[Selective coil embolization of a distal anterior choroidal artery aneurysm associated with moyamoya disease: a case report].

Intracranial hemorrhage in patients with moyamoya disease is often caused by rupture of the associated aneurysms. Of these aneurysms, distal anterior choroidal artery (AChoA) aneurysms are rare. In patients with moyamoya disease, the AChoA constitutes collateral vessels and the aneurysm requires careful treatment strategy. However, reported cases of distal AChoA aneurysms include various procedures including conservative therapy, direct surgery, and endovascular therapy. Herein, we report a case of coil embolization of a distal AChoA aneurysm associated with moyamoya disease and discuss the treatment strategy. A 39-year-old female presented with severe headache and subsequent deep coma. Computed tomography (CT) revealed thick intraventricular hemorrhage, and three-dimensional CT angiography revealed a right distal AChoA aneurysm. Bilateral ventricular drainage was performed and subsequent ventriculoperitoneal (VP)shunt was performed. The persisting distal AChoA aneurysm was coil embolized without any complication. Rebleeding did not occur during the 1-year follow-up period. Endovascular treatment is effective for distal AChoA aneurysms associated with moyamoya disease to preserve collateral circulation.

Magnetoencephalographic detection of synchronized epileptic activity between the hippocampus and insular cortex.

Most magnetoencephalographic signals are derived from synchronized activity in the brain surface cortex. By contrast, the contribution of synchronized activity in the deep brain to magnetoencephalography (MEG) has remained unclear. We compared stereotactic electroencephalography (sEEG) with simultaneous MEG findings in a patient with temporal lobe epilepsy to determine the conditions under which MEG could also detect sEEG findings. The synchrony and similarity of the waves were evaluated using visual inspection and wavelet coherence. A 45-year-old woman with intractable temporal lobe epilepsy underwent sEEG and MEG simultaneously to determine the laterality and precise location of the epileptic focus. When spike-and-waves were seen in the right hippocampal head alone, no distinct spike-and-waves were observed visually in the right temporal MEG. The seizure then spread to the right insula on sEEG with a rhythmic theta frequency while synchronous activity was observed in the right temporal MEG channels. When polyspikes appeared in the right hippocampus, the right temporal MEG showed electrical activity with relatively high similarity to that of the right hippocampal head and insular cortex but less similarity to that of the right lateral temporal lobe cortex. MEG might detect epileptic activity synchronized between the hippocampus and insular cortex.

Retained Intracerebral Depth Electrode after Stereotactic Electroencephalography Monitoring: A Case Report.

Stereotactic electroencephalography (SEEG) is an increasingly popular surgical modality for localizing the epileptogenic zone. Robot-guided stereotactic electrode placement has been covered in Japan by National Health Insurance since 2020. However, several surgical devices, such as the anchor bolt (a thin, hollow, metal shaft that serves as a guide screw or fixing for each electrode), have not been approved. A 14-year-old female who underwent SEEG for intractable epilepsy and required additional surgery to remove a retained depth electrode from the skull after the SEEG monitoring was finished. She had uncontrolled focal seizures consisting of nausea and laryngeal constriction at the onset. After a comprehensive presurgical evaluation, robot-guided stereotactic electrode implantation was performed to evaluate her seizures by SEEG. Nine depth electrodes were implanted through the twist drill hole. The electrodes were sutured to her skin for fixation without anchor bolts. When we attempted to remove the electrodes after 8 days of SEEG monitoring, one of the electrodes was retained. The retained electrode was removed through an additional skin incision and a small craniectomy under general anesthesia. We confirmed narrowing of the twist drill hole pathway in the internal table of the skull due to osteogenesis, which locked the electrode. This complication might be avoided if an anchor bolt had been used. This case report prompts the approval of the anchor bolts to avoid difficulty in electrode removal. Moreover, approval of a depth electrode with a thinner diameter and more consistent hardness is needed.

Evaluation of recurrence factors and Gorei-san administration for chronic subdural hematoma after percutaneous subdural tapping.

Recent reports have shown that administration of Gorei-san (Tsumura, Tokyo, Japan) can prevent recurrence of chronic subdural hematoma (CSDH). However, no report has shown its potential, including its correlation with other recurrent clinical factors. We retrospectively evaluated the recurrent factors and the effects of Gorei-san on CSDH using percutaneous subdural tapping. Between April 2009 and February 2012, we performed percutaneous subdural tapping on 160 patients with intact CSDH. Of this population, 125 patients with unilateral hematoma and measurable initial hematoma pressure were included in this study. From April 2010, Gorei-san was routinely administered to patients. Patient characteristics such as age, sex, neurological grading, alcohol, diabetes mellitus, antiplatelet agent, anticoagulant agent, trauma, midline shift on CT images, hematoma volume on CT images, initial hematoma pressure, volume of the removed hematoma, and administration of Gorei-san were analyzed. Recurrence was recognized in 35/125 (28.0%) patients. Multivariate analysis revealed that a greater midline shift on CT images (p = 0.033) and initial hematoma pressure (p = 0.031) predicted recurrence. Gorei-san was administered to 94/125 (75.2%) patients, but they showed no changes in recurrence (27.7% vs. 29.0%; p = 1.0). Among 13 patients for whom Gorei-san administration was started before surgery, CSDH recurrence was reported in only 1 (7.7%). However, the group showed a significantly lower number of recurrent factors. Patients with a greater midline shift in their CT images or higher initial hematoma pressure need close postsurgical observation. The potential of Gorei-san for preventing recurrence of CSDH needs further examination.

Magnetoencephalographic spikes with small spikes on simultaneous electroencephalography have high spatial clustering in temporal lobe epilepsy.

OBJECTIVE: To classify magnetoencephalographic (MEG) spikes according to the findings of simultaneous scalp electroencephalography (EEG) to study dipole estimation in patients with temporal lobe epilepsy. METHODS: We analyzed MEG and simultaneous scalp EEG in 27 patients with intractable temporal lobe epilepsy. We classified MEG spikes into three groups (H-EM-spikes, L-EM-spikes, M-spikes) based on the amplitude of simultaneous EEG (50 µV or higher, lower than 50 µV, no spike morphology on EEG, respectively). We calculated parameters of the dipoles, such as goodness of fit (GOF), current moment, and location. RESULTS: We detected 707 MEG spikes, consisting of 175 H-EM-spikes, 245 L-EM-spikes, and 287 M-spikes. Dipoles of H-EM-spikes showed the highest current moment among the three spike groups. Dipoles of L-EM-spikes showed the highest GOF, a moderate current moment, the highest density to cluster, and the highest proportion of being located in the temporal lobe among the three groups. Dipoles of M-spikes showed the lowest GOF and current moment among the three groups. CONCLUSIONS: The characteristics of the dipoles of the MEG spikes differ depending on the simultaneous scalp EEG findings, though most of the MEG spikes were located in the temporal lobe. MEG spikes with concurrent small spikes on simultaneous scalp EEG may have higher spatial clustering in temporal lobe epilepsy.

Hippocampal volumetry to determine the resection side in patients with intractable non-lesional bilateral temporal lobe epilepsy.

Bilateral Temporal lobe epilepsy (BTLE) cases may result in poor surgical outcomes due to the difficulty in determining/localizing the epileptogenic zone. In this study, we investigated whether hippocampal volume (HV) would be useful for the determination of the best resection side in BTLE. Eighteen cases of BTLE determined by a scalp video electroencephalogram (SVEEG) underwent resection via intracranial electroencephalography (IVEEG). Patients with lesions or semiologically determined focus lateralization were excluded. In addition to SVEEG, an epilepsy protocol magnetic resonance imaging (MRI) including hippocampus fluid-attenuated inversion recovery (FLAIR) and HV, 18F-fluorodeoxyglucose positron emission tomography (FDG-PET), single-photon emission computed tomography with 123I-iomazenil (IMZ-SPECT), and magnetoencephalography (MEG) were performed for the preoperative evaluation of the lateralization. The resection side was determined based on the IVEEG results, and the seizure outcome at two years postoperatively was classified as either a well-controlled seizure outcome (Engel class I), or residual (classes II-V). We used a Fisher's exact test to compare the concordance between the determination of the epileptic focus by each modality and the resected side where patients achieved a well-controlled seizure outcome. Seizures were well controlled in 9/18 patients after surgery. Eight out of 11 patients (72.7%), in whom the HV results (strongly atrophic side) and the resection side were matched, had well-controlled seizure outcomes (P = 0.0498). The concordance of other presurgical evaluations with the resection side was not significantly related to a well-controlled seizure outcome. HV may be a useful method to determine the optimal resection side of the epileptic focus/foci in cases of suspected BTLE.

Y-configured double stent-assisted coil embolization with double microcatheter technique for complex basilar bifurcation aneurysm.

Y-configured double stent technique is useful for coil embolization of a bifurcation wide neck aneurysm while preserving the patency of the two important vessels. However, if the important vessels emanating directly from the aneurysm comprised four vessels, two vessels not deployed, Y-stents might not be preserved with the Y-stent technique by itself. We report a case treated with Y-configured double stent-assisted coil embolization with a double microcatheter technique for complex basilar bifurcation aneurysm. A 78-year-old woman presented with a subarachnoid hemorrhage (SAH) of poor grade. CT-angiography showed a wide neck and shallow aneurysm of complex basilar bifurcation involving both posterior cerebral arteries (PCAs) and superior cerebellar arteries (SCAs). In the chronic stage of SAH, Y-configured double stent-assisted coil embolization with a double microcatheter technique was performed. After Y-stent (two Enterprise) deployment from both the PCAs to the basilar artery, coil embolization of a basilar bifurcation aneurysm was performed using a double microcatheter technique to preserve both SCAs.

Characterization of cortical activity in juvenile myoclonic epilepsy by gradient magnetic field topography.

OBJECTIVE: Gradient magnetic field topography (GMFT) illustrates the magnetic field gradients of epileptic spike or polyspikes (S/PS) activities on a volume-rendered brain surface. The purpose is to characterize cortical activation in juvenile myoclonic epilepsy (JME). METHODS: We compared interictal S/PS activities in 10 patients with JME to five patients with Lennox-Gastaut syndrome (LGS). We defined areas with gradients exceeding 300fT/cm as activated zones (AZs) on GMFT. We defined the hemisphere where an AZ initially appeared as the "preceding hemisphere". We localized the foci where AZs arose and evaluated their spatiotemporal changes. RESULTS: In JME, the localization of S/PS in the preceding hemisphere was frontal in 18 activities (28%), parietal in 10 (15%), and frontal/parietal in 33 (51%), and in the contralateral hemisphere it was frontal in 14 (32%), parietal in 6 (14%), and frontal/parietal in 19 (43%). In LGS, AZs arose in every lobe of the brain. The median interhemispheric time difference was 7 ms (range: 0-20) in JME, which was significantly shorter than the 19 ms (1-50) observed among patients with LGS (p < 0.0001). CONCLUSIONS: AZs are localized within the bilateral frontal and parietal regions. AZs arose serially from foci with small time differences. SIGNIFICANCE: These results are consistent with regional network involvement in JME.

Comparison of seizure outcomes and ADL recovery period after total or anterior corpus callosotomy in adolescent and young adults with drop attacks and severe mental retardation.

PURPOSE: The aim of this study was to evaluate seizure outcomes and postoperative neurologic complications, with an emphasis on the recovery period of activities of daily living (ADL) between anterior partial corpus callosotomy (ACC) and total corpus callosotomy (TCC) in adolescent and young adults with drop attacks and severe mental retardation. METHODS: We retrospectively reviewed the clinical records of consecutive patients with intractable epilepsy who underwent corpus callosotomy (CC) for drop attacks between 2010 and 2019 in the Department of Neurosurgery, Hiroshima University hospital, with a minimum follow-up of one year. Inclusion criteria of this study were 1) age at surgery: 11-39 years, 2) preoperative intelligence quotient <35, and 3) preoperative Barthel index (BI) ≥30. Postoperative full ADL recovery was defined as complete recovery to the preoperative BI score. We compared the postoperative days required for 1) recovery of oral intake ability, 2) discharge from our hospital, 3) returning home from any hospital, 4) returning home with full ADL recovery, and 5) seizure outcomes in patients with ACC versus those with one-stage TCC. RESULTS: Ten patients with ACC and 14 patients with one-stage TCC met the inclusion criteria. The period for returning home with full ADL recovery was a median of 15 days (range 9-45 days) after ACC, while the median was 21.5 days (range 10-62 days) after one-stage TCC (p = 0.2904). Although there was a tendency for the ADL recovery period to be longer after one-stage TCC, there were no statistically significant differences in any category of ADL recovery period. Eleven of 14 (78.6 %) patients who received a one-stage TCC showed favorable seizure outcomes, with drop attack cessation, which was significantly better than 1 of 10 (10 %) patients with ACC (p = 0.0009). CONCLUSIONS: From the viewpoint of postoperative seizure outcomes and ADL recovery period, one-stage TCC is preferred to ACC for adolescent and young adults with severe mental retardation.

Secondary epileptogenesis on gradient magnetic-field topography correlates with seizure outcomes after vagus nerve stimulation.

OBJECTIVE: To determine the correlation between secondary unilateral or bilateral spreading on gradient magnetic-field topography (GMFT) before and after vagus nerve stimulation (VNS), and postoperative seizure outcomes. METHODS: We analyzed pre- and post-VNS magnetoencephalography (MEG) in 15 patients with VNS implants. We applied McHugh classification to evaluate seizure outcomes. GMFT visualized the spatiotemporal spread of the gradient magnetic field from MEG (>300 fT/cm) before and after the spike peak. We compared the proportion of bilaterally spreading (PBS) MEG spikes and seizure outcomes. We also compared the interhemispheric time difference (ITD) between patients with and without corpus callosotomy. RESULTS: We allocated patients with favorable seizure outcomes of class I and II to group A (9 patients) and poor outcomes of class III-V to group B (6 patients). The number of post-VNS MEG spikes was significantly reduced compared to pre-VNS MEG spikes in group A, but not in group B. Group A showed significantly higher preoperative PBS than group B. Postoperative ITD significantly decreased in 5 patients who underwent corpus callosotomy compared to 10 patients without. CONCLUSION: GMFT can detect the inter- and intrahemispheric spreading of spikes with high spatiotemporal resolution on the brain surface. Frequent interictal MEG spikes propagating bilaterally on GMFT may reflect a favorable seizure outcome after VNS. GMFT can identify dependent secondary epileptogenic spikes responding to VNS, which may be used to control generalized seizures in a subset of patients with pharmaco-resistant epilepsy.

Simple aspiration with balloon catheter technique (simple ABC technique) against proximal internal carotid artery occlusion in cases of cardiogenic cerebral embolism.

Background In cases of acute ischemic stroke, manual aspiration of the thrombus is commonly performed with a balloon guiding catheter placed in the cervical segment of the internal carotid artery (ICA). However, most manual aspirations using a balloon guiding catheter are combined with inner catheters, as in the direct aspiration first pass technique (ADAPT). We experienced some cases of acute ischemic stroke with proximal ICA occlusion due to cardiogenic thrombus where we obtained sufficient recanalization by simple manual aspiration from inflated Optimo 9F balloon catheters (Tokai Medical Products, Japan) placed in the origin of the cervical segment of the ICA without any inner catheter or stent retriever. We perform by preference this procedure, named the simple Aspiration with Balloon Catheter (simple ABC) technique. Herein, we report two recent cases and discuss this procedure. Case presentation Case 1: An 80-year-old man with paroxysmal atrial fibrillation developed left ICA occlusion. We performed the simple ABC technique and obtained a large amount of dark red and white thrombus. Puncture-to-reperfusion time was 14 minutes with Thrombolysis in Cerebral Infarction (TICI) grade 3. Case 2: A 69-year-old man with chronic atrial fibrillation developed left internal carotid occlusion. We performed the simple ABC technique and obtained a large amount of dark red thrombus. Puncture-to-reperfusion time was 15 minutes with TICI grade 2b. Conclusion The simple ABC technique is useful to deal with a large amount of thrombus, shortens procedure time, enables less invasive thrombectomy, and can shift immediately to subsequent procedures such as delivering a stent retriever or ADAPT.

Intraoperative cone-beam computed tomography contributes to avoiding hypoglossal nerve palsy during transvenous embolization for dural arteriovenous fistula of the anterior condylar confluence.

BACKGROUND: Dural arteriovenous fistula of the anterior condylar confluence (ACC-DAVF) is a rare subtype of DAVFs that occurs around the hypoglossal canal. Transvenous embolization (TVE) with coils has been performed for most ACC-DAVFs with a high clinical cure rate. However, some reports call attention to hypoglossal nerve palsy associated with TVE due to coil mass compression of the hypoglossal nerve caused by coil deviation from the ACC to the anterior condylar vein (ACV). Herein, we report a case of ACC-DAVF in which an intraoperative cone-beam computed tomography (CT) contributed to avoiding hypoglossal nerve palsy. CASE PRESENTATION: A 74-year-old man presented with left pulse-synchronous tinnitus. An angiography detected left ACC-DAVF mainly supplied by the left ascending pharyngeal artery and mainly drained through the ACV. The two fistulous points were medial side of the ACC and the venous pouch just cranial of the ACC. We performed TVE detecting the fistulous points by contralateral external carotid angiography (ECAG). The diseased venous pouch and ACC were packed with seven coils but a slight remnant of the DAVF was recognized. Because a cone-beam CT revealed that the coil mass was localized in the lateral lower clivus osseous without deviation to the hypoglossal canal, we finished TVE to avoid hypoglossal nerve palsy. Postoperatively, no complication was observed. No recurrence of symptoms or imaging findings were detected during a five-month follow-up period. CONCLUSION: An intraoperative cone-beam CT contributed to avoiding hypoglossal nerve palsy by estimating the relationship between the coil mass and the hypoglossal canal during TVE of ACC-DAVF.

Intraoperative idiopathic subarachnoid hemorrhage during carotid artery stenting: A case report and literature review.

Carotid artery stenting (CAS) has a fatal complication of intracranial hemorrhage (ICH) associated with cerebral hyperperfusion syndrome (CHS), i.e. brain hemorrhage and subarachnoid hemorrhage (SAH). Although SAH accounts for a small percentage of these patients, it is difficult to make a differential diagnosis of this syndrome from CHS without ICH because the clinical presentations resemble each other. Furthermore, not only does the cause of SAH following CAS remain unclear but also the role of controlling postoperative blood pressure is not detected in preventing ICH after CAS. Herein, we report a case of SAH following CAS and review previous literature to discuss the mechanism and the management of this fatal complication. A 78-year-old woman with a history of arteriosclerotic obliteration and myocardial infarction was referred to our department for intervention to asymptomatic severe stenosis of the right internal carotid artery. We performed CAS under local anesthesia. Although her blood pressure was controlled to normotension during the procedure, the patient complained of headache following predilation. Postoperative emergent non-contrast computed tomography revealed SAH with leakage of contrast medium occupying the right sylvian fissure. We continued strict blood pressure control, and the patient was discharged without any neurological deficit. A well-opened lumen of the stent was recognized three months later at the outpatient visit. Strict control of intraoperative and postoperative blood pressure may improve the outcome of SAH following CAS though the role in preventing ICH after CAS is unclear.