Takayuki Mizunari

Giant intracranial aneurysm of the anterior communicating artery treated by direct surgery using A3–A3 side-to-side anastomosis and A3-RA graft-STA anastomosis

SummaryWe describe a giant aneurysm of the anterior communicating artery (ACoA) which was treated with a STA-RA graft-A3 bonnet bypass and A3–A3 side-to-side anastomosis. A giant and partially thrombosed ACoA aneurysm was partially coated 3 years before his current presentation, its gradual increase producing visual field disturbances. An A3–A3 side-to-side anastomosis and STA-RA graft-A3 bonnet bypass were performed. The aneurysm was dissected, and the thrombus removed under transient parent-artery occlusion. The aneurysmal neck was successfully clipped without encountering ischemic changes. This strategy may be useful for treating giant or thrombosed aneurysms in the region of the ACoA.

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.

Aneurysm of the distal posteroinferior cerebellar artery of extracranial origin: case report.

OBJECTIVE AND IMPORTANCE We describe a very rare case involving a ruptured intracranial aneurysm at the distal posteroinferior cerebellar artery (PICA) branching from the extracranial vertebral artery. CLINICAL PRESENTATION A 53-year-old woman experienced the sudden onset of a severe occipital headache and vomiting. Computed tomographic scanning revealed subarachnoid and intraventricular hemorrhage. Cerebral angiography of the left vertebral artery demonstrated the left PICA branching from the extracranial segment of the extracranial vertebral artery at the level of C2; a saccular aneurysm arose from the intracranial portion of the distal PICA. INTERVENTION Via the transcondylar approach, we were able to obtain adequate visualization without retracting important structures. To avoid injury to the anomalous PICA, the aneurysm was clipped. CONCLUSION Only four other cases of a distal aneurysm of the PICA branching from the extracranial vertebral artery have been reported in the literature. In all cases, the aneurysm originated at the intradural extracranial portion of the PICA. To our knowledge, the case presented here is the first report of a ruptured aneurysm at the level of the intracranial portion of the PICA branching from the extracranial segment of the vertebral artery.

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.

Impact of polyunsaturated fatty acid consumption prior to ischemic stroke

The Japanese have higher levels of n‐3 polyunsaturated fatty acids (PUFAs) such as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) in their diets. These facts may contribute to the lower rates of atherosclerosis in Japanese. The purposes of this study were to assess the PUFA levels in patients with subtypes of acute ischemic stroke and to assess the relationship between severity and PUFA levels.

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.

Surgical Technique for the Prevention of Cerebrospinal Fluid Leakage After Bifrontal Craniotomy

BACKGROUND Cerebrospinal fluid leakage and meningitis caused by frontal sinus (FS) exposure are characteristic complications of bifrontal craniotomy used for treating skull base tumors and anterior communicating artery aneurysms. Prevention of these complications is of utmost importance. We describe in detail our procedure for sealing exposed FSs during bifrontal craniotomy and present the results and outcomes of the procedure. METHODS A total of 51 consecutive patients who had undergone bifrontal craniotomy for tuberculum sellae meningiomas, craniopharyngiomas, anterior cerebral artery aneurysms, or other frontal skull base lesions at our institute were selected for the study. Our technique for sealing exposed FSs is described below. The mucosa was sterilized using surgical cotton dipped in iodine. After craniotomy, the exposed mucosa was sealed using 7-0 nylon sutures, whereas Gelfoam with fibrin glue was used to ensure watertight closure. The exposed portions of the FSs were covered by bone covers made of internal table bone and sealed. As a final layer, frontal periosteal flaps were sutured to the frontal base dura mater. RESULTS Postoperative cerebrospinal fluid leakage or meningitis did not occur in any of our patients. CONCLUSION Our results indicate the effectiveness of our technique in the prevention of FS-related postoperative complications.

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.

Analysis of ischemic cerebral lesions using 3.0-T diffusion-weighted imaging and magnetic resonance angiography after revascularization surgery for ischemic disease.

BACKGROUND Cerebral revascularization surgery (CRS) is increasingly recognized as an important component in the treatment of complex cerebral vascular disease and tumors. CRS requires that the incidence of perioperative neurological complications should be minimized, because CRS for ischemic disease is often not the goal of treatment, but rather a prophylactic surgery. CRS carries the risk of focal postoperative neurological deficits. Little has been established concerning mechanisms of post-CRS ischemia. We used 3.0-T diffusion-weighted magnetic resonance imaging (DWI) and magnetic resonance angiography (MRA) to analyze the incidence and mechanism of ischemic lesions. METHODS We studied the anterior circulation territory after 20 CRS procedures involving 33 vascular anastomosis procedures (13 double anastomoses and 7 single anastomoses) in 12 men and 8 women between June 2007 and October 2011. The operations included single or double superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis to treat internal carotid artery/MCA occlusions or severe MCA stenosis. A combined STA-MCA anastomosis and indirect bypass were performed for moyamoya disease. Postoperative DWI and MRA were obtained in all patients between 24 and 96 h after surgery to detect thromboembolism, hypoperfusion, or procedural ischemic complications and vasospasms of the donor STA. RESULTS Follow-up DWI and MRA were carried out 1.8±0.6 days after CRS (range, 1-4 days). Temporary occlusion time for anastomoses averaged 18.9 min (range, 16-32 min). Asymptomatic new hyperintensities occurred in the ipsilateral hemisphere of 2 patients on postoperative DWI (10% patients/6.0% anastomoses), and 1 moyamoya patient (5.0% patients/3.0% anastomoses) developed a symptomatic hyperintensity in the ipsilateral occipital lobe in response to the operation. Two abnormal small (<5 mm) cortical DWI lesions were caused by sacrifices of a small branch of the recipient MCA. CONCLUSION This study is the first postoperative 3.0-T DWI study of CRS and related clinical events. The incidence of symptomatic postoperative DWI abnormalities was restricted to 1 moyamoya patient representing 5.0% of total patients and 3.0% anastomoses. Although some postoperative DWI abnormalities occurred, CRS was found to be safe with a low risk of symptomatic ischemia.

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.