A case report of hydrocephalus due to diffuse villous hyperplasia of the choroid plexus: surgical treatment by combination a flexible videoscope with a rigid endoscope.

PURPOSE: Diffuse villous hyperplasia of the choroid plexus (DVHCP) and choroid plexus papilloma (CPP) are rare benign tumors usually diagnosed as a result of progressive hydrocephalus, especially in childhood. We present the case of a Japanese boy diagnosed with progressive hydrocephalus due to DVHCP. METHODS: Case: A 2-year and 3-month-old Japanese boy was found to have delayed motor development (equivalent to 1 year and 2 months old), an enlarged head circumference of 51 cm within + 1.5 standard deviation (S.D.), and incomplete closure of the anterior fontanel. The magnetic resonance imaging (MRI) showed lobular enlargement of the bilateral choroid plexuses extending from the trigone to the body and inferior horn of the lateral ventricle. The endoscopic choroid plexus coagulation surgery was performed to reduce the CSF formation rate. RESULTS: DVHCP was diagnosed both pathologically and clinically. Postoperatively, the patient progressed without complications, such as cerebrospinal fluid leakage. Although ventricular enlargement persisted, the anterior fontanel recessed, and the expansion of the head circumference stopped. CONCLUSION: Few cases of bilateral DVHCP and CPP have been reported in the literature. We encountered a case in which effective choroid plexus coagulation was performed for hydrocephalus due to DVHCP using less invasive endoscopic technique. It also represented an association between DVHCP and the gain of chromosome 9p.

Persistent Primitive Hypoglossal Artery with Ipsilateral Symptomatic Carotid Artery Stenosis and Cerebral Aneurysm.

OBJECTIVE: Persistent primitive hypoglossal artery (PPHA) is a rare type of persistent carotid-basilar anastomosis sometimes associated with other vascular lesions. We treated an extremely rare case of PPHA with concomitant ipsilateral symptomatic cervical internal carotid artery (ICA) stenosis and unruptured aneurysm. CASE PRESENTATION: A 67-year-old woman visited our institution with acute onset of diplopia. Magnetic resonance imaging revealed multiple acute infarctions in the right anterior and posterior circulations. Digital subtraction angiography demonstrated the right PPHA concomitant with ipsilateral cervical ICA stenosis and an unruptured ICA aneurysm with maximum diameter of 8 mm. The multiple infarctions were considered to result from artery-to-artery embolism due to microthrombi from the ICA plaque passed along the PPHA, so carotid endarterectomy was performed as the first step with preoperative modified Rankin Scale (mRS) grade 1. During the operation, the patient had impaired ICA perfusion due to internal shunt catheter migration into the PPHA followed by acute infarction in the right hemisphere causing mild left hemiparesis. The patient was transferred to the rehabilitation hospital with mRS grade 3. After 3 months of rehabilitation, the patient recovered to mRS grade 1 and clipping surgery for the unruptured right ICA aneurysm was performed as the second step with uneventful postoperative course. CONCLUSION: The treatment strategy should be carefully considered depending on the specific blood circulation for such cases of PPHA with unique vasculature.

[Analysis of a Spontaneous Spinal Epidural Hematoma Mimicking Cerebral Infarction:A Case Report and Review of the Literatures].

Spontaneous spinal epidural hematoma is a rare disease, and the critical form may mimic cerebral infarction in the acute stage. Consequently, misdiagnosis of a cerebral infarction may result in unnecessary antithrombotic therapy. The present study investigated 19 cases of spontaneous spinal epidural hematoma first diagnosed as cerebral infarctions and treated with antithrombotic therapy. Of these, 16 cases(84.2%)presented with pain in the neck, shoulder, and back on admission, 19 cases(100%)with hemiplegia not including the face, 7 cases(36.8%)with limb sensory disturbance, and all 19 cases(100%)underwent MRI findings for definite diagnosis. After diagnosis, 6 of the 19 cases(31.6%)were treated with recombinant tissue-type plasminogen activator(rt-PA)administration, 13 cases(68.4%)with surgical treatment, and 9 cases(47.4%)were without after effect and showed good progress. MRI is effective in detecting spontaneous spinal epidural hematoma, however, CT is also used for this diagnosis. The most common site of spontaneous spinal epidural hematoma is the cervicothoracic spine junction or thoracolumbar spine junction, but occurrence in the upper cervical vertebra may present with hemiplegia similar to cerebral infarction. Pathognomonic symptoms include pain in the neck, shoulder, and back, however, symptoms such as hemiplegia not including the face, cervical spine, and cervical cord lesion may be important indicators. Although, some cases may not present with pain and sensory disturbance symptoms, therefore an initial misdiagnosis of cerebral infarction may be made and subsequent antithrombotic therapy can result in increased bleeding and serious after-effects. In particular, 4 of the 6 cases(66.7%)treated with hyperacute phase thrombolytic therapy(rt-PA treatment)in this study required surgical treatment, and the time until definite diagnosis was shorter compared with other antithrombotic agents, presumably due to the rapid increase in hematoma. Therefore, the possibility of spinal cord epidural hematoma should be considered before beginning rt-PA therapy with careful examination to confirm the presence of lesions in the cervical spine and cervical cord.

[Ruptured Aneurysms on the Cortical Segment of the Distal Posterior Inferior Cerebellar Artery:A Report of Two Cases and a Literature Review].

Two unusual cases of ruptured distal posterior inferior cerebellar artery(PICA)aneurysm on the cortical segment were successfully treated with open surgery. A 76-year-old woman presented with a Hunt and Kosnik(H&K)grade II Subarachnoid hemorrhage(SAH). CT showed a slight SAH in the cisterna magna and around the vermis, and fourth intraventricular hematoma. Cerebral angiography revealed an aneurysm on the cortical segment of the distal PICA. Intraoperative findings identified the aneurysm as fusiform. Trapping of the aneurysm was performed, and the indocyanine green angiography fiuding confirmed aneurysmal flow disappearance and good circulation in the cerebellar cortex. An 89-year-old woman presented with H&K grade II SAH. CT revealed a thick SAH in the posterior cranial fossa, and third to fourth intraventricular hematoma with hydrocephalus. Cerebral angiography revealed an aneurysm on the cortical segment of the distal PICA. Intraoperative findings showed that the aneurysm was fusiform. Trapping and resection of the aneurysm were performed. Thirteen previous cases of aneurysms on the cortical segment of the distal PICA have been reported. Distal PICA aneurysms apparently show rebleeding more frequently than do aneurysms at other locations, so immediate direct surgery is necessary to avoid rebleeding. After proximal ligation or trapping of the aneurysm, indocyanine green angiography is useful to determine the need for revascularization.

Modified Extradural Temporopolar Approach for Paraclinoid Aneurysms: Operative Nuance and Surgical Result.

BACKGROUND: Extradural temporopolar approach can provide extensive exposure of the anterior clinoid process, which can prevent intraoperative neurovascular injury in anterior clinoidectomy for paraclinoid aneurysms. The present study investigates the usefulness of this modified technique, and operative nuances are discussed here. METHODS: We retrospectively reviewed the medical charts of 30 consecutive patients with paraclinoid aneurysms who underwent treatment with this modified extradural temporopolar approach between September 2009 and March 2016. RESULTS: Worsening of visual acuity was documented postoperatively in three patients (10.0%), and visual field function worsened in three patients (10.0%). Postoperative outcome was good recovery in all patients. No operation-related mortality occurred in the series. CONCLUSION: Extradural anterior clinoidectomy via the modified extradural temporopolar approach is safe and may be recommended for surgical treatment of paraclinoid aneurysms to reduce the risk of intraoperative optic neurovascular injury.

[Frontal Base Penetrating Brain Injury by a Gardening Scissors:A Case Report].

A 43-year-old woman accidentally fell from a 1.5-m height with gardening scissors, and the cutting edge of the scissors pierced into her skull base through the left nasal cavity. After she pulled the scissors out by herself, her consciousness immediately deteriorated. She was transferred to Juntendo University Shizuoka Hospital by an ambulance helicopter. Intracerebral hematoma in the right frontal lobe caused by the middle cerebral artery injury was detected using brain computed tomography. Emergent hematoma evacuation with decompressive craniectomy was performed. In this procedure, cerebrospinal fluid(CSF)leakage was repaired using a multi-layered flap technique, which placed both the free autologous dura mater and pedicled temporalis muscle flaps into the damaged skull base space. After the surgery, CSF drainage was managed to control both intracranial pressure and CSF leakage. Upon discussion, several clinical issues can be highlighted. First, the gardening scissors were pulled out by the patient herself. Second, the foreign material penetrating the intracranial space might have conferred a high infection risk. Finally, it might be difficult to repair the severe damage inflicted upon the skull base by the large gardening scissors. In conclusion, it was considered that favorable results were obtained by the emergent surgical intervention and by repairing the skull base through forming a multi-layered flap with a combination of free and pedicled tissues.

[Dissecting Aneurysm of the Distal Middle Cerebral Artery Formed the Out Pouch during Long-term Follow-up:A Case Report].

A 40-year-old man with a rare case of dissecting aneurysm of the distal middle cerebral artery(MCA, M2 segment)presented with ischemic stroke, manifesting as headache, nausea, and visual disorder. Computed tomography(CT)scan revealed cerebral infarction, and three-dimensional CT angiogram revealed stenotic change at the M2 segment. The patient was conservatively treated and remained neurologically stable. Ten months later, CT scan and magnetic resonance imaging(MRI)revealed outpouching of the M2 segment at the location of the initial stenosis. Angiogram revealed pearl and string sign at the M2 segment of the inferior trunk. The preoperative diagnosis was spontaneous dissecting aneurysm of the right distal MCA. The patient was treated with direct surgery for aneurysm resection and revascularization using the superficial temporal artery. The brain surface in contact with the dissecting aneurysm was colored xanthochromic, so minor bleeding from the dissecting aneurysm was highly suspected. Previously, 19 cases of dissecting aneurysm of the distal MCA have been reported. Distal dissecting aneurysms seem to rupture more frequently in the MCA than in the proximal segment. Long-term follow-up MRI and angiogram might be important, not only in the acute stage in patients with atypical caliber changes in the distal MCA. Immediate direct surgery is indicated to avoid hemorrhagic stroke if dilatation of the major trunk at the dissection is suspected.

A comparison between evacuation from the scene and interhospital transportation using a helicopter for subarachnoid hemorrhage.

PURPOSE: We investigated the changes in the vital signs and the final outcomes subarachnoid hemorrhage (SAH) patients who were evacuated from the scene using the doctor-helicopter (Dr. Heli) service and those who only underwent interhospital transportation using the doctor-helicopter Dr. Heli service to investigate safety of this system. METHODS: We retrospectively investigated all of the patients with non-traumatic SAH who were transported by a Dr. Heli between January 2010 and March 2016. The subjects were divided into two groups: the Scene group included subjects who were evacuated from the scene by a Dr. Heli, while the Interhospital group included subjects who were transported by a ground ambulance to a nearby medical facility and then transported by a Dr. Heli to a single tertiary center. RESULTS: The systolic blood pressure, ratio of cardiac arrest, and Fisher classification values of the patients in the Scene group were significantly greater than those in the Interhospital group. The Glasgow Coma Scale in the Scene group was significantly lower than that in the Interhospital group. After excluding the patients with cardiac arrest, the Glasgow Coma Scale scores of the patients in the two groups did not differ to a statistically significant extent during, before or after transportation. There were no significant differences in Glasgow Outcome Scores or the survival ratio of the two groups, even when cardiac arrest patients were included. CONCLUSION: The present study indirectly suggests the safety of using a Dr. Heli to evacuate SAH patients from the scene.

Retrograde Suction Decompression Through Direct Puncture of the Common Carotid Artery for Paraclinoid Aneurysm.

BACKGROUND: Surgical clipping of paraclinoid aneurysm can be very difficult because strong adhesions may hinder the dissection of the perforators and surrounding anatomical structures from the aneurysm dome. We describe our experience with using retrograde suction decompression during the clipping of paraclinoid aneurysms and discuss the relative advantages and pitfalls. MATERIALS AND METHODS: This study included 23 patients with large and giant paraclinoid aneurysms who underwent surgical treatment consisting of direct clipping with suction decompression between March 2004 and August 2014. Direct puncture of the common carotid artery (CCA) was performed with a 20-gauge needle. The aneurysm was temporarily trapped by clamping of the CCA and external carotid artery (ECA), followed by temporary clipping of the intracranial internal carotid artery (ICA) distal to the aneurysm neck. Blood was then gently aspirated through a catheter introduced into the cervical ICA, resulting in collapse of the aneurysm. Therefore, safe aneurysm dissection was feasible during interruption of the blood flow, which could be maintained for up to 5 min. This procedure was repeated until dissection and clipping of the aneurysm were completed. RESULTS: Seven patients were admitted with SAH, 11 with asymptomatic unruptured aneurysm, and 5 with symptomatic unruptured aneurysm. The aneurysms were located on the paraclinoidal segment of the ICA in 15 cases, on the ICA-posterior communicating artery (PComA) in 6, at the ICA bifurcation in 1, and on the anterior wall of the ICA in 1. None of them suffered complications related to the CCA puncture. Surgical outcome was good recovery in 13 patients, moderate disability in 4, severe disability in 4, and vegetative state in 1. CONCLUSION: Retrograde suction decompression through direct puncture of the common carotid artery is a useful adjunct technique for the clipping of paraclinoid ICA aneurysms.

Introduction of a physician-staffed helicopter emergency medical service in eastern Shizuoka prefecture in Japan.

OBJECTIVE: To analyze the operating situation of a physician-staffed helicopter emergency medical service in eastern Shizuoka prefecture. METHODS: A retrospective analysis was performed using the conveyance records reported by staff members of the physician-staffed helicopter. A comparison between 2007 (n = 619) and 2012 (n = 678) was performed. RESULTS: There were no significant differences between the 2 groups with regard to the sex, ratio of cardiopulmonary arrest, and survival ratio. In contrast, the duration from the request of dispatch to arrival at the hospital in 2007 was significantly longer than that in 2012 (53.7 vs 48.2 minutes, P < 0.0001). The average age in 2007 was significantly younger than in 2012 (55.7 vs 59.4 years, P < 0.01). The ratio of trauma case in the 2012 was higher than that in 2007 (47 vs 37%, P < 0.001). The ratio of severe cases in 2007 was higher than in 2012 (45 vs 39%, P < 0.05). CONCLUSION: Japan is an aging society. In eastern Shizuoka prefecture, the increase in the number of trauma and minor injury cases may have increased due to the emphasis on the importance of early medical intervention by the fire department.

[Extradural temporopolar approach for surgical management of paraclinoid lesions].

OBJECTIVE: Surgical treatment of paraclinoid tumors adjacent to important anatomical structures, such as the optic nerve, optic chiasm, pituitary stalk, and internal carotid artery, should emphasize maximum resection and preservation of visual function. Thus, early localization and exposure of the optic nerve, and complete mobilization and decompression of the optic nerve and internal carotid artery, are necessary in order to prevent intraoperative neurovascular injuries. However, this technique requires wide exposure of the optic-carotid space through the interpeduncular cistern. We have developed an extradural temporopolar approach for resection of paraclinoid tumors, which can also allow early devascularization of arteries that feed the tumors. We evaluated the surgical outcomes of this approach, paying special attention to clinical and visual outcomes. PATIENTS AND METHODS: Thirteen patients(4 men, 9 women;24-78 years, mean age 54 years), underwent tumor removal using an extradural temporopolar approach between March 2000 and April 2013. We retrospectively reviewed medical charts, radiological findings, intensive care unit flow sheets, and surgical records. RESULTS: Histological diagnoses included craniopharyngioma(4 cases), pituitary adenoma(3 cases), medial sphenoid ridge meningioma(2 cases), tuberculum sellae meningioma(2 cases), trigeminal neurinoma(1 case), and malignant epidermoid(1 case). Tumors were 1.5-6.0cm in length(mean 3.2cm). Tumors were cystic in all 4 craniopharyngiomas and solid in the other 9 cases. Preoperative neurological deficits included visual disturbance in 10 patients, double vision caused by oculomotor nerve palsy in 2 patients, and vertigo in 1 patient. Additional orbitozygomatic craniotomies were performed in 8 patients. Total tumor removal was performed in 7 patients and subtotal removal performed in 6. The pituitary stalk was microscopically preserved in all patients. Postoperative complications included transient diabetes insipidus in 2 patients, chronic subdural hematoma in 1 patient, and abducens palsy in 1 patient. All complications were completely resolved. Surgical outcomes on discharge were recorded as follows:good recovery(11 patients), moderate disability(1 patient), and severe disability(1 patient, who suffered preoperative consciousness disturbance). Visual outcomes were improved in 7 patients, unchanged in 5, and worsened in 1, with recurrence. CONCLUSIONS: The present extradural temporopolar approach, which allows early decompression of the optic nerve, and early devascularization and detachment of the tumor, may lead to greater tumor resection and improved visual outcomes in patients with paraclinoid tumors.

A Single-Center Experience of Mechanical Thrombectomy for Cancer-Associated Ischemic Stroke.

Objectives: Cancer-associated ischemic stroke tends to extend over multiple vascular territories and develops under poor general conditions. Owing to the rarity of such cases and poor prognoses, no comprehensive studies on mechanical thrombectomy for cancer-associated ischemic stroke have been reported in Japan. The present study investigated the radiological and clinical characteristics of mechanical thrombectomy in patients with cancer-associated ischemic stroke at our institution. Methods: We retrospectively reviewed 108 patients who underwent mechanical thrombectomy for large cerebral artery occlusion between January 1, 2021, and October 31, 2022, at our institution. The characteristics of mechanical thrombectomy in the cancer-associated ischemic stroke group were compared with those in the control group. Results: Of the 108 patients (112 procedures), seven patients (eight procedures) with clinically diagnosed cancer-associated ischemic stroke underwent mechanical thrombectomy. Of the eight procedures, six were performed during hospitalization. In contrast, only 10 of 104 procedures were performed in the control group. The in-hospital onset rate was higher in the cancer-associated ischemic stroke group (75.0%) compared to that in the controls (9.6%); p <0.001. The puncture-to-reperfusion time was significantly longer in the cancer-associated ischemic stroke group in comparison to that in the controls with a median interquartile range of 69 minutes (60.0-82.0 minutes) and 59.5 minutes (44.5-69.3 minutes), respectively (p <0.01). However, the rates of successful recanalization defined as thrombolysis in cerebral infarction ≥2b were not significantly different between the cancer-associated ischemic stroke group and controls with values of 62.5% and 79.8%, respectively (p = 0.250). Of the eight cases in the cancer-associated ischemic stroke group, only one (12.5%) had a good outcome on a modified Rankin Scale score of 0 to 2 at discharge, in contrast to 23 of the 104 (23.1%) cases in the controls (p = 0.523). Histopathological examination of six retrieved thrombi in the cancer-associated stroke group using hematoxylin and eosin staining revealed that only one case showed an erythrocyte-dominant thrombus while five displayed a fibrinoplatelet-dominant component. Conversely, 65 of 92 retrieved thrombi in the control group were erythrocyte dominant. Cancer was pathologically diagnosed in four of seven patients, all of which were adenocarcinomas. Conclusion: Cancer-associated ischemic stroke tends to occur during hospitalization. Coagulation disorders associated with cancer, especially adenocarcinoma, may be related to the formation of thrombi with fibrinoplatelet-dominant components, leading to ischemic stroke. The procedural time for mechanical thrombectomy in cancer-associated ischemic stroke tends to be longer.

Effectiveness of Keyhole Clipping of Unruptured Intracranial Aneurysms Detected by "Brain Dock" in Healthy Japanese Adults.

In Japan, brain docking has enhanced the detection of unruptured intracranial aneurysms in healthy adults. At our institution, surgical clipping is the first-line treatment for unruptured intracranial aneurysms (UIA). In this study, the differences in neurological and radiological outcomes, as well as cognitive and psychological results, between standard clipping and keyhole clipping for these aneurysms detected via brain docking were evaluated. The study included 131 aneurysms detected via "brain dock." Of these, 65 were treated with keyhole clipping surgery (keyhole clipping group), and 66 were treated with standard clipping surgery (standard clipping group). Evaluations at 3 months included the National Institutes of Health Stroke Scale, modified Rankin Scale, Mini-Mental State Examination, Hasegawa's Dementia Scale-revised, Beck Depression Inventory, Hamilton Rating Scale for Depression, and radiological abnormalities. The mean operative time and postoperative hospitalization period were significantly shorter in the keyhole clipping group than in the standard clipping group (p < 0.001). Between the groups, no significant differences in postoperative neurological complications or radiological abnormalities were found. The keyhole clipping group demonstrated slightly but significantly better Beck Depression Inventory and Hamilton Rating Scale for Depression scores than the standard clipping group (Beck Depression Inventory, p = 0.046; Hamilton Rating Scale for Depression, p < 0.01). Both the Beck Depression Inventory and Hamilton Rating Scale for Depression scores at 3 months were significantly enhanced (p < 0.001) in the keyhole clipping group. These findings propose that keyhole clipping could be considered a new therapeutic option for small UIA detected via brain docking.

Cerebrospinal fluid rhinorrhea with meningoencephalocele related to Sternberg's canal: A report of two cases.

Background: Cerebrospinal fluid (CSF) rhinorrhea with meningoencephalocele (MEC) associated with Sternberg's canal is rare. We treated two such cases. Case Description: A 41-year-old man and a 35-year-old woman presented with CSF rhinorrhea and mild headache worsening with standing posture. Head computed tomography showed a defect close to the foramen rotundum in the lateral wall of the left sphenoid sinus in both cases. Head magnetic resonance (MR) imaging and MR cisternography revealed that brain parenchyma had herniated into the lateral sphenoid sinus through the defect of the middle cranial fossa. The intradural and extradural spaces and bone defect were sealed with fascia and fat through both intradural and extradural approaches. The MEC was cut away to prevent infection. CSF rhinorrhea completely stopped after the surgery. Conclusion: Our cases were characterized by empty sella, thinning of the dorsum sellae, and large arteriovenous malformations that suggest chronic intracranial hypertension. The possibility of Sternberg's canal in patients with CSF rhinorrhea with chronic intracranial hypertension should be considered. The cranial approach has the advantages of lower infection risk and the ability to close the defect with multilayer plasty under direct vision. The transcranial approach is still safe if performed by a skillful neurosurgeon.

Effect of intrathecal magnesium sulfate solution injection via a microcatheter in the cisterna magna on cerebral vasospasm in the canine subarachnoid haemorrhage model.

OBJECTIVE: To evaluate intracisternal injection of magnesium sulfate (MgSO(4)) solution via a lumbar catheter for the treatment of cerebral vasospasm in the canine subarachnoid haemorrhage (SAH) model. MATERIALS AND METHODS: SAH was induced in 7 beagle dogs using the dual haemorrhage model. Vertebral angiography was repeated on Day 1 (before SAH), and on Day 7 (during cerebral vasospasm) before and 1.5 hours after injection of 0.5 mL/kg of 15 mmol/L MgSO(4) in Ringer solution via the tip of a microcatheter placed in the cisterna magna from the lumbar spine. RESULTS: After injection of MgSO(4) solution, the cerebrospinal fluid magnesium ion concentration significantly increased to 3.89 ± 0.97 mEq/L (P < 0.01) from the baseline value (1.49 ± 0.07 mEq/L). The arterial diameters of the basilar artery (BA), vertebral artery (VA), and superior cerebral artery (SCA) on Day 1 were 1.26 ± 0.19 mm, 1.10 ± 0.13 mm, and 0.74 ± 0.21 mm, respectively. On Day 7 before injection, the arterial diameters of the BA, VA, and SCA significantly decreased to 0.75 ± 0.27 mm, 0.74 ± 0.25 mm, and 0.36 ± 0.21 mm, respectively (P < 0.01), due to vasospasm, and were significantly increased to 0.91 ± 0.27 mm (P < 0.01), 0.91 ± 0.31 mm (P < 0.05), and 0.54 ± 0.14 mm (P < 0.01), respectively, after intracisternal injection of MgSO(4) solution. CONCLUSIONS: Intracisternal MgSO(4) therapy using a microcatheter from the lumbar spine may be effective against vasospasm in the clinical setting of endovascular treatment of ruptured aneurysm.

Temporal profile of the effects of intracisternal injection of magnesium sulfate solution on vasodilation of spastic cerebral arteries in the canine SAH model.

PURPOSE: the temporal profiles of the effects of intracisternal injection of magnesium sulfate (MgSO(4)) on vasodilation and cerebrospinal fluid (CSF) magnesium ion (Mg(2+)) concentration were investigated in the canine subarachnoid hemorrhage (SAH) model. METHOD: cerebral vasospasm was induced using the two-hemorrhage model in seven female beagles. On day 7, 0.5 ml/kg of 15 mmol/l MgSO(4) in Ringer solution was injected into the cerebellomedullary cistern. Angiography was performed on day 1 (before SAH), and before and 1, 3, and 6 h after the intracisternal injection on day 7. CSF Mg(2+) was measured at the same time. RESULTS: the diameters of the basilar artery (BA), vertebral artery (VA), and superior cerebellar artery (SCA) before the intracisternal injection on day 7 were 0.59 ± 0.15, 0.41 ± 0.17, and 0.35 ± 0.17 mm, respectively, and were significantly decreased (p < 0.01) compared with the baseline diameters on day 1. The BA diameters at 1 h (0.74 ± 0.16 mm) and 3 h (0.73 ± 0.13 mm), the VA diameter at 1 h (0.64 ± 0.14 mm), and the SCA diameter at 3 h (0.54 ± 0.08 mm) after the injection were significantly increased (p < 0.05). The CSF Mg(2+) concentration was significantly increased (p < 0.01) at 1 h (3.59 ± 0.76 mEq/l) and 3 h (2.00 ± 0.31 mEq/l) after the injection compared with the baseline value (1.35 ± 0.23 mEq/l). CONCLUSIONS: the reversible effect of intracisternal MgSO(4) solution injection on the spastic artery depends on maintenance of the optimal CSF Mg(2+) concentration.

Significance of endoscopic hematoma evacuation in elderly patients with spontaneous putaminal hemorrhage.

BACKGROUND: The efficacy of endoscopic surgery for spontaneous intracerebral hemorrhages (ICH) has been previously reported, but differences in the effect between early and late elderlies remain unclear. METHODS: Ninety-seven patients diagnosed with putaminal hemorrhage (age, ≥65 years; hematoma volume, ≥30 mL) were included in this retrospective analysis and separated into three treatment groups: craniotomy surgery (CR), endoscopic surgery (EN), and non-surgical (NS) groups. The patients were additionally subdivided into two groups according to age: patients aged 65-74 years ("early elderlies") and patients aged ≥75 years ("late elderlies"). Their clinical data and outcomes at discharge were compared using statistical analyses. RESULTS: The CR and the EN groups were associated with lower mortality rates (P < 0.001), lower modified Rankin Scale (mRS; P = 0.007), and lower National Institutes of Health Stroke Scale (NIHSS; P = 0.029) compared to the NS group. Early elderlies in the CR and EN groups with ICH scores of 3 also had significantly better outcomes (P = 0.001). The proportion of patients with mRS ≤ 4 was highest in the early elderlies of the EN group (P = 0.553). Although significant differences in the change of NIHSS scores between the early and late elderlies was not observed, significantly improved NIHSS scores were observed in the EN group compared to the NS group, even in the late elderlies (P = 0.037). CONCLUSION: The evacuation of deep-seated intracranial hematomas using the endoscope might improve functional outcomes and mortality, regardless of age.

[Comparison of the far lateral approach, transcondylar fossa approach, and transcondylar approach using a three-dimensional skull base model with artificial vertebral artery].

The far lateral approach, transcondylar fossa approach, and transcondylar approach are widely accepted as basic suboccipital lateral skull base techniques to treat various pathologies located in the lateral to anterior regions of the cervico-medullary junction. Surgical simulations were performed to evaluate the differences between these techniques using a three-dimensional dissectable skull base model with an artificial vertebral artery. The far lateral approach provided space around the intradural vertebral artery at the level of the jugular foramen. The transcondylar fossa approach allowed better visualization of the vertebral artery at the level between the jugular foramen and the hypoglossal canal. The transcondylar approach did not offer significantly better visualization of the vertebral artery compared with the transcondylar fossa approach except at the level below the hypoglossal canal. However, the transcondylar approach offered more extensive removal of the jugular tubercle than the transcondylar fossa approach because the removed occipital condyle, including the atlanto-occipital joint provided space for introduction of a surgical drill into the anterior part of this bony protuberance. Evaluation using the dissectable skull base model clearly demonstrated the differences in the surgical exposures of the intradural vertebral artery provided by these skull base approaches.

Limited Indications for Clipping Surgery of Paraclinoid Aneurysm Based on Long-Term Visual Morbidity.

OBJECTIVE: Clipping of paraclinoid aneurysm is still challenging because of poor visual morbidity. The extradural temporopolar approach was applied to clip paraclinoid aneurysms, with the expectation of reducing visual morbidity. Factors related to poor visual morbidity were evaluated, to assess the results for clipping of paraclinoid aneurysms. METHODS: A series of 40 unruptured paraclinoid aneurysms in 38 patients were clipped via extradural temporopolar approach. Preoperative and postoperative states of visual cognitive function and radiological outcomes were investigated. Aneurysms were classified into dorsal type or non-dorsal type, and small (<9 mm) or not-small (≥9 mm), respectively, to identify factors correlated with visual morbidity. RESULTS: Complete clipping rate was 90.0% without any recurrence (mean: 5.2 years). Visual morbidity was unexpectedly high at 28.9%, including 2.7% of blindness immediately after the operation, and 23.7% and 2.7% at the final examination (mean: 3.6 years). Multivariate analysis showed aneurysm size was significantly correlated with worse visual outcome. Visual morbidity was 13.3% and 11.1% for dorsal and the non-dorsal small aneurysms, respectively, and all these cases showed visual field defect limited to the nasal quadrant without decreased visual acuity. In contrast, the non-dorsal not-small aneurysms showed significantly worse visual morbidity (60%) with decreased visual acuity. CONCLUSIONS: Clipping via extradural temporopolar approach can achieve durable treatment for small unruptured paraclinoid aneurysms with acceptable visual morbidity. Visual morbidity of the not-small non-dorsal type, however, was poor. The indications for clipping of paraclinoid aneurysm should be limited to small aneurysms, especially the dorsal type in young patients.

Novel vasodilatory effect of intracisternal injection of magnesium sulfate solution on spastic cerebral arteries in the canine two-hemorrhage model of subarachnoid hemorrhage.

OBJECT: The extracellular Mg++ has a vasodilatory effect on the cerebral artery. The present study investigated the effect of intracisternal injection of MgSO4 solution on cerebral vasospasm in a canine model of subarachnoid hemorrhage (SAH). METHODS: Subarachnoid hemorrhage was induced in 10 beagles using the two-hemorrhage model. Angiography of the vertebrobasilar artery was performed on Day 1 (baseline values before SAH) and on Day 7 (during cerebral vasospasm after induced SAH) before and after intracisternal injection of 0.5 ml/kg of 15 mmol/L MgSO4 solution into the cerebellomedullary cistern. RESULTS: The cerebrospinal fluid Mg++ concentration was significantly increased to 3.15 +/- 1.14 mEq/L after intracisternal injection from the preinjection value (1.45 +/- 0.09 mEq/L; p < 0.01). The diameters of the basilar artery, vertebral artery, and superior cerebellar artery on Day 7 were significantly decreased to 58.0 +/- 10.9%, 71.0 +/- 10.1%, and 60.9 +/- 13.8%, respectively, of their baseline diameters on Day 1 (p < 0.01). After intracisternal injection of MgSO4, these diameters significantly increased to 73.8 +/- 14.3%, 83.0 +/- 14.8%, and 74.1 +/- 13.5%, respectively (p < 0.01). CONCLUSIONS: Intracisternal injection of MgSO4 solution causes significant dilation of spastic cerebral arteries in the canine two-hemorrhage model of SAH.