High-flow bypass with radial artery graft followed by internal carotid artery ligation for large or giant aneurysms of cavernous or cervical portion: clinical results and cognitive performance.

High-flow bypass followed by ligation of the internal carotid artery (ICA) is an effective treatment, but the impact of abrupt occlusion of the ICA is unpredictable, especially on postoperative cognitive function. The present study evaluated the clinical results as well as cognitive performances after high-flow bypass using radial artery graft (RAG) with supportive superficial temporal artery (STA)-middle cerebral artery (MCA) bypass, followed by ICA ligation. Ten consecutive patients underwent high-flow bypass surgery for large or giant ICA aneurysms of cavernous or cervical portion. Demographics, clinical information, magnetic resonance (MR) imaging, computed tomography, digital subtraction angiography (DSA), intraoperative somatosensory evoked potentials, neuropsychological examinations including the Wechsler Adult Intelligence Scale-Third Edition and the Wechsler Memory Scale-Revised (WMS-R), and follow-up data were analyzed. The aneurysm was located on the cavernous segment in eight cases and cervical segment in two cases, and mean aneurysm size was 27.9 mm. Postoperative DSA demonstrated robust bypass flow from the external carotid artery to MCA via the RAG, and no anterograde flow into the aneurysm. No patient showed new symptoms after the operation. Follow-up clinical study and MR imaging were performed in nine patients and showed no additional ischemic lesion compared with preoperative imaging. Seven patients completed neuropsychological examinations before and after surgery. All postoperative scores except WMS-R composite memory score slightly improved. High-flow bypass followed by ICA ligation can achieve good clinical outcomes. Successful high-flow bypass using RAG with supportive STA-MCA bypass and ICA ligation does not adversely affect postoperative cognitive function.

Technique for rerouting a bridging vein that hinders the anterior interhemispheric approach: a technical note.

BACKGROUND: The frontal bridging vein, which is the venous drainage route of the frontal cortex into the superior sagittal sinus (SSS), sometimes poses an obstacle in the anterior interhemispheric approach during surgery for anterior cerebral artery aneurysms. Although severe complications including venous infarction or edema due to damage to the bridging vein are well known, only a few reports have discussed how to avoid venous injury when we must sacrifice the bridging vein to obtain an appropriate surgical field. This report describes a microvascular technique performed in two patients who underwent rerouting of the bridging vein to obtain an appropriate anterior interhemispheric surgical corridor to treat a ruptured anterior cerebral artery aneurysm. The hindering bridging vein was resected from the entrance to the SSS and anastomosed toward the adjacent cortical vein. METHODS: A 65-year-old male and a 43-year-old male were admitted to our hospital for sudden headache. Computed tomography, magnetic resonance angiogram, or digital subtraction angiography demonstrated a subarachnoid hemorrhage and an anterior cerebral artery aneurysm in both patients. In both cases, a relatively robust bridging vein, which appeared problematic to sacrifice, was draining into the SSS, resulting in a limited surgical corridor. Thus, we performed cortical vein reconstruction, and the aneurysms were successfully clipped under a wider surgical view. RESULTS: We confirmed completed clipping without postoperative venous complications. One patient demonstrated patency of reconstructed venous flow by digital subtraction angiography. No apparent cognitive impairment was seen in either patient. CONCLUSIONS: This technique may be useful for obtaining an appropriate surgical corridor when the frontal bridging vein may be damaged.

Tailored flow sequestration treatment using high-flow and low-flow bypass for partially thrombosed giant internal carotid artery aneurysm-a technical case report.

Direct clipping of giant partially thrombosed intracranial internal carotid artery (ICA) aneurysms is challenging, especially when important perforating arteries are involved. Proximal occlusion with bypass represents a possible alternative approach. An 80-year-old female presented with worsening visual acuity and severe headache caused by partially thrombosed giant (38 mm in diameter) aneurysms of the right ICA, suggestive of impending rupture. Direct clipping in conjunction with temporary occlusion of the lesion involving the anterior choroidal artery (AChA) was considered too risky. Thus, we sequestrated the ipsilateral ICA flow into a low-flow and a high-flow system using two external carotid artery (ECA)-ICA bypasses and one in situ bypass with cervical ICA ligation. As a result, the low-flow system by the superficial temporal artery-middle cerebral artery (MCA) bypass perfused mainly the proximal MCA lesions and aneurysm, whereas the high-flow system by ECA-radial artery-M2 bypass exclusively supplied the residual distal MCA area. This tailored flow sequestration successfully interrupted intra-aneurysmal flow and accelerated near-complete thrombosis of the aneurysm while preserving the AChA and avoiding any significant neurological deterioration. We conclude that this method is effective for the management of giant partially thrombosed aneurysms of the ICA, especially when direct clipping is difficult.

Extracranial-intracranial bypass for internal carotid/middle cerebral atherosclerotic steno-occlusive diseases in conjunction with carotid endarterectomy for contralateral cervical carotid stenosis: clinical results and cognitive performance.

Clinical results as well as cognitive performances after extracranial to intracranial (EC-IC) bypass in conjunction with contralateral carotid endarterectomy (CEA) are poorly understood. Data from 14 patients who underwent unilateral EC-IC bypass for atherosclerotic internal carotid artery (ICA)/middle cerebral artery (MCA) steno-occlusive disease in conjunction with CEA for contralateral cervical carotid stenosis were retrospectively reviewed. Postoperative results were evaluated by MRI imagings. Nine patients also underwent neuropsychological examinations (NPEs), including assessment by the Wechsler Adult Intelligence Scale-Third Edition and the Wechsler Memory Scale-Revised (WMS-R) before and about 6 months after bilateral surgeries. Postoperative MRI follow-up (median, 8 months; interquartile range, 7-8 months) confirmed successful bypass in all patients, with no additional ischemic lesions on T2WI when compared with preoperative imaging. Further, MRA showed patent bypass and contralateral smooth patency at CEA portion in all patients. In the group rate analysis, all five postoperative NPE scores (Verbal IQ, Performance IQ, WMS-memory, WMS-attention, and Average scores of all those four scores) were improved relative to preoperative NPE scores. Performance IQ and Average score improvements were statistically significant. Clinical results after EC-IC bypass in conjunction with contralateral CEA were feasible. Based on the group rate analysis, we conclude that successful unilateral EC-IC bypass and contralateral carotid endarterectomy does not adversely affect postoperative cognitive function.

Postoperative transient neurological symptoms and chronic subdural hematoma after extracranial-intracranial bypass for internal carotid/middle cerebral atherosclerotic steno-occlusive diseases: negative effect on cognitive performance.

BACKGROUND: The mechanisms underlying post-extracranial to intracranial (EC-IC) bypass neurocognitive changes are poorly understood. METHODS: Data from 55 patients who underwent a unilateral EC-IC bypass for atherosclerotic internal carotid artery (ICA)/middle cerebral artery (MCA) steno-occlusive disease were retrospectively evaluated. These patients underwent neuropsychological examinations (NPEs), including assessment by the Wechsler Adult Intelligence Scale-Third Edition and Wechsler Memory Scale-Revised (WMS-R) before and 6 months after EC-IC bypass. Results of NPEs were converted into Z-scores from which preoperative cognitive composite scores (CSpre) and postoperative cognitive composite scores (CSpost) were obtained. The association between the change of composite score between pre- and postoperative NPEs (CSpost-pre = CS post - CS pre) and various variables were assessed. These latter variables included occluded artery (ICA or MCA), preexisting ischemic lesion as verified in preoperative T2WI, robust bypass patency as verified by MRA performed approximately 6 months postoperatively, and postoperative transient neurological symptoms and/or postoperative chronic subdural hematoma (CSDH), both of which were dichotomized as postoperative events. RESULTS: Postoperative MRI follow-up (median, 6 months; interquartile range, 5-8 months) confirmed successful bypasses in all patients, with no additional ischemic lesions on T2WI when compared with preoperative imaging. Further, MRA showed patent bypasses in all patients. A nearly statistically significant CS post-pre decrease was observed in patients with postoperative events when compared with those without postoperative events (-0.158 vs. 0.039; p = 0.069). A multiple regression model predicting CSpost-pre was performed. After controlling for occluded arteries, postoperative events were identified as an independent predictor of a decline in CSpost-pre (p = 0.044). In the group rate analysis, three of four postoperative NPE scores (Performance IQ, WMS-memory, WMS-attention) were significantly improved relative to preoperative NPE scores. CONCLUSIONS: Postoperative transient neurological symptoms and/or CSDH might play a significant role in the subtle decline in cognition following an EC-IC bypass. However, this detrimental effect was small, and based on the group rate analysis, we concluded that a successful unilateral EC-IC bypass does not adversely affect postoperative cognitive function.

Surgical embolectomy for internal carotid artery terminus occlusion.

The aim of this study was to assess the efficacy and safety of surgical embolectomy for internal carotid artery terminus (ICA-T) occlusion. Twenty-five consecutive patients with acute ischemic stroke attributed to embolic ICA-T occlusion who underwent surgical embolectomy were retrospectively reviewed. Twenty-four patients were examined based on magnetic resonance imaging, with one patient included based on a computed tomography scan. Recanalization rate, recanalization time, complications, National Institutes of Health Stroke Scale (NIHSS) score improvement at 1 month, and modified Rankin Scale (mRS) at 3 months were evaluated. Final recanalization status was Thrombolysis in Myocardial Infarction (TIMI) 3 in 24 patients (96 %). Median recanalization time from symptom onset and from start of surgery was 281 and 79 min, respectively. Two patients (8 %) had major hemorrhagic complications related to surgery. Seventeen patients (68 %) demonstrated NIHSS score improvement of more than 10 points at 1 month. At 3 months, eight patients (32 %) were mRS 0-2, five patients (20 %) were mRS 3, and three patients (12 %) had died. Surgical embolectomy for ICA-T occlusion demonstrated a high complete recanalization rate and should be reconsidered as an additional therapeutic strategy to overcome this devastating situation.

Trapping and V3-radial artery graft-V4 bypass for ruptured dissecting aneurysm of the vertebral artery.

The authors show a surgical technique of trapping/resection of ruptured dominant vertebral artery aneurysm in conjunction with reconstruction of vertebral artery by V3-radial artery (RA) graft-V4 bypass through suboccipital craniotomy and far lateral approach. Step by step muscle dissection in posterior fossa enable fine exposure of occipital artery for possible OA-PICA bypass and V3 portion of vertebral artery. Extradural drilling of posterior one-third condyle and condylar fossa facilitate exposure of triangular surgical corridor made by medulla, spinal root of 11th nerve and lower cranial nerves, and thus enabling aneurismal resection and RA-V4 anastomosis. The video can be found here: http://youtu.be/LxsARGdHSVw .

Combined interhemispheric and pterional approach for ACOM and left MCA aneurysms.

This video demonstrates combined two separate craniotomies for two difficult unruptured cerebral aneurysms. The anterior communicating artery (ACOM) aneurysm existed at a high position, projected posteriorly, and thus necessitated an interhemispheric approach. Left middle cerebral artery (MCA) aneurysm with complex figure was treated through a separate pterional approach. Meticulous micro-cisternal opening under high magnification enabled safe and effective exposure of both aneurysms with minimal brain retraction, which alleviated brain damage as shown in postoperative images. The video can be found here: http://youtu.be/mBYsaAVekCA .

Clipping and STA-MCA bypass for unruptured AcomA aneurysm associated with unilateral MCA occlusion.

The authors show a surgical technique of clipping in conjunction with superficial temporal artery (STA)-middle cerebral artery (MCA) bypass to treat unruptured anterior communicating artery (AcomA) aneurysm associated with unilateral MCA occlusion. First, through MCA occlusion side, fronto-temporal craniotomy, extra-dural drilling of lesser sphenoid wing, and followed by wide exposure of Sylvian fissure, STA-MCA bypass was performed. Then, through trans-Sylvian, fronto-basal, and lateral trajectory, interhemispheric fissure was dissected from the base, which enabled good exposure and clipping of high positioned AcomA aneurysm. The video can be found here: http://youtu.be/GWItnRSs3m4 .

Emergent cervical surgical embolectomy for extracranial internal carotid artery occlusion.

BACKGROUND: Acute extracranial internal carotid artery (ICA) occlusion by a huge cardiogenic embolus is rare, but can be catastrophic. METHODS: Seven patients with acute ischemic stroke due to embolic occlusion of extracranial ICA who underwent emergent cervical surgical embolectomy were retrospectively reviewed. Diagnosis was made in six patients with magnetic resonance imaging (MRI) with optional digital subtraction angiography (DSA), while computed tomography (CT) and DSA were used in one patient with an implanted pacemaker. Clinical outcomes, including recanalization rate, recanalization time, complications, modified Rankin scale (mRS) at 3 months, and National Institute of Health Stroke Scale (NIHSS) score improvement at 1 month were evaluated. RESULTS: Complete recanalization was obtained in seven patients (100 %). Median recanalization time from symptom onset and from start of surgery was 402 and 40 min, respectively. All seven patients showed severe left ventricular hypertrophy (LVH) according to an increased cardiothoracic ratio (CTR) ≥50 %. Complications included recurrence of cardioembolic stroke with the right middle cerebral artery occlusion, minimal expansion of infarction, and aggravation of heart failure, each in one patient, respectively. Four (57.1 %) patients had a history or postoperative recurrence of cardioembolic stroke. Median NIHSS at 1 month was 2 (range, 0-30). Median mRS at 3 months was 2 (range, 0-5). Five patients (71.4 %) had a favorable outcome (mRS2). CONCLUSIONS: Cervical surgical embolectomy for acute extracranial ICA occlusion resulted in a high complete recanalization rate with an acceptable safety profile. A possible association between severe cardiac illness and huge embolus occluding proximal large artery was suggested.

A3-A3 anastomosis and superficial temporal artery-radial artery graft-A3 bypass to treat bilateral ACA steno-occlusive hemodynamic ischemia with cognitive and executive dysfunction: a technical note.

BACKGROUND: Executive functions are complex cognitive control functions that include cognitive flexibility, inhibition (self-control, self-regulation), and working memory. Bilateral frontal lobe ischemia is associated with cognitive impairment, especially in the context of dysexecutive syndrome. This report describes two patients who underwent bilateral anterior cerebral artery (ACA) reconstruction by A3-A3 anastomosis in conjunction with superficial temporal artery (STA)-radial artery (RA) graft-A3 bypass to treat bilateral ACA steno-occlusive hemodynamic ischemia accompanying cognitive and executive dysfunction. METHOD: A 74-year-old woman and a 73-year-old woman were admitted to our hospital for unilateral cerebral infarction in the frontal lobe. Magnetic resonance angiogram (MRA) demonstrated severe bilateral ACA steno-occlusive pathology in both patients. Considering the presence of impaired cognitive function with dysexecutive syndrome as well as hemodynamic compromise shown by single photon emission computed tomography (SPECT), we proceeded with A3-A3 anastomosis in conjunction with STA-RA-A3 bypass. Various neuropsychiatric tests were performed before and after the surgery. RESULTS: We confirmed good bypass patency without periprocedural complications. One patient recovered from apallic and bedridden status and regained ambulatory condition and ability to take in an oral diet. Another patient demonstrated improved scores in several cognitive tests with some persistent executive dysfunction. CONCLUSIONS: Bilateral ACA revascularization was technically feasible in two patients. This bypass surgery could have some positive effects in some basic cognitive function, such as memory, attention, and concentration by bilateral ACA hemodynamic improvement, although executive function, which is specific to prefrontal function, might not be reversible.

Stratification of intraoperative ischemic impact by somatosensory evoked potential monitoring, diffusion-weighted imaging and magnetic resonance angiography in carotid endarterectomy with routine shunt use.

BACKGROUND: Routine shunting to minimize ischemia during carotid endarterectomy (CEA) is controversial. The aim of this study was to stratify the ischemic parameters associated with CEA and evaluate the effect of routine shunting in attempting to mitigate those ischemia. METHOD: Data from 248 CEAs with routine shunting were retrospectively evaluated. Our assessment included somatosensory evoked potential (SSEP) amplitude reduction more than 50 % and longer than 5 min (SSEP<50%, >5 min), new postoperative diffusion-weighted imaging lesions (new DWI lesions), and severe stenosis as indicated by reduced ipsilateral middle cerebral artery (MCA) signal on preoperative magnetic resonance angiography (MRA asymmetry), as surrogates of hypoperfusion, microembli, and hemodynamic impairment, respectively. RESULTS: SSEP<50%, >5 min occurred in 15 % of CEAs during cross-clamping, and shunting reversed the SSEP changes. New DWI lesions were observed in 4.1 %. Pre-clamping the common and external carotid artery during dissection (pre-clamp method) decreased the rate of new DWI lesions compared to without pre-clamping (3.5 % vs. 7.5 %, P = 0.22). Occlusion time was significantly longer in the pre-clamp method than without pre-clamping (P < 0.0001). However, the incidence of SSEP<50%, >5 min was not increased with the pre-clamp method (p = 1.0) when using information regarding SSEP and collaterals to modify the speed of shunt manipulation. MRA asymmetry was identified in 39 CEAs (15.8 %) with correction of asymmetry postoperatively. MRA asymmetry correlated with symptomatic hyperperfusion (P = 0.0034). Only three CEAs had symptomatic hyperperfusion (1.2 %) with minimal symptoms. Ten CEAs sustained transient ischemia, symptomatic hyperperfusion, or 30-day-stroke (composite postoperative ischemic symptoms). Logistic regression analysis confirmed that SSEP<50%, >5 min (p = 0.009), new DWI lesions (p = 0.004) and MRA asymmetry (p = 0.042) were independent predictors of　composite postoperative ischemic symptoms. CONCLUSIONS: SSEP<50%, >5 min, new DWI lesions, and MRA asymmetry were able to stratify the ischemic impacts in CEA. Meticulous routine shunting could mitigate those appropriately.

Surgical embolectomy for large vessel occlusion of anterior circulation.

OBJECT: The aim of this study was to assess the technical details and the efficacy and safety of surgical embolectomy for occlusion of large vessels in the anterior circulation. METHODS: Twenty-three consecutive patients with acute ischemic stroke attributed to embolic occlusion of large arteries of the anterior circulation who underwent treatment with surgical embolectomy were retrospectively reviewed. Twenty patients were treated based on data from magnetic resonance angiography (MRA)-diffusion weighted imaging (DWI) mismatch, while three other patients had contraindications to magnetic resonance imaging (MRI) and were treated based on computed tomography (CT) and digital subtraction angiography (DSA) findings. Clinical outcomes, including recanalization rate, recanalization time, complications, modified Rankin Scale (mRS) at 3 months, and National Institute of Health Stroke Scale (NIHSS) score improvement at 1 month, were evaluated. RESULTS: Among the 23 patients (median age, 80 years; median presenting NIHSS score, 21 points), the occlusion site was the internal carotid artery (ICA) terminus in six patients, the M1 segment of the middle cerebral artery (MCA) in 10 patients, and the M2 division of the MCA in seven patients. Final recanalization status was thrombolysis in myocardial infarction (TIMI) 3 in 21 patients (91%). Median recanalization time from symptom onset and from start of surgery was 282 min and 70 min, respectively. One patient (4.3%) had symptomatic haemorrhage. Three patients (13%) had brain oedema due to massive infarction of affected vessel area; two of these patients had undergone embolectomy based on CT findings and had successful recanalization, while one patient underwent embolectomy based on MRI findings and did not have successful recanalization. All 18 patients who underwent embolectomy based on MRA-DWI mismatch and had successful recanalization did not develop additional confluent ischaemic lesion on postoperative DWI. At 3 months, seven patients (30%) had a mRS score of 0-2, eight patients (35%) had a mRS score of 3, and none of the patients had died. Sixteen patients (70%) demonstrated NIHSS score improvement of more than eight points at 1 month. CONCLUSION: Surgical embolectomy for occlusion of large vessels in the anterior circulation resulted in a high complete recanalization rate with an acceptable safety profile. Use of MRA-DWI mismatch as an indication for surgical embolectomy was associated with a reduced complication rate.

Orbital Arteriovenous Fistula Causing Only Visual Impairment due to Compression of the Optic Nerve by the Dilated Superior Ophthalmic Vein.

Orbital arteriovenous fistula (AVF) is a rare disease, and its standard therapeutic strategy has not been established. A 70-year-old male consulted an ophthalmologist due to a visual field defect in his left eye. Neurological findings showed visual impairment but no symptoms such as exophthalmos, conjunctival congestion, or diplopia. Magnetic resonance imaging showed marked dilation of the left superior ophthalmic vein (SOV). Cerebral angiography revealed an AVF that was limited to the left orbit. The feeder was a branch of the ophthalmic artery that originated from the first portion, and the drainer was the SOV, which was meandering and significantly dilated. Since the only symptom was visual impairment, the etiology was considered to be compression of the optic nerve due to a dilated SOV rather than increased venous pressure. Transvenous embolization via the facial vein was performed, and a visual field examination 1 week after the operation revealed marked improvement. Orbital AVF that develops only with visual impairment is extremely rare. As demonstrated with this case, coil embolization for proper position and reduction of the venous pressure, which relieves compression on the optic nerve, may be useful in improving the visual impairment.

Phase II study of oral etoposide and intravenous irinotecan for patients with platinum-resistant and taxane-pretreated ovarian cancer: Japan Clinical Oncology Group Study 0503.

A single-arm Phase II study evaluating combination chemotherapy utilizing oral etoposide and irinotecan for platinum-resistant and taxane-pretreated ovarian cancer has started. The aim of this study is to evaluate the efficacy and safety of this regimen as a test arm regimen in a subsequent Phase III trial. Patients with platinum-resistant and taxane-pretreated ovarian cancer are given etoposide at 50 mg/m(2) p.o. from days 1 to 21 and irinotecan 70 mg/m(2) i.v. at days 1 and 15, repeated every 28 days, up to six cycles. A total of 60 patients will be enrolled at 36 institutions. The primary endpoint is response rate. The secondary endpoints include adverse events and progression-free and overall survival.

Acute to subacute surgical revascularization for progressing stroke in atherosclerotic vertebrobasilar occlusion.

BACKGROUND: Acute vertebrobasilar artery (VBA) occlusion is catastrophic. For embolic occlusion, thrombolysis is reasonable. However, if the occlusion is atherosclerotic, the best therapeutic approach remains unclear. The aim of this study was to characterize the clinical course, case selection, techniques and complications associated with acute to subacute surgical revascularization in atherosclerotic vertebrobasilar occlusion under appropriate patient selection based on diffusion-weighted imaging (DWI) combined with careful evaluation of progressive neurological symptoms. METHODS: We retrospectively reviewed nine consecutive patients who were scheduled to undergo acute to subacute surgical revascularization for progressing stroke in atherosclerotic VBA occlusion consisting of a relatively small DWI lesion. Clinical characteristics, radiological findings, results of revascularization, and 3-month outcomes (mRS) were assessed. RESULTS: Seven patients underwent surgical revascularization (superficial temporal artery [STA]-superior cerebellar artery [SCA] bypass, n = 5; occipital artery [OA]-posterior inferior cerebellar artery [PICA] bypass, n = 1; vertebral endarterectomy, n = 1). Revascularization distal to the occlusion was successful in all seven patients. Two patients scheduled for STA-SCA bypass sustained irreversible confluent brainstem infarction before surgical intervention and died. The median time between admission and surgical treatment or irreversible coma was 20 h (range, 4-72 h). The modified Rankin Scale (mRS) at 3 months of seven patients who underwent surgical revascularization was good (mRS 0-2) in four patients, poor (mRS 3-6) in three patients. Mid- to long-term bypass patency was confirmed by magnetic resonance angiography (MRA) in the surviving five patients at a median follow-up of 7 months (range, 1-25 months). CONCLUSION: Atherosclerotic vertebrobasilar artery (VBA) occlusion presented with stuttering onset of symptoms and patients developed worsening symptoms of vertebrobasilar insufficiency over hours to days. DWI was a useful modality to help guide the appropriate selection of patients for acute to subacute surgical revascularization for progressing stroke in atherosclerotic VBA occlusion. The surgical methods themselves were feasible. Poor outcomes were related to delay of treatment rather than surgical or technical failure.

Extradural Middle Fossa and Transcavernous Approach for Resection of Trigeminal Neurinoma at Lateral Cavernous Sinus.

We present a 52-year-old male case of right trigeminal neurinoma at lateral cavernous sinus. The tumor was 40 mm in maximum diameter, obviously compressed temporal lobe and encased internal carotid artery. Extradural middle fossa and transcavernous approach was applied and the tumor was resected via Parkinson's triangle. This approach enabled safe and effective tumor resection, sufficient visualization, and operative field ( Figs. 1 and 2 ). We performed dissection of the tumor from trigeminal nerve, tentorium, and middle fossa and resect the tumor around internal carotid artery sufficiently. Postoperative course was good without any new neurological deficit. This surgical method is considered safe and effective for the resection of the tumor at lateral cavernous sinus. The link to the video can be found at: https://youtu.be/2ekuILIgEuo.

STA-A3 Bypass Using Radial Artery Graft for Progressive Cerebral Infarction of Bilateral ACA Region after STA-MCA Bypass Surgery for Moyamoya Disease.

Direct revascularization surgery, such as superficial temporal artery (STA)-middle cerebral artery (MCA) bypass, is effective in preventing ischemia and hemorrhage for moyamoya disease. On the other hand, when ischemia of the anterior cerebral artery (ACA) region progresses after ipsilateral STA-MCA bypass, it is difficult to perform revascularization from the viewpoint of the donor artery. A 55-year-old woman with right hemiparesis was diagnosed with cerebral infarction due to moyamoya disease. Left STA-MCA bypass was performed with no postoperative complications, but memory impairment and decreased motivation were observed 2 months after the operation. Magnetic resonance imaging and angiography revealed new infarction in the bilateral ACA area and deterioration in the signal intensity of bilateral ACAs. Revascularization of the bilateral ACA regions was considered necessary, but the left STA was already used in the previous surgery. Therefore, STA-radial artery (RA)-A3 bypass using RA graft combined with right STA-MCA bypass was performed. STA-A3 bypass using an RA graft may be the optimal treatment for ischemia of the ACA region that progresses after STA-MCA bypass.

Melphalan-prednisolone and vincristine-doxorubicin-dexamethasone chemotherapy followed by prednisolone/interferon maintenance therapy for multiple myeloma: Japan Clinical Oncology Group Study, JCOG0112.

A multicenter phase III study for untreated multiple myeloma was conducted to investigate a switch-induction chemotherapy with melphalan-prednisolone and vincristine-doxorubicin-dexamethasone followed by randomization on maintenance therapy for patients achieving plateau. Between November 2002 and November 2005, 34 patients were registered. The study was closed early because of poor accrual. Thirty-three eligible patients, with a median age of 65 years (range: 47-77 years) were analyzed for the secondary purpose. For induction therapy, 16 patients were treated with vincristine-doxorubicin-dexamethasone and 17 with melphalan-prednisolone initially. In eight cases, induction therapy was switched because of a poor response. Both regimens were well tolerated, but neutropenia, anorexia, constipation and infection with neutropenia were more frequent for vincristine-doxorubicin-dexamethasone. Best response rates were 44% (95% confidence interval, 20-70) and 47% (95% confidence interval, 23-72), respectively, for vincristine-doxorubicin-dexamethasone and melphalan-prednisolone. Vincristine-doxorubicin-dexamethasone/melphalan-prednisolone switch-induction therapy might be feasible and effective for Japanese patients with multiple myeloma.

T11/T12 ossification of the yellow ligament contributing to thoracic myelopathy in patient with posterior fossa arachnoid cyst and acquired incidental Chiari I malformation/syrinx.

BACKGROUND: Thoracic ossification of the yellow ligament (OYL) may contribute to myelopathy. In the case presented, the patient additionally had a chronic posterior fossa arachnoid cyst with an acquired Chiari I malformation and cervicothoracic syrinx. CASE DESCRIPTION: A 40-year-old female with a posterior fossa arachnoid cyst found 17 years ago, and newly acquired Chiari I malformation (tonsils down 5 mm) with a C7-T5 syrnix, presented with the new onset of lower extremity myelopathy. The MR documented marked dorsolateral cord compression due to T11/T12 OYL. Six months following a laminectomy for resection of OYL, the patient was asymptomatic. CONCLUSION: In patients presenting with the new onset of lower extremity myelopathy, evaluation of the complete neuraxis may be warranted. Here, the patient has an unchanged posterior fossa arachnoid cyst with an acquired Chiari I malformation/C7-T5 syrinx. However, the patient's symptoms were fully attributed to the MR-documented T11/T12 OYL that was successfully resected.