Introduction: The ultrasonic scalpel (Harmonic Scalpel; Ethicon, CO) can peel arteries from collagen-poor tissues, including adipose tissue, without damage to the arteries themselves. This procedure has been applied to skeletonization such as of an internal thoracic artery in the field of cardiac surgery and has become widespread. We have recently performed harvesting of the superficial temporal artery (STA) using an ultrasonic scalpel for bypass surgery, but reports of such procedures in the neurosurgical field has been rare. We herein investigated histological changes to the STA for safety assessment.
Material and Method: Bypass surgery was performed in 15 consecutive patients (mean age, 62 years; range, 34-80 years; atheroma, n=10; moyamoya disease, n=3; arterial dissection, n=2) from January 2012 to February 2014. Twenty-two STA specimens were peeled using the ultrasonic scalpel and evaluated histologically.
Results: Degeneration of the vascular wall was found in adventitia to media in 1 specimen (5%), and adventitia alone in 4 specimens (18%). No specimens showed intimal degeneration (0%).
Conclusion: STA harvesting by ultrasonic scalpel can be performed safely, although thermal injury was histologically evident in 23% of the 15 cases (22 specimens) examined. Some mastery of skills is needed for further safety.

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Purpose: An increased prevalence of patent foramen ovale (PFO) has been reported in patients with migraine with aura compared with non-migraine subjects. This study aimed to investigate the prevalence of PFO in Japanese patients with migraine.
Methods: Fifty-four consecutive patients with migraine were recruited from the headache outpatient clinic of our department. Migraine was diagnosed according to the International Classification of Headache Disorders, second edition. Patients were divided into migraine with aura (MWA) and migraine without aura (MWOA) groups. Transcranial ultrasound was performed, while contrast agent was injected intravenously with the Valsalva maneuver. PFO was diagnosed if micro-embolic signals in the right middle cerebral artery were identified soon after injection of contrast agent and Valsalva load release.
Results: No significant differences in patient characteristics were observed between the MWOA group (n=22) and MWA group (n=32). The prevalence of PFO was 46.3% among all migraine patients, 56.3% in the MWA group, and 31.8% in the MWOA group. Patients with MWA thus tended to show a higher prevalence of PFO compared to those with MWOA (p = 0.077).
Conclusion: The tendency toward an increased prevalence of PFO in the MWA group in this study suggests a possible association between MWA and PFO.

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Introduction: Pediatric patients presenting with head masses are not rare. However, it is difficult to make a diagnosis based solely on clinical findings. Although CT or MRI can be used for diagnosis, the former has problems associated with radiation exposure. In addition, pediatric patients must be sedated for examination using these methods. Ultrasonography can be performed easily at the bedside, and using a high-frequency probe, it is possible to obtain high-resolution images that surpass MRI images. Here, we report the usefulness of ultrasonography for the diagnosis of superficial soft-tissue head lesions in two children.
Case 1: A 6-month-old girl was referred to our hospital due to a pulsatile mass in the midline of the occipital region. Ultrasonography showed a compressible, hypoechoic, tubular structure, and its vascular communication between the superior sagittal sinus and extracranial vessel through the cranial defect was detected by the color Doppler method. A diagnosis of sinus pericranii was made.
Case 2: A 7-month-old boy was referred to our hospital due to a swelling in the right temporal region. Scalp hematoma and skull fracture were confirmed by ultrasonography. The patient was closely observed without treatment until the fracture healed.
Conclusions: Ultrasonography is useful in the diagnosis of superficial soft-tissue head lesions in children. As ultrasonography can be performed repeatedly and noninvasively, it is useful not only for diagnosis, but also for follow-up.

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Purpose: Peripheral artery disease (PAD) is known to be related to atherothrombotic brain infarction (ATBI). Atherothrombosis (ATIS) is a complex process wherein thrombus formation occurs via atherosclerosis. This study aimed to investigate the relationship between stenotic segments in PAD and either ATBI or transient ischemic attack (TIA).
Methods: We performed ultrasonography in 148 patients with suspected PAD (86 men; mean age, 77.8±7.9 years). PAD was classified according to region into iliac, femoro-popliteal, and below-knee. Correlations with ATBI and TIA were analyzed. Odds ratio (OR) and 95% confidence interval (CI) were calculated with multivariate logistic regression analysis. Adjustment factors were age, sex, smoking history, hypertension, diabetes mellitus, and dyslipidemia.
Results: Multivariate logistic regression analysis revealed femoro-popliteal region (OR, 3.298; 95%CI, 1.691-5.983) and diabetes mellitus (OR, 2.265; 95%CI, 1.564-4.628) as independent predictors of ATBI or TIA.
Conclusion: Stenosis in the femoro-popliteal region in PAD is a risk factor for ATBI or TIA.

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Mobile lesions of the carotid artery, which can generally be found by ultrasonography (US), are treated as unstable plaque. Mobile lesions ≥2 mm in diameter were observed for 7 patients (6 men, 1 woman) treated in our hospital between January 2002 and July 2015. Mean age was 67.8 years (range, 52-84 years). Diagnosis was major stroke in 1 patient and transient ischemic attack/minor stroke in 6 patients. Surgical treatment was performed in 6 cases: carotid endarterectomy in 4 and carotid artery stenting in 2. The remaining patient did not undergo surgery because of a marked reduction in size of the mobile lesion after observation for 5 days. Surgical intervention was performed at a mean of 20 days (range, 1-52 days) after onset. None of the 6 operated patients had any complications pre- or postoperatively. We proposed four mechanisms for mobile lesions on imaging, based on pathological findings and responses to antithrombotic therapy: floating plaque entangled with ulcer edge; mobile thrombus adherent to ulcer edge or erosion of the plaque; pulsatile dissected arterial wall; and oscillating lodged embolus in the carotid artery. Choosing the operative procedure and timing in accordance with the underlying mechanism is important.

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Purpose: Deep venous thrombosis (DVT) is an important complication for stroke patients, often causing fatal pulmonary thromboembolism. However, factors related to DVT in stroke patients remain unclear. We evaluated factors contributing to DVT in patients with acute stroke.
Methods: Our study included 71 patients with acute-stage stroke, comprising 58 patients with cerebral infarction and 13 patients with cerebral hemorrhage. DVT was diagnosed by ultrasonography within 2 weeks of stroke onset. Associations of DVT with laboratory parameters such as D-dimer and BNP levels, and clinical factors including age, stroke type, level of consciousness, lower limb score of National Institute of Health Stroke Scale (NIHSS), and antithrombotic therapy were assessed.
Results: Among 71 patients with acute stroke, DVT was found in 14 patients. Level of lower limb palsy and D-dimer were significantly higher in the DVT group than in the non-DVT group. Univariate logistic regression analysis revealed NIHSS score ≥2 was associated with increased risk of DVT with an odds ratio of 7.68 (p=0.0117).
Conclusions: Our study results suggest lower limb palsy as a predictor of DVT in patients with acute stroke.

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Purpose: The aim of this study was to investigate the usefulness of ultrasonography (US) in carotid artery stenting (CAS) using Mo.Ma Ultra.
Methods: We included 49 consecutive patients who underwent CAS using Mo.Ma Ultra. Thirty-five patients underwent US examination during Mo.Ma Ultra (US group), and the other 14 patients did not (non-US group). In the US group, blood flow in the internal carotid artery was examined by color Doppler US after application of the Mo.Ma Ultra protection system. If flow stasis was not achieved by Mo.Ma Ultra alone, we adopted the distal protection system. Between the US and non-US groups, we compared the number of high-intensity spots on diffusion-weighted imaging (DWI) after CAS.
Results: The frequency of patients showing <4 high-intensity spots on DWI after CAS using Mo.Ma Ultra alone was significantly higher in the US group (100%) than in the non-US group (62.5%, p=0.021).
Conclusions: Intraoperative ultrasonography is useful when using Mo.Ma Ultra from the perspective of determining whether to use an additional protection device.

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Purpose: The purpose of this study was to determine the most suitable laser irradiation start position for endovenous laser ablation (EVLA) of the small saphenous vein.
Methods: Ultrasonography (US) was used to evaluate 78 patients (151 limbs) with lower limb varices at our hospital. The distances between the tibial nerve and small saphenous vein were measured at 20-mm intervals (20, 40, 60, and 80 mm) distal to the sapheno-popliteal junction (SPJ) in 112 of the limbs. The remaining 39 limbs were excluded because the small saphenous vein did not branch off from a deep part of the vein due to a congenital abnormality.
Results: The small saphenous vein and tibial nerve were immediately adjacent in 98/112 limbs at the SPJ (1.0±3.3 mm), in 25/112 limbs 20 mm distal to the SPJ (3.9±3.7 mm), in 4/112 limbs 40 mm distal to the SPJ (7.5±3.8 mm), and in none of the limbs 60 mm and 80 mm distal to the SPJ.
Conclusion: We recommend points 20 to 40 mm distal from the SPJ as landmarks for the laser irradiation start position for EVLA of the small saphenous vein, because this is where the tibial nerve stops being adjacent to the small saphenous vein.

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Intravenous immunoglobulin therapy (IVIg) has been used to treat patients with a wide range of neuromuscular diseases, but may carry a risk of causing or exacerbating deep venous thrombosis (DVT) in the lower extremities. To investigate whether IVIg induces DVT, we retrospectively reviewed patients with neuromuscular disease who had received IVIg. Medical records of patients with neurological disorders administered IVIg between January and October 2014 were reviewed. Of 66 patients who received IVIg, 14 underwent ultrasonography. DVT was detected in 3 patients (4.5%): after IVIg in 2; and before IVIg in 1. Activities of daily living were impaired in all 3 patients due to neurological symptoms. All received immediate anticoagulation and achieved favorable outcomes without any thromboembolic events, demonstrating regression or organization of DVT on repeat ultrasonography. When conducting IVIg in patients with neuromuscular diseases, clinicians should monitor changes in clinical symptoms or markers of fibrinolytic activity such as D-dimer to detect DVT early.

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A 77-year-old man with a history of radiation therapy for pharyngeal cancer and consequent asymptomatic left common carotid artery (CCA) occlusion showed asymptomatic ischemic stroke and left transient monocular blindness, and he was admitted to our hospital. He was found to have an indication for bypass surgery because of a remarkable reduction in cerebral blood flow in the ipsilateral middle cerebral artery (MCA) territory. Carotid ultrasonography revealed retrograde blood flow of the ipsilateral external carotid artery (ECA) and a U-turn phenomenon to the internal carotid artery (ICA). Cerebral angiography demonstrated spontaneous bonnet bypass flow from the right superficial temporal artery (STA) to the left STA, but the blood flow via the bypass was not enough to supply the left MCA. Bypass surgery to anastomose the bonnet bypass to the left MCA was performed, and postsurgical cerebral blood flow to the ipsilateral MCA territory improved. On STA duplex ultrasonography (STDU), the pulsatility index value of the contralateral STA changed from an ECA pattern before surgery to an ICA pattern after. Moreover, postsurgical mean flow velocity of the bonnet bypass to the left MCA was relatively higher than the presurgical retrograde mean flow velocity of the left STA. These ultrasonographic findings correlated with those on single photon emission computed tomography (SPECT) and cerebral angiography. As demonstrated in the present case, ultrasonography including STDU is useful in the evaluation of cerebral hemodynamics before and after cerebral artery bypass surgery and in the usual STA-MCA anastomosis.

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A 60-year-old Japanese man who had undergone stent treatment for stenosis of the left carotid artery received another stent 5 months later to treat a stenotic region of the left vertebral arterial origin. Color flow ultrasonography of the carotid artery before the second stenting procedure revealed good blood flow without any defects in the previous stent. However, the day after implantation of the vertebral arterial stent, carotid color flow ultrasonography identified a new low-echoic mobile structure at the left carotid stent. This structure was diagnosed as thrombus after showing a marked decrease in size after starting anticoagulant therapy. We speculate that the coagulation system, promoted by stent implantation at the vertebral arterial origin, contributed to thrombus formation in the stent at the left carotid artery. Carotid color flow ultrasonography was helpful for detecting low-echoic mobile thrombus in a carotid stent in the present case, and may prove useful for similar future cases.

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In carotid ultrasonography, it has been emphasized that the existence of ramifications is an important differential finding between the external carotid artery (ECA) and the cervical internal carotid artery (CICA). We report the case of a patient with an abnormal artery originating from the CICA accompanied by hypoplastic vertebrobasilar arteries (VBA) who developed a brainstem infarction.
The patient was a 73-year-old woman. In 2013, carotid ultrasonography showed an abnormal artery (diameter 2.2 mm, time-averaged maximal velocity 34 cm/s, pulsatility index 2.4) originating from the CICA that was located 2 cm distal from the right carotid bifurcation. In December, 2014, she developed paresthesia from the neck to the right ear, numbness of the right arm and leg, and right foot motor weakness. MRI showed an infarction in the rostral pons extending to the left midbrain. The abnormal artery that originated from the right CICA associated with the right primitive trigeminal artery and hypoplastic VBAs were confirmed by MRA.
This was a very rare case of an abnormal artery originating from the CICA. It is necessary to keep in mind that the presence of branching arteries cannot always be used in the differential diagnosis between the ECA and CICA in carotid ultrasonography.

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