Neurosurgical intraoperative ultrasonography using contrast enhanced superb microvascular imaging -vessel density and appearance time of the contrast agent.

BACKGROUND: Ultrasonography (US) provides real-time information on structures within the skull during neurosurgical operations. Superb microvascular imaging (SMI) is the latest imaging technique for detecting very low-velocity flow with minimal motion artifacts, and we have reported on this technique for intraoperative US monitoring. We combined SMI with administration of contrast agent to obtain detailed information during neurosurgical operations. MATERIALS AND METHODS: Twenty patients diagnosed with brain tumor (10 meningiomas, 5 glioblastomas, 2 hemangioblastomas, 1 schwannoma, 1 malignant lymphoma, 1 brain abscess) underwent neurosurgery under US with SMI and contrast agent techniques. Vessel density and appearance time following contrast administration were analyzed. RESULTS: Flow in numerous vessels was not visualized by SMI alone, but appeared following injection of contrast agent in all cases. Flow in tumors was drastically enhanced by contrast agent in schwannoma, hemangioblastoma and meningioma, compared to normal brain tissue. Flows in the dilated and bent vessels of glioblastoma were also enhanced, although flow in hypoechoic lymphoma remained inconspicuous. The characteristics of tumor vessels were clearly visualized and tumor borders were demonstrated by the difference between tumor flow and brain flow, by the increased tumor vessel density and decreased appearance time of contrast agent compared to normal brain vessels. CONCLUSIONS: The combination of SMI and contrast agent techniques for intraoperative US monitoring could provide innovative flow images of tumor and normal brain. The neurosurgeon obtains information about tumor flow and tumor borderline before tumor resection.

Mapping of flow velocity using spatiotemporal changes in time-intensity curves from indocyanine green videoangiography.

OBJECTIVE: The present study developed an image-based analysis method that uses indocyanine green videoangiography (ICG-VA) to measure flow velocity in the arteries and veins of the cortical surface in patients undergoing neurosurgery. METHODS: MATLAB-based code was used to correct motion artifacts in the ICG-VA and determine the time-intensity curve of the ICG. The slope of the initial increase in ICG intensity following the bolus injection was measured and normalized using the predicted input function in the imaging field. Flow velocity over a certain distance determined by the user was measured based on a time shift of the time-intensity curves along the centerline of the vessels. RESULTS: The normalized slope of ICG intensity represented the expected differences in the flow velocity among the artery (0.67 ± 0.05 s-1 ), parenchymal tissue (0.49 ± 0.10 s-1 ), and vein (0.44 ± 0.11 s-1 ). The flow velocities measured along the vessel centerline were 2.5 ± 1.1 cm/s and 1.1 ± 0.3 cm/s in the arteries (0.5 ± 0.2 mm in diameter) and veins (0.6 ± 0.2 mm in diameter), respectively. CONCLUSIONS: An image-based analysis method for ICG-VA was developed to map the expected differences in the flow velocity based on the rising slope of ICG intensity and to measure the absolute flow velocities using the flexible zone and cross-correlation methods.

Intralateral and Perilateral Ventricular Arteries on Original Axial Magnetic Resonance Angiography in Adult Moyamoya Disease.

BACKGROUND: Patients with moyamoya disease often develop cerebral infarction and hemorrhage, but the ischemic and hemorrhagic subtypes are difficult to diagnose prior to disease onset. We aimed to differentiate the ischemic and hemorrhagic subtypes of moyamoya disease by analyzing the intralateral and perilateral ventricular arteries on the original axial magnetic resonance angiography (MRA) images. METHODS: We retrospectively analyzed the intralateral and perilateral ventricular arteries on the original axial time-of-flight (TOF)-MRA images of 18 patients with hemorrhagic moyamoya disease, 25 patients with ischemic moyamoya disease, and 22 control patients with unruptured aneurysms. RESULTS: There were significantly more intralateral and perilateral ventricular arteries on the original axial MRA images in the patients with hemorrhagic moyamoya disease (6.3 ± 2.7) than in those with ischemic moyamoya disease (0.8 ± 0.9) and those with unruptured aneurysms (0.4 ± 0.8). CONCLUSION: The intralateral and perilateral ventricular arteries on the original axial TOF-MRA images might suggest the hemorrhagic type of moyamoya disease prior to onset.

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.

Dermal Fibroblasts Internalize Phosphatidylserine-Exposed Secretory Melanosome Clusters and Apoptotic Melanocytes.

Pigmentation in the dermis is known to be caused by melanophages, defined as melanosome-laden macrophages. In this study, we show that dermal fibroblasts also have an ability to uptake melanosomes and apoptotic melanocytes. We have previously demonstrated that normal human melanocytes constantly secrete melanosome clusters from various sites of their dendrites. After adding secreted melanosome clusters collected from the culture medium of melanocytes, time-lapse imaging showed that fibroblasts actively attached to the secreted melanosome clusters and incorporated them. Annexin V staining revealed that phosphatidylserine (PtdSer), which is known as an 'eat-me' signal that triggers the internalization of apoptotic cells by macrophages, is exposed on the surface of secreted melanosome clusters. Dermal fibroblasts were able to uptake secreted melanosome clusters as did macrophages, and those fibroblasts express TIM4, a receptor for PtdSer-mediated endocytosis. Further, co-cultures of fibroblasts and melanocytes demonstrated that dermal fibroblasts internalize PtdSer-exposed apoptotic melanocytes. These results suggest that not only macrophages, but also dermal fibroblasts contribute to the collection of potentially toxic substances in the dermis, such as secreted melanosome clusters and apoptotic melanocytes, that have been occasionally observed to drop down into the dermis from the epidermis.

Collateral Flow and White Matter Disease in Patients with Internal Carotid Artery Occlusion.

BACKGROUND: When an internal carotid artery (ICA) occludes, a patient may develop cerebral infarction (CI). We investigated whether CI caused by ICA occlusion (ICAO) is associated with collateral flow through the anterior and posterior communicating arteries (ACoA and PCoA). METHODS: In 100 patients with ICAO, we investigated CI and white matter disease by performing an MRI and the anatomy of the ACoA and PCoA were investigated by performing magnetic resonance angiography. All patients were divided into the symptomatic CI group or the no-CI group. The collateral flow pathway was estimated by the anterior cerebral artery (ACA)-PCoA score and the collateral flow volume after ICAO was estimated by the middle cerebral artery (MCA) flow score, based on how well the MCA was visualized. RESULTS: Of 100 patients with ICAO, the symptomatic CI group included 36 patients. ACA-PCoA score and white matter disease grades were significantly higher in the CI group (indicating poor collateral flow). More than 80% of patients with an ACA-PCoA score of 4 (poor collateral) experienced symptomatic CI. Thirty-one symptomatic CI patients (86%) had an MCA flow score of 1 or 2 (decreased MCA flow). CONCLUSION: The ACA-PCoA score and white matter disease grade may suggest an increased risk of CI following ICAO.

Veno-Arterial Extracorporeal Membrane Oxygenation with Conventional Anticoagulation Can Be a Best Solution for Shock Due to Massive PE.

While most of pulmonary thromboembolism (PE) cases can be managed by thrombolytic and anticoagulation therapy, massive PE remains a life-threatening disease. Although surgical embolectomy can be a curative therapy for massive PE, peri-operative mortality for hemodynamically collapsed PE is extremely high. We present a case of hemodynamically collapsed massive PE. We avoided either thrombolytic therapy or surgical embolectomy, because the patient had recent cerebral contusion. Therefore, we managed the patient with the combination of veno-arterial extracorporeal membrane oxygenation (V-A ECMO) and conventional anticoagulation, which dramatically improved the patient's hemodynamics. In conclusion, the combination of V-A ECMO and conventional anticoagulation may be the preferred first line therapy for the patients with cardiogenic shock following massive PE.

Leukocyte plugging and cortical capillary flow after subarachnoid hemorrhage.

BACKGROUND: It is believed that increased intracranial pressure immediately after subarachnoid hemorrhage (SAH) causes extensive brain ischemia and results in worsening clinical status. Arterial flow to the cerebral surfaces is clinically well maintained during clipping surgery regardless of the severity of the World Federation of Neurological Societies grade after SAH. To explore what kinds of changes occur in the cortical microcirculation, not at the cerebral surface, we examined cortical microcirculation after SAH using two-photon laser scanning microscopy (TPLSM). METHODS: SAH was induced in mice with an endovascular perforation model. Following continuous injection of rhodamine 6G, velocities of labeled platelets and leukocytes and unlabeled red blood cells (RBCs) were measured in the cortical capillaries 60 min after SAH with a line-scan method using TPLSM, and the data were compared to a sham group and P-selectin monoclonal antibody-treated group. RESULTS: Velocities of leukocytes, platelets, and RBCs in capillaries decreased significantly 60 min after SAH. Rolling and adherent leukocytes suddenly prevented other blood cells from flowing in the capillaries. Flowing blood cells also decreased significantly in each capillary after SAH. This no-reflow phenomenon induced by plugging leukocytes was often observed in the SAH group but not in the sham group. The decreased velocities of blood cells were reversed by pretreatment with the monoclonal antibody of P-selection, an adhesion molecule expressed on the surfaces of both endothelial cells and platelets. CONCLUSIONS: SAH caused sudden worsening of cortical microcirculation at the onset. Leukocyte plugging in capillaries is one of the reasons why cortical microcirculation is aggravated after SAH.

Early diagnosis of cerebral ischemia in cerebral vasospasm by oxygen-pulse near-infrared optical topography.

PURPOSE: Early diagnosis of vasospasm is a key factor in the choice of treatment after subarachnoid hemorrhage (SAH). However, a noninvasive method of diagnosing delayed ischemic neurological deficit (DIND) has not been established. We therefore propose a new method of diagnosing cerebral ischemia using near-infrared optical topography (OT) with oxygen inhalation. MATERIALS AND METHODS: We used a 44-channel OT system that covers the bilateral front otemporoparietal areas to assess 29 patients who underwent surgery within 72 h of the onset of SAH. The patients inhaled room air followed by oxygen for 2 min, and then peripheral oxygen saturation (SpO2) was continuously monitored at the index fingertip. The patients were assessed by N-isopropyl-p-[¹²³I]iodoamphetamine (IMP)-SPECT and OT on the same day. Ischemic findings were confirmed using principal component analysis with reference to the systemic SpO2value. RESULTS: Seven of 29 patients developed DIND. Evidence of ischemia was identified by OT in all seven of these patients before the onset of DIND. The OT and SPECT findings agreed in 27 (93 %) of the 29 patients. DISCUSSION AND CONCLUSIONS: Our method might detect cerebral ischemia before the onset of DIND and thus be clinically useful for assessing cerebral ischemia with vasospasm.

Hypoxic regulation of the cerebral microcirculation is mediated by a carbon monoxide-sensitive hydrogen sulfide pathway.

Enhancement of cerebral blood flow by hypoxia is critical for brain function, but signaling systems underlying its regulation have been unclear. We report a pathway mediating hypoxia-induced cerebral vasodilation in studies monitoring vascular disposition in cerebellar slices and in intact mouse brains using two-photon intravital laser scanning microscopy. In this cascade, hypoxia elicits cerebral vasodilation via the coordinate actions of H(2)S formed by cystathionine ß-synthase (CBS) and CO generated by heme oxygenase (HO)-2. Hypoxia diminishes CO generation by HO-2, an oxygen sensor. The constitutive CO physiologically inhibits CBS, and hypoxia leads to increased levels of H(2)S that mediate the vasodilation of precapillary arterioles. Mice with targeted deletion of HO-2 or CBS display impaired vascular responses to hypoxia. Thus, in intact adult brain cerebral cortex of HO-2-null mice, imaging mass spectrometry reveals an impaired ability to maintain ATP levels on hypoxia.

Microvascular decompression under neuroendoscopic view in hemifacial spasm: rostral-type compression and perforator-type compression.

We report microvascular decompression (MVD) under neuroendoscopic view in hemifacial spasm (HFS) patients with rostral- and perforator-type compression of the root exit zone (REZ) of the facial nerve. Using either a wireless iPad Mini as a monitor on the microscope or a high-resolution monitor, microscopic and endoscopic views enabled MVD for complete cure of HFS with rostral-type compression (the offender compressing the REZ on the opposite rostral side to the operative approach) or perforator-type compression (the offender tethered to the REZ by the perforator). MVD under neuroendoscopic view may offer more accurate MVD and complete resolution of HFS.

Endonasal ultrasonography-assisted neuroendoscopic transsphenoidal surgery.

We report endonasal ultrasonography (US)-assisted neuroendoscopic transsphenoidal surgery (TSS) in seven patients. With sagittal and coronal US images, internal carotid arteries, anterior cerebral arteries, residual tumor, and lateral ventricles were recognized, and the tumors were removed without leakage of cerebrospinal fluid in patients with pituitary adenoma. US images clearly depicted the carotid arteries, anterior cerebral arteries, middle cerebral arteries, chiasmatic cistern, and residual tumor. Endonasal US images can provide real-time animated information and may help neuroendoscopic TSS, whenever needed during TSS.

The Early Postoperative Course of Cognitive Function and Preoperative Cerebrovascular Reserve.

BACKGROUND: Patients with severe steno-occlusive disease of a main cerebral artery without causative lesions on magnetic resonance imaging (MRI) often develop cognitive impairment. However, the effects of revascularization surgery and the source of the cognitive impairment remain unclear. Therefore, we investigated the early postoperative course of cognitive function and its association with cerebral blood flow (CBF), cerebrovascular reserve (CVR), white matter disease (WMD), lacunar infarction, and cerebrovascular risk factors. METHODS: Cognitive function was examined using neurobehavioral cognitive status examination (COGNISTAT) in 52 patients with steno-occlusive disease of a main cerebral artery before and at 6 months after superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis. We examined how cognition changed before and at 1, 3, and 6 months after STA-MCA anastomosis in 27 of 52 patients. CVR and CBF were calculated from 123I-N-isopropyl-p-iodoamphetamine single photon emission computed tomography, in addition to other cerebrovascular risk factors in 34 of 52 patients. Cerebral infarction and WMD (periventricular hyperintensity [PVH] and deep subcortical white matter hyperintensity) were also evaluated preoperatively by MRI. RESULTS: COGNISTAT scores improved at 1 month after STA-MCA anastomosis in patients with severe steno-occlusive disease of a main cerebral artery. Multiple stepwise regression analysis revealed that CVR (regression coefficient = -2.237, p = 0.0020) and PVH (regression coefficient = 2.364, p = 0.0029) were the best predictors of postoperative improvement in COGNISTAT scores (R 2 = 0.415; p = 0.0017). CONCLUSION: Cognitive function improves in relation to preoperative CVR and PVH early after STA-MCA anastomosis in patients with steno-occlusive disease of a main cerebral artery.

Assessing the usability of aromatic mouthwashes in alleviating physiological stress responses.

Background: Mouthwashes play a pivotal role in oral care, and their efficacy has been explored extensively across various dimensions. As a contribution to the development of novel oral care products, this study aims to investigate the psychophysiological effects of aromatic mouthwashes during the resilience period from a short-term cognitive stressor utilizing biological signals and subjective evaluations. Methods: A within-participant experimental design with 22 healthy females was conducted with four mouthwashes; peppermint (Mint), peppermint + bergamot (MB), peppermint + sweet orange (MO), and peppermint + lavender (ML), and water as the control (Ctl), after a 20-min calculation task. Subjective evaluations and physiological responses including skin conductance level and electrocardiogram were recorded throughout the experiment. Results: Citrus mouthwashes (MO and MB) showed a greater decrease in heart rate and a significant increase in the high-frequency component of heart rate variability. The participants indicated a significant effect in terms of "flavor preference" and "refreshing sensation" for mouthwash use compared to the Ctl. Conclusion: The results suggest that rinsing with citrus-flavored mouthwashes has a positive impact in alleviating the physiological stress response (in terms of cardiac activity). These findings may have implications for the development of innovative, novel oral care products that promote stress reduction and improve oral health.

Ultrasonography monitoring with Superb Microvascular Imaging during cerebrovascular surgery.

INTRODUCTION: Ultrasonography (US) is used as a real-time dynamic imaging modality during neurosurgery. A novel Doppler US technique, Superb Microvascular Imaging (SMI), can be used to visualize low-velocity flow of small vessels at high resolution with high frame rates. We visualized vessel flow using this US SMI technique and contrast agent during cerebrovascular surgery. METHODS: Forty-three patients with an unruptured cerebral aneurysm (control), ischemic and hemorrhagic moyamoya disease, carotid artery stenosis, hemangioblastoma, severe stenosis of the middle cerebral artery, venous angioma, and intracerebral hemorrhage (ICH) underwent neurosurgery with US SMI monitoring using a contrast agent. The diameter, length, and number of penetrating vessels were analyzed in patients with an unruptured cerebral aneurysm (control), moyamoya disease, and ICH. RESULTS: Diameter and length of cerebral penetrating vessels were significantly increased in patients with moyamoya disease and ICH compared to control patients. The number of penetrating vessels was increased in moyamoya disease patients compared to control and ICH patients. In hemorrhagic moyamoya disease, flow in the penetrating vessels originated from a deep periventricular point and extended to the cerebral surface. Pulsatile cerebral aneurysms during clipping surgery and carotid artery stenosis during carotid endarterectomy were easily identified by SMI. Drastically increased vessel flow in patients with a hemangioblastoma or a venous angioma was observed. CONCLUSION: Using the US SMI technique and contrast agent, we obtained useful flow information of the vascular disease structure and intracerebral deep small vessels during cerebrovascular surgery. Further quantitative analysis will be informative and helpful for cerebrovascular surgery.

Endoscopic ultrasound imaging with high flow mode for endonasal transsphenoidal pituitary surgery.

Intraoperative ultrasound during transsphenoidal surgery (TSS) for pituitary tumors has been reported. In reports of endonasal ultrasound (US), Doppler US vessel images were informative and effective in endoscopic TSS. We performed endoscopic US imaging with high flow mode, which is a novel technology, to visualize small vessels during endonasal endoscopic TSS. Six patients (five with pituitary adenomas and one with Rathoke's cleft cyst) underwent endoscopic US-assisted TSS. A small endoscopic US probe (Olympus, BF-UC260FW; diameter, 6.9 mm) was inserted transsphenoidally to the sellar floor and into the sella turcica, and endoscopic US monitoring was performed. By rotating the endoscopic US probe, the internal carotid artery, anterior cerebral artery, middle cerebral artery, various small vessels, optic nerve, and residual tumor were clearly visualized on the endoscopic US images. Real-time animated vessel images around the tumor could be generated when needed during TSS. The tumors were removed without leakage of cerebrospinal fluid in the six patients, and their visual acuity was restored. Endoscopic US with high flow mode can visualize not only main cerebral arteries but also intracranial small vessels on B-mode US images. Pituitary tumors were clearly recognized and removed safely and precisely by monitoring the cerebral artery and its small branches as landmarks.

Characterization of stable hypoxia-preconditioned dental pulp stem cells compared with mobilized dental pulp stem cells for application for pulp regenerative therapy.

BACKGROUND: Dental pulp stem cells (DPSCs) have been developed as a potential source of mesenchymal stem cells (MSCs) for regeneration of dental pulp and other tissues. However, further strategies to isolate highly functional DPSCs beyond the colony-forming methods are required. We have demonstrated the safety and efficacy of DPSCs isolated by G-CSF-induced mobilization and cultured under normoxia (mobilized DPSCs, MDPSCs) for pulp regeneration. The device for isolation of MDPSCs, however, is not cost-effective and requires a prolonged cell culture period. It is well known that MSCs cultured under hypoxic-preconditions improved MSC proliferation activity and stemness. Therefore, in this investigation, we attempted to improve the clinical utility of DPSCs by hypoxia-preconditioned DPSCs (hpDPSCs) compared with MDPSCs to improve the potential clinical utility for pulp regeneration in endodontic dentistry. METHODS: Colony-forming DPSCs were isolated and preconditioned with hypoxia in a stable closed cultured system and compared with MDPSCs isolated from the individual dog teeth. We examined the proliferation rate, migration potential, anti-apoptotic activity, and gene expression of the stem cell markers and angiogenic/neurotrophic factors. Trophic effects of the conditioned medium (CM) were also evaluated. In addition, the expression of immunomodulatory molecules upon stimulation with IFN-γ was investigated. The pulp regenerative potential and transplantation safety of hpDPSCs were further assessed in pulpectomized teeth in dogs by histological and immunohistochemical analyses and by chemistry of the blood and urine tests. RESULTS: hpDPSCs demonstrated higher proliferation rate and expression of a major regulator of oxygen homeostasis, HIF-1α, and a stem cell marker, CXCR-4. The direct migratory activity of hpDPSCs in response to G-CSF was significantly higher than MDPSCs. The CM of hpDPSCs stimulated neurite extension. However, there were no changes in angiogenic, migration, and anti-apoptotic activities compared with the CM of MDPSCs. The expression of immunomodulatory gene, PTGE was significantly upregulated by IFN gamma in hpDPSCs compared with MDPSCs. However, no difference in nitric oxide was observed. The regenerated pulp tissue was quantitatively and qualitatively similar in hpDPSC transplants compared with MDPSC transplants in dog teeth. There was no evidence of toxicity or adverse events of the hpDPSC transplantation. CONCLUSIONS: These results demonstrated that the efficacy of hpDPSCs for pulp regeneration was identical, although hpDPSCs improved stem cell properties compared to MDPSCs, suggesting their potential clinical utility for pulp regeneration.

Comparison of Macrophage Activation Using γ-Globulin and Serum-derived Macrophage Activating Factor.

BACKGROUND/AIM: Serum-derived macrophage activating factor (serum-MAF) can rapidly activate macrophage phagocytic activity by inducing characteristic membrane ruffles designated as Frill-like structures. Serum-MAF contains γ-globulin, an activator of phagocytosis. This study examined whether serum-MAF and γ-globulin activate macrophages similarly. MATERIALS AND METHODS: Morphological changes in macrophages were observed by time-lapse imaging and the efficiency of engulfment was analysed quantitatively. Immunological staining of talin-1 and a calpain inhibitor were performed. RESULTS: The engulfment efficiency of serum-MAF- and γ-globulin-activated macrophages was significantly different. Talin-1 showed weak co-localisation with the Frill-like structures. Treatment with a calpain inhibitor similarly down-regulated phagocytosis irrespective of the activation factor. CONCLUSION: There was a difference between macrophage activation mechanisms by γ-globulin and serum-MAF. Talin may slightly contribute to serum-MAF activation. It is possible to distinguish between the calpain-dependent fundamental 'mechanism of phagocytosis' and the activating factor-dependent rapid 'activation mechanism'.

Exploration of an Easy and Simple Method for Decompressive Craniectomy: The "Spiral Dural Incision Method".

Decompressive craniectomy (DC) is performed to alleviate intracranial hypertension as much as possible. There are two additional goals that surgeons should strive to achieve: minimization of operating time (i.e., the time issue) and avoidance of manually pushing on the surface of the bulging brain to prevent iatrogenic brain injury (i.e., "stuffing risk"). Many authors have made progress on the time issue, but stuffing risk remains largely unmitigated. We recently presented a new DC method that resolved both issues, but the incision design was too complicated for general use. A recent study has presented a duraplasty method that does not use watertight sutures and does not exacerbate the risk associated with DC. Employing the simplified method without sutures, we developed a new, easy-to-perform DC method that resolves stuffing risk. We analyzed the incision design geometrically and verified it by simulations generated with a physics engine. Three patients with massive cerebral infarction, subarachnoid hemorrhage, and hemorrhagic infarction underwent the new procedure. The targeted incision design was composed of four or five curved incision lines. Expansion of the dura resulted in transformation into a centroclinal form with spiral rifts and canopy. The dura expanded as expected in each case, and no cases required manual stuffing of the bulging brain. The operative time was acceptable, and no complications were reported. The concept of the incision design could be applied to any polygonal duraplasty in DC. We developed a new DC method that involves a simple and easily executed incision design, avoided stuffing risk.

Ultrasonographic superb microvascular imaging for emergency surgery of intracerebral hemorrhage.

Ultrasonography (US) has been used as a reliable imaging modality, providing real-time information during neurosurgical operations. One recent innovative US technique, superb microvascular imaging (SMI), visualizes small vessels and flow, which are not detected with standard US with doppler. We apply SMI to intraoperative US monitoring in emergency surgery for intracerebral hemorrhage (ICH). Eleven consecutive patients with ICH underwent endoscopic emergency surgery under US monitoring with SMI. After performing a small craniotomy, US images were obtained using SMI, a fusion technique, and a contrast agent technique, with the probe on the brain surface during surgery. Fusion images were obtained with the probe on the head before craniotomy in some patients. Animated US images with SMI could differentiate hematoma containing no vessels from brain tissue, and flow images using SMI and contrast agent techniques clarified the borderlines. Animated fusion images of intraoperative US and preoperative CT provided information on the extent of hematoma and residual hematoma during emergency surgery. We made various fusion CT images showing intracranial hematoma with US probes and decided on the skin incision line before beginning surgery, as if we were using a neuronavigation system. US with SMI, contrast agent, and fusion techniques provide information on the extent of intracranial hematoma and residual hematoma with no vessels and no flow. Monitoring by US and fusion CT images is useful for ICH surgery as a next-generation neuronavigator.