Neurologia medico-chirurgica
Online ISSN : 1349-8029
Print ISSN : 0470-8105
ISSN-L : 0470-8105
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Volume 38, Issue suppl
Displaying 1-50 of 54 articles from this issue
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  • Aneurysm Geometry: An Important Criterion in Selecting Patients for Guglielmi Detachable Coiling
    Gerard M. DEBRUN, Victor A. ALETICH, Pierre KEHRLI, Mukesh MISRA, Jame ...
    1998 Volume 38 Issue suppl Pages 1-20
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_1
    JOURNAL FREE ACCESS
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    The study was aimed determine the criteria for treating cerebral aneurysms, ruptured and unruptured, suitable for endovascular Guglielmi detachable coiling (GDC) with least morbidity and mortality. We will discuss the importance of knowledge of the geometry of cerebral aneurysm and its impact on the results of coiling. We have treated 324 patients with cerebral aneurysms at the University of Illinois Hospital from May 1, 1994 to June 1997. During this period 139 patients were treated with GDC and 185 patients were treated surgically. Of 139 patients treated with coils 54 patients with 54 aneurysms were ruptured and the remaining 85 patients with 90 aneurysms were unruptured. For initial 25 patients, the selection of aneurysms for coiling was random and the geometry of the aneurysm was not considered as an important factor in the selection for coiling, however, in the later series of 114 patients with 119 aneurysms were selected for coiling only when the geometry looked favorable in the angiogram. With time we realized that the dome/neck ratio more than or equal to 2/1 and the diameter of the neck not ex-ceeding 5mm were most suitable for coiling. The initial series of 25 patients (May 1994 to February 1995) treated without taking geometry of the aneurysms as an important criteria for coiling led to high morbidity and mortality and less than 50% of these aneurysms were angiographically occluded at 6-month follow-up. In the second series of 114 patients (March 1995 to June 1997) with 119 aneurysms we had 0% mortality related to the coiling and only 1.8% permanent morbidity. We found complete aneurysm occlusion in 78% of the subarachnoid hemorrhage and 76% of unruptured group when the dome/neck ratio was more than or equal to 2/1. However, the occlusion rate dropped to 50% when the dome/neck ratio was less than 2/1. This preliminary experience suggests that GDC is a safe technique with low mortality-morbidity for the treatment of intracranial aneurysms in appropriately selected patients. The percentage of complete occlusion of the aneurysm following tight and dense packing is strongly dependent on the geometry of the aneurysm and we conclude that the best results are achieved when the dome/neck ratio is more than or equal to 2/1.
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  • Management of Intracranial Aneurysms by Surgical and Endovascular Treatment
    Modalities and Results from a Series of 395 Cases
    Guillaume LOT, Emmanuel HOUDART, Jean COPHIGNON, Alfredo CASASCO, Bern ...
    1998 Volume 38 Issue suppl Pages 21-25
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_21
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    The selective occlusion of saccular intracranial aneurysms may be achieved by two techniques: microsurgical clipping and endovascular coiling. Each of them have particular indications which need to be defined. From September 1992 to June 1996, 395 consecutive patients with small or large aneurysms were treated either by surgery (n=102) or by endovascular coiling (n=293). Coiling was chosen each time the shape of the aneurysm seemed to be appropriate for this treatment: narrow neck and ratio neck diameter by sac diameter less than one third.
    Satisfying results with complete or subtotal obliteration and no recanalization on the following con-trols at 1, 6, 12, and 36 months were obtained in 92% before retreatment and in 98.8% after retreatment. Unsatisfying results were observed after surgery in seven cases and in 25 cases after embolization. Af-ter retreatment, it remains three post-surgical and two post-endovascular cases. Good and excellent clin-ical outcome was noted in 90% for small aneurysms and in 86.5% for large ones. Mortality is of 4.8% in the overall series.
    In a series in which were applied both types of treatment, surgery in 25% and endovascular tech-niques in 75%, good results in terms of efficiency and clinical results were achieved. These results are as good as the best series in which surgery was the only choice. Therefore with appropriate selection, en-dovascular treatment is a good alternative for treatment of the majority of saccular aneurysms.
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  • Contribution of Guglielmi Detachable Coil Technique in the Treatment of Intracranial Aneurysms
    Fernando VINUELA, Gary DUCKWILER, Y. Pierre GOBIN, Guido GUGLIELMI
    1998 Volume 38 Issue suppl Pages 26-32
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_26
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  • Endoscope-assisted Microsurgery for Cerebral Aneurysms
    Axel PERNECZKY, Hans Gerd BOECHER-SCHWAZ
    1998 Volume 38 Issue suppl Pages 33-34
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_33
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    A total of 66 patients with intracranial aneurysms were endoscopically assisted treated during a 3 years period. Among those were five individuals with giant aneurysms and 27 patients with aneurysms of the posterior circulation. The endoscope was used only for checking the anatomical structures surround the aneurysms in 16 cases. In 43 patients the aneurysm sac was also dissected under endoscopical con-trol. Even the clipping procedure was performed in seven cases exclusively under endoscopical obser-vation. Only one prematural rupture occurred intraoperatively during preparation of a basilar tip aneurysm. Postoperatively three individuals with aneurysms located in the posterior circulation were temporarily neurologically impaired, and one patient with a basilar tip aneurysm suffered from a surgi-cal related hemiparesis. The use of an endoscope in aneurysm surgery improves the visualization of the aneurysm itself and the surrounding anatomical structures. This minimizes the retraction of the ner-vous structures and leads to a reduced morbidity.
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  • Role of a Perivascular Ultrasonic Micro-flow Probe in Aneurysm Surgery
    Fady T. CHARBEL, William E. HOFFMAN, Mukesh MISRA, Kelly HANNIGAN, Jam ...
    1998 Volume 38 Issue suppl Pages 35-38
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_35
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    There are various intraoperative monitoring devices available today for helping the neurosurgeons the progress of the intracranial aneurysm surgery. Till now the intraoperative ultrasonic blood flow probes has been used only in vascular, cardiac, and transplant surgery. In the University of Illinois at Chicago we have been able to use the same technology in various neurovascular surgeries. We describe the use of the ultrasonic perivascular blood flow probes in patients operated for clipping of intracranial aneurysm. The use of this perivascular micro-flow probe and its importance in cerebral aneurysm will be discussed.
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  • Titanium Aneurysm Clips: Mechanical Characteristics and Clinical Trial
    Tetsuya NAGATANI, Masato SHIBUYA, Keiji OOKA, Yoshio SUZUKI, Masakazu ...
    1998 Volume 38 Issue suppl Pages 39-44
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_39
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    Titanium clip is well documented to reduce the artifact observed in computed tomography (CT) or mag-netic resonance (MR) imaging and improve the quality of these images. There are, however, some de-merits based on metallic characteristics including large spring portions, lack of long and fenestration clips, and difficulties to produce. We examined the mechanical characteristics of Sugita titanium aneurysm clips (product of 6 aluminium-4 vanadium-titanium) and investigate the safety in clinical use and the imaging quality compared with those of cobalt (Co) alloy clips. On mechanical test, Sugita titanium clips showed no significant difference in closing force compared with the conventional Co al-loy clips. The closing force reduced about 10% after 100 times repeated opening in titanium clips in con-trast with no remarkable changes in Co alloy clips. Sixty-four patients with ruptured or unruptured cerebral aneurysms (total number of 71 aneurysms) were treated with Sugita titanium clips through the microsurgical technique. None of the unfavorable outcome occurred in related to the titanium clips. Neither clip dislocation nor deformation was experienced in this series during the follow-up period. The clip artifacts seen in CT and MR image were markedly reduced, however, MR angiography had less quality to resolve anatomical structures due to an existence of vessel gap. These results indicate that in spite of some disadvantages, Sugita titanium clips allow safe and beneficial use routinely in aneurysm surgery insofar as the complete clipping is obtained.
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  • Aneurysm Surgery in the Acute Stage
    Results of Structured Treatment
    Yasuhiro YONEKAWA, Hans Georg IMHOF, Nobuyoshi OGATA, Rene BERNAYS, Ya ...
    1998 Volume 38 Issue suppl Pages 45-49
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_45
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    To evaluate the results of a structured treatment approach to aneurysm surgery in the acute stage, 150 consecutive patients with aneurysmal subarachnoid hemorrhage were studied, including 46 males and 104 females; World Federation of Neurological Surgeons grade I: 21 cases, II: 65, III: 41, IV: 23; day of operation≤day 3:103 cases, ≤day 7:131. Patients underwent angiography on the day of admission or the next followed by surgery. The lamina terminalis and the membrane of Liliequest were routinely opened at surgery. The aneurysm neck was radically clipped after temporary clipping or trapping of the parent arteries. Intraoperative hemodynamic monitoring was used, and the craniotomies were closed without cisternal, epidural, or subgaleal drains. Nimodipine was given perioperatively (48 mg i.v./day for 10 to 14 days). Cases of symptomatic vasospasm were treated with selective intra-arterial adminis-tration of papaverine, sometimes combined with angioplasty. Outcome at discharge and 3 months later is good recovery in 61% and 75%, and death in 6% and 7%. The incidence of symptomatic vasospasm was 17%. Devastating vasospasms were observed in 5%. One-third of patients had mean flow velocities exceeding 120 cm/sec determined by transcranial Doppler sonography between days 4 and 14. Com-municating hydrocephalus necessitating ventriculoperitoneal shunt occurred in 9%. Our results clearly show a favorable outcome compared with previous reports, especially with respect to the reduced occur-rence of fatal vasospasm, hydrocephalus, and technical insufficiency.
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  • Surgical Management of Complex Middle Cerebral Artery Aneurysms
    Fernando G. DIAZ, Murali GUTHIKONDA, Lisa GUYOT, Bernard VELARDO, Vick ...
    1998 Volume 38 Issue suppl Pages 50-57
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_50
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    Complex middle cerebral artery (MCA) aneurysms are defined in this review as aneurysms larger than 20mm, arising from the MCA bifurcation, and requiring unusual surgical approaches for their oblitera-tion. The direct surgical approaches to complex MCA aneurysms can be divided into five techniques: 1) direct clipping, 2) trapping, 3) trapping and extracranial-intracranial anastomosis, 4) excision and end-to-end anastomosis, and 5) external wrapping. The pertinent surgical anatomy, preoperative prepara-tion, intraoperative procedures, operative approaches, and potential complications will be reviewed.
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  • Treatment and Results of Partially Thrombosed Giant Aneurysms
    Hirotoshi SANO, Yoko KATO, Krupa SHANKAR, Narimasu KANAOKA, Motoharu H ...
    1998 Volume 38 Issue suppl Pages 58-61
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_58
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    Partially thrombosed giant aneurysms are one of the most difficult diseases in the neurosurgical field. We have had 18 of these cases namely, three in vertebral artery, four in basilar artery, four in internal carotid artery, five in middle cerebral artery, and two in anterior communicating artery. Nine aneurysms were clipped, two aneurysms were removed with anastomosis, two cases were treated inter-ventionally, and five cases were treated conservatively because of serpentine and fusiform types of aneurysms in internal carotid artery bifurcation. These conservatively treated patients died due to in-farction. When surgery is selected in the thrombosed giant aneurysms, the approach is the most im-portant to secure the neck. Three-dimensional computed tomography angiography was useful to plan the strategy for surgery. If the neck is big enough for placement of a clip, arterial reconstruction is the choice. The reconstruction must be done including an adequate size of the artery because of the thick wall. If the aneurysm neck is too small to reconstruct, aneurysmectomy with anastomosis is one of the choices.
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  • Long-term Outcome of Surgical Treatment of Intracavernous Giant Aneurysms
    Isao DATE, Takashi OHMOTO
    1998 Volume 38 Issue suppl Pages 62-69
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_62
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    A number of approaches have been proposed for the treatment of intracavernous giant aneurysms. In the present study, we have analyzed long-term surgical outcome of 27 consecutive cases of our ex-perience. All the cases were unruptured and symptomatic, showing symptoms such as extraocular movement disorder or visual disturbances. Thirteen cases were male and 14 cases were female. The age of the patients ranged between 11 and 75 years (average 52.2 years) and follow-up periods were between 1 and 20 years (average 7.7 years). Abducens nerve was disturbed in 20 cases, oculomotor nerve in 12 cases, optic nerve in six cases, trigeminal nerve in six cases, and trochlear nerve in five cases. In addi-tion to conventional angiography, three-dimensional computed tomographic angiography, balloon test occlusion (BTO), slow injection angiography, aneurysmography, and single photon emission computed tomography with BTO were used to determine a method of treatment. Therapeutic modalities of the present series were as follows: four cases were unoperated, common carotid artery ligation was per-formed in eight cases, internal carotid artery (IC) ligation in three cases, IC ligation plus superficial tem-poral artery (STA)-middle cerebral artery (MCA) anastomosis in four cases, IC ligation plus high flow vein bypass in three cases, IC trapping plus STA-MCA anastomosis in three cases, and direct clipping in two cases. Although two cases showed early and late ischemic complications, other cases demonstrat-ed improvement of cranial nerve dysfunction relatively soon after surgical treatment and long-term outcome was generally good. It is concluded that good long-term surgical outcome is obtained for in-tracavernous giant aneurysms by selecting adequate surgical treatment based upon careful preopera-tive evaluation of these aneurysms using sophisticated diagnostic methods.
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  • Basilar Bifurcation Aneurysms
    Atos Alves de SOUSA
    1998 Volume 38 Issue suppl Pages 70-73
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_70
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    Direct operative management of basilar bifurcation aneurysms is one of the most challenging proce-dures in the realm of vascular neurosurgery, as these lesions are deeply situated in the interpeduncular region and maintain an intimate relationship with important anatomical structures. Direct clipping of aneurysms generally represents the gold standard of surgical treatment, as it allows exclusion of the aneurysmal sac from the circulation, evacuation of aneurysmal contents for decompression, and preser-vation of efferent flow. The author describes his experience with 123 operated patients of basilar bifur-cation aneurysms from January 1977 till December 1995. In these 123 consecutive surgeries the results were 85% good outcome, 8.1% morbidity, and 6.5% mortality. In the first years of this series the pterional or subtemporal approaches were used, depending on the level of the basilar bifurcation, the ex-act origin of the sac, its projection and size. From 1987 on all patients were operated by a modified pterional approach described initially by Sano as temporopolar approach.
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  • Technical Points to Improve Surgical Results in Cases with Basilar Tip Aneurysms
    Hideaki NUKUI, Shigeru MITSUKA, Tsutomu HOSAKA, Toshiyuki KAKIZAWA, To ...
    1998 Volume 38 Issue suppl Pages 74-78
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_74
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    Surgical results in 82 cases with aneurysm (61 ruptured and 21 unruptured) of the bifurcation of the basilar artery were analyzed and the causes of unfavorable outcome and its measures were discussed. Operation was performed in grade I, II, III, or IV of the Hunt and Kosnik's classification for the patients with ruptured aneurysm. Both in ruptured and unruptured cases, patient's age was not con-sidered. As it turned out, 10 elderly (70 years old or older) cases (8 ruptured and 2 unruptured) were in-cluded in this study. Unilateral pterional approach was adopted for all but one case, and temporary clip and/or division of the hypoplastic posterior communicating artery was actively used. Surgery was com-pleted with clipping of the aneurysm in all but six cases and overall surgical result consists of 70% of favorable outcomes. The main causes of unfavorable outcome were surgical procedures and primary brain damage due to subarachnoid hemorrhage. And the factors influenced to increase surgical techni-cal damage to the brain were the patient's age, size of the aneurysm, and/or height of the neck from bicli-noids line. The outcome of the higher grade (grade III or IV) in elderly cases was miserable, whereas it was not different from anterior circulation aneurysms in younger cases. From the result we concluded that the surgical indication for elderly cases should be limited in cases with lower grade (grade I or II) without large and/or high-positioned aneurysm. To obtain further improvement of the surgical result in younger cases, additional surgical techniques have to be considered to avoid the injury of perforating ar-teries from P1 and to reduce the pressure of the brain retraction which are the most important hazards for aneurysm surgery in this area.
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  • Factors Influencing Surgical Outcome of the Basilar Bifurcation Aneurysms
    Yuichiro TANAKA, Shigeaki KOBAYASHI, Kazuhiko KYOSHIMA, Hirohiko GIBO
    1998 Volume 38 Issue suppl Pages 79-82
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_79
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    To contribute to a better understanding of the clipping operation of the basilar bifurcation aneurysm, factors influencing the surgical outcome were analyzed in 80 patients. The age range of the patients was 34-74 years, with a mean age of 58.4 years, and there were 61 females and 19 males. Fifty-eight patients had been admitted because of subarachnoid hemorrhage and a basilar bifurcation aneurysm ruptured in 49 patients. The size of the aneurysms ranged between 2 and 19mm with a mean of 7.9±3.9mm. The height of the aneurysm neck was between -10 and 17mm measured above a biclinoid line with a mean of 4.8±5.2mm. Pterional approach was utilized in 72 patients and subtemporal in eight. Optic unroofing or removal of anterior clinoid process were performed in five patients, zygomatic osteotomy in 10, posterior clinoid removal in seven, and anterior petrosectomy in one. A bridging vein of the tem-poral lobe was divided in 16 patients. A short and/or hypoplastic posterior communicating artery was divided in 11 patients. Temporary occlusion of the basilar trunk was performed in 39 patients. Surgical outcome (Glasgow Outcome Scale) at 3 months after the operation was good recovery in 42 (53%), moderately disabled in 23 (29%), severely disabled in five (6%), vegetative survival in two (3%), and dead in eight (10%). The aneurysm size proved to be a single preoperative factor which significantly cor-related with the surgical outcome (Spearman's rank correlation test, p<0.0001). Division of the posterior communicating artery significantly contributed to the surgical outcome as an intraoperative factor (Mann-Whitney's U test, p=0.01). The larger the aneurysm size was, the more often the posterior communicating artery was sectioned. Extreme care should be taken to obliterate a large aneurysm with a clip graft especially when division of the posterior communicating artery is required.
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  • Giant Basilar Artery Aneurysms Encorporating the Posterior Cerebral Artery: Bypass Surgery and Coil Occlusion
    Two Case Reports
    Christian EWALD, Dieter KUHNE, Werner HASSLER
    1998 Volume 38 Issue suppl Pages 83-85
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_83
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    Giant aneurysms of the basilar artery are rare. With a diameter of 25 mm or more they are often partial-ly thrombosed and show atheromatous plaques. There are some problems in the treatment especially when the aneurysm is broadbased with bulbous origin encorporating the origin of the posterior cerebral artery (PCA). In many of these cases neither operative clipping alone nor coil embolization alone will be practical without causing an ischemia in the depending brain areas. We will report about two patients with giant aneurysms of the basilar artery involving the origin of the PCA and a combined surgical and interventional neuroradiological approach. Preoperatively both patients showed only mild neurologi-cal symptoms (slight left hemiparesis, incomplete hemianopsia). We anastomosed the superficial tem-poral artery as an extracranial-intracranial bypass end-to-side to the PCA followed by clipping the PCA out of the aneurysm. Next day embolization of the aneurysm with Guglielmi ditachable coils was done. Both patients recovered without complications. An angiographic control showed no more filling of the aneurysm and a free running bypass feeding the PCA. In our opinion this combined approach is an ef-fective method to treat giant aneurysms of the basilar artery which involve the origin of the PCA when clipping alone is impossible.
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  • Direct Surgery of Basilar Trunk and Vertebrobasilar Junction Aneurysms via the Combined Transpetrosal Approach
    Volker SEIFERT
    1998 Volume 38 Issue suppl Pages 86-92
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_86
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    Surgical access to aneurysms of the basilar trunk and vertebrobasilar junction is hampered by their direct proximity of these lesions to highly vulnerable neural structures like the brain stem and cranial nerves, as well by the bony structure of the petrous bone blocking the direct surgical approach to these aneurysms. Only recently lateral approaches directed through parts of the petrous bone have been reported for surgery of basilar trunk and vertebrobasilar junction aneurysms like the anterior trans-petrosal, the retrolabyrinthine transsigmoid, as well as the combined supra-infratentorial posterior transpetrosal approach. As experience in the use of this approach is limited in the neurosurgical litera-ture we present our surgical experiences in 11 patients with basilar trunk and vertebrobasilar junction aneurysms, operated on using the supra-infratentorial posterior transpetrosal approach. In 10 patients, including one patient with a giant partially thrombosed basilar trunk aneurysm, direct clipping of the aneurysm via the transpetrosal route was possible. In one patient with a giant vertebrobasilar junction aneurysm, the completely calcified aneurysm sac was resected after occlusion of the vertebral artery. Of the whole series, one patient died and in three patients postoperative accentuation of preexisting cranial nerve deficits occurred. Except transient cerebrospinal fluid leak in two patients, the postopera-tive course was uneventful in the remaining patients. Postoperative angiography demonstrated com-plete aneurysm clipping in ten patients and relief of preoperative brain stem compression in the patient with the giant vertebrobasilar junction aneurysm. It is concluded, that the supra-infratentorial posterior transpetrosal approach allows excellent access to the basilar artery trunk and vertebrobasilar junction and can be considered the approach of choice to selected aneurysms located in this area.
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  • Management of Aneurysms of the Vertebral Artery-Posterior Inferior Cerebellar Artery Complex
    Helmut BERTALANFFY, Ulrich SURE, Michael PETERMEYER, Ralf BECKER, Joac ...
    1998 Volume 38 Issue suppl Pages 93-103
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_93
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    Aneurysms of the vertebral artery (VA) and posterior inferior cerebellar artery (PICA) account for only about 3% of all diagnosed intracranial aneurysms. The surgical therapy of these aneurysms is complex and difficult due to the close topographical relationship between the neurovascular structures. Here, we report upon 27 patients with 29 such aneurysms. Of these, 22 patients (81%) were hospitalized because of a subarachnoid hemorrhage. Sixteen of these patients (72%) had an additional intraventricular hemorrhage. Twenty-one patients (78%) were surgically treated for their aneurysms, three of them also for an associated arteriovenous malformation. Aneurysms of the VA and the proximal PICA were ex-posed via a transcondylar (n=11) or lateral suboccipital (n=3) approach, those originating from the distal PICA via a paramedian suboccipital (n=7) route. Endovascular therapy was used in three patients. A patient with a fusiform aneurysm of the vertebrobasilar junction was treated with a ven-triculoperitoneal shunt only. Three aneurysms with a complex morphology were not treated. Of the patients operated upon, two died postoperatively due to vasospasm. Two other patients developed an in-complete dorsolateral medullary syndrome. One individual was lost for follow-up. The median follow-up period was 4.6 years (range 3-86 months). Both, the overall mortality (2/27) and morbidity (2/27) were 7.5%, respectively. Our results show that even complex vascular lesions of the posterior fossa can be treated with a satisfactory long-term outcome in the majority of our patients (85%). The multimodal management and an individually tailored microsurgical approach are key issues for the treatment of such aneurysms.
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  • Surgical Treatment for Ruptured Vertebral Artery Dissecting Aneurysms
    Isao FUKASAWA, Hideo SASAKI, Hideaki NUKUI
    1998 Volume 38 Issue suppl Pages 104-106
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_104
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    We analyze 20 cases of ruptured vertebral artery dissecting aneurysms and discuss the best choices for the surgical procedure. The preoperative Hunt and Kosnik grade was I in nine cases, Ia in four cases, II in three cases, III in three cases, and IV in one case. Rebleeding occurred in six cases, in four cases within 24 hours after the initial bleeding, and in every case within 6 days. In two cases surgery was performed within 3 days after the initial bleeding, in two cases within 4 to 7 days, in 16 cases after more than 7 days. A total of 22 operations were performed in the 20 patients (coating in 12, trapping in 6, proximal clipping of the vertebral artery in 2, clipping of the bleeding point in 2). A case of proximal clipping re-bled 32 days after the operation and subsequently died. Both cases of clipping of the bleeding point were reoperated because of rebleeding and a slipped clip, respectively. All cases in which trapping or coating was performed resulted in a good outcome. Trapping is the most reliable method of preventing rebleed-ing. Coating or proximal clipping is an optional procedure, but cannot always prevent rebleeding be-cause of the continuing circulation.
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  • Clinical Characteristics of Vertebrobasilar Artery Dissection
    Dae Hee HAN, O Ki KWON, Chang Wan OH
    1998 Volume 38 Issue suppl Pages 107-113
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_107
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    Sixteen patients with the diagnosis of vertebral or basilar artery dissection who were admitted at the Seoul National University Hospital from 1972 to 1996 are described. During the same period, we en-countered 76 patients with posterior circulation aneurysms, so the vertebrobasilar artery dissection was 21% of posterior circulation aneurysms. The mean age was 44 years, and male predominated. Nine patients presented with subarachnoid hemorrhage (SAH) and seven with ischemic symptoms. The characteristic angiographic finding of patients with SAH was aneurysmal dilatation (pseudoaneurysm) in eight of nine cases. In cases of ischemic symptoms, only one case had aneurysmal dilatation. Some other angiographic findings were demonstrated such as string sign, tapered narrowing, complete occlu-sion, or double lumen. Clinical course of SAH group was much different from that of ischemic group. Rebleeding occurred in three patients of SAH group; immediately after the rebleeding all patients became comatose, but after extraventricular drainage, all patients with rebleeding recovered rapidly. In SAH group, four of nine cases died but there was no mortality in the ischemic group. These four patients showed signs of stem failure, when computed tomography (CT) demonstrated no evidence of ad-ditional bleeding and follow-up CT showed the infarction at a part of stem and/or cerebellum. Vasospasm or sudden extensive extension of dissection could be the cause of death. Surgical manage-ment was performed in three patients, endovascular intervention in four, and conservative manage-ment in two. The patients with incomplete embolization or conservative management had poor out-come. In ischemic group, all underwent conservative management including anticoagulation and/or antiplatelet therapy. On follow-up, most of the patients with ischemic symptoms made complete or very good recoveries.
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  • Aneurysm Surgery in Asia
    Japanese Situation
    Yuichiro TANAKA, Shigeaki KOBAYASHI, Michihiko OSAWA, Kazuhiko KYOSHIM ...
    1998 Volume 38 Issue suppl Pages 114-117
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_114
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    This report is based on the results of the questionnaires conducted for the Japan Stroke Surgery Meeting 1996 (President: S. Kobayashi). The questionnaires were sent to all neurosurgical training institutions approved by The Japan Neurosurgical Society, numbering 959. The response rate was 54.2% (520 insti-tutions). All statistics dealt with cases from January 1995 to December 1995. The total number of aneurysm surgery performed was 13, 166. The average operative case number per institution during the year was 25. About 20% of the institutions exceeded 35 cases. Of all operative cases, 76.3% were rup-tured aneurysms and 23.7% were nonruptured. Giant aneurysms were 2.9%; dissecting aneurysms 2.4%. Surgical procedures performed were clipping in 90.3%, wrapping in 5.2%, proximal ligation 1.6%, and bypass in 0.7%. Intravascular surgery was performed for 2.3% of the cases. Sugita clips were mainly used in 80.5% of the institutions, Yasargil clips in 6.6%, and both in 12.9%. For anterior com-municating artery aneurysms pterional approach was mainly used in 81.0% of the institutions, in-terhemispheric in 7.2%, and both in 11.7%. For basilar terminal aneurysms, pterional approach was mainly used in 88.3% of the institutions, subtemporal approach in 6.6%, and both in 5.1%. The nonoper-ative cases included 24.9% of the ruptured aneurysms, 31.7% of the unruptured aneurysms, 38.4% of the giant aneurysms, and 52.1% of the dissecting aneurysms. The above statistics suggest that aneurysms are treated in Japan in most training institutions and that open surgical treatment is still the main proce-dure of choice.
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  • Intracranial Aneurysms in Korea
    Jae Hong SIM
    1998 Volume 38 Issue suppl Pages 118-121
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_118
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    We have 32 university hospitals and 18 general hospitals for neurosurgical training in Korea. Recently I have analyzed intracranial aneurysm cases which had an operation in 28 university hospitals and nine general hospitals. I have reported 2863 aneurysm operation cases. The location of the aneurysm consist-ed of 865 aneurysms (30.2%) in the anterior communicating artery, 724 aneurysms (25.3%) in the inter-nal carotid artery, 687 aneurysms (24.0%) in the middle cerebral artery, 129 aneurysms (4.5%) in the an-terior cerebral artery, 152 aneurysms (5.3%) in the posterior circulation, and 306 (10.7%) multiple aneurysms. The overall approximation of the operation rate of aneurysm is approximately 6.6 cases per 100, 000 population in 1996 in Korea.
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  • Aneurysmal Subarachnoid Hemorrhage in Taiwan
    Liang-Shong LEE, Shen-Long HUANG
    1998 Volume 38 Issue suppl Pages 122-123
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_122
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    In 1993, the annual report about prospective survey and registry of stroke revealed there were 439 cases of ruptured intracranial aneurysms in Taiwan area. Thirty-two of them had multiple aneurysms; there-fore, totally 476 aneurysms occurred in these cases. The anatomic distribution of these aneurysms were as the following: internal carotid artery-posterior communicating artery 32%, anterior communicating artery 30%, middle cerebral artery 18%, carotid bifurcation 6%, anterior cerebral artery 4%, carotid-ophthalmic artery 2%, intracavernous carotid artery 2%, and vertebrobasilar system 6%. 364 cases received surgical or interventional treatment, which 88% was clipping procedure, 8% was intervention-al procedure with coil, and 4% was wrapping. The surgical mortality was 13%.
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  • Management of Non-traumatic Subarachnoid Hemorrhage in Filipinos
    Renato Q. SIBAYAN
    1998 Volume 38 Issue suppl Pages 124-127
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_124
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    A retrospective study of a consecutive series of 110 Filipino patients with non-traumatic subarachnoid hemorrhage (SAH) treated by the author in an urban setting is presented as to etiology, sex and age, diag-nostic procedures employed, and short- and long-term results of non-surgical and surgical manage-ment. Aneurysms were the source of hemorrhage in 48%, arteriovenous malformation in 9%, and "other SAH" (hypertension/undetermined causes) in 43%. Fifty-seven (52%) patients were initially seen by a general practitioner, 44 (40%) by a neurologist, and only nine (8%) were seen directly by the neurosurgeon. A male sex preponderance for aneurysm was seen below the age of 50 years and a female preponderance for other SAH and aneurysm above age 50 years. The great majority of patients were ad-mitted on the same day they had SAH-usually within 8 hours of onset. Delay in hospitalization did not adversely affect the clinical grade. SAH was demonstrated by lumbar puncture (71%) and computed tomography (29%). Of 74 patients who underwent angiography, vasospasm was associated mainly with aneurysms and present in 50% of these cases. Medications most commonly utilized were for control of edema, sedation, and anti-vasospasm. Forty-three of 53 patients with aneurysms underwent surgical procedures of various types. In general, patients admitted with good clinical grade had good outcomes of treatment. For high grade patients the attitude was to wait for an improvement in clinical grade be-fore performing surgery.
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  • Incidence of Subarachnoid Hemorrhage from Aneurysmal Rupture in India
    Sanat N. BHAGWATI
    1998 Volume 38 Issue suppl Pages 128-130
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_128
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    Incidence of subarachnoid hemorrhage from aneurysmal rupture is low in India when compared with that in Western world and Japan. A review of aneurysms seen in eight institutions of the country in 1985 and 1986 has shown a very small incidence of aneurysms. A study of circle of Willis in 1021 con-secutive autopsies has also shown only two aneurysms on middle cerebral artery, the incidence being only 0.2%. For last 2-3 years, after an increasing awareness of its entity amongst the physicians and the population, only 300-350 aneurysms were seen in the cities of Bombay and Delhi with a population of 13 and 8 million, respectively.
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  • Intracranial Aneurysm Surgery in Bangladesh
    Muhammad Abdul MANNAN, Muhammad Khalilur RAHMAN, Rezaul Karim KHAN, Na ...
    1998 Volume 38 Issue suppl Pages 131-133
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_131
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    In this study of 1000 cerebrovascular disease patients, the commonest age are 50 to 70 years with male predominance. The urban patients are large in number and the risk factors are sedentary life, stress and strain, smoking, and hypertension. The patients are more chronic than acute and transport facilities are poor. Fifteen percent are hemorrhagic stroke, some of them may be due to intracranial aneurysm. In the absence of proper diagnostic facilities and adequate neurosurgeons, infrequent surgical treatment, and lack of statistics of intracranial aneurysm, this study may be a basis for further study of aneurysmal sur-gery in Bangladesh.
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  • Aneurysm Surgery in Pakistan
    Iftikhar Ali RAJA, Muhammad Athar JAVAID
    1998 Volume 38 Issue suppl Pages 134-137
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_134
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    The purpose of this study was to find out the incidence and outcome of aneurysms being operated in Pakistan. The data was collected from various neurosurgical centers in Pakistan where facilities for aneurysm surgery are available. The population of Pakistan is 130 million, with 28 neurosurgical cen-ters in the country but only eight are equipped with facilities for performing aneurysm surgery. The period of study extended from January 1994 to December 1996. During this period 350 patients present-ed with subarachnoid hemorrhage (SAH). Diagnosis of SAH was confirmed by computed tomography (CT) brain scan, diagnostic lumbar puncture was performed in few patients only where CT scan was negative. After angiography, 240 patients had intracranial aneurysms, 79 had arteriovenous malforma-tions, and three had bled in brain tumors. Of the 240 patients with proven intracranial aneurysms, 122 (51%) were male and 118 (49%) were female. The mean age at presentation was 40.5 years with a range from 7 to 68 and a peak incidence between 41 and 50 years. Subarachnoid bleeding was noticed in 179 (74.6%) patients, 52 (21.7%) had SAH associated with intracerebral hemorrhage, and nine (4%) patients presented with the third cranial nerve palsy. Anterior communicating artery was the commonest site for aneurysms (120, 50%), followed by posterior communicating artery (46, 19%) and middle cerebral ar-tery (45, 19%). Aneurysm surgery was performed in 134 (56%) patients. Operative mortality was about 10%. At 3 months follow up 49% patients were in grade I Glasgow Outcome Scale. We conclude that in-tracranial aneurysms occur with equal frequency in both sexes with a peak incidence between 41-50 years and anterior communicating artery is the commonest site. SAH is the most common mode of presentation and is still a neglected form of stroke in Pakistan. Medical specialists and family physi-cians require education for early diagnosis and timely referral of patients with SAH to neurosurgical centers.
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  • Prevention of Vasospasm after Subarachnoid Hemorrhage in Dogs by Continuous Intravenous Infusion of PD156707
    R. Loch MACDONALD, Lydia JOHNS, George LIN, Linda S. MARTON, Hussein H ...
    1998 Volume 38 Issue suppl Pages 138-145
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_138
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    This randomized, blinded study tested the prophylactic effect of PD156707, a nonpeptide competitiveantagonist of endothelin A receptors, against vasospasm after subarachnoid hemorrhage in dogs.Twenty-two dogs were allocated on day 0 to undergo cerebral angiography followed by injection of arterialblood (0.5 ml/kg) into the cisterna magna. Dogs had central venous catheters implanted for continuousinfusion of drug vehicle (n=10) or PD156707 (n=12). Cisternal blood injection was repeatedon day 2. Drug levels were measured in plasma on days 2, 4, 6, and 7 and in cerebrospinal fluid (CSF) ondays 2 and 7. Angiography was repeated on day 7 to assess vasospasm. After angiography on day 7, acute effects of infusion of PD156707, 100 mg, or drug vehicle on established vasospasm were assessed.Analysis of physiological variables within (analysis of variance) groups across time and between (unpairedt-test) groups at each time showed that drug-treated animals had significantly increased heartrate on day 7 compared to day 0 (p<0.005). Comparison of basilar artery diameters at day 7 showedthat PD156707 significantly decreased the degree of basilar artery vasospasm (placebo: -47±5%reduction [mean±SE] versus PD156707: -28±7%, p<0.05, unpaired t-test). There was, however, significant vasospasm when comparing within groups (paired t-test, placebo: p<0.0001, PD156707: p<0.005). Mean plasma PD156707 levels (322±123 ng/ml) were adequate to block responses of endothelin-1 on endothelin A receptors in vitro although CSF levels (11±7 ng/ml) were substantially lower. Infusionof PD156707 into the basilar artery on day 7 caused a small but significant 10±3% (paired ttest, p<0.01) increase in diameter compared to placebo (3±3% increase, p=0.32). This infusionalso was associated with a substantial increase in CSF drug levels to 19±9 mg/ml. These results suggestthat endothelin A receptors mediate some of the vasospasm that occurs after SAH in dogs and thatblockade of these receptors may be a beneficial treatment for vasospasm.
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  • Trigeminal Nerve and Brainstem Catecholamine Systems in Cerebral Vasospasm
    Niels-Aage SVENDGAARD, Murat GOKSEL, Sophia WESTRING
    1998 Volume 38 Issue suppl Pages 146-151
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_146
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    Cisternal blood injection in the rat and squirrel monkey produces a biphasic cerebral vasospasm, a decrease in cerebral blood flow (CBF) and an increase in glucose uptake (CMRglu) due to an anaerobic glucolysis actually representing a decrease in metabolism. Lesioning of the A2-nucleus, its ascending cathecolamine pathways or their projection site, the median eminence in the hypothalamus, prevents the occurrence of spasm. A unilateral postganglionic trigeminal lesion causes an ipsilateral constric-tion of the cerebral arteries while a preganglionic lesion does not affect the baseline arterial diameter. Both kinds of trigeminal lesions induce a global increase in glucose uptake of about 50% without in-fluencing CBF. Following subarachnoid hemorrhage (SAH) the decrease in CBF in both groups of lesioned animals is similar to that seen in controls. After SAH there is no further change in CMRglu in the animals with a preganglionic lesion, while in the postganglionically lesioned animals there is an ad-ditional increase in CMRglu of about 50% as compared to controls or animals with a preganglionic le-sion. Treatment with the peptidergic substance P (SP) antagonist, spantide, or gammaglobulin against SP prevents or significantly reduces the degree of spasm and the changes in flow and metabolism nor-mally seen post-SAH. The non-peptidergic neurokinins NK1 and NK3 antagonists do not influence flow and metabolism in SAH animals. The NK2 seems to change both flow and metabolism post-SAH in rats.
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  • Transcranial Doppler Pattern after Intracarotid Papaverine and Prostaglandin E1 Incorporated in Lipid Microsphere in Patients with Vasospasm
    Kenji KANAMARU, Shiro WAGA, Yoshihiro KUGA, Fumiaki NAKAMURA, Naoki KA ...
    1998 Volume 38 Issue suppl Pages 152-155
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_152
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    We studied the effects of intracarotid papaverine and prostaglandin E1 incorporated in lipid microsphere (Lipo-PGE1) in relation with transcranial Doppler parameters such as mean flow velocity (MFV) and pulsatile index (PI) of the proximal segment of the middle cerebral artery. Eighty patients with subarachnoid hemorrhage (SAH) were included in this study. In the case of angiographic vasospasm, papaverine at 7mg/min with total dose below 300mg per artery and 10-20 μg of Lipo-PGE1 were injected in the supraclinoid portion of the internal carotid artery. Vasospasm was improved in 24 patients (63%), however, it was unchanged in 14 patients (37%). The former patients had more favora-ble outcomes than the latter patients (p<0.005). After intracarotid injection therapy, the correlation be-tween MFV and PI was classified into three types: type 1, both MFV and PI decreased; type 2, MFV decreased but PI increased; and type 3, both MFV and PI fluctuated. The Glasgow Outcome Scale 3 months after SAH was as follows: type 1 (n=15), good in 14 (93%) and moderate disability in one (7%); type 2 (n=9), good in eight (89%) and vegetative state in one (11%); and type 3 (n=14), moderate disability in five (36%), severe disability in seven (50%), and death in two (14%). Chi-square analysis showed significant differences between type 1 and type 3 (p<0.005), and type 2 and type 3 (p<0.005). In conclusion, intracarotid papaverine combined with Lipo-PGE1 was effective for vasospasm but type 3 patients require a different treatment protocol.
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  • The Effect and Management of Delayed Vasospasm after Aneurysmal Subarachnoid Hemorrhage
    Nicholas W. C. DORSCH
    1998 Volume 38 Issue suppl Pages 156-160
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_156
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    Delayed cerebral vasospasm after aneurysm rupture is one of the major complications of subarachnoid hemorrhage. The purpose of this review was to determine the true incidence of vasospasm. All litera-ture on cerebral aneurysms from 1960 onwards was reviewed, and the figures extracted from publica-tions that mentioned vasospasm. Angiographic vasospasm, where patients were studied at the time of peak incidence, was reported in about two thirds of cases. Symptomatic vasospasm or delayed ischemia affects about one third. Untreated, nearly a third of those with ischemic deficits die and a similar proportion are left permanently disabled. Variations of Triple-H (hypervolemia, hypertension, hemodilu-tion) therapy, used early after hemorrhage for prophylaxis of vasospasm, are associated with a decrease of nearly half in the incidence of delayed ischemia. When used as therapy outcome also appears better, with a reduction particularly in the death rate. Calcium antagonists have been widely used, especially nimodipine. In several controlled trials the incidence of delayed ischemia was significantly reduced. More importantly, the overall outcome of all subarachnoid hemorrhage patients was better with nimodi-pine prophylaxis. The 21-aminosteroid tirilazad mesylate has been the subject of several trials. In one the overall outcome of all patients was improved, but the effect was essentially in males only. Further studies with larger doses in females are being analyzed.
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  • Expression of Transforming Growth Factor-β Complex in Arteriovenous Malformations
    Ghaus MALIK, Saleem ABDULRAUF, Xiao Yi YANG, Jorge A. GUTIERREZ, Sandr ...
    1998 Volume 38 Issue suppl Pages 161-164
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_161
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    The factors responsible for the development of cerebral arteriovenous malformations (AVMs) are not well known. Patients with hereditary hemorrhagic telangiectasia (HHT) have cutaneous vascular dys-plasia and a high propensity to develop systemic and cerebral AVMs. Transforming growth factor-β (TGF-β) complex has been implicated in HHT. The aim of this study was to evaluate the expression of TGF-β1, TGF-β2, TGF-β3, and their two receptors (R1 and R2) in AVMs and in normal brain vessels. Formalin-fixed, paraffin-embedded tissues from 20 patients with cerebral AVMs (including two patients with HHT) were sequentially sectioned into 6μm sections. Similar sections from normal brain tissue were obtained from five patients without AVMs and no intracranial pathology, who had died from unrelated causes. The normal tissue sections included large intracranial arteries, small arteries, venous sinuses, cortical veins, and brain tissue containing arterioles, capillaries, and venules. All speci-mens underwent immunohistochemical analyses with polyclonal antibodies to the following antigens: TGF-β1, TGF-β2, TGF-β3, and R1 and R2. The immunoreactivity, when present, was consistently noted in endothelial cells and in the medial smooth muscle. The intensity of vessel wall immunostaining was graded on a scale from 0 to 3. The mean staining grades of normal vessels for TGF-β1, TGF-β2, TGF-β3, R1, and R2 were 0.6 (range 0-1), 3, 2.8 (range 2-3), 1.6 (range 0-2), and 3, respectively, whereas the mean staining grades of AVM vessels were 0.3 (range 0-1), 0.8 (range 0-1), 0.6 (range 0-1), 1.4 (range 0-2), and 0.9 (range 0-1), respectively. The study thus demonstrated that normal brain vessels (arteries, veins, small vessels) have strong (range 2.8-3) immunostaining for TGF-β2, TGF-β3, and R2, and that the AVM nidus vessels have a paucity (range 0.8-0.9) of staining for these factors. In AVM vessels that had zero immunoreactivity to the above three factors, the vessel wall was fibrocollagenous rather than muscular. Further studies to examine the TGF-β complex behavior in AVMs are needed.
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  • Angioarchitecture Related to Hemorrhage in Cerebral Arteriovenous Malformations
    Shinji HIRAI, Seiichiro MINE, Iwao YAMAKAMI, Junichi ONO, Akira YAMAUR ...
    1998 Volume 38 Issue suppl Pages 165-170
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_165
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    A retrospective study was conducted to determine the angioarchitecture related to hemorrhage in patients with cerebral arteriovenous malformations (AVMs), who underwent conservative treatment and long-term follow-up. The average observation period was 9.3 years, and the annual bleeding rate was estimated at 3.6%. In all cases angiographic findings were reviewed in detail. The average AVM grade by Spetzler-Martin was 3.5. Higher bleeding rate was observed in large AVM (5.4%) compared with small (2.1%) or medium AVM (2.9%). Deep venous drainage (8.6%/year) was strongly correlated to hemorrhage. Concerning location of nidus, hemorrhage was frequently found in insular, callosal, and cerebellar AVMs. Venous ectasia, feeder aneurysm, and external carotid supply were commonly demon-strated on angiograms. Comparison of annual bleeding rate revealed that AVMs with intranidal aneurysm (8.5%) and venous stenosis (5.5%) had a high propensity to hemorrhage. Therapeutic strategy should be focused on these potentially hazardous lesions by the use of endovascular embolization or stereotactic radiosurgery, even if surgical resection is not indicated.
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  • Increased Brain Tissue Oxygenation During Arteriovenous Malformation Resection
    Fady T. CHARBEL, William E. HOFFMAN, Mukesh MISRA, James I. AUSMAN
    1998 Volume 38 Issue suppl Pages 171-176
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_171
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    The purpose of this study was to determine if baseline oxygen pressure (PO2), carbon dioxide pressure (PCO2), and pH in brain tissue adjacent to an arteriovenous malformation (AVM) is different from meas-ures in control patients. In addition, PO2, PCO2, and pH changes were measured during the course of AVM resection. Two groups were studied. Group 1(n=8) were non-ischemic patients scheduled for cerebral aneurysm clipping. Group 2(n=13) were patients undergoing neurosurgery for AVM resec-tion. Following craniotomy, the dura was retracted and a PO2, PCO2, pH sensor inserted into non-ischemic brain tissue in Group 1. In Group 2, the sensor was inserted into tissue adjacent to the AVM. Following equilibration, tissue gases and pH were measured during steady state anesthetic conditions in Group 1 and during AVM resection in Group 2. The results show that under baseline conditions be-fore the start of surgery, tissue PO2, was decreased in AVM compared to control patients but PCO2 and pH were not changed. During AVM resection, PO2, increased, PCO2 decreased, and pH increased com-pared to baseline measures. These parameters did not change in control patients over a similar time period. The results suggest that chronic cerebrovascular adaptation occur in AVM patients with decreased tissue perfusion pressure as an adjustment for decreased oxygen delivery. During AVM resec-tion, this adaptation produces a hyperemic environment with relative tissue hyperoxia, hypocapnia, and alkalosis which is not corrected by the end of surgery.
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  • Multidisciplinary Approach to Arteriovenous Malformations
    Evandro de OLIVEIRA, Helder TEDESCHI, Jair RASO
    1998 Volume 38 Issue suppl Pages 177-185
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_177
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    The treatment of arteriovenous malformations (AVMs) depends on the efforts of a multidisciplinary team whose ultimate goal is to achieve better results when compared to the natural history of the pathol-ogy. The role of adjuvant treatment modalities such as radiosurgery and endovascular embolization is discussed. Treatment strategies and surgical results from a personal series of 344 patients operated in a 10-year period are reviewed. The Spetzler and Martin classification was modified to include subgroups IIIA (large size grade III AVMs) and IIIB (small grade III AVMs in eloquent areas) to assist the surgical resection criteria. The treatment strategy followed was surgery for grades I and II, embolization plus surgery for grade IIIA, radiosurgery for grade IIIB, and conservative for grades IV and V. According to the new proposed classification 45 (13%) patients were grade I, 96 (28%) were grade II, 44 (13%) grade IIIA, 97 (28%) grade IIIB, 45 (13%) grade IV, and 17 (5%) were grade V. As for surgical results 85.8% of the patients had a good outcome (no additional neurological deficit), 12.5% had a fair outcome (minor neurological deficit), 0.6% had a bad outcome (major neurological deficit), and 1.2% died. These figures indicate that the treatment of AVMs can achieve better results compared to the natural history if managed by a well trained group of specialists led by an experienced neurosurgeon.
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  • Multimodality Treatment for Large and Critically Located Arteriovenous Malformations
    Kazuo MIZOI, Hidefumi JOKURA, Takashi YOSHIMOTO, Akira TAKAHASHI, Masa ...
    1998 Volume 38 Issue suppl Pages 186-192
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_186
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    To define the current status of the multimodality treatment for large and critically located ar-teriovenous malformations (AVMs), we have made a retrospective review of 54 consecutive patients with Spetzler-Martin grade IV and V AVMs. The size of nidus is larger than 3 cm in diameter in all cases. Initially, all but one were treated by nidus embolization with the aim of size reduction. Only one patient had complete nidus occlusion by embolization alone. In 52 patients, the obliteration rate of ni-dus volume averaged 60% after embolization. Ten patients underwent complete surgical resection of AVMs following embolization with no postoperative neurological deterioration. Thirty-one patients un-derwent stereotactic radiosurgery following embolization. At the time of this analysis, 30 patients un-derwent follow-up angiography 2-3 years after radiosurgery. The results of radiosurgery correlated well with the preradiosurgical AVM volume. Of 16 patients with small residual AVMs (<10cm3, a mean volume of 4.7cm3), nine (56%) had complete obliteration, and six (38%) had near-total or subtotal obliteration by 3 years after radiosurgery. In contrast, of 14 patients with large residual AVMs (≥10cm3, a mean volume of 17.9cm3), only two (14%) had complete obliteration, and eight (57%) had near-total or subtotal obliteration. Repeat radiosurgery was performed for the patients with remaining AVMs at 3-year follow-up review. This study indicates that a certain number of large and critically located AVMs can be safely treated by either microsurgery or radiosurgery following a significant volume reduction by nidus embolization. The present data also suggest the need and possible role of repeat radiosurgery in improving complete obliteration rate of large difficult AVMs, since many of those AVMs have significantly responded to initial radiosurgery.
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  • Embolization of Cerebral Arteriovenous Malformations (AVMs)
    Material Selection, Improved Technique, and Tactics in the Initial Therapy of Cerebral AVMs
    Katsuya GOTO, Ken UDA, Noboru OGATA
    1998 Volume 38 Issue suppl Pages 193-199
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_193
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    Successful embolization can be achieved only when the following three factors are correct and in co-operation: catheter tip position, flow control, and the setting time of normal-butyl cyanoacrylate (NBCA). Otherwise, the procedure may end with unsatisfactory results or complications. The current principle of safe and efficient embolization of cerebral arteriovenous malformation (AVM) is based on superselective cannulation of every strategically important feeding pedicle and injection of liquid em-bolic material under flow control. This study was based upon our experiences of embolizing 92 cases with cerebral AVM performed under the above conditions at our department. Results showed very en-couraging new observations with implications for further procedures: total removal of the AVM nidus after embolization was achieved in 90% of the cases, preradiosurgical embolization achieved 52% volume reduction and successfully maneuvered all cases into the gamma knife focal spot. Recently im-proved microcatheters with increased flexibility and minimal friction made it possible to place the tip of the microcatheter into the nidus with a higher success rate and better safety factors. In order to ob-literate a substantial amount of the AVM nidus and prevent penetration into the draining veins, the cre-ation of optimal flow status, and optimal setting time of NBCA have paramount importance.
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  • Microsurgical Resection of Incompletely Obliterated Intracranial Arteriovenous Malformations Following Stereotactic Radiosurgery
    Steven D. CHANG, Gary K. STEINBERG, Richard P. LEVY, Michael P. MARKS, ...
    1998 Volume 38 Issue suppl Pages 200-207
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_200
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    Radiosurgery is effective in obliterating small arteriovenous malformations (AVMs), but less successful in thrombosing larger AVMs. This study reviewed patients who underwent surgical resection of their large AVMs following failed radiosurgical obliteration. AVMs from 36 patients (aged 7 to 64 years, mean 29.9) were surgically resected 1 to 11 years after radiosurgery. Initial AVM volumes were 0.7 to 117cm3 (mean 21.6cm3), and radiosurgical doses ranged from 4.6 to 45 Gray equivalent (GyE) (mean 21.1 GyE). Thirty AVMs (83%) were located in eloquent tissue. Venous drainage was deep (14), superfi-cial (13), or both (9). Spetzler grades were II (2), III (12), IV (18), and V (4). Nine patients suffered re-hemorrhage after radiosurgery but prior to surgery, while three patients developed radiation necrosis. Twenty-seven patients underwent endovascular embolization prior to surgery. During microsurgical resection, the AVMs were found to be significantly less vascular and more easily resected, compared to AVMs in patients who had not received radiosurgery. Histology showed endothelial proliferation with hyaline and mineralization in vessel walls. Partial or complete thrombosis of some AVM vessels, and evidence of vessel and brain necrosis were noted in many cases. Clinical outcome was excellent or good in 34 cases, with two patients dying of rebleeding from residual AVM. Five patients were neurologically worse following microsurgical resection. Final outcome was largely related to the pretreatment grade. Radiosurgery several years prior to surgical resection appears useful in treating unusually large and complex AVMs.
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  • Management of Pericentral Arteriovenous Malformations
    James I. AUSMAN, Fady T. CHARBEL, Gerard M. DEBRUN, Mukesh MISRA, Vict ...
    1998 Volume 38 Issue suppl Pages 208-216
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_208
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    Pericentral arteriovenous malformations (AVMs) have more often been deemed inoperable lesions be-cause of their complexity, owing to their critical locations and dismal outcome. This study discusses the management of this group of patients with a variety of treatments which includes surgery, nidus em-bolization, and radiosurgery. Out of 89 patients treated for AVMs in our institute over a period of 30 months (1992 through May 1995), we present a case series of 34 patients who had AVMs located in the pericentral region. All the treated AVMs were Spetzler and Martin grade III (6 patients), grade IV (13 patients), and grade V (15 patients). The neurological outcome remained, normal or improved from base-line in 68% of patients following treatments; of the remaining 32%, 19% remained in the same condi-tion (with continuing preoperative deficits) and 10% showed some deterioration from their pretreat-ment condition. Thus 87% were unchanged or improved after the treatment regime. There was a 3% mortality (one patient who died as result of initial hemorrhage) in the series. Our multimodality treat-ment for this group of AVMs confirms the efficacy of the practiced strategies for their management. The results derived from the experience with this selected group of patients with AVMs lead us to recom-mend treating these patients with multimodality regimen rather than awaiting the natural history of the disease in the best interest of the patients.
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  • Successful Resection of Arteriovenous Malformations in Eloquent Areas Diagnosed by Surface Anatomy Scanning and Motor Evoked Potential
    Yoko KATO, Hirotoshi SANO, Narimasu KANAOKA, Fumihiro IMAI, Kazuhiro K ...
    1998 Volume 38 Issue suppl Pages 217-221
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_217
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    Successful resection of cerebral arteriovenous malformations (AVMs) involving the sensorimotor cor-tex was achieved in 17 cases. The theoretical basis for performing resection of AVMs in eloquent areas is the fact that the brain in and around the nidus about 1 mm in thickness is considered not to be fun-ctioning. It is also considered that any center of important function, when an AVM is involved, shifts to the near-by cortex from the original site. Nevertheless, it is critically important to recognize the cortex functioning as sensorimotor centers before and during operation. For this purpose, we have used sur-face anatomy scanning (SAS) in combination with magnetic resonance angiography. SAS is found to be very useful for the recognition of the topographical relationship between the surface anatomy and AVM. During operation, the motor cortex is identified with motor evoked potential. We have found that, in some cases, the motor center has shifted to the accessory motor cortex. With these information, it is possible to start resection of the lesion from dissection of the main feeders and dissection of the ni-dus from a silent cortex toward the critical area. Apparent neurological improvements were achieved in 15 of 17 patients treated surgically (88%). With this result, we think that AVMs in eloquent areas can be treated successfully when the surgery is well-designed and well-oriented with the combined use of diag-nostic imaging and monitoring. As for control of intraoperative bleeding, careful attention to small but important surgical techniques avoids troublesome bleeding during AVM surgery.
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  • Surgical Techniques for Arteriovenous Malformations in Functional Areas: Focus on the Superior Temporal Gyrus
    Shokei YAMADA, Floyd BRAUER, Lloyd DAYES, Shoko YAMADA
    1998 Volume 38 Issue suppl Pages 222-226
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_222
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    Direct surgical intervention of arteriorvenous malformations (AVMs) in functional areas has been ac-cepted as a standard mode of treatment. However, safe and successful intervention requires that such factors as exact location, size, vascular supply, and drainage be considered. Importantly, surgical tech-niques must be individualized to each patient, based on hemodynamic anatomy of the AVM. This paper discusses AVMs in the superior temporal lobe, which have a complex neuronal anatomy and circulato-ry system; the authors present 22 patients with AVMs of various sizes and describe the surgical tech-niques specific for the indicated location. Surgical procedures adhered to the following principles: 1) avoid brain tissue removal; 2) preserve microcirculation; 3) maintain circulation of the isolated major draining vein to access the AVM core; 4) compartmental isolation; and 5) preservation of functional area cortex covering the AVM. All patients underwent total resection except one, who had a subtotal resection. Neurological and occupational recovery was remarkable except for partial hemianesthesia in one patient; two patients are still in rehabilitation. This is the first description of a direct surgical ap-proach to AVMs in the superior temporal gyrus, where management is challenging because the lesions may extend elsewhere, such as to Broca's and Wernicke's areas. The results suggest that the procedure is promising.
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  • Surgery for Deeply Seated Arteriovenous Malformation
    With Special Reference to Thalamic and Striatal Arteriovenous Malformation
    Kazuo YAMADA, Mitsuhito MASE, Takashi MATSUMOTO
    1998 Volume 38 Issue suppl Pages 227-230
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_227
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    Surgery for deeply seated arteriovenous malformation (AVM) is controversial because stereotactic ir-radiation is applicable to the lesion. We have, however, experienced 30 deeply seated AVMs treated by direct surgery and/or endovascular treatment. The present study shows profiles of those patients and results of surgery. They include AVM in the thalamus in 12 cases, striatum in four cases, paraventricu-lar area in five cases, medial temporal lobe in three cases, intraventricular area in three cases, and other regions in three cases. They were treated by surgery alone in 23 cases, embolization followed by surgery in four cases, and embolization alone in three cases. AVM in the mediodorsal thalamus and for-nix (5 cases) was best treated by transcallosal approach. Venous aneurysm was commonly found in the AVM of this region and was a good navigator to the AVM. Pulvinar AVM was accessible through posterior interhemispheric approach (2 cases). None of these cases had additional neurological deficits. Cadaver dissection was useful for acquisition of surgical approach. Striatal AVM was approached through hematoma cavity with minimal manipulation to the surrounding structures, yet two of four cases showed progression of their weakness. The present study indicates that thalamic AVM can be ap-proached surgically with careful selection of the approach. On the other hand, striatal AVM is not a good candidate for direct surgery and better treated by stereotactic irradiation.
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  • Treatment Strategies and Results in Spinal Vascular Malformations
    Beate C. HUFFMANN, Uwe SPETZGER, Marcus REINGES, Helmut BERTALANFFY, A ...
    1998 Volume 38 Issue suppl Pages 231-237
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_231
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    We report the treatment strategies and results of 70 patients with spinal vascular malformations. For-ty-six had dural arteriovenous fistulas, 12 spinal cavernous angiomas, nine intramedullary angiomas, and three intradural arteriovenous fistulas. The diagnosis was established for cavernomas by magnetic resonance images only and in the other cases by selective spinal angiography in patients whose neuro-logical deficits, myelograms or magnetic resonance images suggested the presence of a spinal vascular malformation. All patients had symptomatic vascular malformations and were treated microsurgically. Intramedullary angiomas were operated when embolization seemed too dangerous or impossible and when they had a contact to the dorsal or lateral surface of the spinal cord. All but one were completely resected. In one angioma a small ventral residual fistula area was left. Complete obliteration of all fistu-las was achieved. The cavernomas were primarily resected. Apart from one postoperative permanent de-terioration with a paresis of the left arm in a patient with an intramedullary angioma, 16 cases present-ed only a transitory worsening of their neurological status after surgery. The long-term outcome of all these patients was good. Five patients had to be operated on again: three patients showed difficult locali-zations of dural fistulas which were still visible in the postoperative angiograms, one patient suffered a spinal epidural hematoma, and another patient showed a cerebrospinal fluid accumulation. We con-clude that spinal dural arteriovenous fistulas, small intradural fistulas, spinal cavernomas, and sympto-matic spinal angiomas with contact to the lateral or dorsal surface can be treated microsurgically with low perioperative morbidity.
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  • Complications of Angioma Surgery
    Personal Experience in 191 Patients with Cerebral Angiomas
    Werner HASSLER, Nedal HEJAZI
    1998 Volume 38 Issue suppl Pages 238-244
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_238
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    In the last years, treatment decisions of arteriovenous malformations (AVMs) were influenced by the improvementof stereotactic radiosurgery and were revolutionized by development of embolization techniques.The aim of this report was to examine the results, effectiveness, and complications associatedwith angioma surgery. 191 patients with AVMs were operated by the first author between 1981 and1996. Angioma localization was distributed as follows: frontal 51 (26.7%), temporal 44 (23%), parietal45 (23.6%), and occipital 24 (12.6%). Twelve (6.3%) AVMs were located in the cerebellum and 15 (7.9%)in other deep regions. Twenty-nine (15.2%) AVMs were associated with single or multiple aneurysms.The preoperative symptoms were hemorrhage (50.3%), seizure (33.5%), headache (23.0%), focal neurologicaldeficits (12.6%), and other minor symptoms. In 9.9%, the disease remains preoperatively asymptomatic.Based on the Spetzler/Martin scale (S/M), 38 patients were grade I, 39 grade II, 52 grade III, 39 grade IV, and 23 grade V. The following severe complications were observed: postoperative hemorrhagein 13 (6.8%), infection in six (3.1%), infarction in two (1.0%), and death in three (1.6%). The riskfor postoperative complications was related to the preoperative S/M grade of the AVM. Severe complicationsonly occurred in AVM grades IV and V. In 62 patients with grade IV and V AVM, three patientsdied (4.8%) and 12 showed neurological deterioration (19.4%). Only 3/129 (2.3%) patients with grade IIIIAVM deteriorated postoperatively. No severe complications were observed in preembolized and recentlyoperated patients. Microsurgical management of cerebral AVMs seems to be a reasonably safeprocedure especially in grade I-III AVMs, with a mortality of less than 2%. With enough experienceand exact attention to detail, the experienced neurosurgeon can remove many of these AVMs with aminimum of risk to the affected patient. Although hemorrhage from an AVM can be disabling or deadly, the course in many nonoperated high-grade AVMs (S/M grades IV and V) can be quite benign, if comparedwith their surgical risk. This may justify conservative treatment or treatment with radiosurgeryin some high-grade (S/M grades IV and V) angiomas, especially in elderly patients.
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  • Intracranial Cavernomas: Indications for and Results of Surgery
    H. Maximilian MEHDORN, Harald BARTH, Ralph BUHL, Arya NABAVI, Dieter W ...
    1998 Volume 38 Issue suppl Pages 245-249
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_245
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    Between April 1991 and April 1997, 46 patients were treated in our department presenting with in-tracranial cavernomas. Initial symptoms were focal seizures, bleeding episodes, and/or headaches. Mean age was 41 year (range 9 to 68 years). There were 24 female and 22 male patients. Computed tomography and magnetic resonance imaging were performed in order to establish the diagnosis, an-giography was only indicated when the hemorrhaged area was so close to the subarachnoid space in the vicinity of the basal cisterns that an aneurysm had to be ruled out. Aggressive indication for surgery also in brainstem cavernomas was based on the natural history of the lesion, since the majority of patients presenting with intracranial bleeding had suffered several (up to six) episodes of previous hemorrhages. Patients' clinical status upon admission and accessibility of the cavernoma were taken into account for planning the operation. The operative planning and approach were greatly facilitated by using a neuronavigational device and intraoperative electrophysiological monitoring particularly in cavernomas located in the brainstem, thalamus, and medulla oblongata. Surgical removal of the lesions resulted in a new permanent neurological deficit only in two patients (4%). These data show that patients benefit from modern neurosurgical techniques in contrast to conservative approach in this dis-ease of rather prolonged natural course.
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  • Surgery of Angiomas in the Brainstem With a Stress on the Presence of Telangiectasia
    Masashi FUKUI, Toshio MATSUSHIMA, Kiyonobu IKEZAKI, Yoshihiro NATORI, ...
    1998 Volume 38 Issue suppl Pages 250-254
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_250
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    This report deals with the surgery of angiomas other than arteriovenous malformation in the brain-stem. The surgical cases were three cavernomas, two telangiectasias, and two venous malformations. We performed surgery when an angioma bled and the resulting hematoma was situated near the surface of the brainstem or the fourth ventricle. The cases were operated on at the subacute or chronic stages af-ter hemorrhage. Although a magnetic resonance (MR) image showed a subacute or chronic localized hematoma with a low intensity rim, the case was not always a cavernoma, but a telangiectasia. Caverno-mas could be totally removed, but telangiectasia could not. In the cases of medullary venous malforma-tion the diagnosis was obtained radiologically, and when the hematoma was large, only hematoma evacuation was performed. In all cases the postoperative Karnofsky scores were improved or un-changed. Postoperative rebleeding in the hematoma cavity continued insidiously in a case of telangiec-tasia. The abnormal vessels of telangiectasia in the brainstem were preoperatively not visualized by cerebral angiography or MR imaging, but became visualized by enhanced MR imaging after evacuation of hematoma in two cases. It is stressed that an angioma with a hematoma intensity core surrounded by a low intensity rim on MR images is not always a cavernoma, but possibly is a telangiectasia.
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  • Cerebral Cavernous Malformations
    Serial Magnetic Resonance Imaging Findings in Patients with and without Gamma Knife Surgery
    Pyeong Ho YOON, Dong Ik KIM, Pyoung JEON, Young Hoon RYU, Geum Joo HWA ...
    1998 Volume 38 Issue suppl Pages 255-261
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_255
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    To classify the cerebral cavernous malformations and to investigate the natural history of cavernous malformations according to the classification, 41 patients with 61 cavernous malformations (40 caver-nous malformations from 22 patients treated with gamma knife surgery) were regularly followed up us-ing magnetic resonance (MR) imaging for a mean period of 25.5 months in treated cavernous malforma-tions and 20.7 months in untreated cavernous malformations, respectively. Cavernous malformations were classified into four types: type I, extralesional gross hemorrhage beyond cavernous malformation; type II, mixture of subacute and chronic hemorrhage; type III, area of hemosiderin with small central core; and type IV, area of hemosiderin deposition without central core. Follow-up MR images were ana-lyzed to evaluate changes in size, signal intensity, rebleeding, and perilesional adverse reaction of ir-radiation. A total of 61 cavernous malformations including 17 in type I, 23 in type II, 10 in type III, and 11 in type IV showed usual degradation of blood product in 22 cavernous malformations, no change in shape and signal intensity in 31 cavernous malformations, and eight cavernous malformations with rebleedings in the serial MR images. In these eight cavernous malformations with rebleedings, six oc-curred in type II and two in type III, but none in type I or IV. Rebleedings were more frequent in type II than in other types (p=0.044). Adverse reaction of irradiation was observed in five of 22 patients treat-ed with gamma knife surgery. Although most cerebral cavernous malformations showed evolution of hemorrhage or no change in size or shape on follow-up MR images, cerebral cavernous malformations represented as mixture of subacute and chronic hemorrhage with hemosiderin rim (type II) have a higher frequency to rebleed than other types of cerebral cavernous malformations. Cerebral cavernous malformations represented as hemosiderin deposition without central core (type IV) have a lower ten-dency to rebleed than other types and do not need any treatment. Most of the adverse reaction of irradia-tion after gamma knife surgery around cavernous malformations are transient findings and are consi-dered to be perilesional edema.
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  • Changes in Messenger Ribonucleic Acid Species in Gerbil Brain Perturbation
    Hidenori KOBAYASHI, Shigeru MATSUKAWA, Shinjiro KOBAYASHI, Masanori KA ...
    1998 Volume 38 Issue suppl Pages 263-267
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_263
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    The differential display technique was applied to observe the molecular dynamism of messenger ribonucleic acid (mRNA) in this study. Using this technique, the changes in mRNAs in brain perturba-tion such as ischemia was observed to understand the molecular base of the reaction. The transient cerebral ischemia was induced by clipping both common carotid arteries for 5 minutes in Mongolian gerbils. The total RNA was extracted from the hippocampal tissue samples before ischemia, 6 hours and 2 days after ischemia. The mRNAs were reverse transcribed and subsequently amplified by polymerase chain reaction (PCR). PCR products were displayed by autoradiography as ladders on a denaturing poly-acrylamide gel. According to the autoradiography, mRNAs were divided into three patterns: 1) mRNAs obtained from the control decreased at 6 hours after 5-minute ischemia and disappeared at 2 days com-pletely; 2) decreased mRNAs at 6 hours after ischemia recovered at 2 days; and 3) new mRNAs appeared after cerebral ischemia. Located bands of interest on a gel were cut out and reamplification of com-plementary deoxyribonucleic acid was performed. The pGEM-T Vector System was used for subcloning of the amplified PCR products. The differential display technique is the powerful method for detecting genes that are unique to ischemic processes and reactions.
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  • Current Indications for Carotid Endarterectomy
    Christopher M. LOFTUS
    1998 Volume 38 Issue suppl Pages 268-274
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_268
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    Four randomized cooperative trials for asymptomatic carotid artery disease and three randomized cooperative trials of symptomatic carotid artery disease have been completed and published. There are now firm and proven indications for carotid artery reconstruction. Asymptomatic carotid artery dis-ease with 60% or greater linear stenosis on angiography has been shown to be better treated with sur-gery than with medical therapy alone. For symptomatic patients, linear stenoses of 50% or greater have been shown to have a significant benefit with surgical treatment. All surgical recommendations are based on a morbidity/mortality of 3% or less for the individual surgeon.
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  • Indication for Carotid Endarterectomy
    Isao YAMAMOTO, Hiroshi KANNO, Satoshi FUJII
    1998 Volume 38 Issue suppl Pages 275-278
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_275
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    From recent randomized studies, carotid endarterectomy (CEA) is highly beneficial to the patients with a symptomatic high-grade carotid artery stenosis (70-99%), but the surgical indication for an asympto-matic carotid artery disease remains unsolved. Sixty-three atheromatous plaques (symptomatic 51, asym-ptomatic 12) were obtained from 57 patients who underwent CEA. The presence of an intraplaque hemorrhage was noted in 75% from symptomatic plaques, compared with 33% from asymptomatic ones. A plaque disruption occurred over protruding mounds of intraplaque hemorrhage and was noted in 76% and 42% from symptomatic and asymptomatic ones, respectively. However, asymptomatic plaques, which were angiographically demonstrated as carotid ulcer of types B and C, had a high inci-dence of intraplaque hemorrhage as well as plaque disruption. Three patients followed with asympto-matic contralateral carotid artery disease developed a stroke following ipsilateral revascularization and all three specimens showed the presence of plaque hemorrhage and disruption. It is concluded that before prophylactic CEA is considered, an intraplaque hemorrhage and/or plaque disruption should be detected by less invasive procedures such as ultrasonography.
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  • Carotid Endarterectomy under Regional Anesthesia
    Atos Alves de SOUSA
    1998 Volume 38 Issue suppl Pages 279-283
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_279
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    Regional anesthesia for carotid endarterectomy is a simple, reliable, and virtually complication-free technique. We began to perform a series of carotid endarterectomy under regional anesthesia at our in-stitution in May 1990. This report describes our experience with 180 operated patients from May 1990 till December 1995, with regional anesthesia. All patients were operated with microsurgery and we uti-lized the deeply cervical plexus block at the C-4 level associated with superficial block, along the posterior border of the externocleidomastoid muscle. The main advantage of this technique of anesthesia is that it is the only exact method of assessing the need of a shunt by using the neurological status of the awaken patient during trial carotid cross-clamping. The regional anesthesia allows carotid endarterec-tomy to be safely performed on patients with advanced cardiac disease or severe chronic obstructive pul-monary disease who were not good candidates for general anesthesia. In this 180 patients we performed 198 consecutive endarterectomies (10% bilateral) with a total morbidity-mortality rate of 2.0%.
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  • Restenosis Following Carotid Endarterectomy
    Clinical Profiles and Pathological Findings
    Kazuo YAMADA, Toshinobu KISHIGUCHI, Mamoru ITO, Hideo OTSUKI, Eiji KOH ...
    1998 Volume 38 Issue suppl Pages 284-288
    Published: 1998
    Released on J-STAGE: April 17, 2008
    DOIhttps://doi.org/10.2176/nmc.38.suppl_284
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    Restenosis following carotid endarterectomy is not a rare condition. Among 122 endarterectomies we experienced, five restenoses (4.1%) were encountered and treated by the second surgery. The present report clarifies the clinical profiles and pathological findings of restenosis following carotid endarterec-tomy. Mean age of restenosis group (59 years old) was not significantly different from the group without restenosis (62 years old). Average duration between the first endarterectomy and the second surgery was 17 months (8-30 months). Initial symptoms were transient ischemic attack in three sides, minor stroke in one side, and asymptomatic in one. Degree of stenosis was tight (≥90%) in two and moderate (70-89%) in three. It is interesting to note that no ulcer was noted in the first endarterectomy specimen. At surgery for restenosis, two cases had symptoms and another two cases were asymptomatic, though all had neck bruits. Four of five lesions were treated by short venous graft from common carotid artery to distal internal carotid artery and another lesion was treated by second endarterectomy and Dacron patch graft. Pathology was studied in four and all showed myointimal hyperplasia. Three of four reste-nosis tissues showed mutant form p53 by immunohistochemistry. The present study indicates that reste-nosis following carotid endarterectomy is not a rare status. Short venous bypass across the stenotic por-tion is the treatment of choice. Monoclonal growth of smooth muscle with mutant form p53 might be related to the restenosis.
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