Kenta Koketsu

Intraoperative Matas Test Using Microscope-Integrated Intraoperative Indocyanine Green Videoangiography with Temporary Unilateral Occlusion of the A1 Segment of the Anterior Cerebral Artery

OBJECTIVE The aim of the present study was to assess a new technique of surgical microscope-based indocyanine green (ICG) videoangiography (VAG) to confirm the patency of the anterior communicating artery (AcomA) after clipping AcomA aneurysms. METHODS Aneurysmal clipping of five cases of unruptured, broad-neck AcomA aneurysm was performed using the Carl Zeiss Surgical Microscope OPMI Pentero INFRARED 800. RESULTS In all five patients, after clipping AcomA aneurysms, the patency of AcomA was confirmed using ICGVAG findings and temporary unilateral occlusion of the A1 segment of the anterior cerebral artery using temporary clips. Images were excellent and enabled a real-time surgical assessment because the structures of interest, including vessels, perforating arteries, or residual aneurysm neck, were visible to the surgeons eye under the microscope in all five patients. CONCLUSIONS ICGVAG and temporary unilateral occlusion with clips provides a simple, reliable, real-time, and rapid intraoperative assessment of the patency of AcomA. This technique may help to improve the quality of neurosurgical procedures.

Preoperative liquid embolization of cerebeller hemangioblastomas using N-butyl cyanoacrylate

IntroductionWe aim to present and discuss clinical outcomes of preoperative liquid embolization of hemangioblastomas (HB) using N-butyl cyanoacrylate (NBCA).MethodsFrom 1999 through 2010, 19 patients presenting with symptoms of vertigo and/or headaches were diagnosed with HB based on preoperative magnetic resonance imaging and cerebral angiographic findings at our institution. Preoperative embolization with NBCA was performed on tumors in 10 of 21 operations for 19 patients. For each of these patients, the lesion was pathologically confirmed as HB.ResultsEmbolization had a favorable outcome in all patients. No permanent neurological complications were observed after preoperative embolization using NBCA. However, thalamic infarction and minor hemorrhage were observed in two patients with cerebellar HB.ConclusionThe authors recommend NBCA as an embolization material for large cerebellar HB.

Gremlin, a Bone Morphogenetic Protein Antagonist, Is a Crucial Angiogenic Factor in Pituitary Adenoma

Gremlin is an antagonist of bone morphogenetic protein (BMP) and a major driving force in skeletal modeling in the fetal stage. Several recent reports have shown that Gremlin is also involved in angiogenesis of lung cancer and diabetic retinopathy. The purpose of this study was to investigate the role of Gremlin in tumor angiogenesis in pituitary adenoma. Double fluorescence immunohistochemistry of Gremlin and CD34 was performed in pituitary adenoma tissues obtained during transsphenoidal surgery in 45 cases (7 PRLoma, 17 GHoma, 2 ACTHoma, and 2 TSHoma). Gremlin and microvascular density (MVD) were detected by double-immunofluorescence microscopy in CD34-positive vessels from tissue microarray analysis of 60 cases of pituitary adenomas (6 PRLoma, 23 GHoma, 22 NFoma, 5 ACTHoma, and 4 TSHoma). In tissue microarray analysis, MVD was significantly correlated with an increased Gremlin level (linear regression: P < 0.005,  r 2 = 0.4958). In contrast, Gremlin expression showed no correlation with tumor subtype or Knosp score. The high level of expression of Gremlin in pituitary adenoma tissue with many CD34-positive vessels and the strong coherence of these regions indicate that Gremlin is associated with angiogenesis in pituitary adenoma cells.

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.

Target-controlled infusion technique with indocyanine green videoangiography for radial artery graft

OBJECT To understand the relationship between the parent artery and its distal arteries, blood vessels running through the subarachnoid space need to be extensively dissected, which is time-consuming. We examined the efficacy of temporary clipping with the indocyanine green (ICG) technique (target-controlled infusion (TCI) technique), in which the parent artery is occluded using a temporary clip, and ICGV (videoangiography) is performed to clarify the relationship between the distal M4 and proximal M2. METHODS Thirteen radial artery grafts (RAGs) for internal carotid aneurysm underwent TCI to confirm the relationship between M2 and cortical M4. To monitor the perfusion pressure of the cortical middle cerebral artery, superficial temporal artery (STA) to M4 anastomosis was performed before RA-M2 anastomosis. We performed anastomosis of the recipient of STA- M4 that was distal and downstream of the M2 segment that is the recipient of RA-M2 anastomosis. To select the proper recipient M4 of the STA-M4 anastomosis, the ICGV image range was set sufficiently wide to accommodate the possibility that the distal artery was not the one anticipated. ICGV followed complete occlusion by temporary clipping of the recipient M2. RESULTS In 2 of the 13 cases, the relationship between the M2 and M4 could not be clarified. CONCLUSIONS In cases with developed collateral circulation or small perfusion area of the occluded M2, it was difficult to ascertain the relationship by TCI. Nevertheless, TCI was useful in 11 of the 13 cases, suggesting that unnecessary dissection in the subarachnoid space may be reduced using this technique.

Reversible cerebral vasoconstriction syndrome associated with subarachnoid hemorrhage triggered by hydroxyzine pamoate

Abbreviations: CBF, cerebral blood flow; CT, computed tomography; CTA, comuted tomography angiography; FLAIR, fluid-attenuated inversion recovery; IMP, -isopropyl[123I]-p-iodoamphetamine; MRA, magnetic resonance angiography; RI, magnetic resonance imaging; RCVS, reversible cerebral vasoconstriction synrome; SAH, subarachnoid hemorrhage; SPECT, single photon emission computed omography. ∗ Corresponding author at: Department of Neurosurgery, Nippon Medical School, -1-5 Sendagi, Bunkyo-ku, Tokyo 113-8603, Japan. Tel.: +81 3 3822 2131; ax: +81 3 5685 0986. E-mail addresses: shunchan.ryouchan@gmail.com, s00-078@nms.ac.jp, 00-080@nms.ac.jp (F. Matano).

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.

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 (Spearmans 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 (Spearmans 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.

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.

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.