Tomoyuki Tanabe

Comprehensive Evaluation of Diagnostic and Treatment Strategies for Idiopathic Spinal Subarachnoid Hemorrhage

BACKGROUND Idiopathic spinal subarachnoid hemorrhage (IS-SAH), defined as spinal SAH without apparent cause, is extremely rare. The objective of the present study was to establish a consensus on the diagnosis and management of IS-SAH. METHODS We enrolled 5 consecutive cases of IS-SAH at our institution, and we enrolled 19 previously published cases as a literature review. The patient presentations, diagnostic test findings, treatment strategies, and outcomes were retrospectively assessed. Possible causes of spinal SAH were basically excluded by multimodalities, including brain and spinal digital subtraction angiographies. RESULTS IS-SAH usually developed in middle-aged people around 55 years old and typically presented with acute migrating back pain. Lumbar puncture and spinal magnetic resonance imaging demonstrated xanthochromia or an abnormal intensity area around the spine in all study patients who underwent these diagnostic tests. All of the patients from our institution were discharged with 1 patient (20%) complaining of neurologic dysfunction at discharge, and 1 patient (5.3%) in the published cases died during hospitalization and 5 (26.3%) complained of neurologic dysfunction at discharge. In addition, the surgical findings in 1 case from our institution suggested that one of the mechanisms of IS-SAH is a bleeding from a microvessel around the spine, and we newly propose spinal drainage as one of the treatment options in patients with IS-SAH based on our experience. CONCLUSIONS We summarized our experience of 5 cases of IS-SAH with a literature review. We demonstrated that spinal drainage could be one of the treatment options in patients with IS-SAH.

Endovascular Treatment for Aneurysmal Subarachnoid Hemorrhage with Neurogenic Pulmonary Edema in the Acute Stage.

AIM Severe neurogenic pulmonary edema (NPE) can occur in a variety of brain insults, including subarachnoid hemorrhage (SAH), and severe case of NPE can cause devastating consequences. But the literature on the treatment strategy about aneurysmal SAH with NPE is very scant. We present that SAH patients with severe NPE, who were treated first by embolization of aneurysm followed by insertion of lumbar spinal drainage, had comparatively good outcome. MATERIAL AND METHODS We present 12 consecutive cases of aneurysmal SAH with NPE in the acute stage, which were treated by endovascular treatment between April 2002 and December 2012. We classified the patients according to the Hunt and Hess grading system as follows: grade-3 (1 patient), grade-4 (4 patients), and grade-5 (7 patients). All patients needed respiratory management, with the assistance of a ventilator, and underwent endovascular treatment for the ruptured aneurysms within 72 hours from onset. For all the patients, immediately after the endovascular treatment, we performed lumbar spinal drainage. RESULTS The pulmonary edema disappeared rapidly after respiratory management and endovascular treatment. The outcomes were as follows: good recovery (GR; 3 patients), moderate disability (MD; 4 patients), severe disability (SD; 3 patients), and death (D; 2 patients). Five patients (42%) developed pneumonia, and we postponed extubation until recovery from pneumonia. The cause for severe disability and death was symptomatic vasospasm and primary brain damage. No patients had rebleeding from ruptured aneurysms. CONCLUSION Endovascular treatment for ruptured aneurysm and placement of lumbar spinal drainage is an excellent treatment option for severe SAH with NPE.

Responding to Arterial Perforation during Endovascular Neurosurgery

During endovascular neurosurgery, various devices, such as catheters, are passed through the intracranial arteries to access target vessels; the arteries can thereby be perforated. Even though such incidents are serious and should be dealt with appropriately, few case reports or standard procedures have been published. Herein, we report two cases of arterial perforation that occurred recently in our hospital. In the first case, the patient had been treated preoperatively using feeder occlusion of an arteriovenous malformation; the microcatheter perforated the feeder, which branched from the middle cerebral artery. The feeder and perforation site were occluded by injection of n-butyl 2-cyanoacrylate (NBCA) through the same microcatheter, and complete hemostasis was thereby achieved. The second case occurred during an embolization of the middle meningeal artery (MMA) to treat a refractory chronic subdural hematoma;the microcatheter perforated a branch of the MMA. Both the perforation and the artery were embolized using platinum coils and by injecting NBCA, and hemostasis was achieved. Considering the anatomical and pathological properties of the injured vessels, favorable results were achieved with appropriate intervention.

Ischemic complications of anterior choroidal artery aneurysm treatment

Ischemic stroke of the anterior choroidal artery(AChA)is the most common and serious complication after AChA aneurysm treatment. The purpose of this study was to retrospectively evaluate and compare the treatment-related ischemic complications after surgical clipping and endovascular coiling of AChA aneurysms. Between June 2006 and March 2013, 32 patients with 34 AChA aneurysms were treated in our hospital by surgical clipping or endovascular coiling. There were 12 cases of ruptured aneurysms, seven cases of unruptured aneurysms, and 15 cases of incidentally identified unruptured aneurysms. Of the 34 aneurysms, 19 were managed with surgical clipping and 15 were managed with endovascular coiling. No rebleeding or retreatment occurred in any case during 4-84 months(median, 25 months)of follow-up, and no significant differences in clinical outcome were seen between clipping and coiling cases. Although there were four cases(11.8%;surgical clipping in three;endovascular coiling in one)of postoperative AChA infarction, we believe that we preserved the blood flow of the AChA during the procedure. The occurrence of subarachnoid hemorrhage and premature rupture during surgical clipping were significantly correlated with AChA infarction.