Kojiro Tateyama

Ischemic complications after radial artery grafting and aneurysmal trapping for ruptured internal carotid artery anterior wall aneurysm.

OBJECTIVE Treatment of ruptured internal carotid artery anterior wall (ICAW) aneurysms presents a surgical challenge because limitations and difficulties are encountered with either clipping or endovascular treatment. The present study examined clinical outcomes after aneurysmal trapping followed by radial artery grafting for management of these difficult lesions. METHODS Radial artery grafting was followed immediately by parent artery occlusion in five sides of five patients with acute ruptured ICAW aneurysm (3 men, 2 women; mean age 55.2 years). All patients underwent postoperative angiography and computerized tomography to assess graft patency and ischemic complications including vasospasm. RESULTS Of the five patients, only one had a poor outcome. However, temporary ischemic complications due to vasospasm developed in four (80%) of the five patients. Long-term results of radial artery grafting and internal carotid trapping for acute stage ruptured ICAW were satisfactory, but detailed analysis indicated a high risk of ischemic complications. CONCLUSIONS The long-term result was satisfactory, but there was a high rate of acute stage ischemic complications due to delayed vasospasm and low perfusion from the radial artery graft. Based on these results, the investigators recommend that, in addition to intraoperative anticoagulation therapy, in cases where the cerebral blood flow study in the early postoperative period indicates low cerebral perfusion or in cases with World Federation of Neurological Societies grade III-V, the patients should be placed under the highest level of intensive care to detect ischemic complications.

Radial artery grafts for symptomatic cavernous carotid aneurysms in elderly patients

BACKGROUND Radial artery grafts (RAG) have been used in the treatment of complex vascular lesions, but not for symptomatic cavernous carotid aneurysms in elderly patients. AIM To investigate the safety, usefulness, and perioperative complications of RAGs for symptomatic cavernous carotid aneurysms in elderly patients. MATERIAL AND METHODS Of the 74 consecutive patients, in whom RAGs were used, we retrospectively investigated the postoperative outcomes and complications in eight elderly patients aged over 70 years with symptomatic internal carotid artery aneurysms in cavernous sinus. RESULTS Postoperative complications included one case of cerebral infarction, one case of symptomatic seizures, and one case of delayed cranial nerve palsy. OUTCOME Seven patients had an mRS score of 0, and one patient had a score of 2. Postoperatively there was improvement in cranial nerve palsy in seven patients and the patients who had symptoms for one year and eight months had residual deficits. Although it cannot be stated that the frequency of perioperative complications was low, the final outcomes were favorable. CONCLUSION Even in carotid disease that is difficult to treat among the elderly, RAG would appear to be a useful and safe treatment.

A simple technique to prevent and correct graft vessel kinking in the subcutaneous tunnel: Technical note

OBJECT A simple method for preventing and correcting graft kinking for vascular reconstructive surgery through a subcutaneous tunnel is described. PATIENTS AND METHODS Using a chest tube, 1-0 silk suture and cerebral aneurysmal clips, the problem of postoperative ischemic complications due to kinking can be solved. CONCLUSION The main advantages of this method are its simplicity and low cost. Using this method does not require any special equipment and the problem of postoperative ischemic complications due to vascular injury, kinking and vasospasms can be addressed.

4D flow preliminary investigation of a direct carotid cavernous fistula due to a ruptured intracavernous aneurysm

Inadequate information is available about the cerebral blood flow and surgical strategies of a direct aneurysmal carotid cavernous fistula (daCCF). We report a quantitative analysis of flow velocity and volume using preoperative time-resolved phase-contrast MRI (four-dimensional (4D) flow MRI) in a daCCF. This is the first report of 4D flow findings with a daCCF. A 55-year-old woman developed a sudden headache and bruit of the right orbit, and MRI suggested the presence of a daCCF. Quantitative analysis using preoperative 4D flow MRI revealed the flow volume of the right internal carotid artery. The daCCF was successfully treated by high-flow bypass using a radial artery graft and internal carotid artery trapping. Postoperative angiography showed a complete obliteration of the daCCF. Studies to collect data from additional cases are required so that 4D flow findings can be further used in the management of daCCFs.

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.

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.