Efficacy of intraoperative irrigation with artificial cerebrospinal fluid in chronic subdural hematoma surgery: study protocol for a multicenter randomized controlled trial.

BACKGROUND: The surgical techniques for treatment of chronic subdural hematoma (CSDH), a common neurosurgical condition, have been discussed in a lot of clinical literature. However, the recurrence proportion after CSDH surgery remains high, ranging from 10 to 20%. The standard surgical procedure for CSDH involves a craniostomy to evacuate the hematoma, but irrigating the hematoma cavity during the procedure is debatable. The authors hypothesized that the choice of irrigation fluid might be a key factor affecting the outcomes of surgery. This multicenter randomized controlled trial aims to investigate whether intraoperative irrigation using artificial cerebrospinal fluid (ACF) followed by the placement of a subdural drain would yield superior results compared to the placement of a subdural drain alone for CSDH. METHODS: The study will be conducted across 19 neurosurgical departments in Japan. The 1186 eligible patients will be randomly allocated to two groups: irrigation using ACF or not. In either group, a subdural drain is to be placed for at least 12 h postoperatively. Similar to what was done in previous studies, we set the proportion of patients that meet the criteria for ipsilateral reoperation at 7% in the irrigation group and 12% in the non-irrigation group. The primary endpoint is the proportion of patients who meet the criteria for ipsilateral reoperation within 6 months of surgery (clinical worsening of symptoms and increased hematoma on imaging compared with the postoperative state). The secondary endpoints are the proportion of reoperations within 6 months, the proportion being stratified by preoperative hematoma architecture by computed tomography (CT) scan, neurological symptoms, patient condition, mortality at 6 months, complications associated with surgery, length of hospital stay from surgery to discharge, and time of the surgical procedure. DISCUSSION: We present the study protocol for a multicenter randomized controlled trial to investigate our hypothesis that intraoperative irrigation with ACF reduces the recurrence proportion after the removal of chronic subdural hematomas compared with no irrigation. TRIAL REGISTRATION: ClinicalTrials.gov jRCT1041220124. Registered on January 13, 2023.

Bilateral Distal Transradial Approach for Coiling of Basilar Artery Aneurysm: A Technical Note.

Distal transradial approach (dTRA) for neuroendovascular procedures has received much attention in recent years as a newer and less invasive alternative to the conventional transfemoral or transradial approaches. We present the case of an 89-year-old woman with a basilar artery aneurysm requiring simultaneous catheterization of the bilateral vertebral arteries who was successfully embolized using bilateral dTRA. The aneurysm was accessed from the right vertebral artery using the right dTRA. Control angiograms during the procedure were performed from the left vertebral artery via the left dTRA. The operator's posture was ergonomically comfortable, and the catheters were easy to handle during the procedure. To the best of our knowledge, this is the first case of a bilateral dTRA used for neuroendovascular procedures. Bilateral dTRA is a safe and minimally invasive method for patients and ergonomically comfortable for operators.

[Distal Radial Approach for Neuroendovascular Procedure:Initial Experience].

We report the initial experience of the distal radial approach(DRA)via the anatomical snuffbox for various neuroendovascular procedures. DRA was attempted in 16 patients and catheterization of the targeted vessel was successfully performed in 15. In one patient, the puncture was successful, but the wire could not be advanced into the radial artery and a switch to the conventional transradial approach was needed. Among the 15 patients who underwent successful DRA, five patients underwent diagnostic cerebral angiography, five underwent coil embolization of a cerebral aneurysm, three underwent carotid artery stenting, one underwent liquid embolization of an arteriovenous malformation, and one underwent liquid embolization of a chronic subdural hematoma. Operability during the procedures was favorable and good hemostasis was obtained in all cases. There were no complications related to this approach. Our initial experience demonstrates that DRA is technically feasible for various neuroendovascular procedures. It can be a less invasive alternative to the conventional approach.

Parallel Stent Retriever Technique for a Refractory Middle Cerebral Artery Embolism: A Technical Case Report.

Objective: To report a patient who achieved complete recanalization using the parallel stent retriever (SR) technique for a refractory acute middle cerebral artery (MCA) embolism. Case Presentation: An 86-year-old woman underwent an emergency thrombectomy for acute right MCA occlusion. Although thrombectomy has been attempted three times with the conventional technique using a single SR, no recanalization was achieved. Then, an innovative technique was used to deploy two SRs in parallel with the M1 segment of the MCA. Pulling them back simultaneously, the thrombus was retrieved, and complete recanalization was achieved. Conclusion: The parallel SR technique is a feasible method and can be considered as one of the last treatment resorts for acute refractory embolisms at the major MCA trunk.

A Rare Cause of Difficult Catheterization to the Left Brachiocephalic Vein during Transfemoral Transvenous Embolization.

Objective: We experienced a case of difficult catheterization to the left brachiocephalic vein (LBCV) during transfemoral transvenous embolization for traumatic carotid-cavernous fistula. We discussed the cause of this phenomenon. Case Presentation: A 78-year-old woman with a traumatic carotid-cavernous fistula was treated with combined transarterial and transvenous embolization; however, catheterization to the LBCV was very difficult. A balloon guiding catheter (BGC) already placed in the left common carotid artery (LCCA) caused displacement of the LCCA and further compression of the originally stenotic LBCV.A CT investigation of 104 cases of neuroendovascular treatment in our hospital revealed that the distance between the ventral bones and the dorsal arteries sandwiching the LBCV was significantly negatively correlated with age (r = -0.41, p = 0.000020). Aging and arteriosclerotic change are possibly related to the LBCV stenosis. Conclusion: When catheterization to the LBCV is difficult during transfemoral transvenous embolization, not only the presence of anatomical variations and stenosis or occlusion of LBCV itself but also compression from surrounding structures should be considered, especially in elderly patients. In rare cases, a catheter inserted in an adjacent artery may cause further compression of the LBCV.

[A Case of Carotid Free-Floating Thrombus Treated by Carotid Ultrasonography-Guided Endovascular Approach].

We experienced a case of carotid free-floating thrombus treated by carotid ultrasonography-guided endovascular approach. A 63-year-old man was brought to our hospital with the chief complaint of sudden onset left hemiplegia. MRI revealed acute infarction of the right MCA territory due to the right M1 occlusion. Carotid ultrasonography showed a pedunculated, polypoid mobile plaque floating with the cardiac beat. We attempted ultrasonography-guided endovascular treatment. Under proximal balloon protection, the floating plaque was successfully aspirated into the Penumbra aspiration catheter. Carotid stent was also placed to stabilize the residual pedicle of the plaque. Aspirated plaque was identified as fresh thrombus by pathological examination. Carotid ultrasonography-guided endovascular approach was effective for getting the picture of real-time dynamics of the carotid FFT.

Selective propofol injection into the M1 segment of the middle cerebral artery (MCA Wada test) reduces adverse effects and enhances the reliability of the Wada test for determining speech dominance.

OBJECT: The Wada test is had been the most reliable for determining speech dominance. Drugs injected into the internal carotid artery, however, may be heterogeneously distributed as the result of asymmetry of the anterior cerebral arteries and the presence of a fetal-type posterior cerebral artery. Variations in drug distribution could occasionally alter consciousness and complicate the evaluation of the test results. We examined selective propofol injection into the M1 segment of the middle cerebral artery (MCA Wada test). METHODS: For the MCA Wada test (17 patients), 7 or 8 mg of propofol was injected via a microcatheter navigated into the M1 segment, and language function was evaluated by patient performing several tasks. The conventional Wada test (internal carotid artery [ICA] Wada test) was performed in four patients (both the ICA and MCA Wada tests were performed in one patient). The efficacy and adverse effects of both procedures were evaluated; all tests were performed by well-trained interventional neuroradiologists. RESULTS: Immediately after propofol injection during the MCA Wada test, patients developed transient contralateral hemiplegia and transient aphasia (in the case of injection on the dominant side). Confusion and other severe adverse effects did not occur during the MCA Wada test, but two of four patients who underwent the ICA Wada test showed altered consciousness that affected the performance of the test. CONCLUSIONS: The MCA Wada test is a feasible and reliable preoperative evaluation, if performed by a trained team of interventional neuroradiologists.

The effect of musical experience on hemispheric lateralization in musical feature processing.

Music consists of a variety of spectral and temporal features. Generally, brain processing of these features is reported as being right hemisphere dominant. However, there are contradicting results as to whether musical experience affects hemispheric laterality or not. In the present study, we investigated the effect of musical experience on hemispheric lateralization of musical feature processing using magnetoencephalography (MEG). Mismatch fields (MMFs) were measured from 8 musicians and 8 nonmusicians in oddball tasks with four different musical features, including pitch, chord, timbre and rhythm. Regardless of the features, the MMFs showed right-hemispheric dominance in nonmusicians, whereas musicians showed symmetrical MMF amplitudes in both hemispheres. The electrical activity around the auditory cortex to the MMFs also supported the right-hemispheric dominance in nonmusicians and bilateral activation in musicians. Voxel-based morphometry did not detect any group differences around the auditory cortices. These results suggest that musical training changes the hemispheric roles for musical feature processing in the pre-attentive stage, and this functional alteration can occur without apparent anatomical changes.

[Assessment of mental condition and anxiety in patients receiving neuroendovascular treatment].

OBJECTIVE: Neuroendovascular treatment (NET) is an effective and minimally invasive procedure used for patients with vascular disease of the central nervous system. The purpose of this study was to examine anxiety levels using standardized psychometric tools and an original questionnaire among patients before and after NET. METHOD: A total of 40 patients who underwent NET were included. There were 18 patients with unruptured cerebral aneurysm, 18 with carotid stenosis, and 4 other cases. Patients were asked to complete a State-Trait Anxiety Inventory (STAI) and also to fill out a questionnaire about perioperative anxiety. It elicited the following information: (a) state-anxiety score and level before and after NET; (b) trait-anxiety score and level before and after NET; and (c) perioperative anxiety about NET. In all cases, the procedure was performed under local anesthesia. RESULTS: The preprocedural state-anxiety score was high in many patients (82%). The principal cause of the preprocedural anxiety was the procedure-related complications (92%). Patients with cerebral aneurysm experienced anxiety during the procedure because they could not know which stage of the procedure was involved. Their state-anxiety score was improved in the postprocedural examination (88%). However, patients were still anxious about postoperative complications and recurrence, particularly those with cerebral aneurysm. Patients with cerebral aneurysm generally tended to experience a higher level of anxiety than those with carotid stenosis. CONCLUSION: Though NET is apt to be thought as a relatively easy procedure, patients actually felt much anxiety, especially those with cerebral aneurysm. Due care for perioperative anxiety in patients who undergo NET is important.

Usefulness of three-dimensional digital subtraction angiography in endovascular treatment of a spinal dural arteriovenous fistula.

The use of 3D digital subtraction (DS) angiography provides a better understanding of spinal vascular lesion architecture. The authors report on 2 cases involving a spinal dural arteriovenous fistula (DAVF) and demonstrate the usefulness of 3D DS angiography for endovascular treatment of these spinal DAVFs. In both cases, middle-aged male patients suffered from bilateral leg hypesthesia, gait disturbance, and urinary dysfunction several months before treatment. Spinal angiography revealed DAVFs that were fed by a radicular artery branching from the intercostal artery and draining veins proceeding superiorly along the perimedullary veins. Endovascular embolization was performed in both cases. Selective 3D DS angiography of the intercostal artery clearly demonstrated the tortuous course of the feeder and the relationship among the feeding artery, fistula point, and draining veins in each case. This information was very useful in selecting a working angle for manipulating the microcatheter and for glue injection. In addition, the maximum intensity projection image from rotational DS angiography data clearly showed the fistula point at the dural sleeve and feeder entering the spinal canal via the intervertebral foramen and the relationship with the bone structure. Successful obliteration of the fistulae was achieved in both cases. Selective spinal 3D DS angiography was very useful in understanding the complex spinal vascular architecture and in choosing the best working angle and therapeutic strategy for endovascular treatment of spinal DAVFs.