Vagus nerve stimulation (VNS) is a surgical treatment of epilepsy. The cervical course of left vagus nerve originates from jugular foramen and descends at deep lateral side along with left common carotid artery (CCA), then changes to superficial anterior side, and this location varies by individual. Ultrasound could preoperatively identify the anatomical assessment of vagus nerve, which could be helpful for surgeons. In this study, we tried to evaluate preoperative vagus nerve location with ultrasound. From January 2012 to October 2022, every patient who underwent VNS in our institution was enrolled. With ultrasound, vagus nerve crossing point from deep lateral to superficial anterior was classified into 3 types according to location based on sternocleidomastoid (SCM), when crossing point was in upper half of SCM: high type, when within bottom third quarter of SCM: middle type, and when lower than bottom fourth quarter of SCM: low type. We enrolled 23 patients who underwent VNS. Mean age (±SD) was 28.4±12.9, and 13 patients (57%) were male. Two patients (8.7%) were high type, 5 patients (21.7%) were middle type, and 16 patients (69.6%) were low type. Of all patients, intraoperative vagus nerve locations corresponded with preoperative ultrasonography findings. The crossing point of left vagus nerve from deep lateral to superficial anterior side varied by individual and ultrasound could preoperatively identify the location. Preoperative anatomical knowledge of vagus nerve with ultrasound is essential for VNS surgeons.

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A woman in her 20s fell down during cheerleading practice and she was referred to our neurosurgical outpatient clinic the next day due to persistent headache, neck pain, and dizziness. Neurological examination showed left upper limb paresis. MRI revealed a remarkably dilated flow void along the dural sac on the left side between C2 and C3 levels. Cerebral angiography confirmed a shunt from the left vertebral artery to the vein. Preoperative ultrasonography showed that the diameter of the left vertebral artery was markedly dilated to 10mm, and the blood flow volume between the cervical vertebrae was 1,873ml/min. Retrograde flow was detected in the distal part of the left vertebral artery using the foramen magnum approach. The patient underwent coil embolization of the left vertebral arteriovenous fistula and the shunt blood flow was significantly reduced. Ultrasonography performed the day after embolization revealed the blood flow volume of 748ml/min, and the retrograde flow in the left vertebral artery remained. On the seventh postoperative day, the blood flow volume was 135ml/min, and the peripheral left vertebral artery had changed to antegrade flow. On the 90th postoperative day, the blood flow volume was 95ml/min, and vertebral angiography at the same time showed that shunt blood flow had disappeared. Vascular ultrasound was useful in the preoperative evaluation and follow-up of vertebrobasilar arteriovenous fistula.

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Introduction: For patients with acute intracranial hemorrhage during warfarin therapy, there is no guideline for the use of 4-factor prothrombin complex concentrate (4F-PCC) at a PT-INR less than 2.0.
Purpose/Methods: We retrospectively investigated the appropriate dose of 4F-PCC in 11 consecutive patients with intracranial hemorrhage, 8 with intracerebral hemorrhage and the other 3 with acute subdural hematoma.
Results: The median PT-INR before and after administration of 4F-PCC was 1.80 (range 1.49–1.93), and 1.13 (range 1.03–1.42), respectively. In nine patients with PT-INR < 1.30 after administration, median 19.1 IU/kg (14.5–23.8) of the 4F-PCC was given while in the other two patients with PT-INR was 1.42 and 1.30 after correction, 4F-PCC of 10.5 and 19.5 IU/kg were administered, respectively. Hematoma enlargement was observed in 2 cases with PT-INR < 1.30 after correction. No thromboembolism occurred after the 4F-PCC administration. No deaths were observed.
Conclusions: It seems that 4F-PCC of 14.5–23.8 IU/kg is safe and effective to achieve PT-INR < 1.30 in patients with intracranial hemorrhage during warfarin therapy and PT-INR < 2.0.

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