Pathological Findings of Donor Vessels in Bypass Surgery.

(1) Background Cerebral revascularization is necessary to treat intracranial arterial stenosis caused by moyamoya disease, atherosclerosis, or large complex aneurysms. Although various donor vascular harvesting methods have been reported safe, there are no reports on the histological evaluation of donor vessels for each disease, despite the variety of diseases wherein vascular anastomosis is required. (2) Methods Pathological findings of the superficial temporal artery (STA), radial artery (RA), occipital artery (OA), and saphenous vein (SV) harvested at the institution were analyzed. Patients classified according to aneurysm, atherosclerosis, and moyamoya disease were assessed for pathological abnormalities, medical history, age, sex, smoking, and postoperative anastomosis patency. (3) Results There were 38 cases of atherosclerosis, 15 cases of moyamoya disease, and 30 cases of aneurysm in 98 donor vessels (mean age 57.2) taken after 2006. Of the 84 STA, 11 RA, 2 OA, and 1 SV arteries that were harvested, 71.4% had atherosclerosis, 11.2% had dissection, and 10.2% had inflammation. There was no significant difference in the proportion of pathological findings according to the disease. A history of hypertension is associated with atherosclerosis in donor vessels. (4) Conclusions This is the first study to histologically evaluate the pathological findings of donor vessels according to disease. The proportion of dissection findings indicative of vascular damage due to surgical manipulation was not statistically different between the different conditions.

A Case of Ruptured Carotid Traumatic Blood Blister-like Aneurysm.

Ruptured cerebral aneurysms that occur in the anterior wall of the internal carotid artery (ICA) are known as blood blister-like aneurysms (BBAs); they have been reported to account for 0.3% to 1% of all ruptured ICA aneurysms. In this report, we describe the treatment of an unusual traumatic BBA (tBBA) with high-flow bypass using a radial artery graft, which resulted in a favorable outcome. A 59-year-old female suffered from an acute epidural hematoma, traumatic subarachnoid hemorrhage, and traumatic carotid-cavernous sinus fistula (tCCF) after being involved in a motor vehicle accident. Her angiography results showed tCCF and a tBBA on the anterior wall of the right ICA. On the fourth day after injury, we found rebleeding from the tBBA and performed an emergency high-flow bypass using a radial artery graft with lesion trapping as a curative procedure for the tCCF and tBBA. Postoperatively, right abducens nerve palsy appeared, but no other neurological symptoms were noted; the patient was thereafter transferred to a rehabilitation hospital 49 days after injury. Traumatic ICA aneurysms commonly occur close to the anterior clinoid process, form within 1 to 2 weeks of injury, and often rupture around 2 weeks after trauma. This case was considered rare as the ICA was likely injured and bleeding at the time of injury, resulting in a form of tBBA; this allowed early detection and appropriate treatment that resulted in a good outcome.

Preliminary Clinical Surgical Experience with Temporary Simultaneous Use of an Endoscope during Exoscopic Neurosurgery: An Observational Study.

The use of an endoscope in exoscopic transcranial neurosurgery for skull-base lesions has not yet been investigated. Thus, this study aimed to investigate the advantages, disadvantages, and safety of "simultaneous temporary use of an endoscope during exoscopic surgery" (exo-endoscopic surgery (EES)). Consecutive exo-endoscopic surgeries performed by experienced neurosurgeons and assistants were analyzed. Surgical complications and time were compared with previous consecutive microsurgeries performed by the same surgeon. A questionnaire survey was conducted on 16 neurosurgeons with experience in both "temporary simultaneous use of endoscope during microscopic surgery" (micro-endoscopic surgery (MES)) and EES. EES was performed in 18 of 76 exoscopic surgeries, including tumor removal (n = 10), aneurysm clipping (n = 5), and others (n = 3). There were no significant differences in operative time, anesthesia time, or complications from microsurgery by the same operator. According to the questionnaire survey results, compared with MES, EES had a wider field of view due to its lack of an eyepiece, was easier when loading and unloading instruments into and out of the surgical field, and was more suitable for the simultaneous observation of two fields of view. Overall, 79.2% of surgeons indicated that EES may be better suited than MES to simultaneously observe two fields of view.

The impact of sarcopenia on low back pain and quality of life in patients with osteoporosis.

PURPOSE: Osteoporosis combined with sarcopenia contributes to a high risk of falling, fracture, and even mortality. However, sarcopenia's impact on low back pain and quality of life (QOL) in patients with osteoporosis is still unknown. The purpose of this study is to investigate low back pain and QOL in osteoporosis patients with sarcopenia. METHODS: We assessed 100 ambulatory patients who came to our hospital for osteoporosis treatment. Low back pain was evaluated using the Visual Analogue Scale (VAS) with 100 being an extreme amount of pain and 0 no pain. The Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) score was used to assess QOL after adjustment for age, history of vertebral fracture, and adult spinal deformity. Differences in low back pain intensity assessed by VAS between groups were evaluated by the Willcoxon rank-sum test. Covariance analysis was used to assess QOL. All data are expressed as either median, interquartile range, or average, standard error. RESULTS: Patients were classified into the sarcopenia group (n = 32) and the non-sarcopenia group (n = 68). Low back pain intensity assessed by VAS was significantly higher in the sarcopenia group than in the non-sarcopenia group (33.0 [0-46.6] vs. 8.5 [0-40.0]; p < 0.05). The subscales of the JOABPEQ for low back pain were significantly lower in the sarcopenia group than in the non-sarcopenia group (65.0 ± 4.63 vs. 84.0 ± 3.1; p < 0.05). CONCLUSION: In this cross-sectional study, sarcopenia affected low back pain and QOL in ambulatory patients with osteoporosis. Sarcopenia may exacerbate low back pain and QOL.

Factors Influencing Long-Term Blood Flow in Extracranial-to-Intracranial Bypass for Symptomatic Internal Carotid Artery Occlusive Disease: A Quantitative Study.

BACKGROUND: Maintaining the patency of extracranial-to-intracranial (EC-IC) bypass is critical for long-term stroke prevention. However, reports on the factors influencing long-term bypass patency and quantitative assessments of bypass patency are limited. OBJECTIVE: To quantitatively evaluate blood flow in EC-IC bypass using four-dimensional (4D) flow magnetic resonance imaging (MRI) and investigate factors influencing the long-term patency of EC-IC bypass. METHODS: Thirty-six adult Japanese patients who underwent EC-IC bypass for symptomatic internal carotid or middle cerebral artery occlusive disease were included. We examined the relationships between decreased superficial temporal artery (STA) blood flow volume and perioperative complications, long-term ischemic complications, patient background, and postoperative antithrombotic medications in patients for whom STA flow could be quantitatively assessed for at least 5 months using 4D flow MRI. RESULTS: The mean follow-up time was 54.7 ± 6.1 months. One patient presented with a stroke during the acute postoperative period that affected postoperative outcomes. No recurrent strokes were recorded during long-term follow-up. Two patients died of malignant disease. Seven cases of reduced flow occurred in the STA, which were correlated with single bypass (P = .0294) and nonuse of cilostazol (P = .0294). STA occlusion was observed in 1 patient during the follow-up period. Hypertension, age, smoking, dyslipidemia, and diabetes mellitus were not correlated with reduced blood flow in the STA. CONCLUSION: Double anastomoses and cilostazol resulted in long-term STA blood flow preservation. No recurrence of cerebral infarction was noted in either STA hypoperfusion or occlusion cases.

Use of a Contest Format for Objective Assessment of Microsurgical Technique: An Observational Study.

BACKGROUND: Few studies have used simulation models to examine long-term improvement in microsurgical technique. We investigated whether improvement in surgical technique could be assessed by continuous, objective, contest-format evaluation of the same microsurgical task. METHODS: Since 2014, neurosurgeons with 1-10 years of experience participated in a biannual competition-format test. The task involved creating as many sutures as possible during the 5-minute interval after arteriotomy of a 1-mm artificial vessel. A modified version of the Objective Structured Assessment of Technical Skills examination was created and used. Changes and differences in scores over time were examined for each evaluator. RESULTS: Overall, 103 neurosurgeons participated in the study at least once, and those who participated more than once were divided into two groups: those who had the highest score in each contest and those who had the lowest score. The linear regression equations for the highest and lowest scorers were y=7.62x+81.56 (R2=0.628) and y=1.94x+67.93 (R2=0.0433), respectively. High scorers had high scores from the first time they participated, and their scores tended to increase further, while scores for low scorers tended not to increase with additional experience. Scores for the four evaluators did not significantly differ. CONCLUSIONS: Our results suggest that technical improvement in surgery can be assessed by long-term, continuous evaluation of microsurgical technique and that the present evaluation system might help increase surgical safety.

Suspected Low-Pressure Hydrocephalus Caused by Spinal Drainage after Subarachnoid Hemorrhage.

Hydrocephalus induced by low cerebrospinal fluid (CSF) pressure is extremely rare and sporadically reported. Subarachnoid hemorrhage, head trauma, and spinal drainage were reported to be causative factors for surgical treatment. A 33-year-old man with subarachnoid hemorrhage caused by right vertebral artery aneurysm rupture developed headache. Trapping surgery was performed, and a spinal drain was inserted from L4/5 for subarachnoid hemorrhage washout. On postoperative day 3, subdural fluid accumulation had increased at the posterior fossa craniotomy site and the cerebellar sulci had narrowed; the ventricles were slightly enlarged. The patient reported headache during head elevation. Low-pressure hydrocephalus (LPH) was suspected. After the spinal drain was removed, headache resolved, and cerebral ventriculomegaly disappeared. The subsequent clinical course was good. The patient was discharged 3 weeks after surgery. LPH is a rare disease caused by various factors and is treated by correcting liquorrhea or overdrainage, when present. Otherwise, drainage at negative CSF pressure is necessary. The symptoms and image findings for LPH are similar to those for intracranial hypertension and normal-pressure hydrocephalus. This report describes a suspected case of LPH caused by spinal drainage after subarachnoid hemorrhage and reviews the literature.

Grip Strength as a Predictor of the Functional Outcome of Hip-Fracture Patients.

BACKGROUND: Patients with hip fracture are limited as to physical activity. It is difficult to evaluate the physical function of the legs at admission; however, it is easy to measure grip strength, which has been reported to be correlated with systemic muscular strength and physical function. The objective of this study was to investigate the utility of grip strength in predicting functional outcome after hip fracture. METHODS: Fifty-seven patients who underwent surgery for hip fracture were evaluated for height, weight, Body Mass Index (BMI), grip strength, bone density (femoral neck), hemoglobin, Hemoglobin A1c (HbA1c), Hasegawa's Dementia Scale-Revised (HDS-R), and albumin at admission and Functional Independence Measure (FIM) at discharge. Spearman's rank correlation coefficient was used to evaluate the relation between grip strength and the above variables. Furthermore, factors of walking acquisition were analyzed by logistic regression analysis and decision-tree analysis. RESULTS: Correlation analysis showed that grip strength was positively correlated with bone density at admission and FIM at discharge and negatively correlated with age. In the logistic regression analysis, the independent factor associated with walking acquisition was grip strength (OR 1.26; 95%CI 1.018-1.566; p=0.0339). In the decisiontree analysis, grip strength was the initial divergence variable for walking acquisition (the percentage with walking acquisition was 80.0% of the patients with grip strength ≧13.2 kg VS. 18.7% of the patients with grip strength < 13.2 kg). CONCLUSIONS: Grip strength at admission was definitive in predicting the functional outcome of patients with hip fracture who underwent surgery.

Investigation of Objectivity in Scoring and Evaluating Microvascular Anastomosis Simulation Training.

The increase in minimally invasive surgery has led to a decrease in surgical experience. To date, there is only limited research examining whether skills are evaluated objectively and equally in simulation training, especially in microsurgery. The purpose of this study was to analyze the objectivity and equality of simulation evaluation results conducted in a contest format. A nationwide recruitment process was conducted to select study participants. Participants were recruited from a pool of qualified physicians with less than 10 years of experience. In this study, the simulation procedure consisted of incising a 1 mm thick blood vessel and suturing it with a 10-0 thread using a microscope. Initially, we planned to have the neurosurgical supervisors score the simulation procedure by direct observation. However, due to COVID-19, some study participants were unable to attend. Thus requiring some simulation procedures to be scored by video review. A total of 14 trainees participated in the study. The Cronbach's alpha coefficient among the scorers was 0.99, indicating a strong correlation. There was no statistically significant difference between the scores from the video review and direct observation judgments. There was a statistically significant difference (p <0.001) between the scores for some criteria. For the eight criteria, individual scorers assigned scores in a consistent pattern. However, this pattern differed between scorers indicating that some scorers were more lenient than others. The results indicate that both video review and direct observation methods are highly objective techniques evaluate simulation procedures.

Recurrent Cervical Spinal Epidural Hematoma: Case Report and Literature Review.

Spinal epidural hematoma (SEDH) is an uncommon pathology. Here, we report a case of SEDH with recurrences, along with a literature review of relevant cases to identify characteristics of SEDH recurrence. A 13-year-old girl experienced sudden-onset of back pain and bilateral leg weakness. She was diagnosed with a cervical idiopathic epidural hematoma, and the symptoms subsided with conservative management. Four months after the event, she again experienced back pain due to recurrence of the cervical epidural hematoma, but she was observed because no neurological deficits could be detected. Fifteen months after the initial SEDH, she experienced severe back pain and tetra-paresis due to recurrence. The SEDH was located in the left ventral and dorsal aspect at the C6-T1 level, with severe spinal cord compression. The hematoma was removed through left hemilaminectomy. Bleeding was noted from the epidural venous plexus along the left C6 spinal root, which had coagulated. After hematoma resection, her symptoms gradually improved, and she was discharged 3 weeks after surgery without any neurological deficits. No hematoma recurrence has since been experienced. Recurrent SEDH is relatively rare, with only 11 cases previously reported. Recurrent hematoma cases are more common in young, female patients, while SEDH, in general, is more common in males in their late forties. The recurrence interval is shorter in non-surgical cases than those requiring surgery. Knowledge of these characteristics may be useful in the future management of SEDH.

Second Free Flap Surgery for Skull Base Tumors: Case Report and Literature Review.

Tumors of the skull base, such as meningiomas, tend to recur. With progress in free vascularized flap surgery, an increasing number of studies are investigating skull base reconstruction with free flaps after tumor removal. In this report, we discuss the results of second free flap surgery after skull base reconstructive surgery. We retrospectively analyzed data from patients treated at our center during the period from 2013 through 2017. All four patients identified had skull base anaplastic meningioma and had undergone radiotherapy. In all cases, the flap and donor blood vessel were sourced from sites that differed from those used in the previous surgeries. No complications developed, such as cerebrospinal fluid leakage, meningitis, wound infection, wound hemorrhage, or flap necrosis. Because the first flap was found to be unviable, it was difficult to preserve and was removed. Essential points in preventing complications are anchoring at the appropriate site, pinprick testing of the created flap, and use of multilayered countermeasures to prevent cerebrospinal fluid leakage.

The Ivy Sign on Fluid Attenuated Inversion Recovery Images Related to Single-Photon Emission Computed Tomography Cerebral Blood Flow in Moyamoya Disease: A Case Report.

Moyamoya disease is an idiopathic progressive cerebrovascular steno-occlusive disorder characterized by the formation of numerous collaterals called Moyamoya vessels. Accurate evaluation of vascular status and cerebral blood flow (CBF) is needed for prompt treatment to prevent ischemic and/or hemorrhagic events. The pathogenesis of the ivy sign on fluid attenuated inversion recovery (FLAIR) images of Moyamoya disease patients is unclear. We report a Moyamoya disease case wherein the ivy sign changed in relation to single-photon emission computed tomography (SPECT)-measured CBF during progression and following treatment. A 49-year-old female presented with slight aphasia and right hemiparesis. Magnetic resonance imaging (MRI) diffusionweighted image revealed cerebral infarction in the left frontal lobe. Cerebral angiography images showed bilateral distal internal carotid artery stenosis and Moyamoya vessels. FLAIR images exhibited the ivy sign. We performed superficial temporal arteryâ€" middle cerebral artery (STA-MCA) bypass surgery with encephalogaleosynangiosis (EGS) and encephalomyosynangiosis (EMS) on the left side 6 months after first presentation. After operation, left-side resting CBF gradually improved on SPECT and the ivy sign decreased. On the other hand, right-side CBF gradually deteriorated at rest, and the ivy sign increased. Therefore, we performed STAâˆ'MCA bypass with EGS and EMS on the right side 4 years after first presentation. After the operation, the resting CBF increased and the ivy sign decreased. The FLAIR ivy sign may be a useful indicator of both deterioration and improvement of CBF status without the need for CBF imaging using contrast material.

Serum glucose/potassium ratio as a clinical risk factor for aneurysmal subarachnoid hemorrhage.

OBJECTIVE: Aneurysmal subarachnoid hemorrhage (SAH) can result in poor outcomes, and biomarkers for predicting poor prognosis have not yet been established. The aim of this study was to clarify the significance of the serum glucose/potassium ratio for predicting the prognosis of aneurysmal SAH. METHODS: The authors retrospectively reviewed the records of 565 patients with aneurysmal SAH between 2006 and 2016. The patient group comprised 208 men and 357 women (mean age 61.5 years, range 10-95 years). A statistical analysis was conducted of the clinical and laboratory risk factors of poor outcome, including the serum glucose/potassium ratio. RESULTS: On estimation of the initial assessment using Hunt and Kosnik (H-K) grading, 233 patients (41.2%) were classified as the severe SAH group (H-K Grade IV or V). There were significant correlations between the severe SAH group and serum glucose/potassium ratio (p < 0.0001). Serum glucose/potassium ratio was elevated in an H-K grade-dependent manner (Spearman's r = 0.5374, p < 0.0001). With the estimation of the Glasgow Outcome Scale (GOS) score at discharge, 355 patients (62.8%) were classified as poor outcome (GOS score 1-3). The serum glucose/potassium ratio was elevated in a GOS score at discharge-dependent manner (Spearman's r = 0.4006, p < 0.0001), and was significantly elevated in the poor outcome group compared with the good outcome group (GOS score 4 or 5; p = 0.0245). There were significant correlations between poor outcome and serum glucose/potassium ratio (p < 0.0001), age (p < 0.0001), brain natriuretic peptide levels (p = 0.011), cerebral infarction due to vasospasm (p < 0.0001), and H-K grade (p < 0.0001). Multivariate logistic regression analyses showed significant correlations between poor outcome and serum glucose/potassium ratio (p = 0.009). CONCLUSIONS: In this study, the serum glucose/potassium ratio of patients with aneurysmal SAH at admission was significantly correlated with H-K grade and GOS score at discharge. Therefore, this ratio was useful for predicting prognosis of aneurysmal SAH, especially in severe cases.

Quantitative Comparison of the Intraoperative Utility of Indocyanine Green and Fluorescein Videoangiographies in Cerebrovascular Surgery.

BACKGROUND: A quantitative analysis comparing indocyanine green videoangiography (ICG-VAG) and fluorescein videoangiography (FL-VAG) in cerebrovascular surgery has not been reported so far. OBJECTIVE: To clear the differences of characteristics of ICG-VAG and FL-VAG by quantitative assessment. METHODS: We prospectively analyzed results from 23 patients (3 males; mean age at surgery: 60.9 years, range: 14-75 years) at our hospital from August 2014 to July 2015. Eighteen patients had cerebral aneurysms for clipping, and 5 had intracranial arterial stenosis for superficial temporal artery (STA)-middle cerebral artery bypass. We imported data from the operative image data, converted by Audio Video Interleave to Aquacosmos as picture fluorescence intensity-analyzing software. Regions of interest were set at the parent artery, dome of aneurysms, and perforating artery in cases of clipping of aneurysms, and setting at 3 points in STA, in case of bypass. The transition of fluorescence intensity at each region of interest was calculated and plotted using Aquacosmos. RESULTS: Thick-walled artery, such as parent artery ( P = .0017) and STA ( P = .0182), was more significantly visualized by ICG-VAG than FL-VAG, whereas the perforating artery, especially in deep surgical fields, such as anterior communicating artery, internal carotid artery, and basilar artery, was better visualized by FL-VAG than ICG-VAG ( P < .0001). CONCLUSION: In this quantitative analysis of fluorescence study, ICG-VAG showed greater efficacy than FL-VAG in visualizing relatively thick arteries, such as parent artery and STA. However, FL-VAG has greater efficacy than ICG-VAG in visualizing perforating artery, especially in deep surgical fields with characteristic vessel walls.

Retrograde suction decompression of a large internal carotid aneurysm using a balloon guide catheter combined with a blood-returning circuit and STA-MCA bypass: a technical note.

It is difficult to treat large internal carotid aneurysms with simple surgical clipping. Here, we present a retrograde suction decompression (RSD) procedure for large internal carotid aneurysms using a balloon guide catheter combined with a blood-returning circuit and a superficial temporal artery to middle cerebral artery (STA-MCA) bypass.All patients underwent an STA-MCA bypass before the temporary occlusion of the internal carotid artery (ICA). A 6-French sheath was inserted into the common carotid artery (CCA), and a 6-French Patrive balloon catheter was placed into the ICA 5 cm past the bifurcation. Aneurysm exposure was obtained; temporary clips were placed on the proximal M1, A1, and posterior communicating (Pcom) segments; and an extension tube was then connected to the balloon catheter. A three-way stopcock was placed, and aspiration was performed through the device to collapse the aneurysm. The aspirated blood was returned to a venous line with an added heparin to prevent anemia after aspiration. During the decompression, the blood flow to the cortical area was supplied through the STA-MCA bypass. After the aneurysm collapse, the surgeon carefully dissected the perforating artery from the aneurysm dome or neck, and permanent clips were then placed on the aneurysm neck. Our procedure has several advantages, such as STA-MCA bypass without external carotid artery occlusion for preventing ischemic complications of the cortical area, anemia may be avoided because of the return of the aspirated blood, and a hybrid operation room is not required to perform this method.

Protection Device Made of a Modified Syringe for Muscle Protection During Cranial Perforation: Technical Note.

In neurosurgical procedures, avoiding damage of surrounding tissues such as muscle and periosteum during a craniotomy is important for esthetic and other reasons. We devised a protection tool by using an amputated syringe barrel to cover the perforating drill and protect temporal muscle damage. This device made it possible to prevent damage to surrounding tissues, such as the muscle and periosteum, during cranial perforation. This method could be useful as it is cost-effective, simple, and versatile.