The routine steps described herein are essential for safe carotid endarterectomy (CEA). We considered performing microsurgical CEA with routine methods is effective on education. Our surgical method is as follows: The microscope is introduced through a skin incision. The cervical fascia is dissected along the anterior margin of the sternocleidomastoid muscle. The submandibular space is widely opened by subluxation of the mandibular. The distal internal carotid artery is exposed by dissection around the hypoglossal nerve by cutting the sternocleid artery. The carotid sheath is opened just above the carotid artery and pulled up with hooks. The plaque is removed through interintimal dissection without tacking sutures at the distal edge. Of 144 procedures, ischemic complications were recorded in three cases and peripheral nerve palsy was recorded in one case. The dissection methods were divided into three categories by analyzing the surgical videos recorded by using high-vision microscopy. The first method is dissection between the membranes, the second method is opening a tiny space around the vessels and nerves, and the third method is making a dissection plane without membranes. This categorization of dissection methods is also applicable to brain surgery. CEA is performed by using routine steps; hence, a trainee can easily acquire the microsurgical techniques. Microsurgical CEA is considered to be useful in microsurgical education of young neurosurgeons.
In carotid endarterectomy (CEA), plaque progress evaluation of the internal carotid artery to the distal portion is important. We determined the duration of the dissection of the internal carotid artery to the distal portion by measuring the length of the plaques that developed in the distal portion from carotid bifurcation by preoperatively performing magnetic resonance imaging and three-dimensional computed tomographic angiography. These techniques did not require tacking suture during CEA.
Topics: Performing safe CEA surgery - Technical Note
The basic procedure of carotid endarterectomy (CEA) has been almost established. However, beginners sometimes have difficulty dissecting the plaque at the same plane and treating the distal end of the plaque, even in typical cases. A simple, safe, and standardized procedure is important for beginners. We use the internal shunt in all cases to secure adequate blood flow and take advantage of the shunt tube as the tool for plaque dissection at the distal end. We introduce our surgical technique and review our procedure from a beginner's point of view. We tack up the skin, muscle, and carotid sheath by using sutures to make wide and shallow operative fields without retractors. We insert the internal shunt tube after arteriotomy. Beginners need to rehearse the tube insertion before the procedure. At the proximal side of the plaque, we connect both sides of the dissection plane across the shunt to secure the same plane. The distal end of the intima of the internal carotid artery (ICA) is fastened by using a shunt tube and tourniquet. The plaque can be easily cut off at the position of the tourniquet. If the plaque remains, we can peel off the plaque remnant like peeling onion skin. A shunt tube is used as the template of the ICA lumen in the distal end. Beginners can easily master these procedures, which can be performed safely without distress, even in high-positioned stenosis. These procedures enable the beginners to accomplish CEA securely.
The number of elderly patients presenting with aneurysmal subarachnoid hemorrhage (SAH) is increasing. Population aging in the region is higher than in the urban areas. Hence, regional clinical data can be indicative of the future impact of increasing population aging in the urban areas. We retrospectively analyzed 448 patients with subarachnoid hemorrhage, treated at the Ise Red Cross Hospital between April 2004 and March 2014. The average age was 64.9 years (age range 23-98 yr.). Females predominated men (M:F = 145:303). Among men, the age distribution was 64 years or younger (66%), 65-74 years (23%), 75-84 years (10%), and 85 years or older (1%). Among females, the age distribution was 64 years or younger (39%), 65-74 years (24%), 75-84 years (24%), and 85 years or over (12%). We analyzed the Hunt and Hess grade, the location of aneurysms, treatments, cerebral vasospasms, shunt operations, and the modified Rankin Scale. Most of the elderly patients presented with poor-grade SAH, and were managed conservatively. Majority of the treated patients were aged over 75 years, and had a modified Rankin Scale (mRS) score of 4 and 5. The patients in the mRS 4 group were categorized as either paralysis-type, or a decline-in-muscle-power-type. In the elderly patients group, we had more decline in muscle power-type patients than paralysis-type patients. Among the patients who underwent a shunt operation, 27% were from the elderly patient group, while 8% of the patients were aged 64 years or under. Favorable outcomes in elderly patients can be obtained by good postoperative care to maintain patient amenity.
Objective: Indocyanine green videoangiography (ICG-VA) has been widely used in vascular surgery. While vessels are clearly visible as white regions on a black background, other structures cannot be observed. We developed a new system to simultaneously capture both, light and near-infrared (NIR) fluorescence images in ICG-VA (dual-image VA [DIVA]), allowing for observation of other cranial structures. We are attempting to make this technology commercially available. Materials and Methods: We used our new technology with 10 different neurovascular cases. The operative field was illuminated via an operating microscope (OPMI PENTERO 900; Carl Zeiss Meditec, Jena, Germany). In the camera unit, visible light was filtered to 400-700 nm. NIR fluorescence emission light was filtered to 800-900 nm using a special sensor unit with an optical filter. Light and NIR fluorescence images were simultaneously visualized on a single monitor. Results: All 10 cases showed a clearly visualized operative field including both fluorescence-enhanced blood vessels and other cranial structures. In aneurysm surgeries, we were able to confirm complete clipping and preserve blood flow in the parent and perforating arteries. In cases of arteriovenous malformation, feeding arteries, nearby passing arteries, and draining veins were all easily visualized and detected. Conclusions: We developed a high-resolution intraoperative imaging system to enable real-time visualization of the color operative field along with ICG fluorescence-enhanced blood flow.
The surgical approaches and intravascular interventions for the treatment of dural arteriovenous fistula (dAVF) are important treatment options. Especially surgery should be indicated for non-sinus dAVF, which is often located on the anterior cranial base or the posterior cranial fossa. In this study, cases with dAVF treated with the surgical approach were retrospectively reviewed to etiologically evaluate the efficacy of surgery. Materials and Methods: Twenty-eight patients diagnosed as having dAVF were treated in the Juntendo University Shizuoka Hospital between 2009 and 2014. Of all the patients, 9 (32.1%) were treated with direct surgery to disconnect the abnormal vessels from the dAVF to the cortical veins. Four patients were asymptomatic, and the remaining 5 were symptomatically diagnosed. The 4 cases were onset by intracranial hemorrhage, and one case had an ischemic event. Results: All the cases treated with surgery were classified as Borden type III dAVF, in which abnormal vessels were drained into the cortical veins through the subarachnoid venous system. In this type, socalled the non-sinus type, obliteration by intravascular treatment might be difficult because of the absence of the sinus targeted in the transvenous embolization. In this study, no morbidity or mortality associated with the surgical procedures occurred in any of the patients. Intraoperative angiography with indocyanine green was definitely useful and is an important modality. Conclusions: Direct surgery combined with skull base techniques and intraoperative angiography is safe and effective for Borden type III dAVF.
Anterior communicating artery aneurysm has a high rupture risk. Although several surgical approaches that take into account the complexity and importance of preserving perforators have been reported, few reports have evaluated the relationship among subarachnoid hemorrhage (SAH) severity, aneurysm projection, and clinical outcomes. We retrospectively evaluated 102 patients (41 men and 61 women; mean age, 61.0 ± 12.8 years) who underwent treatment for ruptured anterior communicating artery aneurysm at our institution between January 2006 and May 2015. The severity of SAH and clinical outcomes were evaluated by using the World Federation of Neurological Surgeons (WFNS) classification and modified Rankin scale (mRS), respectively. Aneurysm projections were classified as anterior, inferior, lateral, superior, and posterior by using three-dimensional computed tomographic angiography or digital subtraction angiography. A mRS score of <4 at the time of discharge was defined as a favorable outcome. We also identified possible prognostic factors by using multivariate logistic regression analysis. The distribution of aneurysm projection was as follows: anterior, 45; inferior, 25; lateral, 20; superior, 9; and posterior, 3. The WFNS grades at admission were as follows: grade I, 5; grade II, 36; grade III, 16; grade IV, 17; and grade V, 28. The anterior group had significantly larger aneurysms than the lateral group, and the former had significantly better outcomes. Eighteen patients had a dissociation between SAH severity and clinical outcomes (i.e., good outcomes despite poor SAH grade). The anterior group consisted of 61% of these patients. In a multivariate logistic regression analysis, clipping as treatment modality and good SAH grade were found to be predictive of good outcomes. By contrast, neither aneurysm projection nor presence of hydrocephalus was predictive of good outcomes. SAH severity in ruptured anterior communicating artery aneurysm may depend not only on primary brain damage by hemorrhage but also on disturbed blood flow to the hypothalamus and limbic system, which may partly explain the dissociation between SAH severity and clinical outcome in the anterior projection group.
A 53-year-old woman was referred to our hospital because of multiple unruptured cerebral aneurysms, including right middle cerebral artery, anterior communicating artery, and right paraclinoid internal carotid artery aneurysms. Three-dimensional rotational angiography (3D-RA) revealed the right ophthalmic artery exclusively deriving from the right middle meningeal artery (MMA) and the relationships to the bony anatomy. The morphology of the aneurysms was suitable for microsurgical clipping rather than endovascular coiling. We performed clipping for all the aneurysms via the right frontotemporal craniotomy without resection of the lesser wing of the sphenoid bone and with intradural anterior clinoidectomy to preserve the MMA based on the 3D-RA findings. The patient was discharged from the hospital without visual disturbance. A case of ophthalmic artery originating from the MMA is rare but has a risk of causing visual disturbance due to intraoperative injury of the MMA. Compared with other neuroimaging modalities, 3D-RA is more useful for preoperative evaluation.
We present a case of recurrent internal carotid artery aneurysm successfully treated with superficial temporal artery-middle cerebral artery (STA-MCA) bypass followed by surgical flow reduction. A 6-year-old boy had a subarachnoid hemorrhage and underwent successful neck clipping at the age of 3 years. Follow-up angiography 3 years after the operation revealed a recurrent aneurysm in the anterior medial part of the internal carotid artery (ICA) near the clip, so he underwent a second operation. Operative findings showed a fusiform aneurysm that was unsuitable for clipping or trapping. Therefore, the aneurysm was treated with STA-MCA bypass followed by proximal occlusions of the ICA and posterior communicating artery. The postoperative course was uneventful, and angiography performed 20 months after the second operation revealed obliteration of the aneurysm. Collateral flow to the right MCA territory before the second operation was sufficient based on the Matas and Alcock test. However, blood flow through the bypass to the right MCA territory increased within 6 months. Our case and previous reports suggest that surgical flow reduction may have a curative effect and few complications of complex aneurysms in pediatric patients. Moreover, low-flow bypass may play a role in preventing chronic complications in such cases.
A 65-year-old man with a 6-year history of diabetes mellitus presented with left-sided sensory disorder, hemiparesis, and dysarthria. Magnetic resonance imaging (MRI) of the brain revealed multiple cerebral infarcts in the right cerebral hemisphere. Doppler ultrasonography, three-dimensional computed tomography angiography (3D-CTA), and MRI detected a 60% stenosis of the right cervical carotid artery resulting from a soft and lipid-rich plaque. The patient underwent right carotid endarterectomy (CEA) 3 months after the cerebral infarction had occurred. On postoperative day (POD) 7, he developed a high-grade fever and an elevated C-reactive protein (CRP). Blood cultures, chest and abdominal CT, and echocardiography did not reveal any evidence of infection. Although his CRP fell to 0.9 mg/dl on POD 20, the fever of unknown origin persisted in a remittent pattern. On POD 22, the patient experienced a severe headache around his left forehead, followed by a sudden onset of visual disturbance. He soon lost light perception in his left eye and became blind. Increased intraocular pressure and uveitis were noted. The ophthalmologist suspected endogenous bacterial endophthalmitis (EBE), and bacillus species bacteria were cultured from the hydatoid of anterior chamber and the peripheral blood. To prevent the spread of infection, he underwent enucleation of his left eye on POD 27. We present a case of a rare complication of CEA. As the patient was noted to suffer from cholesterol crystal embolization after the onset of EBE, we hypothesize that the EBE might have resulted from an infected atherosclerotic plaque within the aortic arch or iliac arteries.
A 49 year-old man presented with right hemifacial spasm and right facial neuralgia caused by a giant thrombosed fusiform dissecting aneurysm in the right vertebral artery. The ipsilateral posterior inferior cerebellar artery was not involved in the aneurysm. Endovascular internal trapping with coils was performed 9 hours before he lost his consciousness, and computed tomography showed subarachnoid hemorrhage mainly in the posterior fossa. Digital subtraction angiography revealed a de novo dissecting aneurysm in the contralateral vertebral artery. He died 3 days after the endovascular procedure for the right giant aneurysm because of repeated subarachnoid hemorrhage. Autopsy and pathological examinations showed a newly developed ruptured dissecting aneurysm in the contralateral vertebral artery. Ten cases of de novo vertebral artery dissecting aneurysms after trapping or occlusion of a dissecting aneurysm in the contralateral vertebral artery have been reported previously. We report our case and review of 11 reported cases, including ours.
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