Clipping Surgery for Unruptured Middle Cerebral Artery Aneurysms.

Clipping surgeries for 139 consecutive unruptured middle cerebral aneurysms were performed between April 1991 and March 2014. Left hemiparesis occurred in one case (0.7 %). Transient symptoms arose in six patients due to perforator injury, arterial branch occlusion, damage to the venous system, or chronic subdural hematoma. Neither mortality nor decline in cognitive function was noted in this study. Clipping surgery for unruptured middle cerebral artery aneurysms can be done with minimal morbidity. However, meticulous management during the perioperative period as well as the use of modern technologies during the surgery, such as MEP monitoring and ICG videoangiography, are needed for safe and secure clipping surgery.

[A case of infected subdural hematoma accompanied by cerebral infarction].

Infected subdural hematoma(ISH)is a rare disease caused by hematogenous infection of a preexisting subdural hematoma. We report a rare case of ISH accompanied by cerebral infarction. A 76-year-old man who had suffered a closed head injury 3 months before presented fever, headache and left hemiparesis during the medical treatment of acute cholangitis and obstructive jaundice with pancreatic cancer at the department of surgical gastroenterology. At the consultation, computed tomography(CT)scan indicated right chronic subdural hematoma. We performed a burr hole opening surgery on the same day. Abscess and hematoma was aspirated from the subdural space, and methicillin-resistant Staphylococcus aureus(MRSA)was detected in this specimen. Thus the diagnosis of the infected subdural hematoma was confirmed. However, despite the antibiotics therapy, follow-up CT showed a low-density area close to the residual abscess, which suggested cerebral infarction. Cerebral angiography showed a vasospasm at the cortical segment of the right middle cerebral artery near the residual abscess. Eventually we carried out a small craniotomy to evacuate the abscess. Our case showed that prompt surgical treatment is required in case of ISH and the whole hematoma and abscess should be removed as soon as possible with an image diagnosis and an additional surgical operation.

Bailout Technique for Coil Unraveling with a KUSABI Exchange Catheter: A Case Report.

Objective: Coil unraveling is a rare, yet dangerous complication of endovascular coiling. In this study, we report a patient in whom an intraoperatively unraveled coil was successfully retrieved using a KUSABI exchange catheter, which is used in the field of cardiovascular medicine to facilitate catheter exchange in coronary interventions. Case Presentation: The patient was a 90-year-old woman. To treat an unruptured aneurysm of the right internal carotid artery, endovascular coil embolization was performed. During the filling step, the coil started to unravel. Early attempts to retrieve the unraveled coil using a microsnare were complicated when the ensnared part broke off during the process. The broken tip of the unraveled coil was maneuvered inside the guiding catheter, after which a KUSABI catheter was inflated inside the guiding catheter to press and immobilize the unraveled coil against its inner lumen. This fragment of the unraveled coil was extricated from the patient by retracting the entire guiding catheter assembly. We guided a microsnare along the remaining unraveled coil to capture the intact part of the coil, and eventually retrieval was successful. Conclusion: To our knowledge, no study has reported retrieval with a KUSABI trapping balloon catheter for the management of coil unraveling. However, this method is considered effective. We report this case and review the literature.

Surgical procedure and results of cisternal washing therapy for the prevention of cerebral vasospasm following SAH.

In 1994, we started cisternal washing therapy (CWT) using urokinase combined with head-shaking method in order to prevent cerebral vasospasm. In this paper, we showed the surgical procedure for CWT and reported the effect of this therapy in preventing vasospasm following SAH. A total of 332 consecutive cases with Fisher group 3 SAH since 1988 were analyzed. Of these patients, 118 cases (56 cases before 1994 and 62 cases after 1994) had not CWT, and, 214 cases after 1994 had this therapy. All of these patients had clipping surgery within 3 days following SAH, and had postoperative management both with normovolemia and normal to mild hypertension. In these two groups, the incidence of symptomatic vasospasm (transiently symptomatic vasospasm without infarction), cerebral infarction due to vasospasm on CT, and mortality and morbidity (M&M) due to vasospasm were analyzed. In the group without CWT, the incidences of symptomatic vasospasm, cerebral infarction on CT, and M&M due to vasospasm were 4.2%, 28.8%, and 17.8%, respectively. On the other hand, in the group with CWT, they were 3.7%, 6.5%, and 2.8%, respectively. In the patients with CWT, the incidence of cerebral infarction on CT due to vasospasm and M&M due to vasospasm were significantly (p < 0.05) decreased. CWT was effective in preventing cerebral vasospasm.

Importance of the initial grade of subarachnoid hemorrhage in the patients with the age of 80 years and older from a single center analysis.

In the developed countries, especially Japan, elderly population is rapidly increasing, but outcomes of elderly patients with the age of 80 years and older suffering from subarachnoid hemorrhage (SAH) remain still unclear. We retrospectively reviewed the medical records of nontraumatic SAH patients aged 80 years and older, who were hospitalized in a single center between 1998 and 2009. There were 28 patients (80-90 years old and 75% female), representing 5.9% of all non-traumatic SAHs (n = 474). Of those, 16 patients received an intervention (ten clipping and six endovascular coiling) and the remaining 12 patients were managed conservatively. The median survival time of intervention group was 110 days and that of conservative group 49 days (p = 0.12, log rank analysis). Cox's proportional hazards model yielded two variables, the Japan Coma Scale (JCS) grade on admission ( hazard ratio: 2.93 [p = 0.009]) and conservative treatment (hazard ratio: 2.14 [p = 0.054]). In the outcome of the modified Rankin Scale between these two groups, logistic regression analysis had significant variable; the JCS grade on admission (odds ratio: 280, [p = 0.020]). In the elderly patients with good initial clinical condition, an acute intervention may have good outcome.

Comparison of the Physical Characteristics of Support Stents for Cerebral Aneurysm Embolization.

Objective: There is a limited understanding of the characteristics of individual intracranial stents used for aneurysm treatment. We used an experimental model to evaluate the physical characteristics of support stents for aneurysm embolization. Methods: Enterprise 2 VRD 4.0 × 39 mm, Neuroform Atlas 4.5 × 21 mm, and LVIS 4.5 × 32 mm stents were: 1) observed under light microscopy and subjected to measurements of 2) circumferential radial force, 3) strut tension, 4) stent compression, and 5) conformability upon bending. Results: 1) Light microscopy showed a large structural difference between laser-cut (Enterprise 2 VRD, Neuroform Atlas) and braided (LVIS) stents. 2) Within the range of indicated blood vessel diameters, the radial force of Enterprise 2 VRD was higher than that of Neuroform Atlas. An extremely large force was required to decrease the LVIS diameter. 3) Neuroform Atlas easily deformed compared to Enterprise 2 VRD, while LVIS was extended with a smaller traction force than that required for Neuroform Atlas. 4) The compression strength was in the order of Enterprise 2 VRD >Neuroform Atlas >LVIS. 5) Enterprise 2 VRD showed a decreased cell area on the concave side, and Neuroform Atlas showed deformation with overlapping struts on the concave side. LVIS naturally adhered to the wall of the blood vessel model. Conclusion: Laser-cut and braided stents showed different physical characteristics that were visualized and shown as numerical data. These findings improve the understanding of the proper use of these stents in clinical applications.

Spinal cerebrospinal fluid leaks detected by radionuclide cisternography and magnetic resonance imaging in patients suspected of intracranial hypotension.

PURPOSE: Although many studies have described various features of neuroimaging tests associated with intracranial hypotension, few have examined their validity and reliability. We evaluated the association between CSF leaks detected by radionuclide cisternography and abnormal MRI findings in the accurate diagnosis of intracranial hypotension. PATIENTS/METHODS: We retrospectively assessed 250 patients who were suspected of intracranial hypotension and underwent subsequent radionuclide cisternography. We obtained 159 sagittal and 153 coronal T2-weighted MRI images and 101 gadolinium-enhanced T1-weighted MRI images. We assessed the CSF leaks in relation to a sagging brain, the maximum subdural space in sagittal and coronal images, and dural enhancement. RESULTS: Overall, 186 (74%) patients showed CSF leaks on radionuclide cisternography. A sagging brain was observed in 21 (13%) of the 159 patients with sagittal MRIs. A sagging brain was not associated with CSF leaks (14% vs. 10%; p=0.49). Compared to patients without CSF leaks, those with CSF leaks tended to have a larger maximum subdural space in both the sagittal (3.7 vs. 4.1mm) and coronal (2.5 vs. 2.8mm) images; however, the differences were not significant (p=0.18 and p=0.53, respectively). Dural enhancement was observed only in one patient, who presented with CSF leaks on radionuclide cisternography. CONCLUSIONS: Our study, which included a relatively large population, did not find any association between the findings of radionuclide cisternography and MRI. Future research should focus on identifying more valid neuroimaging findings to diagnose intracranial hypotension accurately.