Surgery for Cerebral Stroke
Online ISSN : 1880-4683
Print ISSN : 0914-5508
ISSN-L : 0914-5508
Volume 25, Issue 5
Displaying 1-11 of 11 articles from this issue
  • Slobodan MARINKOVIC, Hirohiko GIBO, Ivana NIKODIJEVIC
    1997 Volume 25 Issue 5 Pages 339-343
    Published: September 30, 1997
    Released on J-STAGE: October 29, 2012
    JOURNAL FREE ACCESS
    Because of their great clinical significance, the authors examined the anastomoses among the perforating arteries in twenty injected hemispheres.
    Direct anastomoses were found among the typical perforators of the PCA (65% and 75% of the hemispheres), the BA (45%), the VA (40%), and the premammillary artery (35%). The perforators of the ICA, AChA, MCA and Heubner's artery were connected to the pial arteries in 20%-55%. The anastomoses among the hypothalamic branches were present in 90%-95% of the cases. The authors discussed the possible significance of the anastomoses in the cerebrovascular occlusive diseases.
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  • Kazuhiro KATADA, Yuko OGURA
    1997 Volume 25 Issue 5 Pages 344-351
    Published: September 30, 1997
    Released on J-STAGE: October 29, 2012
    JOURNAL FREE ACCESS
    The recent development of three-dimensional CT angiography (3D-CTA) allows non-invasive, three-dimensional evaluation of intracranial arteries and veins. However, estimation of normal anatomical variants of intracranial vasculature by 3D-CTA has yet to be reported. We illustrate the usefulness of high-resolution 3D-CTA in the evaluation of the clinical significance of anatomical variations of intracranial arteries and veins. We received 100 consecutively examined 3D-CTAs. Variations of the anterior communicating artery complex were diagnosed in 23% of these cases.
    These include fenestration of anterior communicating artery (Acom) in 10, fenestration of proximal anterior cerebral artery (A1) in 2, broad anterior communicating artery in 5, broad attachment of Acom in 4, absence of Acom in 1 and other variations in 3. Fourteen out of 23 were accompanied with cerebral aneurysm. Diagnosis of other arterial variations such as median artery of corpus callosum, azygos anterior cerebral artery were readily possible. As for the vertebro-basilar system, fenestration of proximal basilar artery was detected in 6 cases in which 3 were accompanied with cerebral aneurysm. Primitive trigeminal artery was detected in 1 patient.
    Three-dimensional CT angiography was also useful in evaluating variations of intracranial veins.Veins of the skull base, deep cerebral veins, posterior fossa veins as well as major cortical veins and dural sinuses were visualized by means of 3D-CTA. Our preliminary study suggests that 3D-CTA has a potential to be a powerful modality in evaluating anatomical variation of intracranial vasculature.
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  • Tadashi NONAKA, Masafumi OHTAKI, Teiji UEDE, Sumiyoshi TANABE, Kazuo H ...
    1997 Volume 25 Issue 5 Pages 352-358
    Published: September 30, 1997
    Released on J-STAGE: October 29, 2012
    JOURNAL FREE ACCESS
    Recovery of visual function after the operation of large carotid-ophthalmic aneurysms is not always satisfactory, although a“combined epi- and subdural approach”(Dolenc's approach) has recently been applied for such operations. This report tries to point out a strategy to secure the visual activity with this operation.
    We summarize 5 cases. All aneurysms were large enough to compress the optic nerves, causing severe visual disturbance before operation. Two aneurysms had intramural thrombosis or marked calcification. In these cases, visual function subsequently became worse, even if the case was taken to minimize the intraoperative damage to the optic nerves. In the other 3 patients, visual symptoms improved immediately after the operation. A direct neck clipping was performed in cases where intramural thrombosis or marked calcification was not present in the aneurysm. In other cases removal of thrombus was performed after temporary occlusion of the internal carotid artery.
    Although the size of aneurysms did not affect the result of postoperative visual functions, the presence of intramural thrombosis or marked calcification in aneurysms caused worsening of visual symptoms. For these aneurysms an indirect operation such as trapping of the carotid artery with or without EC-IC bypass would be a better option.
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  • Yoshiaki SHIOKAWA, Isamu SAITO
    1997 Volume 25 Issue 5 Pages 359-364
    Published: September 30, 1997
    Released on J-STAGE: October 29, 2012
    JOURNAL FREE ACCESS
    Carotid artery aneurysms arising near the dural ring and the ophthalmic segment pose conceptual and technical controversies with regard to their classification and the extent of anterior skull base exposure. We review 58 operated patients with 60 such aneurysms and propose surgical procedure-orientated classification. According to the direction and size of the aneurysms, we classified them into 4 categories: supraoptic type, suboptic type, paraophthalmic type and global type.
    The supraoptic type include true ophthalmic artery aneurysms and “blister aneurysms” at the anterior wall of the carotid artery. The suboptic type arising at the superior hypophyseal artery necessitates the optic canal opening for obliteration with fenestrated clips. The paraophthalmic type had no branches near the aneurysm and opening the optic canal and removal of the anterior clinoid process is usually not necessary. The global type is often found by visual symptoms, and extensive exposure near the distal ring is necessary.
    Aneurysms arising near the dural ring have been frequently reported and the normenclature and the indication of the treatment have seemed to be confused. The risk of causing subarachnoid hemorrhage is the most important concern and the anatomical relation of the aneurysm and the distal ring is critical. When the C2 and C3 border is defined as the distal ring, the terminology of the nearby aneurysms becomes simple. However, accurate preoperative assessment of the border from the imaging study is not always possible. That is why the distal ring runs obliquely along the longitudinal axis of the C2 and C3, and the branching point of the ophthalmic artery does not always correspond to the C2 and C3 border.
    We discuss surgical indication and our understanding of reported aneurysms near the distal ring such as infraclinoidal aneurysm, transitional cavernous aneurysm and carotid cave aneurysm.
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  • Kenji SHIMAZAKI, Takeshi KAWASE, Takashi HORIGUCHI, Masahito KOBAYASHI ...
    1997 Volume 25 Issue 5 Pages 365-369
    Published: September 30, 1997
    Released on J-STAGE: October 29, 2012
    JOURNAL FREE ACCESS
    Twelve patients with unclippable giant cerebral aneurysms seen at Keio University Hospital between 1982 and 1995, underwent balloon Matas tests (BMT), measurement of mean stump pressure (MSP) and mean arterial blood pressure (MABP). Eleven of these patients had carotid aneurysms and 1 had a vertebral aneurysm. Two patients, whose MSPs were under 50mmHg, did not tolerate BMT and 10 patients tolerated BMT. Six patients finally underwent proximal occlusion of the parent artery, and their postoperative course was observed. The mean follow-up period was 4 years (range 2 months to 12 years).
    One of the patients, who did not tolerate BMT (MSP was 49mmHg) received STA-MCA anastomosis before proximal occlusion of the parent artery, and he did not suffer from any delayed ischemic complication after the occlusion. Another patient who tolerated BMT suffered from a cerebral infarction 4 days after the occlusion due to thrombosis of the perforating artery near the aneurysm, but she did not suffer from any delayed ischemic complication of the cortical branch. The other patients did not suffer from any ischemic complication and their aneurysms were thrombosed and absorbed. Delayed ischemic complications can occur after proximal occlusion of the parent artery for unruptured giant aneurysms, although the patient may have tolerated BMT. The measurement of MSP and cerebral blood flow (CBF) by Xe-CT or SPECT during BMT have been accepted methods to predict delayed ischemic complications. Xe-CT during BMT is less practical because it requires moving a patient from the angiography room to the CT room. CBF values that can be measured by SPECT are not an absolute but a relative value.
    It is considered that delayed ischemic complications rarely occur when the MSP is over 50mmHg. The measurement of MSP during BMT, although not a new method, is simple and practical. In conclusion, the measurement of MSP during BMT is very useful to decide if arterial reconstruction is indicated before proximal occlusion of the parent artery and to predict delayed ischemia of the cortical branch. Occurrence of delayed ischemic complications will be rare if troubles can be avoided during the aneurysm-thrombosing process.
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  • Kazuhiko KYOSHIMA, Susumu OIKAWA, George KOIKE, Masanobu HOKAMA, Toshi ...
    1997 Volume 25 Issue 5 Pages 370-377
    Published: September 30, 1997
    Released on J-STAGE: October 29, 2012
    JOURNAL FREE ACCESS
    We report a classification of juxta-dural ring aneurysms of the internal carotid artery (ICA). These aneurysms are classified into three types according to their relation to the carotid dural ring and the long axis of the ICA: paraclinoid intradural, carotid cave and infraclinoid extradural aneurysms. Another set of classification is made according to their location in relation to the cross section of the ICA as lateral, medial, ventral or dorsal type.
    The paraclinoid intradural aneurysms arise from the ICA distal to the origin of the ophthalmic artery and are close to the dural ring, which may include some of so-called carotid-ophthalmic aneurysms. The carotid cave aneurysms are located intradurally in the carotid cave, a dural recess in the infraclinoid carotid groove, and proximal to the origin of the ophthalmic artery. They are located at the angiographical genu angiographically and in the intradural space anatomically. The infraclinoid extradural aneurysms are located extradurally in the infraclinoid segment close to the dural ring.
    The infraclinoid extradural aneurysms should be differentiated from aneurysms in the cavernous sinus, because they are located in the infraclinoid carotid groove sinus, which is a peripheral venous space to the cavernous sinus.
    Clipping of these aneurysms requires essentially the same surgical techniques: removal of the anterior clinoid process, unroofing of the optic canal, opening of the dural ring and exposure of the infraclinoid segment including the surgical genu and axilla of the ICA via the ipsilateral pterional approach.
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  • Katsunobu TAKANO, Hiroyasu KAMIYAMA, Kenichi MAKINO, Nobumitsu KOBAYAS ...
    1997 Volume 25 Issue 5 Pages 378-385
    Published: September 30, 1997
    Released on J-STAGE: October 29, 2012
    JOURNAL FREE ACCESS
    It is well known that hyperperfusion syndromes sometimes occur after high flow bypass or carotid endarterectomy (CEA). In this paper we discuss cases that showed hyperperfusion syndrome after CEA and high flow bypass using radial artery graft (RA graft).
    Twenty cases that were treated between April 1993 and January 1996 were selected for this study. All patients complained of TIA, RIND, or minor completed stroke. Their cerebral angiograms demonstrated severe stenosis or occlusion in the ipsilateral internal carotid artery or middle cerebral artery. The regional cerebral blood flow (rCBF) was measured with 123I-IMP single emission computed tomography (SPECT), and measured after administration of 1 gram of acetazolamide intravenously. For these 20 patients 15 cases of CEA and 5 cases of RA graft were performed.
    Three cases of hyperperfusion syndrome were observed: 1 case was seizure after RA graft, and 2 cases were hemorrhage (1 patient was after CEA and the other was after RA graft). This hyperperfusion syndrome group (H group) showed hypoperfusion at rest and markedly decreased acetazolamide reactivity before operation.
    On the other hand the rCBF was not decreased in non-hyperperfusion group (N group) after acetazolamide administration. In the N group all patients were uneventful after surgery.
    According to Kuroda's classification, the cases who have decreased resting rCBF and impaired acetazolamide reactivity are classified as“Type 3.”In our study the H group cases showed markedly decreased acetazolamide reactivity compared with the“Type 3”cases of the N group. The cerebral blood vesseles of this H group may be paralytic and have no vasocontraction ability.
    We propose the“vasoparalytic type”for these cases. They have decreased resting rCBF and severely impaired acetazolamide reactivity.
    For these patients superficial temporal artery-middle cerebral artery anastomosis or PTA should be performed prior to CEA and RA graft.
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  • Hiroyuki HASHIMOTO, Junichi IIDA, Katsuya MASUI, Noriyuki NISHI, Toshi ...
    1997 Volume 25 Issue 5 Pages 386-390
    Published: September 30, 1997
    Released on J-STAGE: October 29, 2012
    JOURNAL FREE ACCESS
    Arteriovenous malformations (AVMs) in elderly patients are rare. The natural history of AVMs in elderly patients has not been well known. We report 2 cases of AVMs of elderly patients presenting with a cerebral hemorrhage. Both of them were surgically excised with a satisfactory outcome.
    Case 1 was a 75-year-old man who presented with right frontal hemorrhage. Cerebral angiography disclosed an undefined vascular lesion. A thrombosed AVM was identified during surgery, and was proven by histological examination of the surgical specimen.
    Case 2 was a 72-year-old man who had a history of mild right hemiparesis from early childhood. He presented with a left frontal hemorrhage. Cerebral angiography showed an AVM in the left mortor cortex. He left the hospital with a neurological recovery to the level before the onset. AVMs in elderly patients may be prone to bleed. Surgical treatment of AVMs in elderly patients might be a useful option when they are easily accessible.
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  • Naoki TOKUMITSU, Hiroyasu KAMIYAMA, Nobuaki KOBAYASHI, Haruo TAKAMURA
    1997 Volume 25 Issue 5 Pages 391-397
    Published: September 30, 1997
    Released on J-STAGE: October 29, 2012
    JOURNAL FREE ACCESS
    For surgery of giant or large cerebral aneurysm, we have used the intraoperative monitoring of cortical blood pressure to safely perform surgery and to get optimal clipping, when the risk of parent arteries stenosis caused by aneurysmal clipping may be higher. We report the merits and demerits of this method compared with usual methods for CBF monitoring such as ultrasonic Doppler flowmeter.
    We studied 5 giant aneurysms and 3 large aneurysms by applying this method. In the 3 cases of giant aneurysm, high flow EC-IC bypass using radial artery (RA) free graft and ICA proximal ligation was performed. And in the other 2 cases, direct aneurysmal clipping under a temporary use of RA was employed. On the other hand, all 3 cases of large aneurysm had atheroscrelotic change in its wall. They were treated by direct clipping.
    To monitor the cortical blood pressure, the following procedure was used. At first, we prepared two branches of superficial temporal artery (STA). After this, one of the branches was anastomosed to one of the branches of the middle cerebral artery (MCA) just distal to the aneurysm. Next, cannulation was performed into another branches of STA using a plastic needle, which was connected to a pressure transducer. By cutting off the blood flow from the main trunk of the STA, cortical blood pressure of the MCA was monitored through the bypass pathway.
    Our study shows the differences between the two types of cases. In cases of direct clipping surgery, the change of cortical blood pressure indicated whether the parent artery was stenotic or not. And in cases of performing RA free graft bypass, it showed whether bypass flow could be used as a substitute for ICA flow or not. These results show it is easy to evaluate the direct blood pressure quantitively. In conclusion, this monitoring is considered a useful method to ensure safe surgery for patients with giant or large aneurysms.
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  • Report of Six Cases
    Hiroyuki KINOUCHI, Yoshihide NAGAMINE, Akira TAKAHASHI, Kuniaki OGASAW ...
    1997 Volume 25 Issue 5 Pages 398-404
    Published: September 30, 1997
    Released on J-STAGE: October 29, 2012
    JOURNAL FREE ACCESS
    Spinal dural arteriovenous shunts (dAVS) is commonly located in the thoracic and lumbar regions. The symptoms of dAVS are usually gradual in onset and hemorrhage is less common. We experienced 6 unusual cases with dAVS in the cranio-cervical junction. There were 2 females and 4 males. Four patients presented with subarachnoid hemorrhage (SAH) and 1 patient showed slowly progressive tetraparesis due to myelopathy. The remaining 1 patient was diagnosed incidentally.
    Angiograms revealed that all dAVSs were fed with the dural branches of C1 radicular artery from the vertebral artery and drained into the medullary veins. In the patient with myelopathy, venous drainage was in a caudal direction and further into the anterior spinal vein. In contrast, in the patients with SAH, shunting flow drained into the intracranial venous system, and there was an aneurysmal venous distension in the drainer. In all patients, the draining vein was interrupted surgically at the point where the drainer enters the subarachnoid space. The postoperative courses were uneventful in all patients. Symptoms of myelopathy in 1 patient had improved gradually. We discuss pathophysiology and surgical treatment of dAVS in the cranio-cervical junction.
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  • A Case Report
    Arata WATANABE, Hirofumi NAGANUMA, Tsutomu YAGISHITA, Takashi SATOH, Y ...
    1997 Volume 25 Issue 5 Pages 405-408
    Published: September 30, 1997
    Released on J-STAGE: October 29, 2012
    JOURNAL FREE ACCESS
    We present a case of cavernous angioma in the medulla oblongata that was successfully excised. A 29-year-old man complained of gait disturbance, dysphagia, vertigo, diplopia and numbness of his left hand. Neurological examination revealed left VI, VII, IX, and X cranial nerve palsy. He also had left hemiparesis and right hemihypesthesia. MRI scan demonstrated a ring-like high intensity area in the dorsal portion of the medulla oblongata in T1-weighted images. Three weeks after the onset, the patient underwent an operation in which a suboccipital approach was used. The lesion was mostly hematoma, and a small vascular mass was resected. Histological examination disclosed a cavernous angioma. After surgery, the patient's neurological deficits improved. Surgical resection of cavernous angioma in the medulla oblongata is a reasonable choice of treatment, in accordance with previous reports.
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