Surgery for Cerebral Stroke
Online ISSN : 1880-4683
Print ISSN : 0914-5508
ISSN-L : 0914-5508
Volume 32, Issue 3
Displaying 1-10 of 10 articles from this issue
Topics: Treatment Strategy for the Brain Stem Cavernous Angioma
  • Kazuo HASHI, Takahiro SASAKI, Masahito FUJISHIGE, Yoshihiro MINAMIDA
    2004 Volume 32 Issue 3 Pages 155-160
    Published: 2004
    Released on J-STAGE: June 12, 2007
    JOURNAL FREE ACCESS
    The principle of removal of brain stem cavernous angiomas (BSCA) is to enter the brain stem parenchyma through the point where the lesion appears near the surface. The midpontine lesion situated near the 4th ventricle floor has, therefore, mostly been operated through the incision over the 4th ventricle floor above or below the facial prominence. However, this approach actually carries a high risk of postoperative facial nerve dysfunction because of a limited allowance of retraction due to its upward angle of operative trajectory.
    We introduce a new approach via subtemporal transpetrosal craniotomy with incision on the middle cerebellar peduncle for removal of a BSCA in the midpontine region.
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  • Nobuhito SAITO, Takashi WATANABE, Katsushige WATANABE, Hiroya FUJIMAKI ...
    2004 Volume 32 Issue 3 Pages 161-165
    Published: 2004
    Released on J-STAGE: June 12, 2007
    JOURNAL FREE ACCESS
    We reviewed 6 surgical cases with brain stem cavernous angioma. Three cavernous angiomas in the mesencephalon were removed via the occipital transtentorial approach. Two pontine angiomas were removed via the trans-forth ventricle approach. A cavernous angioma in the medulla oblongata was removed through the lateral suboccipital approach.
    Intraoperative monitoring of somatosensory evoked potential (SEP) and motor evoked potential (MEP) were useful in predicting postoperative neurological deficits. A brain stem incision should be made where the angioma and hematoma are closest to the brain-stem surface.
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  • Yasuhiko KAKU, Shinichi YOSHIMURA, Noboru SAKAI
    2004 Volume 32 Issue 3 Pages 166-171
    Published: 2004
    Released on J-STAGE: June 12, 2007
    JOURNAL FREE ACCESS
    We used a paramedian, infratentorial-supracerebellar, transcollicular approach to resect 6 intrinsic midbrain cavernous malformations. The route of access to the lesions was designed to minimize the anatomic and functional damage to the surrounding structures. Access was through one superior colliculus in 2 cases, through one inferior colliculus in 2 cases, and through the superior and inferior colliculi of one side in 2 cases. All 6 lesions were completely removed; the preoperative ocular symptoms improved in 4 of these 6 patients and did not change in 2. The neurological deficits except ocular symptoms improved in 2 patients. No recurrence of bleeding was observed during the follow-up period (mean 52 months).
    We conclude that the paramedian, infratentorial-supracerebellar, transcollicular approach permits safe removal of intrinsic midbrain cavernous malformations. Resection of the superior or inferior colliculus, or both, on one side appears to be neurologically well tolerated.
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Topics: Management of Carotid Stenosis
  • Kanji YAMANE, Takeshi SHIMA, Masahiro NISHIDA, Takashi HATAYAMA, Chie ...
    2004 Volume 32 Issue 3 Pages 172-178
    Published: 2004
    Released on J-STAGE: June 12, 2007
    JOURNAL FREE ACCESS
    Carotid endarterectomy (CEA) is becoming a standard treatment of the internal carotid artery (ICA) stenosis in Japan. But frequency of high-risk patients for CEA and management of high-risk patients to reduce operative complications have not been well established. The purpose of this study is to determine frequency of high-risk patients for CEA and to discuss management of high-risk patients.
    Between 1984 and 2002, 230 CEAs under general anesthesia were performed in our institute. High-risk patients for CEA were defined according to the following criteria: (1) patients older than 71 years, (2) patients with stenosis positioned higher than the second cervical vertebra, (3) patients vulnerable to ischemia during cross-clamping of the ICA, (4) patients at risk of hyperperfusion, and (5) patients with ischemic heart disease.
    Fifty-one high-aged patients (22%) were operated without any complications due to high age. Twenty-one patients (14%) had high-positioned stenosis. There were no complications due to high position. Cerebral ischemia after cross-clamping of the ICA occurred in 24% of the patients according to the intraoperative monitorings of ICA stump pressure, somatosensory evoked potential, and oxygenation of the cerebral cortex. Hyperperfusion, diagnosed by the ICA flow, velocity of the middle cerebral artery by TCD, and postoperative measurement of cerebral blood flow, occurred in about 5% of the patients.
    To avoid ischemic complications, we have routinely used a T-shaped internal shunt and maintained the systemic blood pressure during CEA. Management of hyperperfusion comprised strict control of the systemic blood pressure and barbiturate therapy. Ischemic heart disease was associated in 24% of the patients. Coronary artery revascularization such as coronary artery bypass grafting (CABG), coronary angioplasty, or stenting were performed in 4 patients before CEA.
    We have not done combined CABG and CEA. There was no myocardiac infarction in the perioperative time. In this series, perioperative mortality and morbidity were 0% and 1.7%, respectively. Although there were fewer perioperative complications, proper management for high-risk patients is essential.
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Original Articles
  • Naohiro YAMAZOE, Masatsune ISHIKAWA
    2004 Volume 32 Issue 3 Pages 179-182
    Published: 2004
    Released on J-STAGE: June 12, 2007
    JOURNAL FREE ACCESS
    The optimal strategy for treatment of unruptured aneurysms remains controversial because of their natural history. Especially the nature of the aneurysmal wall remains uncertain.
    To elucidate them, we retrospectively analyzed intraoperative findings of unruptured aneurysms. Fifty-six patients with 70 asymptomatic unruptured aneurysms were microsurgically treated during January 1999-March 2002. The location, size, and the irregularity and thickness of domes were examined retrospectively with the operation video and records.
    The patient population comprised 23 male and 33 female patients aged 38 to 78 years (mean age 61.7 years). Twenty aneurysms were located in the internal cerebral artery, 35 in the middle cerebral artery, and 15 in the anterior cerebral artery. Thirty-one aneurysms had irregular-shaped walls, and 39 aneurysms were smooth-walled. Thinning of dome was observed in 61 aneurysms, and among them 30 aneurysms had thin, transparent walls. The incidence of irregular-shaped aneurysms in medium-sized (5-9 mm) and large-sized aneurysms (10-25 mm) was significantly higher (p=0.020 and p=0.020) than that of small-sized aneurysms. Even in small aneurysms (3-4 mm) 15 aneurysms had thin walls, and transparency was recognized in 8 aneurysms. Twenty-four of 34 irregular-shaped aneurysms had thin, transparent walls and only 6 of 36 smooth-walled aneurysms showed transparency. There was a strong correlation between the irregularity and thickness of domes (p<0.001). With growth of aneurysms, thickening and thinning of the dome were intermingled and thin blebs were frequently recognized. These findings indicate that most irregular-shaped aneurysms have thin walls and deserve to be surgically treated regardless of size.
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  • Hiroyuki KATANO, Atsushi UMEMURA, Motoki TANIKAWA, Tomohiro SAKATA, Ta ...
    2004 Volume 32 Issue 3 Pages 183-188
    Published: 2004
    Released on J-STAGE: June 12, 2007
    JOURNAL FREE ACCESS
    We perform several contrives in perioperative management for carotid endarterectomy (CEA) to make it safer, less invasive and surer. We employ three-dimensional CT angiography (3D-CTA) as an alternative to conventional angiography, whose complications are up to 1.2% of all cases in ACAS (Asymptomatic Carotid Atherosclerosis Study). Patients with cardiovascular diseases and with diabetes mellitus should be referred to physicians for perioperative evaluation and management. Aged persons tend to present attenuated physiological function that prevents CEA, but this depends on individuals. Applying a shunt tube during CEA elicits fewer ischemic complications and a surer procedure, resulting in fewer embolic problems. We carry out SPECT study immediately after CEA to detect hyperemia, which may lead to hyperperfusion syndrome, and make every effort to avoid it from the early postoperative state.
    However, the key to prevention of various perioperative complications of CEA lies in not only endeavors of individual neurosurgeons but in the achievement of general management as a medical team in cooperation with physicians and anesthesiologists.
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  • Takakazu KAWAMATA, Yoshikazu OKADA, Akitsugu KAWASHIMA, Tomokatsu HORI
    2004 Volume 32 Issue 3 Pages 189-192
    Published: 2004
    Released on J-STAGE: June 12, 2007
    JOURNAL FREE ACCESS
    Near occlusion of the carotid artery has been defined as very severe stenosis at the site of the residual lumen, delayed flow of angiographic contrast material, and reduced arterial caliber secondary to artery collapse. The management of a patient with an atherosclerotic near occlusion of the carotid artery remains controversial. We basically treat patients with carotid near occlusion with carotid endarterectomy (CEA). In the present study, we investigated the surgical indications for the lesion, benefits of CEA, and intraoperative technique and devices.
    Seven male patients with near occlusion (55-69 years old) were recently treated with CEA during a 4-year period in our institute. Preoperative angiogram and B-mode Doppler did not demonstrate the distal end of the stenotic lesion clearly. All the patients had symptomatic carotid stenotic lesions. We applied the intravascular ultrasound (IVUS) catheter extravascularly to the cervical carotid arteries to obtain intraoperative ultrasound images during CEA not only to expose the lesions sufficiently but also to place the shunt system safely.
    Extravascular application of IVUS catheter before making arteriotomies correctly depicted the distal ends of the internal carotid artery (ICA) stenotic lesions as a thin layer of vascular wall. Postoperative angiography or MRA demonstrated sufficient intracranial blood flow in the patients with near occlusion treated with CEA. Although the patients did not have any perioperative surgical complications in the present series, we should always pay attention to prevent postoperative hyperperfusion syndrome in cases of carotid near occlusion.
    We consider CEA beneficial for near occlusion with a low complication rate, which was not more dangerous than in CEA for usual patients with carotid stenotic lesions.
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  • Masaki IWAKURA, Tetsuro KAWAGUCHI, Kohkichi HOSODA, Yuji SHIBATA, Hide ...
    2004 Volume 32 Issue 3 Pages 193-198
    Published: 2004
    Released on J-STAGE: June 12, 2007
    JOURNAL FREE ACCESS
    To assess the predictor of rerupture, we statistically studied the related factors for 121 subarachnoid hemorrhage (SAH) cases during a recent 5-year period. Rerupture was classified into severe and mild ones; severe is defined as patients whose Hunt & Kosnik grade worsened after rerupture; mild is defined as patients who experienced severe headache or vomiting due to rerupture without a worsening of Hunt & Kosnik grade.
    Twenty-eight rerupture cases (23%) comprised 15 severe and 13 mild ones. Two had rerupture (one was mild, and the another was severe) after admission in spite of their compliance with our protocol for the prevention of rerupture. In all the rerupture cases, there was no factor that significantly affected aneurysmal rerupture. However, its incidence increased in the cases of vertebrobasilar artery aneurysm, bleb, and multiple aneurysms. On the other hand, in severe rerupture cases, vertebrobasilar artery aneurysm and multiple aneurysms significantly affected aneurysmal rerupture (p=0.049, 0.037, respectively) in comparison with the no-rerupture cases. Furthermore, when comparison was made between severe rerupture cases and mild ones, there was no factor that significantly affected aneurysmal severe rerupture. However, the incidence of severe rerupture was higher in the cases of vertebrobasilar aneurysm and multiple aneurysms, while the incidence of mild rerupture was the same in the cases of internal carotid artery aneurysm and bleb. Rerupture, especially severe ones, occurred mainly within 6 hours before hospitalization after the initial SAH.
    Glasgow outcome scales (GOS) of mild rerupture cases were almost similar to no-rerupture ones; however, severe rerupture cases showed significantly worse results than the others (p=0.038).
    To improve the outcome of SAH, we should be especially careful and plan an adequate management even in the period before hospitalization.
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  • Yasuki ONO, Tsuyoshi KAWAMURA, Jun ITO, Shigeaki KANAYAMA
    2004 Volume 32 Issue 3 Pages 199-203
    Published: 2004
    Released on J-STAGE: June 12, 2007
    JOURNAL FREE ACCESS
    Water and sodium balance is very important in patients with subarachnoid hemorrhage (SAH). We reviewed surgical outcomes with regard to cerebral vasospasm in 92 patients with SAH whose water and sodium balance was differently managed. All patients underwent surgery within 96 hours of the SAH. Water balance was controlled only by fluid in Group 1 (1998.1-1999.4), vasopressin was used to control urine output in Group 2 (1999.5-2000.5), and mineralocorticoids were also used to prevent sodium diuresis in Group 3 (2000.6-2001.12). Anti-inflammatory neuroprotective therapy using indomethacin was also employed in Groups 2 and 3. In Group 2, vasopressin effectively controlled urine volume, but also caused hyponatremia, and the incidence of vasospasm increased especially in patients with Hunt & Kosnik Grade 2. In Group 3, although mineralocorticoids prevented sodium diuresis, and reduced the incidence of hyponatremia and vasospasm in patients with Hunt & Kosnik Grade 2, there was no significant improvement on the Glasgow outcome scale or in the incidence of vasospasm in patients with Hunt & Kosnik Grades 3 and 4. Indomethacin reduced the number of high fever cases, but did not improve surgical outcome. Intravascular infusion of vasodilators or systemic hypothermia may be more effective in improving overall outcomes after SAH, especially in severe cases.
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Case Report
  • Kenta FUJIMOTO, Shoichiro KAWAGUCHI, Toshisuke SAKAKI, Hiroyuki NAKAGA ...
    2004 Volume 32 Issue 3 Pages 204-207
    Published: 2004
    Released on J-STAGE: June 12, 2007
    JOURNAL FREE ACCESS
    We present a case of 64 year-old man with subclavian steal syndrome associated with internal carotid artery occlusion. We evaluated flow velocity of bilateral vertebral arteries, carotid arteries, and ophthalmic arteries with color Doppler flow imaging (CDFI). CDFI revealed to-and-fro flow in the right vertebral artery, which was enhanced with right-arm exercise. And we confirmed increased flow velocity of the contralateral left vertebral artery with a right-arm task. The left internal carotid artery was occluded and the ophthalmic artery flowed in the reverse direction. Angiography confirmed a severe right subclavian artery stenosis and reversed flow of the right vertebral artery. The left internal carotid artery was occluded and fed through the left posterior communicating artery. After angioplasty using balloon-expandable stent, flow direction was normalized immediately. Follow-up CDFI showed normograde flow of both vertebral arteries, and left ophthalmic artery flow changed to the to-and-fro pattern. We discuss the flow velocity changes of both vertebral arteries and ophthalmic artery after arm task and treatment.
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