Hirotaka Hasegawa

A3-A3 anastomosis and superficial temporal artery-radial artery graft-A3 bypass to treat bilateral ACA steno-occlusive hemodynamic ischemia with cognitive and executive dysfunction: a technical note

BackgroundExecutive functions are complex cognitive control functions that include cognitive flexibility, inhibition (self-control, self-regulation), and working memory. Bilateral frontal lobe ischemia is associated with cognitive impairment, especially in the context of dysexecutive syndrome. This report describes two patients who underwent bilateral anterior cerebral artery (ACA) reconstruction by A3-A3 anastomosis in conjunction with superficial temporal artery (STA)-radial artery (RA) graft-A3 bypass to treat bilateral ACA steno-occlusive hemodynamic ischemia accompanying cognitive and executive dysfunction.MethodA 74-year-old woman and a 73-year-old woman were admitted to our hospital for unilateral cerebral infarction in the frontal lobe. Magnetic resonance angiogram (MRA) demonstrated severe bilateral ACA steno-occlusive pathology in both patients. Considering the presence of impaired cognitive function with dysexecutive syndrome as well as hemodynamic compromise shown by single photon emission computed tomography (SPECT), we proceeded with A3-A3 anastomosis in conjunction with STA-RA-A3 bypass. Various neuropsychiatric tests were performed before and after the surgery.ResultsWe confirmed good bypass patency without periprocedural complications. One patient recovered from apallic and bedridden status and regained ambulatory condition and ability to take in an oral diet. Another patient demonstrated improved scores in several cognitive tests with some persistent executive dysfunction.ConclusionsBilateral ACA revascularization was technically feasible in two patients. This bypass surgery could have some positive effects in some basic cognitive function, such as memory, attention, and concentration by bilateral ACA hemodynamic improvement, although executive function, which is specific to prefrontal function, might not be reversible.

Role of endoscopic transnasal surgery for skull base chondrosarcoma: a retrospective analysis of 19 cases at a single institution

OBJECTIVE Skull base chondrosarcoma is one of the most intractable tumors because of its aggressive biological behavior and involvement of the internal carotid artery and cranial nerves (CNs). One of the most accepted treatment strategies for skull base chondrosarcoma has been surgical removal of the tumor in conjunction with proactive extensive radiation therapy (RT) to the original tumor bed. However, the optimal strategy has not been determined. The goal of this study was to evaluate the early results of endoscopic transnasal surgery (ETS). METHODS The authors retrospectively analyzed 19 consecutive patients who underwent ETS at their institution since 2010. Adjuvant stereotactic radiosurgery (SRS) was performed only for the small residual tumors that were not resected to avoid critical neurological complications. Histological confirmation and evaluation of the MIB-1 index was performed in all cases. The Kaplan-Meier method was used to determine the actuarial rate of tumor-free survival. RESULTS The median tumor volume and maximal diameter were 14.5 cm3 (range 1.4-88.4 cm3) and 3.8 cm (range 1.5-6.7 cm), respectively. Nine patients (47%) had intradural extension of the tumor. Gross-total resection was achieved in 15 (78.9%) of the 19 patients, without any disabling complications. In 4 patients, the surgery resulted in subtotal (n = 2, 11%) or partial (n = 2, 11%) resection because the tumors involved critical structures, including the basilar artery or the lower CNs. These 4 patients were additionally treated with SRS. The median follow-up duration was 47, 28, and 27 months after the diagnosis, ETS, and SRS, respectively. In 1 patient with an anterior skull base chondrosarcoma, the tumor relapsed in the optic canal 1 year later and was treated with a second ETS. Favorable tumor control was achieved in all other patients. The actuarial tumor control rate was 93% at 5 years. At the final follow-up, all patients were alive and able to perform independent activities of daily living without continuous neurological sequelae. CONCLUSIONS These preliminary results suggest that ETS can achieve sufficient radical tumor removal, resulting in comparative resection rates with fewer neurological complications to those in previous reports. Although the follow-up periods of these cases were relatively short, elective SRS to the small tumor remnant may be rational, achieving successful tumor control in some cases, instead of using proactive extensive RT. Thus, the addition of RT should be discussed with each patient, after due consideration of histological grading and biological behavior. To determine the efficacy of this strategy, a larger case series with a longer follow-up period is essential. However, this strategy may be able to establish evidence in the management of skull base chondrosarcoma, providing less-invasive and effective options as an initial step of treatment.

Mobilization of the sphenoparietal sinus: a simple technique to preserve prominent frontobasal bridging veins during surgical clipping of anterior communicating artery aneurysms: technical case report.

BACKGROUND AND IMPORTANCE: Bridging veins arising from the frontal base (frontobasal bridging veins, FBBVs) can pose obstacles when performing clipping of anterior communicating artery (ACoA) aneurysms via the pterional approach. Although FBBVs can in general be sacrificed without critical complications to achieve an adequate retraction of the frontal lobe, neurosurgeons sometimes encounter postoperative venous infarction or contusion of the retracted frontal lobe, which may be accounted for by the damage to the venous drainage system. Thus, preservation of intracranial veins is desirable to prevent postoperative venous complications, especially when they are prominent. CLINICAL PRESENTATION: A 66-year-old female patient was revealed to have multiple unruptured aneurysms at the ACoA, bilateral middle cerebral arteries, and the left internal carotid artery. In the first stage of the operation, clipping of the right middle cerebral artery and ACoA aneurysms was performed via a right pterional approach. Because the ACoA aneurysm was located at a high position and projecting posteriorly, a transsylvian “lateral” trajectory was preferred to a subfrontal “anterior” trajectory. Intraoperatively, her FBBV was revealed to be so prominent that the sacrifice would be harmful. Thus, we performed posteriorward displacement of the sphenoparietal sinus extradurally, thereby achieving adequate retraction of the frontal lobe intradurally without sacrificing the FBBV. With this simple technique, the ACoA aneurysm was successfully treated. CONCLUSION: This technique is useful for retracting the frontal lobe sufficiently to enable establishment of an appropriate surgical field for a pterional approach to ACoA aneurysms with prominent FBBVs. ABBREVIATIONS: ACoA, anterior communicating artery FBBV, frontobasal bridging vein MCA, middle cerebral artery SPS, sphenoparietal sinus

Urgent treatment of severe symptomatic direct carotid cavernous fistula caused by ruptured cavernous internal carotid artery aneurysm using high-flow bypass, proximal ligation, and direct distal clipping: Technical case report.

Background: Direct carotid cavernous fistula (CCF) secondary to ruptured carotid cavernous aneurysms (CCAs) is rare, but patients with this condition who develop acutely worsening and severe neuro-ophthalmic symptoms require urgent treatment. Endovascular methods are the first-line option, but this modality may not be available on an urgent basis. Case Description: In this article, we report a 45-year-old female with severe direct CCF due to rupture of the CCA. She presented with intractable headache and acute worsening of double vision and visual acuity. Emergent radiographic study revealed high-flow fistula tracked from the CCA toward the contralateral cavernous sinus and drained into the engorged left superior orbital vein. To prevent permanent devastating neuro-ophthalmic damages, urgent high-flow bypass with placement of a radial artery graft was performed followed by right cervical internal carotid artery (ICA) ligation and the clipping of the ICA at the C3 portion, proximal to the ophthalmic artery. In the immediate postoperative period, her symptoms resolved and angiography confirmed patency of the high-flow bypass and complete occlusion of the CCF. Conclusion: With due consideration of strategy and techniques to secure safety, open surgical intervention with trapping and bypass is a good treatment option for direct severe CCF when the endovascular method is not available, not possible, or is unsuccessful.

Single-Fractionated Stereotactic Radiosurgery for Intracranial Meningioma in Elderly Patients: 25-Year Experience at a Single Institution

BACKGROUND Stereotactic radiosurgery (SRS) has been accepted as a therapeutic option for intracranial meningiomas; however, the detailed data on outcomes in elderly patients remain unclear. OBJECTIVE To delineate the efficacy of SRS for meningiomas in elderly patients. METHODS The outcomes of 67 patients aged ≥65 yr who underwent SRS for benign intracranial meningioma (World Health Organization grade I) between 1990 and 2014 at our institution were retrospectively analyzed. The median age was 71 yr (range, 65-83 yr), and the mean and median follow-up were 62 and 52 mo (range, 7-195 mo), respectively. Tumor margins were irradiated with a median dose of 16 Gy, and the median tumor volume was 4.9 cm3 (range, 0.7-22.9 cm3). RESULTS Actuarial local tumor control rates at 3, 5, and 10 yr after SRS were 92%, 86%, and 72%, respectively. Previous surgery and parasagittal/falcine location were statistically significant predictive factors for failed tumor control. Mild or moderate adverse events were noted in 9 patients. No severe adverse event was observed. A higher margin dose was significantly associated with adverse events by univariate analysis. CONCLUSION SRS is one of the standard therapies for meningiomas in elderly patients, providing both favorable tumor control and a low risk of adverse events under minimum invasiveness.