Chronological Change of the Clinical Features and Treatment Outcomes for Subarachnoid Hemorrhage in Japan: A Multicenter Retrospective Study.

Aneurysmal subarachnoid hemorrhage (SAH) treatment has progressed, and patients are rapidly aging in Japan. Consequently, dynamic changes must have emerged in the clinical practice of SAH. This study aimed to elucidate chronological changes of aneurysmal SAH and the prognostic factors in the previous quarter century in Japan. We conducted a retrospective survey regarding aneurysmal SAH in eight institutions in Japan. The study included 848, 863, and 781 patients in the first (1989-1993), second (1999-2003), and third (2009-2013) periods, respectively. The chronological changes of factors that influenced the poor outcomes and differences between the nonelderly (<75 years) and elderly patients were investigated. Mean age was significantly higher in patients in the third period (61.4 years) than in those in the other two periods (first, 57.8 years; second, 59.5 years). During these periods, the proportion of good outcomes did not change; however, the mortality rate significantly decreased from 19% in the first period to 11% and 9.2% in the second and third periods, respectively. The poor outcome was mainly caused by the significantly higher incidence of systemic complication and procedural complication in the first period and the significantly lower incidence of delayed ischemic neurological deficit in the third period. The elderly patients had significantly poorer clinical outcomes than the nonelderly ones. During the last 25 years, the age of patients with aneurysmal SAH has rapidly increased. The study results may contribute to the improvement of the treatment strategy of SAH in advanced countries with a rapidly aging population.

A Novel Staged Revascularization Strategy for Bilateral Severe Internal Carotid Artery Stenosis at High Risk for Hyperperfusion Syndrome.

OBJECTIVE: Since bilateral severe internal carotid artery stenosis often is associated with severely decreased cerebrovascular reactivity (CVR) due to poor collateral blood flow, revascularization carries a high risk for development of hyperperfusion syndrome. In this study, we report a new staged strategy to prevent postoperative hyperperfusion syndrome in such patients. METHODS: Bilateral severe cervical internal carotid artery stenosis patients with decreased CVR to 10% or less on one side were prospectively enrolled in this study. We first performed carotid artery stenting on the side with the milder CVR decrease (lower-risk side), aiming to improve hemodynamics associated with the severe CVR decrease on the greater-risk side. Then, carotid endarterectomy or carotid artery stenting was performed on the contralateral side after an interval of 4-8 weeks. RESULTS: In all 3 cases enrolled in this study, CVR on the greater-risk side improved to 10% or more 1 month after the first treatment. The ratio of regional cerebral blood flow on the contralateral greater-risk side was 114% 1 day after the second treatment, and HPS did not develop in any of the cases. CONCLUSIONS: Our treatment strategy, in which revascularization on the lower-risk side precedes that on the greater-risk side, is effective for the prevention of HPS in bilateral ICA stenosis patients.

Neuronal dysfunction and hemodynamic disturbance due to venous congestion in dural arteriovenous fistula revealed by 123I-iomazenil SPECT.

OBJECTIVE: Retrograde leptomeningeal venous drainage (RLVD) of a dural arteriovenous fistula (dAVF) is associated with neurological morbidity and unfavorable outcomes. However, the direct damage to cortical neurons by dAVF with RLVD has not been elucidated. 123I-iomazenil (123I-IMZ) SPECT can reveal cerebral blood flow and cortical neuronal damage in early and late images, respectively. This study aimed to assess the cerebral venous congestive encephalopathy caused by dAVF using 123I-IMZ SPECT. METHODS: Based on the pre- and posttreatment MRI findings, patients were divided into three groups: a normal group, an edema group, and an infarction group. Radioactive counts in the early and late images of 123I-IMZ SPECT were investigated using the affected-to-contralateral side asymmetry ratio (ACR). RESULTS: None of the patients in the normal group showed any symptoms related to venous congestion. In contrast, all the patients in the edema and infarction groups developed neurological symptoms. The ACR in early images in the edema group was significantly lower than that in the normal group and significantly higher than that in the infarction group. The ACR in the late images of the infarction group was significantly lower than those of the normal and edema groups. After treatment, the neurological signs disappeared in the edema group, but only partial improvement was observed in the infarction group. The ACR in early images significantly improved after treatment in the edema group, but the ACR in late images did not change in any groups. CONCLUSIONS: 123I-IMZ SPECT is useful for evaluating hemodynamic disturbances and neuronal damage in dAVFs. The reduction in early images was correlated with the severity of venous congestive encephalopathy, and the significant reduction in late images is a reliable indicator of irreversible venous infarction caused by RLVD.

Blood Blister-Like Aneurysms at the Junction of the Internal Carotid and Posterior Communicating Artery: Characteristics and Treatment Strategies.

BACKGROUND: Blood blister-like aneurysms (BBAs) usually arise from the anterior walls of the internal carotid artery, and such lesions at the junction of the internal carotid artery and posterior communicating artery (PCoA) have not been reported to date. Here, we report our experiences of BBAs at PCoA. We studied their clinical and angiographical characteristics including the internal carotid-PCoA angle, an indicator of hemodynamic stress at the bifurcation. METHODS: Three patients with BBAs located at the origin of PCoA were studied. Wrap-clipping was adopted as the first-line therapy, but direct clipping was conducted when difficult. RESULTS: All patients were elderly females (mean age 81.3 years), and BBAs were small in size (mean maximum diameter 1.5 mm), which arose at the origins of wide-angled fetal-type PCoAs (mean internal carotid-PCoA angle 37.8 degrees). All the lesions were treated by surgery (direct clipping 2, wrap-clipping 1), and severe atherosclerotic changes were observed at adjacent arterial walls in all cases. Ordinary wrap-clipping using a polytetrafluoroethylene membrane via the transsylvian approach was difficult because of the limited working space, requiring some special techniques such as usage of fenestrated clips, polyglycolic acid sheets, and combined approach with subtemporal craniotomy. Good clinical outcomes were achieved in 2 patients. CONCLUSION: BBAs at PCoA were predominantly occurred as the small bulges at the origins of wide-angled fetal-type PCoAs in elderly females. Hemodynamic stress and atherosclerosis would contribute to the aneurysmal formation. Wrap-clipping or direct clipping with additional techniques would be useful for this rare condition.

Recurring cervical internal carotid artery vasospasm elicited by head rotation: illustrative case.

BACKGROUND: Idiopathic extracranial internal carotid artery vasospasm (IEICAV) is a rare cerebrovascular disorder causing transient or permanent cerebral ischemia. The pathophysiology underlying this disorder is not well understood. Although various medical treatments have been tried, complete remission of vasospasm is difficult to achieve. The first case of bilateral IEICAV induced by head rotation, which was successfully treated by carotid artery stenting (CAS), was presented. OBSERVATIONS: A 40-year-old woman with bilateral IEICAV had been conservatively treated for 13 years. However, transient ischemic attacks (TIAs) were not suppressed. She eventually presented with a large brain infarction in the left hemisphere and was referred to our department. Digital subtraction angiography clearly demonstrated the triggering of internal carotid artery (ICA) vasospasm by head rotation. After CAS treatment, the TIAs disappeared completely. LESSONS: Clinicians should recognize that ordinary mechanical stimulation to the ICA by head rotation can induce vasospasm, and CAS should be performed for refractory IEICAV at the appropriate time to avoid cerebral infarction causing severe neurological deficits.

Spinal glomus AVM presenting solely with groin pain: illustrative case.

BACKGROUND: Spinal glomus arteriovenous malformations (AVMs) are rare and can cause neurological morbidity due to spinal hemorrhage, venous hypertension, or mass effect. OBSERVATIONS: The authors presented a rare case of spinal glomus AVM presenting with groin pain due to nerve root compression by a feeder aneurysm. A 41-year-old woman was referred to the hospital with initial right groin pain that had worsened over 2 months. Magnetic resonance imaging showed intra- and extramedullary abnormal flow voids at the T11-12 level, and spinal angiography revealed an intramedullary AVM, with extramedullary protrusion of an aneurysm on the feeder vessel, which arose from the sulcal artery of the anterior spinal artery. Because compression of the right L1 nerve root by the aneurysm was the likely cause of the patient's pain, endovascular embolization was performed. The feeder aneurysm disappeared after partial n-butyl 2-cyanoacrylate embolization, and the groin pain disappeared immediately after treatment. Her clinical status has been stable with no recurrence during 1 year of follow-up. LESSONS: This is the first report of glomus-type AVM presenting with radiculopathy alone. One should not overlook the possibility of spinal AVM among patients with groin pain.

Neuroprotective roles of HAX-1 in ischemic neuronal injury.

Hematopoietic cell-specific protein 1 associated protein X-1 (HAX-1) is a novel mitochondrial protein that regulates oxidative stress-induced apoptosis. However, the roles of HAX-1 in ischemic neuronal injury have not been thoroughly elucidated. In this study, the expression and roles of HAX-1 after ischemic stress were investigated using in vivo and in vitro models. The effect of oxidative stress on the regulation of HAX-1 was examined using knockout mice lacking nicotinamide-adenine dinucleotide phosphate oxidase 2 (NOX2), which is a major source of reactive oxygen species (ROS) after cerebral ischemia. Male C57BL/6 J mice were subjected to transient forebrain ischemia induced by 22-min occlusion of the bilateral common carotid arteries, and striatum samples were analyzed. For in vitro ischemic experiments, oxygen and glucose deprivation (OGD) in a rat pheochromocytoma cell line was utilized. Western blotting and immunofluorescence analysis revealed HAX-1 expression in neuronal mitochondria, which was significantly decreased after ischemia in vivo and in vitro. In NOX2 knockout mice, ischemia-induced decrease in HAX-1 expression and ischemic neuronal injury was significantly alleviated compared to those in wild-type mice. Inhibition of HAX-1 using small interfering RNA significantly increased injury in cultured cells after OGD. These findings suggest that HAX-1 has a neuroprotective effect against ischemic neuronal injury, and downregulation of HAX-1 by NOX2-produced ROS induces apoptosis after cerebral ischemia.

Primary Spinal Intradural Extramedullary Mesenchymal Chondrosarcoma.

BACKGROUND: Among chondrosarcomas arising from bones and soft tissues, mesenchymal chondrosarcoma (MCS), especially primary spinal intradural extramedullary MCS, is extremely rare, and only 18 cases have been reported to date. We report an adult case of this rare condition mimicking meningioma. CASE DESCRIPTION: A 42-year-old woman presented with paraplegia and sensory disturbance associated with right-sided Brown-Séquard syndrome following back pain. Magnetic resonance imaging showed an intradural mass in the right dorsal spinal canal with homogeneous enhancement and dural tail sign at the T8 level. Computed tomography demonstrated a calcified portion in the mass. Following T7-8 laminectomies, an intradural extramedullary tumor was completely removed after detaching the tumor from the dura mater. The histopathologic diagnosis was MCS, and positron emission tomography showed no metastatic lesions at other sites. The patient did not receive adjuvant therapy, and magnetic resonance imaging revealed no evidence of recurrence during 2-year follow-up. CONCLUSIONS: Primary spinal intradural extramedullary MCS has been reported to have a better prognosis than MCS occurring in other regions. In a case with early complete surgical resection, adjuvant therapy should be considered at the time of recurrence.

Metastasis of Carcinoma to a Cerebral Arteriovenous Malformation.

BACKGROUND: Although carcinoma metastasis to primary intracranial neoplasms has occasionally been reported, metastasis to a cerebral arteriovenous malformation (AVM) has been exceedingly rare, with only 5 cases reported to date. In the present study, we have reported a case of lung carcinoma that had metastasized to a cerebral AVM. To the best of our knowledge, the present report is the first case in which the pathological examination detected the bleeding mechanism of this rare condition, showing destruction of the feeders by the metastatic tumor. CASE DESCRIPTION: A 61-year-old man who had had a tumor shadow in the right middle lung field identified at a medical examination 5 weeks previously had suddenly experienced a disturbance of consciousness. Head computed tomography and computed tomography angiography revealed a right occipital subcortical hemorrhage with abnormal vessels, suggesting a ruptured AVM. Magnetic resonance imaging with gadolinium-based contrast agents did not show any other lesions. Cerebral angiography revealed a Spetzler-Martin grade III AVM in the right occipital lobe. Endovascular feeder embolization and subsequent removal of the AVM were performed. Histopathological examination of the resected mass showed a small cell carcinoma that had metastasized to the AVM. The tumor cells had infiltrated to the vessel walls of the feeders, which might have elicited the bleeding. CONCLUSION: Although rare, clinicians should recognize that undifferentiated carcinomas can metastasize to AVMs and cause bleeding. Because the preoperative diagnosis can be difficult, even using the latest imaging modalities, careful examination of the resected specimen is required to reveal such pathological conditions.

Detection of Transient Increase of Cerebral Blood Flow and Reversible Neuronal Dysfunction by Iodine-123-Iomazenil Single Photon Emission Computed Tomography After Cerebral Hyperperfusion Syndrome After Revascularization Surgery for Moyamoya Disease.

BACKGROUND: Early and late images of single photon emission computed tomography (SPECT) using 123I-iomazenil (123I-IMZ) can demonstrate cerebral blood flow and cortical neuronal viability. Hyperperfusion syndrome is one of the serious complications after revascularization surgery for moyamoya disease; therefore, the real-time observation of the hemodynamics and neuronal viability is important for the treatment after the revascularization. Here we report, a case of moyamoya disease where 123I-IMZ SPECT had a significant efficacy to delineate the hemodynamics and transient neuronal dysfunction in hyperperfusion state after revascularization. CASE DESCRIPTION: A 47-year-old woman presented with motor aphasia 3 days after superficial temporal artery-middle cerebral artery anastomosis with indirect revascularization. Magnetic resonance imaging (MRI) on the same day showed no new ischemic changes but high intensities along the left frontal sulci observed on fluid-attenuated inversion recovery images, and 123I-IMZ SPECT demonstrated the increased uptake on the early images and the decreased uptake on the late images around the anastomosis site. The patient was completely recovered 1 month after surgery, and abnormal changes on MRI and 123I-IMZ SPECT returned to normal along with the symptom withdrawal. CONCLUSIONS: These findings indicate that 123I-IMZ SPECT could be the index for the treatment of revascularization for obstructive vascular diseases such as moyamoya disease.

Anterior Approach Combined with Endoscopic Fluorescence Video Angiography for a Cervical Perimedullary Arteriovenous Fistula.

BACKGROUND: Perimedullary arteriovenous fistulas (pAVFs) of the anterior cervical spinal cord are rare and difficult to eradicate by surgery because of the limitations of the approach routes. Because of the anatomic relationships, an anterior approach with corpectomy can provide direct observation. However, a narrow corridor to the lesion is the drawback of this approach. Therefore, to overcome this limitation, we introduced angled endoscopes integrated with fluorescence video angiography to observe the real-time blood flow. CASE DESCRIPTION: A 47-year-old woman was incidentally found to have a pAVF fed by multiple radicular arteries, and she underwent direct surgery via the anterior approach. Although observation of the entire lesion was difficult with the microscope alone, the introduction of the angled endoscope made it possible to observe the lateral portion of the spinal cord hidden behind the dura mater. Furthermore, endoscopic fluorescein video angiography visualized residual fine feeding arteries that were then electrocoagulated, which contributed to complete obliteration of the shunt. CONCLUSIONS: The anterior approach with endoscopic assistance is a reasonable strategy for the treatment of ventrally located cervical pAVFs. Furthermore, integration of a fluorescence video angiography system with the endoscope enables confirmation of the complicated real-time hemodynamics of the pAVFs, contributing to reliable treatment.

Iodine-123-Iomazenil SPECT Revealed Recovery of Neuronal Viability in Association with Improvement in Symptoms Following Treatment for Obstructive Hydrocephalus due to a Giant Posterior Cerebral Artery Aneurysm.

BACKGROUND: Early and late images of 123I-iomazenil (123I-IMZ) single-photon emission computed tomography (SPECT) are considered to show cerebral blood flow and neuronal activity, respectively, and this modality may demonstrate temporal dysfunction of the frontal lobes in obstructive hydrocephalus. In this report, we examined 123I-IMZ SPECT in a patient with chronic obstructive hydrocephalus owing to compression of the aqueduct by a partially thrombosed aneurysm of the left posterior cerebral artery for the first time. CASE DESCRIPTION: A woman aged 77 years presented with progression of cognitive decline, gait disturbance, and urinary incontinence. She had a medical history of epilepsy and subarachnoid hemorrhage due to a ruptured left posterior cerebral artery aneurysm, treated conservatively when she was age 56 years. Magnetic resonance imaging revealed a mass lesion in the pineal region, which showed a target sign with gadolinium-based contrast agents, causing obstructive hydrocephalus owing to compression of the cerebral aqueduct. A right vertebral angiogram confirmed the presence of a partially thrombosed giant aneurysm at the left posterior cerebral artery. To rule out the involvement of nonconvulsive status epilepticus in her pathology, we performed 123I-IMZ SPECT, and both early and late images demonstrated low uptake in the bilateral frontal cortex. After surgical trapping of the parent artery and resection of the aneurysm, hydrocephalus was relieved, and the symptoms disappeared along with improvement in early and late 123I-IMZ SPECT images. CONCLUSIONS: The findings in the present case indicate that 123I-IMZ SPECT can detect reversible cerebral blood flow reduction and neuronal viability in the frontal lobes, which may affect the clinical manifestation of obstructive hydrocephalus.

Endoscope-Integrated Fluorescence Video Angiography for the Surgery of Ventrally Located Perimedullary Arteriovenous Fistula at Craniocervical Junction.

BACKGROUND: Intraoperative confirmation of the vascular anatomy and blood flow contributes to the safety of the surgery for perimedullary arteriovenous fistulas (PAVF). However, because the PAVF at the craniocervical junction (CCJ) is mainly located on the ventral spinal cord surface, it is difficult to observe the entire pathology by a conventional surgical approach. To achieve increased viewing angle and visualization of real time blood flow, we introduced endoscope-integrated fluorescein video angiography in the treatment for PAVF at the CCJ for the first time. CASE DESCRIPTION: A 63-year-old man presented with subarachnoid hemorrhage due to rupture of PAVF at the CCJ, fed by both the right C1 radiculomedullary artery and the anterior spinal artery (ASA). Suboccipital craniotomy and C1 hemilaminotomy was performed and microscopic observation revealed partial anatomy of the PAVF covered by subarachnoid clots on the ventrolateral surface at the right C1 nerve root level. However, pathology ventral to the C1 nerve root was obscure and an endoscope-integrated fluorescein video angiography was introduced, which clearly demonstrated the PAVF components and the ASA. CONCLUSIONS: According to these findings, the PAVF was coagulated and the ASA was preserved. Endoscope-integrated fluorescein video angiography allowed to visualize its real-time blood flow, leading to a safe and reliable treatment.

Efficacy of Intraarterial Fluorescence Video Angiography in Surgery for Dural and Perimedullary Arteriovenous Fistula at Craniocervical Junction.

OBJECTIVE: Confirming the exact location of a fistula and the origins of draining veins during surgery for dural and perimedullary arteriovenous fistulas (AVFs) is crucial but sometimes inadequately performed, which can result in incomplete elimination of the lesion. Intraoperative digital subtraction angiography (DSA) is the gold standard for confirming the hemodynamics of an AVF; however, it cannot reveal the location of an AVF in the operative field. In this study, the efficacy of intraoperative intraarterial fluorescence video angiography during surgery for craniocervical junction dural and perimedullary AVFs was investigated. METHODS: We repeatedly employed this technology to evaluate its usefulness in revealing the flow dynamics and anatomy of AVFs and to confirm complete elimination of the fistula. RESULTS: Seven AVFs were included in this study. Their locations were C1 in 5 cases and C2 in 2 cases. Intraarterial fluorescence video angiography precisely revealed the locations of 3 dural AVFs, 1 perimedullary AVF, and 3 co-occurring dural and perimedullary AVFs. Frame-by-frame review of the fluorescence video angiography clearly demonstrated that fluorescence appeared earlier in the perimedullary AVF than in the draining vein through the dural AVF after intraarterial injection in all 3 co-occurring cases. Complete elimination of the AVF was also confirmed in all cases by fluorescence video angiography, as well as intraoperative and follow-up DSA. CONCLUSIONS: Intraarterial fluorescence video angiography, particularly frame-by-frame review, enables surgeons to distinguish the flow dynamics of AVFs and contributes to the planning of effective surgical strategies for optimal results.

Long-Term Clinical and Angiographic Outcomes of Wrap-Clipping for Ruptured Blood Blister-Like Aneurysms of the Internal Carotid Artery Using Advanced Monitoring.

BACKGROUND: Wrap-clipping is one of the recommended treatments for ruptured blood blister-like aneurysms (BBAs) of the internal carotid artery (ICA). However, the long-term clinical and angiographic outcomes of this procedure have not yet been elucidated. The present study examined the long-term efficacy of wrap-clipping using a polytetrafluoroethylene membrane, an ideal wrapping material, for BBAs. METHODS: The data from 9 patients with ruptured BBAs treated at our institutes from 2007 to 2016 were retrospectively analyzed. Wrap-clipping was performed with advanced monitoring techniques, including fluorescence video angiography and endoscopy. Angiographic follow-up was achieved using 3-dimensional computed tomography angiography or digital subtraction angiography. Clinical outcomes were assessed using the modified Rankin scale. RESULTS: Wrap-clipping was performed without any permanent morbidity in all patients. Endoscopy visualized accurate margins of the aneurysmal pathological wall with high magnification and revealed the position of the clip blades and the surrounding perforators in the dead angles of the microscope. Fluorescence video angiography could confirm the blood flow of the ICA and the surrounding arteries. Regrowth of the aneurysm owing to the presence of a neck remnant occurred 1 month after treatment in 1 case that was repaired surgically. However, no other recurrence of BBAs or progression of ICA stenosis was observed by angiography with a mean follow-up period of 37 months. No repeat rupture or ischemic complications occurred, and all patients had a modified Rankin scale score of 0 with a mean follow-up period of 61 months. CONCLUSION: Wrap-clipping using a polytetrafluoroethylene membrane for ruptured BBAs is a useful and acceptable procedure with long-term effectiveness. The effectiveness of this method can be ensured using modern monitoring methods.

Neuroprotective effects of microglial P2Y1 receptors against ischemic neuronal injury.

Extracellular ATP, which is released from damaged cells after ischemia, activates P2 receptors. P2Y1 receptors (P2Y1R) have received considerable attention, especially in astrocytes, because their activation plays a central role in the regulation of neuron-to-glia communication. However, the functions or even existence of P2Y1R in microglia remain unknown, despite the fact that many microglial P2 receptors are involved in several brain diseases. Herein, we demonstrate the presence and functional capability of microglial P2Y1R to provide neuroprotective effects following ischemic stress. Cerebral ischemia resulted in increased microglial P2Y1R expression. The number of injured hippocampal neurons was significantly higher in P2Y1 R knockout (KO) mice than wildtype mice after forebrain ischemia. Propidium iodide (PI) uptake, a marker for dying cells, was significantly higher in P2Y1R KO hippocampal slices compared with wildtype hippocampal slices at 48 h after 40-min oxygen-glucose deprivation (OGD). Furthermore, increased PI uptake following OGD was rescued by ectopic overexpression of P2Y1R in microglia. In summary, these data suggest that microglial P2Y1R mediate neuroprotective effects against ischemic stress and OGD insult.

Embolization of a peripheral cerebral aneurysm associated with intracranial major artery occlusion through a transdural anastomotic artery: Case report.

A peripheral cerebral aneurysm is known to develop at collateral vessels as a result of hemodynamic stress by the occlusion of the intracranial major arteries. We report a case of successful embolization of a ruptured aneurysm through a transdural anastomotic artery. The aneurysm formed at the developed collateral vessel from the meningeal branch of the occipital artery (OA) to the posterior pericallosal artery. A 59-year-old man presented with acute-onset headache, and computed tomography revealed subarachnoid hemorrhage and intracerebral hemorrhage at the splenium of the corpus callosum with intraventricular hemorrhage. Digital subtraction angiography demonstrated a ruptured aneurysm located at a transdural anastomotic artery from the right OA to the posterior pericallosal artery. The patient underwent endovascular treatment for the aneurysm through the transdural anastomotic artery with a coil and n-butyl-2-cyanoacrylate. Because it was impossible to navigate a microcatheter to the aneurysm through the right anterior cerebral artery because of the occlusion of its proximal portion, it was advanced through the transdural anastomosis from the right OA. The aneurysm was completely occluded without complications. Endovascular embolization is a useful treatment option for a peripheral cerebral aneurysm developed at a collateral vessel with intracranial major artery occlusion.

Efficacy of Endoscopic Fluorescein Video Angiography in Aneurysm Surgery-Novel and Innovative Assessment of Vascular Blood Flow in the Dead Angles of the Microscope.

BACKGROUND: In aneurysm surgery, assessment of the blood flow around the aneurysm is crucial. Recently, intraoperative fluorescence video angiography has been widely adopted for this purpose. However, the observation field of this procedure is limited to the microscopic view, and it is difficult to visualize blood flow obscured by the skull base anatomy, parent arteries, and aneurysm. OBJECTIVE: To demonstrate the efficacy of a new small-caliber endoscopic fluorescence video angiography system employing sodium fluorescein in aneurysm surgery for the first time. METHODS: Eighteen patients with 18 cerebral aneurysms were enrolled in this study. Both microscopic fluorescence angiography and endoscopic fluorescein video angiography were performed before and after clip placement. RESULTS: Endoscopic fluorescein video angiography provided bright fluorescence imaging even with a 2.7-mm-diameter endoscope and clearly revealed blood flow within the vessels in the dead angle areas of the microscope in all 18 aneurysms. Consequently, it revealed information about aneurysmal occlusion and perforator patency in 15 aneurysms (83.3%) that was not obtainable with microscopic fluorescence video angiography. Furthermore, only endoscopic video angiography detected the incomplete clipping in 2 aneurysms and the occlusion of the perforating branches in 3 aneurysms, which led to the reapplication of clips in 2 aneurysms. CONCLUSION: The innovative endoscopic fluorescein video angiography system we developed features a small-caliber endoscope and bright fluorescence images. Because it reveals blood flow in the dead angle areas of the microscope, this novel system could contribute to the safety and long-term effectiveness of aneurysm surgery even in a narrow operative field.

A Case of Ruptured Vertebrobasilar Junction Aneurysm Associated with Subclavian Steal Phenomenon.

A 77-year-old woman with arteriovenous shunt for hemodialysis in the left forearm suffered from subarachnoid hemorrhage due to the rupture of a saccular aneurysm located on the left lateral wall of vertebrobasilar junction. Her left subclavian artery was severely stenosed and subclavian steal phenomenon was demonstrated on the digital subtraction angiography. Embolization of the parent artery including the aneurysm using detachable coils resulted in the successful obliteration of the aneurysm through the revascularized left subclavian artery. This is the first case in which the vertebrobasilar junction aneurysm would be caused by the hemodynamic stress due to the subclavian steal phenomenon combined with the shunt for hemodialysis in the left forearm.

Phase II Trial of Intravenous Low-Dose Granulocyte Colony-Stimulating Factor in Acute Ischemic Stroke.

BACKGROUND: Granulocyte colony-stimulating factor (G-CSF) has shown neuroprotective and neurogenerative activities in experimental studies, and our previous phase I clinical study suggested the safety and potential efficacy of low-dose G-CSF in acute ischemic stroke patients. The present phase II trial is aimed to evaluate the effect of G-CSF administration on neurological function and infarct volume, compared with a placebo group. METHODS: Forty-nine acute ischemic stroke patients (29 males, 20 females; 71 ± 10 years) within 24 hours after onset were recruited. Eligible patients were randomized 2:2:1 to receive G-CSF 150 µg/body/day, G-CSF 300 µg/body/day, and placebo, respectively. We evaluated clinical outcome in terms of the National Institutes of Health Stroke Scale, the modified Rankin Scale, and the Barthel Index at 90 days after onset, together with changes in infarct volume on magnetic resonance imaging. RESULTS: We found no serious adverse event, including change in leukocyte levels, which remained below 31,000/µL, at 150 and 300 µg G-CSF/body/day. Clinical outcome scores did not show any significant difference among the 3 groups. Chronological changes in infarct volume also showed no significant difference. CONCLUSIONS: G-CSF was well-tolerated at 150 and 300 µg/body/day in patients with acute ischemic stroke. However, administration of G-CSF at both 150 and 300 µg/body/day neither contributed to functional recovery nor reduced infarct volume at 3 months after onset, compared with the control group. The apparent lack of effectiveness may have been due to the small sample size. A trial of combination therapy with recombinant tissue plasminogen activator and G-CSF is planned.