The safety and efficacy of the ultrasonic scalpel (Harmonic Scalpel; Ethicon Endo-Surgery, Cincinnati, OH) for carotid endarterectomy (CEA) were evaluated.
Material and Methods: CEA was performed in 28 consecutive patients (27 men, 1 woman; mean age, 72 years) using the ultrasonic scalpel from April 2011 to October 2012. Eighteen cases involved high-position stenosis. Mean percentage stenosis was 78%. Complications were compared to those in 27 consecutive cases treated without the ultrasonic scalpel, performed prior to March 2011.
Results: One patient treated using the ultrasonic scalpel suffered ischemic complication (not significant). No patient using the ultrasonic scalpel died (not significant). Five patients treated using the ultrasonic scalpel showed increased signal hyperintensity on postoperative diffusion-weighted magnetic resonance imaging (not significant). Four patients treated using the ultrasonic scalpel suffered transient hoarseness, including 1 patient with recurrent nerve paralysis (not significant). However, only 3 of the 18 patients treated using the ultrasonic scalpel with high-position stenosis suffered transient hoarseness, showing a significant decrease compared to the 6 of 11 patients with high-position stenosis treated without the ultrasonic scalpel (P<0.05).
Discussion: The ultrasonic scalpel reportedly causes less heat injury to vessels than electrocautery, which may account for the reduced number of complications caused by temporary damage to the superior laryngeal nerve.
Conclusion: The ultrasonic scalpel is a useful tool for CEA, particularly for high-position stenosis.

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Bow hunter’s syndrome (BHS) is a rare condition resulting from mechanical occlusion or stenosis of the vertebral artery (VA) during head rotation. We report herein a case of BHS in a 54-year-old woman who complained of dizziness, paresthesia, and weakness of the right extremities on rotation of the head by ≥60° to the right. Cervical radiography, magnetic resonance (MR) imaging, MR angiography and carotid Doppler ultrasonography of the neck in the neutral position revealed no abnormality. After rightward rotation of the head by 60°, end-diastolic flow in the left VA disappeared and peak systolic velocity gradually decreased. We diagnosed BHS and treated the patient conservatively. Four-dimensional computed tomography (CT) angiography proved that symptoms were attributable to severe mechanical compression with stenosis of the left VA at the C1-C2 level during rightward rotation of the head. Four-dimensional CT angiography is sufficiently effective for evaluation of hemodynamics and anatomical correlations with surrounding organs. For diagnosis of BHS, intra-arterial digital subtraction angiography (IA-DSA) is undoubtedly the gold standard; however, unlike CT angiography, IA-DSA is an invasive method. To the best of our knowledge, this represents the first report describing the usefulness of four-dimensional CT angiography for diagnosis of this uncommon condition.

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We describe the case of a patient who was born through vacuum extraction at a gestational age of 40 weeks. Birth weight was 2714 g and Apgar score was 9. On the day of birth (Day 1), she was transferred to our neonatal intensive care unit due to poor feeding, frequent vomiting, and cyanosis. Echo imaging of the brain showed a hypoechoic area in the left posterior fossa, obstruction of the cerebral aqueduct due to anterior displacement of the cerebellum, and dilation of the cerebral ventricles. Computed tomography (CT) of the head indicated the presence of a high-density lesion in the same fossa, and posterior fossa subdural hematoma was therefore diagnosed. She was then transferred to another hospital for surgery. Oral feeding improved after surgical removal of the hematoma, and she was discharged on day 17. Early diagnosis of posterior fossa subdural hematoma is important, as the condition of affected patients may rapidly deteriorate, potentially resulting in death. Studies have reported the difficulty of detecting hematomas in the posterior fossa using brain echo imaging, as well as the utility of head magnetic resonance imaging and CT for definitive diagnosis. However, based on the findings in this case, we believe that the presence of a hypoechoic area in the posterior fossa, displacement of the cerebellum, and ventricular dilatation on brain echo imaging are essential in making a diagnosis of posterior fossa subdural hematoma.

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Reports on findings from carotid ultrasonography vary among individual hospitals. In 2008, Shimane University Hospital converted its paper-based records of carotid ultrasonography to an electronic format. The format for reporting the findings of carotid ultrasonography was constructed with the cooperation of the departments of diabetic internal medicine, neurology, and neurosurgery, focusing on the perioperative management of carotid artery stenting. B-mode ultrasonography was used to measure vessel diameter, maximum intima-media thickness of bilateral arteries (common carotid artery, carotid bulb, internal carotid artery, and vertebral artery), total plaque score, and rate of stenosis in the internal carotid artery. Doppler mode was used to measure peak systolic flow velocity, end-diastolic flow velocity, and resistance index. The most important issue was the sonographer’s impression. The schema drawn by the sonographer using a built-in drawing tool was very useful for enabling the attending physician to understand the patient’s carotid situation, although this was somewhat time-consuming. The greater the increase in the number of carotid ultrasound examinations, the more time needed to draw such a schema. The development of carotid ultrasound reporting is ongoing, and more sophisticated approaches are needed.

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We aimed to discuss the current reporting systems for carotid ultrasonography used in Japan, with a view to achieving further improvement. Our hospital performs carotid artery ultrasonography mainly in patients with cerebrovascular disease. The common, internal and external carotid arteries, and vertebral artery are routinely examined. We measure plaque score, properties of plaque, maximum intima-media thickness and end-diastolic ratio, in addition to stenosis ratio (i.e., diameter ratio, NASCET, and ECST methods), area of stenosis, and peak systolic velocity at the point of stenosis. Transcranial sonography is employed to measure middle cerebral artery and basilar artery blood flow velocities, and to evaluate substantia nigra hyperechogenicity for Parkinsonian disorders. Sonographic examinations of the temporal artery for temporal arteritis, lower extremity, and aortic arch are performed as needed. We use two types of reports: hand-written and electronic. Electronic reports are useful and linked to the electronic medical record; however, they are also time-consuming. Therefore, we mainly use handwritten reports, which are suitable for describing and delineating the status of carotid plaque in detail. We discuss herein the merits and deficits of the types of carotid ultrasonography used in our and other facilities in order to develop the most appropriate methods for reporting.

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