Arterial Spin Labeling Magnetic Resonance Imaging in the Assessment of Non-Convulsive Status Epilepticus in Alzheimer's Disease: A Report of Two Cases.

BACKGROUND The diagnosis of early non-convulsant status epilepticus (NCSE) can be challenging and can overlap with other critical conditions. Two patients with Alzheimer's disease are reported with clinically suspected NCSE presenting in the emergency setting who were diagnosed using arterial spin-labeling magnetic resonance imaging (ASL-MRI) sequences. CASE REPORT In Case 1, a 69-year-old woman with mild Alzheimer's disease and diabetes presented with acute worsening of cognitive status and fluctuating level of consciousness. In Case 2, a 70-year-old man with mild cognitive impairment due to Alzheimer's disease and hypertension presented with acute loss of consciousness and left hemiparesis, without evidence of hypoglycemia or a hypertensive crisis. In both cases, ASL-MRI perfusion images showed focal cerebral hyperperfusion in the posterior cingulate and parietal associative cortex, which involved neurodegenerative areas associated with epilepsy in early Alzheimer's disease. In both cases, the patients developed generalized tonic-clonic epileptic seizures that lasted for 5 minutes or more, which indicated the emergence of status epilepticus that developed from the initial presentation of NCSE. In both cases, electroencephalogram (EEG) findings confirmed that the seizures were controlled by intravenous administration of antiepileptic drugs. Both patients discharged home from the hospital without recurrence of seizures, between 10-12 days after the onset of symptoms. CONCLUSIONS These two cases have demonstrated that ASL-MRI is feasible as an emergency diagnostic tool in clinically suspected NCSE in patients with Alzheimer's disease.

Identification of non-convulsive status epilepticus with bradylalia using arterial spin-labeling magnetic resonance imaging.

CASE: Non-convulsive status epilepticus (NCSE) is among the differential diagnoses of decreased consciousness, but often presents a diagnostic challenge. A 65-year-old woman was admitted to our emergency department with bradylalia. No abnormal finding was detected by computed tomography or magnetic resonance imaging. Subsequently, acquired arterial spin-labeling images showed hyperperfusion in the right hemisphere. OUTCOME: After the examination, the patient began experiencing left hemifacial seizures, which were relieved by diazepam; however, she was still agitated. Ictal confusion due to NCSE was suspected. Electroencephalography revealed periodic, generalized epileptiform activities with brief seizures of facial muscles by intermittent photic stimulation. Another supportive case of NCSE detected by arterial spin-labeling from a 56-year-old right-handed man has also been presented. CONCLUSION: Arterial spin-labeling magnetic resonance perfusion imaging provides valuable information regarding cerebral perfusion status in NCSE patients in emergency/acute settings.

Performance of Electrical Velocimetry for Noninvasive Cardiac Output Measurements in Perioperative Patients After Subarachnoid Hemorrhage.

BACKGROUND: Fluid therapy guided by cardiac output measurements is of particular importance for adequate cerebral perfusion and oxygenation in neurosurgical patients. We examined the usefulness of a noninvasive electrical velocimetry (EV) device based on the thoracic bioimpedance method for perioperative hemodynamic monitoring in patients after aneurysmal subarachnoid hemorrhage. PATIENTS AND METHODS: In total, 18 patients who underwent surgical clipping or endovascular coiling for ruptured aneurysms were examined prospectively. Simultaneous cardiac index (CI) measurements obtained with EV (CIEV) and reference transpulmonary thermodilution (CITPTD) were compared. A total of 223 pairs of data were collected. RESULTS: A significant correlation was found between CIEV and CITPTD (r=0.86; P<0.001). Bland and Altman analysis revealed a bias between CIEV and CITPTD of -0.06 L/min/m, with limits of agreement of ±1.14 L/min/m and a percentage error of 33%. Although the percentage error for overall data was higher than the acceptable limit of 30%, subgroup analysis during the postoperative phase showed better agreement (23% vs. 42% during the intraprocedure phase). Four-quadrant plot and polar plot analyses showed fair-to-poor trending abilities (concordance rate of 90% to 91%, angular bias of +17 degrees, radial limits of agreement between ±37 and ±40 degrees, and polar concordance rate of 72% to 75%), including the subgroup analysis. CONCLUSIONS: Absolute CI values obtained from EV and TPTD are not interchangeable with TPTD for perioperative use in subarachnoid hemorrhage patients. However, considering the moderate levels of agreement with marginal trending ability during the early postoperative phase, this user-friendly device can provide an attractive monitoring option during neurocritical care.

[Contribution of increasing age to carotid plaque morphology and symptoms].

OBJECTIVE: Aging is considered to cause atherosclerotic changes in the carotid artery, but few studies have evaluated this relationship. In this study, we used carotid plaques removed from patients with carotid artery stenosis and investigated how aging contributes to carotid plaque morphology and symptoms. MATERIALS AND METHODS: A total of 60 patients(55 men, 5 women; mean age, 70.5 years; range, 53-85 years) treated at our hospital between January 2009 and April 2012 were enrolled in this study. All patients underwent carotid endarterectomy; their carotid plaques were stained with hematoxylin-eosin and/or Elastica-Masson stain and examined by a pathologist. Using these data, the carotid systolic velocity and plaque morphology were analyzed considering the age by decade as well as the symptomatology. RESULTS: Of the 60 patients, 29 were symptomatic(transient ischemic attack (TIA) in 8 patients; infarction in 20;and amaurosis in 1). Symptoms were less common as patient age increased. The incidence of TIA also tended to decrease with an increase in age, although the opposite trend was seen with infarction. In plaque morphology, the presence of active plaque, macrophage, inflammatory infiltration, and capillary angiogenesis decreased as age increased, while the presence of degenerative plaques, decrease in smooth muscle cell number, and calcification inversely increased. Active, degenerative, and combined (active/degenerative) lesions are statistically unrelated to symptoms as well as systolic velocity (cm/sec) at the carotid stenosis. The rates of hemorrhagic lesions were similar among decades, but the lesion statistically contributed to increasing symptoms (p=0.0045) and increasing systolic velocity (p=0.031). CONCLUSION: Increasing age contributes to morphological changes in carotid plaques and symptoms. When hemorrhagic lesions are suspected in carotid plaques, patients will be symptomatic and may require surgery.

Which should be the essential components of stroke centers in Japan? A survey by questionnaires sent to the directors of facilities certified by the Japan stroke society.

BACKGROUND: We conducted a survey by questionnaire to identify the essential components of stroke centers in Japan and compared our results with the European Expert Survey. METHODS: In 2007, a questionnaire was mailed to the directors of 740 facilities certified by the Japan Stroke Society to ask their opinion on the essential components of comprehensive stroke centers (CSC), primary stroke centers (PSC) and any hospital ward (AHW) admitting acute stroke patients. The directors were asked to provide 1 of the following 6 possible answers regarding 112 components: 'irrelevant'; 'useful but not necessary'; 'desirable'; 'important but not absolutely necessary'; 'absolutely necessary', or 'question unclear or ambiguous'. The components considered 'absolutely necessary' by more than 75% of the respondents were compared between our survey and the European Expert Survey. In addition, we compared the rates of neurosurgeons and neurologists who answered 'absolutely necessary' with regard to each component. RESULTS: Responses were obtained from 428 directors (57.8% response rate). Among these respondents, 298 (69.6%) were neurosurgeons. There was no component considered 'absolutely necessary' for AHW by more than 75% of the respondents, and this was similar to the results of the European Expert Survey. The following components were considered 'absolutely necessary' for PSC in our survey: brain CT scanning 24 h a day, 7 days a week (24/7); automated monitoring of the ECG, pulse oximetry, blood pressure and breathing, and respiratory support. In both our survey and the European Expert Survey, the essential components for CSC were as follows: physiotherapist; brain CT scanning 24/7; monitoring of the ECG, pulse oximetry and blood pressure; carotid surgery; angioplasty and stenting, and intravenous recombinant tissue plasminogen activator protocols. The components multidisciplinary stroke team, stroke-trained nurse, ultrasonography, collaboration with an outside rehabilitation center, stroke pathway and clinical research were deemed essential only in the European Expert Survey. However, MRI 24/7, MR angiography 24/7, conventional angiography 24/7, respiratory support as well as most neuroendovascular and neurosurgical treatments were considered necessary for CSC by more than 75% of the respondents in our survey. Analyzing the responses from only neurologists reduced the differences between our survey and the European Expert Survey. CONCLUSIONS: The present study indicated the essential components expected for stroke centers in Japan. Our survey demonstrated that more emphasis was likely to be placed on installations than on a dedicated stroke team and the use of stroke care maps. In addition, the results of this study may reflect some characteristics of the stroke care environment in Japan, such as the predominance of neurosurgeons and widespread use of MRI.

Performance of Third-generation FloTrac/Vigileo system during hyperdynamic therapy for delayed cerebral ischemia after subarachnoid hemorrhage.

BACKGROUND: Monitoring of cardiac output (CO) is important for promising safe approach to goal-directed hemodynamic therapy for delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH), but is often precluded by the invasiveness and complexity of ongoing monitoring modalities. We examined the clinical utility of less-invasive management using an uncalibrated arterial pressure waveform-derived cardiac output (APCO) monitor with refined algorithm (Third-generation FloTrac/Vigileo, Edwards, Irvine, CA, USA) during hyperdynamic therapy for post-SAH DCI, compared with transpulmonary thermodilution (PiCCO, Pulsion, Munich, Germany) as a reference technique. METHODS: Forty-five patients who underwent surgical clipping within 24 h of SAH onset and subsequently developed clinical deterioration attributable to DCI were investigated. Validation of the APCO-derived cardiac index (CI) during dobutamine-induced hyperdynamic therapy was compared with a reference CI analyzed by transpulmonary thermodilution in 20 patients. In a subsequent trial of 48 cases, the overall clinical results from patients managed with each device were compared. RESULTS: The APCO underestimated CI with an overall bias ± SD of 0.33 ± 0.26 L/min/m(2) compared with transpulmonary thermodilution, resulting in an error of 14.9%. The trends of CI for both techniques at each dobutamine dose were similar (r(2)= 0.77; P < 0.0001). No statistically significant differences were observed between the device groups for frequencies of neurological improvement, cerebral infarction, cardiopulmonary complications, or functional outcomes at 3 months. CONCLUSIONS: These data suggest that the refined APCO tends to underestimate CI compared with reference transpulmonary thermodilution during hyperdynamic therapy with dobutamine for reversing DCI, but may be acceptable in this select category of patients to obtain comparable clinical results.

Pathologically confirmed cryptic vascular malformation as a cause of convexity subarachnoid hemorrhage: case report.

BACKGROUND AND IMPORTANCE: We report a rare case of pathologically confirmed cryptic vascular malformation as a cause of primary convexity subarachnoid hemorrhage (SAH) of unknown etiology. CLINICAL PRESENTATION: A 48-year-old woman presented with sudden severe headache. Localized right convexity SAH was observed on computed tomography (CT) scan, but the origin could not be detected despite extensive workup covering the entire head by using 3.0-Tesla magnetic resonance (MR) imaging with MR angiography and CT angiography combined with venous-phase imaging with a 320-detector row CT scanner. Subsequent digital subtraction angiography (DSA) performed 2.5 hours after admission failed to reveal any cause of SAH; however, a right frontoparietal avascular region was suspected to be due to a newly developed intracerebral hematoma. The lesion was simultaneously confirmed by angiographic cone-beam CT imaging. Because she remained neurologically intact, we decided to perform a follow-up study later with medical management. However, she developed left hemiparesis 3 hours after DSA. CT scan demonstrated progression of the hematoma, and her symptoms gradually worsened. Emergent surgical exploration along the SAH superficial to the postcentral sulcus and hematoma evacuation were performed, with favorable functional outcome. Pathological examination confirmed cryptic vascular malformation with several abnormally dilated arterioles within the subarachnoid space surrounded by a thick SAH clot. CONCLUSION: It is important to consider the possibility of ruptured cryptic vascular malformation as a cause of nontraumatic nonaneurysmal convexity SAH when recurrent hemorrhage occurs despite thorough diagnostic workup, because surgical resection may be the only curative treatment option to eliminate the risk of rebleeding and disabling symptoms.

Ruptured de novo posterior communicating artery aneurysm associated with arteriosclerotic stenosis of the internal carotid artery at the supraclinoid portion.

BACKGROUND: Several de novo intracranial aneurysms have been described related to changes in hemodynamics after therapeutic occlusion of internal carotid artery (ICA); however, de novo aneurysms related to a supraclinoid arteriosclerotic stenosis of the ICA have not been described yet. Authors consider that it is important to bear in mind the possibility of developing an aneurysm in these special conditions. CASE DESCRIPTION: The evolution of a 62-year-old patient with subarachnoid hemorrhage, intraparenchymal frontal hematoma with some atypical circumstances that were presented together as well as the treatment he received are shown in this report. We can see this patient suffered a right thalamic hemorrhage at the age of 51 years; this condition was associated to a severe atherosclerotic stenosis of right supraclinoid ICAy. A long term had elapsed since the diagnosis of the stenosis and the discovery of a ruptured ipsilateral de novo supraclinoid internal carotid artery-posterior communicating artery (ICA-PcomA) aneurysm. CONCLUSIONS: IT SEEMS LIKE BOTH CONDITIONS: the atherosclerotic supraclinoid ICA which tells of an Samano et at: Ruptured De Novo PcomA Aneurysm Associated with Arteriosclerotic Stenosis of Supraclinoid ICA. Altered vessel environment coupled to a long exposure time, hemodynamic changes, unbalance in the wall sheer stress could all of them lead to the development of the de novo aneurysm.

[CSF leakage and anosmia in aneurysm clipping of anterior communicating artery by basal interhemispheric approach].

We studied the incidence of postoperative infection related to CSF leakage and anosmia in basal interhemispheric approach (BIH). Between April, 1990 to March, 2009, 142 cases of anterior communicating (Acom) aneurysm including both unruptured and ruptured have been treated by clipping surgery using BIH. We retrospectively obtained clinical informations from medical records and video records about infectious complications, CSF leakage of cerebrospinal fluid (CSF), olfactory dysfunction and intraoperative findings of damage to the olfactory nerve. In most cases (139 patients, 97%), frontal sinus were opened at craniotomy. Of all, CSF rinorrhea occurred in 4 cases (2.8%), and meningitis in 6 cases. There was only one patient who sufferd from meningitis due to CSF rinorrhea. All that patients recovered completely without deficit. Anosmia occurred in 6 cases (4.2%), and intraoperative injuries in 4 cases (2.8%). There was only one patient in whom anosmia was consistent with nerve injury. In conclusion, BIH is an appropriate procedure for infection risk control in Acom aneurysm surgery. It is difficult to avoid olfactory dysfunction completely, even if olfactory nerves are preserved in form.

Factors influencing cooperation among healthcare providers in a community-based stroke care system in Japan.

Community-based stroke care in Japan is currently provided in acute hospitals, convalescent rehabilitation units, general practices, sanatorium-type wards, nursing care facilities, and in-home/commuting care services. We conducted a nationwide survey to identify factors influencing cooperation among the various providers of community-based stroke care. We sent questionnaires to 11,178 facilities and assessed the independent variables of excellent and fair cooperation among the care providers. Of the providers that responded, 66% were engaged in medical practice or long-term care for stroke patients. The following independent variables were inversely associated with excellent or fair cooperation in the community: area with the higher population density among 3 groups divided by tertile threshold (odds ratio [OR], 0.53; 95% confidence interval [CI], 0.41-0.69), facilities covered by long-term care insurance (OR, 0.27; 95% CI, 0.22-0.34), and insufficient communication with local government (OR, 0.19; 95% CI, 0.14-0.24). Positive independent variables of excellent or fair cooperation were the sharing of patient information in the community (OR, 2.53; 95% CI, 1.78-3.66), use of a scale for assessing activities of daily living (OR, 1.93; 95% CI, 1.42-2.63), appropriate utilization of care support managers (OR, 1.91; 95% CI, 1.43-2.55), and adequate comprehension of the long-term care insurance system (OR, 1.54; 95% CI, 1.24-1.92). Our findings suggest that improved communication between healthcare providers and local government, along with appropriate attention to the problems facing providers covered by long-term care insurance, may improve community-based stroke care in Japan.

A new polyvinyl alcohol hydrogel vascular model (KEZLEX) for microvascular anastomosis training.

BACKGROUND: Microvascular anastomosis is a challenging neurosurgical technique that requires extensive training for one to master it. We developed a new vascular model (KEZLEX, Ono and Co., Ltd., Tokyo, Japan) as a non-animal, realistic tool for practicing microvascular anastomosis under realistic circumstances. METHODS: The model was manufactured from polyvinyl alcohol hydrogel to provide 1.0-3.0 mm diameter (available for 0.5-mm pitch), 6-8 cm long tubes that have qualitatively similar surface characteristics, visibility, and stiffness to human donor and recipient arteries for various bypass surgeries based on three-dimensional computed tomography/magnetic resonance imaging scanning data reconstruction using visible human data set and vessel casts. RESULTS: Trainees can acquire basic microsuturing techniques for end-to-end, end-to-side, and side-to-side anastomoses with handling similar to that for real arteries. To practice standard deep bypass techniques under realistic circumstances, the substitute vessel can be fixed to specific locations of a commercially available brain model with pins. CONCLUSION: Our vascular prosthesis model is simple and easy to set up for repeated practice, and will contribute to facilitate "off-the-job" training by trainees.

Novel brain model for training of deep microvascular anastomosis.

Models of the brain and skull were developed using a selective laser sintering method for training in the procedures of deep microvascular anastomosis. Model A has an artificial skull with two craniotomies, providing fronto-temporal-subtemporal and suboccipital windows. The brain in Model A is soft and elastic, and consists of the brainstem and a hemispheric part with a detailed surface. Rehearsals or training for anastomosis to the insular part of the middle cerebral artery, superior cerebellar artery, posterior cerebral artery, and posterior inferior cerebellar artery can be performed through the craniotomies. Model B has an artificial skull with a bifrontal craniotomy and an artificial brain consisting of the bilateral frontal lobes with an interhemispheric fissure and corpus callosum. Rehearsals or training for anastomosis of the callosal segment of the anterior cerebral artery can be practiced through this craniotomy. These realistic models will help to develop skills for deep vascular anastomosis, which remains a challenging neurosurgical procedure, even for experienced neurosurgeons.

Inraoperative and Histological Visualization of Disrupted Vulnerable Plaques following Diagnostic Angiography of Moderate Carotid Stenosis.

Background. Digital subtraction angiography (DSA) remains an important tool for diagnosis of carotid stenosis but is associated with risk for periprocedural complications. This is the first report of direct intraoperative and histolopathologic visualization of DSA-related carotid plaque disruption. Case. A 64-year-old man diagnosed to have a 60% right carotid stenosis received diagnostic DSA for therapeutic decision-making. He developed transient left hand numbness and weakness immediately after the procedure. Intraoperative imaging during carotid endarterectomy revealed a fragile plaque with sharp surface laceration and intraplaque hemorrhage at the bifurcation. Microscopy of the specimen demonstrated a large atheromatous plaque with fibrous hypertrophy and intraplaque hemorrhage filled with recent hemorrhagic debris. Conclusion. The visualized carotid lesion was more serious than expected, warning the danger of embolization or occlusion associated with the catheter maneuvers. Thus the highest level of practitioner training and technical expertise that ensures precise assessment of plaque characteristics should be encouraged.

Continuous cardiac output and near-infrared spectroscopy monitoring to assist in management of symptomatic cerebral vasospasm after subarachnoid hemorrhage.

BACKGROUND: Hemodynamic augmentation by increasing cardiac output with dobutamine (DOB) is believed to be a useful method of elevating decreased cerebral blood flow in the territory affected by vasospasm following aneurysmal subarachnoid hemorrhage (SAH). We described the clinical utility of uncalibrated radial artery-based pulse contour cardiac output (APCO) and near-infrared spectroscopy regional cerebral oxygen saturation (rSO(2)) monitoring for reversing vasospasm symptoms with DOB-induced hyperdynamic therapy. METHODS: Seven consecutive patients who underwent surgical clipping within 24 h of SAH onset and subsequently developed delayed ischemic neurological deficits attributable to vasospasm were investigated. They were treated with DOB administered at a dose of 3 µg/kg/min and then increased in 3 µg/kg/min increments until resolution of the symptoms. Continuous APCO and rSO(2) measurements in conjunction with the assessment of clinical courses and outcomes were performed. RESULTS: In spasm-affected territories, decreased and/or fluctuating rSO(2) was detected at baseline compared with recordings in other brain regions. Patients who exhibited rapid elevation of APCO in response to an incremental dose of DOB had subsequent uptake and stabilization of rSO(2) followed by improvement of vasospasm-related clinical symptoms with a maximal dose of DOB, resulted in favorable functional outcomes thereafter. A fairly strong relationship was found between peak APCO slope and rSO(2) elevation, with a significantly high area under the receiver operating characteristic curve predicting neurological improvement with DOB treatment. CONCLUSIONS: Our clinical experience indicates that integrative monitoring with APCO and rSO(2) may provide continuous, real-time, and clinically relevant information on the effectiveness of medical treatment of distal vessel vasospasm.

Impact of early surgical evacuation of sylvian hematoma on clinical course and outcome after subarachnoid hemorrhage.

The present study aimed to evaluate the impact of early surgical evacuation of sylvian hematoma caused by ruptured middle cerebral artery (MCA) aneurysm on clinical outcome after subarachnoid hemorrhage. Hospital records and computed tomography scans for 26 patients with MCA aneurysm who underwent surgical clipping between June 2001 and January 2008 were retrospectively reviewed. All patients presented with sylvian hematoma associated with subarachnoid hemorrhage and received surgery at 7.9 +/- 3.6 (mean +/- standard deviation) hours of ictus. They were divided postoperatively into two groups, achievement (n = 16) and non-achievement (n = 10) of extensive hematoma evacuation, and their clinical course and functional outcomes were compared. The frequencies of delayed ischemic neurological deficit and vasospasm-related cerebral infarction were significantly less (p < 0.05) in the achievement group. Better functional outcomes were obtained in patients with successful evacuation (p < 0.05), as assessed by improvement of hemiparesis on manual muscle testing scale at postoperative 1-month follow up and by the modified Rankin scale at postoperative 3 and 6 months. Clinical outcomes were also better in the achievement group. These results suggest that better clinical course and outcome can be expected in patients who undergo early successful hematoma evacuation with surgical clipping of a ruptured MCA aneurysm.

[Cerebral complications induced by neurotoxity of nonionic contrast medium after embolization of unruptured cerebral aneurysms: report of 2 cases].

We successfully performed endovascular coil embolization for 2 patients with unruptured saccular aneurysms. However, transient cortical blindness and generalized seizure associated with CNS neurotoxity of contrast medium were noted for each patient after the procedure. In the first case of a 62-year-old woman with a right BA-SCA aneurysm, she complained of blindness with restlessness one day after the intervention but no evidence of embolism on MRA. Abnormal EEG with slow, large amplitudes and 99mTc-HMPAO SPECT-evidenced hyperperfusion were observed in the occipital area. Accompanied by resolution of the edematous changes on MRI in conjunction with normalization of EEG and rCBF by anticonvulsant administration, her visual acuity completely recovered 8 days after the onset. According to these findings, we considered this case as transient cortical blindness. In the second case of a 68-year-old man with a left MCA aneurysm, he exhibited generalized seizure 8 hours after the procedure. CT scan revealed retention of the contrast medium over the left hemisphere. Postictal EEG one day after the seizure showed left frontal slowing but had no evidence of contrast medium retention or hyperperfusion. He recovered well with corticosteroid, anticonvulsant, and intravenous hydration. His follow-up DSA 2 years after the coiling was performed without trouble by reducing the amount/concentration of the contrast medium and by prophylactic steroid and hydration. Non-ionic contrast medium-related neurotoxity as represented by transient cortical blindness or generalized seizure should be recognized as a possible complication of endovascular surgery where patients' brain areas are locally vulnerable to contrast medium exposure.

Application of the FlexiForce contact surface force sensor to continuous extraocular compression monitoring during craniotomy for cerebral aneurysms.

The aims of this study were to introduce our newly developed device equipped with a contact surface force sensor (FlexiForce) for monitoring extraocular compression continuously, and to illustrate its potential clinical application using this device in patients undergoing uncomplicated frontotemporal or bifrontal craniotomy for surgical clipping of unruptured anterior circulation aneurysms. In a pilot study with volunteers, we determined the critical force of 100 gf to cause painful ocular sensation. Then we performed the bilateral extraocular force measurements in 15 patients undergoing uncomplicated frontotemporal or bifrontal craniotomy for surgical clipping of unruptured anterior circulation aneurysms. Extraocular force increased immediately after retraction of the flap, increased to 144+/-26 gf (mean+/-SD) during lower craniotomy close to the orbit, was maintained at 91+/-18 gf during microsurgery, and returned close to baseline at 24+/-14 gf after restoration of skin flap retraction. Such changes were observed only on the surgical side in frontotemporal craniotomy. Abnormal increase in extraocular force was effectively reduced by placing a real-time digital panel meter to warn surgeons to avoid excessive skin flap retraction during the surgical procedure. In conclusion, this new tool may allow us to monitor the external forces that can be applied intraoperatively to the ocular globe in the supine position.

[Application of the FloTrac arterial pressure-based continuous cardiac output monitor to dobutamine-induced hyperdynamic therapy for cerebral vasospasm after subarachnoid hemorrhage].

The aim of this study was to examine the usefulness of an uncalibrated radial arterial pressure-based cardiac output monitor (FloTrac, Edwards Lifesciences, Irvine CA, USA) for dobutamine-induced hyperdynamic therapy in patients with cerebral vasospasm following subarachnoid hemorrhage (SAH). In 18 SAH patients diagnosed with vasospasm, the cardiac index (CI) was analyzed continuously via the radial FloTrac system. The time-course changes in hemodynamic variables following dobutamine infusion at each dose increment (3-24 microg/kg/min) for reversing vasospasm-related delayed ischemic neurological deficit (DIND) and infarction were measured. At therapeutic dobutamine doses (3-15 microg/kg/min), CI increased immediately after the onset of each dose administration, which gradually fell to a level slightly higher than the baseline value. In all of the cases whose neurological findings were able to be examined, an improvement of DIND occurred during the phase of acute elevation. However at high-dose (20-24 microg/kg/min), dobutamine depressed stroke volume which was compensated for by increasing the pulse rate, thus raising CI only slightly from the baseline values. These data suggest that step-up increase of dobutamine dosage is not always effective in raising CI in patients suffering from post-SAH vasospasm, but rather may cause some adverse effects associated with increased myocardial oxygen consumption as evidenced by high-dose infusion. The less-invasive FloTrac system might be useful as a device for tracking trends in hemodynamic outcomes of hyperdynamic therapy.

Universal external carotid artery to proximal middle cerebral artery bypass with interposed radial artery graft prior to approaching ruptured blood blister-like aneurysm of the internal carotid artery.

Blood blister-like aneurysms are dangerous aneurysms with fragile walls arising from the supraclinoid internal carotid artery (ICA). Primary treatment of these aneurysms in the acute stage is challenging, due to the substantial risk of periprocedural bleeding. We describe a series of 4 patients who presented with ruptured blister-like aneurysm of the ICA and were treated with completion of extracranial-intracranial high-flow bypass followed by inspection and trapping of the aneurysm. All patients were treated in the acute stage, within 48 hours of bleeding. External carotid artery to proximal middle cerebral artery bypass with interposed radial artery (RA) graft was established followed by approach to the lesion and trapping of the parent vessels. The aneurysms in 3 patients ruptured during dissection of the lesion from the surrounding structures, but bleeding was easily controlled. RA grafts were patent in all patients and no postoperative symptomatic ischemic or hemorrhagic complications were encountered, resulting in excellent outcomes with modified Rankin scale scores of 0 at follow up after 3 months. Our present strategy for surgical treatment of blister-like aneurysms completely avoided the risk of devastating intraoperative hemorrhage, offering a most cautious strategy associated with minimal risk of intraoperative massive bleeding.