早川 基治

OBJECTIVE: Knowledge of the location of tumor-feeding arteries is necessary for the safe surgery of intracranial meningiomas. Hence, this retrospective study aimed to comprehensively analyze the distribution of tumor-feeding arteries. METHODS: Patients who underwent intracranial meningioma surgery at our institution between 2015 and 2023 were included in this study. The tumor attachment sites and tumor-feeding arteries were evaluated based on the results of preoperative examinations. The tumor attachment sites were classified as non-skull bases (convexity, parasagittal, and falx) or skull bases (anterior skull base, sphenoid ridge, sphenopetroclival, petrous, tentorial, cerebellar convexity, and foramen magnum). These tumors were further subdivided according to their attachment areas. RESULTS: Among the 180 patients included, the tumor-feeding arteries were identified in 177 patients (98.3%). In 67 patients with non-skull base meningiomas, the middle meningeal artery primarily functioned as a tumor-feeding artery in the anterior and middle regions (78 of 108 feeding arteries, 72.2%), while the extracranial artery served as a tumor-feeding artery in the posterior region (20 of 37 feeding arteries, 54.1%). Conversely, skull base meningiomas exhibited a higher frequency of having tumor-feeding arteries derived from the internal carotid artery (132 of 278 feeding arteries; 47.5%); these tumor-feeding arteries are often found at the deepest part of the surgical field during tumor resection and require careful intraoperative handling. CONCLUSIONS: Tumor-feeding arteries originate from different dural arteries depending on the tumor attachment site. These findings could help enhance surgical safety, especially in patients with meningiomas who have not undergone preoperative angiography.

BACKGROUND AND PURPOSE: Tumor embolization through the meningohypophyseal trunk and inferolateral trunk is known to be effective in skull-based tumors; however, microcatheter cannulation into these arteries is difficult, and the number of cases that can be safely embolized is limited. In this study, we present a novel embolization procedure for meningohypophyseal trunk and inferolateral trunk using the distal balloon protection technique and detail its clinical efficacy and complication risks. We developed this procedure to allow safe embolization in patients who cannot be adequately cannulated with microcatheters into these arteries. MATERIALS AND METHODS: Patients who underwent meningohypophyseal trunk or inferolateral trunk embolization using the distal balloon protection technique for skull-based tumors at our institution between 2010 and 2023 were included. In this procedure, the ICA was temporarily occluded with a balloon at the ophthalmic artery bifurcation, the microcatheter was guided to the meningohypophyseal trunk or inferolateral trunk vicinity, and embolic particles were injected into the arteries. The balloon was deflated after the embolic particles, that had refluxed into the ICA, were aspirated. RESULTS: A total of 25 meningohypophyseal trunks and inferolateral trunks were embolized during 21 surgeries. Of these 25 arteries, only nine (36.0%) were successfully cannulated with microcatheters. Nevertheless, effective embolization was achieved in all cases. Permanent complications occurred in only one case (4.8%), in which the central retinal artery was occluded during inferolateral trunk embolization, resulting in a visual field defect. No permanent complications resulting from the embolic cerebral infarction were observed. Of 16 cases that underwent MRI within a week after embolization, however, 11 (68.8%) demonstrated embolic cerebral infarctions. CONCLUSIONS: In patients with skull-based tumors with meningohypophyseal trunk or inferolateal trunk feeders that cannot be catheterized directly, embolization using the distal balloon protection technique for tumor supply can be considered as a salvage technique. ABBREVIATIONS: MHT = meningohypophyseal trunk; ILT = inferolateral trunk; GC = guide catheter; AC = aspiration catheter; FR = flow reverse.

BACKGROUND: In intraventricular surgery using a flexible endoscope, the lesion is usually aspirated via the working channel. However, the surgical view during aspiration is extremely poor because the objective lens is located adjacent to the working channel. METHOD: To address this issue, we developed a novel surgical procedure using an angiographic catheter. In this procedure, the catheter is inserted into the working channel, and the lesion is aspirated through the catheter. Besides, continuous intraventricular irrigation is performed via the gap between the catheter and the working channel. CONCLUSION: This procedure maintains a clear view during surgery and reduces complications.

Ischemia-induced postoperative scalp necrosis in the superficial temporal artery (STA) region is known to occur after STA-middle cerebral artery anastomoses. However, no reports have evaluated the risk of postoperative scalp necrosis in the occipital artery (OA) region. This study examined the surgical procedures that pose a risk for postoperative scalp necrosis in the OA region following posterior cranial fossa surgery. Patients who underwent initial posterior fossa craniotomy at our institution from 2015 to 2022 were included. Clinical information was collected using medical records. Regarding surgical procedures, we evaluated the incision design and whether a supramuscular scalp flap was prepared. The supramuscular scalp flap was defined as a scalp flap dissected from the sternocleidomastoid and/or splenius capitis muscles. A total of 392 patients were included. Postoperative scalp necrosis occurred in 19 patients (4.8%). There were 296 patients with supramuscular scalp flaps, and supramuscular scalp flaps prepared in all 19 patients with postoperative necrosis. Comparing incision designs among patients with supramuscular scalp flap, a hockey stick-shaped scalp incision caused postoperative necrosis in 14 of 73 patients (19.1%), and the odds of postoperative scalp necrosis were higher with the hockey stick shape than with the retro-auricular C shape (adjusted odds ratio: 12.2, 95% confidence interval: 3.86-38.3, p = 0.00002). In all the cases, ischemia was considered to be the cause of postoperative necrosis. The incidence of postoperative necrosis is particularly high when a hockey stick-shaped scalp incision is combined with a supramuscular scalp flap.

Objective  Plaque induction through intimal injury using a balloon catheter in small animals and by artificial ligation of the carotid artery in large animals have been reported. However, these reports have not yet succeeded in inducing stable plaques nor creating a high degree of intimal thickening to be used as animal models. We have previously developed a plaque induction model in rats but have failed to obtain a plaque incidence frequency that can be used as a model. Thus, in the current study, we aimed to create a versatile disease model to examine the pharmacokinetics of drug administration, determine the efficacy of treatment, and examine the process of intimal thickening. We also attempted to create an improved model with shorter, more frequent, and more severe intimal thickening. Materials and Methods  The common carotid artery of male Wistar rats was surgically exposed and completely ligated with a wire and 6-0 nylon thread. Then, the wire was removed to create a partial ligation. To create a high frequency and high degree of intimal thickening, 72 rats were divided into two groups: a single lesion group with a 0.25-mm wire and a single ligature point, and a tandem lesion group with a 0.3-mm wire and two ligature points. Each group was further divided into normal diet and high cholesterol diet groups. The presence and frequency of intimal thickening were examined for each group after 4, 8, and 16 weeks of growth. Results  In the single lesion group, intimal thickening was observed in 42% of the 4-week group and 75% of the 8-week group. In the tandem lesion group, intimal thickening was observed in 75% of the 4-week group and 50% of the 8-week group. In addition, 50% of the individuals reared for 16 weeks developed intimal thickening. Conclusion  We successfully induced intimal thickening in the carotid arteries of rats with high frequency in the single lesion and tandem lesion groups. The results also showed that the tandem lesion group tended to induce intimal thickening earlier than the single lesion group.

BACKGROUND: The Uncal vein (UV), downstream of the deep middle cerebral vein (DMCV), has a similar drainage pattern to the superficial middle cerebral vein (SMCV) and may be involved in venous complications during the anterior transpetrosal approach (ATPA). However, in petroclival meningioma (PCM), where the ATPA is frequently used, there are no reports evaluating drainage patterns of the UV and the risk of venous complications associated with the UV during the ATPA. METHODS: Forty-three patients with petroclival meningioma (PCM) and 20 with unruptured intracranial aneurysm (control group) were included. Preoperative digital subtraction angiography was used to evaluate UV and DMCV drainage patterns on the side of the tumor and bilaterally in patients with PCM and the control group, respectively. RESULTS: In the control group, the DMCV drained to the UV, UV and BVR, and BVR in 24 (60.0%), eight (20.0%), and eight (20.0%) hemispheres, respectively. Conversely, the DMCV in the patients with PCM drained to the UV, UV and BVR, and BVR in 12 (27.9%), 19 (44.2%), and 12 (27.9%) patients, respectively. The DMCV was more likely to be drained to the BVR in the PCM group (p < 0.01). In three patients with PCM (7.0%), the DMCV drained only to the UV, and furthermore, the UV drained to the pterygoid plexus via the foramen ovale, posing a risk for venous complications during the ATPA. CONCLUSIONS: In the patients with PCM, the BVR functioned as a collateral venous pathway of the UV. Preoperative evaluation of the UV drainage patterns is recommended to reduce venous complications during the ATPA.

OBJECTIVE: Although a qualitative diagnosis of plaque causing carotid stenosis has been attempted with carotid computed tomography angiography (CaCTA), no clear findings have been reported. We examined the correlation between the plaque CT values and plaque images obtained by magnetic resonance imaging to derive a qualitative diagnosis of the plaque using CaCTA. METHODS: Preoperative CaCTA images acquired from patients stented for carotid stenosis were retrospectively analyzed with respect to magnetization-prepared rapid acquisition with gradient echo and time-of-flight magnetic resonance angiography data. Carotid plaques in the stenosed region were quantified in terms of CT density and the plaque/muscle ratio (magnetization-prepared rapid acquisition with gradient echo), and correlations between these 2 features were determined. Plaques were classified as stable or unstable based on the plaque/muscle ratio, with the smallest plaque/muscle ratio observed among plaques positive for intraplaque hemorrhage set as the cutoff value (1.76). RESULTS: A total of 165 patients (179 plaques) were included. Perioperative complications included minor stroke (n = 3), major stroke (n = 1, fatal), and hyperperfusion (n = 2). The correlation between CT density and the plaque/muscle ratio was nonlinear (P = 0.0139) and negative (P < 0.0001). The cutoff point (1.76) corresponded to a CT density of 83 HU, supporting this value as a standard reference for plaque stability. CONCLUSIONS: Computed tomography density exhibits a nonlinear (P = 0.0139) and highly negative correlation (P < 0.0001) with the plaque/muscle ratio. Our results demonstrate that plaque characteristics can be meaningfully diagnosed based on CaCTA image data.

Collateral circulation in the circle of Willis (CoW), closely associated with disease mechanisms and treatment outcomes, can be effectively investigated using one-dimensional-zero-dimensional hemodynamic simulations. As the entire cardiovascular system is considered in the simulation, it captures the systemic effects of local arterial changes, thus reproducing collateral circulation that reflects biological phenomena. The simulation facilitates rapid assessment of clinically relevant hemodynamic quantities under patient-specific conditions by incorporating clinical data. During patient-specific simulations, the impact of clinical data uncertainty on the simulated quantities should be quantified to obtain reliable results. However, as uncertainty quantification (UQ) is time-consuming and computationally expensive, its implementation in time-sensitive clinical applications is considered impractical. Therefore, we constructed a surrogate model based on machine learning using simulation data. The model accurately predicts the flow rate and pressure in the CoW in a few milliseconds. This reduced computation time enables the UQ execution with 100 000 predictions in a few minutes on a single CPU core and in less than a minute on a GPU. We performed UQ to predict the risk of cerebral hyperperfusion (CH), a life-threatening condition that can occur after carotid artery stenosis surgery if collateral circulation fails to function appropriately. We predicted the statistics of the postoperative flow rate increase in the CoW, which is a measure of CH, considering the uncertainties of arterial diameters, stenosis parameters, and flow rates measured using the patients' clinical data. A sensitivity analysis was performed to clarify the impact of each uncertain parameter on the flow rate increase. Results indicated that CH occurred when two conditions were satisfied simultaneously: severe stenosis and when arteries of small diameter serve as the collateral pathway to the cerebral artery on the stenosis side. These findings elucidate the biological aspects of cerebral circulation in terms of the relationship between collateral flow and CH.

Meningiomas are a common pathology in the central nervous system requiring complete surgical resection. However, in cases of recurrence and post-irradiation, accurate identification of tumor remnants and a dural tail under bright light remains challenging. We aimed to perform real-time intraoperative visualization of the meningioma and dural tail using a delayed-window indocyanine green (ICG) technique with microscopy. Fifteen patients with intracranial meningioma received 0.5 mg/kg ICG a few hours before observation during the surgery. We used near-infrared (NIR) fluorescence to identify the tumor location. NIR fluorescence could visualize meningiomas in 12 out of 15 cases. Near-infrared visualization during the surgery ranged from 1 to 4 h after the administration of ICG. The mean signal-to-background ratio (SBR) of the intracranial meningioma in delayed-window ICG (DWIG) was 3.3 ± 2.6. The ratio of gadolinium-enhanced T1 tumor signal to the brain (T1BR) (2.5 ± 0.9) was significantly correlated with the tumor SBR (p = 0.016). K^trans, indicating blood–brain barrier permeability, was significantly correlated with tumor SBR (p &amp;lt; 0.0001) and T1BR (p = 0.013) on dynamic contrast-enhanced magnetic resonance imaging (MRI). DWIG demonstrated a sensitivity of 94%, specificity of 38%, positive predictive value (PPV) of 76%, and negative predictive value (NPV) of 75% for meningiomas. This is the first pilot study in which DWIG fluorescence-guided surgery was used to visualize meningioma and dural tail intraoperatively with microscopy. DWIG is comparable with second-window ICG in terms of mean SBR. Gadolinium-enhanced T1 tumor signal may predict NIR fluorescence of the intracranial meningioma. Blood–brain barrier permeability as shown by K^trans on dynamic contrast-enhanced MRI can contribute to gadolinium enhancement on MRI and to ICG retention and tumor fluorescence by NIR.

OBJECTIVE: Relationships between aneurysm initiation and hemodynamic factors remain unclear since de novo aneurysms are rarely observed. Most previous computational fluid dynamics (CFD) studies have used artificially reproduced vessel geometries before aneurysm initiation for analysis. In this study, the authors investigated the hemodynamic factors related to aneurysm initiation by using angiographic images in patients with cerebral aneurysms taken before and after an aneurysm formation. METHODS: The authors identified 10 cases of de novo aneurysms in patients who underwent follow-up examinations for existing cerebral aneurysms located at a different vessel. The authors then reconstructed the vessel geometry from the images that were taken before aneurysm initiation. In addition, 34 arterial locations without aneurysms were selected as control cases. Hemodynamic parameters acting on the arterial walls were calculated by CFD analysis. RESULTS: In all de novo cases, the aneurysmal initiation area corresponded to the highest wall shear stress divergence (WSSD point), which indicated that there was a strong tensile force on the arterial wall at the initiation area. The other previously reported parameters did not show such correlations. Additionally, the pressure loss coefficient (PLc) was statistically significantly higher in the de novo cases (p < 0.01). The blood flow impact on the bifurcation apex, or the secondary flow accompanied by vortices, resulted in high tensile forces and high total pressure loss acting on the vessel wall. CONCLUSIONS: Aneurysm initiation may be more likely in an area where both tensile forces acting on the vessel wall and total pressure loss are large.

Transvenous embolization (TVE) through the superior ophthalmic vein (SOV) is a useful approach for the treatment of cavernous sinus (CS) dural arteriovenous fistulae (DAVFs). This venous route is usually confirmed by angiography. Herein, we present a case of favorable embolization of the CS DAVF through the angiographically occlusive SOV. A 61-year-old man presented with progressive exophthalmos and hypertonia. The patient was diagnosed with a CS DAVF, and TVE was planned. The first approach through the inferior petrosal sinus was infeasible; therefore, we attempted to approach the fistula through the left facial vein. The microcatheter was easily advanced to the shunt point through the angiographically occlusive SOV. We performed coil embolization, and the CS DAVF was completely obstructed.

PURPOSE: A high packing density (PD) (i.e., coil volume per aneurysm volume) helps prevent recanalization after endosaccular embolization of cerebral aneurysms. We hypothesized that the use of soft coils may be useful to raise PD and retrospectively investigated the correlation between the ED coil volume rate (i.e., volume ratio of all placed coils) and PD in patients treated with endosaccular embolization using this coil. METHODS: Excluding aneurysms treated with a stent, 292 aneurysms treated using ED coils were included in this study. The 292 aneurysms and aneurysms with ≥30%, ≥40%, and ≥50% ED coil volume rates (202, 168, and 129 aneurysms, respectively) underwent linear regression analysis of the following seven factors' influence on PD:ED ratio, aneurysm volume, neck width, height, maximum diameter, dome-to-neck ratio, and aspect ratio. RESULTS: Independent factors of a high PD were high ED ratio and small neck width on analyses of aneurysms with an ED ratio of ≥40% and ≥50%. Only neck width was an independent factor on analyses of all 292 aneurysms and aneurysms with ED ratio of ≥30%. CONCLUSION: The use of ED coils in high volume rate correlated with a high PD and may contribute to prevent recanalization in small aneurysms.

When using detachable coils for cerebral aneurysm embolization, it is necessary to place a microcatheter with radiopaque markers at 2 sites (tip and 3 cm proximal from the tip) in most cases. Detachable coils that can be positioned independently from the proximal marker may facilitate new applications utilizing their characteristics. Herein, we report 2 cases that were treated with new applications. Detachable coils that function to electrically detect the moment they come out of the microcatheter were used. In one patient with a large aneurysm with an irregular shape, coil embolization was applied by advancing the catheter more than 3 cm from the aneurysm neck to the caudally protruded compartment near the proximal end of the neck, which was difficult to reach with the coil. In the other patient with cerebral arteriovenous malformation (AVM), microcatheters for AVM without a proximal marker were used for coil embolization before Onyx injection: Coil embolization was applied through one microcatheter to a site more proximal than the tip of the other microcatheter, followed by Onyx injection through the distal catheter, by which the nidus was continuously penetrated from the initiation of injection, obtaining an effect similar to that of the plug and push technique. Through the use of detachable coils, which are not dependent on the visibility of the proximal marker, the limitation of catheter positioning is reduced and the applicable types of catheter increase, which may facilitate to enable its use for new clinical indications.

<p>Objective: A case of cerebral embolism due to left atrial myxoma successfully treated using a direct aspiration first pass technique (ADAPT) is reported with a review of the literature.</p><p>Case Presentation: The patient was a 31-year-old male who developed left hemiparesis and dysarthria and was transported to our hospital. Based on MRI and MRA findings, a diagnosis of acute cerebral infarction due to occlusion of the distal part of M1 of the right middle cerebral artery, and transthoracic echocardiography suggested left atrial myxoma. Intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) and mechanical thrombectomy were carried out, and complete recanalization could be achieved 196 minutes after the onset. The symptoms were resolved, and the embolus was pathologically confirmed to be left atrial myxoma.</p><p>Conclusion: ADAPT using Penumbra was suggested to be useful for the treatment of cardiogenic cerebral embolism due to left atrial myxoma.</p>

2006年1月〜2015年5月迄に、発症後48時間以内の早期に根治的治療を行った前交通動脈瘤破裂によるクモ膜下出血(SAH)102例を対象に、破裂前交通動脈瘤の発育方向を中心に重症度と治療予後の関係について、後方視的に検討した。性別は男性41例(40.1%)、女性61例(59.8%)、年齢は31〜82歳(平均61.0±12.8歳)、治療内訳は脳動脈瘤頸部クリッピング術が63例、コイル塞栓術が39例であった。WFNS分類による102例の内訳はGr.I 5例、II 36例、III 16例、IV 17例、V 28例、瘤径の全体平均は5.5±0.3mmであった。重症SAH(Gr.IV〜V)が占める割合と瘤径において有意差を認めたが、脳内出血、脳室内出血、急性水頭症の合併、カテコールアミン値は各群間で有意差を認めなかった。予後良好率はsup.が88%と最も高値で、post.が33%と最も低値であったが、両群間に統計学的有意差は認めなかった。しかし、ant.はlat.と比べ有意に予後が良好で、ant.はinf.よりも予後がよい傾向がみられた。また、重症度と治療予後の比較において、重症度が高いにもかかわらず退院時予後がよい症例を「重症度と治療予後の乖離」と定義すると、そのような症例が計18例認められた。

BACKGROUND: In embolizing a cerebral aneurysm, achievement of a high-volume embolization ratio (VER: volume of inserted coils / aneurysm volume) is important because it may prevent coil compaction and recanalization. The goal of the study is to examine whether use of softer and longer coils gives an adequate VER with fewer coils, particularly for small aneurysms. METHODS: Aneurysm volumes, VERs, and numbers of inserted coils were investigated in 23 cases of small aneurysms embolized using Infini coils, a long soft coil with a primary diameter of 0.010 inches (Infini group). An aneurysm volume- and VER-matched control (non-Infini) group of 59 cases was selected from patients treated at our facility. Data were also compared between subgroups of patients (n = 18 and n = 34 in the Infini and non-Infini groups, respectively) who were not treated with thicker coils with primary diameters of 0.0135-0.015 inches (18-type coils), since these coils affect the number of coils by increasing VER rapidly. RESULTS: Average aneurysm volumes and VERs did not differ significantly between the Infini and non-Infini groups. Significantly fewer coils were used per 0.1 ml aneurysm volume in the Infini group (4.08 coils in average) compared with the non-Infini group (5.67) (p < 0.001). In the non-18-type subgroups, the number of coils used remained significantly smaller in the Infini group (4.49) compared with the non-Infini group (6.72), (p < 0.001). CONCLUSION: To achieve VER ≥20%, use of Infini coils significantly decreased the number of coils required per unit volume of a small aneurysm.