Intra- and Extra-Articular Deformity of Lower Limb: Tibial Condylar Valgus Osteotomy (TCVO) and Distal Tibial Oblique Osteotomy (DTOO) for Reconstruction of Joint Congruency.

Osteotomies are the established surgical procedure for the deformity of the lower limb induced by osteoarthritis (OA) of the knee and ankle. Closed-wedge (CW) and open-wedge (OW) high tibial osteotomy (HTO) are extra-articular surgery, which aim to shift the mechanical axis from medial to slightly lateral and reduce the overload in the medial compartment of the varus deformed knee by extra-articular correction. However, varus deformity of the knee with the teeter effect, which could be accompanied with subluxation and thrust due to the medial-lateral soft tissue imbalance, is not resolved only by the shift of mechanical axis. The depression of the medial tibia plateau, so-called pagoda deformity, is the intra-articular deformity, which could potentially cause the teeter effect and involves intra-articular incongruency. In such case, the osteotomy with novel concept should be developed to overcome the issues, both the imbalance of soft tissue and intra-articular deformity. Tibial condylar valgus osteotomy (TCVO) is an intra-articular osteotomy, which improves the joint congruency of the medial-compartment knee OA with subluxation and/or intra-articular deformity and also provides better joint stability. A similar argument is raised in the treatment of the ankle OA. Low tibial osteotomy (LTO) is an extra-articular surgery to correct malalignment of lower leg. Distal tibial oblique osteotomy (DTOO) is a novel surgery to improve the bony congruency of the ankle OA. In DTOO, the distal tibia is cut obliquely from the proximal medial to the distal lateral in the coronal plane and towards the center of the tibiofibular joint to improve the bony congruency of the ankle joint. Tibial condylar valgus osteotomy (TCVO) and distal tibial oblique osteotomy (DTOO) can correct intra-articular deformity of knee and ankle, respectively. The rationale and indication of TCVO and DTOO for the treatment of the lower limb by reconstructing the joint congruency are discussed.

Fistula of the posterior communicating artery and cavernous sinus.

A 24-year-old man was admitted with conjunctival hyperemia of the left eye and progressive chemosis and proptosis 1 month after a head injury. An angiogram showed an arterial-cavernous sinus fistula of the posterior communicating artery, which was treated with minicoils. The atypical configuration, transvenous embolization, and unusual nature of the communication suggested that communication developed through a newly generated vessel in granulation tissue.

Direct thrombosis of a pseudoaneurysm after obliteration of a carotid-cavernous fistula with cellulose acetate polymer: technical case report.

A 55-year-old man who suffered a head injury resulting in a left traumatic carotid-cavernous fistula was successfully treated with an intravascular detachable balloon. A pseudoaneurysm formed adjacent to the balloon. Seven months after the initial procedure, treatment with cellulose acetate polymer, a new liquid thrombotic material, occluded the pseudoaneurysm and preserved the internal carotid artery.

Surgical treatment of moyamoya disease: operative technique for encephalo-duro-arterio-myo-synangiosis, its follow-up, clinical results, and angiograms.

Moyamoya syndrome is defined as the development of collateral anastomosis pathways at the base of the brain, associated with chronic progressive stenosis of the carotid fork. Both reconstructive vascular surgery and conservative strategies are used to treat this syndrome, but the latter cannot prevent the disease from progressing. We describe the procedure of encephalo-duro-arterio-myo-synangiosis (EDAMS), and report the results in 17 patients (28 sides) who underwent EDAMS. The clinical symptoms of moyamoya disease include transient ischemic attacks, reversible ischemic neurological deficits, stroke, seizures, Gerstmann's syndrome, involuntary movements, or mental retardation resulting from the lack of cerebral blood flow. The clinical results of EDAMS were poor in one patient, fair in two, good in five, excellent in eight, and fair on one side and excellent on the other side in one patient. Postoperative angiograms showed widespread collateral circulation on the ischemic brain surface in patients undergoing EDAMS.

Embolization of cerebral arteriovenous malformations with cellulose acetate polymer: a clinical, radiological, and histological study.

OBJECTIVE: A cellulose acetate polymer (CAP) solution was hypothesized to be useful for the embolization of arteriovenous malformations (AVMs). To investigate this possibility, we analyzed the clinical, radiological, and histological results of patients with AVMs embolized by using a CAP solution. METHODS: We reviewed the cases of 11 patients with AVMs treated by embolization before surgical resection. We used two types of CAP solutions, CAP-M and CAP-L, which are mixtures of 250 mg of solid CAP and 1800 or 2250 mg of bismuth trioxide dissolved in 5.5 or 7.0 ml of dimethyl sulfoxide, respectively. After the embolization procedure, percent reduction of the nidus volume was measured, and thereafter, the clinical course and computed tomographic scans and/or magnetic resonance imaging scans were evaluated. All patients underwent surgical resection 1 to 51 days after embolization. Resected specimens were stained for light microscopic examination. RESULTS: Thirty-nine feeding vessels were embolized. The reduction rate of the nidus volume ranged from 20% to nearly 100%. Transient and persistent ischemic deficits occurred in three patients and one patient, respectively, and there were no hemorrhagic complications. All AVMs but one were completely resected by surgery. The embolized AVMs were soft enough to be easily cut and retracted. The histological examinations disclosed no or mild inflammatory reactions within 2 weeks after embolization. The internal elastic lamina was preserved in every case. Recanalization through the cast of the CAP mass was not observed until 51 days after embolization. CONCLUSION: CAP solution is a safe and useful embolic agent for AVMs.

Cellulose acetate polymer thrombosis for the emergency treatment of aneurysms: angiographic findings, clinical experience, and histopathological study.

Cellulose acetate polymer solution is a liquid thrombotic material that hardens into the shape of an aneurysm into which it is injected. Therapy using this solution is a rapid technique that helps prevent the rupture of aneurysms, especially those that extravasate contrast material during angiography in the acute stage of subarachnoid hemorrhage. Using this polymer solution and an endovascular technique, we treated two patients who had aneurysms of the basilar and anterior communicating arteries with extravasation of contrast material during angiography a few hours after the initial subarachnoid hemorrhage. In one patient with an aneurysm of the anterior communicating artery, the aneurysm's wall was perforated with the catheter during neurointerventional procedures. In both patients, postoperative angiograms demonstrated obliteration of the aneurysmal dome, including the site of extravasation or perforation. The parent artery and surrounding perforating branches were preserved. Although we do not advocate aggressive therapy for patients who bleed during angiography, we pursued this therapy in these two patients because of the opportunity to introduce cellulose acetate polymer in an attempt to preserve the patients' lives. Unfortunately, both patients died. Histopathological studies performed at the time of autopsy demonstrated that the luminal surface of cellulose acetate polymer was covered with thrombus by 6 days after cellulose acetate polymer thrombosis. By 10 days, the thrombus had a prominent fibrin network, a concentrated plasma component, and few fibrocytes adhering to its luminal surface.(ABSTRACT TRUNCATED AT 250 WORDS)

Partial thrombosis of canine carotid bifurcation aneurysms with cellulose acetate polymer.

OBJECTIVE: To investigate the usefulness of a cellulose acetate polymer (CAP) solution for partial thrombosis of aneurysms. METHODS: We created 14 canine cervical carotid bifurcation aneurysms, 11 of which were subsequently thrombosed partially with CAP solution. We then conducted angiographic and histological investigations. RESULTS: Nine aneurysms were thrombosed 50 to 70% by volume, although a significant crescent crevice between the aneurysmal sac and the CAP mass was left in four of the aneurysms. In the remaining two aneurysms in which a crescent crevice had been seen in the initial stage of CAP injection, 80% and more than 95% thrombosis were needed to occlude the crevice, respectively. Follow-up angiograms of the seven aneurysms with no crescent crevice revealed no shifts of position of the CAP mass toward the bottom of the aneurysm sac, but slight ballooning of the remnants was observed in two of them. The angiograms of the other four aneurysms with significant crescent crevices demonstrated rupture with a massive hematoma in one and shifts of the CAP mass with marked enlargement of remnants in three. Histologically, the seven aneurysms with no enlarged remnants had newly developed membranes consisting of endothelium, infiltrated spindle-shaped cells, collagen, and elastic fibers. In contrast, in the three markedly enlarged aneurysms, there were only recent clots between the CAP mass and the aneurysm lumen and no development of endothelium. CONCLUSION: Partial thrombosis with CAP solution is useful to keep aneurysms in a stable configuration, unless a crescent crevice has been left.

Prophylactic thrombosis to prevent new bleeding and to delay aneurysm surgery.

Six aneurysms in five patients with acute aneurysmal subarachnoid hemorrhages were treated with direct thrombosis using cellulose acetate polymer within 4 hours of rupture. The aneurysms involved the internal carotid and posterior communicating arteries (two patients), the anterior choroidal artery (one patient), the bifurcation of the basilar artery (one patient), and the middle cerebral artery (two patients). Four patients underwent aggressive volume expansion after direct thrombosis with cellulose acetate polymer. The aneurysms remained thrombosed until operations on the necks were performed 2 to 7 weeks after the subarachnoid hemorrhages. Three patients were given intrathecal tissue plasminogen activator. One patient, who remained at neurological Grade V, was not treated surgically and died from cardiac failure. Five aneurysms in the remaining four patients were successfully clipped. These preliminary data suggest that immediate aneurysmal thrombosis, then aggressive preoperative prophylactic volume expansion and/or administration of intrathecal tissue plasminogen activator, can help prevent new bleeding and reduce delayed cerebral ischemia in patients after aneurysmal subarachnoid hemorrhages.

Contralateral external carotid-to-middle cerebral artery graft using the saphenous vein. Case report.

A variation of the extracranial-intracranial arterial bypass, using a long saphenous vein graft, is presented. The saphenous vein graft was inserted from the contralateral external carotid artery to the distal middle cerebral artery to replace the common and internal carotid arteries in a patient with a large neck tumor that invaded the common and internal carotid arteries, the esophagus, and the trachea. The patient had a positive balloon Matas' test. The saphenous vein was covered with an artificial vascular graft so that turning of the head or movement of the mandible did not displace or compress the graft. A large volume of flow began immediately after anastomosis. A description of the case and the operative technique is presented herein.

Direct thrombosis of aneurysms with cellulose acetate polymer. Part I: Results of thrombosis in experimental aneurysms.

The authors have developed a liquid material for thrombosing aneurysms. This material is a mixture of cellulose acetate polymer and bismuth trioxide dissolved in dimethyl sulfoxide. On contact with blood, the dimethyl sulfoxide diffuses and cellulose acetate polymer forms, which balloons when slowly injected into the blood. The polymer solidifies from surface to core in 5 minutes. Cellulose acetate polymer was injected directly into experimental aneurysms created in 10 dogs; it rapidly hardened in the shape of the aneurysms, completely obliterating them but preserving the parent vessels in all cases. No distal migration of the polymer was seen. The good results of this experimental trial led to a clinical study using a cellulose acetate polymer, as described in Part II.

Superficial temporal artery interposition graft after resection of bilateral anterior cerebral arteries. Case report.

A patient with an olfactory neuroblastoma in the frontal skull base was treated with primary tumor excision and partial resection of the A2 segment of both anterior cerebral arteries (ACA's). Revascularization was carried out using a superficial temporal artery (STA) interposition graft between the proximal and distal stumps with A3 segment-to-A3 segment end-to-side anastomosis. This technique established flow to the peripheral territories of the ACA's through the interposed STA graft. The technical aspects and possible role of this procedure are presented.

Direct thrombosis of experimental aneurysms with cellulose acetate polymer (CAP): technical aspects, angiographic follow up, and histological study.

Experimental aneurysms were created using a microsurgical technique to produce anastomosed venous pouches in the bilateral common carotid arteries of 12 dogs. The 24 aneurysms were then thrombosed via an endovascular approach with injection of a cellulose acetate polymer (CAP) solution that the authors have developed for use as a liquid thrombotic material. Angiography performed 1 to 4 weeks after CAP injection revealed complete thrombosis of the aneurysm with patency of the parent artery in 16 aneurysms. Histological analysis disclosed that the aneurysmal orifice in these cases was completely covered with newly formed endothelial cells 2 weeks after CAP thrombosis. Three other aneurysms exhibited parent artery occlusion caused by protrusion of the CAP mass through the aneurysmal orifice into the parent artery; this was thought to be caused by over-injection of the CAP solution. Histological analysis of the remaining five aneurysms, initially shown to have incomplete occlusion, revealed that they each possessed a residual neck that was partially covered with endothelial cells. No rupture of the aneurysms or migration of CAP into the distal arteries was observed. These results suggest that using an endovascular approach, direct thrombosis of cerebral aneurysms with CAP is safe and effective. This technique may prove to be an alternative treatment for such aneurysms. However, there is a potential risk of regrowth or rupture of aneurysms that retain a residual neck and long-term follow-up studies will be required to evaluate this issue.

Direct thrombosis of aneurysms with cellulose acetate polymer. Part II: Preliminary clinical experience.

The authors report the treatment of seven intracranial aneurysms in six patients with direct infusion of cellulose acetate polymer solution, a new liquid thrombotic material. These aneurysms were considered inoperable because of their size or location, or because of the patient's neurological condition. This material avoids the difficulties associated with balloon occlusion, and completely fills even irregularly shaped aneurysms. Cellulose acetate polymer solution hardens in about 5 minutes and remains solid once inside the aneurysm. Because this technique is less invasive than surgery, it can be used for high-risk patients in the acute stage of subarachnoid hemorrhage. Transient motor aphasia occurred in one patient. A small residual neck, which caused rebleeding 3 months after the treatment, remained in another patient. This article describes the new material, the procedure for direct thrombosis, and preliminary clinical results.

Meningiomas arising from the falcotentorial junction. Clinical features, neuroimaging studies, and surgical treatment.

Meningiomas arising from the falcotentorial junction are extremely rare. The authors describe the clinical features, neuroimaging studies, and results of surgical treatment of meningiomas of the falcotentorial junction and clarify the characteristics of this lesion based on a review of the literature and seven patients treated at their institution. The most common symptoms resulted from intracranial hypertension. Upward-gaze palsy appeared in only one patient. Computerized tomography (CT) showed no specific findings, but there was no evidence of edema around the tumor. Magnetic resonance (MR) imaging revealed a round, smooth-bordered mass with a peritumoral rim, without edema, and showing marked contrast enhancement. The multiplanar capability of MR imaging delineated the relationship between the tumor and adjacent structures better than did CT. Detailed knowledge of the vascular structures, especially evidence of occlusion of the galenic venous system and the development of collateral venous channels, is critical for successful surgery; stereoscopic cerebral angiography is necessary to achieve this aim. The seven patients described developed five types of collateral venous channels: through the basal vein of Rosenthal to the petrosal vein, through the veins on the medial surface of the parietal and occipital lobes to the superior sagittal sinus, through superficial anastomotic veins, through veins of the posterior fossa to the transverse or straight sinus, and through the falcian veins to the superior sagittal sinus. The first three types mainly developed after occlusion of the galenic system. The tumors were removed through the occipital transtentorial approach with a large window at the posterior part of the falx. A favorable prognosis for patients undergoing surgical treatment of falcotentorial junction meningiomas can be expected if detailed neuroimaging studies and microsurgical techniques are used.

Early treatment of subarachnoid hemorrhage after preventing rerupture of an aneurysm.

Twelve patients with Hunt and Hess neurological Grades III to V underwent thrombosis of aneurysms using cellulose acetate polymer within 23 hours of aneurysm rupture. On computerized tomography (CT), nine of these patients had difuse or localized thick subarachnoid blood clots, two had diffuse thin clots and one had intraventricular clots. Immediately after thrombosis, all patients were administered tissue plasminogen activator (TPA) through spinal or ventricular catheters. The pressure of the lumbar cerebrospinal fluid was maintained at 100 to 150 mm H2O. The TPA was given as multiple injections of 2 mg on Day 0 and 1 to 2 mg on the following 1 to 2 days. In two patients the second injection of TPA was not given because of severe brain damage resulting from the initial subarachnoid hemorrhage. Ten patients showed complete clearance of the cisternal clot on CT within 72 hours after thrombosis. Seven partially thrombosed aneurysms and five multiple aneurysms were clipped during delayed surgery. Only one patient experienced mild vasospasm as shown on the follow-up angiogram. Eight patients improved clinically and had a good recovery, two had severe disability, and two died. Urgent thrombosis of a ruptured aneurysm followed by immediate postthrombotic administration of TPA may be a safe and reasonable means of preventing vasospasm and improving patient outcome.

Intermittent propofol sedation during embolization of cerebral arteriovenous malformations.

Embolization procedure was performed for a 12-year-old boy with a left parietal arteriovenous malformation. Although provocative tests for the feeders to be occluded were considered very informative, the patient had to be sedated during microcatheter insertion. We used intermittent sedation with propofol during the interventional procedure, and obtained successful embolization.

A case of pontine lacunar infarction with ulcerative colitis.

We present the case of a young man who experienced a sudden onset of pure motor hemiplegia in association with ulcerative colitis. Based on a review of earlier reports, ulcerative colitis was suspected to be the background disease leading to cerebral infarction. A cerebral infarction of the lacunar type in the right ventromedial aspect of the upper pons was seen on magnetic resonance images. These images detected small lesions in the brain stem, and were used to follow-up their transitions.

Obliteration of the primary empty sella by transsphenoidal extradural balloon inflation: technical note.

Extradural inflation of a balloon with silicone via the transsphenoidal approach is an easy, safe, and effective technique for plugging the empty cavity of the sella and raising the entire sellar contents. It relieves headaches and visual symptoms secondary to the primary empty sella syndrome.

Artificial embolization with isobutyl-2-cyanoacrylate for the treatment of carotid-ophthalmic aneurysm.

A large carotid-ophthalmic aneurysm was successfully obliterated by the combined treatment of clipping the aneurysmal neck and intraaneurysmal injection of isobutyl-2-cyanoacrylate. Reflux of the glue into the artery was prevented by temporary trapping of the carotid artery. The obliteration of an aneurysm with isobutyl-2-cyanoacrylate is an effective procedure in cases where clipping of the aneurysmal neck is not completed due to technical difficulties.

Ribbon enchephalo-duro-arterio-myo-synangiosis for moyamoya disease.

In patients with advanced moyamoya disease, reconstructive surgery alone may not prevent the deterioration of blood flow in the territory of the anterior cerebral artery. These types of surgery include superficial temporal artery-to-middle cerebral artery anastomosis and encephalo-duro-arterio-myo-synangiosis (EDAMS). Bilateral encephalo-duro-arterio-synangiosis (EDAS) gradually reduced the transient ischemic attacks in one of our patients who experienced motor weakness in the left extremities. After surgery, however, persistent bilateral attacks still occurred in the patient's legs. In a subsequent maneuver, we inserted the pedicle of the galea on both sides into the interhemispheric fissure, which induced marked vascularization in the territory of the anterior cerebral artery, and the attacks disappeared. Since then, we have combined this "ribbon" technique with EDAMS to treat eight patients with moyamoya disease. Postoperative angiograms showed widespread collateral circulation on the ischemic brain surface in six patients undergoing ribbon EDAS or EDAMS. Postoperative measurements of cerebral blood flow revealed improved circulation in the frontal region in four patients. The clinical results were excellent in six patients, and good in one, and we lost follow-up in one. The ribbon EDAMS procedure is effective on moyamoya disease with symptomatic cerebral ischemia of the anterior circulation.