Transradial versus transfemoral access for middle meningeal artery embolization: Choice of the access route considering delirium in the elderly.

Background: Treatment of chronic subdural hematoma (CSDH) with middle meningeal artery embolization (MMAE) is becoming well established. Transradial artery access (TRA) is considered less invasive than transfemoral artery access (TFA) and is increasingly indicated in the field of endovascular therapy. Therefore, this study focused on postoperative delirium and compared access routes. Methods: This is a single-center and retrospective study. The strategy was to perform MMAE for CSDH with symptomatic recurrence at our hospital. Cases from July 2018 to September 2022, when MMAE was introduced in our hospital, were included in this study. Patients were divided into TRA and TFA groups and were compared descriptively for patient background, procedure duration, and incidence of postoperative delirium. Results: Twenty-five patients underwent MMAE, of whom 12 (48%) were treated with TRA. The overall median age was 82 years, with no clear differences between the TRA and TFA groups in the presence or absence of preexisting dementia or antithrombotic therapy. Delirium requiring medication tended to be lower in the TRA group: 2/12 (16.7%) in the TRA group versus 6/13 (46.2%) in the TFA group, and the mean procedure time for patients undergoing bilateral MMAE was 151 min (interquartile range [IQR]: 140-173 min) in the TRA group versus 174 min (IQR: 137-205 min) in the TFA group. Conclusion: TRA was associated with an overall shorter procedure time than TFA. MMAE through TRA tended to have a lower incidence of delirium. MMAE through TRA may be useful in recurrent CSDH with a high elderly population.

Balloon-Assisted Stent Visualization: A Simple Technique for Precise Measurement of Previously Placed Stent Diameter.

Stent-assisted coil embolization is effective for treating intracranial aneurysms, improving outcomes and reducing recurrence rates. However, accurately measuring the diameter of a previously placed stent during imaging can be challenging due to coil artifacts. This poses difficulties in determining the coil packing and size of additional stents needed during retreatment. In a reported case, the use of a balloon enabled precise assessment of stent deployment. A 50-year-old male with a history of basilar artery-left superior cerebellar artery aneurysm underwent coil embolization, direct clipping, and stent-assisted coil embolization (SAC) over a span of 14 years. However, the aneurysm showed reenlargement over time. To address the recurrence, a balloon was used to assess the previously placed Neuroform Atlas stent. Additional coils were inserted outside the stent, and a Low-profile Visualized Intraluminal Support Blue stent was added. Postoperatively, there were no new neurological issues, and a follow-up magnetic resonance imaging showed no ischemic lesions . Balloon-assisted stent visualization (BASV) may be a useful method in the retreatment of SAC. It has the potential to provide valuable information for treatment planning.

Double-tube burr hole irrigation in the treatment of subdural empyema following chronic subdural hematoma surgery: A case report.

INTRODUCTION AND IMPORTANCE: Subdural empyema (SE) following chronic subdural hematoma (CSDH) surgery is an uncommon but serious complication. The best treatment approach, typically a choice between craniotomy and burr hole surgery, is still debated. This case report introduces an innovative method using burr hole surgery with double-tube irrigation, a potentially effective alternative to the more invasive craniotomy. CASE PRESENTATION: An 81-year-old male, 48 days post-CSDH surgery, developed SE with Methicillin-resistant Staphylococcus aureus infection. The initial treatment with burr hole drainage was complicated by recurrence, leading to a second procedure with double tubes inserted anteriorly and posteriorly for continuous irrigation therapy. The patient was treated with systemic antibiotics and vancomycin irrigation, resulting in successful resolution without further recurrence. CLINICAL DISCUSSION: While burr hole surgery is often deemed less effective than craniotomy for SE, this case demonstrates the potential efficacy of double-tube irrigation via burr hole surgery. This method could be especially beneficial when craniotomy poses significant risks. Continuous irrigation could help in managing intracranial pressure, making the intervention safer. However, further research is needed to refine this technique and establish clear treatment guidelines. CONCLUSION: Burr hole surgery with double-tube irrigation emerges as a promising treatment option for SE, especially when craniotomy is not feasible. This approach's success in this case encourages further exploration and study to validate its wider application in similar clinical scenarios.

Oblique Angled Retractor for Lumboperitoneal Shunt Implantation via Lateral Abdominal Laparotomy.

BACKGROUND: A normal retractor often interferes with the ribs and/or thighs of the ipsilateral side when the skin and abdominal muscles are towed while performing the lumboperitoneal shunt (LPS) procedure in the lateral position. To overcome this, we developed an obtuse-angled retractor. METHODS: We modified the traditional retractors into oblique-angled retractors. The blade of the new retractors was bent to 60 degrees, the entire blade was thinned, and the tip of the blade was tapered. RESULTS: To date, we have performed approximately 30 LPS procedures in the lateral position using the new oblique-angled retractor and confirmed its usefulness. CONCLUSION: An oblique-angled retractor helps confirm the accurate placement of the tip of the retractor blades, even in obese patients in whom the retractor often interferes with the ribs and/or thighs.

Repeated shunt dysfunction due to Barium allergy that was difficult to differentiate from shunt infection.

We encountered a case of repeated shunt dysfunction caused by barium allergy. The patient was a 60-year-old male who underwent ventricular peritoneal shunting for hydrocephalus following subarachnoid hemorrhage due to a ruptured aneurysm;however, it malfunctioned many times. A patch test performed after the third reconstruction was positive for barium. To the best of our knowledge, this is the first case report of shunt malfunction due to barium allergy. The patch test is useful in cases of suspected allergy-related dysfunction. We recommend the introduction of barium into antigen testing using the patch test. J. Med. Invest. 70 : 521-523, August, 2023.

Migration of the ventriculoperitoneal shunt into the thoracic cavity: A case report and pitfalls of the rib structure.

Background: Although ventriculoperitoneal shunting (VPS) is a universal treatment for hydrocephalus, it is generally well-known that the procedure often has complications. Shunt catheter migration is one such complication, but no reports of migration into the thoracic cavity are associated with the surgical technique. Herein, I present a case of thoracic cavity migration of a shunt catheter alongside anatomical pitfalls of the rib structure. Case Description: The patient was a 62-year-old male diagnosed with subarachnoid hemorrhage due to craniocervical junction arteriovenous fistula and underwent direct surgery to occlude the fistula. We performed VPS for secondary hydrocephalus 1 month later. During VPS, the peritoneal catheter was tunneled subcutaneously over the clavicle to pass from the head to the abdomen. Several months later, the peritoneal catheter had migrated from the peritoneal cavity to the thoracic cavity. A computed tomography scan showed that the peritoneal catheter tunneled subcutaneously over the clavicle, penetrated the thoracic wall through the intercostal space between ribs 1 and 2, and entered the thoracic cavity. Conclusion: When performing VPS, it is not enough to send the passer through the skin over the clavicle; it must also be tunneled subcutaneously over the ribs while confirming the position of the tip by touch.

Vascular Repair for Iatrogenic Injury during Microsurgical Procedures: Clinical Investigation and Review of 18 Cases at a Single Institution.

BACKGROUND: Intracranial vascular injury (VI) due to surgery is a critical complication that can lead to serious neurologic deficits. To our knowledge, only a few review articles on VI during an operation have been published so far. We retrospectively investigated the type, cause, and measurement of VI during surgery at our institution. METHODS: Unexpected VI cases occurred in 18 of 2,228 craniotomy procedures, including 794 aneurysm clippings and 357 tumor resections. We investigated the causes and coping techniques of the VI cases, as well as their full details. RESULTS: There were six cases of aneurysm neck tear, one case of sylvian vein injury, and one case of superior trunk perforation during direct clipping. Regarding tumor resection procedures, nine cases of arterial injury and one case of cortical vein injury were extracted. Almost all VIs were caused by carelessness or basic manipulation mistakes. We repaired all these cases with simple placement of suture threads with or without pinch clips, flow alteration using bypass techniques, and in 16 cases no neurologic deficit or deterioration on imaging occurred; however, 3 patients were verified to have ischemic changes on postoperative imaging. CONCLUSIONS: Most VIs were directly caused by a simple error and carelessness of an operator or an assistant. Many of these injuries can be avoided if a basic set of rules are followed and remembered during the surgical procedure. However, the surgical procedure involves human work, and errors cannot be eradicated even upon maximum concentration levels. Neurosurgeons should be prepared for an eventual quick repair of an unexpected cerebral VI.

Ultrasound localization of embolic material to guide resection of brain AVM: Report of two cases.

Background: The Spetzler-Martin Grade (SMG) is widely used to evaluate the risk of resection of cerebral arteriovenous malformation (AVM), and direct surgery is strongly recommended for low SMG lesions. Micro-AVMs are defined as AVMs with a nidus <1 cm in diameter, and sometimes, the challenge is identifying the exact lesion site during AVM resection, although identification of the site is very important in the procedure. Here, we present two cases in which the sites of micro-AVM were marked using presurgical embolization and easily confirmed by intraoperative ultrasonography (IUS) and discuss the benefits of IUS in combination with presurgical embolization for low-grade micro-AVM. Case Description: (Patient 1) A 30-year-old man was brought to our hospital and diagnosed with a micro-AVM, which was classified as SMG II AVM. He underwent evacuation of the intracerebral hematoma and subsequently underwent AVM resection. However, the lesion was not identified because it was not exposed in the cerebral cortex although we searched for the lesion. Therefore, endovascular embolization was performed before subsequent surgical resection. During AVM resection following embolization with Onyx, the IUS clearly demonstrated the Onyx-embolized lesion, and it was resected uneventfully. (Patient 2) A 46-year-old man with a ruptured SMG II AVM underwent AVM resection using a microsurgical technique with IUS after embolization for AVM preoperatively. IUS clearly showed abnormal vessels embolized with Onyx and indicated the correct location of the nidus, although the lesion was not observed directly from the brain surface. After identifying some embolized AVM constructions, we excised the entire AVM with ease and safety. Conclusion: The combined use of presurgical embolization, which focuses on marking the lesions and IUS, may contribute to improving surgical outcomes of low SMG micro-AVMs, which are not exposed on the brain surface.

Inside Out Cranioplasty: A Novel Technique for One-Stage Reconstruction of Persistent Scalp Necrosis.

BACKGROUND: Cranioplasty can be a challenging procedure in certain patients, such as those with scalp necrosis, or when performed after multiple surgical procedures. Herein, we present a patient in whom a part of the skull was placed inside out in a setting where the scalp wound could not be simply sutured because of multiple previous operations. METHODS: A 66-year-old patient with a history of multiple craniotomies to resect an intracranial tumor suffered significant skin flap necrosis after harvesting the superficial temporal artery for a bypass intending to ligate the internal carotid artery. He subsequently underwent a one-stage reconstruction surgery, in which the central part of the bone was excised, turned over, and fixed at the inner plate of the bone flap on the outside, and the outer plate on the inside. RESULTS: This technique reduced the skin tension and reduced the epidural dead space, allowing skin flap healing with acceptable cosmetic results. CONCLUSION: "Inside out cranioplasty" is a valid option for one-stage reconstruction in the cases with scalp necrosis.

Isolated Brainstem Congestion Caused By Craniocervical Junction Arteriovenous Fistula.

Although arteriovenous fistulas (AVFs) at the craniocervical junction (CCJAVFs) are rare, they often develop into a subarachnoid haemorrhage when they have an ascending venous drainage, or cause venous congestion of the spinal cord with descending venous drainage. Isolated brainstem lesions due to CCJAVF are extremely rare, and, to our knowledge, the vascular architectural features that could cause such lesions are unknown. We present a case of CCJAVF manifesting as isolated brainstem congestion and review the literature on the vessel architecture of these rare lesions. A 64-year-old man was admitted to our hospital with gradually worsening nausea, dysphagia, double vision, grogginess, and gait disturbances. On admission, the patient showed dysarthria, horizontal ocular nystagmus to the left, paresis of cranial nerves IX and X, and ataxia on the right side. Magnetic resonance imaging (MRI) revealed an isolated lesion in the medulla. Cerebral angiography (CAG) showed a CCJAVF with the coexistence of intradural AVF and dural AVF, fed by the right first cervical radiculomedullary, right vertebral, and intradural posterior inferior cerebellar arteries, which were drained by the anterior spinal vein in an ascending direction. The patient underwent direct surgery to occlude dural and intradural fistulas. Postoperatively, the patient returned to work with full recovery from the neurological deficits via rehabilitation. MRI revealed vanishing brainstem congestion, and CAG revealed complete disappearance of the AVF. CCJAVFs with venous drainage around the brainstem, regardless of their direction (ascending or descending), can cause isolated brainstem congestion, although this condition is rare.

Adhesion between an extruded coil and the oculomotor nerve: Unexpected interference due to coil extrusion.

Background: When direct clipping is performed for a recurrent aneurysm after coil embolization, there are sometimes findings of the coil adhering to the surrounding tissue, after it has been extruded from inside the aneurysm into the subarachnoid space and brain parenchyma. However, there have only been few previous reports on extruded coils adhering to the cranial nerves, preventing aneurysm dissection and clip application. Case Description: We performed the coil embolization of a ruptured aneurysm originating from the bifurcation of basilar artery and superior cerebellar artery in a 36-year-old male patient. Recurrence was confirmed 5 years after embolization and direct clipping was performed. The intraoperative finding was that part of the coil was strongly adhering to or encircling the oculomotor nerve, making it difficult to achieve sufficient mobility of the cerebral aneurysm. Conclusion: When direct clipping is performed after coil embolization of an intracranial aneurysm, part of the coil may be extruded from the aneurysm and then adhere strongly to the cranial nerve.

String-like mobile echodensities on postoperative ultrasound after CEA: A retrospective observational study.

BACKGROUND: String-like mobile echodensities (SLMEs) are sometimes found on postoperative duplex ultrasound (DUS) performed after carotid endarterectomy (CEA); however, they may not be visible on intraoperative DUS. The reasons for these echo findings and associated clinical course remain unknown. METHODS: Routine postoperative DUS evaluation after CEA was retrospectively examined in 101 consecutive patients (107 lesions) who underwent CEA between April 2015 and December 2021, at our institution. RESULTS: Ten SLMEs were identified in eight patients. All SLMEs were 1-3 mm long, mobile, and extended straight from the intima-media complex of the wall of the common carotid artery or carotid bulb. Most lesions resolved spontaneously; a few lesions were observed repeatedly, albeit not causing cerebral infarction or transient ischemic attacks. CONCLUSIONS: SLMEs can be observed in a small percentage of patients after CEA, and they do not seem to be of clinical significance.

Posttraumatic rapid growing extradural meningioma: A case report on the effectiveness of echosonography.

BACKGROUND: Most meningiomas related to head trauma have been reported to show intradural lesions; however, they can also occur as primary extradural meningiomas (PEMs) and have often been reported to histologically demonstrate atypical or malignant subtypes. Therefore, early detection and complete resection of related tissues are required; however, to date, only a few PEM cases related to trauma or injury have been reported. Herein, we present a patient with a rapidly growing posttraumatic PEM, in which echosonography is efficient not only for early diagnosis but also for intraoperative strategies. CASE DESCRIPTION: A 62-year-old male presented to a nearby clinic with a complaint of a painless head bump that gradually grew larger in relation to trauma 6 weeks earlier. He underwent echosonography and pointed out the possibility of a cranial tumor and consulted our hospital. Although preoperative imaging studies, such as computed tomography or magnetic resonance imaging, did not provide reliable information on dura mater invasion, echosonography demonstrated dural invasion and intradural lesions in which large vessels passed the surface of the lesion. Based on these findings, we could safely resect the lesion within a sufficient range. CONCLUSION: Echosonography may not only be a cue for an early diagnosis but also provide important information for the treatment strategy of PEM that is related to head trauma.

Sheath formation around peritoneal tube: possible explanation for unknown cause of ventriculoperitoneal shunt failure.

Ventriculoperitoneal (VP) shunt failures are common and are frequently associated with an obstruction of the peritoneal tube. This study aimed to explore the possible causes of peritoneal tube obstruction, which are largely unknown. From January 1981 to June 2018, we performed VP shunting in 646 patients with hydrocephalus. Among the procedures performed, 148 shunt revision procedures were performed in 98 patients with VP shunt failure. Of the study participants, 64 (43.2%) patients were diagnosed with peritoneal tube obstruction and five patients developed sheath formation that obstructed the end of the peritoneal tubes. Sheath formation around the peritoneal tube is a possible cause of VP shunt dysfunction.

Recurrence of internal carotid artery dissection associated with elongated styloid process: A case report.

BACKGROUND: An elongated styloid process is known to cause ischemic stroke. Previous reports claim that internal carotid artery (ICA) dissection due to the elongated styloid process has good outcomes when treated conservatively; however, long-term follow-up has not been attempted and recurrence in the later period has not been reported so far. We report a case of recurrence of symptoms over a decade after the initial onset. CASE DESCRIPTION: A 59-year-old man experienced a transient ischemic attack (TIA) 10 years ago. Six years ago, he experienced hemispheric TIA, and magnetic resonance angiography revealed a diminished signal of the left ICA; however, no further examination was performed. Four years ago, he experienced another transient amaurosis attack and was treated with antiplatelet therapy because no embolic source was detected using ultrasonography examination, and he was diagnosed with idiopathic ICA dissection. Recently, he experienced a third amaurosis fugax attack. Digital subtraction angiography and cone-beam computed tomography demonstrated left cervical ICA dissection due to elongated styloid process. He underwent surgical resection of the left styloid process and cervical stent placement. He had no ischemic attacks postoperatively. CONCLUSION: The elongated styloid process may cause recurrent ischemic attacks over a decade due to ICA dissection.

Cerebral venous thrombosis following spontaneous intracranial hypotension diagnosed by craniotomy: A case report and diagnostic pitfalls.

BACKGROUND: Cerebral vein and dural sinus thrombosis (CVT) is a rare but important complication of spontaneous intracranial hypotension (SIH). The diagnosis is difficult in cases lacking typical symptoms and typical imaging findings. CASE DESCRIPTION: A 29-year-old male patient with a seizure attack was admitted to our hospital. Based on the head imaging findings, we misdiagnosed the patient with primary cerebral parenchymal lesion and performed an open biopsy. However, during the procedure, the patient was diagnosed with low cerebrospinal fluid pressure and cerebral cortical vein thrombosis. CONCLUSION: Thus, CVT due to SIH should be considered as a probable cause of secondary parenchymal lesions.

Massive intracerebral hemorrhages due to peripheral middle cerebral artery aneurysm rupture: A case report with a surgical video.

BACKGROUND: Saccular aneurysm in the distal segment of the middle cerebral artery (DMCA) occurs very rarely and often represents with a rupture. We report a successful surgical case of a DMCA aneurysm rupture with large cerebral and subarachnoid hemorrhage. CASE DESCRIPTION: A 44-year-old female presented a sudden onset headache and coma (the Glasgow Coma Scale was 3). Head computed tomography (CT) revealed a subarachnoid hemorrhage around the right Sylvian fissure and large intracranial hematoma in the right parietal lobe. The CT angiography showed a saccular aneurysm in the peripheral cortical segment of the right angular branch of the right DMCA. We decided to perform a right craniotomy to evacuate hematoma and interrupt the aneurysm. Just after the dural incision, the aneurysm ruptured again. We applied a temporary clip on the artery proximal to the aneurysm before excising it. CONCLUSION: Aneurysm in DMCA can be treated safely with surgical excision and risk of sudden recurrent hemorrhage needs to be anticipated.

Colored ligature: Trivial but innovative modification.

BACKGROUND: Vascular ligation and its detachment remain a necessary skill for a surgeon. We often use two threads of the same color to ligate a vessel. However, some problems (grasping the mixed-up threads and/or difficulty in releasing the entanglement) may occur while using same colored ligatures. To solve these problems, we devised to use ligatures of different colors, and here, we present this ingenious idea. METHODS: When a vessel is encountered that needs to be cut, we pass two different colored threads behind it. RESULTS: We can grasp the two threads without mixing them up. In addition, in case of entanglement, unwinding of the entangled threads is quicker. We then finally tie a knot with these threads and cut the vessel visible between them. CONCLUSION: Using different colored ligatures enhance surgical convenience in the operating room.

Acute central nervous system vasculitis as a manifestation of neurosarcoidosis: A case report and literature review.

Neurosarcoidosis (NS) affects various sites of the central nervous system, including the cranial nerve, meninges, brain parenchyma, hypothalamus, and pituitary gland. NS rarely causes intracerebral vasculitis and subsequent strokes, or cerebral infarction and hemorrhage, which are associated with high mortality. Herein, we report a 71-year-old woman's case of stroke associated with NS, which showed aggressive cerebral vasculitis with brain herniation; it was resolved with corticosteroid therapy after accurate histopathological diagnosis. This case highlights the necessity of expecting NS to sometimes follow an aggressive course, presenting with vasculitis. Most patients with NS satisfactorily respond to corticosteroids, but this is not always the case. In cases of unfamiliar ischemic or hemorrhagic lesions, the possibility of NS must be considered.

Complete relief of vasospasm - Effect of nicardipine coating during direct clipping for the patient with symptomatic vasospasm of subarachnoid hemorrhage.

BACKGROUND: Some patients come to the hospital presenting with ischemic neurological deficits due to postsubarachnoid hemorrhage (SAH) cerebral vasospasm. In such a situation, neurosurgeons tend to avoid direct clipping, since mechanical irritation to the vessels could worsen the vasospasm and exacerbate ischemic symptoms. The optimal timing of direct clipping in patients with evidence of vasospasm is undetermined. Herein, we present the case of a patient who underwent direct clipping in the presence of severe symptomatic and post-SAH angiographic vasospasm. During surgery, we coated the severely spastic artery with nicardipine. CASE DESCRIPTION: A 49-year-old woman was admitted to our hospital with the diagnosis of ruptured intracranial aneurysm and severe vasospasm. On the admission day, we performed direct clipping together with direct application of nicardipine to the spastic artery. Postoperative immediate cerebral angiography showed complete disappearance of the vasospasm. CONCLUSION: Direct clipping should not be contraindicated during the vasospasm period in patients with a ruptured aneurysm, and direct application of nicardipine on the spastic artery would completely relieve vasospasm.