Vertebral artery V3 portion-radial artery-distal common carotid artery (V3-RA-dCCA) bypass for large basilar trunk aneurysm with bilateral proximal common carotid artery occlusion-technical note.

BACKGROUND: Large basilar trunk aneurysm caused by bilateral occlusion of the proximal common carotid artery is rare. We treated one case with vertebral V3 portion-radial artery-distal common carotid artery (V3-RA-dCCA) bypass. CASE DESCRIPTION: Basilar trunk aneurysm and bilateral occlusion of the proximal CCA were found incidentally in a 70-year-old woman. During the next 5 years, the aneurysm gradually enlarged to 12 mm, and blood flow of the anterior circulation was supplied through the posterior communicating artery. V3-RA-dCCA bypass was performed to reduce the stress of blood flow and prevent aneurysm growth and rupture. After exposing the neck portion, forearm of RA, and V3 portion of the vertebral artery, we created a space just below the sternocleidomastoid muscle to bypass the RA. We flushed the RA with albumin to stiffen the artery and temporarily clamped the bilateral sides of the RA to prevent twisting. We anastomosed the V3 and RA with a 9-0 thread and temporarily clamped the V3. After flushing the RA with albumin to prevent twisting, we clamped the external and internal carotid arteries, opened the dCCA with a vascular punch to prevent arterial dissection, and anastomosed the RA to the dCCA. The patency of the bypass was confirmed with Doppler and indocyanine green video angiography. The postoperative course was uneventful, bypass patency was good, and the aneurysm did not expand further. CONCLUSION: V3-RA-dCCA bypass may be an effective and low-risk treatment for large basilar trunk aneurysms with bilateral occlusion of the proximal common carotid artery.

White Matter Lesions as Brain Frailty and Age are Risk Factors for Surgical Clipping of Unruptured Intracranial Aneurysms in the Elderly.

INTRODUCTION: We aimed to identify the risk factors for surgical treatment of unruptured intracranial aneurysms (UIAs) in individuals aged >60 years, particularly focusing on white matter lesions (WMLs). MATERIAL AND METHODS: We investigated a total of 214 patients with UIAs. The patient group comprised 53 males and 151 females with an average age of 68.2 years. UIA size ranged from 2.7 to 26 (mean: 7.3) mm. The primary endpoint of the study was patient prognosis evaluated at the time of discharge using the modified Rankin Scale. We examined the risk factors for poor outcome and WMLs using magnetic resonance imaging. RESULTS: Poor outcome was observed in 23 (10.7%) patients. Significant correlations were observed between poor outcome and UIA size (P < 0.0001), UIAs located posteriorly (P = 0.0204), UIA thrombosis (P = 0.0002), and presence of WMLs (P < 0.0001) in univariate regression analysis. However, no significant correlations were noted between poor outcome and age (P = 0.1438). Multivariate logistic regression analyses showed significant correlations between poor outcome and UIA size (P < 0.0001), presence of WMLs (P = 0.001). Severe WMLs based on the Fazekas classification was correlated to age (P < 0.0001) and atherosclerosis (P = 0.0001). Severe WMLs were associated with ischemia (P < 0.001) and epilepsy (P = 0.0502) as well as length of hospitalization (P < 0.0001). CONCLUSION: Severe WMLs are risk factors for surgical treatment of UIAs in the elderly. Surgical indications must be considered and caution should be taken when managing patients with severe WMLs.

Long-term patency of superficial temporal artery to middle cerebral artery bypass for cerebral atherosclerotic disease: factors determining the bypass patent.

Long-term patency of superficial temporal artery to middle cerebral artery (STA-MCA) bypass surgery for atherosclerotic disease and associated risk factors for loss of patency have rarely been discussed. We retrospectively analyzed long-term patency following STA-MCA bypass and evaluated various demographic and clinical factors to identify the ones predictive of postsurgical loss of patency using records of 84 revascularization procedures (58 patients, 45 males; mean age at surgery 63.6 years, range 31-78 years). Bypass patency was diagnosed based on magnetic resonance angiography or three-dimensional computed tomography. The mean follow-up period was 24.7 months (range 6-63 months). Decreased bypass patency was observed in 4 of 58 patients (6.9 %) who collectively underwent 6 bypasses (7.1 %) of 84. All cases of decreased bypass patency were first detected within 6 months of surgery. Bypass patency was not correlated with age, sex, number of anastomoses, postoperative cerebral infarction, or control of postoperative diabetes mellitus. We found a significant association of bypass patency with hyperperfusion (p = 0.01) and postoperative smoking (p = 0.0036). Furthermore, we found a significant association of hyperperfusion with STA diameter (p < 0.0001), location of anastomosis (p = 0.075), and preoperative cerebral blood flow (p = 0.0399). In our retrospective study, hyperperfusion and smoking after surgery may be risk factors for decreased bypass patency in cerebral atherosclerotic disease patients. Careful monitoring of patency to prevent hyperperfusion and cessation of smoking are recommended, particularly within 6 months of the surgery.

Olfactory preservation during anterior interhemispheric approach for anterior skull base lesions: technical note.

Anosmia is not a rare complication of surgeries that employ the anterior interhemispheric approach. Here, we present a fibrin-gelatin fixation method that provides reinforcement and moisture to help preserve the olfactory nerve when using the anterior interhemispheric approach and describe the results and outcomes of this technique. We analyze the outcomes with this technique in 45 patients who undergo surgery for aneurysms, brain tumors, or other pathologies via the anterior interhemispheric approach. Anosmia occurred in 4 patients (8.8%); it was transient in 2 (4.4%) and permanent in the remaining 2 (4.4%). Brain tumors clearly attached to the olfactory nerve were resected in the patients with permanent anosmia. We found a significant difference in the presence of anosmia between patients with or without lesions that were attaching the olfactory nerve (p = 0.011). Our results suggested that fibrin-gelatin fixation method can reduce the reported risk of anosmia. However, the possibility of olfactory nerve damage is relatively high when operating on brain tumors attaching olfactory nerve.

Indocyanin green videoangiography study of hemangioblastomas.

OBJECTIVE: We present herein the intraoperative indocyanin green videoangiography (ICGVAG) findings for three cases of cerebellar hemangioblastoma (HB). CASES: Cerebellar HB was detected in three patients presenting with symptoms of vertigo and/or headaches and diagnosed on the basis of preoperative magnetic resonance imaging (MRI) and cerebral angiographic findings. Preoperative embolization of the tumor feeding artery was not performed in any of the patients. None of the patients underwent any procedure prior to ICGVAG that would affect the ICG findings, such as perilesional hemostatic coagulation or ablation. In each patient, it was possible to judge the approximate location of the tumor in relation to the brain surface and to distinguish the feeding and draining vessels. Following resection of the tumor, ICGVAG images confirmed that the mural nodule had been eliminated. None of the patients required blood transfusion, either during or after the surgery. For each patient, the lesion was pathologically confirmed as HB, postoperative contrast-enhanced MRI confirmed the absence of residual tumor, and diffusion-weighted MRI revealed no ischemic changes. RESULTS: Differentiation of feeding and draining vessels in the region of the lesion is particularly important for successful surgical removal of HB. In the present three patients, ICGVAG findings enabled easy vascular differentiation and were also useful for confirming that there was no residual tumor. Indocyanin green videoangiography was concluded to be useful for safe resection of HB.

Radial artery grafts for symptomatic cavernous carotid aneurysms in elderly patients.

BACKGROUND: Radial artery grafts (RAG) have been used in the treatment of complex vascular lesions, but not for symptomatic cavernous carotid aneurysms in elderly patients. AIM: To investigate the safety, usefulness, and perioperative complications of RAGs for symptomatic cavernous carotid aneurysms in elderly patients. MATERIAL AND METHODS: Of the 74 consecutive patients, in whom RAGs were used, we retrospectively investigated the postoperative outcomes and complications in eight elderly patients aged over 70 years with symptomatic internal carotid artery aneurysms in cavernous sinus. RESULTS: Postoperative complications included one case of cerebral infarction, one case of symptomatic seizures, and one case of delayed cranial nerve palsy. OUTCOME: Seven patients had an mRS score of 0, and one patient had a score of 2. Postoperatively there was improvement in cranial nerve palsy in seven patients and the patients who had symptoms for one year and eight months had residual deficits. Although it cannot be stated that the frequency of perioperative complications was low, the final outcomes were favorable. CONCLUSION: Even in carotid disease that is difficult to treat among the elderly, RAG would appear to be a useful and safe treatment.

Lesion Trapping with High-Flow Bypass for Ruptured Internal Carotid Artery Blood Blister-Like Aneurysm Has Little Impact on the Anterior Choroidal Artery Flow: Case Series and Literature Review.

OBJECTIVE: To examine the relationship between trap location and cerebral infarction in the anterior choroidal artery (AChA) region and associated risks in ruptured internal carotid artery blood blister-like aneurysm (BLA) treatment with high-flow bypass and lesion trapping. METHODS: We included 26 patients diagnosed with BLAs and treated with high-flow bypass and trapping. We examined clinical characteristics including age, aneurysm trap location, final prognosis, cerebral infarction on postoperative magnetic resonance imaging, and modified Rankin Scale score at discharge. We also searched the literature for similar studies. RESULTS: The modified Rankin Scale score at discharge was 0-2 in 20 patients, 3-5 in 2 patients, and 6 in 2 patients. In 19/26 patients (73.1%), the trapped segment was between the posterior communicating (PcomA) and the ophthalmic arteries. In 2 patients (7.7%), the trapped segment included the PcomA and the AChA; in 4 patients (15.4%), the trapped segment was within the PcomA. In these patients, the PcomA was occluded, and blood from the high-flow bypass flowed out to the AChA alone. No patient showed cerebral infarction. Our systematic review identified 70 patients. Of all 96 patients, 12 had AChA cerebral infarction; however, the infarction affected the prognosis of only 2 patients. CONCLUSIONS: When treating BLAs with high-flow bypass and lesion trapping, the frequency of AChA cerebral infarction is low even when the PcomA is occluded, leaving the AChA as the only outflow vessel during high-flow bypass. However, PcomA occlusion may be associated with risks when treating patients with advanced arteriosclerosis near C1-2.

Open surgical embolectomy for cardiogenic cerebral embolism: Technical note and its advantages.

BACKGROUND AND IMPORTANCE: In cardiogenic cerebral embolism, early recanalization is the most important factor for good prognosis. However, endovascular thrombectomy often fails to achieve recanalization. We present an open surgical embolectomy technique and discuss its advantages. CLINICAL PRESENTATION: A 79-year-old woman developed right hemiparesis and severe aphasia. Magnetic resonance imaging revealed an acute cerebral infarction caused by left middle cerebral artery (MCA) occlusion. We attempted endovascular thrombectomy but failed because it was impossible to guide the catheter to the occlusion site. Hence, we converted to open surgical embolectomy. Sylvian fissure was widely opened. After confirming the range of thrombosis using indocyanine green videoangiography (ICGVAG), the proximal and distal arteries were secured, and a temporary clip was placed on the distal M2 to prevent distal thrombosis migration. MCA was cut approximately 3 mm from the bifurcation, and thrombosis was removed using micro-forceps. The proximal clip was simultaneously inserted but was not clamped because the thrombus was extruded by proximal vascular flow. Immediately after removing the thrombus, intense bleeding occurred from the proximal flow. An assistant clamped the proximal artery using the prepared clip, and the incised area of MCA was sutured using 9-0 threads. We finally confirmed blood flow after recanalization using ICGVAG. The time from skin incision to recanalization was 27 min. After the procedure, the patient developed slight aphasia but had no hemiparesis and was later transferred to a rehabilitation hospital. CONCLUSION: Open surgical embolectomy may be a secondary rescue treatment option in the case of endovascular thrombectomy failure.

Severe Aneurysmal Subarachnoid Hemorrhage after Warning Headache during Pregnancy: A Case Report.

BACKGROUND: Aneurysmal subarachnoid hemorrhage is a rare but important cause of maternal death during pregnancy. CASE DESCRIPTION: A 34-year-old primigravida (31 weeks of pregnancy) with acute headache but no neurological deficits or neck stiffness was prescribed medication and returned home. Four weeks later she presented with severe headache and consciousness disturbance. She was admitted to our hospital, where she fell into a deep coma. Brain CT and three-dimensional CT angiography showed subarachnoid hemorrhage and a 5-mm right internal carotid-posterior communicating artery aneurysm. Fetal heart rate was 60 beats per minute. Emergent cesarean section and surgical clipping were performed. Intraoperative examination revealed that the aneurysm originated at the right posterior communicating artery. There were no postoperative neurological focal deficits. On postoperative day 13 she developed delayed cerebral ischemia of the right temporo-parieto-occipital lobe. She was discharged home 36 days after surgery with left hemianopsia. The infant was free of complications and was discharged at age 17 days. CONCLUSIONS: A pregnant woman with severe headache should undergo brain CT or magnetic resonance imaging to rule out subarachnoid hemorrhage.

Petrous Internal Carotid Artery Aneurysm: A Systematic Review.

OBJECTIVE: Petrous internal carotid aneurysm (PA) concomitant with a mass lesion and cranial nerve palsy is relatively rare. Flow-diverter stent implantation is now widely used as an alternative treatment for PA. However, alternative treatments sometimes cannot be used because of tortuosity of the carotid artery, allergies to contrast material, and high costs. The outcomes of different treatment methods should therefore be assessed. Here, we review the available literature on treatments for PA. METHODS: In a search using the terms "aneurysm", "carotid artery", and "petrous" on PubMed, MEDLINE, and databases such as OvidSP, 221 articles were identified. We also performed a literature review and discuss and compare the causes, symptoms, treatment methods, and clinical outcomes of PA. RESULTS AND CONCLUSIONS: Onset of secondary aneurysm was generally heralded by bleeding (p<0.001), while onset of primary aneurysm was heralded by cranial nerve deficit (p= 0.0014). Outcomes after treatment of 34 cranial nerve palsies in 25 patients are reported.

Hydrocephalus Secondary to Intradural Extramedullary Malignant Melanoma of Spinal Cord.

BACKGROUND: Hydrocephalus secondary to spinal cord tumors is rare. CASE DESCRIPTION: We present a 39-year-old male with gradual-onset headache whose initial diagnosis was cerebral aneurysm and communicating hydrocephalus. The correct diagnosis was primary intradural extramedullary malignant melanoma of the spinal cord. Initial brain magnetic resonance imaging demonstrated slight dilation of cerebral ventricles and a 3-mm unruptured anterior communicating artery aneurysm. He was placed under observation therapy. Two months later he was seen again due to severe headache. There was no intracranial hemorrhage on brain computed tomography scans. As we suspected rupture of the aneurysm, we operated on him for surgical clipping; however, there was no aneurysmal rupture. We found no lesions responsible for hydrocephalus, so we placed a ventriculoperitoneal shunt. His headache subsequently resolved. Nine months later he developed gait disturbance; a large volume of ascites was observed. Gadolinium-enhanced lumbar magnetic resonance imaging revealed an intradural extramedullary mass at the L-1 to S-5 level. Cytology and immunohistochemistry of the cerebrospinal fluid and ascites identified a few atypical cells positive for HMB-45, S-100 protein, and Melan-A. Whole-body examinations detected no primary lesions outside the central nervous system. Our final diagnosis was primary intradural extramedullary malignant melanoma of the spinal cord with cerebrospinal fluid dissemination. CONCLUSIONS: Our findings indicate that communicating hydrocephalus may be due to primary malignant melanoma of the spinal cord.

Preliminary Clinical Microneurosurgical Experience With the 4K3-Dimensional Microvideoscope (ORBEYE) System for Microneurological Surgery: Observation Study.

BACKGROUND: The exoscope has been reported as a novel neurosurgical instrumentation in clinical practice. OBJECTIVE: To investigate the possibility that ORBEYE (OE), a novel instrument that excludes eyepiece lenses and allows for microsurgery by observation of the 4K3D monitor, could replace microscopes. METHODS: We report 22 clinical cases by 5 experienced neurosurgeons and the comparative results of training 10 residents. An observation study with questionnaire survey was conducted on usability. Twelve items including image quality, eyestrain, and function of the arm were evaluated. RESULTS: The following 22 clinical procedures were conducted: surgery for intracranial hemorrhage (n = 2) and brain tumor (n = 8), laminectomy (n = 3), aneurysm clipping (n = 3), vascular anastomosis (n = 2), carotid endarterectomy (n = 2), and nerve decompression (n = 1). No complications were observed. The fluorescent study, including indocyanine-green and 5-aminolevunic acid, allowed for clear depiction on the 4K monitor. The surgeon could operate in a comfortable posture. Similar to the microscope, it was possible to change the optical and viewing axes with the OE, but the OE was switched to the microscope or endoscope in hematoma removal and pituitary surgery. Residents judged that eyestrain was strong (P = .0096). Experienced neurosurgeons acting as assistants judged that the scope arm's range of movement was narrow (P = .0204). Sixty percent of residents judged that the OE was superior to the microscope. CONCLUSION: Although based on limited experience, it was not possible to substitute the microscope with the OE in all operations; however, the OE surpasses the microscope in terms of ergonomic features.

Serum glucose/potassium ratio as a clinical risk factor for aneurysmal subarachnoid hemorrhage.

OBJECTIVE: Aneurysmal subarachnoid hemorrhage (SAH) can result in poor outcomes, and biomarkers for predicting poor prognosis have not yet been established. The aim of this study was to clarify the significance of the serum glucose/potassium ratio for predicting the prognosis of aneurysmal SAH. METHODS: The authors retrospectively reviewed the records of 565 patients with aneurysmal SAH between 2006 and 2016. The patient group comprised 208 men and 357 women (mean age 61.5 years, range 10-95 years). A statistical analysis was conducted of the clinical and laboratory risk factors of poor outcome, including the serum glucose/potassium ratio. RESULTS: On estimation of the initial assessment using Hunt and Kosnik (H-K) grading, 233 patients (41.2%) were classified as the severe SAH group (H-K Grade IV or V). There were significant correlations between the severe SAH group and serum glucose/potassium ratio (p < 0.0001). Serum glucose/potassium ratio was elevated in an H-K grade-dependent manner (Spearman's r = 0.5374, p < 0.0001). With the estimation of the Glasgow Outcome Scale (GOS) score at discharge, 355 patients (62.8%) were classified as poor outcome (GOS score 1-3). The serum glucose/potassium ratio was elevated in a GOS score at discharge-dependent manner (Spearman's r = 0.4006, p < 0.0001), and was significantly elevated in the poor outcome group compared with the good outcome group (GOS score 4 or 5; p = 0.0245). There were significant correlations between poor outcome and serum glucose/potassium ratio (p < 0.0001), age (p < 0.0001), brain natriuretic peptide levels (p = 0.011), cerebral infarction due to vasospasm (p < 0.0001), and H-K grade (p < 0.0001). Multivariate logistic regression analyses showed significant correlations between poor outcome and serum glucose/potassium ratio (p = 0.009). CONCLUSIONS: In this study, the serum glucose/potassium ratio of patients with aneurysmal SAH at admission was significantly correlated with H-K grade and GOS score at discharge. Therefore, this ratio was useful for predicting prognosis of aneurysmal SAH, especially in severe cases.

Reuse of a Reversed "Bone Pad" to Perforate Incompletely Penetrated Burr Holes Created by Automatic-Releasing Cranial Perforators.

BACKGROUND: It can be difficult to make complete burr holes using a perforator with automatic releasing systems in cases of a soft diploe or thick calvarial bone. OBJECTIVE: To demonstrate the utility of a flipped "bone pad" (BP) in recovery of penetration failure when using an automatic releasing perforator. METHODS: For craniotomy or ventricular drainage, the first step is to make 1 or more burr holes using a craniotome. Neurosurgeons sometimes incompletely penetrate the skull using the latest tools. As a countermeasure for such cases, we have developed a simple and practical method. When making a perforation using a high-speed perforator, a round bone piece we call the BP is formed just above the dura. We pulled the BP from a completed burr hole, and placed the reversed BP in position at the bottom of the incompletely perforated burr hole. The BP acted as a new hard surface, preventing the automatic releasing system from activating, and allowed the burr hole to be completed by the craniotome without the need for additional tools. RESULTS: With this technique, we have successfully completed 6 out of 7 imperfectly perforated burr holes using a perforator with an automatic releasing system. There were no technique-related complications, such as plunging or dural laceration. CONCLUSIONS: The method has the advantage that the BP can be obtained without drilling an additional burr hole, and can be completed without the need for increasing cost, time, or instrument usage.

Recovery of Visual and Ophthalmologic Symptoms After Treating Large or Giant Internal Carotid Artery Aneurysm by High-Flow Bypass with Cervical Ligation.

OBJECTIVE: Large or giant internal carotid artery (ICA) aneurysms often cause visual deficits and cranial nerve palsy. The aim of this study was to investigate the efficacy of ligation of the ICA with high-flow bypass. METHODS: We retrospectively analyzed the findings from patients with visual deficit and ophthalmologic symptoms due to ICA aneurysms. In addition, we analyzed the recovery factors associated with the visual deficit and ophthalmologic symptoms postoperatively, focusing on the type of cranial nerve palsy, aneurysm size, location, and the time to treatment from first symptoms. RESULTS: We identified 38 patients (35 women, 3 men) with a mean age at surgery of 63.6 years (range, 24-81 years) with visual and ophthalmologic symptoms due to large or giant internal carotid aneurysm. Aneurysms ranged in size from 15-50 mm (mean, 25.2 mm). Visual disturbance (7 cases, 18%) and ophthalmoplegia (31 cases, 82%) were the only preoperative cranial nerve palsies. Aneurysms were completely thrombosed in 94.7% of cases (36/38). Visual disturbance improved in 28.5% of cases (2/7), and ophthalmoplegia improved in 87.1% of cases (27/31). Time to therapy from developing a visual disturbance was longer than time to therapy from developing ophthalmoplegia (P = 0.001). Time to therapy was significantly associated with recovery from cranial nerve palsy (P < 0.0001). The recovery of visual disturbance was worse than that of ophthalmoplegia (P = 0.001). CONCLUSION: Early treatment is recommended when the visual and ophthalmologic symptoms are present because treatment delay is a risk factor for nonimprovement of symptoms.

Persistent primitive trigeminal artery aneurysm associated with cerebellar hemangioblastoma. Case report.

A 72-year-old man presented with a cerebellar vermian tumor manifesting as headaches and vertigo. Angiography disclosed a vascular tumor fed by the superior cerebellar artery and an aneurysm of a primitive trigeminal artery. The patient underwent right occipital craniotomy to remove the highly vascular tumor via an occipital transtentorial approach. Association of a cerebral aneurysm with a hemangioblastoma has been reported previously in only five cases. Only three aneurysms were located on the feeding artery. The aneurysm in this case was not on the feeding artery. Simple coincidence might account for this case.

Intraoperative middle cerebral artery pressure measurements during superficial temporal artery to middle cerebral artery bypass procedures in patients with cerebral atherosclerotic disease.

OBJECTIVE No previous study has monitored middle cerebral artery (MCA) pressure during the superficial temporal artery (STA)-MCA bypass procedure for cerebral atherosclerotic disease. In this paper, the authors describe their method of monitoring MCA pressure and report their initial data on intraoperative MCA pressure and its relationship with hemodynamics prior to and after the bypass procedures. METHODS The results from a total of 39 revascularization procedures performed between 2004 and 2014 were analyzed. The patient group included 27 men and 12 women, and their mean age at surgery was 67.6 years (range 39-83 years). The authors investigated the MCA pressure via the STA during STA-MCA bypass procedures. After one branch of the STA was anastomosed to the MCA, the other branch was connected to an arterial line, and a clip was placed temporally on the main STA trunk to monitor the pre-anastomosis MCA pressure. Simultaneously, the radial artery (RA) pressure was determined before removing the temporal clip to measure the post-anastomosis MCA pressure. The relationship between MCA pressures and single photon emission computed tomography findings and the risk factors for hyperperfusion after STA-MCA bypass were analyzed. RESULTS The MCA/RA (%) pressure was significantly correlated with that of the resting stenotic/normal side cerebral blood flow (CBF) ratio (%) in the linear regression analysis (slope 1.200, r2 = 0.3564, F = 20.49, p < 0.0001). The intraoperative MCA pressure was 39.3% of RA pressure in patients with Powers' Stage 2 cerebral atherosclerotic disease. After 1 branch of the STA was anastomosed, the intraoperative MCA pressure increased to 75.3% of the RA pressure. The rate of increase in pressure was significantly correlated with the increase in the STA diameter in the linear regression analysis (slope 2.59, r2 = 0.205, F = 9.549, p = 0.0038). Hyperperfusion occurred in 2 cases. When mean values for these 2 patients were compared with those for the 37 patients without hyperperfusion, significant differences were found in the stenotic/normal side CBF ratio (p = 0.0001), pre-anastomosis MCA pressure (p = 0.02), rate of increase in pressure (p = 0.02), pre-anastomotic MCA/RA pressure ratio (p = 0.01), vascular reserve (p = 0.0489), and STA diameter (p = 0.0002). CONCLUSIONS The measurement of intraoperative MCA pressure may be a useful technique to assess cerebral perfusion and for predicting the risk of hyperperfusion. Monitoring MCA pressure is recommended during STA-MCA bypass procedures for atherosclerotic disease.

4D flow preliminary investigation of a direct carotid cavernous fistula due to a ruptured intracavernous aneurysm.

Inadequate information is available about the cerebral blood flow and surgical strategies of a direct aneurysmal carotid cavernous fistula (daCCF). We report a quantitative analysis of flow velocity and volume using preoperative time-resolved phase-contrast MRI (four-dimensional (4D) flow MRI) in a daCCF. This is the first report of 4D flow findings with a daCCF. A 55-year-old woman developed a sudden headache and bruit of the right orbit, and MRI suggested the presence of a daCCF. Quantitative analysis using preoperative 4D flow MRI revealed the flow volume of the right internal carotid artery. The daCCF was successfully treated by high-flow bypass using a radial artery graft and internal carotid artery trapping. Postoperative angiography showed a complete obliteration of the daCCF. Studies to collect data from additional cases are required so that 4D flow findings can be further used in the management of daCCFs.

Fluorescence Angiography with Temporary Occlusion to Confirm the Distal Artery: Technical Notes.

Confirming the patency of the proximal parent and distal artery is necessary in cerebral aneurysm surgery. To understand the relationship between the parent and distal arteries of the aneurysm, the blood vessels running through the subarachnoid space should be extensively dissected, which is time consuming. To examine the efficacy of a temporary clip with indocyanine green (ICG) technique, in which the parent artery is temporarily occluded using a temporary clip, an ICG videoangiography (ICGVAG) is performed to clarify the relationship between the distal artery and the proximal parent artery. Three patients with a distal aneurysm. This technique was used to confirm the connection of the parent and the distal artery in distal aneurysms. With regard to middle cerebral artery (MCA), the procedure is conducted as follows. First, the M2 within the Sylvian fissure is investigated to ensure the absence of atherosclerosis and perforators and that this vessel could undergo occlusion by temporary clipping. The subarachnoid space surrounding the distal artery of the lesion site suspected of an existent aneurysm is dissected. The image range of the ICGVAG is set sufficiently wide to accommodate the possibility that the distal artery is not the artery that was anticipated. Subsequently, after the temporary clip occlusion is completed, the ICGVAG is recorded. In the three distal aneurysms, the relationship between the aneurysm, the distal artery, and the parent artery was confirmed. This method was useful, suggesting that unnecessary dissection in the subarachnoid space might be reduced.

Target-controlled infusion technique with indocyanine green videoangiography for radial artery graft.

OBJECT: To understand the relationship between the parent artery and its distal arteries, blood vessels running through the subarachnoid space need to be extensively dissected, which is time-consuming. We examined the efficacy of temporary clipping with the indocyanine green (ICG) technique (target-controlled infusion (TCI) technique), in which the parent artery is occluded using a temporary clip, and ICGV (videoangiography) is performed to clarify the relationship between the distal M4 and proximal M2. METHODS: Thirteen radial artery grafts (RAGs) for internal carotid aneurysm underwent TCI to confirm the relationship between M2 and cortical M4. To monitor the perfusion pressure of the cortical middle cerebral artery, superficial temporal artery (STA) to M4 anastomosis was performed before RA-M2 anastomosis. We performed anastomosis of the recipient of STA- M4 that was distal and downstream of the M2 segment that is the recipient of RA-M2 anastomosis. To select the proper recipient M4 of the STA-M4 anastomosis, the ICGV image range was set sufficiently wide to accommodate the possibility that the distal artery was not the one anticipated. ICGV followed complete occlusion by temporary clipping of the recipient M2. RESULTS: In 2 of the 13 cases, the relationship between the M2 and M4 could not be clarified. CONCLUSIONS: In cases with developed collateral circulation or small perfusion area of the occluded M2, it was difficult to ascertain the relationship by TCI. Nevertheless, TCI was useful in 11 of the 13 cases, suggesting that unnecessary dissection in the subarachnoid space may be reduced using this technique.