Exploring the Factors Affecting the Transferability of Vancomycin to Cerebrospinal Fluid in Postoperative Neurosurgical Patients with Bacterial Meningitis.

Vancomycin (VCM) is a standard treatment for bacterial meningitis. However, little is known about the transferability of VCM to cerebrospinal fluid (CSF), thus evidence of the transferability of VCM to CSF during bacterial meningitis is needed. In this study, we evaluated the concentration of VCM in the plasma and CSF of postoperative neurosurgical patients with bacterial meningitis and evaluated the factors that affect the transferability of VCM to CSF. The concentrations of VCM in plasma (trough) and CSF were determined in eight patients (four males and four females) with bacterial meningitis who were treated with VCM using HPLC. The ratio of the VCM concentrations in CSF/plasma was also calculated by estimating the blood VCM concentration at the same time as the VCM concentration in CSF was measured. The results showed that the VCM concentration in CSF was 0.9-12.7 µg/mL and the CSF/plasma VCM concentration ratio was 0.02-0.62. We examined the effect of drainage on the transferability of VCM to CSF, which showed that the VCM concentration in CSF and the CSF/plasma VCM concentration ratio were significantly higher in patients not undergoing drainage than in patients who were undergoing drainage. The CSF protein and glucose concentrations, which are diagnostic indicators of meningitis, were positively correlated with the VCM concentration in CSF and the CSF/plasma VCM concentration ratio. Thus, VCM transferability to CSF may be affected by changes in the status of the blood-brain barrier and blood-cerebrospinal fluid barrier due to drainage or meningitis.

Influences of protein levels on the cerebrospinal fluid distribution of ceftazidime & ceftriaxone in the cerebrospinal fluid of patients with inflamed meningitis.

INTRODUCTION: Ceftazidime and ceftriaxone are used to treat various gram-negative pathogens, such as Streptococcus pneumoniae and Pseudomonas aeruginosa, and have shown excellent therapeutic efficacy against bacterial meningitis. However, there is insufficient information on the pharmacokinetic characteristics of their cerebrospinal distribution. Here, we investigated the association of clinical laboratory data in cerebrospinal fluid with ceftazidime and ceftriaxone concentration in the cerebrospinal fluid of patients with inflamed meningitis. METHODS: Cerebrospinal fluid samples were collected from eight adult patients with inflamed meningitis who intravenously received either ceftazidime or ceftriaxone (ceftazidime: a total of 25 samples from three patients, ceftriaxone: a total of 12 samples from five patients). Total cell number, protein concentration, and glucose concentration in the cerebrospinal fluid were retrospectively collected from electronic medical charts. All ceftazidime and ceftriaxone concentrations in the cerebrospinal fluid were determined using high-performance liquid chromatography. RESULTS: Both ceftazidime and ceftriaxone concentrations in cerebrospinal fluid correlated with protein concentration in cerebrospinal fluid; however, no significant correlation was observed in total cell number and glucose concentration in cerebrospinal fluid. CONCLUSIONS: This is the first report on the relationship between the cerebrospinal distribution of these antibiotics and clinical laboratory data in cerebrospinal fluid of adult patients with meningitis.

Extracranial-intracranial bypass for internal carotid/middle cerebral atherosclerotic steno-occlusive diseases in conjunction with carotid endarterectomy for contralateral cervical carotid stenosis: clinical results and cognitive performance.

Clinical results as well as cognitive performances after extracranial to intracranial (EC-IC) bypass in conjunction with contralateral carotid endarterectomy (CEA) are poorly understood. Data from 14 patients who underwent unilateral EC-IC bypass for atherosclerotic internal carotid artery (ICA)/middle cerebral artery (MCA) steno-occlusive disease in conjunction with CEA for contralateral cervical carotid stenosis were retrospectively reviewed. Postoperative results were evaluated by MRI imagings. Nine patients also underwent neuropsychological examinations (NPEs), including assessment by the Wechsler Adult Intelligence Scale-Third Edition and the Wechsler Memory Scale-Revised (WMS-R) before and about 6 months after bilateral surgeries. Postoperative MRI follow-up (median, 8 months; interquartile range, 7-8 months) confirmed successful bypass in all patients, with no additional ischemic lesions on T2WI when compared with preoperative imaging. Further, MRA showed patent bypass and contralateral smooth patency at CEA portion in all patients. In the group rate analysis, all five postoperative NPE scores (Verbal IQ, Performance IQ, WMS-memory, WMS-attention, and Average scores of all those four scores) were improved relative to preoperative NPE scores. Performance IQ and Average score improvements were statistically significant. Clinical results after EC-IC bypass in conjunction with contralateral CEA were feasible. Based on the group rate analysis, we conclude that successful unilateral EC-IC bypass and contralateral carotid endarterectomy does not adversely affect postoperative cognitive function.

Interhemispheric transchoroidal approach to resect third ventricular teratoma.

The authors demonstrate an interhemispheric transchoroidal approach for third ventricular teratoma resection. Interhemispheric dissection exposed the corpus callosum at a length of about 2 cm. A callosotomy was made to enter into the right lateral ventricle. After septal vein ligation, dissection was made of the space between the right fornix and right internal cerebral vein (ICV); thus bilateral fornix and left ICV would be retracted to the left; right choroid plexus, right ICV to the right. By this transchoroidal approach, the foramen of Monro was extended posteriorly, providing enough of a surgical corridor to resect a posteriorly located third ventricular tumor. The video can be found here: https://youtu.be/gIzPiH3zx_o .

Postoperative transient neurological symptoms and chronic subdural hematoma after extracranial-intracranial bypass for internal carotid/middle cerebral atherosclerotic steno-occlusive diseases: negative effect on cognitive performance.

BACKGROUND: The mechanisms underlying post-extracranial to intracranial (EC-IC) bypass neurocognitive changes are poorly understood. METHODS: Data from 55 patients who underwent a unilateral EC-IC bypass for atherosclerotic internal carotid artery (ICA)/middle cerebral artery (MCA) steno-occlusive disease were retrospectively evaluated. These patients underwent neuropsychological examinations (NPEs), including assessment by the Wechsler Adult Intelligence Scale-Third Edition and Wechsler Memory Scale-Revised (WMS-R) before and 6 months after EC-IC bypass. Results of NPEs were converted into Z-scores from which preoperative cognitive composite scores (CSpre) and postoperative cognitive composite scores (CSpost) were obtained. The association between the change of composite score between pre- and postoperative NPEs (CSpost-pre = CS post - CS pre) and various variables were assessed. These latter variables included occluded artery (ICA or MCA), preexisting ischemic lesion as verified in preoperative T2WI, robust bypass patency as verified by MRA performed approximately 6 months postoperatively, and postoperative transient neurological symptoms and/or postoperative chronic subdural hematoma (CSDH), both of which were dichotomized as postoperative events. RESULTS: Postoperative MRI follow-up (median, 6 months; interquartile range, 5-8 months) confirmed successful bypasses in all patients, with no additional ischemic lesions on T2WI when compared with preoperative imaging. Further, MRA showed patent bypasses in all patients. A nearly statistically significant CS post-pre decrease was observed in patients with postoperative events when compared with those without postoperative events (-0.158 vs. 0.039; p = 0.069). A multiple regression model predicting CSpost-pre was performed. After controlling for occluded arteries, postoperative events were identified as an independent predictor of a decline in CSpost-pre (p = 0.044). In the group rate analysis, three of four postoperative NPE scores (Performance IQ, WMS-memory, WMS-attention) were significantly improved relative to preoperative NPE scores. CONCLUSIONS: Postoperative transient neurological symptoms and/or CSDH might play a significant role in the subtle decline in cognition following an EC-IC bypass. However, this detrimental effect was small, and based on the group rate analysis, we concluded that a successful unilateral EC-IC bypass does not adversely affect postoperative cognitive function.

Surgical embolectomy for internal carotid artery terminus occlusion.

The aim of this study was to assess the efficacy and safety of surgical embolectomy for internal carotid artery terminus (ICA-T) occlusion. Twenty-five consecutive patients with acute ischemic stroke attributed to embolic ICA-T occlusion who underwent surgical embolectomy were retrospectively reviewed. Twenty-four patients were examined based on magnetic resonance imaging, with one patient included based on a computed tomography scan. Recanalization rate, recanalization time, complications, National Institutes of Health Stroke Scale (NIHSS) score improvement at 1 month, and modified Rankin Scale (mRS) at 3 months were evaluated. Final recanalization status was Thrombolysis in Myocardial Infarction (TIMI) 3 in 24 patients (96 %). Median recanalization time from symptom onset and from start of surgery was 281 and 79 min, respectively. Two patients (8 %) had major hemorrhagic complications related to surgery. Seventeen patients (68 %) demonstrated NIHSS score improvement of more than 10 points at 1 month. At 3 months, eight patients (32 %) were mRS 0-2, five patients (20 %) were mRS 3, and three patients (12 %) had died. Surgical embolectomy for ICA-T occlusion demonstrated a high complete recanalization rate and should be reconsidered as an additional therapeutic strategy to overcome this devastating situation.

Symptomatic recurrence of intracranial arterial dissections: follow-up study of 143 consecutive cases and pathological investigation.

BACKGROUND AND PURPOSE: The frequency and pattern of symptomatic recurrence of spontaneous intracranial arterial dissection (IAD) are unknown. METHODS: A follow-up study of 143 patients (85 men, 58 women; mean age, 50.7 [7-83] years) with spontaneous IADs at The University of Tokyo and affiliated hospitals from 1980 to 2000 was conducted. Tissue samples of IAD vessels obtained from 13 patients at various intervals from onset were also examined histologically. RESULTS: With a mean follow-up of 8.2 years, symptomatic recurrence occurred in 47 patients (33%). Of 37 cases initially presenting with hemorrhage, 35 developed hemorrhagic recurrence with a mean interval of 4.8 days, and 2 developed nonhemorrhagic recurrences after 21 and 85 months, respectively. Of 10 patients initially presenting with nonhemorrhagic symptoms, 1 developed hemorrhagic recurrence 4 days later, and 9 developed nonhemorrhagic recurrences with a mean interval of 8.6 months. Histopathologically, the affected vessels in the acute stage of hemorrhage (days 0-6) demonstrated insufficient granulation formation within the pseudolumen, followed by marked intimal thickening around the pseudolumen and recanalizing vessel formation in the late stage (>day 30). In the late stage of brain ischemia, subintimal and subadventitial hemorrhage accompanied with intimal thickening was observed. CONCLUSIONS: These data indicate that IAD is a disease carrying a relatively high risk of symptomatic recurrence, apparently occurring in 3 phases and patterns: early hemorrhagic recurrence, late nonhemorrhagic recurrence, and chronic fusiform aneurysm transformation. Knowledge of this triphasic recurrence and corresponding histopathological characteristics help determine the treatment and follow-up strategy for IAD patients.

Stratification of intraoperative ischemic impact by somatosensory evoked potential monitoring, diffusion-weighted imaging and magnetic resonance angiography in carotid endarterectomy with routine shunt use.

BACKGROUND: Routine shunting to minimize ischemia during carotid endarterectomy (CEA) is controversial. The aim of this study was to stratify the ischemic parameters associated with CEA and evaluate the effect of routine shunting in attempting to mitigate those ischemia. METHOD: Data from 248 CEAs with routine shunting were retrospectively evaluated. Our assessment included somatosensory evoked potential (SSEP) amplitude reduction more than 50 % and longer than 5 min (SSEP<50%, >5 min), new postoperative diffusion-weighted imaging lesions (new DWI lesions), and severe stenosis as indicated by reduced ipsilateral middle cerebral artery (MCA) signal on preoperative magnetic resonance angiography (MRA asymmetry), as surrogates of hypoperfusion, microembli, and hemodynamic impairment, respectively. RESULTS: SSEP<50%, >5 min occurred in 15 % of CEAs during cross-clamping, and shunting reversed the SSEP changes. New DWI lesions were observed in 4.1 %. Pre-clamping the common and external carotid artery during dissection (pre-clamp method) decreased the rate of new DWI lesions compared to without pre-clamping (3.5 % vs. 7.5 %, P = 0.22). Occlusion time was significantly longer in the pre-clamp method than without pre-clamping (P < 0.0001). However, the incidence of SSEP<50%, >5 min was not increased with the pre-clamp method (p = 1.0) when using information regarding SSEP and collaterals to modify the speed of shunt manipulation. MRA asymmetry was identified in 39 CEAs (15.8 %) with correction of asymmetry postoperatively. MRA asymmetry correlated with symptomatic hyperperfusion (P = 0.0034). Only three CEAs had symptomatic hyperperfusion (1.2 %) with minimal symptoms. Ten CEAs sustained transient ischemia, symptomatic hyperperfusion, or 30-day-stroke (composite postoperative ischemic symptoms). Logistic regression analysis confirmed that SSEP<50%, >5 min (p = 0.009), new DWI lesions (p = 0.004) and MRA asymmetry (p = 0.042) were independent predictors of　composite postoperative ischemic symptoms. CONCLUSIONS: SSEP<50%, >5 min, new DWI lesions, and MRA asymmetry were able to stratify the ischemic impacts in CEA. Meticulous routine shunting could mitigate those appropriately.

Surgical embolectomy for large vessel occlusion of anterior circulation.

OBJECT: The aim of this study was to assess the technical details and the efficacy and safety of surgical embolectomy for occlusion of large vessels in the anterior circulation. METHODS: Twenty-three consecutive patients with acute ischemic stroke attributed to embolic occlusion of large arteries of the anterior circulation who underwent treatment with surgical embolectomy were retrospectively reviewed. Twenty patients were treated based on data from magnetic resonance angiography (MRA)-diffusion weighted imaging (DWI) mismatch, while three other patients had contraindications to magnetic resonance imaging (MRI) and were treated based on computed tomography (CT) and digital subtraction angiography (DSA) findings. Clinical outcomes, including recanalization rate, recanalization time, complications, modified Rankin Scale (mRS) at 3 months, and National Institute of Health Stroke Scale (NIHSS) score improvement at 1 month, were evaluated. RESULTS: Among the 23 patients (median age, 80 years; median presenting NIHSS score, 21 points), the occlusion site was the internal carotid artery (ICA) terminus in six patients, the M1 segment of the middle cerebral artery (MCA) in 10 patients, and the M2 division of the MCA in seven patients. Final recanalization status was thrombolysis in myocardial infarction (TIMI) 3 in 21 patients (91%). Median recanalization time from symptom onset and from start of surgery was 282 min and 70 min, respectively. One patient (4.3%) had symptomatic haemorrhage. Three patients (13%) had brain oedema due to massive infarction of affected vessel area; two of these patients had undergone embolectomy based on CT findings and had successful recanalization, while one patient underwent embolectomy based on MRI findings and did not have successful recanalization. All 18 patients who underwent embolectomy based on MRA-DWI mismatch and had successful recanalization did not develop additional confluent ischaemic lesion on postoperative DWI. At 3 months, seven patients (30%) had a mRS score of 0-2, eight patients (35%) had a mRS score of 3, and none of the patients had died. Sixteen patients (70%) demonstrated NIHSS score improvement of more than eight points at 1 month. CONCLUSION: Surgical embolectomy for occlusion of large vessels in the anterior circulation resulted in a high complete recanalization rate with an acceptable safety profile. Use of MRA-DWI mismatch as an indication for surgical embolectomy was associated with a reduced complication rate.

Acute to subacute surgical revascularization for progressing stroke in atherosclerotic vertebrobasilar occlusion.

BACKGROUND: Acute vertebrobasilar artery (VBA) occlusion is catastrophic. For embolic occlusion, thrombolysis is reasonable. However, if the occlusion is atherosclerotic, the best therapeutic approach remains unclear. The aim of this study was to characterize the clinical course, case selection, techniques and complications associated with acute to subacute surgical revascularization in atherosclerotic vertebrobasilar occlusion under appropriate patient selection based on diffusion-weighted imaging (DWI) combined with careful evaluation of progressive neurological symptoms. METHODS: We retrospectively reviewed nine consecutive patients who were scheduled to undergo acute to subacute surgical revascularization for progressing stroke in atherosclerotic VBA occlusion consisting of a relatively small DWI lesion. Clinical characteristics, radiological findings, results of revascularization, and 3-month outcomes (mRS) were assessed. RESULTS: Seven patients underwent surgical revascularization (superficial temporal artery [STA]-superior cerebellar artery [SCA] bypass, n = 5; occipital artery [OA]-posterior inferior cerebellar artery [PICA] bypass, n = 1; vertebral endarterectomy, n = 1). Revascularization distal to the occlusion was successful in all seven patients. Two patients scheduled for STA-SCA bypass sustained irreversible confluent brainstem infarction before surgical intervention and died. The median time between admission and surgical treatment or irreversible coma was 20 h (range, 4-72 h). The modified Rankin Scale (mRS) at 3 months of seven patients who underwent surgical revascularization was good (mRS 0-2) in four patients, poor (mRS 3-6) in three patients. Mid- to long-term bypass patency was confirmed by magnetic resonance angiography (MRA) in the surviving five patients at a median follow-up of 7 months (range, 1-25 months). CONCLUSION: Atherosclerotic vertebrobasilar artery (VBA) occlusion presented with stuttering onset of symptoms and patients developed worsening symptoms of vertebrobasilar insufficiency over hours to days. DWI was a useful modality to help guide the appropriate selection of patients for acute to subacute surgical revascularization for progressing stroke in atherosclerotic VBA occlusion. The surgical methods themselves were feasible. Poor outcomes were related to delay of treatment rather than surgical or technical failure.

[A case of a penetrating brain injury due to an explosion of a construction machine].

Penetrating brain injury caused by a high speed projectile is rather rare in Japan, known for its strict gun-control laws. We report a case of a 55-year-old male, who was transferred to our hospital with a foreign body in the brain due to penetrating head injury, which was caused by an explosion of a construction machine. Neurological examination demonstrated severe motor aphagia with no apparent motor paresis. The patient had a scalp laceration on his left forehead with exposed cerebral tissue and CSF leakage. Head CT scan and plain skull X-ray revealed a 20 mm×25 mm bolt which had penetrated due to the explosion of the machine. The anterior wall of the left frontal sinus was fractured resulting in dural laceration, and scattered bone fragments were seen along the trajectory of the bolt. Digital subtraction angiography showed no significant vascular injuries including superior sagittal sinus. We performed open surgery, and successfully removed the bolt along with the damaged frontal lobe. The patient had no infection or seizure after the surgery, and was transferred for further rehabilitation therapy. We performed a cosmetic cranioplasty six months later. Surgical debridement of the damaged cerebral tissue along the trajectory led to successful removal of the bolt with no further neurological deficit.

Different intra-cerebrospinal distribution of linezolid in patients with inflammatory meningitis.

Linezolid has excellent antibiotic activity against gram-positive organisms and is expected to be an alternative to vancomycin for the treatment of bacterial meningitis. Accumulated evidence has shown the superior pharmacokinetic characteristics of linezolid to vancomycin, such as cerebrospinal fluid penetration. However, in the treatment of meningitis, pharmacokinetic information regarding the intra-cerebrospinal distribution of linezolid and the effects of drainage on the linezolid concentration in the cerebrospinal fluid are unclear. This report describes two patient cases, in which the linezolid concentrations in the cerebrospinal fluid were in the following order: subarachnoid space (cisternal drainage and lumbar puncture) ≥ third ventricle > lateral ventricle. In addition, the linezolid concentration in the cerebrospinal fluid, collected via lumbar puncture, tended to increase after removal of the drainage. This report is novel in presenting two cases of meningitis that showed different intra-cerebrospinal distribution of linezolid in various parts of the central nervous system and an increased linezolid concentration in the cerebrospinal fluid after removal of the drainage.

Cerebral Hyperperfusion Syndrome After a Burr Hole Drainage Surgery for Chronic Subdural Hematoma.

BACKGROUND: Although chronic subdural hematoma (CSDH) has a good prognosis after classical minimally-invasive drainage surgery, severe complications still occur at a substantial rate. Cerebral hyperperfusion syndrome (CHS), which is a common severe complication after carotid endarterectomy or carotid artery stenting for cervical carotid artery stenosis, is rare after drainage surgery for a CSDH. CASE DESCRIPTION: We describe the case of an 82-year-old woman who presented with ipsilesional symptoms including contralateral hemiparesis and dysarthria, progressively worsening consciousness, and status epilepticus after a burr hole drainage surgery for CSDH. Magnetic resonance fluid-attenuated inversion recovery imaging showed diffuse subcortical low intensity in the ipsilesional hemisphere almost simultaneously with the appearance of the symptoms. Arterial spin labeling magnetic resonance perfusion imaging showed the abnormal increase of cerebral blood flow in the hemisphere. Continuous propofol administration and blood pressure management improved the symptoms. CONCLUSIONS: CHS can cause severe postoperative complications after drainage surgery for CSDH. Subcortical low-intensity fluid-attenuated inversion recovery imaging is a useful investigation for early detection of CHS in CSDH, and arterial spin labeling imaging is an effective minimally-invasive modality for confirming the diagnosis.

Direct and primary carotid endarterectomy for common carotid artery occlusion. Report of 2 cases.

BACKGROUND: Cerebral ischemia associated with chronic CCA occlusion is a rare condition and raises strategic dilemma when the revascularization is needed. METHODS: Two patients with CCA occlusion presented with ischemic symptom associated with the affected side. Both patients underwent vascular reconstruction by direct carotid endarterectomy to achieve primary restoration of CCA to ICA flow. RESULTS: Successful reopening of the vessels was obtained in both patients without the evidence of postsurgical ischemic event. Follow-up MRA was obtained at later than 6 months after surgery, which demonstrated patent CCA-ICA in both patients. CONCLUSIONS: Direct carotid endarterectomy of the occluded CCA can be safely performed if the preoperative angiography suggest still patent vessels distal to carotid bifurcation and the substantial "back flow" is obtained from ICA during arteriotomy.

Clipping and superficial temporal artery-M2 bypass for unruptured anterior communicating artery aneurysm associated with atherosclerotic internal carotid artery occlusion: report of 2 cases.

BACKGROUND: The management of the unruptured AcomA aneurysm associated with atherosclerotic occlusion of the unilateral internal carotid artery (ICA) raises several strategic dilemmas. METHODS: Two such patients with unruptured aneurysm on the AcomA, which supply cross-flow toward the hemisphere with ICA occlusion, are presented. RESULTS: Both patients were treated with STA-M2 bypass followed by clipping of the unruptured AcomA aneurysm in 1 stage through the transsylvian route. Both patients were doing well without neurological deficit nor cognitive impairment at 1 year follow-up. CONCLUSIONS: In the surgical treatment of unruptured AcomA aneurysm with atherosclerotic ICA occlusion, preceding bypass would be ideal in case of intraoperative rupture as well as to reduce perioperative ischemia if the bypass procedure itself could be performed with minimal risk. Enough and atraumatic exposure of the sylvian fissure contributed to reduce brain retraction during the clipping of AcomA aneurysm and, in addition, to ease the STA-M2 bypass.

Training of A3-A3 side-to-side anastomosis in a deep corridor using a box with 6.5-cm depth: technical note.

BACKGROUND: Cerebral revascularization in the deep surgical field is technically challenging. Especially, side-to-side anastomosis like A3-A3 could be technically more difficult compared with end-to-side anastomosis. To improve surgeon's dexterity and maneuverability in the deep surgical field, the authors developed an easily accessible and well-simulating training system using prosthetic tubes and a box. METHODS: Two prosthetic tubes (silicon tube, 1.2 mm in diameter) are mounted in parallel on the bottom of 6.5-cm-deep emptied 'tissue paper box.' The orifice of the box is restricted to 2 x 2 cm to simulate a deep and narrow surgical corridor. Using bayonet-shaped micro needle holder and forceps, the side-to-side anastomosis of the tubes is performed with 10-0 nylon under operative microscope. RESULTS: Prosthetic tubes well simulated real A3-A3 anastomosis. From the standpoint of technical difficulty, this training system needed slightly higher level of dexterity compared with real A3-A3 anastomosis because of narrower and deeper surgical corridor, and the wall of prosthetic tube was slightly thicker and more inflexible. After this training, the surgical technique in real A3-A3 anastomosis was improved. CONCLUSIONS: This training system worked well to ease the transition from anastomosis in shallow surgical field to deep and narrow surgical field. The prosthetic tube we used approximates real A3 relatively well, and the ease in setting up this system enabled repeated practice, which resulted in steep learning curve of the technique.

Effectiveness of suturing training with 10-0 nylon under fixed and maximum magnification (x 20) using desk type microscope.

BACKGROUND: Microvascular anastomosis using 10-0 nylon needs a higher level of technical dexterity compared with routine neurosurgical maneuvers. Although this technique remains an important part of treating complex intracranial aneurysms or cerebrovascular disease, the surgeon's clinical experience in using this technique is not so common. METHODS: To improve dexterity and maneuverability in the limited clinical case volume, we developed an easily accessible training system, using commercially available desk type microscope and simply suturing neighboring fibers of the gauze with 10-0 nylon under fixed and highest (x 20) magnification. RESULT: This training system is somewhat of a drawback compared to the simulation of a real clinical setting. However, because of the extremely easy availability and accessibility of the dark type microscope repeated training and the accumulation of more than 10000 stitches, on average, was accomplished. This resulted in a steep learning curve of the technique. CONCLUSION: For residency and post-residency year young neurosurgeons, who need to brush up their skills due to lower surgical case volume compared with what senior neurosurgeons have experienced this easily available training would contribute to establishing daily and long-lasting microsurgical practice.

Terson's syndrome as the initial symptom of subarachnoid hemorrhage caused by ruptured vertebral artery aneurysm. Case report.

A 61-year-old male initially presented to the ophthalmology department complaining of sudden visual loss. Fundus photography and ultrasonography followed by computed tomography identified Terson's syndrome caused by subarachnoid hemorrhage (SAH). Cerebral angiography revealed a dissecting aneurysm of the left vertebral artery. Other than obtunded visual acuity, his neurological examination was normal and he denied any headache. He was treated conservatively with pain and blood pressure control. He complained of headache associated with rerupture of the aneurysm on day 5. The patient died of rerupture on day 14. The clinical course of this patient indicates that Terson's syndrome may occur without sudden increase of intracranial pressure. Terson's syndrome may occur as a rare initial clinical sign of SAH caused by ruptured cerebral aneurysm.

Incidence of ischemic lesions by diffusion-weighted imaging after carotid endarterectomy with routine shunt usage.

Temporary intraluminal shunt was used during 72 consecutive carotid endarterectomies (CEAs) in 61 patients (bilateral CEA in 11 patients) during October 2001 and September 2005. The medical records of these patients were retrospectively reviewed. All procedures were performed with routine shunt insertion without monitoring such as electroencephalography. Pre- and postoperative diffusion-weighted magnetic resonance (MR) imaging was used to detect ischemic complications. Postoperative angiography was performed in 70 cases to detect abnormalities such as major stenosis or dissection of the distal end. Symptomatic ischemic complication occurred in one patient at 1 month. Postoperative diffusion-weighted MR imaging detected new hyperintense lesions in three patients including the symptomatic patient. Postoperative angiography confirmed that the distal end was satisfactory in all cases. The incidence of ischemic lesions of embolic origin after CEA with routine shunt usage is acceptably low if the procedure of shunt device insertion and removal is meticulously conducted.