Surgery for Cerebral Stroke
Online ISSN : 1880-4683
Print ISSN : 0914-5508
ISSN-L : 0914-5508
Volume 37, Issue 6
Displaying 1-11 of 11 articles from this issue
Topics: Carotid Endarterectomy
  • Kazumi OGANE, Mitsuaki HATANAKA, Hidefumi TABATA
    2009 Volume 37 Issue 6 Pages 409-415
    Published: 2009
    Released on J-STAGE: April 16, 2010
    JOURNAL FREE ACCESS
    We performed carotid endarterectomy (CEA) for 24 patients with severe carotid stenosis (greater than 90%) from 2003 to 2007. There were 21 males and 3 females with a mean age of 69 (58-89 years old). Seven were asymptomatic and 17 symptomatic. Carotid angiograms indicated our patients fell into 3 groups: simple stenosis in 12, pseudo-occlusion in 7, and pseudo-occlusion-like in 5. We retrospectively examined clinical features and operative findings and in this article discuss perioperative management for CEA. Although there was no perioperative morbidity or mortality, thrombotic carotid occlusion was recognized in 2 patients after arteriotomy (CEA was successfully performed in 1; another was ligated at the origin of internal carotid artery). CEA is a useful measure for patients with severe carotid stenosis under our perioperative management protocol. To minimize perioperative complications, preoperative examination of coronary artery disease and evaluation for the distal end of atheromatous plaque, meticulous operative and anti-ischemic procedure, and postoperative risk management for CEA are important.
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  • Tomonori TAMAKI, Yoji NODE, Norihiro SAITO, Norishige SUZUKI, Katsuya ...
    2009 Volume 37 Issue 6 Pages 416-420
    Published: 2009
    Released on J-STAGE: April 16, 2010
    JOURNAL FREE ACCESS
    Patch angioplasty with carotid endarterectomy has been advocated to decrease the incidence of recurrent stenosis and postoperative acute occlusion. In this article, we describe our experience with 35 carotid endarterectomies using the Hemashield patch graft. The technique is simple and does not require any special preparation of the patch material. The Hemashield is placed over the arteriotomy and cut to the exact length of the opening. Each end of the patch is then anchored to the arteriotomy with double-armed 6-0 prolene or pronova. The other steps of carotid endarterectomy are unchanged, and the same suture can be used for patch placement. The 30-day major mortality/morbidity rate was 2.8% (1 patient died of postoperative cerebral infarction). There was no postoperative occlusion. We also introduce 3 representative cases treated with a Hemashield patch graft. This patch graft is useful for safer carotid endarterectomy.
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  • Taro KOMURO, Shinichiro OKAMOTO, Kenji HASHIMOTO, Fumiaki ISAKA, Takeh ...
    2009 Volume 37 Issue 6 Pages 421-425
    Published: 2009
    Released on J-STAGE: April 16, 2010
    JOURNAL FREE ACCESS
    It is critical to confirm the condition of the upper end of the stenotic lesion in the carotid endarterectomy (CEA), especially for high-positioned lesions. An alternative is required to evaluate a carotid stenosis without an iodine angiogram. We used an intraoperative carotid echogram by small probes with a curved stick or a flexible cable in the CEA for those cases. The small probes could be inserted even in the narrow operative field of high-positioned lesions. They were useful to evaluate the upper end of the stenotic lesion, thick calcifications and the patency of the carotid artery just after the suture. We were able to mark the upper end of plaques on the arterial wall exactly and very easily.
    The intraoperative carotid echogram with small probes is a very useful tool to make a CEA safe.
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Topics: Surgical Training
  • Waro TAKI
    2009 Volume 37 Issue 6 Pages 426-428
    Published: 2009
    Released on J-STAGE: April 16, 2010
    JOURNAL FREE ACCESS
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  • Junta MOROI, Tatsuya ISHIKAWA, Hiromu HADEISHI, Norikata KOBAYASHI, Ak ...
    2009 Volume 37 Issue 6 Pages 429-433
    Published: 2009
    Released on J-STAGE: April 16, 2010
    JOURNAL FREE ACCESS
    We discuss the usefulness of a distal transsylvian (DTS) approach for microsurgical training of young neurosurgeons and assess the safety of this procedure by evaluating the complication ratio in our institute. In this procedure, residents learn the vulnerability of the pia mater, pial capillary vessels and small superficial sylvian veins and acquire the skill to avoid bleeding from these structures. In addition, if these vulnerable structures bleed, they learn how to keep the field dry by using suction or hemostatic materials without bipolar coagulation. These represent basic skills for dissecting the neck of an aneurysm safely and preserving critical perforators and nerves, which are the most vulnerable structures in aneurysmal surgery. From 1993 to 2008, this approach was used by 17 residents in 225 procedures. No morbidity or mortality caused by this procedure was observed.
    For young neurosurgeons, the DTS approach is one of the best training methods to acquire delicate microsurgical skills that cannot be acquired in conventional off-the-job training.
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  • Nobuaki MOMOZAKI, Tatsuya TANAKA, Eiichiro HONDA, Kazuhito SYO-JIMA
    2009 Volume 37 Issue 6 Pages 434-437
    Published: 2009
    Released on J-STAGE: April 16, 2010
    JOURNAL FREE ACCESS
    The efficiency of training systems for microsurgery has steadily become more important due to both the increasing need for medical oversight because of medico-legal considerations and the reduction in total number of surgeries being performed. Both Gamma-knife radiosurgery and intravascular intervention techniques have led to a reduction in indication for surgery. We have found that the use of opposite-side stereoscopic microscopes by the surgical assistant is a very useful training method. Younger trainee operators can gain surgical experience under the oversight of an experienced operator with very small risk for the patient.
    Opposite-side microscopes appear to provide an opportunity for the younger operator to gain experience in as efficiently as possible.
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Topics: Coil Embolization
  • Hiroshi TENJIN, Ayako MANDAI, Daisuke UMEBAYASHI, Yasuhiko OSAKA, Yosh ...
    2009 Volume 37 Issue 6 Pages 438-442
    Published: 2009
    Released on J-STAGE: April 16, 2010
    JOURNAL FREE ACCESS
    We performed coil embolizations assisted by balloon-expandable stent for vertebral aneurysms in 7 patients. None of the patients were indicated for parent artery occlusion, due to aplasia or hypoplasia of the contralateral vertebral artery, or for other anatomical reasons. Five aneurysms were successfully embolized, although 2 patients died of rebleeding or ischemic complication. We offer tips and discuss pitfalls of coil embolization assisted by balloon-expandable stent.
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  • Yasuhiko OSAKA, Hiroshi TENJIN, Yoshikazu NAKAHARA, Shinji YAMAMOTO, D ...
    2009 Volume 37 Issue 6 Pages 443-446
    Published: 2009
    Released on J-STAGE: April 16, 2010
    JOURNAL FREE ACCESS
    The rate of endovascular coiling as a treatment of cerebral aneurysm is increasing in Japan. However, the results are not necessarily favorable in cases of large aneurysms, and retreatment is required in many cases. Based on this, clipping should be initially considered as curative treatment for large cerebral aneurysm. In cases of critical (Hunt & Kosnik Grade 4 or 5), extensively ruptured brain aneurysm, direct surgery in the acute phase is not straightforward, and the outcomes are not always favorable.
    However, some cases follow favorable courses when they pass the acute phase. In extensively ruptured brain aneurysm, endovascular treatments can be performed in a minimally invasive way, and the risk of rebleeding is surprisingly low even with partial occlusion. We experienced 2 cases of extensively ruptured brain aneurysm, successfully treated with partial occlusion for the aneurysm by interventional radiosurgery performed in the acute phase and surgical clipping in the chronic phase.
    Clipping after endovascular coiling can be difficult to perform when the coil is not removed and is densely filled. Therefore, it is preferable to perform partial occlusion without filling the neck of the aneurysm with the coil.
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  • Hidenori OISHI, Munetaka YAMAMOTO, Kensaku YOSHIDA, Takashi SHIMIZU, H ...
    2009 Volume 37 Issue 6 Pages 447-452
    Published: 2009
    Released on J-STAGE: April 16, 2010
    JOURNAL FREE ACCESS
    We retrospectively reviewed our own experiences of coil embolization for intracranial aneurysms regarding recanalization. Between July 2001 and December 2007, a total of 740 patients underwent coil embolization at our institution or affiliated hospitals. Among those, 271 patients with 278 aneurysms who underwent follow-up cerebral angiography more than 12 months after the initial treatment were the subjects of this study.
    Immediate angiographic results showed complete occlusion in 72.4%, residual neck in 14.0%, and residual filling in 13.6%. Mean follow-up periods were 21.7 and 20.6 months for ruptured and unruptured aneurysms, respectively. The overall recanalization rate was 29.4% (major recurrence 12.6%, minor recurrence 16.8%). Previous rupture and morphology of wide-neck (≥4 mm) or large size (≥10 mm) and location of posterior circulation were the significant risk factors of recanalization (P<0.05). Gender, immediate angiographic results and embolization techniques were not statistically significant. Posttreatment bleeding from the coil-embolized aneurysms occurred in only 0.4% of the cases during the study period.
    Coil embolization of intracranial aneurysms is proving to be a safe method of protecting aneurysms from rupture. However, endovascularly treated patients, particularly those with recanalization risk factors, should undergo long-term follow-up.
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Original Article
  • Shogo NISHI, Yusuke KINOSHITA, Kentaro IZUMI, Susumu FUKAHORI, Tomohir ...
    2009 Volume 37 Issue 6 Pages 453-460
    Published: 2009
    Released on J-STAGE: April 16, 2010
    JOURNAL FREE ACCESS
    For the supra-aortic atherosclerotic stenoses, neurovascular and neuro-interventional approaches have been performed. Interventional approaches have risk of thrombo-embolic events, while vascular approaches have surgical stress. We developed and applied a method for cerebral protection for stenting of supra-aortic stenoses and introduce our method in this article.
    We performed stenting in 20 supra-aortic stenoses from April 2006 to March 2008. Our cerebral protection method, a modified application of the “Mouse Trap” (“Mouse in a Trap”) method usually used for CAS patients, was applied for 5 patients (1 CCA origin stenosis, 1 brachio-cephalic artery stenosis, 1 SA stenosis, 1 VA V3-V4 stenosis, 1 ICA petrous segment stenosis). The stenotic lesion was dilated and stented, while the lesion was endovascularily trapped with the occlusion balloon and so on.
    After each manipulation (predilation, stenting, post-dilation), the blood with the clots and debris was aspirated, filtrated, and returned to the body via the vein. We modified the method for supra-aortic stenotic lesions according to their anatomical location, but maintained the principle of the “Mouse Trap” method.
    In all 5 cases, the protection procedure was done without worsening of clinical findings. However, high intensity areas on DWI were subclinically found in 2 patients.
    Although this study covered only a small number of cases, non-CAS supra-aortic atherosclerotic stenoses cases were safely stented under a modified “Mouse Trap” cerebral protection system.
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Case Report
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