Subclavian Artery-Carotid Artery Bypass for Subclavian Artery or Common Carotid Artery Severe Stenosis or Occlusion.

Various surgical treatments are available for occlusive subclavian and common carotid artery diseases. Nevertheless, to date, when cerebral endovascular treatment is utilized, revascularization via direct surgery may be required. This study reported five symptomatic cases of revascularization for CCA and SCA occlusive and stenotic lesions that were expected to be challenging to treat with endovascular treatment. We performed subclavian artery-common carotid artery or internal carotid artery bypass using artificial blood vessels or saphenous vein grafts in five patients with subclavian steal syndrome, symptomatic common carotid artery occlusion, and severe proximal common carotid artery stenosis. In this study, good bypass patency was achieved in all five cases. Although there were no intraoperative complications, one patient had a postoperative lymphatic leak. Moreover, there was no recurrence of stroke during postoperative follow-up for an average of 2 years. Conclusively, subclavian artery-common carotid artery bypass can be an effective surgical treatment for common carotid artery occlusion, proximal common carotid artery stenosis, and subclavian artery occlusion.

Gamma Knife Thalamotomy for Essential Tremor: A Retrospective Analysis.

BACKGROUND: Gamma knife (GK) thalamotomy has been used as a treatment option for essential tremor (ET). Numerous studies on GK use in ET treatment have reported more varied responses and complication rates. METHODS: Data from 27 patients with ET who underwent GK thalamotomy were retrospectively analyzed. The Fahn-Tolosa-Marin Clinical Rating Scale for Tremor, handwriting, and spiral drawing were evaluated. Postoperative adverse events and magnetic resonance imaging findings were also evaluated. RESULTS: The mean age at GK thalamotomy was 78.1 ± 4.2 years. The mean follow-up period was 32.5 ± 19.4 months. The preoperative postural tremor, handwriting, and spiral drawing scores were 3.4 ± 0.6, 3.3 ± 1.0, and 3.2 ± 0.8, respectively, all of which showed significant improvements to 1.5 ± 1.2 (55.9% improvement, P < 0.001), 1.4 ± 1.1 (57.6% improvement, P < 0.001), and 1.6 ± 1.3 (50% improvement, P < 0.001), respectively, at the available final follow-up evaluations. Three patients presented with no improvement in tremor. Six patients presented with adverse effects, including complete hemiparesis, foot weakness, dysarthria, dysphagia, lip numbness, and finger numbness, at the final follow-up period. Two patients presented with serious complications, including complete hemiparesis due to massive widespread edema and chronic encapsulated expanding hematoma. One patient died of aspiration pneumonia following severe dysphagia secondary to chronic encapsulated expanding hematoma. CONCLUSIONS: GK thalamotomy is an efficient procedure for treating ET. Careful treatment planning is necessary to reduce complication rates. The prediction of radiation complications will increase the safety and effectiveness of GK treatment.

Case Report: Long-Term Suppression of Paroxysmal Kinesigenic Dyskinesia After Bilateral Thalamotomy.

Background: Paroxysmal kinesigenic dyskinesia (PKD) is a movement disorder characterized by transient dyskinetic movements, including dystonia, chorea, or both, triggered by sudden voluntary movements. Carbamazepine and other antiepileptic drugs (AEDs) are widely used in the treatment of PKD, and they provide complete remission in 80-90% of medically treated patients. However, the adverse effects of AEDs include drowsiness and dizziness, which interfere with patients' daily lives. For those with poor compatibility with AEDs, other treatment approaches are warranted. Case Report: A 19-year-old man presented to our institute with right hand and foot dyskinesia. He had a significant family history of PKD; his uncle, grandfather, and grandfather's brother had PKD. The patient first experienced paroxysmal involuntary left hand and toe flexion with left forearm pronation triggered by sudden voluntary movements at the age of 14. Carbamazepine (100 mg/day) was prescribed, which led to a significant reduction in the frequency of attacks. However, carbamazepine induced drowsiness, which significantly interfered with his daily life, especially school life. He underwent right-sided ventro-oral (Vo) thalamotomy at the age of 15, which resulted in complete resolution of PKD attacks immediately after the surgery. Four months after the thalamotomy, he developed right elbow, hand, and toe flexion. He underwent left-sided Vo thalamotomy at the age of 19. Immediately after the surgery, the PKD attacks resolved completely. However, mild dysarthria developed, which spontaneously resolved within three months. Left-sided PKD attacks never developed six years after the right Vo thalamotomy, and right-sided PKD attacks never developed two years after the left Vo thalamotomy without medication. Conclusion: The present case showed long-term suppression of bilateral PKDs after bilateral thalamotomy, which led to drug-free conditions.

Radiofrequency Ablation for Movement Disorders: Risk Factors for Intracerebral Hemorrhage, a Retrospective Analysis.

BACKGROUND: One of the greatest concerns associated with radiofrequency ablation is intracerebral hemorrhage (ICH). However, the majority of previous studies have mainly evaluated Parkinson disease patients with ablation of the globus pallidus internus (GPi). OBJECTIVE: To investigate the hemorrhagic risk associated with radiofrequency ablation using ventro-oral (Vo) nucleus, ventral intermediate (Vim) nucleus, GPi, and pallidothalamic tract. METHODS: Radiofrequency ablations for movement disorders from 2012 to 2019 at our institution were retrospectively analyzed. Multivariate analyses were performed to evaluate associations between potential risk factors and ICH. RESULTS: A total of 558 patients underwent 721 stereotactic radiofrequency ablations for movement disorders. Among 558 patients, 356 had dystonia, 111 had essential tremor, and 51 had Parkinson disease. Among 721 procedures, the stereotactic targets used in this study were as follows: Vo: 230; Vim: 199; GPi: 172; pallidothalamic tract: 102; Vim/Vo: 18. ICH occurred in 37 patients (5.1%, 33 with dystonia and 4 with essential tremor). Symptomatic ICH developed in 3 Vo nuclei (1.3%), 3 Vim nuclei (1.5%), and 2 GPi (1.2%). Hypertension (odds ratio = 2.69, P = .0013), higher number of lesions (odds ratio = 1.23, P = .0221), and younger age (odds ratio = 1.04, P = .0055) were significant risk factors for ICH associated with radiofrequency ablation. CONCLUSION: The present study revealed that younger age, higher number of lesions, and history of hypertension were independent risk factors for ICH associated with stereotactic radiofrequency ablation.

Case Report: Deep Cerebellar Stimulation for Tremor and Dystonia.

Background: The cerebellum plays an important role in the pathogenesis and pathophysiology of movement disorders, including tremor and dystonia. To date, there have been few reports on deep cerebellar stimulation. Case Report: The patient was a 35-year-old previously healthy man with no history of movement disorders. He developed a tremor and stiffness in his left hand at the age of 27 years, which was diagnosed as a dystonic tremor. We performed right thalamotomy, which resulted in a complete resolution of the tremor; however, the dystonia persisted. Subsequently, the patient developed left foot dystonia with inversion and a newly developed tremor in the right hand and foot. The patient underwent left ventralis intermedius (VIM) deep brain stimulation (VIM-DBS) and left pallidothalamic tract DBS (PTT-DBS). Left VIM-DBS completely resolved the right hand and foot tremor, and PTT-DBS significantly improved the left hand and foot dystonia. Three months postoperatively, the patient developed an infection and wound disruption at the surgical site. We performed palliative surgery for deep cerebellar stimulation via the posterior cranial region, which was not infected. The surgery was performed under general anesthesia with the patient lying in the prone position. Eight contact DBS electrodes were used. The placement of electrodes extended from the superior cerebellar peduncle to the dentate nucleus. Both the right hand and foot tremor improved with right cerebellar stimulation. Further, both the left hand and foot dystonia improved with left cerebellar stimulation. Right and left cerebellar stimulation led to no improvement in the left hand and foot dystonia and right hand and foot tremor, respectively. Stimulation-induced complications observed in the patient included dizziness, dysphagia, and dysarthria. After the surgery, the patient developed hypersalivation and hyperhidrosis in the left side of the body, both of which did not improve with adjustments of stimulation parameters. At the 6-month follow-up, the tremor and dystonia had almost completely resolved. Conclusion: Deep cerebellar stimulation deserves consideration as a potential treatment for tremor and dystonia.

Intra-arterial Injection of Fasudil Hydrochloride for Cerebral Vasospasm Secondary to Bacterial Meningitis.

The occurrence of cerebral vasospasm secondary to bacterial meningitis is relatively rare. Furthermore, there is no specific treatment cerebral vasospasm. Endovascular treatment may be essential for cases with the advanced clinical course. Balloon angioplasty or intra-arterial injection of verapamil, nicardipine, or nitroglycerin has been previously reported. We experienced successful treatment using intra-arterial infusion of fasudil hydrochloride. To our knowledge, this is the first case to report the intra-arterial injection of fasudil hydrochloride for treating cerebral vasospasm secondary to bacterial meningitis. A 37-year-old female who presented with dizziness had a right cerebellar tumor that was excised and diagnosed as glioblastoma. On postoperative day 10, Streptococcus oralis meningitis was detected. On postoperative day 20, the patient developed right hemiparesis with a severe vasospasm of the bilateral middle cerebral artery and anterior cerebral artery. Intra-arterial fasudil hydrochloride injection was performed for 3 days, following which the patient's symptoms improved. Symptomatic cerebral vasospasm secondary to bacterial meningitis is relatively rare and difficult to treat; in selected cases, intra-arterial fasudil hydrochloride injection was an effective treatment for cerebral vasospasm secondary to bacterial meningitis.