Effects of superficial temporal artery to middle cerebral artery bypass on postoperative infarction rates among young children (≤ 5 years old) with moyamoya disease.

Revascularization surgery for young children with moyamoya disease (MMD) is challenging. Although indirect revascularization is preferred because of the technical difficulty in direct anastomosis, higher risks of postoperative infarction remain a problem. We aimed to investigate the effect of superficial temporal artery to middle cerebral artery (STA-MCA) bypass on postoperative outcomes during the acute postoperative period in young children ≤ 5 years old with MMD. This retrospective study included consecutive young children with MMD who underwent surgical revascularization of the anterior cerebral circulation. Groups were determined according to the procedures performed, namely, the combined (STA-MCA bypass with indirect revascularization) and the indirect revascularization groups. The incidences of radiological or symptomatic infarction, transient neurological events, and new neurological deficits that remained at discharge were compared between groups. Of 38 surgical procedures, there were 23 combined and 15 indirect revascularizations. The median age of the patients was 3.0 years, which was significantly different between groups (P < .01). When comparing the postoperative outcomes between groups, the incidences of radiological and symptomatic infarction and new neurological deficits that remained at discharge were significantly lower in the combined revascularization group (P < .05). Logistic regression analysis adjusted for potential confounders found that surgical modality was a statistically significant independent risk factor associated with radiological and symptomatic infarctions (indirect/combined, odds ratio: 10.2; 95% confidence interval: 1.30-79.7; P < .05). STA-MCA bypass combined with indirect revascularization can reduce the incidence of postoperative infarction in young children with MMD and might lead to better neurological outcomes.

Increased cerebrospinal fluid S100B protein levels in patients with trigeminal neuralgia and hemifacial spasm.

BACKGROUND: The pathophysiology of neurovascular compression syndrome has not been fully elucidated, and cerebrospinal fluid levels of nerve tissue-related markers involved in this disorder have not yet been reported. METHODS: We measured cerebrospinal fluid levels of S100B protein, neuron-specific enolase, and myelin basic protein in 21 patients with trigeminal neuralgia, 9 patients with hemifacial spasms, and 10 patients with non-ruptured intracranial aneurysms (control). Cerebrospinal fluid levels of these markers were determined using commercially available assay kits. RESULTS: Both trigeminal neuralgia and hemifacial spasm groups showed significantly increased cerebrospinal fluid levels of S100B compared with the control group (1120 [IQR 391-1420], 766 [IQR 583-1500], and 255 [IQR 190-285] pg/mL, respectively; p = 0.001). There were no statistically significant differences in cerebrospinal fluid levels of neuron-specific enolase or myelin basic protein among the groups. CONCLUSION: Cerebrospinal fluid S100B levels were significantly higher in patients with trigeminal neuralgia and hemifacial spasm than in controls, which suggests the involvement of S100B in the underlying pathophysiology of neurovascular compression syndrome.

How I do it: endoscopic supracerebellar infratentorial approach for torcular meningioma removal.

BACKGROUND: Torcular meningioma is a rare type of brain tumor with few reports regarding the appropriate resection approach for this disease. In cases without sinus occlusion, surgeons are advised to spare the sinus; however, the sinus may interfere with the visual field. METHOD: Endoscopic supracerebellar infratentorial approach for removal of torcular meningioma was performed in the prone position. The tumor attachment to sinus or confluence was removed or coagulate safely due to an optimal look-up view with the 0° and 30° endoscope. CONCLUSION: Endoscopic supracerebellar infratentorial approach for infratentorial torcular meningioma is a safe and less invasive technique.

Long-Term Effects on Preventing Stroke after Endovascular Treatment or Bypass Surgery for Intracranial Arterial Stenosis.

BACKGROUND: Intracranial arterial stenosis (ICAS) is an important cause of ischemic stroke worldwide due to its higher risk of recurrence with medical therapy. Although some large randomized studies failed to show the superiority of surgical treatment compared with medical therapy, the results of medical therapy are not sufficient. There are patients who still benefit from surgical treatment. This retrospective analysis aimed to evaluate the long-term efficacy of surgical therapy with percutaneous transluminal angioplasty and/or stenting (PTA/PTAS) or extracranial-intracranial (EC/IC) bypass surgery for patients with ICAS. METHODS: Between October 2005 and December 2016, 55 ICAS patients were treated with PTA/PTAS or EC-IC bypass surgery. Their electronic medical records were retrospectively reviewed and analyzed. The primary outcome was all adverse events beyond 30 days after a revascularization procedure. RESULTS: We performed 21 cases (35%) of PTA, 4 cases (7%) of PTAS, and 34 cases (58%) of EC-IC bypass surgery and the median follow-up duration was 66 months (range 1-144 months). The occurrence rate of the primary outcome was 10.2% and only 1 patient (1.8%) experienced ipsilateral disabling ischemic stroke beyond 30 days. The long-term functional independent survival rate was 83.6%. CONCLUSIONS: We demonstrated a long-term favorable outcome of combined surgical intervention for ICAS patients with PTA/PTAS and EC-IC bypass surgery, and the result was better than previously reported outcomes of medical therapy. Additional multicenter studies are required to draw firm conclusions on the efficacy of reduction of recurrent stroke in patients with ICAS.

Localized Leg Volume Index: A New Method for Body Type-Corrected Evaluation of Localized Leg Lymphedematous Volume Change.

BACKGROUND: Volume measurement is one of the most common evaluations for lower-extremity lymphedema. However, volume comparison between different patients with different physique may be inappropriate, and it is difficult to evaluate localized limb volume change using leg volume evaluation. METHODS: Localized leg volumes (Vk, k = 1-5) and localized leg volume indices (LEVIk) at 5 points (1, thigh; 2, knee; 3, lower leg; 4, ankle; 5, foot) of 106 legs of 53 examinees with no leg edema were calculated based on physical measurements, leg circumferences and lengths, and body mass index (BMI). Interrater and intrarater reliabilities of LEVIk were assessed, and Vk and LEVIk were compared between lower BMI (BMI < 22 kg/m) group and higher BMI (BMI ≥ 22 kg/m) group. RESULTS: Interrater and intrarater reliabilities of LEVIk were all high (all: r > 0.98). Between lower and higher BMI groups, significant differences were observed in all Vk: V1 (P = 3.7 × 10), V2 (P = 4.7 × 10), V3 (P = 4.5 × 10), V4 (P = 1.6 × 10), and V5 (P = 2.4 × 10). Regarding LEVI between groups, significant differences were seen in LEVI3 (P = 0.009), LEVI4 (P = 0.004), and LEVI5 (P = 1.3 × 10); no significant difference was seen in LEVI1 (P = 0.23) or LEVI2 (P = 0.51). CONCLUSIONS: Localized leg volume index is a highly reproducible and convenient method for evaluation of localized volume change of the lower extremity, which is less affected by body type compared with leg volumetry.

Development of Pyriform Sinus Suctioning Programs for Aspiration Pneumonia Prevention During the Acute Stroke.

Aspiration due to dysphagia is a factor associated with pneumonia during acute stroke. In such cases, it is likely that secretions in the pyriform sinuses enter the laryngeal inlet. The present study was based on the idea that it is possible to reduce aspiration pneumonia by periodically suctioning and removing such secretions (pyriform sinus suctioning), a study was conducted in a single facility. The incidence of pneumonia as a dependent variable was compared between before (control) and after (intervention group) intervention with pyriform sinus suctioning as an independent variable. With a view of unifying the quality and frequency of intervention, two programs to: initially confirm the safety of such suctioning; subsequently enhance/evaluate knowledge and skills related to the procedure (educational); and specify conditions for the implementation and criteria for determining its appropriateness (practical), were developed. The study involved 33 (mean age: 74.6 ± 12.4) and 30 (80.0 ± 8.8) control and intervention group members, respectively, 25 (83.3%) of the latter were treated with pyriform sinus suctioning for 5 days after a stroke. Pneumonia developed in 7 (21.2%) and 2 (6.7%) of the former and latter, respectively. As individuals with a Japan Coma Scale (JCS) score of III or a midline shift on head CT tend to develop pharyngeal dysphagia, the patients were also divided into 2 groups to compare the incidence of pneumonia based on the risk level: low: Japan Coma Scale scores of I-II without a midline shift on head CT; and high: scores of II-III with it. In the latter, the incidence after intervention was markedly lower (p = 0.06, φ = 0.326), while the former did not show changes (p = 0.574, φ = 0.066), supporting the effectiveness of pyriform sinus suctioning to prevent aspiration pneumonia among patients with a low risk level.

Ruptured partially thrombosed anterior inferior cerebellar artery aneurysms: two case reports and review of literature.

Aneurysms arising from the distal anterior inferior cerebellar artery (AICA) are very rare. When the parent artery is an AICA-posterior inferior cerebellar artery (PICA) variant, occlusion of the artery, even distal to the meatal loop, leads to a significant area of cerebellar infarction. We report two cases of ruptured partially thrombosed distal AICA aneurysms. In both cases, the parent artery was an AICA-PICA variant. The aneurysms were clipped in one case and trapped following occipital artery (OA)-AICA anastomosis in another case. It is important to keep the OA as a donor artery for revascularization in the treatment of the AICA-PICA variant aneurysms, especially when the absence of intra-aneurysmal thrombus is not comfirmed preoperatively.

Lymphadiposal Flaps and Lymphaticovenular Anastomoses for Severe Leg Edema: Functional Reconstruction for Lymph Drainage System.

BACKGROUND: Collecting lymphatics have lymph-drainage function with contraction of smooth muscle cells. Patients with edema have lost this drainage function due to degeneration of smooth muscle cells. Lymphaticovenular (LV) anastomosis salvages smooth muscle cells from reversible degeneration (mild edema), but muscle cells cannot be recovered from irreversible degeneration (severe edema). Therefore, in severe edema, LV anastomoses cannot reestablish the drainage function of the lymphatic system.To overcome this weakness of LV bypass methods for severe edema, new methods were instituted for repair of this missing drainage function using a lymphadiposal flap from the contralateral foot for hemilateral edema, or transfer of lateral thoracic lymph nodes for bilateral edema. METHODS: A total of 13 cases were repaired with lymphadiposal flaps and additional LV anastomoses. These cases have frequent phlegmon or cellulitis or resisted to previous LV anastomoses and/or compression therapy. The ages ranged from 15 to 75 years. There were four cases of primary edema and nine cases of secondary edema. RESULTS: Regarding the lymphadiposal flap (n = 8), three cases showed an excellent response (37.5%; no need for compression therapy), four cases had a good response (50%; improvement with compression), one case showed no change (12.5%; no improvement), and there were no cases of deterioration. Regarding the lateral thoracic lymph nodes transfer (n = 5), two cases had a good response (40%), three showed no improvement (60%), and there were no cases of deterioration. CONCLUSION: It is concluded that lymphadiposal flap or lymph nodes transfer is suitable for severe edema having frequent cellulitis in unilateral or bilateral lower extremities resisting previous LV anastomoses and/or compression therapy.

[SURGICAL TREATMENT FOR TWENTIES PATIENTS WITH PULMONARY NONTUBERCULOUS MYCOBACTERIOSIS RESISTING CHEMOTHERAPY].

SUBJECTS AND METHODS: We report five cases of surgical treatment for pulmonary nontuberculous mycobac- teriosis (NTM) resisting chemotherapy in twenties. Of the five, one was male and four were female. They had cavitary or nodular lesion in their lung. After chemotherapy, partial resection or lobectomy was performed. RESULT: Though postoperative chemotherapy had contin- ued for only 6 months or 1 year, there was no relapse/recurrence at more than 86 months in average after surgery. Consideration. In younger patients, NTM lesions in the lung are sometimes more localized than senior patients, therefore they can be removed as a smaller portion by the operation, and we can sometimes keep more pulmonary function of the patient. CONCLUSION: Surgical treatment for twenties patients with pulmonary nontuberculous mycobacteriosis resisting chemo- therapy should be carried out aggressively at an early stage to resect a smaller portion of the lung and also decrease relapse/ recurrence after surgery.

[CHANGES IN MAC ANTIBODY LEVELS BEFORE AND AFTER SURGERY AND AT THE TIME OF RELAPSE/RECURRENCE IN MAC LUNG DISEASE--Can MAC Antibodies Be an Indicator of Postoperative Relapse/Recurrence?].

BACKGROUND: Patients receiving surgical treatment for Mycobacterium avium complex (MAC), lung disease should be followed up with careful attention paid to relapse/recurrence, but there is some debate regarding the findings based on which relapse/recurrence should be diagnosed. PURPOSE AND METHODS: We hypothesized that we might be able to use anti-GPL core IgA antibodies (MAC antibodies), which have been attracting attention as a factor that may support diagnosis of MAC lung disease, to diagnose postoperative relapse/recurrence. Therefore, we compared the levels of these antibodies before and at the time of relapse/recurrence, and also compared antibody titers before and after surgery. RESULT: MAC antibody titers were elevated by an average of about 50% at the time of relapse/recurrence compared to those before relapse/recurrence for 6 patients. In contrast, MAC antibody titers were about 30% lower after surgery compared to those before surgery for 37 patients. CONCLUSION: It may be possible to use MAC antibodies as an indicator of postoperative relapse/recurrence for MAC lung disease.

Indocyanine green lymphography and lymphaticovenous anastomosis for generalized lymphatic dysplasia with pleural effusion and ascites in neonates.

BACKGROUND: The fatality rate of generalized lymphatic dysplasia (GLD) with chylous pleural effusion and ascites is particularly high when it persists over a prolonged period. The purpose of this report was to determine the utility of indocyanine green (ICG) lymphography and lymphaticovenous anastomosis (LVA) in GLD with chylous pleural effusion and ascites in neonates. METHODS: We tested the lymphatic function in the 4 extremities for 8 GLD neonate patients using ICG lymphography, and on the basis of the results, we performed LVA for 5 of them. LVA was performed at the extremities under general anesthesia using incisions <1 cm in length. The outcome of LVA was evaluated with the amount of ascites discharged from thoracostomy tube or abdominal tube, except for 1 patient who had no drainage tube. RESULTS: In all cases, ICG lymphography showed varying degrees of dermal backflow in the limbs with lymphostasis. After LVA surgery, effusion stopped in 2 cases and decreased in 1 case. In the cases where effusion stopped, backflow as observed with ICG lymphography was minimal, and in the case where effusion decreased but did not stop, backflow was moderate. CONCLUSIONS: The application of ICG and LVA could possibly be used to diagnose and treat lymphatic pleural effusion or ascites.

[A STUDY OF SURGICAL TREATMENT FOR PATIENTS WITH MYCOBACTERIUM ABSCESSUS PULMONARY DISEASE AND A COMPARATIVE EXAMINATION OF MYCOBACTERIUM AVIUM COMPLEX DISEASE].

OBJECTIVE: This is a retrospective study on six surgical cases of Mycobacterium abscessus pulmonary disease, including a comparison with M. avium complex (MAC) disease. SUBJECTS AND METHODS: We performed surgery for six cases of M. abscessus pulmonary disease between July 2012 and June 2014. In all the cases, video-assisted thoracic surgery alone was performed. Age, sex, bacillus identification method, disease type, preoperative anti-glycopeptidolipid core immunoglobulin A antibody value, preoperative chemotherapy, preoperative chemotherapy period, adaptation of the operation, surgical method, result of the bacillus culture of an organization that was extracted at operation, postoperative hospitalization period, surgical complications, and postoperative relapse were examined for the six cases of M. abscessus pulmonary disease. In addition, the cases were compared with 36 cases of MAC disease for which operation was performed during the same period. RESULT: None of the patients had major surgical complications or in-hospital death. Although three patients survived for more than 1 postoperative year and completed chemotherapy, relapses are not accepted in all cases at present. In the comparison with MAC disease, the mean preoperative chemotherapy period for M. abscessus pulmonary disease was 5.5 months, which was 18.9 months shorter than that for MAC disease, with a statistically significant difference. CONCLUSION AND CONSIDERATION: Surgery for M. abscessus pulmonary disease may be considered a safe and effective therapeutic procedure. Moreover, some physicians believe that surgical treatment is required at an earlier stage of M. abscessus pulmonary disease compared with MAC disease.

Minimally invasive lymphatic supermicrosurgery (MILS): indocyanine green lymphography-guided simultaneous multisite lymphaticovenular anastomoses via millimeter skin incisions.

Among various surgical treatments, lymphaticovenular anastomosis (LVA), which bypasses congested lymph into venous circulation, is the least invasive surgical treatment. However, it usually entails skin incisions of around 3 cm, and operation time of around 4 hours. With multiple supermicrosurgeons under guidance of indocyanine green lymphography, LVAs can be simultaneously performed under local anesthesia within approximately 2 hours via small skin incisions with length less than 1 cm, allowing minimally invasive lymphatic supermicrosurgery (MILS). We performed MILS on 11 limbs of compression-refractory peripheral lymphedema cases. Length of skin incision for LVA ranged from 1 to 9 mm. Average operation time was 1.82 hours. Of the 11 limbs, 10 showed postoperative volume reduction. Indocyanine green lymphography clearly visualizes superficial lymph flows, which helps us to decide precise skin incision sites and find lymphatic vessels in LVA surgery, shortening skin incision length and operation time. Minimally invasive lymphatic supermicrosurgery can serve as the most reasonable treatment of compression-refractory peripheral lymphedema.

Sequential anastomosis for lymphatic supermicrosurgery: multiple lymphaticovenular anastomoses on 1 venule.

BACKGROUND: Supermicrosurgical lymphaticovenular anastomosis (LVA) is becoming a treatment option for progressive lymphedema. Various types of LVA such as end-to-end, end-to-side, side-to-end, and side-to-side are performed to improve the treatment efficacy. METHODS: We applied sequential anastomosis for LVA surgery, in which 2 lymphatic vessels were anastomosed to 1 venule using side-to-side and side-to-end anastomoses. Six lower extremity lymphedema (LEL) patients who underwent sequential anastomosis were included in this study. Feasibility, anastomosis patency, and treatment effect of the method were evaluated. RESULTS: Six sequential anastomoses were performed on 6 lymphedematous limbs. All sequential anastomoses showed good anastomosis patency after completion of anastomoses. A significant decrease in LEL index was seen postoperatively (244.0 ± 14.6; postoperative LEL index vs 263.5 ± 19.4; preoperative LEL index, P = 0.002). CONCLUSIONS: Sequential anastomosis can divert both normograde and retrograde lymph flows from 2 lymphatic vessels into 1 venule. Sequential LVA is a useful method to increase lymph flow bypasses, when there are fewer venules than lymphatic vessels.

Predictive lymphatic mapping: a method for mapping lymphatic channels in patients with advanced unilateral lymphedema using indocyanine green lymphography.

In severe lymphedema, indocyanine green lymphography cannot be used to map lymphatic channels before lymphaticovenular anastomosis (LVA) because linear lymphatics cannot be detected in a severely affected leg. Here, we describe a new method, which we refer to as predictive lymphatic mapping, to predict the location of lymphatics for anastomosis in unilateral lymphedema, thereby improving surgical accuracy and efficiency. The approach consists of marking anatomical landmarks and joining selected landmarks with fixed lines. The distance from these fixed lines to lymphatic channels mapped by indocyanine green lymphography in the unaffected leg is then measured, scaled up based on the difference in circumference between the legs, and transposed to the affected leg. To date, we have used this method in 5 cases of unilateral or asymmetric lymphedema of the lower extremities. In no cases have we failed to find a lymphatic channel suitable for LVA within a 2-cm incision. These results suggest that predictive lymphatic mapping is a useful additional tool for surgeons performing LVA under local anesthesia, which will help to improve the accuracy of incisions and the efficiency of surgery.

Near-infrared illumination system-integrated microscope for supermicrosurgical lymphaticovenular anastomosis.

BACKGROUND: Lymphatic supermicrosurgery, lymphaticovenular anastomosis (LVA), is becoming a treatment option for progressive lymphedema with its effectiveness and minimal invasiveness. It is important to detect and anastomose large functional lymphatic vessels for LVA surgery. This study aimed to evaluate usefulness of a near-infrared illumination system-integrated microscope for lymphatic supermicrosurgery. METHODS: We performed LVA on 12 lower extremity lymphedema (LEL) patients with or without intraoperative microscopic indocyanine green (ICG) lymphography guidance. An operating microscope equipped with an integrated near-infrared illumination system (OME-9000; Olympus, Tokyo, Japan) was used for intraoperative microscopic ICG lymphography guidance. Feasibility, anastomosis patency, and treatment effect of the method were evaluated. RESULTS: Forty LVAs were performed (24 LVAs with intraoperative microscopic ICG lymphography-guidance on 7 limbs, and 16 LVAs without the guidance on 5 limbs). Lymphatic vessels were enhanced by intraoperative microscopic ICG lymphography in 11 of 12 skin incision sites. Time required for detection and dissection of lymphatic vessels in cases with intraoperative microscopic ICG lymphography guidance was significantly shorter than that in cases without the guidance (2.3 ± 1.7 min vs. 6.5 ± 4.0 min, P = 0.010). There was no statistically significant difference in LEL index reduction between cases with and without intraoperative microscopic ICG lymphography guidance (18.3 ± 5.5 vs. 15.0 ± 5.5, P = 0.337). CONCLUSIONS: Intraoperative microscopic ICG lymphography visualized lymphatic vessels, which helps a lymphatic supermicrosurgeon to find and dissect lymphatic vessels earlier.

The effect of lymphatico-venous anastomosis for an intractable ulcer at the lower leg in a marked obese patient.

Secondary lymphedema occurs after trauma, cancer surgery, or obesity, and wounds in lymphedema can easily become intractable. We report positive results using lymphatico-venous anastomosis (LVA) to treat a post-traumatic lymph fistula and an intractable ulcer in a severely obese patient. A 41-year-old male (BMI 51.8), one year prior, had a traffic injury, and had an 18-cm contusion in his right leg. Six months later, lymph leakage in a 14 cm × 8 cm region and a 5 cm × 3 cm skin ulcer occurred in the center of the wound. We made a diagnosis of lymphedema resulting from obesity, accompanied with lymphorrhea and intractable ulcer. He was unable to reach his legs owing to obesity, making complex physical therapy impossible. We performed LVA under local anesthesia. The lymphorrhea healed 2 weeks after the operation and had not recurred 3 months after the operation. The leg lymphedema improved after the surgery without the compression therapy. In cases of intractable ulcers, suspected of being caused by lymphostasis, treatments indicated for lymphedema, for example LVA, may possibly allow satisfactory wound healing. © 2013 Wiley Periodicals, Inc. Microsurgery 34:64-67, 2014.

Safety of antiplatelet therapy during the perioperative period of revascularization surgery for moyamoya disease patients with ischemic onset.

For patients with moyamoya disease, antiplatelet agents are often used during the perioperative periods of revascularization surgeries to prevent ischemic events. However, antiplatelet therapy is associated with the risk of hemorrhagic complications. Further, the influence of antiplatelet therapy on perioperative ischemic or hemorrhagic complications has not been investigated. This study aimed to determine the impact of antiplatelet agents on adult moyamoya disease patients with ischemic onset during the perioperative period. From January 2016 to December 2020, 183 consecutive combined (direct and indirect) revascularization surgeries for moyamoya disease patients were performed. Among these surgeries, 96 consecutive combined revascularization surgeries for adult moyamoya disease patients with ischemic onset were analyzed and perioperative ischemic and hemorrhagic complications were reviewed. Antiplatelet agents were continued during the perioperative period including on the day of surgery and the day after the surgery. Among 96 surgeries, no hemorrhagic complications occurred postoperatively. Infarction occurred in five cases (5.2%). Among the five cases, neurological deficits persisted in two cases and improved in three. The median value of bleeding volume was 112.5 mL (interquartile range, 80.0 - 200.0). Twenty-five cases (26.0%) needed blood transfusion. The modified Rankin Scale score deteriorated in two cases due to cerebral infarction. The incidence of hemorrhagic and ischemic complications after combined revascularization surgery in patients with ischemic moyamoya disease under antiplatelet therapy was low, indicating the safety of continued antiplatelet therapy.