The treatment for cerebrovascular disease has recently drastically changed. Novel endovascular interventions have been introduced and rapidly advanced. Consequently, many cases are being treated by newly developed endovascular interventions. We conducted a nationwide questionnaire survey covering all 3,021 members of the Japanese Society on Surgery for Cerebral Stroke and analyzed the 1,043 (34.5%) replies. The Japan Neurosurgical Society furnished us with the official data: the numbers of neurosurgeons in Japan, neurosurgical wards and institutes, surgeries (cerebrovascular disease, others), and kinds of operable conditions. These data are from 2001 to 2010. The numbers of new neurosurgeons have decreased during the last decade. However, the number of brain surgeries has increased, increasing the burden on neurosurgeons. Coil embolization accounted for 32% of treated unruptured cerebral aneurysms and 24% of treated ruptured cerebral aneurysms in Japan in 2010. The rate of coil embolization in the U.S. is twice that in Japan. If coil embolization increases in Japan as it has in the U.S., Japan will have to double the number of its neurointerventional specialists in the near future. However, the results of questionnaire indicated it will be difficult to obtain the required number of neurointerventional specialists in this country due to a decline in the number of training institutes. Further discussion between the fields of cerebrovascular surgery and neuro-endovascular intervention is indispensable to developing the proper educational system in Japan for the near and long term.
Dural arteriovenous fistulas (DAVFs) of the anterior cranial fossa are rare anomalies that invariably present with cortical venous reflux because of the absence of dural sinus in the affected region. Previous reports have identified intracranial hemorrhage as the major symptom and have confirmed that good surgical outcome can be obtained by open surgery. Recently, however, the widespread use of MRI has led to an increase in the incidental detection of asymptomatic DAVFs of the anterior cranial fossa. Treatments for these asymptomatic lesions are now a focus of discussion. We treated four patients with anterior cranial fossa DAVFs between 2005 and 2010. One of the patients presented intracranial hemorrhage and the other three were asymptomatic. The three patients with intracranial hemorrhage underwent open surgery and the other asymptomatic patient underwent endovascular surgery. The latter patient initially underwent transarterial embolization with only partial success. The patient was completely cured by the transvenous approach with platinum coils. All four patients were successfully treated without any adverse events. Previous papers reported similarly high annual intracranial hemorrhage rates from DAVFs with cortical venous reflux. This suggests that surgical treatment for asymptomatic patients with anterior cranial fossa DAVFs should be considered. Direct surgery has been the treatment of choice for this disease so far. For asymptomatic patients, however, endovascular treatment with transvenous embolization may serve as an effective alternative to open surgery.
Warfarin-related intracranial hemorrhage (ICH) is a medical emergency. Rapid reversal of warfarin anticoagulation is needed to prevent hematoma growth. Current therapy with vitamin K and fresh-frozen plasma (FFP) may be too slow in certain situations.
Seven patients with ICH and eight patients with traumatic intracranial hemorrhage received 80 μg of recombinant activated factor VII (FVII) per kilogram in combination with vitamin K for emergency reversal of warfarin. One patient with ICH was treated with FVII only, to temporarily reverse anticoagulation. No patients were treated with FFP. The median age of the patients, seven males and nine females, is 78.6. After initial FVII administration, the international normalized ratio (INR) decreased from a mean 3.7 (1.45–13.08) to around 1.0 except for two cases. The INR of these two cases decreased a few hours later. Only one patient treated for occlusion at the femoral artery had a recurrence of thromboembolic occlusion after one week. The most common indications for anticoagulation were atrial fibrillation, prothetic valve, deep vein thrombosis, and peripheral artery thrombosis. FVII is safe and highly effective when emergency reversal of coagulopathy is desired. But further study is necessary to demonstrate improvement of patient outcome.
We sought to compare medical costs of coiling and clipping for treatment of cerebral aneurysms. Data of total medical costs for coiling and clipping from 2006 to 2009 were retrieved from the medical reimbursement database at Teikyo University Hospital. There were 32 and 29 cases, respectively, for coiling and clipping of ruptured aneurysm who presented with subarachnoid hemorrhage, and 41 cases each with unruptured aneurysms for coiling and clipping. In patients with ruptured aneurysms, basic hospitalization costs were lower in the coiling group even with higher device-related costs. As a result, total medical costs during hospitalization were equivalent between the coiling and clipping groups. In patients with unruptured aneurysms, however, total medical costs during hospitalization were much higher in the coiling group than those in the clipping group. The difference in an amount of basic hospital costs was not enough to absorb the higher device-related costs in the coiling groups due to relatively shorter length of hospital stays in patients with unruptured aneurysms. Medical costs for treatment of cerebral aneurysms are well balanced between coiling and clipping in patients with subarachnoid hemorrhage. Coiling of unruptured aneurysms, however, pushes up the total amount of medical costs significantly due to higher device-related costs compared with clipping.
We report the clinical characteristics, treatment, and detection rate of dural arteriovenous fistulas (DAVF) in a Wakayama Prefecture study. Between January 1989 and December 2008, 134 patients with DAVF were hospitalized in Wakayama Prefecture: 88 women and 46 men (mean age 63.5 years; range, 11–82). The crude detection rate (per 100,000 persons per year) was 1.06 in Wakayama. Clinical presentations were diplopia/chemosis (32.3%), pulsatile tinnitus (25.6%), hemorrhage (14%), headache/dementia (8.3%), radiculopathy (5.0%), and incidental (10%). The locations of DAVF were cavernous (38.0%), transverse-sigmoid (32.1%), spinal (8.2%), craniocervical (6.7%), superior sagittal sinus (6.0%), tentorium (5.2%), and anterior cranial fossa (2.3%). Most patients (86.5%) underwent endovascular treatment. Complete shunt obliteration was achieved in 67% of the patients, almost complete occlusion in 26% and shunt reduction in 6.6%. The cumulative complication rate was 8.1% (n=15), with minor adverse events in 10 patients and major complications in four patients (2.2%). The detection rate of DAVF was higher in our series than in previous reports. We hypothesize that availability of high spatial and resolute MRI in the screening contributed to the increased detection rate of DAVF.
Elective surgery for asymptomatic small (<5 mm) unruptured intracranial aneurysms (UIAs) remains controversial. To reveal the current trend and outcomes in the management of (UIAs) in daily clinical practice, we retrospectively analyzed treatment options and surgical morbidity of small UIA cases in our institute (Group A: 129 aneurysms) and from the Nagasaki UIA Registry (Group B: 610 aneurysms) over the four recent years (2006–2009). After discreet discussions including recent prospective data of rupture risk and guidelines for treatment of small UIAs as part of informed consent procedure, only 7% (9 aneurysms) of the patients in Group A chose surgical treatment of either clipping or coiling, on which no intra- or post-surgical morbidity was observed. Direct surgical or endovascular interventions were performed in 267 aneurysms in Group B, in which a significant number of complications were reported (mRS≥2=5.9%; mRS 1=7.7%, at three months after the surgery). In view of recent studies suggesting low annual rupture rates (0.3–0.5%/yr) with significant morbidity rates (2–7%) of small UIAs, more conservative management should be considered, especially for UIAs smaller than 5 mm.
It is very difficult to treat bilateral large vertebral dissecting aneurysms, because of the anatomical complexity and the technical difficulty of vascular reconstruction. We report a case of a 46-year-old male who presented with numbness of extremities and dysphagia caused by large bilateral vertebral dissections. The left vertebral dissection was trapped first, but subarachnoid hemorrhage caused by rupture of a right dissecting aneurysm occurred two days after surgery. The second operation was performed about one month after the first one by trapping of the right dissecting aneurysm combined with vertebral-posterior cerebral artery bypass using a radial artery graft. The patient returned to daily life about three months after the second operation. Surgical strategy for bilateral large vertebral dissections should be determined in consideration of the aneurysmal fragility, accessibility for vascular reconstruction and anatomical aspects.
We report a rare case of ruptured dissecting aneurysm of the distal middle cerebral artery. A 57-year-old male suffered from headache with a subarachnoid hemorrhage (SAH). Computed tomography showed SAH and a small intracerebral hematoma in the right frontal lobe. Three-dimensional digital subtraction angiography (DSA) using a flat panel detector (FPD) revealed irregular dilatation at the M3 portion of the right middle cerebral artery. Contrast-enhanced three-dimensional T1 weighted images showed a low-intensity mass around the abnormally dilatated right M3 branch. Surgery was performed to prevent critical rebleeding. The lesion was excised, and flow to the distal MCA branch was preserved with superficial temporal artery-middle cerebral artery anastomosis. A histological examination revealed that irregular dilatation of the right MCA was due to arterial dissection caused by disruption of the internal elastic lamina. Three-dimensional-DSA and contrast-enhanced three-dimensional MRI were indispensable for accurate preoperative diagnosis and informed the surgeon of the exact orientation of the aneurysm.
Intracranial aneurysms are extremely uncommon in the pediatric population. Their epidemiology is poorly understood and certain features, including their location, morphology and presentation, make them unique compared with their adult counterparts. In this report, we present the case of a 6-year-old boy with basilar aneurysm admitted to our hospital. Digital subtraction angiography and three-dimensional CT angiography revealed a giant (26-mm) basilar aneurysm located in the prepontine cistern. Clipping of the aneurysm was performed successfully. This report also includes a thorough review of the literature on pediatric giant aneurysm. Continuous follow-up is essential for this patient group.
The treatment of large cerebral arteriovenous malformations (AVMs) is still difficult and challenging. Reported here is a case of complete cure of a large right parietal AVM treated by multi-staged embolization and gamma knife surgery (GKS). A 31-year-old woman was referred to our hospital with intraventricular hemorrhage caused by a large AVM in the right parietal lobe. The nidus size was 68×69×37 mm. The main feeders were the right anterior cerebral arteries (ACA), right middle cerebral arteries (MCA) and right posterior cerebral arteries (PCA), and drained by the cortical veins. We embolized feeders of the PCA, ACA and MCA with coils and polyvinyl acetate (PVAc) four times. Thereafter, nidus size was reduced to less than 30 mm and she underwent the first GKS. An angiogram showed the nidus size had been reduced to 6×4×4 mm two years after the first GKS, and a further angiogram one year later showed the nidus size had been reduced to 3×2×2 mm. The patient underwent GKS again four years after the first GKS as the size of the nidus remained unchanged from the last angiogram. An angiogram two years after the second GKS showed the nidus had disappeared. The second GKS was successfully achieved in this patient without neurological deterioration. Repeated GKS treatment minimizes endovascular complications and maximizes the treatment effect when multimodality therapy is used for large AVMs, illustrating the effectiveness of this approach.
Direct neck clipping of basilar top aneurysm is still difficult because this aneurysm is so deeply located that the operative field is narrow and restricted by many surrounds of important perforators and nerves. Moreover, because the transsylvian approach for these lesions is chosen, the internal carotid artery and the posterior communicating artery often restrict the access to the basilar top aneurysm. In surgery for basilar top aneurysm accompanied with ipsilateral internal carotid aneurysm, the transsylvian approach has the advantage that both aneurysms are clipped under the same operative field, though clipping for both aneurysms is more difficult and challenging than basilar tip aneurysm alone. We describe several methods to obtain a wider approach for successful clipping of both aneurysms located internal carotid and basilar top.