脳卒中の外科
Online ISSN : 1880-4683
Print ISSN : 0914-5508
ISSN-L : 0914-5508
45 巻, 1 号
選択された号の論文の11件中1~11を表示しています
特集 CAS と術後評価
  • 佐藤 洋平, 戸根 修, 原 睦也, 唐鎌 淳, 橋本 秀子, 渡邊 顕弘, 原 祥子, 玉置 正史
    2017 年 45 巻 1 号 p. 1-6
    発行日: 2017年
    公開日: 2017/04/21
    ジャーナル フリー
    Hyperperfusion syndrome is a complication of carotid artery stenting (CAS) that leads to a poor outcome. Therefore, prevention of hyperperfusion syndrome is important in the perioperative management of CAS. We performed CAS under general anesthesia with both proximal balloon protection and distal filter protection. We used the Invos system to monitor regional cerebral oxygen saturation (rSO2) for 2 days after CAS. Although the Invos system provides continuous and less-invasive monitoring, rSO2 values may be influenced by the patient's respiratory or circulatory conditions. In this study, we compared perioperative rSO2 monitoring and single-photon emission computed tomography (SPECT) imaging, and report the efficacy of rSO2 monitoring in predicting hyperperfusion syndrome.
    Methods: SPECT was performed before and one day after CAS; rSO2 monitoring was continuously performed from immediately before induction of general anesthesia until two days after CAS.
    Results: In total, 44 patients underwent 49 CAS operations at our institution between January 2012 and December 2013. One patient who did not undergo SPECT imaging 1 day after CAS was excluded. The median age of all patients was 74 years and 88% patients were male. One patient experienced asymptomatic subarachnoid hemorrhage after CAS. According to the SPECT imaging results, hyperperfusion phenomenon was diagnosed in 4 patients, in 3 of whom the increase in the ratio of rSO2 on balloon deflation was above 0.2 and the decrease in ratio of rSO2 on balloon inflation was below 0.15. In one of these 4 patients, compared to the preoperative status, the difference between ipsilateral rSO2 and contralateral rSO2 increased by more than 5% after CAS.
    Conclusion: A change in the rSO2 ratio by proximal balloon protection could be one of the indices of hyperperfusion phenomenon. In some cases, rSO2 monitoring alone may not detect hyperperfusion. Therefore, another method such as SPECT imaging may be used in combination with rSO2 to detect hyperperfusion syndrome after CAS.
  • 野村 達史, 笹森 大輔, 野中 雅, 高橋 明, 米増 保之, 恩田 敏之, 本田 修, 橋本 祐治, 大坊 雅彦, 茅野 伸吾, 山下 ...
    2017 年 45 巻 1 号 p. 7-13
    発行日: 2017年
    公開日: 2017/04/21
    ジャーナル フリー
    Computed tomography angiography (CTA) is useful for postoperative evaluation of restenosis and plaque protrusion after carotid artery stenting (CAS). However, stent artifacts are a common problem in the evaluation of CTA images, which are dependent on characteristics such as stent structure and raw materials. Especially Carotid Wallstent Monorail (CWS; Boston Scientific, Natick, MA, USA), which is made of cobalt-chromium alloy and tantalum, generates severe artifacts as compared with nitinol stents because of the high atomic number of tantalum. CWS is a closed-cell stent; thus, the braided wire is characteristically linear and cyclic. Therefore, we hypothesized that the effects of tantalum can be avoided by appropriate positioning of the patient in the CT scanner. In this study, we aimed to establish an optimal protocol for CTA after CAS with CWS.
    Material and methods: CWS (10 × 24 mm) was used as a blood vessel model. After reconstitution of the contrast agent in diluent, CTA was performed by varying the tilt angle of the stent with respect to the Z-axis from 0° to 60°. The CT value was measured in any of the three points in the stent strut. Thirty consecutive patients who underwent CAS with CWS were examined to determine the relationship between the tilt angle and the CT value of the stent strut retrospectively.
    Results: In the phantom experiment with a blood vessel model, the CWS artifacts in the curved multiplanar reconstruction (MPR) images evaluated by using Noise SD decreased with the tilt angle, especially at the tilt angle of 35–45°. Noise SD is largest at the narrowest blood vessel diameter, even at the same tilt angle. In the 30 clinical cases, a negative correlation was observed at the tilt angle of 13–40° (r = -0.73). A negative correlation was also observed between the Noise SD and minimum vessel diameter (r = -0.36).
    Conclusion: CTA after CAS with CWS could be useful for evaluating the in-stent lumen with the appropriate tilt angle to reduce artifacts.
特集 くも膜下出血後の正常圧水頭症に関する話題
  • 中塚 慶徳, 川北 文博, 安田 竜太, 梅田 靖之, 当麻 直樹, 阪井田 博司, 鈴木 秀謙
    2017 年 45 巻 1 号 p. 14-18
    発行日: 2017年
    公開日: 2017/04/21
    ジャーナル フリー
    The development of shunt-dependent hydrocephalus is a well-known complication of aneurysmal subarachnoid hemorrhage (SAH). Cilostazol is known to prevent the development of symptomatic vasospasm after aneurysmal SAH. We retrospectively analyzed 153 patients with SAH admitted to our hospital between January 2008 and December 2014 to determine whether cilostazol inhibits development of hydrocephalus. Patients with SAH of unknown origin, traumatic SAH, and mycotic aneurysm were excluded, and 98 patients were studied. Of these, 64 received cilostazol and 34 did not. Clinical factors including cerebrospinal fluid diversion were examined in each group. The cilostazol group was associated with lower incidence of shunt-dependent hydrocephalus after aneurysmal SAH (cilostazol (-), 11 of 34 patients [32%]; cilostazol (+), 9 of 64 patients [14%]; p=0.039). The findings suggested that cilostazol may suppress the development of post-SAH shunt-dependent hydrocephalus, although further studies are needed to elucidate the precise role of cilostazol in the development of hydrocephalus.
  • 藤本 康倫, 梶川 隆一郎, 木下 喬弘, 井筒 伸之, 森 康輔, 芳村 憲泰, 久村 英嗣, 若山 暁, 吉峰 俊樹
    2017 年 45 巻 1 号 p. 19-22
    発行日: 2017年
    公開日: 2017/04/21
    ジャーナル フリー
    Objective: This study evaluated the results of treatment for hydrocephalus secondary to aneurysmal subarachnoid hemorrhage (aSAH) using a lumboperitoneal shunt (LPS) as a first-line procedure.
    Materials and methods: We studied 114 patients with aSAH treated in our institute between July 2012 and June 2014. Of these, 39 patients who underwent shunt placements were analyzed retrospectively.
    Results: An LPS was placed in 18 patients (46.2%) and a ventriculoperitoneal shunt (VPS) in 21 (53.8%). An LPS was placed in 9 of 23 patients (39.1%) who had undergone coil embolization and in 9 of 16 (56.3%) who had undergone clipping or coating of aneurysms. LPS was preferentially chosen over VPS for patients who were younger, and those with intraventricular hemorrhage and a longer interval between the onset of aSAH and shunt placement. There was no significant difference in shunt efficacy and symptomatic surgical complications between the two procedures. Hemorrhagic complications or intracerebral hemorrhage along the ventricular catheter tract developed in two patients receiving aspirin after VPS following coil embolization.
    Conclusion: LPS was as safe and effective as VPS for the treatment of hydrocephalus secondary to aSAH.
原  著
  • 藪崎 肇, 水谷 徹, 杉山 達也, 松本 政輝, 中條 敬人, 鷲見 賢司, 飯塚 一樹, 加藤 優, 久保 美奈子, 阪本 有, 今泉 ...
    2017 年 45 巻 1 号 p. 23-27
    発行日: 2017年
    公開日: 2017/04/21
    ジャーナル フリー
    Carotid endarterectomy (CEA) is an effective choice of treatment for the prevention of stroke in patients with carotid artery stenosis. The prevention of cranial nerve injury during CEA is necessary in order to improve the surgical outcome. In our institute, 641 CEA procedures were performed by 34 operators between January 1997 and June 2013. All the procedures were performed in a unified way, such that they were performed in the carotid sheath. We found that the incidence of persistent cranial nerve injury was 1.4%, which is a very good result.
    We report our surgical considerations regarding protecting the cranial nerves and improving the surgical outcomes.
  • 森﨑 雄大, 米澤 泰司, 明田 秀太, 井上 美里, 新 靖史, 鄭 倫成, 輪島 大介, 古家一 洋平, 岡本 愛, 角谷 美帆, 古田 ...
    2017 年 45 巻 1 号 p. 28-34
    発行日: 2017年
    公開日: 2017/04/21
    ジャーナル フリー
    The efficacy of and indications for acute carotid endarterectomy (CEA) in patients with stroke-in-evolution are still unclear. Here, we discuss the safety and plaque features of five patients undergoing acute CEA.
    We studied five male patients (mean age of 70.6 years) with thromboembolism from cervical plaques. The preoperative median value of the National Institutes of Health Stroke Scale (NIHSS) score was 1 (0-10).
    Preoperative plaque imaging studies showed three cases with low intensity, one with ulceration, and one with a floating atheroma. All five patients had undergone CEA within a week of onset between March 2011 and March 2014. None had postoperative recurrence.
    We believe that CEA is more beneficial for patients with thromboembolic diseases such as carotid atheroma and stroke-in-evolution than management with medication alone.
  • 前田 匡輝, 石川 達哉, 師井 淳太, 引地 堅太郎, 小林 慎弥, 齋藤 浩史, 田邉 淳, 鈴木 明文
    2017 年 45 巻 1 号 p. 35-40
    発行日: 2017年
    公開日: 2017/04/21
    ジャーナル フリー
    Seizures, including generalized convulsions and simple and complex partial seizures, rarely occur after surgical clipping of unruptured cerebral aneurysms. We conducted a detailed investigation of cases of seizures after clipping for unruptured aneurysms. A total of 235 patients (78 men and 157 women; mean age, 63.0±9.1 years) with 251 aneurysms underwent surgical clipping of unruptured aneurysms. Intravenous administration of prophylactic antiepileptic drugs was continued for 1 or 2 days after surgery. Seventeen patients (6.7%) had seizures after surgery. Patients who underwent surgery through a transsylvian approach developed seizures significantly more frequently when compared with patients treated through other approaches, such as an interhemispheric approach (p=0.008). Onset of seizures occurred 3.5±2.5 days after surgery, and 13 patients (76.4%) developed seizures within 4 days. Three patients developed generalized seizures, 2 developed secondarily generalized seizures, and 12 developed partial seizures. Magnetic resonance imaging was obtained in 14 patients immediately after a seizure; 4 patients (28.5%) had high signals on diffusion-weighted imaging. Most of the patients discontinued antiepileptic drug therapy within 1 year after surgery. Because most patients with unruptured aneurysms are asymptomatic, seizures after surgery should be prevented whenever possible. Therefore, it is necessary to use appropriate prophylactic treatment for postoperative seizures.
症  例
  • 中川 実, 河村 茂雄, 豊嶋 敦彦, 藤原 賢次郎
    2017 年 45 巻 1 号 p. 41-45
    発行日: 2017年
    公開日: 2017/04/21
    ジャーナル フリー
    We report a case of a large thrombosed internal carotid-posterior communicating artery aneurysm presenting with atypical trigeminal neuralgia. A 67-year-old woman presented with atypical trigeminal neuralgia of the left ophthalmic nerve territory. The patient underwent several nerve block therapies for the pain, and the symptoms got better each time. The patient considered neurosurgery after a left oculomotor palsy occurred. Magnetic resonance imaging revealed a left partially thrombosed large internal carotid-posterior communicating artery aneurysm distorting the left trigeminal nerve. The aneurysm was successfully treated using the neck clipping method, following which, both the trigeminal neuralgia and oculomotor nerve palsy improved.
  • 林 健太郎, 林 之茂, 松尾 義孝, 白川 靖, 上之郷 眞木雄
    2017 年 45 巻 1 号 p. 46-52
    発行日: 2017年
    公開日: 2017/04/21
    ジャーナル フリー
    Carotid artery atheroma may rupture and result in acute thrombotic occlusion or artery-to-artery cerebral embolism. Here, we report a case of internal carotid artery (ICA) occlusion treated emergently by endovascular recanalization and by carotid endarterectomy in the chronic phase. A 62-year-old man was brought to our hospital because of sudden onset of right hemiparesis. His National Institutes of Health Stroke Scale score was 15. Computed tomography (CT) showed no abnormality except for left middle cerebral artery (MCA) hyperdensity. Magnetic resonance imaging with diffusion weighted imaging (MRI-DWI) showed hyperintensity in the left basal ganglia and left frontal lobe, indicating acute ischemia. Neither the left ICA nor the MCA was visible on magnetic resonance angiography. Following intravenous tissue plasminogen activator therapy, endovascular treatment was employed. First, ICA occlusion was treated with a thrombus aspiration device and M1 occlusion was recanalized using a stent-type thrombus retriever. Since the right ICA was reoccluded, balloon angioplasty was additionally performed. Complete recanalization was obtained and the patient recovered completely. Carotid endarterectomy was performed for the residual stenosis three weeks later, preventing hemorrhagic infarction or hyperperfusion syndrome. The postoperative course was uneventful. Endovascular treatment was useful for the acute ICA occlusion and radical surgical treatment was recommended for residual stenosis in the chronic phase.
  • 田島 洋佑, 早坂 典洋, 奥山 翼, 海老原 幸一, 岡 陽一, 須田 純夫
    2017 年 45 巻 1 号 p. 53-58
    発行日: 2017年
    公開日: 2017/04/21
    ジャーナル フリー
    We report a case of middle cerebral artery (MCA) occlusion with intracranial internal carotid artery (ICA) stenosis in a patient who underwent percutaneous transluminal angioplasty (PTA) and thrombectomy.
    A 73-year-old man with right hemiparesis and aphasia was brought to our hospital by ambulance, 280 minutes after symptom onset. Diffusion-weighted imaging (DWI) showed acute infarction of the left caudate lenticular nucleus, insular cortex, frontal lobe, and corona radiata. Magnetic resonance angiography (MRA) showed left MCA occlusion and left intracranial ICA stenosis. We performed PTA for intracranial ICA stenosis initially, and then performed thrombectomy. Finally, we achieved successful recanalization (Thrombolysis in Cerebral Infarction grade 3). After interventional therapy, the right hemiparesis and aphasia improved. The modified Rankin scale score was 1 at 3 months after onset. Restenosis of the intracranial ICA was detected on digital subtraction angiography (DSA) and MRA after 3 months. Because no further progression of stenosis was observed after 6 months, we continued medical therapy and close follow-up.
    Emergency PTA and subsequent thrombectomy were comparatively safe and useful. However, the risks of recurrence and restenosis are problematic. Strict medical therapy and imaging follow-up are needed.
  • 一桝 倫生, 橋本 孝朗, 小山 俊一, 渡辺 大介, 岡田 博史, 田中 悠二郎, 加藤 大地, 大橋 智生, 河野 道宏
    2017 年 45 巻 1 号 p. 59-63
    発行日: 2017年
    公開日: 2017/04/21
    ジャーナル フリー
    Background: A vertebral arteriovenous fistula (VAVF) is an abnormal shunt between an extracranial vertebral artery (VA) and the neighboring vein.
    We had two patients with the diagnosis of spontaneous VAVF. One case was treated with parent artery occlusion (PAO), and another was treated with fistula embolization.
    Case 1: A 31-year-old male with neurofibromatosis-1 (NF-1) presented with left cervical radiculopathy.
    Digital subtraction angiography (DSA) through the right VA revealed large shunt flow through a huge fistula between the left VA and neighboring vein. Therefore, we performed PAO of the proximal and distal left VA using endovascular technique. The symptoms disappeared 1 year after intervention.
    Case 2: A 41-year-old female presented with abnormal findings on screening magnetic resonance imaging/angiography (MRI/A) for headache. Imaging showed a blurred left VA signal and enlarged neighboring vein, forming a mass effect around the tissue. A single small fistula was clearly identified on DSA. Therefore, only the fistula was obliterated by endovascular coil embolization, and the patency of the left VA was successfully preserved.
    Conclusion: When the entry zone of the feeder is selected as the appropriate occlusion point, it is often possible to preserve VA flow.
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