The Effect of Japanese Herbal Medicines (Kampo) Goreisan and Saireito on the Prevention of Recurrent Chronic Subdural Hematoma: A Prospective Randomized Study.

BACKGROUND AND OBJECTIVES: Chronic subdural hematoma (CSDH) sometimes recurs after surgical treatment and requires reoperation. In Japan, Japanese herbal medicines (Kampo), such as Goreisan and Saireito, have been used as adjunctive therapies to prevent the recurrence of CSDH. However, no prospective randomized study has proven the efficacy of Kampo medicine in all patients. To investigate whether Goreisan and Saireito reduce the postoperative recurrence of CSDH in a prospective randomized study. METHODS: Between April 2017 and July 2019, a total of 118 patients who underwent initial burr hole surgery for CSDH were randomly assigned to the following 3 groups: (1) Goreisan for 3 months (Group G), (2) Saireito for 3 months (Group S), and (3) no medication (Group N). The primary end point was symptomatic recurrence within 3 months postoperatively, and the secondary end point was complications associated with the administration of Kampo medicine. RESULTS: Among 118 patients, 114 (Group N, n = 39; Group G, n = 37; and Group S, n = 38) were included in our analysis. In this study, byakujutsu (containing Atractylodes rhizome ) Goreisan and Saireito were used, unlike other prospective randomized studies in which sojutsu (containing Atractylodes lancea rhizome) Goreisan was used. The overall recurrence rate was 11.4% (13/114: 10 for Group N, 2 for Group G, and 1 for Group S). The recurrence rate of Group G was significantly lower than that of Group N (5.4% vs 25.6%; P = .043). The recurrence rate of Group S was also significantly lower than that of Group N (2.6% vs 25.6%; P = .02). No patients developed complications associated with the administration of Kampo medicine. CONCLUSION: This is the first study to show that Kampo medicine reduced the recurrence rate of CSDH in an overall population. This study demonstrated that byakujutsu Goreisan and Saireito may have favorable effects, unlike other studies, because byakujutsu has stronger anti-inflammatory activity than sojutsu.

Reconstruction of intracranial vertebral artery with radial artery and occipital artery grafts for fusiform intracranial vertebral aneurysm not amenable to endovascular treatment: technical note.

BACKGROUND: Symptomatic fusiform intracranial vertebral artery aneurysms pose a formidable treatment challenge when not amenable to endovascular treatment. In this paper, we illustrate the microsurgical management of such an aneurysm. METHODS: To prevent neurological deterioration, anatomical reconstruction preserving all vessels including posterior inferior cerebellar artery and perforators is essential. In this case illustration, the occipital artery was used as a donor to a perforator originating from the aneurysmal segment. This bypass was performed in an end-to-side fashion. Subsequently, the aneurysmal component of the vertebral artery was resected and an end-to-side (V4 to V3) bypass was performed using a radial artery graft. RESULTS: The patient achieved complete resection of the aneurysm preserving normal anatomy of the posterior circulation without any ischemic complications. CONCLUSIONS: Complex cerebral artery bypass techniques are essential in the armamentarium of cerebrovascular for the treatment of complex lesions not amenable to endovascular therapy.

Cervical radiculopathy due to extracranial vertebral artery dissection treated by stent placement with a flow diversion effect: illustrative case.

BACKGROUND: Cervical radiculopathy due to extracranial vertebral artery dissection (VAD) is extremely rare. The disease is usually treated with conservative treatment because of its favorable prognosis. However, there is a possibility that conservative treatment may bring about no improvement in radiculopathy. Although stent placement with a flow diversion effect may be effective in such cases, there are no reported cases that were treated with stent placement. OBSERVATIONS: A 40-year-old healthy man presented with severe right neck pain, right arm pain, and right arm weakness after cracking his neck. A neurological examination revealed right C5 radiculopathy. Neuroimaging studies revealed right extracranial VAD. The VAD compressed the right C5 nerve root. Although medications were administered, there was no improvement in the symptoms. He experienced severe radicular pain. The authors performed stent placement with a flow diversion effect 10 days after the onset of VAD. His radicular pain improved immediately after the procedure, and the remaining radiculopathy completely improved within 1 month. Follow-up angiography showed complete improvement of the VAD. LESSONS: Stent placement with a flow diversion effect may be considered when radiculopathy that hinders a patient's daily life exists. Stent placement may bring about rapid improvement in radiculopathy, especially radicular pain.

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.

The use of intraoperative near-infrared indocyanine green videoangiography in the microscopic resection of hemangioblastomas.

BACKGROUND: The authors assessed the usefulness of intraoperative near-infrared indocyanine green videoangiography (ICG-VA) in the microscopic resection of hemangioblastomas. METHODS: From January 2009 to February 2012, nine consecutive patients (seven men, two women) who underwent surgery for hemangioblastomas using intraoperative ICG-VA were included in this study. Surgery was performed on four cystic cerebellar lesions with mural nodules, two solid tumors (one in the cerebellar hemisphere and one in the medulla oblongata), one spinal tumor and multiple tumors in two patients with von Hippel-Lindau disease. Of the nine patients, three were treated for recurrent tumor. The ICG-induced fluorescence images of hemangioblastomas with variable presentation were evaluated. RESULTS: All tumors could be completely removed en bloc. Blood flow in the tumor and tumor-related vessels at the brain surface were clearly detected by ICG-VA in all cases, except one recurrent tumor where postoperative adhesive scar tissue obstructed ICG-induced fluorescence resulting in poor delineation of the blood flow patterns and tumor margins. ICG-VA was also helpful for detecting the multiple small mural nodules within the cyst or the tumors buried under thin gliotic neural tissue despite reduced fluorescence. CONCLUSION: Intraoperative ICG-VA is a safe and easy modality for confirming the vascular flow patterns in hemangioblastomas. In addition, ICG-VA provided useful information for intracystic small lesions or lesions concealed under thin brain tissue in order to accomplish total resection of these tumors.

Preoperative Predictive Factors of Short-Term Outcome in Idiopathic Normal Pressure Hydrocephalus.

BACKGROUND: Surgical treatment of idiopathic normal pressure hydrocephalus (iNPH) by ventriculoperitoneal (VP) or lumboperitoneal (LP) shunting can achieve long-term recovery of activities of daily living; however, in a subset of patients, maintenance of independence lasted for <6 months. This study examined positive preoperative predictive factors of short-term outcome for shunted iNPH patients. METHODS: Over a 9-year period, consecutive patients from multiple centers diagnosed with probable iNPH underwent either VP or LP shunt surgery. Preoperative variables of age, symptom duration, iNPH severity, tap test response, and magnetic resonance imaging findings of disproportionately enlarged subarachnoid space hydrocephalus (DESH) or incomplete DESH were retrospectively evaluated in relation to 1-year postoperative outcome. RESULTS: Outcome for 154 shunt patients (12 VP, 142 LP) as measured by postoperative disability modified Rankin Scale (mRS) and iNPH-gait disturbance (GD) was the same regardless of age. Symptom duration was inversely correlated with both iNPH severity (P < 0.0001) and postoperative improvement at 1 year (P = 0.0015). Severity also correlated inversely with postoperative improvement at 1 year (P < 0.0001). Age was not significantly correlated with the degree of postoperative improvement (mRS: P = 0.487; iNPH grading scale [GD]: P = 0.725). Outcome at 1 year (mRS, gait domain, and activities of daily living significantly improved in patients with a good response to the tap test (P < 0.0001) Preoperative DESH correlated with improvement in mRS and GD (P < 0.0001). CONCLUSIONS: Mild preoperative iNPH severity, shorter preoperative symptom duration, good tap test response, and complete DESH were associated with good short-term postoperative outcome at 1 year. These positive factors may be useful for prediction of short-term surgical outcome in iNPH patients.

Boron neutron capture therapy for newly diagnosed glioblastoma.

We evaluate the clinical results of a form of tumor selective particle radiation known as boron neutron capture therapy (BNCT) for newly-diagnosed glioblastoma (NDGB) patients, especially in combination with X-ray treatment (XRT). Between 2002 and 2006, we treated 21 patients of NDGB with BNCT utilizing sodium borocaptate and boronophenylalanine simultaneously. The first 10 were treated with only BNCT (protocol 1), and the last 11 were treated with BNCT followed by XRT of 20 to 30 Gy (protocol 2) to reduce the possibility of local tumor recurrence. No chemotherapy was applied until tumor progression was observed. The patients treated with BNCT (protocol 1 plus 2) showed a significant survival prolongation compared with the institutional historical controls. BNCT also showed favorable results in correspondence with the RTOG- and EORTC-RPA subclasses. The median survival time (MST) was 15.6 months for protocols 1 and 2 together. For protocol 2, the MST was 23.5 months. The main causes of death were cerebrospinal fluid dissemination as well as local recurrence. Our modified BNCT protocol showed favorable results of patients with NDGB not only for those with good prognoses but also for those with poor prognoses.

Hepatocyte growth factor activator inhibitor type 1 (HAI-1) is required for branching morphogenesis in the chorioallantoic placenta.

Hepatocyte growth factor activator inhibitor type 1 (HAI-1) is a membrane-associated Kunitz-type serine proteinase inhibitor that was initially identified as a potent inhibitor of hepatocyte growth factor activator. HAI-1 is also a cognate inhibitor of matriptase, a membrane-associated serine proteinase. HAI-1 is expressed predominantly in epithelial cells in the human body. Its mRNA is also abundant in human placenta, with HAI-1 specifically expressed by villous cytotrophoblasts. In order to address the precise roles of HAI-1 in vivo, we generated HAI-1 mutant mice by homozygous recombination. Heterozygous HAI-1+/- mice underwent normal organ development. However, homozygous HAI-1-/- mice experienced embryonic lethality which became evident at embryonic day 10.5 postcoitum (E10.5). As early as E9.5, HAI-1-/- embryos showed growth retardation that did not reflect impaired cell proliferation but resulted instead from failed placental development and function. Histological analysis revealed severely impaired formation of the labyrinth layer, in contrast all other placental layers, such as the spongiotrophoblast layer and giant cell layer, which were formed. Our results indicate that mouse HAI-1 is essential for branching morphogenesis in the chorioallantoic placenta and lack of HAI-1 function may result in placental failure.

Suprasellar hemangioblastoma.

A 59-year-old woman presented with disturbance of consciousness and decreased visual acuity caused by a suprasellar mass identified on MRI. A bifrontal interhemispheric approach allowed removal of the top and lateral sides of the tumor from the wall of the third ventricle. The hypothalamus appeared to be the origin of the mass, which proved to be hemangioblastoma, a rare tumor in this location.

Rationale for graft selection in patients with complex internal carotid artery aneurysms treated with extracranial to intracranial high-flow bypass and therapeutic internal carotid artery occlusion.

OBJECTIVE After internal carotid artery (ICA) sacrifice without revascularization for complex aneurysms, ischemic complications can occur. In addition, hemodynamic alterations in the circle of Willis create conditions conducive to the formation of de novo aneurysms or the enlargement of existing untreated aneurysms. Therefore, the revascularization technique remains indispensable. Because vessel sizes and the development of collateral circulation are different in each patient, the ideal graft size to prevent low flow-related ischemic complications (LRICs) in external carotid artery (ECA)-middle cerebral artery (MCA) bypass with therapeutic ICA occlusion (ICAO) has not been well established. Authors of this study hypothesized that the adequate graft size could be calculated from the size of the sacrificed ICA and the values of MCA pressure (MCAP) and undertook an investigation in patients with complex ICA aneurysms treated with ECA-graft-MCA bypass and therapeutic ICAO. METHODS In the period between July 2006 and January 2016, 80 patients with complex ICA aneurysms were treated with ECA-MCA bypass and therapeutic ICAO. Preoperative balloon test occlusion (BTO) was performed, and the BTO pressure ratio was defined as the mean stump pressure/mean preocclusion pressure. Low flow-related ischemic complications were defined as new postoperative neurological deficits and ipsilateral cerebral blood flow reduction. Initial MCAP (iMCAP), MCAP after clamping the ICA (cMCAP), and MCAP after releasing the graft (gMCAP) were intraoperatively monitored. The MCAP ratio was defined as gMCAP/iMCAP. Based on the Hagen-Poiseuille law, the expected MCAP ratio ([expected gMCAP]/iMCAP) was hypothesized as follows: (1 - cMCAP/iMCAP)(graft radius/ICA radius)2 + (cMCAP/iMCAP). Correlations between the BTO pressure ratio and cMCAP/iMCAP, and between the actual and expected MCAP ratios, were evaluated. Risk factors for LRICs were also evaluated. RESULTS The mean BTO pressure ratio was significantly correlated with the mean cMCAP/iMCAP (r = 0.68, p < 0.0001). The actual MCAP ratio correlated with the expected MCAP ratio (r = 0.43, p < 0.0001). If the expected MCAP ratio was set up using the BTO pressure ratio instead of cMCAP/iMCAP (BTO-expected MCAP ratio), the mean BTO-expected MCAP ratio significantly correlated with the expected MCAP ratio (r = 0.95, p < 0.0001). During a median follow-up period of 26.1 months, LRICs were observed in 9 patients (11%). An actual MCAP ratio < 0.80 (p = 0.003), expected MCAP ratio < 0.80 (p = 0.001), and (M2 radius/graft radius)2 < 0.49 (p = 0.002) were related to LRICs according to the Cox proportional-hazards model. CONCLUSIONS Data in the present study indicated that it was important to use an adequate graft to achieve a sufficient MCAP ratio in order to avoid LRICs and that the adequate graft size could be evaluated based on a formula in patients with complex ICA aneurysms treated with ICAO.

Subarachnoid hemorrhage after surgical treatment of unruptured intracranial aneurysms.

OBJECTIVE Only a few previous studies have investigated subarachnoid hemorrhage (SAH) after surgical treatment in patients with unruptured intracranial aneurysms (UIAs). Given the improvement in long-term outcomes of embolization, more extensive data are needed concerning the true rupture rates after microsurgery in order to provide reliable information for treatment decisions. The purpose of this study was to investigate the incidence of and risk factors for postoperative SAH in patients with surgically treated UIAs. METHODS Data from 702 consecutive patients harboring 852 surgically treated UIAs were evaluated. Surgical treatments included neck clipping (complete or incomplete), coating/wrapping, trapping, proximal occlusion, and bypass surgery. Clippable UIAs were defined as UIAs treated by complete neck clipping. The annual incidence of postoperative SAH and risk factors for SAH were studied using Kaplan-Meier survival analysis and Cox proportional hazards regression models. RESULTS The patients' median age was 64 years (interquartile range [IQR] 56-71 years). Of 852 UIAs, 767 were clippable and 85 were not. The mean duration of follow-up was 731 days (SD 380 days). During 1708 aneurysm years, there were 4 episodes of SAH, giving an overall average annual incidence rate of 0.23% (95% CI 0.12%-0.59%) and an average annual incidence rate of 0.065% (95% CI 0.0017%-0.37%) for clippable UIAs (1 episode of SAH, 1552 aneurysm-years). Basilar artery location (adjusted hazard ratio [HR] 23, 95% CI 2.0-255, p = 0.0012) and unclippable UIA status (adjusted HR 15, 95% CI 1.1-215, p = 0.046) were significantly related to postoperative SAH. An excellent outcome (modified Rankin Scale score of 0 or 1) was achieved in 816 (95.7%) of 852 cases overall and in 748 (98%) of 767 clippable UIAs at 12 months. CONCLUSIONS In this large case series, microsurgical treatment of UIAs was found to be safe and effective. Aneurysm location and unclippable morphologies were related to postoperative SAH in patients with surgically treated UIAs.

Roles of Kunitz domains in the anti-invasive effect of hepatocyte growth factor activator inhibitor type 1 in human glioblastoma cells.

Hepatocyte growth factor activator inhibitor type 1 (HAI-1) is a membrane-bound serine proteinase inhibitor having two extracellular Kunitz-type proteinase inhibitor domains (KD) namely KD-1 and KD-2. It efficiently inhibits hepatocyte growth factor activator, matriptase, hepsin, prostasin and trypsin. We have previously reported that the expression of HAI-1 suppresses the in vitro invasive capability of human glioblastoma cells. In this study we examined the role of each KD in the anti-invasive effect of HAI-1. Engineered over-expression of the mature membrane-form HAI-1 suppressed in vitro fibrin gel invasion of two human glioblastoma cell lines, U251 and YKG-1. The migratory activity on type IV collagen was also suppressed by the HAI-1 expression. These effects were not affected by the deletion of intracytoplasmic domain of HAI-1. A truncated secreted form of HAI-1 also suppressed in vitro invasion of the cells, indicating that the extracellular portion of HAI-1 was responsible for the anti-invasive effect. To determine the roles of each KD in the anti-invasive effect of HAI-1 in vitro, we constructed expression plasmids for HAI-1 with or without mutation at the P1 position of the reactive site of each KD. The results revealed that the proteinase inhibitor activity of N-terminal KD (KD-1) is responsible for the anti-invasion effect of HAI-1.

Graft Occlusion and Graft Size Changes in Complex Internal Carotid Artery Aneurysm Treated by Extracranial to Intracranial Bypass Using High-Flow Grafts with Therapeutic Internal Carotid Artery Occlusion.

BACKGROUND: Although the extracranial-to-intracranial high-flow bypass (EC-IC HFB) continues to be indispensable for complex aneurysms, the risk factors for the graft occlusion and whether the graft size changes after the bypass have not been well established. OBJECTIVE: To evaluate the risk factors for the graft occlusion and to confirm whether graft diameters changed over time. METHODS: The data of 75 patients who suffered from complex internal carotid artery (ICA) aneurysms and were treated by EC-IC HFB using radial artery graft (RAG) or saphenous vein graft (SVG) with therapeutic ICA occlusion were evaluated. Clinical and radiological characteristics were compared in patients with and without the graft occlusion by the log-rank test. Graft diameters measured preoperatively, postoperatively, at 6 months, and at 1 year were compared by paired t-test. RESULTS: During a follow-up period (median 26.2 months), graft occlusions were seen in 4 patients (5.3%), and these were the SVGs. Only SVG was related to graft occlusion (P < .001). There was a significant increase with time in RAG diameters (preoperative, 3.1 ± 0.41 mm; postoperative, 3.6 ± 0.65 mm; 6 months, 4.3 ± 1.0 mm; 1 year, 4.4 ± 1.0 mm), while there were no significant diameter changes in SVGs. CONCLUSION: The present study showed that the SVG was related to the graft occlusion and RAGs gradually enlarged. Unless Allen test is negative, RAG may be better to be used as a graft in EC-IC HFB if therapeutic ICA occlusion is needed.

A Contralateral Transcondylar Fossa Approach with Bilateral V3 Segment Exposure for Repairing Complex Vertebral Artery Aneurysms.

BACKGROUND AND IMPORTANCE: Microsurgical treatment for vertebral artery aneurysms can be approached through the lateral aspect of the brainstem and cerebellum. A contralateral approach may be selected in complex aneurysms with tortuous running and the intracranial vertebral artery distal to the aneurysm located in the contralateral cerebellopontine angle. When repairing the aneurysm, exposing the V3 segment before craniotomy is advantageous. We describe the detailed surgical procedures of the contralateral transcondylar fossa approach with bilateral V3 segment exposure for the repair of a complex vertebral artery aneurysm. CLINICAL PRESENTATION: A 48-year-old woman presented with a 23-mm unruptured thrombosed fusiform aneurysm in the right vertebral artery. The aneurysm and the V4 segment distal to it deviated to the left, and the aneurysm was compressing the left anterior aspect of the medulla oblongata. We treated the patient with trapping and thrombectomy, using a contralateral transcondylar fossa approach with bilateral V3 exposure. During the procedure, proximal vascular control was achieved by occluding the contralateral V3 segment and distal control was achieved by occluding the V4 segment. The aneurysm was successfully trapped and decompressed. The patient's postoperative course was good and she was discharged with a modified Rankin Scale score of 0. CONCLUSIONS: The contralateral transcondylar fossa approach with bilateral V3 exposure is feasible for the repair of complex vertebral artery aneurysms showing a deviated and difficult to access V4 segment proximal to the aneurysm. Bilateral V3 exposure may also facilitate aneurysm bypass procedures such as those using a V3-V4 anastomosis.

Surgical Microanatomy of the Posterior Condylar Emissary Vein and its Anatomical Variations for the Transcondylar Fossa Approach.

BACKGROUND: It is essential to identify and be aware of the anatomy of the posterior condylar emissary vein (PCEV) for achieving an adequate operative field for the transcondylar fossa approach (TCFA). OBJECTIVE: To describe the variations in the drainage patterns of PCEVs and the technical issues encountered in such cases. METHODS: This was a retrospective analysis of the anatomy of PCEVs in 104 sides in 52 cases treated by the TCFA. Preoperative findings of multidetector-row computed tomography (CT) and CT venography (CTV) were compared with the intraoperative findings. The drainage patterns were classified as 5 types: the sigmoid sinus (SS), jugular bulb (JB), occipital sinus (OS), anterior condylar emissary vein (ACEV), and marginal sinus (MS). RESULTS: The SS, JB, ACEV, and OS types were observed in 33 (31.7%), 42 (40.3%), 8 (7.7%), and 1 (1.0%) side(s), respectively. One side (1.0%) each had combined drainage from MS and JB, and ACEV and JB, respectively. In 17 sides (16.3%), the PCEVs and posterior condylar canals could not be identified on CT and CTV. CONCLUSIONS: Preoperative CT and CTV findings correlated well with the intraoperative findings. To make a sufficient operative field for TCFA, PCEVs should be appropriately dealt with based on the preoperative knowledge of their running course, pattern, and origin.

The Valveless Saphenous Vein Graft Technique for EC-IC High-Flow Bypass: Technical Note.

OBJECTIVE: Extracranial to intracranial (EC-IC) high-flow bypass using radial artery or saphenous vein (SV) graft has remained vital for complex aneurysms. If an Allen test is positive, the radial artery cannot be harvested because of poor palmer collateral circulation. The valves are thought to be one of causes of SV graft failure. Herein we illustrate the "valveless SV graft technique" as bypass conduits. METHODS: Between August 2014 and December 2014 at the Department of Neurosurgery at Teishinkai Hospital, 4 patients whose Allen test was positive underwent EC-IC bypass with the valveless SV graft for complex internal carotid artery (ICA) aneurysm. After SV harvesting, we identified the SV valve, cut it, and performed an end-to-end anastomosis using the fish mouth trimming technique. Graft patency was confirmed by computed tomography angiography. RESULTS: We have not encountered any problems related to graft failure, and all valveless SV grafts were patent during the follow-up period (median, 210 days; interquartile range, 93-287 days). CONCLUSIONS: The valveless SV graft technique is a useful technique in patients with complex ICA aneurysms who undergo EC-IC high-flow bypass with therapeutic ICA occlusion and whose Allen tests are positive.

Surgical case of intracranial osteoma arising from the falx.

Intracranial osteomas completely unrelated to osseous tissues are extremely rare. In the present study, the case of a 40-year-old female who presented with persistent headache is reported. Computed tomography (CT) and bone window CT revealed an ossified lesion in the frontal area. Fast imaging employing steady-state acquisition (FIESTA)/CT venography fusion imaging demonstrated that the mass was located just below the superior sagittal sinus and cortical veins, and had adhered partially to these veins. Surgery achieved complete tumor removal with preservation of the cortical veins and superior sagittal sinus. The histological examination findings were compatible with osteoma. The present postoperative course was uneventful. The present rare case of intracranial osteoma originating from the falx was successfully treated surgically. Preoperative FIESTA/CT venography fusion imaging was very useful to demonstrate adhesion between the tumor mass and the superior sagittal sinus and cortical veins.

Is Age a Risk Factor for Poor Outcome of Surgical Treatment of Unruptured Intracranial Aneurysms?

OBJECTIVE: Advanced age is known to be a significant risk factor for the rupture of intracranial aneurysms. The impact of age on outcomes of surgically treated patients with unruptured intracranial aneurysms (UIAs) is less clear. METHODS: A total of 663 consecutive patients with 823 surgically treated UIAs were evaluated. UIAs, which need bypass surgery including low-flow or high-flow bypass, were defined as complex aneurysms. Aneurysm size was categorized as small (<15 mm), large (15-24 mm), and giant (≥25 mm). In patients without symptoms, a poor outcome is defined as a modified Rankin Scale (mRS) score of 2-6. In those with mRS score higher than 1 as a result of UIA-related symptoms or other comorbidities, a poor outcome is defined as an increase of 1 or more on the mRS. Outcomes were evaluated at the 6-month and 12-month follow-up examinations. RESULTS: The mean age was 62 ± 12 years and 650 UIAs (78%) were observed in women. Previously treated aneurysm (P = 0.009), posterior circulation aneurysm (P < 0.0001), complex aneurysm (P < 0.0001), a larger size (P = 0.011), and perforator territory infarction (P < 0.0001) were related to poor outcome at 6 months, and posterior circulation aneurysm (P < 0.0001), complex aneurysm (P < 0.0001), a larger size (P = 0.035), and perforator territory infarction (P = 0.013) were related to poor outcome at 12 months. Age was not associated with poor outcome in patients with UIAs who undertook direct surgery. CONCLUSIONS: Although risks and benefits of aneurysm treatment in older patients should be carefully considered, surgical treatment of UIAs in the elderly should be considered positively.

Technical Description of the Medial and Lateral Anterior Temporal Approach for the Treatment of Complex Proximal Posterior Cerebral Artery Aneurysms.

BACKGROUND: Posterior cerebral artery (PCA) aneurysms are often fusiform and associated with multiple intracranial aneurysms. A bypass procedure in combination with proximal occlusion or aneurysm trapping is considered to be effective for the treatment of patients with complex PCA aneurysms. Because of the deep, narrowed surgical corridor and the surrounding sensitive neuroanatomic structures, microsurgical procedures applied to the PCA are technically demanding. The authors present a technical report of a complex aneurysm formation located at the postcommunicating segment of the PCA (PCA-P2) treated via an anterior temporal approach. METHODS: A 68-year-old woman had an unruptured PCA-P2 aneurysm formation, which was discovered incidentally. The fusiform aneurysm shape of the distal aneurysm aggravated direct microsurgical and endovascular treatment. After an individual case discussion, the patient underwent a microsurgical clipping of the proximal P2 segment aneurysm and the distal PCA-P2 segment aneurysm was treated by trapping after the application of a superficial temporal artery (STA) to PCA-P2 bypass using an anterior temporal approach. RESULTS: Postoperative computed tomography angiography showed the exclusion of the proximal PCA-P2 aneurysm and an adequate flow from the STA to PCA-P2 bypass to the distal PCA segments. The patient showed a modified Rankin scale of 0 after follow-up at 1 and 3 months. CONCLUSIONS: The anterior temporal approach is feasible for the microsurgical management of complex postcommunicating PCA aneurysms and the application of bypass procedures.

Risk factors for neurological worsening and symptomatic watershed infarction in internal carotid artery aneurysm treated by extracranial-intracranial bypass using radial artery graft.

OBJECT The revascularization technique, including bypass created using the external carotid artery (ECA), radial artery (RA), and M2 portion of middle cerebral artery (MCA), has remained indispensable for treatment of complex aneurysms. To date, it remains unknown whether diameters of the RA, superficial temporal artery (STA), and C2 portion of the internal carotid artery (ICA) and intraoperative MCA blood pressure have influences on the outcome and the symptomatic watershed infarction (WI). The aim of the present study was to evaluate the factors for the symptomatic WI and neurological worsening in patients treated by ECA-RA-M2 bypass for complex ICA aneurysm with therapeutic ICA occlusion. METHODS The authors measured the sizes of vessels (RA, C2, M2, and STA) and intraoperative MCA blood pressure (initial, after ICA occlusion, and after releasing the RA graft bypass) in 37 patients. Symptomatic WI was defined as presence of the following: postoperative new neurological deficits, WI on postoperative diffusion-weighted imaging, and ipsilateral cerebral blood flow reduction on SPECT. Neurological worsening was defined as the increase in 1 or more modified Rankin Scale scores. First, the authors performed receiver operating characteristic curve analysis for continuous variables and the binary end point of the symptomatic WI. The clinical, radiological, and physiological characteristics of patients with and without the symptomatic WI were compared using the log-rank test. Then, the authors compared the variables between patients with and without neurological worsening at discharge and at the 12-month follow-up examination or last hospital visit. RESULTS Symptomatic WI was observed in 2 (5.4%) patients. The mean MCA pressure after releasing the RA graft (< 55 mm Hg; p = 0.017), mean (MCA pressure after releasing the RA graft)/(initial MCA pressure) (< 0.70 mm Hg; p = 0.032), and mean cross-sectional area ratio ([RA/C2 diameter](2) < 0.40 mm [p < 0.0001] and [STA/C2 diameter](2) < 0.044 mm [p < 0.0001]) were related to the symptomatic WI. All preoperatively independent patients remained independent (modified Rankin Scale score < 3). After adjusting for age and sex, left operative side (p = 0.0090 and 0.038) and perforating artery ischemia (p = 0.0050 and 0.022) were related to neurological worsening at discharge (11 [29%] patients) and at the 12-month follow-up or last hospital visit (8 [22%] patients). CONCLUSIONS Results of the present study showed that the vessel diameter and intraoperative MCA pressure had impacts on the symptomatic WI and that operative side and perforating artery ischemia were related to neurological worsening in patients with complex ICA aneurysms treated by ECA-RA-M2 bypass.