Initial Progressions of Carotid Artery Plaque Are Associated with Risk Factors of Cardiovascular Disease.

BACKGROUND: Carotid artery plaque, white matter disease (WMD), and silent lacunae infarcts (initial indicators) are associated with symptomatic cerebral infarction (CI) caused by atherosclerosis. We retrospectively examined the association between the initial indicators and risk factors for cerebrovascular disease, considering the primary prevention of symptomatic CI. METHODS: We divided 1503 individuals who were neurologically healthy and enrolled in a brain screening program (brain dock) at our institution, into three initial plaque grades (grade 0, 1, and 2) based on having no plaques, having plaques on the right or left carotid artery, or having plaques on both carotid arteries, respectively. We analyzed the risk factors according to the presence/absence of the initial indicators. RESULTS: WMD and the risk factors (low-density lipoprotein [LDL], hemoglobin A1c, systolic blood pressure [BP], and smoking cigarettes) were positively correlated with the initial plaque grades, even when their laboratory values were within normal ranges. Systolic BP (116.5 ± 14.0 mmHg) was significantly lower in group 00 (without carotid plaque and WMD) than that in age-adjusted others (with carotid plaque or WMD). In young participants aged between 40 and 52 years, LDL (132.8 ± 24.5 mg/dl) was significantly higher in subgroup ++ (with carotid plaque and WMD) compared to others (without carotid plaque or WMD). CONCLUSION: Initial plaque grade and WMD grade as clinical initial indicators of symptomatic CI are associated with risk factors. To avoid deterioration of the initial indicators, it was suggested that the risk factors should be maintained at the lower ends of normal ranges and smoking cessation should be recommended.

Development of a Robust Autofluorescence Lifetime Sensing Method for Use in an Endoscopic Application.

Endoscopic autofluorescence lifetime imaging is a promising technique for making quantitative and non-invasive diagnoses of abnormal tissue. However, motion artifacts caused by vibration in the direction perpendicular to the tissue surface in a body makes clinical diagnosis difficult. Thus, this paper proposes a robust autofluorescence lifetime sensing technique with a lens tracking system based on a laser beam spot analysis. Our optical setup can be easily mounted on the head of an endoscope. The variation in distance between the optical system and the target surface is tracked by the change in the spot size of the laser beam captured by the camera, and the lens actuator is feedback-controlled to suppress motion artifacts. The experimental results show that, when using a lens tracking system, the standard deviation of fluorescence lifetime is dramatically reduced. Furthermore, the validity of the proposed method is experimentally confirmed by using a bio-mimicking phantom that replicates the shape, optical parameters, and chemical component distribution of the cancerous tissue.

Intentional Severing of the Internal Carotid Artery in the Surgical Treatment.

BACKGROUND: Thrombosed brain aneurysm is usually treated by cerebrovascular surgery rather than endovascular surgery. The basilar-superior cerebellar artery (BA-SCA) aneurysm can be accessed via the transsylvian, temporopolar, or anterior temporal approaches. However, a disadvantage of these approaches is that the surgical route is obstructed by the internal carotid artery (ICA). Therefore, we propose that after establishing a high-flow bypass, severing the ICA will enable safe clipping of a BA-SCA aneurysm. CLINICAL PRESENTATION: In this case, we sought to clip a large thrombosed BA-SCA aneurysm; however, the operative field was limited by the ICA after using a zygomatic anterior temporal approach with anterior clinoidectomy, including severing of the distal dural ring. Therefore, after establishment of a high-flow bypass, the operative field was widened by intentional severing of the ICA between the ophthalmic artery and posterior communicating artery. Using this procedure, we achieved complete obliteration of the thrombosed BA-SCA aneurysm without additional arterial ischemic complications. DISCUSSION AND CONCLUSIONS: Intentional severing of the ICA after establishing a high-flow bypass will not become the standard technique for treatment of upper basilar artery aneurysms. However, this technique can extend the operative field to allow clipping of an upper basilar artery aneurysm after several skull base techniques.

Bladder recovery relates with increased mid-cingulate perfusion after shunt surgery in idiopathic normal-pressure hydrocephalus: a single-photon emission tomography study.

AIMS OF STUDY: It is reported that severe bladder disorder in idiopathic normal-pressure hydrocephalus (iNPH) is predicted by right frontal hypoperfusion. However, it is not known whether bladder recovery is predicted by brain perfusion change after shunt surgery. To address this issue, we compared bladder and brain function before and after shunt surgery in iNPH. METHODS: We enrolled 75 patients in the study. Before and 12 months after shunt surgery, we analyzed brain perfusion by SPECT and bladder disorder by a specialized grading scale. The scale consisted of grade 0, none; grade 1, urinary urgency and frequency; grade 2, urinary incontinence 1-3 times a week; grade 3, urinary incontinence >daily; and grade 4, loss of bladder control. More than one grade improvement is defined as improvement, and more than one grade decrement as worsening; otherwise no changes. RESULTS: Comparing before and after surgery, in the bladder-no-change group (32 cases) there was an increase in blood flow which is regarded as reversal of enlargement in the Sylvian fissure and lateral ventricles (served as control). In contrast, in the bladder-improved group (32 cases) there was an increase in bilateral mid-cingulate, parietal, and left frontal blood flow (p < 0.05). In the bladder-worsened group (11 cases) no significant blood flow change was observed. CONCLUSION: The present study showed that after shunt surgery, bladder recovery is related with mid-cingulate perfusion increase in patients with iNPH. The underlying mechanism might be functional restoration of the mid-cingulate that normally inhibits the micturition reflex.

Distal internal carotid artery dissection due to the carotid shunt during carotid endarterectomy.

We described two cases of shunt-related distal internal carotid artery (ICA) dissection from high cervical ICA stenosis. These cases suggest that for high cervical internal carotid endarterectomy, surgeons should reconsider using a carotid shunt to reduce the risk of ICA dissection.

A modified anterior temporal approach for low-position aneurysms of the upper basilar complex.

BACKGROUND: Although surgery for aneurysms of the upper basilar complex is generally accomplished by a pterional or subtemporal approach, both techniques have disadvantages. Therefore, attempts have been made to combine both the approaches, such as an anterior temporal approach, which exposes the anterior aspect of the temporal lobe during standard fronto-temporal craniotomy. However, in all these techniques, the temporal vein is sacrificed to allow posterior retraction of the temporal lobe, which may cause venous infarction in the temporal lobe. METHODS: Our institutional review board approved this prospective study. We modified the anterior temporal approach for low-position aneurysms of the upper basilar complex by performing posterior clinoidectomy as necessary, thereby preventing the sacrifice of all vessels. RESULTS: From 2007 to 2014, seven patients were operated on using this modified approach, and four patients underwent additional posterior clinoidectomy. Complete clip ligation was performed for all aneurysms without sacrificing any vessels, and there were no permanent complications attributable to manipulation for clipping or posterior clinoidectomy. CONCLUSIONS: The modified anterior temporal approach allows a wider operating field within the retro-carotid space, without sacrificing any vessels, and permits safer posterior clinoidectomy and aneurysm clipping in patients with low-position aneurysms of the basilar complex.

Surgical embolectomy for middle cerebral artery occlusion after thrombolytic therapy: A report of two cases.

BACKGROUND: Occlusion of the intracranial main trunk results in a poor functional outcome and a high mortality rate. Accordingly, some revascularization procedures such as intravenous administration of recombinant tissue plasminogen activator (rt-PA), endovascular surgery, or surgical embolectomy in the very acute stage have been attempted. CASE DESCRIPTION: We describe two patients with middle cerebral artery occlusion due to cardiogenic embolism. One patient was subjected to surgical embolectomy shortly after intravenous rt-PA and the other was subjected to same after intra-arterial urokinase. Complete recanalization without new cerebral infarction territory was achieved in both patients. CONCLUSION: Based on our experience, we think that surgical embolectomy is an effective and safe procedure and should be attempted when no response to early thrombolytic therapy is obtained.

Prognostic paradox: brain damage around the glioblastoma resection cavity.

Hyperintense lesions around the resection cavity on magnetic resonance diffusion-weighted imaging (MR-DWI) frequently appear after brain tumor surgery due to the damage of surrounding brain. The putative connection between the lesion and the prognosis for patients with glioblastoma (GBM) was explored. This retrospective study reviewed consecutive sixty-one patients with newly diagnosed GBM. Postoperative MRI was performed within 2 weeks after the initial surgery. We classified the cases into two groups depending on whether DWI hyperintense lesions were observed or not [DWI(+) group and DWI(-) group]. Progression-free survival (PFS) and overall survival (OS) were compared between the two groups. Forty-two patients were identified. The various extents of hyperintense lesions around the resection cavity were observed in 28/42 (66.7%) cases. In the DWI(+) and DWI(-) groups, median PFS was 10.0 [95% confidence interval (CI) 8.4-11.5] and 6.7 (95% CI 4.9-8.5) months, respectively (p = 0.042), and median OS was 18.0 (95% CI 12.2-23.8) and 17.0 (95% CI 15.7-18.3) months, respectively (p = 0.254). On multivariate analysis, the presence of DWI hyperintense lesion was more likely to be an independent predictor for 6-month PFS (p = 0.019; HR, 0.038; 95% CI 0.002-0.582). Tumor recurrence appeared outside the former DWI hyperintense lesion. Hyperintense lesions surrounding the resected GBM on MR-DWI might be a favorable prognostic factor in patients with GBM.

Vertebral artery-to-vertebral artery bypass with interposed radial artery or occipital artery grafts: surgical technique and report of three cases.

BACKGROUND: The treatment of unclippable vertebral artery (VA) aneurysms incorporating the posterior inferior cerebellar artery with parent artery preservation is among one of the most formidable challenges for cerebrovascular microsurgery and endovascular surgery. We propose that intracranial VA reconstruction using an extracranial VA-to-intracranial VA (VA-VA) bypass with a radial artery graft or an occipital artery graft may be an additional technique in the armamentarium to treat these formidable lesions. The rationale, surgical technique, and complications are discussed. METHODS: Three illustrative cases are described, in which the lesions were a VA dissecting aneurysm with ischemic lesions, bilateral asymptomatic unruptured VA aneurysms, and a VA giant aneurysm with subarachnoid hemorrhage. RESULTS: The partial extreme lateral infrajugular transcondylar approach was used. Computed tomographic angiography was useful for preoperative evaluation of the depth of the distal aneurysmal neck. A VA-VA bypass was performed in two patients. Because there was another ipsilateral aneurysm at the V2 segment in one patient, an external carotid artery-VA bypass was performed. Although two patients were discharged with good clinical results, one patient with subarachnoid hemorrhage died because of brainstem infarction. CONCLUSIONS: The VA-VA bypass using a radial artery graft or an occipital artery graft is an option that can be considered in the strategy for treating VA aneurysms to preserve the normal anatomic vascular configuration in the posterior circulation.

Discrepancy between preoperative imaging and postoperative pathological finding of ruptured intracranial dissecting aneurysm, and its surgical treatment: case report.

The choice of therapeutic strategy for intracranial dissecting aneurysm is often based on radiographic features, including characteristic geometry (e.g., irregular stenosis, segmental stenosis, aneurysm formation [pearl-and-string sign]), irregular fusiform or aneurysmal dilation, double lumen, and tapering occlusion. However, there is often a discrepancy between preoperative radiographic data and actual dissecting length. The present report describes three cases in which there was a discrepancy between preoperative radiographic data and actual dissecting length in patients undergoing direct trapping with or without revascularization. All three cases experienced good outcomes, but these cases underscore the fact that open surgery is a good option for management of ruptured intracranial dissecting aneurysms for determination of the rupture point, dissecting length, and the relationship between dissecting area and small arteries arising from the associated vessel.

[Carotid endarterectomy for high cervical internal carotid artery stenosis: study of 22 consecutive patients].

In general, carotid endarterectomy(CEA)for high cervical internal carotid artery(ICA)stenosis is considered a difficult technique. Among 132 patients who underwent CEA between May, 1996 and December, 2012 in our institute, 22 showed high cervical ICA stenosis. A wide operation field was obtained by wide range dissection of shallow anatomical structures without special techniques and the first cervical vertebra was palpable in all patients. All patients underwent CEA and adverse events occurred in 4 patients. We describe the technique and pitfalls of CEA for high cervical ICA stenosis from the anatomical viewpoint.

[A case of cavernous sinus aspergillosis].

We reported a case of cavernous sinus aspergillosis. A 62-year-old man complained of trigeminal neuralgia in the right V1 region. Neurological examination on admission showed ptosis, loss of light reflex and ophthalmoplegia externa in the right side. MRI enhanced with gadolinium demonstrated sphenoid sinusitis and mass lesion in the right cavernous sinus. MRA revealed right internal carotid artery occlusion. An open biopsy using the extradural temporopolar approach was performed. Pus discharge was observed from the cavernous sinus and histological examination showed hypha of Aspergillus. With early voriconazole treatment, the patient had improvement in headache, ptosis and ophthalmoplegia externa. Cavernous sinus aspergillosis is often found after sphenoiditis. It results in invasion to an internal carotid artery and worsens the patient's prognosis by cerebral infarction, so early diagnosis and treatment are important. We should consider aspergillosis as one of the differential diagnoses of a mass in the cavernous sinus. The epidural approach to this lesion was available to obviate aspergillus dissemination into the medullary cavity.

[Evaluation of deep infection of the surgical site after spine surgery].

OBJECTIVE: Surgical site infection(SSI)is commonly seen following spinal surgery, and it can be associated with serious morbidity, mortality, and increased resource utilization. The objective of this study was to identify specific independent risk factors for SSI occurring after spinal surgery. METHODS: We performed a retrospective study of patients who had spinal surgeries performed from January 2007 to July 2012 at our hospital. 10 patients with deep incisional SSI(dSSI)were identified and compared with 304 uninfected control patients. Risk factors for dSSI were determined with Mann-Whitney's U test, univariate analyses, and multivariate logistic regression. RESULTS: The overall rate of dSSI was 3.2%(10 of 314). Mann-Whitney's U test and univariate analyses showed surgery time and duration of postoperative drainage to be significantly higher in patients in whom dSSI developed than in uninfected control patients. Independent risk factors for dSSI that were identified by multivariate analysis were surgery time(odds ratio=9.891, 95% confidence interval=2.434-40.195). CONCLUSION: We identified independent risk factors for dSSI. Surgery time was associated with the highest independent risk of spinal surgical site infection. Duration of postoperative drainage was associated with a significantly increased risk of dSSI in Mann-Whitney's U test and the univariate analysis. However, it did not remain significantly different in multivariate analysis(p value=0.0854, odds ratio=3.227, 95% confidence interval=0.849-12.262).

[The limits and countermeasures of the anterior temporal approach for unruptured upper basilar artery aneurysms].

BACKGROUND AND PURPOSE: In general, upper basilar artery aneurysms are treated following the transsylvian or subtemporal approach. These approaches have both advantages and disadvantages. Therefore, we followed the anterior temporal approach that provides a wider surgical field in the retro-carotid space. METHODS: We reviewed the clinical records of 37 patients with an upper basilar artery aneurysm operated on following the anterior temporal approach between 2002 and 2012 in our institute, and evaluated the usefulness of this approach. RESULTS: In 23 cases, several additional techniques were performed. In all these cases a wide operation field was obtained in the retro-carotid space and the aneurysm was completely obliterated. The post operative adverse events were temporary oculomotor palsy in 6 cases, permanent oculomotor palsy in 3 and temporary epilepsy, aphasia due to venous infarction and asymptomatic cerebral infarction in 1 case each. CONCLUSIONS: The anterior temporal approach allows the additional use of several techniques and provides a wide surgical field. Therefore, we consider this approach is useful to reach and treat upper basilar artery aneurysms.

Resection of metachronous lymph node metastases from hepatocellular carcinoma after hepatectomy: report of four cases.

We report 4 cases of surgical resection of metachronous lymph node (LN) metastases from hepatocellular carcinoma (HCC) following hepatectomy. Clinicopathological features and results of LN dissection were investigated in the 4 patients. One patient was found to have a single metastasis in the mediastinal LNs, another had multiple metastases in the mediastinal and abdominal LNs, and the other 2 had single metastases in the abdominal LN. The locations of the abdominal LN metastases were behind the pancreas head in 2 patients and around the abdominal aorta in 1 patient. They all underwent surgical resection of metastatic LNs and had no postoperative complications. The 3 patients whose LN metastases were solitary have been alive for more than 2 years after LN resection, and one of them is free from recurrence. The patient with multiple LN metastases died 13 months after LN resection due to carcinomatosis. With the expectation of long-term survival, a single metachronous LN metastasis from HCC after hepatectomy should be resected in patients without uncontrollable intrahepatic or extrahepatic tumors.

[Pilocytic astrocytoma of the cerebrum presenting in an elderly patient: a case report].

We report a case of pilocytic astrocytoma of the cerebrum presenting in an elderly patient. A 76-year-old man was admitted to our department due to the development of dysarthria. MRI showed a cystic mass with an enhanced small mural nodule in the left frontal lobe. At surgery, the cyst contents were aspirated, and the mural nodule was excised. Histological examination showed a pattern that is usually seen in pilocytic astrocytoma of the cerebellum, including loose and compact areas composed of pilocytic and stellate cells, a few eosinophilic granular bodies, but not Rosenthal fibers. Pilocytic astrocytoma is a common type of pediatric brain tumor that can arise within either the cerebellum or the hypothalamic/chiasmatic region, but rarely seen in the cerebral hemisphere at an advanced age. To our knowledge, only 45 cases of pilocytic astrocytoma of the cerebrum developing in an adult are reported. In those cases, the symptoms of the disease developed during the third decade of life. The onset at a most advanced age as in the present case is thought to be extremely rare.

Diagnosis of idiopathic normal pressure hydrocephalus is supported by MRI-based scheme: a prospective cohort study.

BACKGROUND: Idiopathic normal pressure hydrocephalus (iNPH) is a treatable neurological syndrome in the elderly. Although the magnetic resonance imaging (MRI) findings of tight high-convexity and medial subarachnoid spaces and the ventriculo-peritoneal (VP) shunt with programmable valve are reportedly useful for diagnosis and treatment, respectively, their clinical significance remains to be validated. We conducted a multicenter prospective study (Study of Idiopathic Normal Pressure Hydrocephalus on Neurological Improvement: SINPHONI) to evaluate the utility of the MRI-based diagnosis for determining the 1-year outcome after VP shunt with the Codman-Hakim programmable valve. METHODS: Twenty-six centers in Japan were involved in this study. Patients aged between 60 and 85 years with one or more of symptoms (gait, cognitive, and urinary problems) and MRI evidence of ventriculomegaly and tight high-convexity and medial subarachnoid spaces received VP shunt using the height/weight-based valve pressure-setting scheme. The primary endpoint was a favorable outcome (improvement of one level or more on the modified Rankin Scale: mRS) at one year after surgery, and the secondary endpoints included improvement of one point or more on the total score of the iNPH grading scale. Shunt responder was defined by more than one level on mRS at any evaluation point in one year. RESULTS: The full analysis set included 100 patients. A favorable outcome was achieved in 69.0% and 80.0% were shunt responders. When measured with the iNPH grading scale, the one-year improvement rate was 77.0%, and response to the surgery at any evaluation point was detected in 89.0%. Serious adverse events were recorded in 15 patients, three of which were events related to surgery or VP shunt. Subdural effusion and orthostatic headache were reported as non-serious shunt-related adverse events, which were well controlled with readjustment of pressure. CONCLUSIONS: The MRI-based diagnostic scheme is highly useful. Tight high-convexity and medial subarachnoid spaces, and enlarged Sylvian fissures with ventriculomegaly, defined as disproportionately enlarged subarachnoid-space hydrocephalus (DESH), are worthwhile for the diagnosis of iNPH. This study is registered with ClinicalTrials.gov, number NCT00221091.

Choroid plexus papilloma originating in the sella turcica--case report.

A 51-year-old female presented with a rare case of choroid plexus papilloma originating in the sella turcica manifesting as headaches that was not readily distinguishable preoperatively from pituitary adenoma. Head magnetic resonance imaging revealed a tumor extending from the sella turcica to the suprasellar cistern. The tumor was removed via an endonasal transsphenoidal approach. Histological examination indicated a papillary structure covered with a layer of columnar epithelial cells that resembled normal choroid plexus. These findings, together with immunohistochemistry, led to a diagnosis of choroid plexus papilloma.

Surgical removal of chondroma of the petrous apex resulting in hearing improvement--case report.

An 18-year-old male presented with a chondroma in the petrous apex manifesting as major complaints of headaches and sensorineural hearing disturbance on the right. Head computed tomography and magnetic resonance imaging revealed a neoplastic lesion in the right petrous apex, which had bulged to compress the internal auditory meatus. Surgical removal improved his hearing with normalization of the postoperative air conduction threshold by reduction of the pressure of the internal auditory meatus, suggesting that the function of the cochlea was retained and the tumor was compressing the cochleal nerve at the level of the internal auditory meatus. Histological examination showed the tumor consisted of hyaline cartilage tissue without cellular atypia and the diagnosis was chondroma.

Use of bioabsorbable plates for cranial fixation.

LactoSorb fixation plates are made of a bioabsorbable polymer (82% poly-L-lactic acid and 18% polyglycolic acid), and the strength is not inferior to titanium plates. LactoSorb has been used in the fields of pediatric neurosurgery and facial plastic surgery. Cranial fixation in craniotomy is mostly performed using titanium plates and clamps, but there are issues with esthetics and artifacts on postoperative radiographic images. Absorbable plates solve these problems, but are slightly thicker and more expensive. Here, we describe a technique to solve these disadvantages by inserting absorbable plates into the diploe. The present method was employed in 46 patients, and esthetically favorable results were obtained without intraoperative and postoperative complications. Absorbable plates may replace titanium plates as the main device for cranial fixation. The present method is particularly useful for cranial fixation in adults with a thin scalp.