A 44-year-old man was hospitalized for sudden onset of left hemiplegia. Cerebral angiograms revealed a web-like stenosis at the origin of the bilateral internal carotid artery and occlusion of the right middle cerebral artery. By arterial injection of urokinase and hemodilution therapy, the symptom disappeared at 5 hours after onset. A CT scan on the 2nd day showed an infarction of the right temporo-parietal lobe. Blood data including the coagulation-fibrinolysis system, electorocardiogram and echocardiogram showed no abnormal findings. Based on the belief that the web-like stenosis in the right internal carotid artery is the source of thromboembolism, the right carotid endarterectomy was performed. The resected specimen was diagnosed as intimal fibroplasia histopathologically. As the clinical characteristics of 8 cases with web-like stenosis at the origin of the internal carotid artery including the present case, the disease develops in young adults and focal ischemic symtoms are recognized in all cases. Histopathologically, the proportion of intimal fibroplasia is high with 6 cases, and patients with recurrent symptoms while being medically treated may require surgery.
Beneficial effects of cisternal injection of urokinase (UK) and nicardipine in patients with ruptured intracranial aneurysms were studied. Eighty-two patients with ruptured aneurysms, who were graded II to IV according to Hunt & Hess' classification and underwent early surgery with ventricular and cisternal drainages, were injected with UK (6000-12000 i.u.) and nicardipine (1-2mg) via the cisternal catheter twice a day for 7 to 21 days after surgery. The rate of symptomatic vasospasm (SVS) and outcome of the patients in the treated group were compared with those in 134 patients treated only with early operation and drainages without the cisternal injections. Neurological deficits due to SVS (permanent SVS) were observed in 2 (2%) of 83 patients treated with the cisternal administration of UK and nicardipine, while permanent SVS deficits were observed in 22 (16%) of 134 patients without cisternal injections. A good outcome was significantly higher in the treated group than in the non-treated group. The amount of hemoglobin in cerebrospinal fluid from cisternal catheters increased markedly during the cisternal injections of UK. Regional cerebral blood flow measured by SPECT with 133Xe inhalation increased during the treatment with nicardipine. The present study suggested that cisternal administration of UK and nicardipine is useful for patients with ruptured aneurysms.
We report here on a 10-year follow-up study of two Moyamoya children who underwent an indirect EC-IC bypass operation of encephalo-duro-arterio-synangiosis. Case 1 was 8 years old at the time of the first operation and he now is a 20-year-old post-office clerk. Case 2 was 11 years old at the time of EDAS and he is now a 22-year-old university student at a law school. Case 1 was a TIA type patient and Case 2 was a TIA-infarction type moyamoya patient at the time of the operation. The clinical symptoms of ischemic attacks that they had had rather frequently before the operations disappeared within three months after the operation and recurrence has not been seen since. Postoperative WISC or WAIS scores of both patients have been maintained within normal limits. Angiography revealed substantial anastomoses between transplanted donor arteries and cortical arteries as if the brain feeders had been replaced by the external carotid arterial system. Moyamoya vessels observed preoperatively decreased much in both cases. Cerebral blood flow was measured by means of Xenon enhanced CT and it was revealed that the resting CBF was slightly decreased generally but vascular reserve capacity was abundant in Case 1 and that resting CBF was quite normal but vascular reserve capacity was rather decreased in Case 2. Clinical status in these two cases and natural progress of the non-operated Moyamoya cases were compared based on papers published in the past, and we concluded that our operation EDAS performed on the two cases was effective in modifying their clinical progress.
The dorsal internal carotid artery (ICA) aneurysm is a saccular aneurysm with a wide or semifusiform neck and often its wall and surrounding arterial wall are very fragile. The authors describe details of the operative features of four illustrative cases of dorsal ICA aneurysm. The following are some technical points useful for safe and complete clipping: 1. It is desirable that the aneurysm dome has been dissected and exposed completely before applying a clip so that the clip can be placed parallel to the parent artery and also pressed against the artery to include the thin portion of the surrounding arterial wall in the brades. 2. In order to avoid premature rupture during the approach to the aneurysm, unroofing the optic canal and removing the anterior clinoid process are often helpful to secure the proximal parent artery for temporary occlusion; exposure of the ICA in the neck may be advisable when the aneurysm is located proximally. 3. Subpial dissection of the dome is useful especially when the aneurysm is buried in the brain or tightly adherent with the arachnoid membrane. 4. The aneurysm can grow in various directions from the dorsum of the ICA. The most difficult case for clipping is one in which the aneurysm protrudes toward the inner side of the curve of the parent artery, because parallel clipping without leaving a residual neck is difficult. In such cases, one needs to have various options including the above techniques as well as wrapping.
We compared the results of transvenous and transarterial embolization of dural carotid-cavernous fistulas (dural CCFs). Seven patients with dural CCF were admitted to our clinic to undergo endovascular surgery. Five of them underwent transvenous embolizations alone with platinum coil. Complete disappearance of dural CCF was achieved intraoperatively in four of them and 5 months later in another. One patient underwent a transarterial embolization alone. Platinum coils were used in this patient because of positive provocative test in each feeding artery. The fistula was markedly decreased and occluded after one month. The seventh patient, in whom the fistula was partially occluded by the first transvenous approach, underwent a transarterial embolization by combination of the estrogen alcohol and polyvinyl acetate. But the fistula again recurred from a residual arterial feeder and it was finally occluded by the third transvenous approach. In summary, a successful intraoperative immediate occlusion of the fistula was achieved in 5 of 7 transvenous treatments and none in 2 transarterial treatments and complete cure was achieved finally in all patients. Two complications were related to these procedures. Necrosis of the soft palate followed an embolization of bilateral sphenopalatine arteries in one patient. The same patient had an asymptomatic migration of the platinum coil to the lung during a transvenous procedure. We concluded that transvenous embolization is a radical, safer alternative to the transarterial approach.
With the advant of recent technology, intraoperative digital subtraction angiography (DSA) has become useful in verifying the precision of surgical results. We report our experience using commercially available equipment to demonstrate its application as a diagnostic and therapeutic adjunct to neurological surgery. Intraoperative DSA was performed in 13 patients, including resection of arteriovenous malformations (AVM), obliteration of intracranial aneurysms, creation of bypass graft, carotid endoarterectomy and removal of tumor. In 4 cases, angiography was used to facilitate intraoperative embolization of a vascular lesion. There were no complications in the 13 cases that may be related to the intraoperative angiographic procedure. This technique appears to be a valuable adjunct not only as a diagnostic but also therapeutic tool.
Between 1987 and 1991, 14 patients with cerebral aneurysm were treated by endovascular detachable balloon embolization technique. A detachable latex balloon was directly guided into the aneurysm, inflated with silicone or contrast material and detached. The patients ranged in age from 28 to 69 years (mean age, 48) and consisted of 9 males and 5 females. Five aneurysms distributed in the anterior circulation and 9 in the posterior circulation. Six of the aneurysms were small (<10mm), 7 large (10< <25mm), and 1 giant (25mm<). Nine patients presented with subarachnoid hemorrhage, 4 with mass effect and 1 without symptom. In 3 patients the parent arteries as well as the aneurysm were occluded. In 11 patients direct balloon embolizations were achieved with preservation of the parent arteries. Complications associated directly with balloon embolization therapy included 3 ruptures of the aneurysms that occured as a result of incomplete occlusion in 2 and slight overinflation of balloon in 1. One aneurysm ruptured at 4 months and 2 within 1 day after treatment. Two patients died of subarachnoid hemorrhage and 1 developed carotid-cavernous sinus fisutula that was treated by detachable balloon technique with good outcome. After balloon embolization therapy, 2 patients developed stroke due to narrowing of parent arteries. One patient had Weber's syndrome and another had hemiparesis.
Vertebro-basilar insufficiency frequently occurs because of stenosis in the proximal of the basilar artery and the first portion of the extracranial vertebral artery. In this report, two methods of surgical management of vertebro-basilar occlusive disease are described. First, the technique of interposition venous graft bypass from the external carotid to the superior cerebellar artery for ischemia of the rostral brain stem is described. Venous graft might be considered as a successful substitute for the STA if the STA is not sufficiently long and large. But in this operation, care must be taken to prevent torsion and kinking of the graft and external compression at the subcutaneous site. Therefore we devised double subcutaneous tunnel method. In this technique, a little bit larger size in diameter of artificial vessel is passed subcutaneously from the cervical region to the craniotomized scalp site. Then the vein graft is passed through in the artificial vessel. The second method of treatment is extracranial vertebral artery reconstruction. Though a vertebral artery endarterectomy is a technique that has been much described in reports, the disadvantage of this procedure is that often a sternotomy or the cutting of the clavicle is necessary to expose the extensive operating field. Since the surgical intervention is relatively minor, many cases of successful transposition of the VA to the SA have been reported. But in certain cases, the VA may not be long enough to transpose to the SA. Therefore, to avoid this problem, we have used a short vein bypass between the VA and SA. We have found that transpositions of the vertebral artery to the SA or a short vein bypass are safe and relatively easy technique.
With recent advances in both microneurosurgery and intravascular surgery, excellent results of the treatment of a giant intracavernous aneurysm have been reported in the literature. However, there have still been some reported morbidities such as postoperative ophthalmoplegia or cerebral ischemia. We present 2 cases of a giant aneurysm in the cavernous sinus that could not be treated suclcessfully either by direct surgery or by intravascular surgery. Case 1 is a 73-year-old female with left ophthalmoplegia. Direct surgery was carried on for an intracavernous giant aneurysm. Unexpected massive bleeding occurred by aneurysmectomy even after temporary occlusion at C2 and C5, possibly due to incomplete C5 occlusion. Particularly in case of a giant aneurysm, which commonly accompanies a tough and sclerotic wall of the carotid artery, wider exposure of the C5 portion and occlution of it remote from the aneurysmal neck is mandatory. Preparation of cervical carotid artery would be a safer procedure. Case 2 is a 60-year-old female, whose intracavernous large aneurysm was treated by internal balloon trapping at C4 and cervical ICA, resulting in fatal cerebral infarction due to postoperative thrombosis in spite of anticoagulant therapy. The use of an antithrombogenic material for balloon occlusion of parent arteries needs to be discussed. Use of Silicone may cause postoperative thrombosis less frequently than Latex. The necessity of bypass surgery in spite of the negative carotid occlusion test should also be discussed. Surgical indications for intracavernous giant aneurysm only with slight symptoms of ophthalmoplegia should be carefully considered.
The surgical treatment and indication for multiple occlusive lesions at the extracranial cerebral arteries are controversial. We report on a surgically treated patient who had subclavian artery occlusion and carotid stenosis. He complained of dizziness with unconscious attack. Arterial blood pressure measured at the left arm showed evident low value in comparison to that at the right arm. Angiograms demonstrated the left subclavian arterial occlusion and the right cervical internal carotid arterial stenosis with ulceration. The two-stage operations were performed using an internal shunt system during the carotid arterial cross clamping. The first operation was right carotid endarterectomy and the second was left common carotid-subclavian bypass with Gore-tex vascular prosthesis. Postoperative angiograms demonstrated complete removal of the carotid lesion and patency of the bypass. The clinical course was excellent.
A case of fatal rupture of a giant internal carotid aneurysm is reported, which occurred after an extracranial to intracranial (EC-IC) bypass surgery combined with occlusion of the proximal internal carotid artery (ICA) by detachable balloons. A 65-year-old woman presented with progressive visual deterioration due to an unruptured giant aneurysm at the supraclinoid segment of the ICA. Since the patient did not tolerate a balloon occlusion test of the ICA, saphenous vein graft was undertaken between the proximal external caroid artery and the middle cerebral artery (MCA). Three balloons were placed in the proximal ICA to occlude the ICA six days after the surgery. Although no retrograde filling of the aneurysm from the MCA was seen on the postembolization angiography, a massive subarachnoid hemorrhage (SAH) occurred two days after the embolization. Changes of pressure and/or flow dynamics within the aneurysm induced by the high-flow bypass, and accompanying intramural hemorrhage might cause rupture of the giant aneurysm. It is believed that this complication may be avoided by using a normal-flow bypass with the graft diameter similar to that of the distal recipient artery. The aneurysm should be trapped immediately to prevent rupture, if there is any evidence of retrograde filling of the aneurysm following proximal occlusion.