Surgery for Cerebral Stroke
Online ISSN : 1880-4683
Print ISSN : 0914-5508
ISSN-L : 0914-5508
Volume 40, Issue 6
Displaying 1-11 of 11 articles from this issue
Topics: Unruptured Cerebral Aneurysm
  • Fusao IKAWA, Osamu HAMASAKI, Toshikazu HIDAKA, Yasuharu KUROKAWA, Ushi ...
    2012 Volume 40 Issue 6 Pages 381-386
    Published: 2012
    Released on J-STAGE: May 02, 2013
    JOURNAL FREE ACCESS
    In this study, we discuss the indications for surgery for unruptured cerebral aneurysm and the role of Japan, with special reference to the features of the Japanese medical system based on the data of ruptured cerebral aneurysm. We investigated 506 clipping cases of cerebral aneurysms from 1999 to 2011 in Shimane Prefectural Central Hospital: 182 unruptured cerebral aneurysms and 324 ruptured cerebral aneurysms.
    There were four cases (2.2%) of postoperative major complications of unruptured cerebral aneurysm, including two hemiparesis of symptomatic internal carotid artery aneurysm and two visual disturbance of paraclinoid aneurysms. There were two minor complications of transient memory disturbance and two complications of olfactory disturbance of anterior communicating artery aneurysms. There were 13 (7.1%) transient neurological deficits. Postoperative parenchymal abnormality on CT and/or MRI was seen in 14 (7.7%).
    Data show ruptured aneurysms occur most frequently in males in their 50’s and in females in their 70’s. The mean size of ruptured cerebral aneurysm according to site was 7±3.4 mm, 6.9±4.0 mm, and 5.7±2.5 mm in internal carotid artery posterior communicating artery aneurysms, middle cerebral artery aneurysms and anterior communicating artery aneurysms, respectively. Small aneurysms under 5 mm were 101 (31.1%).
    According to the OECD health data, Japan had the most acute care beds per 1,000 population and the most CT scan and Magnetic Resonance Imaging Units per million population.
    The treatment indication of unruptured cerebral aneurysm should be considered more precisely based on sex, age and site. In Japan, we have the most follow-up data on unruptured cerebral aneurysms and should share that data with the world.
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  • Yoshiaki KUMON, Hideaki WATANABE, Masahiko TAGAWA, Akihiro INOUE, Shir ...
    2012 Volume 40 Issue 6 Pages 387-393
    Published: 2012
    Released on J-STAGE: May 02, 2013
    JOURNAL FREE ACCESS
    We evaluated the neuropsychological functions of 105 patients who underwent 108 surgeries for unruptured cerebral aneurysms. All patients completed the Wechsler Adult Intelligence Scale-Revised (WAIS-R) before and one month after surgery. The aneurysms were located mainly in the anterior cerebral artery, middle cerebral artery, or internal cerebral artery. Deep white matter hyper-intensities (DWMH), brain atrophy and cerebral infarction were evaluated using preoperative magnetic resonance imaging (MRI). Brain contusion (large: 10 mm or more in largest diameter; small: smaller than 10 mm), subdural fluid collection (thick: midline shift observed; thin: mass effect observed without midline shift) and cerebral infarction were evaluated on postoperative MRI and/or computed tomography. A decrease of four points or more in the WAIS-R score postoperatively was interpreted as deterioration.
    Although there was no statistical difference between the preoperative and postoperative WAIS-R scores, 25 of 108 surgeries (23%) showed deterioration of the WAIS-R score postoperatively. Brain contusion on MRI was observed in 15 surgeries (large: 7; small: 8), and six of those surgeries (40%) showed deterioration of the WAIS-R score. Deterioration of the WAIS-R score was observed more frequently in patients with large brain contusion (4 of 7, 57%) than in those without brain contusion (19 of 93, 20%) (p<0.05). Brain contusion occurred more frequently in patients with moderate or severe DWMH (5 of 23, 22%) than in those without DWMH (2 of 43, 5%) (p<0.05), and in patients with ACoA aneurysm (5 of 26, 19%) than in those with MCA aneurysm (1 of 33, 3%) (p<0.05). Although large brain contusion was observed postoperatively in patients with aneurysms localized to the ACoA operated through the pterional approach, damage was not apparent in patients operated with an interhemispheric approach. Subdural fluid collection was observed after 14 surgeries (thick: 5; thin: 9), and four of those patients (29%) showed deterioration of the WAIS-R score. Deterioration of the WAIS-R score was observed more frequently in patients with thick subdural fluid collection (2 of 5, 40%) than in those without subdural fluid collection (21 of 94, 22%), though the difference was not significant. The occurrence of subdural fluid collection was more frequent in patients with brain atrophy (11 of 36, 31%) than in those without brain atrophy (3 of 72, 4%) (p<0.01). Although thick subdural fluid collection was observed in five of 91 surgeries and deterioration of the WAIS-R score was recognized in four of 91 surgeries using physiological saline solution, they were not observed using artificial cerebrospinal fluid. Cerebral infarction was observed in five surgeries, but deterioration of the WAIS-R score was not detected in those patients.
    Neuropsychological dysfunction due to brain damage or subdural fluid collection was observed after clipping unruptured cerebral aneurysms. The aneurysm location, presence of DWMH or brain atrophy were related to the occurrence of brain contusion or subdural fluid collection.
    Our findings suggest that results may be improved by selection of a surgical approach to reduce brain contusion or by usage of artificial cerebrospinal fluid instead of physiological saline solution during surgery.
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  • Shunsuke KAWAMOTO, Kanae MOCHIKI, Hideaki KANAYA, Masahiro OGHINO, Phy ...
    2012 Volume 40 Issue 6 Pages 394-401
    Published: 2012
    Released on J-STAGE: May 02, 2013
    JOURNAL FREE ACCESS
    Detailed preoperative microsurgical information regarding the scheduled route and the surrounding cisternal space around the aneurysm is mandatory for safe aneurysm surgery. We used constructive interference in steady-state imaging (CISS) to evaluate the microsurgical anatomy around the cerebral aneurysms prior to surgery in addition to three-dimensional computed tomography angiography and digital subtraction angiography. Among 219 patients, 243 intracranial unruptured aneurysms were evaluated using CISS before surgery, and 240 aneurysms in 216 patients were surgically obliterated in 218 procedures. The cranial nerves and other neural structures, and efferent and perforating vessels were confirmed during surgery. The high intensity signal of the cerebrospinal fluid (CSF) was used as an indicator of preserved cisternal space without adhesion between the aneurysm and its surrounding structures.
    Microsurgical information regarding the surgical route such as sylvian or interhemispheric fissure, and adhesion or close contact to surrounding tissues including oculomotor, optic and other cranial nerves and the tentorium and other basal dura was very useful for advancing the procedure precisely as planned. Adhesion to large efferent vessels was properly predicted, but identification and description of perforators around the aneurysm was incomplete in some cases, and careful confirmation of these vessels during surgery under direct vision was mandatory. Surgical outcome was excellent with no ischemic complications. Modified Rankin scale (mRS) at six months after surgery was 0 in all but one patient who developed permanent olfactory nerve dysfunction and became mRS1.
    Despite its inadequacy, CISS can contribute to safe aneurysm surgery by providing information on the detailed anatomical structure around the aneurysm and surgical route.
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  • Masataka TORII, Isamu SAITO, Akira TAMURA, Takuji KOUNO, Shiniti OKABE ...
    2012 Volume 40 Issue 6 Pages 402-408
    Published: 2012
    Released on J-STAGE: May 02, 2013
    JOURNAL FREE ACCESS
    Decision making on the prophylactic treatment of unruptured cerebral aneurysms (UCA) is a complicated process. Not only the medical condition but also the patient’s psychological factors can influence the patient’s decision as to whether to accept possibly invasive procedures or choose conservative management that may include an insidious risk of UCA rupture.
    Questionnaires were mailed to patients diagnosed with UCA’s between January 2002 and December 2012 in three affiliated institutions. The contents were factors affecting individual choices of prophylactic treatment or conservative treatment. At the same time, we examined patients’ Quality of Life (QOL) scoring according to Medical Outcome Study Short Form 36 Version2 (SF-36) when the questionnaires were mailed.
    Of the 114 patients who completed the questionnaires, 55 opted for prophylactic treatment for UCA and 59 chose conservative management for UCA. The prophylactic treatment group was strongly influenced by four factors: annual rupture rate, age, effect of SAH on family members, and personal trust in the doctor (p<0.05).
    This retrospective study on QOL of the patient after diagnosis showed the reliability of the health professionals and the psychological relationship between doctor and patient are crucial factors in making appropriate decisions in the prophylactic treatment of UCA.
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Topics: Anterior Choroidal Artery
  • Shunsuke KAWAMOTO, Kanae MOCHIKI, Hideaki KANAYA, Shinji YAMAMOTO, Phy ...
    2012 Volume 40 Issue 6 Pages 409-413
    Published: 2012
    Released on J-STAGE: May 02, 2013
    JOURNAL FREE ACCESS
    Posterior communicating (PCoA) aneurysm is one of the most common microsurgically treated aneurysms, in which the risk of symptomatic ischemic complication is not emphasized unless the anterior choroidal artery (AchA) is involved. We report three cases of PCoA aneurysm in which the AchA was arising from the PCoA. Sixty-seven PCoA aneurysms were surgically clipped over the past three years, and the AchA was found to be arising from the PCoA in three of them (4.5%). In all the three cases, the origin of the AchA was documented by digital subtraction angiography pre- or postoperatively. The PCoA was the fetal type. During surgery, motor evoked potential (MEP) was monitored, and patency of AchA was confirmed by indocyanine-green (ICG) videoangiography. No patient suffered from ischemic complication.
    We emphasize the importance of recognizing such anomalies in surgical treatment to avoid symptomatic ischemic complications. Routine use of MEP and ICG videoangiography is highly recommended even in surgery for PCoA aneurysms.
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  • Yoichi WATANABE, Kyouichi SUZUKI, Tsuyoshi ICHIKAWA
    2012 Volume 40 Issue 6 Pages 414-419
    Published: 2012
    Released on J-STAGE: May 02, 2013
    JOURNAL FREE ACCESS
    We treated 38 cases of the internal carotid artery (IC) aneurysms between April 2007 and December 2011. Twenty-seven cases were IC-posterior communicating artery (PCoA) aneurysms, eight cases were IC-anterior choroidal artery (AChA) aneurysms and three cases were IC anterior wall aneurysms. The intraoperative motor evoked potentials (MEPs) and fluorescein cerebral angiography (FAG) were monitored in these cases, and we estimated the cause and measures of blood flow insufficiency in the anterior choroidal artery. In five patients, disappearance or decrease of MEP amplitude was observed. In three patients with AChA aneurysm, transient MEP changes was caused by stenosis or occlusion of the AChA by the clip, and MEP recovered to the control level after the clip reposition. Postoperative deficits were not observed. In two patients with PCoA aneurysm, the vasospasm of AChA occurred due to mechanical stimulation to AChA during dissection from aneurysm, and MEP disappeared. By application of papaverine hydrochloride to the AChA, MEP recovered in a patient and postoperative neurological deficits did not occur. In the other patient, patency of AChA was observed by FAG but MEP was not recovered and motor deficits were observed. In clip application of the IC-AChA aneurysm, although patency of the AChA was microscopically apparent, the occlusion of the true inside of the AChA did not occur. We should apply clips to preserve the AChA in reference to MEP findings.
    Intraoperative MEP monitoring and FAG are useful to prevent ischemic complication by occlusion of the AChA during IC aneurysm surgery.
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Original Articles
  • Yoshinori SAKATA, Hiromu HADEISHI, Michihiro TANAKA, Yujiro OBIKANE, A ...
    2012 Volume 40 Issue 6 Pages 420-424
    Published: 2012
    Released on J-STAGE: May 02, 2013
    JOURNAL FREE ACCESS
    Of the complications associated with cerebral aneurysm clipping, injury to the perforating branches can greatly affect treatment outcome. Lenticulostriate artery injury is an issue in middle cerebral artery (MCA) aneurysms, occurring with particularly high frequency during surgery for MCA horizontal segment aneurysms. We retrospectively investigated the characteristics and treatment outcomes of MCA horizontal segment aneurysms and considered the therapeutic strategy.
    The subjects were seven patients with MCA horizontal segment aneurysms from among 65 patients with MCA aneurysms in whom aneurysm neck clipping was performed between January 2008 and December 2011. The patients comprised one man and six women, with a mean age of 50.4 years (range, 37–65 years), with either ruptured (n=2) or unruptured (n=5) MCA horizontal segment aneurysms. Aneurysm morphologies included superior-wall (n=4) and inferior-wall (n=3) types, with a mean diameter of 4.5 mm. Multiple cerebral aneurysms were observed in six patients. The incidence of MCA horizontal segment aneurysms represented approximately 10% of the MCA aneurysms treated during the study period, which is comparable with previous study findings. All multiple aneurysm cases involved ipsilateral MCA aneurysms. No surgical complications, including perforating branch injury, were observed; both ruptured and unruptured cases scored 0 on the modified Rankin Scale.
    During surgery, special attention must be given to preserving the perforating branches. Therefore, if we find that the aneurysm is embedded in surrounding parenchyma, it is freed and fully exposed, and the presence or absence of perforating branches behind the aneurysm is confirmed. We also do not advocate temporary occlusion of the parent artery. This wide surgical field and careful manipulation have helped achieve satisfactory surgical outcomes for MCA horizontal segment aneurysms. Previous studies also report comparatively favorable outcomes for unruptured aneurysms.
    The increased surgical difficulty associated with ruptured MCA horizontal segment aneurysms compared to unruptured aneurysms suggests that surgery is indicated for MCA horizontal segment aneurysms even in the unruptured state.
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  • Hidenori SEYAMA, Akio NOGUCHI, Hiroki KURITA, Eishi SATO, Yoshifumi KO ...
    2012 Volume 40 Issue 6 Pages 425-430
    Published: 2012
    Released on J-STAGE: May 02, 2013
    JOURNAL FREE ACCESS
    We report three cases treated with the same concept for intracranial aneurysms not amenable to direct aneurysmal obliteration. Our treatment strategy is to reduce the hemodynamic burden of aneurysms and avoid ischemic complications of perforating arteries. It consists of isolation of several branches from the parent artery of the aneurysm with bypasses and endovascular techniques. Three treated cases comprised two partially thrombosed unruptured aneurysms and one ruptured dissecting aneurysm. Although the three cases involved different disease entities, they were treated under the same treatment concept, and the patients obtained good results. In the two partially thrombosed aneurysms, almost complete or virtually complete thrombosis had been achieved, and significant shrinkage of the aneurysm was observed. Our strategy prevented aneurysmal rupture in all cases, and is considered effective in promoting thrombosis of the aneurysm. All the demonstrated cases also showed shrinkage of the aneurysm.
    Further study on this treatment concept is necessary to confirm its clinical efficacy and safety.
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  • Taku YONEYAMA, Akitsugu KAWASHIMA, Nobuya OKAMI, Kohji YAMAGUCHI, Akir ...
    2012 Volume 40 Issue 6 Pages 431-436
    Published: 2012
    Released on J-STAGE: May 02, 2013
    JOURNAL FREE ACCESS
    Carotid endarterectomy (CEA) has been established to prevent cerebral infarction due to carotid artery stenosis. However, periprocedural risks under 3% for asymptomatic stenosis and 6% for symptomatic stenosis must be maintained to justify the indications. We evaluated our technique and outcomes of CEA to verify whether our protocol of CEA management can meet the criteria. Between February 2007 and September 2010, 121 consecutive patients with 124 stenosed carotid arteries were treated by the same two surgeons. The patients were among the CEAs at our faculty during the same period. There were 108 men and 13 women with a mean age of 70. Symptomatic and asymptomatic arms included 35 and 89 CEAs, respectively. We performed CEAs under general anesthesia with orotracheal intubation, routinely using the T shaped shunt tube. The mean operative time was 186.5 minutes (±34.3). We found that when carotid bifurcation level was higher, the operative time tended to be longer. Mean length of hospital stay after CEA was 10.3 days (±3.5). Of 124 CEAs, three cases demonstrated neurological deteriorations at the time of discharge; one had dysphagia continuing after discharge, one had new cerebral infarction with deteriorated pre-existing hemiparesis and hyperperfusion just after the procedure and one had new cerebral infarction and dysphagia with difficulty of food intake. Three cases had hyperperfusion greater than a 100% increase in the corrected regional cerebral blood flow compared with preoperative values. No cerebral hemorrhage was found in our series during hospitalization. Of 107 CEAs followed up, eight had restenosis (≥50%) detected with ultrasonography within 6-8 months after CEA. Within 30 days after CEA for 116 CEAs, the morbidity rate was 1.7 % (3.1% in the symptomatic arm and 1.2% in the asymptomatic arm) and mortality was 0.0%. The morbidity demonstrated two ischemic strokes and no MI in this series.
    Our method of CEA proved to be a safe and efficient for treatment of carotid artery stenosis.
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Case Reports
  • Tadashi NAKAGAWA
    2012 Volume 40 Issue 6 Pages 437-442
    Published: 2012
    Released on J-STAGE: May 02, 2013
    JOURNAL FREE ACCESS
    The incidence of unilateral optic nerve neuropathy after aneurysm surgery—except paraclinoid internal carotid artery (IC) aneurysm (AN)—is very rare. I experienced three cases of unilateral optic nerve neuropathy in my 431 cases of aneurysm surgery. I report on these three cases: a 58-year-old woman with an unruptured AN arising at the right middle cerebral artery, a 59-year-old woman with a ruptured AN arising at the left middle cerebral artery, and a 58-year-old man with an unruptured AN arising at the left IC. In each case, aneurysm clipping was successful in obliterating the AN and direct optic nerve injury seemed to be remote during surgery. All patients complained of reduced visual acuity and inferior hemianopia ipsilateral to the site of surgery, and an ophthalmological evaluation suggested they suffered ischemic optic neuropathy due to malcirculation of the posterior ciliary artery. Postoperative angiograms revealed an intact ophthalmic artery in each case. Optic nerve neuropathy in the three cases gradually improved during follow-ups of from two to 16 months. Although there are some possible etiological factors concerning optic nerve neuropathy, the pathophysiology of this optic nerve neuropathy after aneurysm surgery is unknown.
    I speculate that even extremely careful surgical manipulation may have injured the surface of the optic nerve and/or the fine vasculature of the optic structures in two of the cases of unruptured ANs and, in addition, ischemia of fragile posterior ciliary artery due to delayed vasospasm seems to have been responsible for the damage of the optic nerve in the case of ruptured AN.
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  • Reiko NAKAU, Fusao IKAWA, Osamu HAMASAKI, Toshikazu HIDAKA, Yasuharu K ...
    2012 Volume 40 Issue 6 Pages 443-447
    Published: 2012
    Released on J-STAGE: May 02, 2013
    JOURNAL FREE ACCESS
    We present a surgical case of a dissecting aneurysm of the middle cerebral artery associated with subarachnoid hemorrhage. A 70-year-old woman was admitted to our hospital, complaining of headache and vomiting. A CT scan showed diffuse subarachnoid hemorrhage. The left carotid angiogram revealed complete occlusion at the M1 portion of the middle cerebral artery and an IC-PC bifurcation aneurysm. We conducted emergency surgery in Shimane prefectural central hospital. We detected an IC-PC bifurcation unruptured aneurysm and a large dissecting aneurysm with a purplish-red wall arising from the left M1 trunk, and trapped the aneurysm with STA-MCA anastomosis.
    We present this case with a review of the literature.
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