010 and September 2014. We examined the association between training frequency and activities of daily living improvements, as indicated by the Barthel Index (BI) effectiveness. Results: In total, 661 patients with cerebral infarctions and 245 with intracerebral hemorrhages (ICHs) were analyzed. The BI effectiveness was highest for patients receiving high-frequency therapy following cerebral infarction. In addition, multiple linear regression analysis indicated that BI effectiveness was significantly and positively correlated with high-frequency therapy (coefficient, 0.072; 95% confidence interval, 0.019–0.126; p < 0.01) in patients with cerebral infarctions. There was no significant difference in BI effectiveness between therapeutic protocols for patients with ICHs. Conclusion: This retrospective cohort study demonstrated that extensive therapy can result in functional recovery in patients with cerebral infarctions. Implications for Rehabilitation Early intervention with intensive rehabilitation therapy is important for improving the functional recovery of patients during acute-care hospitalization. Few acute hospitals provide more than 2 h of daily rehabilitation for patients with acute stroke. In a daily clinical practice setting, this clinical study demonstrates a direct relationship between early intervention with intensive rehabilitation therapy and good functional recovery of stroke patients in an acute ward.