Yuri Aimi

A case of giant common carotid artery aneurysm associated with vascular Behçet disease : successfully treated with a covered stent

BACKGROUND A carotid artery aneurysm associated with vascular Behçet disease is extremely rare and often difficult to treat. In this article, we explore a definitive therapeutic strategy for pseudoaneurysm with vascular Behçet disease. CASE DESCRIPTION A 56-year-old man presented with swelling and a pulsatile subcutaneous mass of the left neck over a 6-month period. The diagnosis of vascular Behçet disease had already been established from the history of right subclavian artery aneurysm, oral ulcerations, and inflammatory skin lesions. Radiologic examination revealed a giant left CCA aneurysm (6.5 x 5.5 cm) with partial thrombosis. Another asymptomatic aneurysm was found in the right ICA. Because mass effects due to aneurysmal rupture and growth rapidly progressed, we decided on radical treatment. The endovascular reconstruction of the carotid artery was selected instead of direct surgery because of skin and connective tissue disorders at the regional site. A covered stent (8 x 60 mm, Passager, Boston Scientific, Fremont, CA) was placed from the CCA to the ICA, covering the whole aneurysmal portion. Postoperatively, the cervical mass remarkably reduced in size, and the patients symptoms dramatically improved. The left carotid artery was patent at 12-month follow-up. CONCLUSIONS A covered stent is very useful in repairing arteries with pseudoaneurysm, particularly in cases unsuitable for direct surgery with parent artery occlusion. The influence of the foreign body at the inflammatory lesion and long-term patency of covered stents should be discussed.

Intraoperative Measurement of Optic Nerve Blood Flow during Dissection of Tuberculum Sellae Meningiomas

Purpose: A major concern of surgery in the area of the optic chiasm is damage to the visual system. We focus on the circulatory disorder of the optic apparatus as the main cause of postoperative visual disturbance. Our object is to determine if the optic nerve blood flow (ONBF) measured by a laser Doppler flowmeter during surgery of the parasellar tumor is sensitive and dynamic enough to detect changes in the function of the visual system. Method: Six consecutive patients with tuberculum sellae meningiomas who were operated between December 2005 and April 2007 were analyzed. Mean age was 56 years old. All patients received an ophthalmologic evaluation before and after surgery. After opening the basal cisterns, the optic canal was unroofed and the tumor was detached from the tubercular origin. The tumor was dissected from the optic nerves, chiasm, and pituitary stalk. The optic canals were inspected bilaterally. The optic nerve blood flow was measured using a laser Doppler flowmeter (TBF-LN1, Unique Medical Co., Japan). The small probe (LP-UCS, Unique Medical Co., Japan) was directly put on the optic nerve. We used the data acquisition system (UAS-108S, Unique Medical Co., Japan) to analyze the waveform of blood flow to obtain the mean value immediately before the dissection of the tumor, during drilling the optic canal, and after removing the tumor. During the manipulation around the optic nerve and drilling the optic canal, the change of blood flow was checked out continuously. Result: Radical surgery (Simpson grade 2) was achieved in all patients. The mean value of the ONBF was 7.9 mL/min/100 g (before dissection), 6.9 mL/min/100 g (while drilling the optic canal), and 10.8 mL/min/100 g (after complete removal). The release of the optic nerves increased the ONBF (p < 0.05). All patients improved to some degree in their visual function. Discussion: Our current study demonstrated that opening the optic canal and subsequent tumor debulking made the blood flow of the affected optic nerve increase significantly, resulting in the improvement of postoperative visual function in all patients. These findings suggest that detecting the ONBF change can protect the affected nerves from postoperative deterioration. Conclusion: In the cases in which ONBF increased after releasing the optic nerves, the postoperative visual function improved. The measurement of intraoperative ONBF may be effective for predicting postoperative visual function.

Surgical Treatment of Skull Base Meningiomas: Risk Factors and Strategy of Treatment

Introduction: Despite recent advancements in skull base surgery, surgical treatment of skull base meningiomas (SBMs) still possesses formidable challenges because of the high possibility of postoperative complications. We retrospectively analyzed our experiences to elucidate risk factors and surgical strategy of SBMs. Methods: From 1990 to 2005, 57 patients with SBMs underwent surgical resection using skull base techniques. Tumor locations: 5 anterior cranial fossa, 23 middle fossa (8 sphenoid ridge, 9 cavernous sinus (CS), 6 middle cranial base 6), 29 posterior fossa (28 petroclival, 1 foramen magnum). We assessed postoperative complications and risk factors. Results: Among anterior fossa meningiomas, 4 showed extracranial extension. All were totally removed using extended frontal approaches with one temporary CSF leak. Middle fossa meningiomas requiring orbitozygomatic approaches (total or subtotal removal in 61%) were complicated by cranial nerve palsy (35%), hypopituitarism (4%), and sacrificed carotid artery (CA) (9%). Extracranial extension, CS extension, and CA involvement were considered to be risk factors. Posterior fossa meningiomas were removed (total or subtotal removal in 79%) using orbitozygomatic, anterior petrosal, combined petrosal, or transcondylar approaches with cranial nerve palsy (41%), brain injury (7%), and meningitis (7%). Risk factors included previous surgery, CS extension, brainstem edema, pial blood supply, and vessel involvement. Conclusion: Meningiomas with extracranial extension are invasive, occasionally requiring aggressive removal. Involvement of CA needs cautious decision-making. CS extension could be treated with radiosurgery after subtotal removal. Tumors with severe edema or pial blood supply should not be dissected from the brain stem and should be treated with radiosurgery.