We report several reconstructive surgeries for various cervical carotid lesions. Representative carotid surgery is carotid endarterectomy (CEA). Our method is a routine use of shunt system in CEA. The outcomes of our CEA are no mortality and 1.0% morbidity, which is attributable to meticulous surgical manipulations and perioperative general management, including blood pressure control under propofol sedation. In the extracranial carotid arterial system, other occlusive lesions have been experienced such as dissecting aneurysmal lesions, aortitis syndrome, non-penetrating carotid injury and common carotid stenotic lesions. We report vein graft and Gore-Tex artificial vessel bypass for dissecting carotid lesions and the common carotid artery severe stenotic lesions, respectively. These surgical reconstructions have resolved most of the patients complaints and symptoms without serious complications. Therefore, these reconstructive surgeries should be established as a guideline for extracranial carotid lesions.

View full abstract

Complex cerebral aneurysm and hemodynamic occlusive cerebrovascular disease require microvascular-anastomosis, mainly superficial temporal artery (STA) to middle cerebral artery (MCA) bypass, as treatment tactics. Preparing a clean, well-drained operative field with a platform for placing microvascular sutures, good visualization of the arteriotomy, and steady hand movements are necessary to achieve a safe and secure bypass procedure. We present representative troubles that may be encountered in STA-MCA bypass surgery and describe how to manage those troubles. We stress that patients whose bypass appears to occlude immediately after surgery are sometimes encountered, because of problems in the STA itself such as spasm, dissection, distortion or pinching by surrounding tissues.

View full abstract

The incidence of stroke in women increases during pregnancy and puerperium. Although it is rare, stroke, especially intracerebral hemorrhage, during pregnancy and puerperium is significantly associated with mortality and morbidity. We report 3 cases of intracerebral hemorrhage during pregnancy and puerperium in which aneurysms or arteriovenous malformations were not found. In the first case, a 37-year-old woman presented with deteriorated consciousness and weakness because of the hematoma in the right frontal lobe. The computed tomography (CT) and the cerebral angiogram did not show any sources of the bleeding, and the hematoma was removed. In the second case, a 30-year-old woman suffered from severe disturbance of consciousness, and the CT indicated a hematoma in the left hemisphere. We removed the hematoma immediately, and the postoperative magnetic resonance imaging and the cerebral angiogram revealed moyamoya disease. In the final case, a 34-year-old woman suffered from HELLP syndrome, followed by continuous general seizure. The CT showed brain swelling and multiple small hemorrhages in the right hemisphere and the left occipital lobe. A decompressive craniectomy was performed because of brain swelling.
In these cases, rapid diagnosis and proper management brought good maternal and neonatal prognosis.

View full abstract

We report 2 pregnant women with intracerebral hemorrhage.
Patient 1 was a 26-year-old woman who presented with headache and consciousness disturbance. She was initially diagnosed with eclampsia. A Cesarean section was performed, but she subsequently developed left hemiparesis, and the disturbance of consciousness deteriorated; she was hence transferred to our hospital. A computed tomography (CT) scan revealed massive intracerebral hemorrhage at the right cerebral hemisphere. She could not be saved.
Patient 2 was a 34-year-old woman who presented with headache. A neurological examination revealed disturbed consciousness and left hemiparesis. A CT scan showed intracerebral hemorrhage in the right frontal lobe. Magnetic resonance imaging (MRI) indicated posterior reversible encephalopathy syndrome (PRES). On the day after Cesarean section, the intracerebral hematoma was evacuated. Aggregated abnormal vessels were identified at the base of the hematoma cavity. The histopathological examination revealed that the lesion was an arteriovenous malformation.
The association of pregnancy and stroke is rare, and it is difficult to distinguish between eclampsia and stroke-induced consciousness disturbance in pregnant women. Intracerebral hemorrhage in a pregnant woman may lead to serious consequences for both the mother and baby. We emphasize that immediate, appropriate diagnosis and treatment of intracerebral hemorrhage in a pregnant woman are crucial to save invaluable lives.

View full abstract

We present a rare case of a dissecting ruptured aneurysm of the right distal middle cerebral artery associated with subcortical hematoma and subarachnoid hemorrhage. A 57-year-old man with sudden onset of severe headache and left hemiplegia was referred to our hospital. A CT scan showed a subarachnoid hemorrhage in the right sylvian fissure associated with subcortical hematoma in the right temporo-parietal lobe. The right carotid angiogram revealed a fusiform aneurysm in the distal middle cerebral artery. The aneurysm was successfully excised. The postoperative course was uneventful, and his left hemiparesis recovered well. The distal middle cerebral dissecting aneurysm is extremely rare. We present this case with a review of the literature.

View full abstract

Posterior cerebral artery (PCA) dissection is rarely experienced, and therefore the treatment of this disease is still controversial. We report here 5 cases, and review the literature to clarify their therapeutic and prognostic aspects. In our group of 5 patients, 1 presented with repetitive subarachnoid hemorrhage (SAH) treated surgically by proximal ligation at the P1 segment. The other cases—2 patients with ischemia, 1 with SAH, and 1 incidental case—were treated conservatively. Over a mean follow-up period of 73 months, all patients remain independent. Three patients showed no neurological deficit and 2 showed mild disability. Angiography showed that 3 symptomatic patients had spontaneous resolution of the dissection. However, 1 patient treated with proximal ligation showed a recurrence of the dissecting aneurysm at the P2 segment via the posterior communicating artery. In our analysis of 53 cases with PCA dissection (including 48 previously reported cases), 21 patients presented with ischemic events and 19 had SAH. Nineteen of the 21 ischemic cases were treated conservatively and all showed good clinical outcomes. The remaining 2 ischemic cases were treated with endovascular surgery and showed good outcomes. Eleven of the 19 SAH cases were treated conservatively and all but 1 had good outcomes. The other 8 SAH cases included 5 patients with endovascular surgery were treated surgically and also showed good results. Conservative treatment with careful monitoring using neuroimaging modalities should be considered when a patient presents with a neurologically and morphologically stable condition.

View full abstract

The favorable surgical result of neck clipping (NC) for ruptured cerebral aneurysms is required even for young neurosurgeons. The results of NC performed by a young neurosurgeon under the supervision of senior neurosurgeons were studied over the last 6 years. The subjects were 32 patients with 34 small aneurysms of anterior circulation (10 males and 22 females) ranging from 27 to 79 years (mean age of 57 years). The location of the aneurysms were 17 of MCA, 13 of ACA and 4 of ICA. Hunt & Hess grade were Grade I to IV without Fisher group 4, and all aneurysms were clipped within 72 hrs of SAH. Outcomes were evaluated by GOS at discharge. Twenty-seven patients (84%) showed favorable outcome (GR+MD) and 3 patients (9.3%) died. Two patients had premature rupture during operation. There was no evidence of radiological cerebral contusion or venous infarction. Six patients (18.7%) developed symptomatic vasospasm and 4 patients (12.5%) had hydrocephalus that required VP shunt. Surgical results of NC for ruptured small aneurysm of anterior circulation by a young neurosurgeon are satisfactory under the supervision of senior neurosurgeon.

View full abstract

A stroke care unit (SCU) was established in Nagasaki University Hospital in June 2008, and comprehensive stroke care, together with a neurologist, neurosurgeon, dentist, physiotherapist, nurse and case worker, started. Totally, 236 patients, 143 males and 93 females aged from 1 to 97 years old (mean 63.3 years), were treated in SCU over a period of 12 months. The diagnostic category treated in SCU was cerebral infarction in 89 patients, cerebral hemorrhage in 71 patients and subarachnoid hemorrhage in 31 patients. In addition to stroke patients, patients with epilepsy or head injury and patients requiring neurological surgery were also treated in SCU. Advanced acute rehabilitation was applied to 160 patients. Dysphasia was evaluated by the dentist, and 87 patients were received dysphasia management. The hospital stay was shortened from 28 days to 22. An SCU is useful for the treatment of stroke patients as well as neurosurgical patients.

View full abstract

Restenosis is an important complication after carotid endarterectomy (CEA), but little is known about which antiplatelet drugs are suitable for prevention of restenosis. We investigated the occurrence of restenosis and the effect of cilostazol on carotid artery intima-media thickness (IMT) of the ipsilateral carotid artery after CEA. From January 2001 to December 2008, CEA was performed on 333 vessels in our hospital. At 30 days, the mortality and morbidity rate was 0.9%, respectively. Restenosis and occlusion occurred in 29 vessels (8.7%) during follow-up period (in 26 vessels during the first year after CEA). Carotid IMT was evaluated after CEA using duplex ultrasonography. Carotid max IMT showed a greater increase in the aspirin treatment group (n = 39) than in the cilostazol treatment with aspirin (n = 17). Especially, in subjects with type 2 diabetes, carotid max IMT showed a significantly greater increase in the aspirin group (n = 14) than in the cilostazol with aspirin group (n = 9). These results indicate that cilostazol therapy with aspirin can attenuate the increase of carotid artery IMT after CEA.

View full abstract

Spontaneous thrombosis of unruptured aneurysm is relatively rare. In previous reported cases, aneurysms thrombosed after some intervention for associated vascular lesions such as AVM, moyamoya or aneurysm. There have been no reports on spontaneous thrombosis of a usual unruptured aneurysm of anterior circulation without any intervention. A 70-year-old female patient visited our hospital for further evaluation of an unruptured aneurysm. One year before visiting our hospital, she was examined by MRI and MRA at another hospital. MRA disclosed an aneurysm at the right internal carotid artery. MRI and MRA at our hospital showed the aneurysm was the same as in the previous examination. The unchanged size and shape of the aneurysm on MRA over the course of a year may mean the aneurysm was not a dissecting aneurysm. Eight months after the initial study at our hospital, 3D-CTA failed to show the aneurysm. The aneurysm was thought to thrombose from the MRI findings. The exact mechanism of spontaneous thrombosis of the aneurysm is obscure.

View full abstract

We report a case of sylvian hematoma enlarging 3 days after neck clipping for a ruptured anterior communicating artery aneurysm, in the contralateral sylvian fissure to the operative approach.
This 65-year-old man was admitted with sudden loss of consciousness by ambulance. Angiography revealed a saccular aneurysm at the anterior communicating artery complex, measuring 2.3×2.4 mm and pointing inferiorly. The aneurysmal neck was successfully clipped by using the right pterional approach. To minimize predictable vasospasm, the hematoma in the left sylvian stem was removed. Postoperative CT scan showed a considerable decrease in hematoma in the basal cistern, but a slight decrease in the vertical portion of the left sylvian fissure. The patient’s consciousness gradually recovered, but deteriorated again 3 days after the operation. CT scan showed a large high-density area in the sylvian fissure suggesting unexpected enlargement of sylvian hematoma. A left fronto-temporal craniotomy was performed. When the subpial hematoma around the sylvial fissure was removed, a large amount of bloody cerebrospinal fluid (CSF) flowed out. The cavity containing bloody fluid was located in the temporal lobe. Postoperative course was uneventful. He recovered well, but moderate sensory aphasia remained.
Sylvian hematoma is rarely associated with ruptured anterior communicating artery aneurysms. Furthermore, there has been no report describing delayed onset sylvian hematoma as far as we are aware. The following mechanism was considered to explain this very rare condition. Removal of subarachnoid hematoma in the left sylvian fissure made a recovery of CSF flow up to the limen insulae, but CSF appeared to be blocked from entering the distal sylvian fissure by the thick subpial sylvian hematoma. Instead of normal CSF flow route, CSF may enter into the weakened subpial space to allow accumulation of bloody CSF in the temporal lobe. Subpial hematoma may act as a one-way valve.

View full abstract