Potential of machine learning to predict early ischemic events after carotid endarterectomy or stenting: a comparison with surgeon predictions.

Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are recommended for high stroke-risk patients with carotid artery stenosis to reduce ischemic events. However, we often face difficulty in determining the best treatment strategy. We aimed to develop an accurate post-CEA/CAS outcome prediction model using machine learning that will serve as a basis for a new decision support tool for patient-specific treatment planning. Retrospectively collected data from 165 consecutive patients with carotid stenosis underwent CEA or CAS and were divided into training and test samples. The following five machine learning algorithms were tuned, and their predictive performance was evaluated by comparison with surgeon predictions: an artificial neural network, logistic regression, support vector machine, random forest, and extreme gradient boosting (XGBoost). Seventeen clinical factors were introduced into the models. Outcome was defined as any ischemic stroke within 30 days after treatment including asymptomatic diffusion-weighted imaging abnormalities. The XGBoost model performed the best in the evaluation; its sensitivity, specificity, positive predictive value, and accuracy were 31.9%, 94.6%, 47.2%, and 86.2%, respectively. These statistical measures were comparable to those of surgeons. Internal carotid artery peak systolic velocity, low-density lipoprotein cholesterol, and procedure (CEA or CAS) were the most contributing factors according to the XGBoost algorithm. We were able to develop a post-procedural outcome prediction model comparable to surgeons in performance. The accurate outcome prediction model will make it possible to make a more appropriate patient-specific selection of CEA or CAS for the treatment of carotid artery stenosis.

Immunohistochemical detection of citrullinated histone H3-positive neutrophils is useful for identifying active glomerular and interstitial lesions in antineutrophil cytoplasmic antibody-associated vasculitis.

AIMS: Activated neutrophils release neutrophil extracellular traps (NETs), resulting in a form of cell death called NETosis. NET formation is reportedly involved in the onset of systemic lupus erythematosus and antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). Citrullination of histones is a key step in NET formation, and the presence of citrullinated histones in neutrophils may be associated with disease induction and activity. The aim of this study was to investigate the relationship between infiltrating citrullinated histone H3 (H3Cit)-positive neutrophils and disease specificity and activity in various glomerulonephritides. METHODS AND RESULTS: We selected 32 kidney biopsies with glomerulonephritides, including AAV, lupus nephritis (LN), Henoch-Schönlein purpura nephritis (HSPN), and poststreptococcal acute glomerulonephritis (PSAGN). We examined the presence of H3Cit in infiltrating neutrophils and their association with necrotising, crescentic lesions and tubulointerstitial lesions. In PSAGN and HSPN, we found many myeloperoxidase (MPO)+ neutrophils in glomeruli; however, only a few were H3Cit+. In LN, MPO+ neutrophils mainly existed in the margins of glomerular tufts forming wire-loop lesions, and some of these were noted to be H3Cit+ neutrophils. In contrast, we found a significantly higher frequency of H3Cit+ neutrophils, despite the small number of MPO+ neutrophils, in microscopic polyangiitis in AAV. In particular, H3Cit+ neutrophils were prominent in necrotising lesions along the glomerular capillaries. Moreover, we also found H3Cit+ neutrophils in the interstitium, with marked peritubular capillaritis in AAV. CONCLUSIONS: H3Cit immunostaining is a useful tool for identifying activated neutrophils. The frequency of H3Cit+ neutrophils is not only a disease-specific marker but also a potential marker for disease activity in AAV.

Stroke Systems of Care During the COVID-19 Epidemic in Kobe City.

BACKGROUND: The novel coronavirus disease 2019 (COVID-19) outbreak raised concerns over healthcare systems' ability to provide suitable care to stroke patients. In the present study, we examined the provision of stroke care in Kobe City during the COVID-19 epidemic, where some major stroke centers ceased to provide emergency care. METHODS: This was a cross-sectional study. The Kobe Stroke Network surveyed the number of stroke patients admitted to all primary stroke centers (PSCs) in the city between March 1 and May 23, 2020, and between March 3 and May 25, 2019. In addition, online meetings between all PSC directors were held regularly to share information. The survey items included emergency response system characteristics, number of patients with stroke hospitalized within 7 days of onset, administered treatment types (IV rt-PA, mechanical thrombectomy, surgery, and endovascular therapy), and stroke patients with confirmed COVID-19. RESULTS: During the period of interest in 2020, the number of stroke patients hospitalized across 13 PSCs was 813, which was 15.5% lower than that during the same period of 2019 (p = 0.285). The number of patients admitted with cerebral infarction, intracerebral hemorrhage, and subarachnoid hemorrhage decreased by 15.4% (p = 0.245), 16.1% (p = 0.659), and 14.0% (p = 0.715), respectively. However, the rates of mechanical thrombectomy and surgery for intracerebral hemorrhage were slightly increased by 12.1% (p = 0.754) and 5.0% (p = 0.538), respectively. PSCs that ceased to provide emergency care reported a decrease in the number of stroke cases of 65.7% compared with the same period in 2019, while other PSCs reported an increase of 0.8%. No case of a patient with stroke and confirmed COVID-19 was reported during the study period. CONCLUSION: Kobe City was able to maintain operation of its stroke care systems thanks to close cooperation among all city PSCs and a temporal decrease in the total number of stroke cases.

[Sellar and Parasellar Inflammatory Lesions with Impaired Visual Function:Clinical Features and Endoscopic Surgical Outcomes of Six Cases].

Accurate diagnosis and treatment of sellar and parasellar inflammatory lesions is difficult. We report six patients with sellar and parasellar inflammatory lesions and impaired visual function, who underwent endonasal endoscopic surgery. These patients included one with aspergillosis, one with hypertrophic pachymeningitis, one patient with abscess, and three with idiopathic granulomatous lesions. Following surgery and medication, visual function improved in patients with aspergillosis, hypertrophic pachymeningitis, and abscess. In patients with idiopathic granulomatous inflammation, visual function improved in one out of three patients. The treatment outcome for sellar and parasellar inflammatory lesions with impaired visual function depends on the surgery as well as on the reaction to postoperative medication. In the present study, the functional prognosis of patients with idiopathic granulomatous lesions was relatively poor when compared with that of patients with other inflammatory lesions.

Radiographic occult cerebellar germinoma presenting with progressive ataxia and cranial nerve palsy.

BACKGROUND: Although the usefulness of susceptibility-weighted imaging (SWI) for detecting basal ganglia germinoma has been reported, the technique is not widely used. We recently encountered an unusual case of primary cerebellar germinoma, presenting with progressive ataxia and cranial nerve palsy, characterized by gradually enlarging low-intensity lesions visible with both T2*-weighted imaging (T2*WI), which were the key to the diagnosis. CASE PRESENTATION: A 30-year-old man was referred to our hospital because of slowly progressive dizziness and mild ataxia. Magnetic resonance imaging (MRI) revealed a small, low-intensity spot in the left cerebellar peduncle on the T2*WI and SWI without enhancement. Cerebral angiography revealed no vascular abnormality. The serum α-fetoprotein value was normal. A steroid-pulse was administered as a therapeutic and diagnostic trial, but the symptoms improved little. The patient was discharged from the hospital but soon developed brainstem dysfunction, characterized by dyspnea or hiccups, and he was readmitted. T2*WI imaging revealed expanded and extended spotty lesions in the cerebellum and brainstem, which had not enhanced with contrast agent previously. Targeted stereotactic biopsy of the newly enhanced cerebellar lesion was performed; histopathological examination of the tissue revealed pure germinoma. Serum and cerebral spinal fluid values of beta-human chorionic gonadotropin were not significantly elevated. Chemotherapy with carboplatin and etoposide was initiated. The enhanced lesion disappeared promptly, but the patient continued to require assisted automatic ventilation because of paralysis of respiratory muscles. CONCLUSIONS: We conclude that enlarging low-intensity lesions on T2*WI and SWI may be a reliable clue to the diagnosis of germinomas, irrespective of their location, even without enhancement. Biopsy of the tumor at an early stage is the only way to make the diagnosis conclusively and enable prompt start of treatment.

Long-Term Outcomes of Carotid Endarterectomy and Carotid Artery Stenting for Carotid Artery Stenosis: Real-World Status in Japan.

BACKGROUND AND PURPOSE: We investigated long-term outcomes of carotid endarterectomy (CEA) and carotid artery stenting (CAS) in our institute to evaluate the outcomes of real-world practice in Japan. METHODS: Between August 2006 and July 2013, 203 consecutive carotid revascularizations with either CEA or CAS were performed in our institute. The initial treatment was regarded as the starting point in the cases of the patients who received treatment by bilateral carotid artery stenosis or retreatment. We assessed the long-term outcomes with survival analyses. RESULTS: A total of 182 patients (CEA 111, CAS 71), including 86 symptomatic patients, were included in the current study with a mean follow-up period of 42.9 months. The periprocedural stroke/death/myocardial infarction (MI) rate was 3.6% for CEA and 5.6% for CAS groups (P = .71). Estimates of the 4-year event-free rate from the primary end point (the composite of any stroke, death, or MI within 30 days, and any ipsilateral stroke thereafter) using competing risk analysis were 3.6% for CEA and 7.1% for CAS (P = .156). Kaplan-Meier estimates of the 4-year event-free rate from the secondary end point (the composite of any stroke, death, or MI within 30 days, and any stroke or death thereafter) were 13.8% for CEA and 19.1% for CAS (P = .072). Age was the only significant predictor for the primary end point. Both age and CAS were significant predictors for the secondary end point. CONCLUSIONS: The current study on real-world practices demonstrated perioperative and long-term outcomes that were comparable to previous major studies of large numbers of patients.

Cilostazol administration with combination enteral and parenteral nutrition therapy remarkably improves outcome after subarachnoid hemorrhage.

OBJECTIVE: In order to prevent cerebral vasospasm (VS) following aneurysmal subarachnoid hemorrhage (SAH), we introduced combined enteral nutrition (EN) and parenteral nutrition (PN) with oral cilostazol administration to the postoperative patient after SAH and investigated the effect on VS. METHODS: After aneurysmal SAH, 130 postoperative patients were enrolled in this study between April 2008 and March 2012. The patients enrolled before April 2010 were treated by conventional therapy (control group). The patients enrolled after April 2010 were administrated cilostazol 200 mg/day and received EN and PN simultaneously (combined group). RESULTS: The combined group consisted of 62 patients and the control group of 68 patients. Angiographic VS occurred in 33.9 % (n = 21) of the combined group and in 51.5 % (n = 35) of the control group (p = 0.051, Fisher exact test). The incidence of symptomatic VS was significantly lower in the combined group (p = 0.001). The incidence of new cerebral infarctions was also significantly lower in the combined group (p = 0.0006). Clinical outcome at discharge was also significantly better in the combined group than in control group (p = 0.031). CONCLUSIONS: Cilostazol administration with combination EN and PN is remarkably effective in preventing cerebral VS after aneurysmal SAH.

[Use of heparinized autologous blood for intraoperative rinsing and storage of vascular grafts].

UNLABELLED: In cerebral revascularization surgery in Japan, the preferred solution for rinsing and intraoperative storage of saphenous vein or radial artery grafts is a heparinized saline solution with albumin. On the other hand, most cardiac surgeons routinely use solutions of heparinized autologous blood during surgery. Here we used the latter type of solution for cerebral revascularization surgery and evaluated its efficacy. PATIENTS AND METHODS: Since December 2011, we have used heparinized autologous blood for saphenous vein grafts during cerebral revascularization surgery. For this, 20mL of the whole blood was obtained from an arterial line;this blood was then mixed with 20mL of a heparinized saline solution containing 500IU of heparin and 40mg of papaverine hydrochloride. The saphenous vein was harvested using standard procedures and immersed in the autologous blood solution just before implantation. RESULTS: Between December 2011 and March 2013, six revascularizations using saphenous vein grafts were performed using this solution. None of the anastomoses presented complications related to revascularization procedures, and all grafts were clearly present postoperatively. DISCUSSION: There is still no evidence that the storage in autologous blood is superior to the use of a saline solution with albumin. However, the national health insurance does not cover the use of albumin products, which carries an additional cost. Furthermore, the autologous blood medium is a red-colored solution that indicates the presence of unfavorable graft leaks when the wall of the graft turns red. CONCLUSION: We recommend the use of heparinized autologous blood for intraoperative rinsing and storage grafts.

Next-Generation Exoscopic Surgery Featuring a Head-Mounted 3-Dimensional Display for Carotid Endarterectomy: 2-Dimensional Operative Video.

Recent advancements in medical equipment have led to the use of exoscopes in neurosurgery, thereby replacing conventional operating microscopes.1,2 These devices enable surgeons to work comfortably, even in situations requiring a tilted visual axis, and their effectiveness in carotid endarterectomy (CEA) for carotid artery stenosis has been reported.3,4 However, the placement of 3-dimensional (3D) monitoring devices is challenging.3,4 To address this issue, we present a case in which CEA was performed using ORBEYE with a 3D head-mounted display. This device allows continuous 3D observation of the surgical field on the preocular screen. Case: A 79-year-old man who had undergone chemoradiotherapy for left maxillary cancer 5 years earlier was referred to our department to undergo treatment for left internal carotid artery stenosis. Computed tomography angiography revealed severe left internal carotid artery stenosis with hypoechoic vulnerable plaques on carotid ultrasound. Carotid artery stenting was considered to be a better option than CEA. However, CEA yields better outcomes, especially in patients with vulnerable soft plaques.5 Left CEA was performed using ORBEYE with a 3D head-mounted display (HOGY Medical Co., Ltd.). The procedure was successfully performed under the observation of the head-mounted display, from skin incision to closure. Postoperatively, the patient had no neurological deficits but experienced transient hoarseness. Using an exoscope under the guidance of a head-mounted display represents a next-generation surgical technique that overcomes the limitations of traditional exoscopic surgery. The patient consented to the procedure, and the participants and any identifiable individuals consented to publication of his/her image. Our institutional review board approved this publication (#B230184).

Acute morphological changes of impending rupture of vertebral artery dissection: clinical management of symptomatic but unruptured vertebral artery dissection. Illustrative case.

BACKGROUND: The reported actual risk of rupture for vertebral artery dissection (VAD) in patients presenting with headache is very low, ranging from 0.4% to 1.0%. The authors report a case in which the dissection site dilated rapidly within several hours after the dissection occurred resulting in subarachnoid hemorrhage (SAH). OBSERVATIONS: A 49-year-old healthy man who had participated in a marathon noticed a headache while running. Magnetic resonance imaging (MRI) performed 2 days later revealed no findings suspicious for right VAD, but a string sign was observed in the left side, suggesting left VAD. Three hours following MRI, he developed severe headaches and became unconscious at home, prompting emergency services to rush him to the hospital. A computed tomography scan showed diffuse SAH and a rapidly enlarged aneurysmal dilatation in the right vertebral artery. He underwent endovascular internal trapping to prevent rebleeding. He was discharged without any neurological symptoms. No recurrence or new dissection occurred after 2 years of follow-up. LESSONS: Even in the absence of typical imaging findings, strict management, such as blood pressure control, is required when clinical findings strongly suggest VAD, and differentiation of VAD from primary headache is important. https://thejns.org/doi/10.3171/CASE24202.

Stereotactic radiotherapy of radiation-induced meningioma previously irradiated retrobulbar for Graves' ophthalmopathy: A case report.

A 69-year-old woman was diagnosed with an asymptomatic intracranial tumor nine years ago and has been followed with annual MR imaging studies. Two years ago, the tumor had grown in size, requiring treatment. She experienced ophthalmopathy due to hyperthyroidism 27 years ago and was treated with 20 Gy in 10 fractions using parallel opposed beams to her bilateral posterior eyeballs, supplemented with steroid pulse therapy. The tumor originated in the medial aspect of the right sphenoid border and compressed the temporal lobe, while bone infiltration was observed, partially extending to the soft tissue outside the maxillary sinus. The tumor was removed by craniotomy. The pathological diagnosis was atypical meningioma (WHO grade II). Four months postsurgery, the resection cavity's tumor exhibited growth inclination, necessitating Gamma Knife radiosurgery. Radiation planning was executed at a marginal tumor dose of 30 Gy in 5 fractions. Since the optic nerve had been previously exposed to radiation, a plan was devised to minimize radiation exposure. The dose on the optic nerve was limited to 6.9 Gy in 5 fractions. She did not experience any visual or visual field disruptions postradiation. This is a case of radiation-induced meningioma resulting from radiation therapy for Graves' ophthalmopathy and is the first reported case of a grade II meningioma. The patient's condition calls for adjuvant radiation therapy following surgical removal. Accordingly, a radiation treatment plan that safeguards the optic nerve, which was previously exposed to radiation, was deemed indispensable.

Expression of EGFR and p16 in Squamous Cell Carcinoma of External Auditory Canal.

The expression of EGFR and p16 in the external auditory canal squamous cell carcinoma (EACSCC) and their impacts on oncological outcomes were not well studied. Seventeen-one consecutive patients who were treated for EACSCC at Kobe University Hospital from 1995 to 2018 were enrolled in this study. The expression of EGFR, and p16 were evaluated and their impacts on oncological outcomes were statistically analyzed. Positive expression of EGFR was observed in 62 patients (87%). Strong positive expression of p16 were observed in 18 patients (32.4%), and weakly positive expression in 30 patients (42.3%), respectively. While the number of the patients with negative EGFR expression were limited, all the surgically treated patients with negative EGFR expression have been alive without disease. In the patients with T3 & T4a EACSCC, prognosis of the patients with positive p16 expression EACSCC tended to be better than those with negative p16 expression. These results suggest the clinical significance of EGFR and p16 expressions in the patients with advanced EACSCC to predict oncological outcomes.

A vertebrobasilar junction aneurysm successfully treated with a combination of surgical clipping and flow diverter placement based on the results of computational fluid dynamics analysis: illustrative case.

BACKGROUND: The treatment of vertebrobasilar junction (VBJ) aneurysms is challenging. Although flow diverters (FDs) are a possible treatment option, geometrical conditions hinder intervention. VBJ aneurysms possess dual inflow vessels from the bilateral vertebral arteries (VAs), one of which is ideally occluded prior to FD treatment. However, it remains unclear which VA should be occluded. OBSERVATIONS: A 75-year-old male with a growing VBJ complex aneurysm exhibiting invagination toward the brainstem and causing perifocal edema required intervention. Preoperative computational fluid dynamics (CFD) analysis demonstrated that left VA occlusion would result in more stagnant flow and less impingement of flow than right VA occlusion. According to the simulated strategy, surgical clipping of the left VA just proximal to the aneurysm was performed, followed by FD placement from the basilar artery trunk to the right VA. The patient demonstrated tolerance of the VA occlusion, and follow-up computed tomography angiography at 18 months after FD treatment confirmed the disappearance of the aneurysm. LESSONS: Preoperative flow dynamics simulations using CFD analysis can reveal an optimal treatment strategy involving a hybrid surgery that combines FD placement and direct surgical occlusion for a VBJ complex aneurysm.

A Case of Olfactory Neuroblastoma Developing Bilateral Retropharyngeal Lymph Node Metastasis 14-years After Skull Base Surgery.

Olfactory neuroblastoma (ONB) is an uncommon malignant tumor and is usually treated by a multidisciplinary approach includes surgery, radiotherapy, and chemotherapy. A 62 years-old male had a tumor in the nasal cavity and diagnosed as ONB with Kadish A stage. Anterior skull base surgery was performed as radical treatment. Since the surgical margin was negative, no postoperative radiotherapy was administered. 14 years after the surgery, bilateral otitis media with effusion (OME) was occurred, we found the recurrence tumor at bilateral retropharyngeal lymph node (RPLN) which surrounded the internal carotid arteries. Since these were unresectable, we planned chemoradiotherapy which was 70Gy of intensity modulated radiotherapy combined with two courses of carboplatin and etoposide. The tumor volume was reduced and bilateral OME were improved. He has been alive for 3 years after salvage treatment. Although ONB has a relatively good prognosis, it is known to often cause cervical lymph node metastasis. Grades III and IV of Hyams classification are considered high risk. This case, initial tumor was limited in the nasal cavity and its clinical classification was early stage, but Hyams classification was grade III. In reference to this case, considering that RPLN metastasis are difficult to radically resect at the salvage surgery, including this area in postoperative radiotherapy was considered an option.

Combined transarterial and transvenous embolization of anterior cranial fossa dural arteriovenous fistula.

Background: Excessive glue injection into the drainage vein in patients with dural arteriovenous fistula (dAVF) can result in venous obstruction. We performed transarterial embolization (TAE) combined with transvenous embolization (TVE) with coils to prevent the glue from migrating into the normal cortical veins. Case Description: A 57-year-old man was pointed out to have a Borden Type III anterior cranial fossa dAVF during a check-up for putaminal hemorrhage. Because a left frontal normal cortical vein drained into the pathological drainage vein, excessive glue injection into the drainage vein may have caused venous obstruction. We performed TVE with coils at the foot of the draining vein to prevent excessive migration of glue into the drainer, followed by TAE with glue. With this technique, complete obliteration of the shunt without venous ischemia was obtained. Conclusion: The combined treatment of TAE and TVE is effective in preventing venous ischemia caused by unintended migration of glue cast into the drainage vein.

Introducing next-generation transcranial surgery with the head-mounted 3D View Vision display in extracorporeal microsurgery: illustrative cases.

BACKGROUND: Exoscopy in neurosurgery offers various advantages, including increased freedom of the viewing axis while the surgeon maintains a comfortable upright position. However, the optimal monitor positioning to avoid interference with surgical manipulation remains unresolved. Herein, the authors describe two cases in which a three-dimensional head-mounted display (3D-HMD) was introduced into a transcranial neurosurgical procedure using an exoscope. OBSERVATIONS: Case 1 was a 50-year-old man who presented with recurrent epistaxis and was diagnosed with an olfactory neuroblastoma that extended from the nasal cavity to the anterior cranial base and infiltrated the right anterior cranial fossa. Case 2 was a 65-year-old man who presented with epistaxis and was diagnosed with a left-sided olfactory neuroblastoma. In both cases, en bloc tumor resection was successfully performed via a simultaneous exoscopic transcranial approach using a 3D-HMD and an endoscopic endonasal approach, eliminating the need to watch a large monitor beside the patient. LESSONS: This is the first report of using a 3D-HMD in transcranial surgery. The 3D-HMD effectively addressed issues with the field of vision and concentration while preserving the effectiveness of traditional microscopic and exoscopic procedures when observed on a 3D monitor. Combining the 3D-HMD with an exoscope holds the potential to become a next-generation surgical approach.

Incidence and Outcomes of Aneurysmal Subarachnoid Hemorrhage: A Multicenter Retrospective Registry-based Descriptive Trial in Kobe City.

The current study aims to evaluate the incidence and results of aneurysmal subarachnoid hemorrhage (aSAH) throughout Kobe City. Based on a multicenter retrospective registry-based descriptive trial involving all 13 primary stroke centers in Kobe City, patients with aSAH treated between October 2017 and September 2019 were studied. A total of 334 patients were included, with an estimated age-adjusted incidence of 11.12 per 100,000 person-years. Curative treatment was given to 94% of patients, with endovascular treatment (51%) preferred over surgical treatment (43%). Of the patients, 12% were treated by shunt surgery for sequential hydrocephalus with a worse outcome at 30 days or discharge (14% vs. 46%, odds ratio (OR): 0.19, 95% confidence interval (CI): 0.088-0.39, p-value <0.001). As for vasospasm and delayed cerebral ischemia, most patients were given intravenous fasudil infusion (73%), with endovascular treatment for vasospasm in 24 cases (7.2%). The fasudil group had more good outcomes (42% vs. 30%, OR: 1.64, 95% CI: 0.95-2.87, p-value = 0.075) and significantly less death (3.3% vs. 35%, OR: 0.064, 95% CI: 0.024-0.15, p-value <0.001) at 30 days or discharge. Mortality rose from 12% at 30 days or discharge to 17% at 1 year, but neurological function distribution improved over time (modified Rankin Scale 0-2 was 39% at 30 days or discharge, 53% at 60 days, and 63% at 1 year). Our retrospective registered trial presented various statistics on aSAH, summarizing the current treatment status and prognosis.

Unilateral Approach for Bilateral Middle Cerebral Artery Aneurysms Assisted by Preoperative Understanding of Aneurysm Wall Properties: Two-Dimensional Operative Video.

Unruptured middle cerebral artery (MCA) aneurysms often exist bilaterally, and a unilateral approach for bilateral MCA aneurysms has been reported; however, this remains challenging because there are various technical nuances.1-4 Wall properties have been reported to be an important issue for this strategy.2,3 Atherosclerotic changes in the aneurysm wall can make clipping difficult. We present a video case demonstrating clipping of bilateral MCA aneurysms via a unilateral craniotomy assisted by preoperative understanding of the aneurysm wall properties using computational fluid dynamic analysis (Video 1). A 71-year-old woman had bilateral MCA bifurcation aneurysms. The oscillatory shear index color map by computational fluid dynamic analysis demonstrated that the contralateral MCA aneurysm did not have a high oscillatory shear index area in the dome, which means that there was no wall thickening, and the ipsilateral MCA aneurysm had scattered high oscillatory shear index areas, which were expected to have extreme wall thickening.5 After pterional craniotomy, the sylvian fissure was widely opened. As expected, the contralateral MCA aneurysm did not have a thick-walled region, enabling simple neck clipping using a straight clip. In contrast, the ipsilateral MCA aneurysm had thick-walled areas, as predicted, necessitating a multiple clip application. Postoperatively, the patient was discharged without any neurological deficits. Prediction of aneurysm wall properties using computational fluid dynamic analysis could assist in determining clippability of intracranial aneurysms, especially for aneurysms approached by narrow and deep surgical fields, such as contralateral MCA aneurysms. The patient consented to the procedure and the publication of their images.

Fatal Fungal Aneurysm Rupture Due to Aspergillosis after Craniopharyngioma Removal via Endoscopic Endonasal Surgery: Case Report and Comparison with Seven Reported Patients.

There has been a noted increase in the incidence of intracranial aspergillosis; this is often attributed to the wider use of antibiotics, corticosteroids, and immunosuppressants. Fungal cerebral aneurysms due to aspergillosis after neurosurgery remain extremely rare; in fact, only seven cases have been reported in the literature. In this study, we present a patient with an Aspergillus aneurysm that elicited subarachnoid hemorrhage after endoscopic endonasal surgery (EES) for craniopharyngioma. A 70-year-old woman with recurrent craniopharyngioma and steroid treatment underwent uneventful EES. On the 5th postoperative day, she suffered subarachnoid hemorrhage. As per her computed tomography angiography findings, an aneurysm was detected on the left internal carotid artery (ICA). Subsequent digital subtraction angiography showed occlusion of the ICA and an irregularly shaped wall. The diagnosis was pseudoaneurysm. We then performed craniotomy to place a left high-flow bypass and to trap the pseudoaneurysm. Despite continuous intensive care, she died on the 25th postoperative day of a huge, left cerebral infarct. The final diagnosis was made at autopsy; it revealed destruction of the ICA and Aspergillus invasion of the vessel wall, confirming the presence of a true fungal aneurysm. Perioperatively, patients with potential immunosuppression must be carefully managed. Advanced age is a risk factor. As surgery via the paranasal sinuses raises the risk for aspergillosis, fungal infection must be ruled out in patients whose postoperative course is deemed concerning.

Efficacy of a High-definition Three-dimensional Exoscope in Simultaneous Transcranial and Endoscopic Endonasal Surgery: A Case Report.

Owing to recent advances in medical optical technology, a high-definition (4K) three-dimensional (3D) exoscope has been developed as an alternative tool to using conventional microscopes for microscopic surgery, and its efficacy for neurosurgery has been reported. We report a case who underwent simultaneous surgery aiming for en bloc resection of an anterior skull base malignancy with concurrent exoscopic transcranial and endoscopic endonasal approaches using a 4K 3D exoscope. The patient was a 76-year-old woman who underwent en bloc resection for an anterior skull base olfactory neuroblastoma 13 years ago. After confirming the recurrence of progressive olfactory neuroblastoma, tumor resection was again decided to be performed. As with the first procedure, surgery was performed in an en bloc manner, using both transcranial and endonasal approaches. Exoscope provided enough space above the surgical field to allow us to perform transcranial and endonasal surgeries simultaneously. Moreover, the surgeons could maintain a comfortable posture throughout the procedure, and total tumor removal was successfully achieved without any abnormal event. To our knowledge, this is the first report of the introduction of an exoscope aiming for en bloc resection of an anterior skull base malignancy while performing simultaneous surgery with both transcranial and endonasal approaches. We believe that the more cases are accumulated, the more efficacy of a 4K 3D exoscope will be elucidated.