田中 里樹

Objective  This study compared intraoperative findings with preoperative computed tomography angiography (CTA) and computational fluid dynamics (CFD) analysis of perianeurysmal findings for the indication of possible vessel wall thinning. Materials and Methods  Participants comprised 38 patients with unruptured middle cerebral artery aneurysms treated by surgical clipping at our hospital between May 2020 and April 2021. We defined parent artery radiation sign (PARS) as the presence of each of the following three findings in CFD analysis based on preoperative CTA: (1) impingement of the stream line on the outer parent vessel wall of the aneurysm; (2) radiation of wall shear stress vectors outwards from the same site; and (3) increased wall pressure compared with the surrounding area. CFD analysis showing PARS was compared with intraoperative findings. Results  In all nine cases with PARS, no morphological abnormalities were found in the same area on CTA. However, intraoperative findings showed thinning of the parent artery wall in one of the nine cases and formation of a very small mass in three cases, differing from CTA findings. All nine patients underwent additional clipping and/or wrapping and coating at the site of PARS. Conclusion  Detecting thinning of the vessel wall or the presence of a microaneurysm may be difficult in endovascular therapy, which is based on the visualization of the vessel lumen. CFD analysis suggests the necessity of confirming findings for the vessel wall around an aneurysm by direct manipulation, as the presence of PARS may indicate partial thinning of the vessel wall or formation of a microaneurysm.

INTRODUCTION: Non-eosinophilic esophagitis eosinophilic gastrointestinal disorders (non-EoE-EGIDs) have limited treatment options to induce histologic and clinical remission. Dupilumab is a human monoclonal antibody against the interleukin-4 receptor ɑ subunit, which has been reported to induce improvement in pediatric patients with non-EoE-EGIDs. METHODS: We conducted a retrospective chart review to identify if patients with eosinophilic gastritis (EoG) and/or eosinophilic duodenitis (EoD) experience clinical and histologic remission with dupilumab. RESULTS: Twelve patients were included (2 patients with EoG and EoD, 4 patients with EoG only, and 6 patients with EoD only). All patients experienced improvement of at least one symptom on dupilumab, 3 patients (25%) had no change in severity of one or more of their symptoms, and no patients had worsening symptoms. On dupilumab, 2 EoG patients (40%) and 3 EoD patients (33.3%) were completely asymptomatic. Histologic changes were investigated in a subanalysis including 8 patients (2 patients with EoG and EoD, 2 patients with EoG only, and 4 patients with EoD only). Median peak gastric eosinophil counts in EoG patients reduced from 80.5 eos/hpf (min-max 32-150, Q1-Q3 45.5-111) to 7.5 eos/hpf (min-max 0-28, Q1-Q3 1.5-16.8). Median peak duodenal eosinophil counts in EoD patients reduced from 39 eos/hpf (min-max 30-50, Q1-Q3 37.3-46.3) to 16.5 eos/hpf (min-max 30-50, Q1-Q3 37.3-46.3). All 4 patients (100%) with EoG, and 4 patients (66.6%) with EoD had histologic remission on dupilumab. DISCUSSION: In this retrospective case series, we show preliminary evidence that dupilumab may be effective in inducing histologic and symptomatic remission in patients with non-EoE-EGIDs.

Objective  Trigeminal neuralgia (TN) is a neurological disorder that often presents as severe toothache. The majority of TN patients visit dental clinics first, so TN represents a potential pitfall for dental practitioners. This report describes the development of a trigeminal neuralgia questionnaire (TNQ), assessing 10 characteristics of TN, to assist dentists in screening for TN in dental clinics, and evaluates the effectiveness of TNQ. Materials and Methods  Fifty-three patients who visited the TN outpatient department in our institute and completed the TNQ were included in this study. All patients were examined by two neurosurgeons and neuroimaging was performed. Statistical Analysis  Patients were classified into a TN group and a non-TN group. TNQ score was retrospectively compared between groups. Furthermore, history and characteristics of TN were investigated in the TN group to clarify the status of the reference situation. Results  Thirty-seven cases were assigned to the TN group, and 16 cases to the non-TN group. Mean TNQ score was 8.3 in the TN group and 6.6 in the non-TN group. Setting a TNQ cutoff score of 7 offered 91% sensitivity and 56% specificity for TN. Investigation of the history of the present illness indicated that 39.2% of TN cases were improperly triaged and referred from initial dental clinics, and interdisciplinary practice was insufficient. Conclusion  TNQ offers a reliable, convenient method to triage TN patients, and may assist dentists in screening for TN. Multidisciplinary practice is necessary for total management of TN and the TNQ is expected to connect dentists and TN specialists.

OBJECTIVES: Superficial temporal artery (STA) to middle cerebral artery (MCA) bypass surgery is a common treatment for preventing cerebral ischemia in patients with intracranial artery stenosis. The aim of this study was to analyze the surgical outcomes of the STA-MCA bypass procedure, particularly with regard to the invasiveness of targeted bypass (TB) with preoperative planning using Amira® software. METHODS: Consecutive patients with single STA-MCA bypass performed by a single neurosurgeon from January 2019 to May 2022 were included. The clinical parameters of seven TB patients were compared with those of 11 patients treated with the conventional method (CM). RESULTS: Compared with CM patients, TB using Amira® software patients had a shorter scalp incision (median [interquartile range]=11.2 [9.7-12.7] cm vs. 16.9 [16.0-17.7] cm, respectively; p=0.004], smaller craniotomy size (11.8 [11.5-14.4] cm2 vs. 20.9 [17.1-22.2] cm2, respectively; p=0.01], shorter surgery duration (201 [195-218] min vs. 277 [229-310] min, respectively; p=0.003], and less intraoperative bleeding (10 [10-20] g vs. 23 [20-50] g, respectively; p=0.033]. However, there were no differences in surgical complications between the two groups. CONCLUSIONS: Detailed preoperative evaluation using Amira® software can reduce the invasiveness of the STA-MCA bypass procedure.

Unruptured cerebral aneurysms (UCAs) are usually asymptomatic and detected incidentally by intracranial examinations. The coexistence of neurovascular compression syndrome (NVCS) and UCAs has not been well described. The aim of this study was to clarify the characteristics of UCAs with the NVCS. A total of 103 cases that underwent microvascular decompression (MVD) for trigeminal neuralgia (TN) or hemifacial spasm (HFS) were assigned to the NVCS group. The prevalence of UCAs in the NVCS group was compared retrospectively to that in 110 control cases (a control group) by neuro-imaging. Overall treatment courses for NVCS and UCAs were investigated in the NVCS group. Sixteen (15.3%; TN 11 cases, HFS 5 cases) of 103 MVD cases had 19 UCAs, a significantly higher prevalence than the 3.6% in the control group. Binomial logistic regression showed that NVCS is a significant factor for predicting the presence of UCAs, with an odds ratio of 4.80. In the NVCS group, 18 UCAs (94.7%) were supratentorial aneurysms, and 17 UCAs (89.5%) were less than 5 mm in size. Nine UCAs were surgically treated with clipping or coiling. Of the surgical cases, 2 UCAs were treated before MVD for NVCS, whereas the other 7 UCAs were treated after MVD. No aneurysms ruptured during the treatment course. The NVCS occurred with UCAs at a significantly higher rate than in the control group. Most UCAs with the NVCS were supratentorial, small aneurysms that did not affect the surgical treatment of NVCS.

Abstract Introduction Preoperative illustration is a part of an important exercise to study the configuration, direction, and presence of any perforations, and is the weakest point in the wall of the cerebral aneurysm. The same illustration is used to study the surrounding brain structures to decide the best and safe surgical approach prior to any surgical procedure. With the evolution of the aneurysm wall study and study of flow dynamic within the involved artery and its aneurysm wall using computational fluid dynamics (CFD), a better surgical plan can be formulated to improve the flow dynamics. As one of the clinical applications of CFD, we propose a study using a composite image that combines preoperative illustration and CFD, which is traditionally widely used in neurosurgery. Methods and Materials We study the use of illustrations of the unruptured cerebral aneurysm of internal carotid-posterior communicating (ICPC) artery and anterior communicating artery (AcomA) treated at our hospital. The combinations of both preoperative illustrations and CFD images by using “ipad Pro” were used. Result and Conclusion Medical illustration in the preoperative study of unruptured cerebral aneurysm with combinations of CFD and surrounding brain structures is helpful to decide the surgical approaches and successful surgical treatments.

Background: The incidence of cavernous carotid aneurysms (CCAs) of intracranial aneurysms is low. Majority of cases presented as incidental findings with benign natural progression. The most common presenting symptoms are multiple cranial neuropathies among symptomatic patients. The treatment modalities for symptomatic patients include direct surgical clipping, endovascular coil embolization, or placement of flow diverter, or indirect procedures such as occlusion of parent artery with and without revascularization techniques. The advancement in the microsurgical treatments and endovascular devices have enable a high success rate in the treatment of patients with CCAs with low morbidity and mortality rates. Objective: To study the surgical outcomes of patients with cavernous aneurysm who underwent high-flow bypass between 2015 and 2020 in our institution. Materials and Methods: A total of six patients in a single institution presented with CCAs who were treated with high-flow bypass surgery were included in this case-series. A single-case illustration was presented focusing on the details of surgical case management of CCA. The intraoperative middle cerebral artery (MCA) pressure monitoring during bypass surgery was also described. Results: All five female patients and one male patient who were diagnosed with cavernous carotid aneurysms were studied. The mean age was 68.8 years old (range: 24-84 years old) and the mean size of the aneurysm was 19.6mm (range: 9.7 – 30mm). There were successfully treated with high flow bypasses using radial artery graft without any neurological sequelae. Conclusion: The surgical treatments of cavernous carotid aneurysms should be limited to experienced neurosurgeons in view of significant risk of morbidity and mortality. Endovascular procedures may be the main stay of treatments. The success shown in this case series with parent artery occlusion and bypass surgery may provide an safe alternative to the endovascular treatment.

Background: The endoscopic supracerebellar-infratentorial (SCIT) approach is a viable method to access pathology of the posterior incisura, but a narrow working space and frequent instrument conflict can potentially limit its surgical efficacy. We planned an endoscopic-assisted paramedian infratentorial supracerebellar approach for pineal cyst. Case Description: Patient was placed in prone position under general anesthesia. His head was rotated to the left side slightly. The location of the transverse sinus was detected with navigation system. A 5 cm linear skin incision was performed, and a 2 cm craniectomy was performed about 2 cm left of the median. The transverse sinus was little bit exposed. Dura was incised in a U-shaped incision with the transverse sinus at the base. The endoscope was advanced along with the culmen. At that time, we observed inferior and superior vermian vein. After reaching to the thick arachnoid near by galenic system, the arachnoid membrane was incised and the CSF was evacuated. After that, the cerebellum became soft and the surgical corridor became large. The arachnoid membrane was incised widely. Pineal cyst, precentral cerebellar vein, bilateral internal occipital vein and great vein of galen were exposed. There were some small veins on the pineal cyst, but the adhesion was not so severe. The cyst was dissected from these small veins. There was no adhesion between the cyst and surrounding brain except for the pineal recess. Bilateral ICV was seen behind the cyst. There was feeding artery and draining vein on the antero-lateral part of the cyst. These vessels were coagulated and cut, then the cyst was removed. After the removal, we confirmed complete removal of the cyst and hemostasis. Conclusion: Endoscopic-assisted paramedian SCIT approach for pineal cyst in prone position is a reasonable and efficient access for posterior third ventricular lesions. The learning curve, maneuverability in small space, and instrument conflict limit efficacy.

INTRODUCTION AND OBJECTIVE: Hemifacial spasm (HFS) is a condition, characterized by painless, involuntary unilateral tonic or clonic contractions of the facial muscles innervated by the ipsilateral facial nerve. HFS starts with contractions in the orbicularis oculi muscle with subsequent eyelid closure and/or eyebrow elevation, but may spread to involve muscles of the frontalis, platysma, and orbicularis oris muscles. Microvascular decompression (MVD) is reliable and accepted surgical treatment for HFS. MVD is the standard surgical technique now for HFS treatment with long-term success rates. MATERIALS AND METHODS: We performed fully endoscopic MVD technique for 1 patient with HFS (a 83-year-old female) at our institution. HFS was diagnosed based on the clinical history and presentation, a neurologic examination, and additional imaging findings. Respectively, the durations of HFS were 3 years, respectively. The patient had been previously treated with repeated botulinum toxin injections. Preoperative evaluation was done with magnetic resonance imaging; three-dimensional computed tomography fusion images examinations had identified the anterior inferior cerebellar artery (AICA) as the offending vessel in this patient. RESULTS: The patient with HFS was treated by fully endoscopic MVD technique. The AICA, which had been identified as the offending vessel by preoperative magnetic resonance imaging, was successfully decompressed. No surgery-related complications occurred and had excellent outcomes with the complete resolution of HFS immediately after the operation. CONCLUSIONS: Endoscopic surgery can provide a more panoramic surgical view than conventional microscopic surgery. Fully endoscopic MVD is both safe and effective in the treatment of HFS. This method minimizes the risks of brain retraction and extensive dissection often required for microscopic exposure. Endoscopic MVD is safe and has advantage over microscope in terms of visualization of structure, identification of neurovascular conflict, but it has a learning curve and technically challenging.

INTRODUCTION: One of the popular treatment strategies for complex cerebral aneurysms with wide necks or low dome-to-neck ratios is stent-assisted coiling. The most widely used intracranial stents for stent-assisted coiling are Neuroform (NF) and Enterprise (EP) stents. The purposes of this study are to review the recent literature of the past 5 years to compare outcomes between the EP and NF stent-assist coiling systems so as to comment on the safety, efficacy, complications, and recurrence rate of stent-assisted coiling in general. METHODS: PubMed was used to search for all published literature of NF or EP stent-assisted coiling of unruptured cerebral aneurysms from January 2014 to August 2019 with the search terms of "Enterprise stent-assisted coiling," "Neuroform stent," and "Neuroform vs. Enterprise stent." RESULTS: Twenty two publications met the inclusion criteria which encompass 1764 patients and 1873 aneurysms. Out of these 1873 aneurysms, 1007 aneurysms were treated with EP stent and 866 aneurysms were treated with NF stent. The overall outcome was low rates of thromboembolic complications (4.37%) and intracranial hemorrhage (1.13%), low permanent morbidity (1.70%) and mortality (0.40%), and lower rate of recanalization (11%). Data analysis shows an overall higher rate of complication and recurrence of aneurysm and lower overall rate of aneurysmal occlusion in the patients where EP stent was used in comparison to NF stent. However, this difference was not statistically significant. CONCLUSIONS: The review of two stent-assisted coiling devices using EP and NF stents including 1873 aneurysms in 1764 patients revealed that overall, it is safe and effective with comparable outcomes.

BACKGROUND: Complex middle cerebral artery (MCA) aneurysms are defined as large (≥10 mm) or giant (≥25 mm) aneurysms with M2 branches arising from the aneurysm rather than M1 segments and usually require some form of reconstruction of the bifurcation. Their management is difficult and surgery is preferred over endovascular modalities because of their peculiar angioarchitecture and association with critical branch points or perforators. OBJECTIVES: The study was aimed at analyzing surgically managed complex MCA aneurysms and discussing characteristics not favorable for endovascular management, surgical nuances and clipping strategies, patient outcomes, and newer diagnostic modalities which help improve management. METHODS: Nine cases of surgically operated complex MCA aneurysms were identified from January 2017 to July 2019. The aneurysm characteristics, surgical nuances, clipping strategies, patient outcomes and points not favoring endovascular management were tabulated and analyzed. RESULTS: The mean maximum aneurysm diameter was 13.4 mm and the mean fundus/neck ratio was 1.6. The average microscope time was 124 min, and the most common method was clip reconstruction. The average number of clips used was 2.7 and the mean follow-up was 13 months. All patients have good postoperative outcome (Modified Rankin Score 0-2). The complete occlusion rate was 88.9% with one intraoperative voluntary residual sac which was coated. Computational fluid dynamic study results done preoperatively correlated with intraoperative findings. CONCLUSIONS: MCA aneurysms pose a significant challenge for endovascular treatment because of various factors such as luminal thrombi, complex angio-architecture, precarious branch/perforator locations, broad necks, and fusiform characteristics. Surgical management in experienced hands can tackle all these problems with an armamentarium of clipping techniques and bypass procedures.

INTRODUCTION: The surgical strategies for clipping of paraclinoid aneurysms are diverse. These aneurysms are unique in their location, as they closely abut the anterior clinoid process (ACP) and the optic nerve. The ultimate goal of clipping encompasses the exposure of neck of the aneurysm which is seldom complete without the manipulation of optic nerve and the ACP. This manipulation may result in disturbances of vision postoperatively. We analyze our results of visual outcomes in the surgery for paraclinoid aneurysms in this retrospective study. MATERIALS AND METHODS: All patients with paraclinoid aneurysms who underwent surgery from June 2014 to June 2019 were included in the study. Surgical procedure was uniform in all patients which included anterior clinoidectomy and clipping of aneurysms as per the Bantane protocol. Glasgow Outcome Scale as well as vision was assessed at discharge and at 1 month and 6 months. RESULTS: There were 77 cases of paraclinoid aneurysms operated during the abovementioned period. All patients had no symptoms related to vision preoperatively. Visual deterioration was noted in two patients. All patients were discharged with a good outcome on the Glasgow Outcome Scale. CONCLUSION: Paraclinoid aneurysm has a good outcome when treated with surgery. The visual deterioration following surgery can be minimized with extradural anterior clinoidectomy and careful handling of the vessels and nerve.

BACKGROUND: Diffusion tensor imaging (DTI) and diffusion tensor tractography (DTT) provide a noninvasive window to study the neural connectivity and reconstruct the tracts. Detection of white matter injury (WMI) by DTT is a recent application being used in stroke, diffuse axonal injury, and neurodegenerative disorders. Fiber tracking in patients with brain hemorrhage can detect loss of fibers and anatomical disruption of the tracts, which can be useful in the prognostication of patient outcome. MATERIALS AND METHODS: DTI and fiber tracking was done in four patients admitted at Fujita Health University Banbuntane Hospital, Japan, with decreased consciousness following brain hemorrhage (3 patients with aneurysmal subarachnoid hemorrhage and one patient with bifrontal hemorrhage), and WMI was analyzed. We also reviewed the literature on tractography in patients with brain hemorrhage and its correlation with consciousness. RESULTS: We found significant frontal WMI in the form of thinning and anatomical disruption in all four cases. The frontal white matter tracts form an important component of the limbic system and ascending reticular activating system and frontal WMI correlated with the poor conscious level and cognitive dysfunction. Structural damage to the fiber tracts demonstrated as thinning, reduction in the volume or absence on tractography with corresponding reduction in the mean fractional anisotropy values in the frontal white matter of the affected side. CONCLUSION: DTI can be useful as a critical tool for revealing the anatomical basis for the cognitive dysfunction and unconsciousness and can be possibly used to prognosticate patient recovery. Early detection of WMI by DTI can also help in tailored rehabilitation. The authors believe that DTT could have a crucial role in the future for detecting structural changes which lead to cognitive dysfunction and further studies are needed to arrive at a specific protocol for detecting WMI.

INTRODUCTION: Posterior circulation aneurysm constitutes 15%-20% of all intracerebral aneurysms. With the advancement of endovascular techniques, the microsurgery for posterior circulation aneurysms has been pushed back a little. Even the International Subarachnoid Aneurysmal Trial gave support to the concepts of endovascular procedures, but microsurgical modality should not be discouraged. We present our institutional experience of microsurgical techniques on posterior circulation aneurysms. MATERIALS AND METHODS: We performed a retrospective analysis of 37 patients of posterior circulation aneurysm from 2015 to 2019, referred to Bantane Hospital, Japan. We included all posterior circulation aneurysms such as basilar tip, basilar trunk, and vertebral artery-posterior inferior cerebellar artery (VA-PICA) aneurysms, admitted and treated with clipping or bypass and trapping. We assessed the outcome as measured by modified Rankin Score (mRS), complications, and mortality. RESULTS: Out of 37 patients, 10 cases were a basilar tip, one case was the basilar trunk, and 26 cases were VA-PICA aneurysm. Intraoperatively, neuromonitoring, indocyanine green dye, dual-image videoangiography (DIVA), and neuro endoscope were used. Two patients of basilar tip aneurysm developed third cranial nerve paresis and six patients of VA-PICA aneurysm developed lower cranial nerve paresis which resolved spontaneously. All the patients were discharged with mRS of 0 or 1. No mortality was recorded in our study. CONCLUSION: Microsurgical clipping of posterior circulation aneurysm is safe in unruptured aneurysm with a very low risk of mortality and morbidity under experienced hands. All postoperative complications in our study were transient and resolved with time with no residual deficits. Preoperative simulation, intraoperative neuromonitoring, DIVA, and neuro endoscope help achieve complete obliteration of aneurysmal sac and avoid complications.

BACKGROUND: Extracranial-intracranial (EC-IC) arterial bypass has been used in the treatment of various cerebrovascular ischemic disease due to atherosclerosis or Moyamoya disease, skull base tumors encasing large IC artery or complex IC aneurysms. AIM: The aim is to analyze surgical technique (EC-IC bypass) and its outcome with intraoperative use of dual image video angiography (DIVA) and Doppler ultrasound. MATERIALS AND METHODS: We studied in this article a series of 23 patients operated in Banbuntane Hotokukai Hospital, Fujita Health University, for which a superficial temporal artery-middle cerebral artery anastomosis was done for steno-occlusive disease, giant IC aneurysm or Moyamoya disease. The study was conducted between 2018 and 2020. We used dual-image video angiography (DIVA) and Doppler ultrasound to assess the luminal patency of anastomosis during the procedure. RESULTS: In this study, three patients presented with Moyamoya disease, 4 had aneurysm, whereas 16 patients presented with the vascular steno-occlusive disease. The patients were divided into three categories (steno-occlusive disease, Moyamoya, and flow replacement for giant aneurysm). Dual image video angiography, along with intraoperative Doppler, helped us in the assessment of luminal patency of the anastomosis. CONCLUSION: Hemodynamic recovery after cerebrovascular bypass brings about a better outcome in ischemic stroke. The result of surgery improves with proper selection of patients with hemodynamic impairment (in Stage 2). With various modalities such as intraoperative Doppler, DIVA (Dual-image Video Angiography) and improved surgical techniques may aid in the reduction of complications and improve clinical outcome.

BACKGROUND: The prevalence of unruptured intracranial aneurysms is increasing in elderly population in Japan. Octogenarians (80-89 years) are more prone to complications due to increased age, comorbidities, increased risk of vasospasm, and treatment risks. AIM: The aim is to study the surgical outcome of unruptured intracranial saccular aneurysms in elderly patients aged between 80 and 89 years. PATIENTS AND METHODS: A retrospective study was conducted involving all the cases of unruptured intracranial saccular aneurysms operated surgically in elderly patients aged between 80 and 89 years. All the cases operated between January 2017 and October 2019 were included in the study. The preoperative neurological status was assessed using the Glasgow Coma Scale (GCS). The comorbidities and risk factors involved were assessed. Postoperative neurological status was assessed by (1) postoperative GCS score and by the (2) presence or absence of the motor weakness of limbs. RESULTS: Thirty-three aneurysms were operated in 27 patients. Two patients were operated two times at separate occasions for different aneurysms during the study period and hence making a total of 29 surgeries. The age range was 80-88 years, with a mean of 82.4 years ± 2.64 standard deviation (SD). There were 7 (24.1%) males and 22 (75.86%) females. All the patients had a preoperative GCS score of 15/15 without focal neurological deficit. The mean size (mm) of the aneurysms was 6.57 ± 4.04 SD. There were 31 (93.94%) aneurysms in the anterior circulation and 2 (6.06%) aneurysms in the posterior circulation. The comorbidities and risk factors were analyzed and found to be not influencing the outcome of the patients. Clipping was done in 32 aneurysms. One case of posterior inferior cerebellar artery (PICA) aneurysm underwent occipital artery to PICA bypass surgery. The postoperative complications include chronic subdural hematoma (CSDH) in 7 (24.13%) patients, extradural hematoma in 1 (3.4%), meningitis in 1 (3.4%), and lower cranial nerve palsy in 1 (3.4%) patient. All the patients were discharged with GCS score 15/15 without motor weakness of the limbs. The mean duration of stay was 16.62 days ± 9.98 SD. CONCLUSION: Surgery for unruptured saccular aneurysms in octogenarians has got a good result in the tertiary care facility. Advanced age alone should not be considered for preferring coiling over clipping. Octogenarians are more prone to developing postoperative CSDH.

Cavernous carotid aneurysms can be managed by different surgical as well as endovascular methods. The aim of treatment is to exclude the aneurysm from circulation and maintain normal cerebral blood flow. We are reporting a case of incidentally detected CCA managed by high flow bypass with radial artery graft. We discuss the surgical technique and nuances of high flow bypass surgery.

Conventionally ventrally located spinal tumor is approached through anterior vertebrectomy which requires bony fixation and then immobilization for a couple of months. The alternative route to deal with such type of tumor is anterolaterally to avoid the surgical and nonsurgical complications. We are reporting a minimally invasive anterolateral approach for C2 neurofibroma in an 84-year-old patient. Postoperatively this patient did not require cervical brace and postoperative discomfort was minimal. It was observed that dumbbell-shaped cervical tumor with no intradural pathology and wide neural foramina could also be taken care through the anterolateral route which did not require bony fusion or immobilization, but the expertise of the surgeon is necessary for performing these types of minimally invasive procedure to achieve the best results.

Middle cerebral aneurysms constitute almost one-third of all anterior circulation aneurysms. Most of the saccular aneurysms originate from the arterial branching sites, but origins other than at the branching site are extremely rare. In this article, we are describing a unique M1 segment middle cerebral artery aneurysm which is not related with any branching site. Our literature search suggests that atherosclerotic changes in the arterial wall and local hemodynamic forces play an important role in the development of these types of aneurysm. Surgical management is not so unique in this type of aneurysm, but due to atherosclerotic parent arterial wall and thin-walled aneurysm sac, a neurosurgeon should be more cautious.

Cortical blindness (CB) due to contrast-induced encephalopathy is a rare complication in endovascular procedure. Although exact mechanism is not known, disruption of blood-brain barrier (BBB) by contrast agent is supposed to be caused. We report two cases of contrast-induced encephalopathies after coil embolization of unruptured aneurysm. A 68-year-old woman with unruptured basilar artery aneurysm was treated with endovascular stent-assisted coil embolization. The procedure was successfully accomplished within 172 min using about 160 ml of contrast medium (iopamidol). However, she manifested with CB 3 h after the procedure and seizure on the next day. Immediate computed tomography revealed the cortical enhancement in both occipital lobes. Diffusion-weighted imaging-magnetic resonance imaging and fluid-attenuated inversion recovery sequence 1 day after the procedure revealed edema in both occipital lobes with no findings of ischemia or hyperperfusion. Electroencephalography showed sharp and slow waves in both occipital lobes. She required endotracheal intubation on day 2 to maintain airways and breathing. Her sensorium improved 4 days after the procedure with administration of steroid and anticonvulsant. She was extubated on day 4 after the procedure. She was discharged with persisting CB as a sequel.

BACKGROUND: Exact preoperative confirmation of the distal dural ring and intradural location of a paraclinoid internal carotid aneurysm has been an age old dilemma. This study was aimed at identifying anatomical landmarks in cases of paraclinoid aneurysms, which were relatively consistent, and would help in predicting the possibility of an extradural inaccessible location of these aneurysms for surgical clipping. METHODS: Ninety surgically managed unruptured paraclinoid aneurysms were retrospectively analyzed with preoperative computerized tomography. Axial relation of the aneurysm neck to the ophthalmic artery (OA), optic strut (OS), and anterior clinoid process (ACP) in terms of vertical distance and the direction of projection were analyzed and tabulated for all 90 cases. Intradural and extradural (inaccessible) aneurysms were compared. RESULTS: Seven out of the 8 inaccessible necks were medially directed and 1 was ventrally placed (P = 0.053). The OA level when compared to the neck had a positive correlation with inaccessible aneurysms for clipping (P = 0.002) The OS location above the level of the neck had significant correlation with inaccessibility of clipping and extradural location (P < 0.001). The tip of the ACP had no statistical significance with inaccessibility (P = 0.351). CONCLUSIONS: Medially projecting aneurysms with necks below the level of the OS and origin of the OA should be managed with a high index of suspicion and an alternate method of treatment should be sought. The relation of the neck to the ACP does not seem to have significant statistical bearing with decision making.

BACKGROUND: The management of cavernous carotid aneurysms (CCAs) poses a significant dilemma to the treating surgeon. Asymptomatic CCAs usually are managed conservatively with clinical and radiologic follow-up. Large size, intradural extension, sphenoid bone erosion, and increasing size on follow-up are usual indications for treating asymptomatic CCAs. However, there are no clear-cut guidelines in literature. We share our experience of 40 asymptomatic CCAs treated by endovascular and surgical methods. METHODS: All the asymptomatic CCAs treated between January 2014 and December 2018 were analyzed retrospectively. Patient demographics, aneurysm characteristics, postprocedural complications, and clinical and radiologic follow-up data were obtained from records. Outcome was evaluated in terms of aneurysm obliteration and maintained cerebral perfusion, postoperative complications, recurrence, and clinically significant complications during follow-up. RESULTS: Endovascular coiling, balloon-assisted coiling, and stent-assisted coiling were performed in 27 (75%), 5 (13.9%), and 4 (11.1%), respectively. Raymond-Roy occlusion classification grade I occlusion was achieved in 88.9% of cases. No immediate or delayed complications were noted. Coil compaction was seen in 4 (11.1%) patients. In the surgery group, all patient underwent high-flow bypass with radial artery graft. Aneurysm exclusion with good graft patency was achieved in all 4 cases without any permanent morbidity or mortality. CONCLUSIONS: The current study demonstrates excellent outcomes of asymptomatic CCAs after treatment. In view of the technical advancements of both surgical and endovascular methods, consideration for treatment should be given to asymptomatic CCAs. Each aneurysm should be individually assessed by experts for choosing the best endovascular or surgical treatment option.

Introduction: A subgroup of complex aneurysms demands multimodal treatment by microscopic and endovascular means. Partial obliteration or remnant postprocedure demands to go further to the other modality. Materials and Methods: All patients between July 2016 and January 2017 who had to undergo multimodality measures for complete obliteration of the aneurysms were included in the study. The patients who had either undergone clipping or coiling for their aneurysms, but with incomplete obliteration of the aneurysm, were also included in the study. Results: Between July 2016 and January 2017, a total of three patients had to undergo coiling after clipping of the aneurysm for complete obliteration. Two patients had to go for clipping following coiling. All five patients had complete obliteration of the aneurysm sac. Conclusion: Both microscopic and endovascular means are complementary measures instead of competing procedures. It is important to realize the technical difficulties when surgical therapy follows initial endovascular treatment. Similarly, coiling a previously clipped aneurysm can be difficult, if the clip obscures normal working projections.

Deep brain stimulation (DBS) of the ventral intermediate nucleus (VIM) of the thalamus is a powerful surgical option in the treatment of essential tremors (ETs). However, its therapeutic efficacy depends on the tremor distribution. DBS is highly efficient in the relief of distal appendicular tremor but not other types of tremor. We report a case of staged DBS of ventral intermediate nucleus (VIM) of thalamus for the suppression of ETs.

OBJECTIVE: To highlight the basic points of brain endoscopic procedure for Putaminal Bleed to achieve repeatability and reproducibility in the results among the new brain endoscopic surgeons. METHOD: Sharing the experience of 10 years as an endoscopic surgeon to bring out the basic insight into the method, challenges, points which need special attention during the surgery and discussion of recent advancements in the endoscopic equipment for safe surgery. CONCLUSION: Procedure of endoscopic evacuation of brain hematoma is simple with learning curve. In the beginning new endoscopic surgeons should operate in the presence of experience surgeon. They should follow standard technique to achieve the good surgical outcome and uniformity in the result every time they perform the surgery.

OBJECTIVE: To highlight the basic points of brain endoscopic procedure for Subcortical (Lobar) Hemorrhage to achieve repeatability and reproducibility in the results among the new brain endoscopic surgeons. METHOD: Sharing the experience of 10 years as an endoscopic surgeon to bring out the basic insight into the method, challenges, points which need special attention during the surgery and discussion of recent advancements in the endoscopic equipment for safe surgery. CONCLUSION: Procedure of endoscopic evacuation of brain hematoma is simple with learning curve. In the beginning new endoscopic surgeons should operate in the presence of experience surgeon. They should follow standard technique to achieve the good surgical outcome and uniformity in the result every time they perform the surgery.

OBJECTIVE: To highlight the basic points of brain endoscopic procedure for Cerebellar and Large Putaminal Hemorrhage to achieve repeatability and reproducibility in the results among the new brain endoscopic surgeons. METHOD: Sharing the experience of 10 years as an endoscopic surgeon to bring out the basic insight into the method, challenges, points which need special attention during the surgery and discussion of recent advancements in the endoscopic equipment for safe surgery. CONCLUSION: Procedure of endoscopic evacuation of brain hematoma is simple with learning curve. In the beginning new endoscopic surgeons should operate in the presence of experience surgeon. They should follow standard technique to achieve the good surgical outcome and uniformity in the result every time they perform the surgery.

OBJECTIVE: To highlight the basic points of brain endoscopic procedure for Thalamic and Intraventricular Hemorrhage to achieve repeatability and reproducibility in the results among the new brain endoscopic surgeons. METHOD: Sharing the experience of 10 years as an endoscopic surgeon to bring out the basic insight into the method, challenges, points which need special attention during the surgery and discussion of recent advancements in the endoscopic equipment for safe surgery. CONCLUSION: Procedure of endoscopic evacuation of brain hematoma is simple with learning curve. In the beginning new endoscopic surgeons should operate in the presence of experience surgeon. They should follow standard technique to achieve the good surgical outcome and uniformity in the result every time they perform the surgery.

Avoidance of complications during cerebral aneurysm surgery marks the future outcome in the patient. Various modalities such as adequate opening of the Sylvian fissure, motor-evoked potential, endoscope-assisted microsurgery, indocyanine green dye, and dual image video angiography are available to reduce these complications during surgery, either by prevention of injury to the small perforators or the parent artery. We present our experience at the Fujita Health University Banbuntane Hospital, Japan, of the cerebral aneurysm surgery along with the use of these modalities in our patients from September 2014 to December 2016 along with a brief review of the various techniques for avoidance of complications.

INTRODUCTION: Paraclinoid aneurysms pose technical difficulty in their approach, mainly because of their close proximity to neurovascular structures, deeper location, and a smaller corridor. Extradural anterior clinoidectomy is a highly beneficial technique in such cases, making more space to deal with these aneurysms. We describe our method of performing extradural anterior clinoidectomy in such patients. MATERIALS AND METHODS: A total of 33 cases of paraclinoid internal carotid artery aneurysms presenting to Fujita Health University Banbuntane Hospital, Japan, were included. Females comprised the majority with 32 cases; the mean age was 54.8 years (range: 35-74 years). The mean size of the paraclinoid aneurysm was 5.3 mm (range: 3-12 mm). RESULTS: Nine paraclinoid aneurysms were found projecting dorsally, 7 laterally, and 17 medially (Kazuhiko Kyoshim et al's. classification). An immediate complete occlusion rate of 100% was present. Visual disturbance was found in 6.2% of our patients. One of our patients developed permanent loss of vision. CONCLUSION: Extradural anterior clinoidectomy enables a better exposure to paraclinoid aneurysms. Precise anatomical knowledge along with microsurgical tactics is required to prevent and manage potential complications to achieve good outcomes.

The recurrence of aneurysms postcoil embolization is a common occurrence. Endovascular coiling has been noted to be more effective for small lesions rather than the giant aneurysms. A postembolization recurrent aneurysm is a difficult condition to manage. We present a case of a recurrent giant aneurysm of the anterior cerebral arteries (ACAs) first segment (A1). It was managed by superficial temporal artery to A3 segment of anterior cerebral artery bypass anastomotic revascularization plus distal A1- segment clipping. A literature review is presented for the management of giant A1 artery aneurysms.

INTRODUCTION: Microsurgical clipping and Endovascular coiling (EC) are both effective alternatives in the management of intracranial aneurysms. EC has been shown to be associated with the risk of recurrent aneurysm (RA) growth. Considering the minimally invasive nature of this procedure, the management of intracranial aneurysms has been skewed toward EC, especially in the developed world. In this scenario, there has been an upsurge of RAs after EC. Since the optimal management of these RAs has not been defined, they pose a unique challenge to the treating surgeons. AIMS AND OBJECTIVES: The aim of this study is to elucidate the optimal management of RAs after EC. MATERIALS AND METHODS: Medical records of all patients who underwent surgery for RAs were reviewed from the period January 2014 to March 2019. The demographic and angiographic patterns of the patients and operative techniques and complications were studied. The outcome was dichotomized into good and bad depending on the Glasgow outcome scale (GOS). RESULTS: There were four cases of RAs operated in our institution between the above-mentioned period. There were varied differences between the initial coiling and time to recurrences. All four patients were operated under neuromonitoring. Three underwent clipping and one patient underwent clipping with bypass. All four patients had good outcome with a GOS of 5/5. CONCLUSION: Operations for RAs constitute many technical challenges and require a lot of expertise. Such surgeries are recommended in high-volume centers, with sufficient experience in both clipping and cerebral bypass.

Abstract The dual-image videoangiography (DIVA) is a new tool which helps identify vessels and surrounding structure. This method is based on use of indocyanine green video angiography (ICG-VA) technology on real time microscopic operative image. In this two case, we report of using DIVA in STA-MCA bypass surgery of 46 years old, female patient of stenosis of right MCA. And using DIVA during clipping ICA paraclinod aneurysm of 35 years old, female. During surgery, it helped in identifying temporal and frontal branches of the STA and there careful selection. After anastomosis, DIVA was used to refine vessel patency and functioning of the anastomosis. DIVA has the potential to replace ICG-VA as a tool for checking the patency of graft during bypass procedures and obliteration of aneurysm along with surgical procedures for AVM and d-AVF. DIVA allows visualization of vessels against a background of normal brain and has better visualization at greater depth and high magnification. This is particularly important during bypass surgery, which very often is performed in deep surgical fields and high magnification.

Intraoperative aneurysmal rupture (IAR) is the most fearsome complication of aneurysm surgery. IAR associates with high morbidity and mortality. In recent years, we have many studies regarding using computational fluid dynamics (CFD) in aneurysm surgery. CFD helps in calculating the velocity of blood flowing in the aneurysm sac, the pressure in the aneurysm sac, and wall shear stress (WSS). CFD also helps in predicting nature of aneurysm wall and thus may warn about different intraoperative microscopy findings in aneurysms. Using its application, surgeon may become more careful in doing microsurgical sharp dissection. A 40-year-old female admitted with diagnosis of unruptured anterior communicating artery aneurysm. CFD analysis demonstrated high intra-aneurysmal pressure and divergent WSS in dome. During sharp dissection, there was intraoperative rupture aneurysm twice which was managed with cotton tamponade and glue and temporary clipping aneurysm. Indocyanine green video angiography showed working parent arteries and nonfunctioning aneurysm. After operation, the patient recovered fully and had a modified Rankin score of 1. This case demonstrated importance of preoperative planning of aneurysm surgery using CFD analysis. IAR is associated with an increased risk for an unfavorable outcome. Accurate preoperative planning with studying flow dynamics and structure of aneurysm may help in use sharp microsurgical dissection more cautiously.

INTRODUCTION: There are many controversies about computational fluid dynamics (CFD) findings and aneurysm initiation, growth, and ultimate rupture. The aim of our work was to analyze CFD data in a consecutive series of patients and to correlate them with intraoperative visual aneurysm findings. METHODS: Hemoscope software (Amin, Ziosoft Corporation, Minato ward, Tokyo, Japan) was used to process images from 17 patients who underwent clipping of 18 aneurysms. Pressure (P), wall shear stress (WSS) gradient and vectors, normalized WSS, and streamlines (SL) direction and velocity were assessed. CFD data were compared to intraoperative visual findings. A total of 39 aneurysm wall areas were assessed. RESULTS: Red, thin aneurysm wall areas were more often associated with low WSS. However, the association of low WSS with high P, diverging WSS vectors, direct impact of SL, and high SL velocity more frequently matched with yellow, atherosclerotic aneurysm walls. CONCLUSIONS: Low WSS alone is not sufficient to determine the thickness of an aneurysm wall. Its association with other parameters might enable one to distinguish preoperatively atherosclerotic, thick areas (high P, diverging WSS vectors, high flow velocity) from thin areas with higher rupture risk (parallel WSS vectors, lower flow velocity). The changing balance between these parameters can modify the features and the risk of rupture of aneurysm wall over time.

Complex intracranial aneurysms (CIAs) rank high among the most technically demanding neurosurgical pathologies. Microsurgery and clip ligation can be challenging in CIAs as circumferential visualization of the aneurysm, parent vessels, branches, perforators, and other neurovascular structures is important to prevent residual aneurysms or strokes from vessel or perforator occlusion. Decompression of the aneurysm sac is often required for CIAs. We reviewed the literature and PubMed advanced search showed 13 results of adenosine-induced flow arrest to facilitate intracranial complex aneurysm clip ligation which included three independent case reports and ten cases in a case series from 1999 to May 2016. Few case series have described the use of adenosine in intracranial aneurysm surgery. Satisfactory aneurysm decompression was achieved in all cases, and all aneurysms were clipped successfully. We recommend that adenosine cardiac arrest is a relatively novel method for decompression of intracranial aneurysms to facilitate clip application. With appropriate safety precautions, it is a reasonable alternative method when temporary clipping of proximal vessels is not desirable or not possible.

INTRODUCTION: One of the underreported complications of clipping of unruptured aneurysm is chronic subdural hematoma/hygroma (CSDH). It can cause sudden deterioration and might need emergency evacuation. Recently, very few papers have studied its incidence and predisposing factors. We are reporting our institutional experience of it along with the study of its risk factors and possible pathogenesis. METHODOLOGY: Totally 91 postoperative patients of unruptured aneurysms were retrospectively analyzed. Totally 21 patients had CSDH who were operated. In rest seventy patients, there was no CSDH. RESULTS: Male sex, old age, anticoagulant use, presence of pneumocephalus and dead space were significantly associated with occurrence of CSDH, whereas arachnoidoplasty significantly protected against it. There was no significant relation of CSDH with Gorei-san use. CONCLUSIONS: We recommend arachnoidoplasty should be carried out in all patients of clipping of unruptured aneurysm. Male patients or/and patients with dead space with pneumocephalus must be given extra attention like avoiding any dead space in postoperative period, doing arachnoidoplasty and regular follow up till 1st year.

BACKGROUND: The management of unruptured cerebral aneurysms (UCA) in elderly population is a challenge. With a very high life expectancy and high risk of rupture in Japan, the need for identifying the best treatment modality is essential to help the patients in decision-making. METHODS: This was a 2-year single-center retrospective comparative analysis of the outcomes of surgical clipping (SC) in patients aged above 75 and <75 years. The modified Rankin score was used to stratify the patients and to analyze the functional outcome. Functional status at discharge was the primary end point. RESULTS: There were 224 patients with 239 aneurysms. About 12.5% of the patients were more than 75 years with a mean age of 77.85. The mean age of patients <75 years was 60.96, and it was statistically significant. The overall male-to-female ratio was 1:3.3. The most common location was the middle cerebral artery followed by internal carotid artery at the posterior communicating and ophthalmic segments, and 22 patients had aneurysms of the posterior circulation. Nearly 77% of the aneurysms were <6 mm. There was no significant difference in size of the aneurysm as the age increased to more than 75 years. There were complications in 6 patients, and there was no mortality in the study population. There was no statistically significant difference in the outcome between the groups. CONCLUSIONS: SC can be considered a safe option for UCA in the aging population.

Grade V subarachnoid haemorrhage (SAH) patients may be dichotomised into those with temporary deterioration and those with irreversible injury, and only the former have a chance of favourable outcomes by aneurysm obliteration. One method of differentiating the two conditions is to wait and observe potential recovery for 12-48hours. However, early rebleeding and non-convulsive seizures may occur during this period. In our institution, grade V SAH patients receive immediate treatment (general anaesthesia induction and aneurysm obliteration within 24hours of onset) to minimise those risks. We focused on therapeutic outcomes in SAH patients presenting with a Glasgow Coma Scale score of 3 (GCS-3). Between January 2006 and December 2013, 82 GCS-3 SAH patients were admitted, among whom 51 (62%) underwent immediate aneurysm obliteration. Their outcomes 90days after onset were evaluated with the Glasgow Outcome Scale, with either good recovery or moderate disability regarded as favourable outcomes. Multivariate logistic regression analysis was performed to identify variables correlated with favourable outcomes. Among the 51 patients, 11 (22%) had favourable 90-day outcomes. Age (odds ratio [OR], 0.838; 95% confidence interval [CI], 0.733-0.959; p=0.010) and intact pupillary light reflex (OR, 21.939; 95% CI, 1.465-328.576; p=0.025) were correlated with favourable outcomes. By contrast, neither intact respiratory pattern nor isocoric pupils was correlated with favourable outcomes. The current results indicate that vigorous intervention may be worth attempting in young GCS-3 SAH patients with intact pupillary light reflex. It remains unclear, however, whether the seemingly high frequency of favourable outcomes was truly due to reduction in early rebleeding or seizures.

We report a rare case of dural arteriovenous fistula at the craniocervical junction manifesting as cerebellar haemorrhage, which posed a diagnostic challenge for physicians. A 77-year-old woman with no history of arterial hypertension presented to our Emergency Department with dizziness, and imaging studies revealed a small cerebellar haemorrhage. She was diagnosed with hypertensive intracerebral haemorrhage and conservatively treated. Four months later, she developed subarachnoid haemorrhage, and imaging studies revealed dural arteriovenous fistula at the left C1 dural sleeve. Disruption of a distended cerebellar vein due to venous hypertension by dural arteriovenous fistula was considered to be responsible for intracerebral haemorrhage and subarachnoid haemorrhage. Dural arteriovenous fistula was cured following surgical ligation of a feeding artery and a draining vein. The present case was educational in that effort to identify the cause of bleeding using vascular imaging studies may be important in patients with seemingly typical hypertensive intracerebral haemorrhage, particularly in those without a past history of arterial hypertension.

BACKGROUND: There are no guidelines regarding the optimal treatment of subarachnoid hemorrhage (SAH) patients complicated by Takotsubo cardiomyopathy (TCM). Although coiling has been favored as the first-line treatment, clipping may also be indicated in patients with ruptured middle cerebral artery aneurysms or in those with massive intracerebral hemorrhage. The study objective is (1) to report the feasibility/safety of clipping/coiling and (2) to identify possible prognosticators in that population. METHODS: Between January 2008 and December 2014, 371 consecutive patients with aneurysmal SAH underwent transthoracic echocardiography after admission, and 30 with TCM (7.7 %) were identified. We reviewed the incidence and type of perioperative complications among clipped (n = 11) and coiled (n = 19) patients. The 30 patients were dichotomized based on their 90-day modified Rankin scale (mRS) scores into favorable (mRS: 0-2) and unfavorable (mRS: 3-6) groups, and their demographic, laboratory and echocardiographic variables were compared. RESULTS: Neither clipped nor coiled patients developed serious perioperative cardiopulmonary complications, but coiled patients had a higher incidence of fatal procedure-related complications. Among the 30 patients, 13 (43 %) had favorable 90-day outcomes, and the favorable group was significantly younger. Age, but not the degree of cardiac dysfunction, correlated with outcomes by multivariate regression analysis. CONCLUSIONS: Clipping was shown to be a safe treatment modality in our cohort, and treatment selection may better be made on a case-by-case basis in most patients with SAH-induced TCM. The lack of correlation between the degree of cardiac dysfunction and outcomes indicates that aggressive intervention is justified in patients with severely impaired cardiac function.