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.

Ganglia-Induced Tarsal Tunnel Syndrome.

BACKGROUND: Tarsal tunnel syndrome (TTS) is a common entrapment neuropathy that is sometimes elicited by ganglia in the tarsal tunnel. METHODS: Between August 2020 and July 2022, we operated on 117 sides with TTS. This retrospective study examined data from 8 consecutive patients (8 sides: 5 men, 3 women; average age 67.8 years) with an extraneural ganglion in the tarsal tunnel. We investigated the clinical characteristics and surgical outcomes for these patients. RESULTS: The mass was palpable through the skin in 1 patient, detected intraoperatively in 1 patient, and visualized on MRI scanning in the other 6 patients. Symptoms involved the medial plantar nerve area (n = 5), lateral plantar nerve area (n = 1), and medial and lateral plantar nerve areas (n = 2). The interval between symptom onset and surgery ranged from 4 to 168 months. Adhesion between large (≥20 mm) ganglia and surrounding tissue and nerves was observed intraoperatively in 4 patients. Of the 8 patients, 7 underwent total ganglion resection. There were no surgery-related complications. On their last postoperative visit, 3 patients with a duration of symptoms not exceeding 10 months reported favorable outcomes. CONCLUSIONS: Because ganglia eliciting TTS are often undetectable by skin palpation, imaging studies may be necessary. Early surgical intervention appears to yield favorable outcomes.

Identification and decompression of superior cluneal nerve implicated in low back pain.

INTRODUCTION: Low back pain (LBP) can be attributable to entrapment of the superior cluneal nerve (SCN) around the iliac crest. Surgical decompression is a useful treatment; however, finding all entrapped SCNs involved in patients with LBP can be difficult. We performed a retrospective study to help identify entrapped SCNs in the narrow surgical field. METHODS: We enrolled 20 LBP patient (22 sides) with SCN entrapment. They were 9 males and 11 females; their mean age was 72.5 years. We developed a 3-step procedure for successful SCN decompression surgery. In step 1, the thoracolumbar fascia is exposed and the SCN penetrating the fascia is released. In step 2, the fascia is opened and the SCN is released. In step 3, the fascia above the iliac crest is opened and the SCN is released. RESULTS: We successfully released 66 nerves; the average was 3.0 ± 0.8 (1-4) per patient. Step 1 detected 18 nerves (27.3%), step 2 identified 35 (53.0%), and in step 3, 13 (19.7%) were recognized. By tracing the thin nerves branching off the SCN, we found 7 nerves (10.6%). We performed 22 operations; step 1 identified 16 SCNs (72.7%), step 2 identified 21 (95.5%), and step 3 found 12 nerves (54.5%). CONCLUSIONS: The SCN is most readily identified upon opening of the thoracolumbar fascia. To identify as many SCN branches as possible, our 3-step method may be useful.

Retrospective Observational Study of Patients With Subdural Hematoma Treated With Idarucizumab.

Use of anticoagulants is increasing with the aging of societies. The safe first-line drug is likely to be a direct oral anticoagulant (DOAC), but outcomes of treatment of traumatic brain injury (TBI) with anticoagulants are uncertain. Therefore, we examined the clinical effect of idarucizumab as reversal therapy in elderly patients with TBI who were treated with dabigatran. A retrospective multi-center observational study was performed in patients ≥65 years of age who developed acute traumatic subdural hematoma during treatment with dabigatran and underwent reversal therapy with idarucizumab. The items examined included patient background, neurological and imaging findings at arrival, course after admission, complications, and outcomes. A total of 23 patients were enrolled in the study. The patients had a mean age of 78.9 years. Cause of TBI was fall in 60.9% of the subjects. Mean Glasgow Coma Scale score at arrival was 8.7; anisocoria was present in 31.8% of cases. Exacerbation of consciousness was found in 30.4%, but only in 13.3% of subjects treated with idarucizumab before consciousness and imaging findings worsened. Dabigatran was discontinued in 81.8% of cases after hematoma development, with a mean withdrawal period of 12.1 days. The favorable outcome rate was 21.7%, and mortality was 39.1%. In multi-variate analysis, timing of idarucizumab administration was associated with a favorable outcome. There were ischemic complications in 3 cases (13.1%), and all three events occurred ≥7 days after administration of idarucizumab. These findings suggest that in cases that develop hematoma during treatment with dabigatran, it is important to administer idarucizumab early and restart dabigatran after conditions stabilize.

Spontaneous middle cerebral artery dissection: a series of six cases and literature review.

Middle cerebral artery (MCA) dissection is rare, and various clinical presentations, including hemorrhage, ischemia, or comorbidities, and the changes in imaging findings over time hinder treatment decisions. The European Stroke Organization guidelines exclude MCA dissection. Few cases have been reported with no review of the relevant literature. Therefore, we reviewed the relevant literature and our own experience with non-traumatic MCA dissection cases to determine appropriate treatment strategies. At our institution and affiliated institutions, we encountered six cases of MCA dissection-five with infarction and one with hemorrhage. Two patients underwent revascularization, and one underwent an aneurysmectomy. We reviewed English and Japanese articles in PubMed and Medical Journal Web and summarized the results based on the relationships among age, sex, location, the presence of an aneurysm, the presence of angiography, history, treatment, and mode of onset. The clinical course, changes in imaging, treatment strategies, and prognosis were discussed. Eighty cases were included in the review. Cerebral aneurysms were more common distal to the M2 area (p = 0.00) and were correlated with hemorrhage (p < 0.001). Most hemorrhagic cases with aneurysms were treated surgically, while ischemic cases were treated with antithrombotic agents, and both had a similar neurological prognosis. There were some cases of rebleeding after antithrombotic therapy, especially in older adults.Surgical treatment is recommended in cases of hemorrhage and confirmed aneurysms, particularly for lesions distal to the M2 area. Patients with aneurysm-associated ischemia should be followed up, and antithrombotic treatment should be considered with particular care in older adults.

Distal Endovascular Occlusion for Incomplete Occlusion of Cavernous Carotid Aneurysms after High-flow Bypass and Cervical Internal Carotid Artery Ligation.

Internal carotid artery (ICA) ligation for placing a high-flow extracranial-intracranial (EC-IC) bypass is used in patients with aneurysms on the cavernous portion of the ICA. Recanalization and rupture after proximal ICA ligation can occur. We present four patients who underwent endovascular distal ICA occlusion and report our surgical technique and treatment results. We ligated the ICA to place an EC-IC bypass using a radial artery (RA) graft. Failure to obtain spontaneous occlusion in the distal region required endovascular treatment an average of 219 days later. A guide catheter was placed in the common carotid artery, a guide or distal access catheter was introduced in the RA graft from the external carotid artery, and a microcatheter was navigated into the cavernous aneurysm through the RA graft. Using detachable coils, endovascular ICA occlusion was from just distal to the aneurysmal neck to a site proximal to the origin of the ophthalmic artery. Aneurysmal occlusion was completed by endovascular occlusion of the distal ICA. Complications were RA graft stenosis and transient consciousness disturbance due to local subarachnoid hemorrhage. Outpatient follow-up for a mean of 109.5 months revealed no recurrences. Distal occlusion of the ICA through the implanted RA graft is simple and presents a low risk for cerebral infarction due to thrombus formation during the procedure. To treat cavernous carotid aneurysms that do not disappear after placing the EC-IC bypass after ICA ligation at the aneurysmal neck, we offer our procedure as a treatment option.

Formation of a large fusiform aneurysm next to a medullary infarction due to posterior inferior cerebellar artery dissection.

Posterior inferior cerebellar artery (PICA) infarction can lead to ischemic stroke at the lateral part of the medullary oblongata. PICA dissection can also elicit an ischemic event in this region but its detection on radiological images is difficult due to the small diameter of the vessel. We report a 48-year-old male with Wallenberg syndrome due to PICA dissection, which was difficult to diagnose on first admission. He reported sudden-onset sensory disturbance on the right side of his face, ataxic gait, and headache. Brain magnetic resonance imaging (MRI) revealed a fresh cerebral infarct in the right lateral medulla oblongata. Serial MRI and magnetic resonance angiography (MRA) performed at the time of his admission failed to demonstrate cerebral vessel abnormalities. MRI study performed 18 months after the attack revealed a fusiform aneurysm on the lateral medullary segment of the PICA; its site was extremely close to the cerebral infarct. We concluded that the infarct was due to PICA dissection because it was sudden onset of the symptom at the event and the lesion enlarged dissecting aneurysm located to be coincident with symptoms of Wallenberg syndrome. The aneurysm was trapped, and an occipital artery-PICA bypass was placed. At the latest follow-up, one year after the operation, he manifested no neurological symptoms.Imaging findings at the time of his first admission indicated that the PICA was intact in this patient with Wallenberg syndrome attributable to PICA dissection, which obscured on imaging studies performed at symptom onset and was diagnosed later. However,18 months later, MRI revealed enlargement of an aneurysm at the site of the dissection. A cerebral infarct in the PICA territory in patients with headache may be indicative of PICA dissection.

External Carotid Artery-Related Adverse Events at Extra-Intra Cranial High Flow Bypass Surgery Using a Radial Artery Graft.

OBJECTIVE: Placing an extracranial-intracranial (EC-IC) high-flow bypass using a radial artery (RA) graft plus internal carotid artery (ICA) trapping or ligation is an option for treating patients expected to be at high risk for complications by direct surgical treatment of the ICA. We focused on the anastomosis between the external carotid artery (ECA) and the RA graft in the cervical region and present adverse events and salvage procedures. METHODS: EC-IC high-flow bypass procedures using an RA graft were performed to treat 87 consecutive patients. The ECA diameter at the midpoint of the planned ECA-RA anastomosis and the non-branched length of the ECA were measured on preoperative angiograms. To study adverse events related to ECA-RA anastomoses, we reviewed the patients' surgical records and intraoperative videos. RESULTS: In 11 patients (12.6%) we encountered adverse events during anastomosis between the ECA and RA. The rate of ECA dissection was significantly higher in male patients (4 of 17; 23.5%) than female patients (3 of 70; 4.3%) (P = 0.012). Logistic regression analysis revealed that male sex, individuals with diabetes mellitus, and patients whose non-branching length of the ECA was short (16.1 ± 6.7 mm) were at high risk of ECA problems. We set the cutoff point at 17.5 mm (the area under the receiver operator characteristic curve was 0.72). CONCLUSIONS: Our findings indicate that patients, especially male patients, treated by EC-IC high-flow bypass using an RA graft are at increased risk for adverse events when the ECA length at the site of the planned anastomosis is shorter than 17.5 mm.

Ring finger protein 213 c.14576G>A mutation is not involved in internal carotid artery and middle cerebral artery dysplasia.

The ring finger protein 213 (RNF213) susceptibility gene has been detected in more than 80% of Japanese and Korean patients with moyamoya disease (MMD), a bilateral internal carotid artery (ICA) occlusion. Furthermore, RNF213 has been detected in more than 20% of East Asians with atherosclerotic ICA stenosis. In this study, we evaluated the frequency of RNF213 mutations in congenital occlusive lesions of the ICA system. This case series was conducted jointly at four university hospitals. Patients with a family history of MMD, quasi-MMD, or related diseases were excluded. Ten patients were diagnosed with abnormal ICA or middle cerebral artery (MCA) angiogenesis. Patients with neurofibromatosis were excluded. Finally, nine patients with congenital vascular abnormalities were selected; of these, five had ICA deficiency and four had twig-like MCA. The RNF213 c.14576G > A mutation was absent in all patients. Therefore, the RNF213 c.14576G > A mutation may not be associated with ICA and MCA congenital dysplasia-rare vascular anomalies making it difficult to study a large number of cases. However, an accumulation of cases is required for accurate determination. The results of this study may help differentiate congenital vascular diseases from MMD.

RNF213 c.14576G>A Is Associated with Intracranial Internal Carotid Artery Saccular Aneurysms.

A mutation in RNF213 (c.14576G>A), a gene associated with moyamoya disease (>80%), plays a role in terminal internal carotid artery (ICA) stenosis (>15%) (ICS). Studies on RNF213 and cerebral aneurysms (AN), which did not focus on the site of origin or morphology, could not elucidate the relationship between the two. However, a report suggested a relationship between RNF213 and AN in French-Canadians. Here, we investigated the relationship between ICA saccular aneurysm (ICA-AN) and RNF213. We analyzed RNF213 expression in subjects with ICA-AN and atherosclerotic ICS. Cases with a family history of moyamoya disease were excluded. AN smaller than 4 mm were confirmed as AN only by surgical or angiographic findings. RNF213 was detected in 12.2% of patients with ICA-AN and 13.6% of patients with ICS; patients with ICA-AN and ICS had a similar risk of RNF213 mutation expression (odds ratio, 0.884; 95% confidence interval, 0.199-3.91; p = 0.871). The relationship between ICA-AN and RNF213 (c.14576G>A) was not correlated with the location of the ICA and bifurcation, presence of rupture, or multiplicity. When the etiology and location of AN were more restricted, the incidence of RNF213 mutations in ICA-AN was higher than that reported in previous studies. Our results suggest that strict maternal vessel selection and pathological selection of AN morphology may reveal an association between genetic mutations and ICA-AN development. The results of this study may form a basis for further research on systemic vascular diseases, in which the RNF213 (c.14576G>A) mutation has been implicated.

High-flow bypass surgery using a radial artery graft for an extracranial internal carotid artery aneurysm: Case reports and literature review.

BACKGROUND: Extracranial carotid artery aneurysms are rare. Surgery may be difficult when vessels are tortuous and on a high cervical level. We report two patients whose tortuous extracranial internal carotid artery (ICA) aneurysm located on a high cervical level was successfully treated by ICA ligation and a high-flow bypass using a radial artery (RA) graft between the external carotid- and the middle cerebral artery. CASE DESCRIPTION: (Case 1) A 47-year-old man suffered a recurrent cerebral infarct despite medical treatment. His right extracranial ICA aneurysm measured 33 mm; it was tortuous and located at a high cervical level. We ligated the ICA after placing a high-flow bypass using an RA graft. The aneurysm was not repaired. (Case 2) A 59-year-old woman noticed pulsatile swelling on her left neck. It was due to an extracranial ICA aneurysm that was large (36 mm), tortuous, and located at a high cervical level. We performed ICA ligation after placing a high-flow bypass using an RA graft without direct aneurysmal repair. Six months after the operation she noted a pulsatile bulge on the left oropharynx. We confirmed recurrence of an aneurysm from retrograde blood flow and performed internal trapping by occluding the distal portion of the ICA aneurysm using an intravascular procedure. CONCLUSION: ICA ligation after placing a high-flow bypass with an RA-graft is a technically demanding, but safe procedure to address extracranial ICA aneurysms that are tortuous and located at a high cervical level.

Lesion Trapping with High-Flow Bypass for Ruptured Internal Carotid Artery Blood Blister-Like Aneurysm Has Little Impact on the Anterior Choroidal Artery Flow: Case Series and Literature Review.

OBJECTIVE: To examine the relationship between trap location and cerebral infarction in the anterior choroidal artery (AChA) region and associated risks in ruptured internal carotid artery blood blister-like aneurysm (BLA) treatment with high-flow bypass and lesion trapping. METHODS: We included 26 patients diagnosed with BLAs and treated with high-flow bypass and trapping. We examined clinical characteristics including age, aneurysm trap location, final prognosis, cerebral infarction on postoperative magnetic resonance imaging, and modified Rankin Scale score at discharge. We also searched the literature for similar studies. RESULTS: The modified Rankin Scale score at discharge was 0-2 in 20 patients, 3-5 in 2 patients, and 6 in 2 patients. In 19/26 patients (73.1%), the trapped segment was between the posterior communicating (PcomA) and the ophthalmic arteries. In 2 patients (7.7%), the trapped segment included the PcomA and the AChA; in 4 patients (15.4%), the trapped segment was within the PcomA. In these patients, the PcomA was occluded, and blood from the high-flow bypass flowed out to the AChA alone. No patient showed cerebral infarction. Our systematic review identified 70 patients. Of all 96 patients, 12 had AChA cerebral infarction; however, the infarction affected the prognosis of only 2 patients. CONCLUSIONS: When treating BLAs with high-flow bypass and lesion trapping, the frequency of AChA cerebral infarction is low even when the PcomA is occluded, leaving the AChA as the only outflow vessel during high-flow bypass. However, PcomA occlusion may be associated with risks when treating patients with advanced arteriosclerosis near C1-2.

Risk factors for ischemic complications in vascular reconstructive surgeries.

OBJECTIVE: There have been reports on postoperative ischemic complications with vascular reconstructive surgery. However, various factors, such as lesions, operative technique, and perioperative treatment, prevent analyzing the causes of ischemic complications in vascular reconstruction surgeries. In the present study, we analyzed the cause of ischemic complications for vascular reconstruction surgeries with the same operator, surgical procedure, and perioperative treatment and without focusing on the lesions. PATIENTS AND METHODS: We retrospectively reviewed 66 patients, including 24 aneurysm cases and 42 ischemic disease cases, between 2008 and 2018. The patient group comprised 35 males and 31 females, and the patient mean age was 63.3 (23-87) years. We investigated the postoperative presence of symptomatic and asymptomatic cerebral ischemia on MRIDWI performed within 4 postoperative days. We conducted a statistical analysis of the ischemic complications and clinical and treatment factors. RESULTS: Symptomatic cerebral ischemia was detected in 3 cases, whereas asymptomatic ischemic findings were identified in 8 cases. All cases of symptomatic cerebral ischemia involved cerebral aneurysms. Results of a univariate analysis revealed an association between symptomatic cerebral ischemia and preoperative antithrombotic therapy (OR, 0.07; p =  0.049 (95 %CI; 0.007-0.8794)), clipping (OR, 4.8; p =  0.0501 (95 %CI; 1.641-342.9)), and aneurysm (OR, 14.16; p =  0.0423 (95 %CI; 0.6991-286.9)). Significant associations were found between asymptomatic cerebral ischemia and preoperative antithrombotic therapy [OR, 0.2941; p =  0.0514 (95 %CI; 0.08335-1.038)], aneurysms [OR, 7.8; p =  0.0146 (95 %CI; 1.414-43.04)] and radial artery grafts (RAGs) [OR, 6.8; p =  0.0192 (95 %CI; 1.410-32.98)]. Multivariate analysis identified clipping [OR, 5.462; p =  0.045 (95 %CI; 1.01-78.25] and preoperative antithrombotic therapy [OR, 0.187; p =  0.037 (95 %CI; 0.004-0.813)] as the risk factors for symptomatic cerebral ischemia. Further, a correlation was found between asymptomatic cerebral ischemia and RAGs [OR, 9.244; p =  0.00013 (95 %CI; 2.34-29.44)]. CONCLUSION: Ischemic complications associated with combined vascular reconstruction surgeries for cerebral aneurysms are possibly associated with procedures related to aneurysmal occlusions. Thus, vascular reconstruction surgeries can be performed relatively safely. Further, preoperative antithrombotic treatment should be considered, and caution is required for asymptomatic cerebral ischemia in RAG cases.

Serum Glucose and Potassium Ratio as Risk Factors for Cerebral Vasospasm after Aneurysmal Subarachnoid Hemorrhage.

OBJECTIVE: Cerebral vasospasm is associated with poor prognosis in patients with aneurysmal subarachnoid hemorrhage (SAH), and biomarkers for predicting poor prognosis have not yet been established. We attempted to clarify the relationship between serum glucose/potassium ratio and cerebral vasospasm in patients with aneurysmal SAH. METHODS: We studied 333 of 535 aneurysmal SAH patients treated between 2006 and 2016 (123 males, 210 females; mean age 59.7 years; range 24-93). We retrospectively analyzed the relationship between cerebral vasospasm grade and clinical risk factors, including serum glucose/potassium ratio. RESULTS: Postoperative angiography revealed cerebral vasospasm in 112 patients (33.6%). Significant correlations existed between the ischemic complication due to cerebral vasospasm and glucose/potassium ratio (P < .0001), glucose (P = .016), and potassium (P = .0017). Serum glucose/potassium ratio was elevated in the cerebral vasospasm grade dependent manner (Spearman's r = 0.1207, P = .0279). According to the Glasgow Outcome Scale (GOS) score at discharge, 185 patients (55.5%) had a poor outcome (GOS scores 1-3). Serum glucose/potassium ratio was significantly correlated between poor outcome (GOS scores 1-3) and age (P < .0001), serum glucose/potassium ratio (P < .0001), glucose (P < .0001), potassium (P = .0004), white blood cell count (P = .0012), and cerebral infarction due to cerebral vasospasm (P < .0001). Multivariate logistic regression analyzes showed significant correlations between cerebral infarction due to cerebral vasospasm and serum glucose/potassium ratio (P = .018), glucose (P = .027), and potassium (P = .052). CONCLUSIONS: Serum glucose/potassium ratio in cases of aneurysmal SAH was significantly associated with cerebral infarction due to cerebral vasospasm and GOS at discharge. Therefore, this factor was useful to predict prognosis in patients with cerebral vasospasm and aneurysmal SAH.

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.

Recovery of Visual and Ophthalmologic Symptoms After Treating Large or Giant Internal Carotid Artery Aneurysm by High-Flow Bypass with Cervical Ligation.

OBJECTIVE: Large or giant internal carotid artery (ICA) aneurysms often cause visual deficits and cranial nerve palsy. The aim of this study was to investigate the efficacy of ligation of the ICA with high-flow bypass. METHODS: We retrospectively analyzed the findings from patients with visual deficit and ophthalmologic symptoms due to ICA aneurysms. In addition, we analyzed the recovery factors associated with the visual deficit and ophthalmologic symptoms postoperatively, focusing on the type of cranial nerve palsy, aneurysm size, location, and the time to treatment from first symptoms. RESULTS: We identified 38 patients (35 women, 3 men) with a mean age at surgery of 63.6 years (range, 24-81 years) with visual and ophthalmologic symptoms due to large or giant internal carotid aneurysm. Aneurysms ranged in size from 15-50 mm (mean, 25.2 mm). Visual disturbance (7 cases, 18%) and ophthalmoplegia (31 cases, 82%) were the only preoperative cranial nerve palsies. Aneurysms were completely thrombosed in 94.7% of cases (36/38). Visual disturbance improved in 28.5% of cases (2/7), and ophthalmoplegia improved in 87.1% of cases (27/31). Time to therapy from developing a visual disturbance was longer than time to therapy from developing ophthalmoplegia (P = 0.001). Time to therapy was significantly associated with recovery from cranial nerve palsy (P < 0.0001). The recovery of visual disturbance was worse than that of ophthalmoplegia (P = 0.001). CONCLUSION: Early treatment is recommended when the visual and ophthalmologic symptoms are present because treatment delay is a risk factor for nonimprovement of symptoms.

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.

Gremlin, a bone morphogenetic protein antagonist, is a crucial angiogenic factor in pituitary adenoma.

Gremlin is an antagonist of bone morphogenetic protein (BMP) and a major driving force in skeletal modeling in the fetal stage. Several recent reports have shown that Gremlin is also involved in angiogenesis of lung cancer and diabetic retinopathy. The purpose of this study was to investigate the role of Gremlin in tumor angiogenesis in pituitary adenoma. Double fluorescence immunohistochemistry of Gremlin and CD34 was performed in pituitary adenoma tissues obtained during transsphenoidal surgery in 45 cases (7 PRLoma, 17 GHoma, 2 ACTHoma, and 2 TSHoma). Gremlin and microvascular density (MVD) were detected by double-immunofluorescence microscopy in CD34-positive vessels from tissue microarray analysis of 60 cases of pituitary adenomas (6 PRLoma, 23 GHoma, 22 NFoma, 5 ACTHoma, and 4 TSHoma). In tissue microarray analysis, MVD was significantly correlated with an increased Gremlin level (linear regression: P < 0.005, r (2) = 0.4958). In contrast, Gremlin expression showed no correlation with tumor subtype or Knosp score. The high level of expression of Gremlin in pituitary adenoma tissue with many CD34-positive vessels and the strong coherence of these regions indicate that Gremlin is associated with angiogenesis in pituitary adenoma cells.

Fluorescence Angiography with Temporary Occlusion to Confirm the Distal Artery: Technical Notes.

Confirming the patency of the proximal parent and distal artery is necessary in cerebral aneurysm surgery. To understand the relationship between the parent and distal arteries of the aneurysm, the blood vessels running through the subarachnoid space should be extensively dissected, which is time consuming. To examine the efficacy of a temporary clip with indocyanine green (ICG) technique, in which the parent artery is temporarily occluded using a temporary clip, an ICG videoangiography (ICGVAG) is performed to clarify the relationship between the distal artery and the proximal parent artery. Three patients with a distal aneurysm. This technique was used to confirm the connection of the parent and the distal artery in distal aneurysms. With regard to middle cerebral artery (MCA), the procedure is conducted as follows. First, the M2 within the Sylvian fissure is investigated to ensure the absence of atherosclerosis and perforators and that this vessel could undergo occlusion by temporary clipping. The subarachnoid space surrounding the distal artery of the lesion site suspected of an existent aneurysm is dissected. The image range of the ICGVAG is set sufficiently wide to accommodate the possibility that the distal artery is not the artery that was anticipated. Subsequently, after the temporary clip occlusion is completed, the ICGVAG is recorded. In the three distal aneurysms, the relationship between the aneurysm, the distal artery, and the parent artery was confirmed. This method was useful, suggesting that unnecessary dissection in the subarachnoid space might be reduced.

Target-controlled infusion technique with indocyanine green videoangiography for radial artery graft.

OBJECT: To understand the relationship between the parent artery and its distal arteries, blood vessels running through the subarachnoid space need to be extensively dissected, which is time-consuming. We examined the efficacy of temporary clipping with the indocyanine green (ICG) technique (target-controlled infusion (TCI) technique), in which the parent artery is occluded using a temporary clip, and ICGV (videoangiography) is performed to clarify the relationship between the distal M4 and proximal M2. METHODS: Thirteen radial artery grafts (RAGs) for internal carotid aneurysm underwent TCI to confirm the relationship between M2 and cortical M4. To monitor the perfusion pressure of the cortical middle cerebral artery, superficial temporal artery (STA) to M4 anastomosis was performed before RA-M2 anastomosis. We performed anastomosis of the recipient of STA- M4 that was distal and downstream of the M2 segment that is the recipient of RA-M2 anastomosis. To select the proper recipient M4 of the STA-M4 anastomosis, the ICGV image range was set sufficiently wide to accommodate the possibility that the distal artery was not the one anticipated. ICGV followed complete occlusion by temporary clipping of the recipient M2. RESULTS: In 2 of the 13 cases, the relationship between the M2 and M4 could not be clarified. CONCLUSIONS: In cases with developed collateral circulation or small perfusion area of the occluded M2, it was difficult to ascertain the relationship by TCI. Nevertheless, TCI was useful in 11 of the 13 cases, suggesting that unnecessary dissection in the subarachnoid space may be reduced using this technique.