Surgery for Cerebral Stroke
Online ISSN : 1880-4683
Print ISSN : 0914-5508
ISSN-L : 0914-5508
Volume 36, Issue 4
Displaying 1-11 of 11 articles from this issue
Review
  • Tatsuya ISHIKAWA
    2008 Volume 36 Issue 4 Pages 259-264
    Published: 2008
    Released on J-STAGE: August 25, 2009
    JOURNAL FREE ACCESS
    Craniotomy and clipping have been the gold standard for treatment of aneurysmal subarachnoid hemorrhage (SAH). From my personal experience, all-over surgical results from craniotomy have not improved, even though surgical skills have improved greatly. Fifteen years has past since endovascular coil embolization became another option. From the result of ISAT, the endovascular coiling appeared to be a robust surgical technique. We are convinced that surgical clipping and endovascular coiling will play a complementary role in the treatment for aneurysm SAH and will improve patients' outcome. Given that younger neurosurgeons experience fewer cases of craniotomy and clipping surgery, a training system is essential to pass on clipping surgery skills.
    Each particular patient suffers problems that may worsen their outcome such as preoperative cardiopulmonary problems, delayed vasospasm, and high age.
    Careful management suitable to the condition of each patient will be necessary to produce a satisfactory outcome.
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Original Articles
  • Masao SATO, Hiroyasu KAMIYAMA, Terumasa KUROIWA, Toshitaka NAKAMURA, K ...
    2008 Volume 36 Issue 4 Pages 265-270
    Published: 2008
    Released on J-STAGE: August 25, 2009
    JOURNAL FREE ACCESS
    We report 4 cases of giant aneurysms in the basilar tip region, comprising 1 large and 3 giant aneurysms located in the basilar tip (2 cases), basilar-SCA (1 case), and PCA (1 case). One of the 4 was ruptured (basilar tip aneurysm). The symptoms were headache (3 cases) and oculomotor palsy (1 case; basilar-SCA). All aneurysms had unilateral internal carotid artery occlusion. In all cases the aneurysms were clipped following EC-RA-M2 bypass to prevent ischemia at the area of the occluded internal carotid artery and to reduce hemodynamic stress within the aneurysm. The clinical courses of 2 basilar tip aneurysms were good but 1 basilar-SCA aneurysm re-grew and ruptured 4 years later after incomplete clipping of the aneurysm. In 1 PCA aneurysm a new basilar tip aneurysm occurred that grew progressively. We consider that the cause of these aneurysms was hemodynamic stress due to internal carotid artery occlusion. It is suggested that the internal carotid artery should not be occluded without an EC-RA-M2 bypass.
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  • Hiroki KURITA, Ryuichi YAMAGUCHI, Toshiki IKEDA, Youichi HARADA, Yoshi ...
    2008 Volume 36 Issue 4 Pages 271-276
    Published: 2008
    Released on J-STAGE: August 25, 2009
    JOURNAL FREE ACCESS
    Between February 2004 and September 2005, revasculization technique was used in 10 patients with intracranial aneurysm to obliterate the aneurysm and to prevent ischemic complications. Five high-flow external carotid-internal carotid (EC-IC) bypasses with radial artery graft (EC-RA-M2) followed by proximal IC occlusion/trapping were used to obliterate unruptured IC-cavernous large/giant aneurysms and ruptured IC anterior wall aneurysms. One patient with ruptured VA-union dissecting aneurysm was successfully treated with vertebral-posterior cerebral artery high-flow bypass (V3-RA-P2) in combination with bilateral VA proximal occlusion. Three ruptured middle cerebral artery (MCA) and 1 distal anterior cerebral artery (ACA) aneurysms were obliterated in association with M2-RA-M2, STA-M2, A3-A3 bypasses preserving the parent artery. Postoperatively, no ischemic or hemorrhagic complications was observed, and all bypasses have remained patent with a mean follow-up period of 3.5 years.
    Adequate vascular reconstruction is effective in the treatment of complex aneurysms.
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  • Hisato NAKAYAMA, Shoichi KATO, Masami FUJII, Tatsuo AKIMURA, Koji KAJI ...
    2008 Volume 36 Issue 4 Pages 277-282
    Published: 2008
    Released on J-STAGE: August 25, 2009
    JOURNAL FREE ACCESS
    The long-term outcomes of aneurysms occluded by clipping are unclear. The present study investigated 5 females aged from 45 to 72 years old (mean 63.6 years) admitted for treatment of recurrent subarachnoid hemorrhage (SAH) 7 to 19 years (mean 9.8 years) after clipping of internal carotid artery-posterior communicating artery (ICA-PCoA) aneurysms, which had caused SAH in 3 patients and were unruptured in 2 patients. Angiography delineated the well-developed PCoA in all patients. Clips had been applied to the aneurysm neck parallel to the ICA trunk at the initial surgery in 3 patients. An additional clip could be applied to the recurrent aneurysm without removal of the first clip in 2 patients, but the original clip had to be removed before reclipping in the other 3 patients. Adhesive materials and Bem-sheet used at the initial operation hindered dissection of the recurrent aneurysm from the surrounding arteries in 1 patient, resulting in infarction in the area of the PCoA perforating arteries. This study suggests that the method of clipping is very important for ICA-PCoA aneurysm, particularly the direction of clip application to the ICA trunk, and the avoidance of unnecessary or excessive wrapping of the residual neck.
    We recommend that neuroimaging follow-up of recurrent aneurysms in patients with a history of clipped aneurysm, especially ICA-PCoA aneurysm, be continued as long as possible.
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  • Teruo KIMURA, Rokuya TANIKAWA, Hajime WADA, Kazutsune KAWASAKI, Naoto ...
    2008 Volume 36 Issue 4 Pages 283-287
    Published: 2008
    Released on J-STAGE: August 25, 2009
    JOURNAL FREE ACCESS
    Because of the recent development of high-performance 3-dimensional computed tomography (3D-CTA), magnetic resonance angiography (MRA) and the consideration of the risk of digital subtraction angiography (DSA), DSA is not always necessary in performing surgery for cerebral aneurysms. However, DSA was necessary in patients in whom the ophthalmic artery from the internal carotid artery (IC) was not visualized on 3D-CTA or MRA, in order to predict the risk of blindness after front-temporal craniotomy.
    In this study, we investigated the preoperative evaluation and the surgical procedure for 330 cases of front-temporal craniotomy for surgery of aneurysm over the past 4.5 years. There were 5 cases without ophthalmic artery from IC in DSA or 3D-CTA, 4 cases with an anomalous ophthalmic artery arising from the middle meningeal artery and 1 case with an anomalous ophthalmic artery arising from unknown origin. Microsurgical procedure is needed to preserve the middle meningeal artery in front-temporal craniotomy in these cases with an anomalous ophthalmic artery arising from the middle meningeal artery, because this anomaly places the ophthalmic artery at risk during procedures in which the dura is elevated from the greater and lesser wings of the sphenoid or when the sphenoid ridge is removed in front-temporal craniotomy.
    Front-temporal craniotomy is difficult in cases with an anomalous ophthalmic artery arising from an unknown origin.
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  • Kazuhito NAKAMURA, Toshihiro YASUI, Hidetoshi IKEDA, Tomoya ISHIGURO, ...
    2008 Volume 36 Issue 4 Pages 288-293
    Published: 2008
    Released on J-STAGE: August 25, 2009
    JOURNAL FREE ACCESS
    In microneurosurgery, one of the most important instruments is the suction instrument. In a right-handed surgeon, the suction instrument is usually held in the left hand during microneurosurgery. However, the basic techniques for using this important instrument have not been discussed very much. The basic techniques of the suction instrument are classified into 6 groups: 1) suction of blood and cerebrospinal fluid, etc., 2) retraction (a: ipsilateral retraction, b: contralateral retraction, c: space holding), 3) suction and holding, 4) compression for hemostasis, 5) dissection, 6) water irrigation. The retraction techniques especially are more difficult for the beginner than for experts in microneurosurgery. Because retraction with the suction instrument is difficult, it is important to master the technique for the dissection of the sylvian fissure, the tumor from the surrounding structures and the aneurysmal neck.
    Beginners will perform microneurosurgery safely and reliably when they have mastered the use of suction techniques.
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  • Taro NIMURA, Akiko NISHINO, Ichiro SUZUKI, Akihiro UTSUNOMIYA, Shinsuk ...
    2008 Volume 36 Issue 4 Pages 294-297
    Published: 2008
    Released on J-STAGE: August 25, 2009
    JOURNAL FREE ACCESS
    The timing of aneurysmal surgery in patients within the period of vasospasm is controversial. In this study we review our experience of surgically treated patients.
    From April 1996 to March 2006, 529 patients presented with an aneurysmal subarachnoid hemorrhage (SAH) and were treated with early surgery. We retrospectively analyzed the patients that had been admitted to our hospital during day 5 to 13 after first the attack of SAH called the subacute operation group. In this study, angiographic vasospasm was characterized in terms of vessel narrowing of less than 50%, and symptomatic vasospasm was diagnosed when a decreased level of consciousness and/or focal deficit occurred after SAH in the presence of angiographic vasospasm without confounding factors. Functional outcomes were assessed on discharge using the Glasgow Outcome Scale (GOS). We also statistically compared the subacute operation group and the overall group in which an aneurysmal surgery was performed within 3 days after onset in the same period.
    Of 13 patients studied, 84.6% were in good clinical grade Hunt & Hess (H&H 1-2) on admission. Intermediate grade: 7.7% (H&H 3); poor grade: 7.7% (H&H 4-5). The good grade in the subacute operation group was significantly more frequent than that in the overall group (p<0.05). Surgery was performed within 24 hours after admission in 92.3% of patients and less than 48 hours in 100%. Preoperative angiographic vasospasm was diagnosed in 15.4%, and no symptomatic vasospasm was observed. Postoperatively, angiographic vasospasm was documented in 23.1% and symptomatic vasospasm in 7.7%. The presence of postoperative angiographic and symptomatic vasospasm in the subacute operation group was similar to that in the overall group. The functional outcome was 84.6% in good recovery, 7.7% in severely disabled and 7.7% in vegetative survival. GOS in the subacute operation group was more favorable than that in the overall group (p<0.05).
    Aneurysmal surgery between day 5 and 13 after SAH is not necessarily contraindicated and might enable optimal treatment of vasospasm in patients in good clinical grade.
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  • Masatou KAWASHIMA, Hiroyuki HAGIWARA, Kenji NAKAYAMA, Kenichi UEMURA, ...
    2008 Volume 36 Issue 4 Pages 298-305
    Published: 2008
    Released on J-STAGE: August 25, 2009
    JOURNAL FREE ACCESS
    Most distal anterior cerebral artery (ACA) aneurysms arise at the pericallosal-callosomarginal (PC-CM) junction, which is usually located in the A3 segment of the ACA around the genu of the corpus callosum. PC-CM aneurysms are divided into 2 types according to their location: supracallosal and infracallosal. Infracallosal distal ACA aneurysms are defined as those located in the lower half of A3, thus making it more difficult to gain proximal control. In this study, we examined the microsurgical anatomy of the distal ACA region, focusing especially on the relationship between the pericallosal and callosomarginal arteries located in the lower half of the A3 (infracallosal) segment, and present the surgical strategy for dealing with distal ACA aneurysms.
    The microsurgical anatomy of the distal ACA region was examined in 22 adult cadaveric cerebral hemispheres after perfusion of the arteries and veins with colored silicone. The relationships of the infracallosal segment of the pericallosal to the callosomarginal was examined. The distance between the nasion and the site at which a parallel line directed along the long axis of the infracallosal peri-
    callosal artery just proximal to the origin of the callosomarginal artery crosses the forehead (PC point) was also measured. Surgical approaches to distal ACA aneurysms were examined in stepwise dissections and applied to 2 clinical cases.
    The PC-CM junctions were located in the supracallosal and infracallosal segments of A3 in 36% and 55% of cases, respectively. In the infracallosal region, it is difficult to identify the proximal pericallosal artery and to establish proximal control of the vessel. The infracallosal part of the proximal pericallosal artery courses almost parallel to the frontal cranial base, and the PC point was 42.2±15.9 mm from the nasion. These findings indicate that there is only a limited space to access an infracallosal distal ACA aneurysm below the PC point and establish proximal control by the anterior interhemispheric approach. When the approach is made above the PC point, an anterior callosotomy prior to final aneurysm dissection and clipping may be necessary to establish proximal control. The PC point is an important surgical landmark in planning the surgical strategy for infracallosal distal ACA aneurysms.
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  • Naoto KUNII, Tomohiro INOUE, Kazuo TSUTSUMI
    2008 Volume 36 Issue 4 Pages 306-310
    Published: 2008
    Released on J-STAGE: August 25, 2009
    JOURNAL FREE ACCESS
    Carotid endarterectomy is still the standard treatment of carotid stenosis even after the introduction of CAS. However, due to the inherent difficulty of this operative technique, as well as the limited volume of surgical cases, it is quite difficult for young surgeons to master the CEA. To overcome this difficulty, we constructed a detailed and sophisticated procedual protocol of CEA. Under this protocol and the supervision of the senior author (K.T.), 7 senior residents performed 112 cases of CEAs between April 2004 and March 2007. The result of 112 cases were acceptable compared to those of large clinical studies to date. To pass the standard CEA technique across generations, a detailed and sophisticated surgical protocol is extremely effective, and the surgical result does not depend on who the surgeon is but on who the supervisor is and what the procedual protocol is.
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Case Reports
  • Atsushi UYAMA, Masato SASAKI, Mitsuru IKEDA, Masahiro ASADA
    2008 Volume 36 Issue 4 Pages 311-315
    Published: 2008
    Released on J-STAGE: August 25, 2009
    JOURNAL FREE ACCESS
    We report a case of dissecting aneurysm of the vertebral artery (VA)-posterior inferior cerebellar artery (PICA) with subarachnoid hemorrhage (SAH) and cerebellar infarction coincidentally. A 40-year-old man presented with severe cervical pain with subsequent serious disturbance of consciousness. CT on admission showed SAH mainly in the posterior fossa, and magnetic resonance imaging (MRI) revealed acute infarction in the left cerebellar hemisphere. Angiography, 3D CT angiography and MRI showed no obvious bleeding source.
    He underwent suboccipital external decompression due to progressive brain edema resulting from the cerebellar infarction. Three weeks later, follow-up angiography revealed a stenotic lesion at the left PICA. Proximal clipping of the left VA proximal to the left PICA was planned under the diagnosis of a dissecting aneurysm. Intraoperative findings revealed an aneurysm at the left VA proximal to the left PICA. The aneurysm dome had a surface dimple with circumferential hematoma, which seemed to be the bleeding source. Trapping of the aneurysm was performed. The patient was discharged with slight cerebellar ataxia.
    We suggest that some dissecting vertebral aneurysms may induce subarachnoid hemorrhage and infarction coincidentally.
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  • Ken KAZUMATA, Katuyuki ASAOKA, Syunsuke TERASAKA, Kouji ITAMOTO, Yuka ...
    2008 Volume 36 Issue 4 Pages 316-323
    Published: 2008
    Released on J-STAGE: August 25, 2009
    JOURNAL FREE ACCESS
    We describe intracranial bypass options employed in direct clipping of the large cerebral aneurysm. The bypass techniques used included STA-MCA bypass (n = 2), radial artery graft (n = 2), ACA-ACA side to side (n = 1), and STA-PCA, STA-SCA bypass (n = 1).
    We consider the options of vascular reconstruction prior to manipulation of the aneurysm when the patency of the parent artery is unpredictable.
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