定藤 章代

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.

Primary optic nerve sheath meningioma (pONSM) is one of the most challenging tumors to manage. Although surgical excision may be considered a treatment option to maintain visual function, the safety of surgery remains debatable due to the non-negligible risk of optic nerve injury. pONSM often grows concentrically around the optic nerve; however, it can also demonstrate an exophytic growth from the optic nerve. The risk of surgical excision of pONSM may vary based on the tumor's growth pattern and area of contact with the optic nerve; however, there has been no detailed report on risk stratification to date. The authors present an illustrative case of an exophytic pONSM which was removed surgically without complications, suggesting that tumor morphology may also influence the surgical risk. In this report, the imaging and intraoperative features of exophytic pONSM are presented in detail, and the risk factors for complications are discussed.

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.

BACKGROUND: We aimed to clarify the relationship between epicardial adipose tissue (EAT) volume and the presence of severe stenoses (SS) on coronary computed tomography angiography (CTA) for risk stratification of the patients with carotid artery stenoses. METHODS: We prospectively performed CTA for 125 consecutive patients (72.4 ± 8.1 years, 85% men) without a history of coronary artery disease (CAD), who were scheduled for carotid artery revascularization from 2014 to 2020. SS was defined as ≥70% luminal stenosis on CTA. EAT was quantified automatically as the total volume of tissue with -190 to -30 HU. RESULTS: Of 125 patients, 76 had SS. Between the patients with and without SS, there were significant differences in coronary artery calcium score (CACS), left ventricular ejection fraction (LVEF), dyslipidemia, and EAT, despite no differences in carotid echocardiography findings. After adjustment for age, gender, and dyslipidemia, EAT was an independent factor associated with SS (p=0.011), as well as CACS and LVEF. The addition of EAT to a baseline model including age, gender, dyslipidemia, LVEF, and CACS achieved both net reclassification improvement (0.505, p=0.003) and integrated discrimination improvement (0.059, p=0.003). CONCLUSIONS: In patients with carotid stenoses, EAT is associated with CAD and is useful for additional risk stratification. Epicardial fat may have a specific role in the development of CAD in patients with suspected systemic atherosclerosis.

BACKGROUND: In vestibular schwannoma (VS) patients treated with stereotactic radiosurgery (SRS), radiation-induced pseudoaneurysm is a rare long-term complication. To the best of our knowledge, there has been only one report of direct surgery in ruptured cases, and the optimal strategy for direct surgery is yet to be clarified. This case report describes a case of ruptured VS-related SRS-induced pseudoaneurysm that was successfully treated by direct surgery. CASE PRESENTATION: A 57-year -old man underwent SRS for VS, and the tumour was well controlled after the SRS. Nine years after the SRS, however, he developed subarachnoid haemorrhage, and a SRS-induced distal anterior inferior cerebellar artery aneurysm was detected on the surface of the tumour. During the trapping surgery, the aneurysm was embedded in the tumour, and it was difficult to separate the aneurysm and tumour. Besides, the facial nerve and tumour restricted exposure of the parent artery. The parent artery proximal to the aneurysm could only be exposed by resecting caudal part of the tumour. The aneurysm was trapped with permanent clips and it was pathologically diagnosed as pseudoaneurysm. CONCLUSION: It was suggested that the VS-related SRS-induced pseudoaneurysm is tightly adhered with surrounding structures and exposure of the parent artery could be limited due to the tumour and facial nerve. In this case report, we describe detailed intraoperative findings that will be useful for developing strategies for trapping surgery in future.

Pial arteriovenous fistulas (AVFs) are rare vascular lesions; their exact pathophysiology is largely unknown. Pial AVFs have been reported to develop within capillary malformation-arteriovenous malformation (CM-AVM); however, only a few cases have been reported. Variants in the RASA1 gene have been reported as a cause of CM-AVM. We report the case of an adult patient with pial AVF, who carried variants in the RASA1 and COL4A2 genes. The patient in the current report was likely to have been affected by CM-AVM and the RASA1 variant seemed to be the primary factor in the pathogenesis of pial AVF. However, COL4A2 may have also contributed to the development of pial AVF because the COL4A2 and RASA1 variants have a common pathophysiology, wherein the patient develops lesions due to collagen type IV deficiency.

<sec><title>Background</title>Thromboembolic complications (TECs) are frequent during the endovascular treatment of unruptured aneurysms. To prevent TECs, dual antiplatelet therapy using aspirin and clopidogrel is recommended for the perioperative period. In patients with a poor response, clopidogrel is a risk factor for TECs. To prevent TECs, our study assessed the stratified use of prasugrel. </sec><sec><title>Methods</title>Patients who underwent endovascular therapy for unruptured cerebral aneurysms from April 2017 to August 2019 were enrolled in this clinical study and given premedication with aspirin and clopidogrel for 2 weeks prior to the procedure. P2Y12 reaction units (PRU) were measured using the VerifyNow assay on the day before the procedure (tailored group). In subgroups with PRU &lt;240, the clopidogrel dose was maintained (CPG subgroup). In subgroups with PRU ≥240, clopidogrel was changed to prasugrel (PSG subgroup). We compared the occurrence of TECs with retrospective consecutive cases from January 2015 to March 2017 without PRU assessments (non-tailored group). The frequency of TECs within 30 days was assessed as the primary endpoint. </sec><sec><title>Results</title>The tailored and non-tailored groups comprised 167 and 50 patients, respectively. TECs occurred in 11 (6.6%) and 8 (16%) patients in the tailored and non-tailored groups (P=0.048), respectively. The HR for TECs was significantly reduced in the tailored group (HR 0.3, 95% CI 0.11 to 0.81); P=0.017) compared with the non-tailored group. </sec><sec><title>Conclusion</title>The results suggest that tailored dual antiplatelet therapy medication with PRU significantly reduces the frequency of TECs without increasing hemorrhagic complications. </sec>

Background The revascularization of carotid stenosis can increase ipsilateral cerebral blood flow (CBF). Occasionally, elevated CBF is also evident on the contralateral side, but this phenomenon is poorly understood. Objective To analyze retrospectively the relationship between a contralateral CBF increase and several clinical and radiologic features. Materials and methods We retrospectively analyzed 40 patients with unilateral cervical carotid stenosis treated by carotid artery stenting (CAS). Using 123 I-iodamphetamine single-photon emission computed tomography (SPECT) we compared pre-and postoperative hemispheric CBF on both sides. We investigated the influence of the following five factors on the increase of the contralateral hemispheric CBF: stenosis grade (≥50% or &lt 50%, according to the North American Symptomatic Carotid Endarterectomy Trial criteria) age the presence of anterior and posterior communicating arteries postoperative hyperperfusion on the stenotic side and the presence of cerebral steal phenomenon during preoperative acetazolamide-challenge SPECT. Results Following unilateral CAS, mean hemispheric CBF increased significantly on both sides: from 33.4±5.6 (mean ± SD) to 38.7±7.8 mL/min on the operated side (paired t test, p&lt 0.001) and f35.4±5.4 to 39.2±7.2 mL/min on the contralateral side (p&lt 0.001). In a general linear model, stenosis grade (≥50%) alone was significantly correlated with the increase of the CBF on the contralateral side (p=0.03). Conclusion Revascularization by CAS for unilateral carotid stenosis can increase hemispheric CBF on both sides. Increase of the contralateral CBF is correlated with stenosis grade (≥50%).

The safety and efficacy of emergency carotid artery stenting (CAS) for patients with acute ischemic stroke resulting from internal carotid artery stenosis are not established. In this retrospective study, we evaluated outcomes for CAS performed within 2 weeks of acute ischemic stroke for 16 patients treated between December 2009 and February 2014. Cases of internal carotid artery occlusion, internal carotid dissection, or intracranial major arterial trunk occlusion were excluded. Five patients were treated with CAS during the hyperacute phase (within 24 h of stroke onset), three in the advanced phase (within 24 h of stroke-in-evolution after admission), and eight in the acute phase (24 h to 2 weeks after onset). We evaluated modified Rankin scale (mRS) scores 90 days after CAS. For patients treated during the hyperacute phase without intravenous tissue-type plasminogen activator (IV-tPA), two had mRS scores of 2 and one had a score of 3. Two patients treated in the hyperacute phase with IV-tPA had scores of 5: one with symptomatic intracerebral hemorrhage and the other with acute brain swelling. For patients treated in the advanced phase, mRS scores were 1, 3, and 5; the patient with 5 had contralateral cerebral infarction. All patients treated in the acute phase had scores of 2 or lower. Patients treated with IV-tPA in advanced or acute phases had no severe post-CAS complications. CAS was effective and safe for treating ischemic stroke within 2 weeks of onset. However, IV-tPA treatment may be a risk factor for CAS treatment during the hyperacute phase.

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。

We report a rare case of concurrent aneurysmal subarachnoid hemorrhage (SAH) and acute aortic dissection (AAD). A 38-year-old man visited our hospital complaining of severe headache, and brain computed tomography (CT) revealed the presence of SAH. Thoracic to neck computed tomography angiography (CTA), performed in addition to brain CTA, suggested a tear in the aortic arch, and subsequent CT aortography established the diagnosis of Stanford type AAAD. The AAD in our patient, who reported no episodes of chest or back pain, was detected incidentally by thoracic to neck CTA. The imaging study has rarely been indicated for SAH except that it provides additional anatomical information in patients for whom extracranial-intracranial bypass surgery or endovascular treatment is considered. Nevertheless, our experience may highlight additional diagnostic value of thoracic to neck CTA in SAH patients.

Patient outcomes following grade V subarachnoid haemorrhage (SAH) have been dismal, although they may have improved following recent technological advances in endovascular treatment (EVT). A single-centre, retrospective study was conducted to evaluate whether outcomes have improved from 2000 to 2014 for patients with World Federation of Neurosurgical Societies (WFNS) grade V SAH. Coiling has been the preferred first-line treatment for grade V SAH patients in our institution since 2000. Patients who underwent EVT (n = 115) were grouped on the basis of their hospital admission year: 2000-2004 (n = 44), 2005-2009 (n = 37) and 2010-2014 (n = 34). Patient demographics, outcomes and in-hospital mortality rates were compared between the groups. Patient outcomes at discharge were evaluated using the Glasgow Outcome Scale (GOS), with GOS scores of 4-5 defined as favourable outcomes. There were no significant intergroup differences in patient demographics. In addition, there were no significant differences in the frequencies of favourable outcomes (14% in 2000-2004,16% in 2005-2009 and 26% in 2010-2014). Mortality rates were 52% in 2000-2004, 43% in 2005-2009 and 24% in 2010-2014, with a significantly lower mortality rate in 2010-2014 than in 2000-2004 (p = 0.01). Both perioperative rebleeding and delayed cerebral ischaemia decreased over time; however, multivariate regression analysis showed that the former contributed more to the decrease in mortality. Age was the only variable associated with favourable outcomes. The results of this study indicate that EVT is an appropriate therapeutic option for grade V SAH patients. However, multi-centre, prospective trials are required to provide evidence-based verification of the efficacy of EVT. (C) 2015 Elsevier Ltd. All rights reserved.

Background Tight coil packing with density of at least 20%-25% is known to be important for preventing recanalization after embolization of cerebral aneurysms. However, large aneurysms sometimes recanalize regardless of the packing density, suggesting that the absolute residual volume which is determined by aneurysm volume and packing density may be more important risk factor for recanalization. To validate this hypothesis, we analyzed the factors affecting the outcomes of treated aneurysms at our institute. Methods and Findings We included 355 small and large aneurysms. The following six factors were obtained from every case: aneurysm volume (mL), neck size (mm), packing density (%), residual volume (mL), rupture status at presentation, and stent assistance (with or without stent). The data were then subjected to multivariate logistic regression analysis to identify significant risk factors for recanalization. Recanalization occurred in 61 aneurysms (17.2%). Significant predictors for recanalization were aneurysm volume (odds ratio, 15.3; P &lt; 0.001) and residual volume (odds ratio, 30.9; P &lt; 0.001), but not packing density (odds ratio, 0.98; P = 0.341). These results showed that for each 0.1-mL increase in aneurysm volume and residual volume, the risk of recanalization increased by 1.3 times and 1.4 times, respectively. Conclusions The most influential risk factor for recanalization after coil embolization was residual volume, not packing density. The larger the aneurysm volume, the greater the packing density has to be to minimize the residual volume and risk of recanalization. Since tight coil packing has already been aimed, further innovation of coil property or embolization technique may be needed. Otherwise, different treatment modality such as flow diverter or parent artery occlusion may have to be considered.

Objective To improve bleeding management during brain tumor surgery, feeder arteries supplying the tumor are often embolized presurgically. However, access to feeder arteries can be limited, and embolization of feeders from internal carotid artery (ICA) branches often causes complications. We evaluated the PercuSurge GuardWire (Medtronic, Minneapolis, Minnesota, United States) system (PGWS) with aspiration catheter as amodification of the embolization technique used to block tumor-supplying branches of the ICA. Methods Two skull-base tumors were treated with preoperative embolization. One was a meningioma; the other was a hemangiopericytoma. In each case, the microcatheter could not be threaded into the ICA feeder arteries. Therefore, particulate embolic material was injected near the ICA branch while maintaining ICA balloon protection by the PGWS at the orifice of the ophthalmic artery. After embolization, we removed the remaining embolic material in the ICA using an aspiration catheter. In both cases, there were no postembolization complications and no high-intensity areas in the diffusion-weighted magnetic resonance image, and the tumorectomy proceeded as scheduled. Conclusion This modified technique may be a promising alternative for reducing embolic complications and improving the success rate, although case accumulation is needed to confirm this result.

When embolizing cerebral aneurysms, dense coil packing may prevent recanalization but this may be influenced by the aneurysm morphology. We have analyzed retrospectively the relationship between anatomic features and the volumetric coil packing density. We analyzed 452 aneurysms in 434 patients treated by coil embolization without stenting, expressing packing density as volume embolization ratio (VER, volume of inserted coils/aneurysm volume). Six morphological variables (neck width, height, maximum diameter, dome to neck ratio (DNR), and aspect ratio), aneurysm location, and whether the aneurysm was ruptured or unruptured were analyzed with respect to dense (VER a parts per thousand yen20 %) or loose (VER &lt; 20 %) packing densities, using logistic regression analysis and ROC analysis. Among 452 aneurysms, VERs &gt; 20 % were achieved for 272 aneurysms, with a mean VER of 24.7 %. The mean VER of the remaining 180 aneurysms was 15.6 %. In univariate analyses, the predictors for dense packing were having an anterior circulation, DNR, aspect ratio, and neck width. In multivariate analysis, the independent predictors were smaller neck width (odds ratio (OR) 0.8735; 95 % confidence interval (CI) 0.7635-0.9993) and larger aspect ratio (OR 1.6679; 95 % CI 1.0460-2.6594). ROC analysis showed optimal cutoff values for an aspect ratio of 1.35 (sensitivity 69.5 %, specificity 51.7 %) and a neck width of 3.13 mm (sensitivity 51.1 %, specificity 27.8 %). Although dense coil packing is still difficult to achieve in wide-necked aneurysms without the use of stents, packing with VER &gt; 20 % is expected to be achieved when the height is 1.35 times larger than the neck width.

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 &lt; 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 &lt; 0.001). Conclusion: To achieve VER &gt;= 20%, use of Infini coils significantly decreased the number of coils required per unit volume of a small aneurysm.

AimTherapeutic intervention to repair unruptured aneurysms (UA) has not been strongly recommended for the elderly, because of their limited life expectancy and low annual bleeding rate. However, physically and mentally healthy older adults with seemingly high risk of aneurysmal bleeding might benefit from having their UA repaired. MethodsA single-center retrospective study was carried out. Among 1078 patients admitted for treatment of UA between 2007 and 2011, the number of patients aged 75 years who underwent surgical and endovascular repair of UA was 30 and 31, respectively. The operative and mid-term outcomes were compared between the two groups. For evaluation of the operative outcomes, frequency and types of adverse events that occurred within 30 days of intervention (operative morbidity) were described. For assessment of the mid-term outcomes, activities of daily living (ADL) at 24 months after intervention were evaluated with the modified Rankin Scale (mRS). ResultsThe operative morbidity rate was 6.7% in the open surgery group and 6.5% in the endovascular surgery group, and they did not differ significantly. The frequency of patients with mRS 0-2 at 24 months after intervention was 85.7% in the open surgery group and 82.8% in the endovascular surgery group, and they did not differ significantly. The adverse event rate of patients with middle cerebral artery aneurysms treated endovascularly was high (80%). ConclusionsThe outcomes of individuals aged 75 years who underwent repair of UA were generally favorable in either treatment group, with more than 80% living an independent life at 24 months after intervention. Geriatr Gerontol Int 2014; 14: 858-863.

AimTherapeutic intervention to repair unruptured aneurysms (UA) has not been strongly recommended for the elderly, because of their limited life expectancy and low annual bleeding rate. However, physically and mentally healthy older adults with seemingly high risk of aneurysmal bleeding might benefit from having their UA repaired. MethodsA single-center retrospective study was carried out. Among 1078 patients admitted for treatment of UA between 2007 and 2011, the number of patients aged 75 years who underwent surgical and endovascular repair of UA was 30 and 31, respectively. The operative and mid-term outcomes were compared between the two groups. For evaluation of the operative outcomes, frequency and types of adverse events that occurred within 30 days of intervention (operative morbidity) were described. For assessment of the mid-term outcomes, activities of daily living (ADL) at 24 months after intervention were evaluated with the modified Rankin Scale (mRS). ResultsThe operative morbidity rate was 6.7% in the open surgery group and 6.5% in the endovascular surgery group, and they did not differ significantly. The frequency of patients with mRS 0-2 at 24 months after intervention was 85.7% in the open surgery group and 82.8% in the endovascular surgery group, and they did not differ significantly. The adverse event rate of patients with middle cerebral artery aneurysms treated endovascularly was high (80%). ConclusionsThe outcomes of individuals aged 75 years who underwent repair of UA were generally favorable in either treatment group, with more than 80% living an independent life at 24 months after intervention. Geriatr Gerontol Int 2014; 14: 858-863.

脳梗塞とクモ膜下出血を併発した前大脳動脈解離の1例を文献的考察と共に報告する。症例は既往に高血圧がある43歳女性。突然の失語・右片麻痺・意識障害を主訴に当院救急搬送された。来院時の頭部単純CTでクモ膜下出血を認め、造影CTでは左前大脳動脈領域のcerebral blood flow/cerebral blood volume低下と左A2描出不良を認めた。第1病日に施行されたDSAでは左recurrent artery of Heubner分岐直後から末梢にかけてpearl & string signを認め、以上の所見から梗塞・出血同時発症の左前大脳動脈解離と診断した。recurrent artery of Heubner領域の梗塞は生じていなかった。既に左前大脳動脈領域の梗塞巣が完成していた為、血行再建術は併用せずrecurrent artery of Heubnerを温存する形で血管内手術による母血管閉塞を施行した。術後は降圧による保存的治療を施行した。術後2週間のfollow up DSAで塞栓部近位側へ解離が進行している可能性が考えられたものの、recurrent artery of Heubner温存目的で追加塞栓は行わずにそのまま保存的治療を継続した。その後は解離の進行や再出血所見を認めず良好な経過を辿っている。前大脳動脈解離で脳梗塞とクモ膜下出血を併発する症例は稀であり、我々が調査し得た限りでは報告されているのは自験例を含めて16症例のみである。半数以上は保存的治療で良好な経過を辿っているが、同様の発症形式で外科的治療を必要とする再出血ハイリスク症例が存在する可能性がある。報告症例数の少ない現時点では困難だが、効果的な治療選択をする上で今後は症例の蓄積と共に再出血ハイリスク因子の同定が必要だと考えられた。(著者抄録)

Many epidemiological studies on unruptured cerebral aneurysms have reported that the larger the aneurysm, the higher the risk of rupture. However, many ruptured aneurysms are not large. Electrocardiography (ECG)-gated 3D-computed tomography angiography (4D-CTA) was used to detect pulsation in unruptured cerebral aneurysms. The differences in the clinical course of patients in whom pulsation was or was not detected were then evaluated. Forty-two patients with 62 unruptured cystiform cerebral aneurysms who underwent 4D-CTA and follow-up 3D-CTA more than 120 days later were studied. The tube voltage, tube current, and rotation speed were 120 kV, 270 mA, and 0.35 s/rot., respectively. ECG-gated reconstruction was performed, with the cardiac cycle divided into 20 phases. Patients with heart rates higher than 80 bpm were excluded, so 37 patients with 56 aneurysms were analyzed. Pulsation was detected in 20 of the 56 unruptured aneurysms. Of these 20 aneurysms, 6 showed a change in shape at the time of follow-up. Of the 36 aneurysms in which pulsation was not detected, 2 showed a change in shape at follow-up. There was no significant difference in the follow-up interval between the two groups. The aneurysms in which pulsation was detected were significantly more likely to show a change in shape (P = 0.04), with a higher odds ratio of 7.286. Unruptured aneurysms in which pulsation was detected by 4D-CTA were more likely to show a change in shape at follow-up, suggesting that 4D-CTA may be useful for identifying aneurysms with a higher risk of rupture.

The vascular type of Ehlers-Danlos syndrome (vEDS) is an autosomal dominant hereditary disease characterized by connective tissue fragility throughout the body, including the arteries, viscera, and gastrointestinal tract. We report a case in which we performed transvenous embolization (TVE) via direct superior ophthalmic vein (SOV) approach to treat a direct carotid-cavernous fistula (CCF) in a patient with Ehlers-Danlos syndrome (EDS). The patient was a 37-year-old woman who developed tinnitus in her left ear and a headache during examination in the outpatient clinic of another hospital in order to make a definitive diagnosis of vEDS, and she was referred to our hospital and examined. Based on the results of all of the studies she was diagnosed with a CCF. Conservative treatment was attempted, but was not very effective. Because of progressing aphasia, TVE was performed via the SOV direct cut. There were no intraoperative or postoperative complications. It has been reported that cerebral angiography is generally contraindicated in vEDS and that the morbimortality associated with endovascular treatment is very high. When performing treatment it is necessary to be sufficiently aware of the risks it entails.