Tomohiro Inoue

High-flow bypass with radial artery graft followed by internal carotid artery ligation for large or giant aneurysms of cavernous or cervical portion: clinical results and cognitive performance

High-flow bypass followed by ligation of the internal carotid artery (ICA) is an effective treatment, but the impact of abrupt occlusion of the ICA is unpredictable, especially on postoperative cognitive function. The present study evaluated the clinical results as well as cognitive performances after high-flow bypass using radial artery graft (RAG) with supportive superficial temporal artery (STA)-middle cerebral artery (MCA) bypass, followed by ICA ligation. Ten consecutive patients underwent high-flow bypass surgery for large or giant ICA aneurysms of cavernous or cervical portion. Demographics, clinical information, magnetic resonance (MR) imaging, computed tomography, digital subtraction angiography (DSA), intraoperative somatosensory evoked potentials, neuropsychological examinations including the Wechsler Adult Intelligence Scale-Third Edition and the Wechsler Memory Scale-Revised (WMS-R), and follow-up data were analyzed. The aneurysm was located on the cavernous segment in eight cases and cervical segment in two cases, and mean aneurysm size was 27.9xa0mm. Postoperative DSA demonstrated robust bypass flow from the external carotid artery to MCA via the RAG, and no anterograde flow into the aneurysm. No patient showed new symptoms after the operation. Follow-up clinical study and MR imaging were performed in nine patients and showed no additional ischemic lesion compared with preoperative imaging. Seven patients completed neuropsychological examinations before and after surgery. All postoperative scores except WMS-R composite memory score slightly improved. High-flow bypass followed by ICA ligation can achieve good clinical outcomes. Successful high-flow bypass using RAG with supportive STA-MCA bypass and ICA ligation does not adversely affect postoperative cognitive function.

Initial Attempt to Select Patients for Mechanical Thrombectomy Using Noncontrast Computed Tomography and Symptom-Based Criteria: Single-Center Experience

BACKGROUNDnIn the treatment of acute ischemic stroke (AIS), patients need to be selected for mechanical thrombectomy (MT) in the acute phase. Selection criteria vary, however, depending on the patients situation. This study investigated the effectiveness of a noncontrast computed tomography and symptom-based protocol for selecting patients for MT.nnnMETHODSnThis retrospective study included 20 patients with AIS. The first 8 patients (earlier group) were screened by magnetic resonance imaging (MRI). Among the later 12 patients, MRI was deliberately skipped in 9, and major vessel occlusion was confirmed by digital subtraction angiography after meeting 4 criteria: 1) hospital arrival within 90 minutes from onset; 2) National Institutes of Health Stroke Scale score 9-25; 3) history or presence of atrial fibrillation; and 4) Alberta Stroke Program Early CT Score of 9-10. The clinical outcomes and time course were compared.nnnRESULTSnAmong the later period group, 9 of 12 patients skipped MRI-based confirmation of large vessel occlusion. They underwent the direct angiography protocol, which had a 78% (7/9) positive predictive value for identifying large-vessel occlusion. In this group, National Institutes of Health Stroke Scale scores on the next day had significantly improved (medianxa0-8 points) compared with those at admission. Good functional outcome did not differ between the groups at 3 months.nnnCONCLUSIONSnNoncontrast computed tomography and symptom-based selection of MT to treat AIS can be useful for achieving better neurologic recovery in a subgroup of patients. This approach could broaden the use of MT.

Combined Interhemispheric and Transsylvian Approach for Resection of Craniopharyngioma

We present a 37-year-old male case of cystic suprasellar huge craniopharyngioma, who presented with significant memory disturbance due to obstructive hydrocephalus. Combined interhemispheric and pterional approach was chosen to resect huge suprasellar tumor. Interhemispheric trans-lamina terminalis approach was quite effective to resect third ventricular tumor, while pterional approach was useful to dissect tumor out of basilar perforators and stalk. The link to the video can be found at: https://youtu.be/BoYIPa96kdo .

Cytomegalovirus Hemorrhagic Cystitis in a Malignant Glioma Patient Treated with Temozolomide

Temozolomide, a key drug in the treatment of malignant glioma, can cause profound lymphopenia and various opportunistic infectious diseases. A 79-year-old woman with anaplastic oligodendroglioma developed a fever and gross hematuria after 8 weeks of standard radiotherapy with concomitant temozolomide treatment. A cytomegalovirus (CMV) antigen test for pp65 antigenemia was positive (137 cells per 75,800 leukocytes), and the findings from a urine cytology test were consistent with CMV-induced hemorrhagic cystitis. She was treated with ganciclovir, and her condition improved. CMV monitoring is needed when patients develop symptoms related to opportunistic infections during temozolomide treatment for malignant glioma.

Safety of urgent STA-MCA anastomosis after intravenous rt-PA treatment: a report of five cases and literature review

BackgroundIntravenous recombinant tissue-type plasminogen activator (rt-PA) with/without endovascular treatment is not as effective in atherosclerotic steno-occlusive acute ischemic stroke. Urgent superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis is effective to some extent in progressing stroke, but the safety of STA-MCA anastomosis soon after rt-PA therapy is unknown. Our aim was to clarify the safety of STA-MCA anastomosis within 24xa0h after intravenous rt-PA.MethodFrom 2005 to 2015, rt-PA was administered to 225 patients presenting with acute ischemic stroke according to the Japanese Stroke Guidelines, in our institution. Five patients underwent urgent STA-MCA anastomosis after rt-PA administration with or without endovascular recanalization. Clinical time course, surgical complications, and patients’ prognosis were investigated.ResultsThe average of patient age was 65.4xa0years (range 49–77xa0years); three patients had internal carotid artery occlusion, and two patients had middle cerebral artery occlusion. The median National Institutes of Health Stroke Scale score on admission was 12.4 (range 6–17 points) and operation occurred 10.6xa0h (range 5.3–23.6xa0h) after intravenous rt-PA administration. Hemostasis was achieved during standard STA-MCA anastomosis, and there were no hemorrhagic complications.ConclusionsIn our consecutive cases, urgent STA-MCA anastomosis after at least 5.3xa0h after intravenous rt-PA was performed safely without hemorrhagic complications.

Changes in Blood Flow Velocity of the Middle Cerebral Artery After Carotid Endarterectomy: Daily Assessment with Transcranial Color-Coded Sonography

BACKGROUNDnHyperperfusion syndrome (HPS) is a well-known complication of carotid endarterectomy (CEA) warranting repeatable inexpensive monitoring. Transcranial color-coded sonography (TCCS) may provide a potential modality for such monitoring, but little is known about TCCS trends after CEA.nnnMETHODSnBetween January 2016 and February 2017, we prospectively included patients with CEA at our institute in this study. TCCS was performed preoperatively and repeated daily from the operation day until postoperative day (POD) 7. Daily trends in mean flow velocity (MFV) at the M1 portion of the middle cerebral artery were compared between patients with and without HPS.nnnRESULTSnAmong 35 patients with CEA, daily TCCS monitoring was performed in 18 patients (mean age ± SD, 72 ± 7 years; male/female, 17:1). Among these 18 patients, 3 had probable HPS. On POD 0, MFV of the 18 patients showed a 32% increase from the initial preoperative value (from 52.5 to 69.4 cm/s, Pxa0= 0.0013). This increased MFV lasted for several days and recovered gradually by POD 7. Patients with probable HPS demonstrated a trend to higher MFV than those without; however, the difference was below the significance level.nnnCONCLUSIONSnWe used daily TCCS after CEA to depict cerebral blood flow changes after CEA in our cohort. This technique may be useful both for the detection and prevention of HPS.

Signal reduction of donor artery on MRI after superficial temporal artery to middle cerebral artery anastomosis: a retrospective analysis

ObjectMicrosurgical anastomosis from the superficial temporal artery (STA) to the middle cerebral artery (MCA) is a treatment option for appropriately selected patients with cranial atherosclerotic steno-occlusive disease (CASD). However, the long-term efficacy and patency of the donor artery remain unclear. We reviewed the signal intensity of the donor artery on magnetic resonance angiography (MRA) after STA-MCA anastomosis in patients with CASD and clarified the incidence of and risk factors for reduction in postoperative signal of STA.MethodsFrom April 2007 to March 2015, 155 STA-MCA anastomosis operations for CASD were performed at our institute. The postoperative imaging findings of 112 patients with available follow-up data for more than 3xa0months were retrospectively reviewed.ResultsOver a median follow-up of 24xa0months, the signal of the donor artery on MRA became weaker than that on MRA performed immediately after surgery in 30 (27%) patients. The rates of signal reduction at 1 and 2xa0years after surgery were 18 and 25%, respectively. Multivariate analysis revealed that a high STA bifurcation (pu2009=u20090.015; odds ratio, 7.14) and the presence of chronic kidney disease (pu2009=u20090.011; odds ratio, 5.59) were independent risk factors for postoperative signal reduction.ConclusionsOur results suggest that the signal intensity of the donor artery of an established STA-MCA bypass decreases in many cases. Both the loose entrance of the STA to the dura and systemic atherosclerosis are related to postoperative vessel remodeling.

Indocyanine green visualization "during" craniotomy for moyamoya disease.

Dear Editor, We read with great interest the article by Nozomu Tanabe and colleagues (Indocyanine green visualization of middle meningeal artery before craniotomy during surgical revascularization for moyamoya disease) [1]. Preservation of the middle meningeal artery (MMA) poses a problem during revascularization surgery, especially when it has collaterals to the cerebral cortex, and their method does contribute to preserving the MMA. In the article, they mention that the bone thickness over the MMA and older age are related to the invisibility of the fluorescence. After reading this article, we had a 62-year-old female with moyamoya disease who had had an infarction on the right side and had direct revascularization for the affected side. Since the cerebral blood flow study by single photon emission tomography showed decreased blood flow and impaired vascular reserve on the left side, we proposed revascularization for the left hemisphere. It seemed important to preserve the MMA since the digital subtraction angiography (DSA) showed collateral flow from the MMA to the anterior cerebral artery territory (Fig. 1a). As the bone thickness over the MMA was 3.5 mm (Fig. 1b), and the patient was older, we decided to file off the compact bone around the possible course of the MMA. After dissection of the temporal muscle and exposure of the bone surface, the initial ICG videoangiography (ICGVAG) could not visualize the MMA (Fig. 1c, d). Then, we drilled the compact bone out with a cutting burr around the possible MMA course, which was estimated from the distance from the parietal branch of the superior temporal artery (Fig. 1e). Then, the ICG was injected again, which showed the MMA course clearly (Fig. 1f). We could carry out a craniotomy posteriorly to the MMA and made an STA-MCA direc t bypass . Postoperatively, the patient did not show any new neurological deficit. Postoperative DSA showed a patent STA and preserved MMA with collaterals (Fig. 1g). There is a small risk of injuring the MMA by the drilling itself, but careful removal of the compact bone before ICG injection will expand the utility of Tanabe’s method to preserve the MMA. * Toshikazu Kimura tkim-tky@umin.ac.jp