Management of Wide-Necked Basilar tip Aneurysms.

While the frequency of direct surgery for basilar tip aneurysms is decreasing, the need for safe and effective surgical treatments for difficult-to-treat aneurysms, including large or wide-necked aneurysms, is likely to continue. In this chapter, our surgical approach for large wide-necked basilar tip aneurysms using the orbitozygomatic approach, the anterior temporal approach, and hybrid surgery are described.

Early Enteral Nutrition with High-Protein Whey Peptide Digestive Nutrients May Improve Prognosis in Subarachnoid Hemorrhage Patients.

Background and Objectives: Nutritional management in patients with subarachnoid hemorrhage (SAH) during the acute phase is important; however, there is no proper evidence or recommendations on the appropriate nutrients for early enteral nutrition. This study compared the influence the two different tube-feeding liquid diets for early enteral nutrition might have on the prognosis of patients with SAH. Materials and Methods: In a seven-year period, this single-center retrospective study included 245 patients with aneurysmal SAH who underwent craniotomy and aneurysm neck clipping and received enteral nutrition. The patients were divided into two groups according to the nutrient received: (1) high-protein whey peptide oligomeric formula diet (oligomeric group, 109 patients); and (2) high eicosapentaenoic acid-containing polymeric formula diet (polymeric group, 136 patients). The modified Rankin Scale (mRS) score at discharge was evaluated as the primary outcome. The presence or absence of diarrhea (watery stool and mushy stool) during the period from initiation of enteral nutrition to discharge from the stroke unit was also evaluated. Results: There were no significant differences in patient characteristics between groups. The time until initiation of enteral feeding in the oligomeric and polymeric groups was 2.8 ± 2.3 and 2.9 ± 2.2 days, respectively. The proportion of patients with mRS scores of 0-1 was significantly higher in the oligomeric group (25.7%) than in the polymeric group (14.7%) (p = 0.036), while the incidence of watery stool was significantly lower in the oligomeric group (15.8% to 34.3% in the polymeric group) (p = 0.003). Multivariate analyses confirmed that the oligomeric diet and the presence or absence of diarrhea significantly affected the mRS scores. Conclusions: The adoption of early enteral nutrition with high-protein whey peptide digestive nutrients might be associated with superior mRS scores at discharge and decreased diarrhea in patients with SA, indicating that the choice of nutrients might affect the outcome and prognosis.

Use of flexible endoscopic aspiration for an intraventricular small floating clot with hemorrhage: a technical note.

BACKGROUND: Although flexible endoscopy is effective for intraventricular lesions, it is less frequently used for hemorrhagic cases. In some hemorrhagic strokes, blood clots may plunge into the cerebral aqueduct and cause acute obstructive hydrocephalus. A flexible endoscope can aspirate clots and prevent acute hydrocephalus. METHODS: Here, we report four cases of hemorrhage: one of intracerebral hemorrhage and three of subarachnoid hemorrhages. RESULTS: In all cases, acute hydrocephalus was not apparent upon admission. Sudden comatose occurred; computed tomography revealed acute obstructive hydrocephalus with a strangulated clot in the cerebral aqueduct. We performed aspiration of the strangulated clot using a flexible endoscope. Consciousness improved in all cases, and acute hydrocephalus was prevented in all cases. CONCLUSION: The use of simple flexible endoscopic aspiration for clots might be a beneficial and less-invasive procedure for acute obstructive hydrocephalus caused by a small clot with hemorrhagic stroke.

Real-world treatment results for ruptured blood-blister aneurysm of the internal carotid artery: analysis of a Japanese nationwide multicenter study.

Ruptured blood-blister aneurysm (BBA) of the internal carotid artery (ICA) remains a challenging lesion, even in the age of modern neurosurgery and endovascular treatment. This retrospective multicenter study aimed to investigate the real-world treatment choice and treatment results. We included 182 ruptured BBAs of the ICA treated at 51 neurosurgical centers in Japan between 2013 and 2017. The baseline patient characteristics, radiological features of the aneurysm, treatment modality, details of treatment, complications of treatment, and treatment results were retrospectively collected. The treatment strategy was divided into deconstructive and reconstructive procedures. Primary clinical outcomes were evaluated using the modified Rankin scale (mRS) at final follow-up. Direct surgery was performed in 144 (79%) cases, and the remaining 38 (21%) cases received endovascular treatment. The majority of treatment selections were deconstructive and reconstructive procedures in the direct surgery group and endovascular treatment group, respectively. Overall, favorable clinical outcomes (mRS 0 to 2) were achieved in 66% of cases, and the mortality rate was 15% at the final follow-up (mean 23 months). There was no significant difference in clinical outcome between direct and endovascular treatment groups. Our large nationwide study compared the real-world treatment options for ruptured BBAs and their results. Our findings may offer beneficial information for treatment decision and for future studies investigating ruptured BBAs.

Familiarization with Contact Aspiration using Non-Penetrating of the Thrombus (CANP) Technique as the Initial Procedure for Acute Ischemic Stroke.

OBJECTIVES: This study aimed to prove the safety and efficacy of the contact aspiration using non-penetrating of thrombus (CANP) technique for the initial procedure for acute ischemic stroke and to increase operator familiarization with the technical aspects of the CANP technique. MATERIALS AND METHODS: A total of 103 patients with large-vessel stroke who were treated using thrombectomy alone at our institution between April 2019 and March 2021 were included in this study. CANP technique was performed using a large lumen catheter (inner diameter, ≥0.060 in.) without penetrating a thrombus. Results of the CANP technique, including the procedure time; first-pass effect (FPE); angiographical recanalization; functional independence; thrombus migration; and intracerebral hemorrhage (ICH) were compared with combined technique. RESULTS: A total of 77 patients (74.8%) were scheduled to undergo the CANP technique for initial procedure, and 50 (64.9%) attempted the CANP technique. Of 50 patients with CANP technique, 33 (66.0%) achieved angiographically good recanalization using CANP technique alone. FPE was achieved in 31 patients (62.0%) in CANP technique group; the rate of FPE was significantly higher (p = 0.008). Asymptomatic ICH were significantly smaller in the CANP technique group (p = 0.008). The median interval of only the CANP technique was 20 (IQR, 16-29.5) min for groin puncture to final recanalization, and was significantly faster (p < 0.001). CONCLUSIONS: CANP technique was safe with low risk of hemorrhagic complication and effective for the initial procedure of acute ischemic stroke.

Predictors of subacute hematoma expansion requiring surgical evacuation after initial conservative treatment in patients with acute subdural hematoma.

BACKGROUND: The aim of this study was to clarify the factors associated with requiring subacute surgery in patients with acute subdural hematoma (ASDH) treated conservatively at admission. METHODS: Among the patients with ASDH admitted to our hospital from 2007 to 2018, we retrospectively reviewed data for 200 patients initially treated conservatively. We compared patients' characteristics, medical history, radiological findings, and clinical outcomes and differences between patients undergoing subacute surgery or no surgery. RESULTS: Of the 200 patients treated conservatively, 17 (8.5%) patients underwent subacute surgery due to deterioration of their clinical and/or computed tomography (CT) findings, while 183 (91.5%) patients did not undergo subacute surgery. There were significant differences in the presence of focal neurological deficits, modified Rankin Scale scores, degree of midline shift, hematoma thickness, hematoma volume, cella media index, Sylvian fissure ratio, and hematoma density between the two groups. CONCLUSIONS: Large hematoma, brain atrophy, and hematoma density may be useful predictors for the need for subacute surgery in patients with ASDH treated conservatively at admission. Intensive investigation of clinical findings or CT images is warranted in patients with adverse prognostic factors, even if their initial symptoms are mild.

Ruptured intrameatal anterior inferior cerebellar artery aneurysm associated with obstructed internal auditory artery in a patient with sudden hearing loss and vertigo.

BACKGROUND: Intrameatal aneurysms arising from the meatal loop of the anterior inferior cerebellar artery (AICA) are extremely rare. CASE PRESENTATION: We report a 60-year-old man presenting with severe vertigo and sudden left hearing loss associated with subarachnoid hemorrhage caused by rupture of a saccular aneurysm arising from the meatal loop of the AICA, which was entirely buried in the meatus. Intraoperatively, we identified the occluded internal auditory artery arising from the meatal loop of the AICA, where the aneurysm originated, and performed neck clipping. CONCLUSION: These findings suggest that internal auditory artery occlusion is a potential cause of loss of auditory and vestibular functions.

Factors related to improvement of cerebrovascular reserve after superficial temporal artery to middle cerebral artery anastomosis for patients with atherosclerotic steno-occlusive disease.

BACKGROUND: This study aimed to investigate factors related to improvement of hemodynamics and evaluated the usefulness of intraoperative Doppler for predicting postoperative hemodynamics in patients with cerebrovascular atherosclerotic steno-occlusive disease (CASD) of the internal carotid artery (ICA) or middle cerebral artery (MCA) who were treated with extracranial-intracranial (EC-IC) bypass surgery. METHOD: Forty-eight patients with CASD of the ICA or MCA who were treated by superficial temporal artery to middle cerebral artery bypass with a follow-up longer than 12 months were enrolled. Repeated transient ischemic attack or completed ischemic stroke was observed under optimal medical therapy in all patients. Intraoperative blood flow velocity of the MCA was evaluated by a Doppler flowmeter. Cerebral blood flow and cerebrovascular reserve (CVR) were evaluated using N-isopropyl-[123I] p-iodoamphetamine (IMP) single photon emission computed tomography (SPECT) preoperatively and 3 months after surgery. Imaging and clinical data were retrospectively reviewed. RESULTS: CVR was significantly increased postoperatively (p = 0.03). One year after the operation, two (4.2%) patients developed cerebral infarction. The change in MCA flow velocity just after anastomosis compared with pre-anastomosis proximal and distal of the anastomosis site was a median of 3.0 and 2.6 times, respectively. However, there was no significant association between changes in intraoperative MCA flow velocity and postoperative CVR. Multivariate analysis showed that the presence of a lower estimated glomerular filtration rate (eGFR) was an independent risk factor for a decrease in CVR (p = 0.036). CONCLUSIONS: A higher eGFR might have prognostic value for improvement in CVR after EC-IC bypass surgery in patients with CASD and misery perfusion.

The distance of cervical vertebral dislocation could be a risk factor for blunt vertebral artery injury after traumatic cervical spine injury.

BACKGROUND: Blunt vertebral artery injury (BVAI) is a well-known potentially fatal complication of cervical spine injury. The condition is reported to be associated with vertebral fractures and cervical hyperextension. However, appropriate patient screening methods remain to be elucidated. This study aimed to identify the risk factors associated with BVAI in patients with cervical spine injury. METHODS: We conducted a retrospective, observational, single-centered study, including 137 patients with cervical spine injury transferred to our center from April 2007 to December 2016. Evaluation for BVAI was available in 62 patients based on magnetic resonance angiography or multi-detector computed tomography angiography. BVAI was classified using the Biffl grade. RESULTS: Among the 62 patients evaluated, 13 (21%) were diagnosed with BVAI. All injuries were classified as Biffl grade 2 (50%) or 4 (50%). Univariate analysis of patients with and without BVAI showed that cervical dislocation (p = 0.041) and low average hemoglobin level (p = 0.032) were associated with BVAI. On multivariate logistic regression analysis, cervical dislocation (odds ratio 1.189; 95% confidence interval 1.011-1.399, p = 0.036) remained a significant predictor of BVAI. Based on receiver operating characteristic (ROC) analysis, a dislocation > 6.7 mm was selected as the optimal cutoff value for prediction of BVAI (sensitivity and specificity, 87.5% and 71.4%, respectively). CONCLUSIONS: BVAI frequently occurred in combination with cervical spine dislocation, and the distance of the cervical dislocation was identified as a useful predictor of BVAI.

Resumption of Direct Oral Anticoagulants in Patients with Acute Spontaneous Intracerebral Hemorrhage.

BACKGROUND: Decisions regarding whether and when to resume direct oral anticoagulants (DOAC) after acute intracerebral hemorrhage (ICH) are challenging. We examined the timing of DOAC resumption and factors that influence decision-making in DOAC resumption. METHODS: We retrospectively analyzed 43 patients with ICH who were treated with DOAC for nonvalvular atrial fibrillation before ICH onset. All patients were divided into 2 groups (resumption of DOAC and no resumption of DOAC) during hospitalization. Clinical backgrounds, laboratory data, and stroke severity were compared between the groups. RESULTS: DOAC were resumed in 19 of 39 (49%) acute ICH survivors and were not resumed in 24 patients, including 4 deceased patients. The National Institutes of Health Stroke Scale score at admission tended to be higher in the no resumption group (median, 17) than in the resumption group (median, 6) (P = .119). The modified Rankin Scale score was slightly poorer in the no resumption group (median, 4) than in the resumption group (median, 3) (P = .070). In the resumption group, DOAC were resumed at a median of 11 days (interquartile range, 5-21 days) after ICH onset. The modified Rankin Scale score at discharge was positively correlated with the days of DOAC resumption (R2 = .31, P = .013). CONCLUSIONS: In half of patients, DOAC were resumed relatively early after ICH onset. Early resumption of DOAC for ICH in patients with nonvalvular atrial fibrillation is considered to be safe. The functional outcome was associated with not only resumption of DOAC but also the timing of resumption.

[Surgical Management of a Thromobotic Extracranial Carotid Artery Aneurysm:A Case Report].

Extracranial carotid artery aneurysms are relatively rare. We present a case involving a giant aneurysm arising from the extracranial carotid artery. The patient was a 79-year-old woman. She had a pulsating mass in the right side of her neck. However, she was neurologically intact. Contrast-enhanced CT scans of the neck showed an enhanced mass lesion with a thrombus in the right side of her neck. Angiography revealed a saccular aneurysm 3.4 cm in size near the bifurcation site of the right common carotid artery into the external carotid artery. She underwent an urgent resection of the aneurysm and a carotid artery reconstruction. Postoperatively, she recovered well and the total resection of the lesion was angiographically confirmed. Histopathological examination revealed that the wall of the aneurysm had undergone fibrosis and contained a few elastic fibers and microhemorrhages. The wall of the aneurysm was also infiltrated by inflammatory cells. The surgical strategy for and appropriate preoperative evaluation of this rare disease was discussed.

A rabbit cisterna magna double-injection subarachnoid hemorrhage model.

In recent years, the shift of research interest in the pathological condition after subarachnoid hemorrhage (SAH) from delayed cerebral vasospasm to early brain injury and the development of molecular genetic approaches in animal experiments has resulted in a diversification of animal SAH models. The properties of each animal SAH model thus need to be validated and the purpose of using each animal model should be clarified. This study presents the settings and technical procedures for a rabbit cisterna magna double-injection SAH model and discusses the advantages and limitations of using this model.

Mechanisms underlying increased vascular smooth muscle contractility in the rabbit basilar artery following subarachnoid hemorrhage.

Increased vascular contractility plays an important role in the development of cerebral vasospasm following subarachnoid hemorrhage (SAH). Here, we summarize our current knowledge regarding molecular mechanisms that contribute to increased smooth muscle contractility of rabbit basilar artery following SAH. Our studies demonstrated that upregulation of receptor expression, impairment of feedback regulation of receptor activity, and enhancement of myofilament Ca²âº sensitization might lead to increased smooth muscle contractility following SAH.

Hyperperfusion syndrome after aneurysm surgery: a case report.

A 74-year-old woman exhibited sensory aphasia with abrupt blood pressure elevation 3 h after clipping of an unruptured large left middle cerebral artery aneurysm. Perfusion computed tomography and single-photon emission computed tomography demonstrated hyperperfusion in one of the distal parent artery areas. She gradually improved and was discharged without neurological deficits. Increased distal blood flow after occlusion of the large cerebral aneurysm and postischemic reperfusion after temporary occlusion of the parent artery during surgery presumably played an important role in the occurrence of this fairly rare condition associated with aneurysm surgery.

Executive function and diffusion in frontal white matter of adults with moyamoya disease.

BACKGROUND: Cognitive impairment is a frequent complication of moyamoya disease (MMD) in adults. Chronic hypoperfusion in frontal lobes can lead to subtle brain injury, resulting in cognitive dysfunctions. Apparent diffusion coefficient (ADC) in normal-appearing white matter on conventional magnetic resonance imaging correlates with cerebral hemodynamics in the frontal lobe. OBJECTIVE: The purpose of this study was to examine the relationship of ADC with executive function in patients with MMD. METHODS: Thirty-one patients (25 women and 6 men; mean age, 32.6 ± 10.4 years) were included in this study. Executive function was evaluated by the Frontal Assessment Battery (FAB) at 21.5 ± 7.5 years after disease onset. ADC was measured in the normal-appearing frontal white matter. RESULTS: ADC was statistically related to the occurrence of executive dysfunction in multivariate analysis (P = .0179). Total FAB score and ADC were negatively correlated (r(2) = .22; P = .0072; Spearman correlation coefficient, -.41; P = .024). Elevated ADC predicted executive dysfunction (area under the receiver operating characteristic curve, .73; 95% confidence interval, .55-.91; P = .029). CONCLUSIONS: The association of ADC with executive function might suggest that ADC is useful in screening for executive dysfunction during follow-up in the outpatient setting.

Clinical Outcomes in Elderly Patients with Chronic Subdural Hematoma: Validation of Irrigation Assignment Based on Hematoma Characteristics.

The number of elderly patients with chronic subdural hematomas (CSDH) is increasing worldwide; however, there is limited data regarding the clinical outcomes in this population. Our therapeutic method using burr hole evacuation for CSDH is based on the hematoma characteristics, using simple drainage for single-layer lesions and drainage with irrigation for multiple-layer lesions. This study aimed to compare the postoperative outcomes of elderly and younger patients, identify the predictors of outcomes in elderly patients, and verify the validity of our therapeutic methods. In total, we included 214 patients who underwent burr hole evacuation between April 2018 and March 2022. Baseline characteristics, hematoma characteristics, recurrence, and clinical outcomes were compared between the elderly and younger patients. Overall, 96 elderly patients (44.9%) were included in the study, and more elderly patients underwent antithrombotic therapy than younger patients (33.3% vs. 19.5%, p = 0.027). Moreover, elderly patients had significantly fewer favorable outcomes than younger patients (70.8% vs. 91.5%; p < 0.001); however, this was not significant after adjusting for the baseline modified Rankin Scale (mRS). Similarly, elderly patients had higher recurrence rates than younger patients (10.4% vs. 2.5%; p = 0.021). However, the baseline mRS score was the only predictor of unfavorable outcomes. In conclusion, although the clinical outcomes of elderly patients were comparable to those of younger patients, the higher rate of preoperative antithrombotic therapy in elderly patients may result in a higher rate of recurrence requiring a long-term follow-up.

Proposed mechanism of cerebral vasospasm: our hypothesis and current topics.

Increased vascular contractility plays an important role in the development of cerebral vasospasm following subarachnoid hemorrhage (SAH). Increased vascular contractility can be attributed to either endothelial dysfunction or increased contractility of vascular smooth muscle. Endothelial damage and dysfunction cause impairment of endothelium-dependent vasodilation of the cerebral artery after SAH. In addition to endothelial damage and dysfunction, receptor upregulation in vascular smooth muscle contributes to the induction and enhancement of contractile responses to agonists. Our recent data revealed that feedback regulation of the activity of the G protein-coupled receptor and myofilament Ca(2+) sensitivity is impaired after SAH. This impaired feedback regulation is suggested to cause a sustained contractile response to various agonists, thereby contributing to increased vascular contractility. In addition, three current topics are reviewed: endothelin type A receptor antagonists, 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors for treatment, and cortical spreading depolarization for the mechanism of cerebral vasospasm.

Preoperative evaluation and surgical strategies for craniocervical junction dural arteriovenous fistula with multiple feeders: case report and review of the literature.

Craniocervical junction dural arteriovenous fistula (CCJDAVF) fed by bilateral vertebral arteries (VAs) is extremely rare. We report a case of a 63-year-old man presenting with progressive myelopathy caused by a CCJDAVF, which was fed by bilateral VAs and occipital and ascending pharyngeal arteries with multiple shunting points and that drained into intracranial sinus and spinal veins. The dural arteriovenous fistula (DAVF) was successfully treated surgically using stepwise indocyanine green (ICG) videoangiography. After surgery, the DAVF disappeared and myelopathy was markedly improved. We show detailed preoperative images and intraoperative findings of this rare DAVF and emphasize the importance of selective angiography for preoperative evaluation of feeding arteries and the usefulness of intraoperative ICG videoangiography for both identification of the fistula and confirmation of its obliteration.

Intraarterial urokinase for thrombus migration after mechanical thrombectomy for large vessel ischemic stroke.

BACKGROUND: Achieving rapid and complete reperfusion is the ultimate purpose for ischemic stroke with large vessel occlusion (LVO). Although mechanical thrombectomy (MT) had been a proverbially important procedure, medium vessel occlusion (MeVO) with thrombus migration can sporadically occur after MT. Moreover, the safe and effective approach for such had been unknown. We reported thrombolysis with intraarterial urokinase for MeVO with thrombus migration after MT. METHODS: We included 122 patients who were treated by MT with LVO stroke at our institution between April 2019 and March 2021. Of 26 patients (21.3%) who developed MeVO with thrombus migration after MT, 11 (9.0%) underwent additional MT (MT group) and 15 (12.3%) received intraarterial urokinase (UK group). The procedure time; angiographically modified Treatment in Cerebral Ischemia Scale (mTICI); functional independence, which was defined as modified Rankin Scale 0-2, on day 30 or upon discharge; and symptomatic and asymptomatic intracerebral hemorrhage (ICH) were compared between the UK and MT groups. RESULTS: The procedure time, mTICI, and asymptomatic ICH did not significantly differ between the groups. In the UK group, 8 of 15 (53.3%) patients obtained functional independence, and the functional independence rate was significantly higher in the UK group than in the MT group (p < 0.05). Symptomatic ICH did not occur in the UK group, and its incidence was significantly smaller than that in the MT group (p < 0.05). CONCLUSION: The results of this study suggest that intraarterial urokinase for MeVO with thrombus migration after MT may safely improve angiographic reperfusion.

Clinical Characteristics of Ruptured Intracranial Aneurysm in Patients with Multiple Intracranial Aneurysms.

OBJECTIVE: It is difficult to correctly identify the ruptured aneurysm in patients with multiple intracranial aneurysms. Here, we investigated the clinical characteristics of ruptured intracranial aneurysms in such patients. METHODS: We retrospectively analyzed 361 patients who underwent microsurgical clipping of ruptured intracranial aneurysms at our institution from 2012 to 2018. Patients' age, sex, Fisher group, World Federation of Neurosurgical Societies grade, size (neck width, depth, maximum diameter), location, and shape of intracranial aneurysm, and hemorrhage pattern on admission were reviewed. RESULTS: In total, 266 patients (74%) had single intracranial aneurysms and 95 (26%) had multiple intracranial aneurysms. Eighty-nine of the 95 multiple intracranial aneurysms (94%) had irregular shape (P < 0.01). The median aspect ratios of ruptured and unruptured intracranial aneurysms were 2.2 ± 1.1 and 1.0 ± 0.4, respectively (P < 0.01). Twelve of 95 patients (13%) had ruptured intracranial aneurysms that were smaller than unruptured intracranial aneurysms. Among the 12 patients, the aspect ratios of ruptured intracranial aneurysms were greater than those of unruptured intracranial aneurysms (P < 0.01). Regarding morphologic characteristics, aspect ratio, maximum size, and irregular shape could be the useful predictive factors, but the greatest aspect ratio among patients with multiple aneurysms was the most predictive of an intracranial aneurysm rupture, after adjustment for aneurysmal size (adjusted odds ratio 217.82; 95% confidence interval 56.41-841.08). CONCLUSIONS: The results of this study indicate that the aspect ratio is the most predictive factor of a ruptured intracranial aneurysm in patients with multiple intracranial aneurysms.