Surgery for Cerebral Stroke
Online ISSN : 1880-4683
Print ISSN : 0914-5508
ISSN-L : 0914-5508
Volume 46, Issue 6
Displaying 1-11 of 11 articles from this issue
Topics: Revascularization 1: CEA
Topics: Revascularization 1: CEA-Original Articles
  • Masami NISHIO, Yoshihiro YANO, Kouji TAKANO, Takuto EMURA
    2018 Volume 46 Issue 6 Pages 411-415
    Published: 2018
    Released on J-STAGE: December 22, 2018
    JOURNAL FREE ACCESS
    Carotid endarterectomy (CEA) is a standard method to prevent stroke in patients with carotid artery stenosis. Carotid artery stenting (CAS) is a newly developed alternative method that we brought to our hospital in 2013. We selected CEA or CAS based on the procedure-related risks specific to each case. High-risk patients, such as those with vulnerable plaque, were more often treated with CEA, which may have influenced the outcomes. This study revealed the clinical results of CEA after introducing CAS.
    Retrospectively collected data for 26 patients each of CEA and CAS performed in our hospital from April 2013 to March 2016 were analyzed. CEA was performed in 22 men and 4 women aged 36-82 years (mean, 66.9 ± 12.9 years). Stenosis rate was 40-99% (mean, 74.9 ± 19.9%). Twenty-two patients underwent CEA because of plaque morphologies, including vulnerable plaque, long plaque, mobile plaque, hematoma in and around the plaque, and heavily calcified plaque. Postoperative complications occurred as follows: transient hemiparalysis in 1 patient, transient hoarseness in 1 patient, pneumonia in 2 patients, and heart failure in 1 patient. No permanent morbidities were recognized. In 3 patients, spotty diffusion-weighted images of high-intensity signal lesions were obtained on post-operative magnetic resonance imaging.
    Even after adopting CAS in our hospital, CEA was performed with low and acceptable complication rates.
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  • Hideaki WATANABE, Yoshiaki KUMON, Masahiko TAGAWA, Akihiro INOUE, Shir ...
    2018 Volume 46 Issue 6 Pages 416-421
    Published: 2018
    Released on J-STAGE: December 22, 2018
    JOURNAL FREE ACCESS
    Recently, because of the rapidly aging society, carotid endarterectomy (CEA) is increasingly being performed in elderly patients. Because previous randomized clinical trials excluded very elderly patients, the exact benefits and risk of CEA in elderly patients remain unclear. Therefore, we performed a comparative investigation of the perioperative and long-term outcomes of CEA in patients aged < 70 years (young group; n = 60) and those aged ≥ 70 years (elderly group; n = 57) in 117 consecutive patients who underwent CEA at our hospital from 2002.
    There were no significant differences in preoperative risk factors between the two groups.
    With respect to perioperative outcomes, mortality and the incidence of cardiovascular events were 0% in both groups. The procedure was performed safely in both groups, with cerebral infarction occurring in only one patient in the elderly group. The mean follow-up was 55 months for the young group and 35 months for the elderly group. The incidence of cerebral stroke during follow-up was 4/60 (7%) in the younger group and 3/57 (5%) in the elderly group, with no significant difference. However, there were two deaths in the young group and seven in the elderly group (five because of a malignant tumor and two because of pneumonia), that is, significantly more deaths in the elderly group.
    CEA in our hospital was safe for elderly patients, who had similarly low rates of perioperative complications and cerebral infarction as those in young patients. Regarding long-term outcomes, however, more deaths occurred in the elderly group, suggesting that more appropriate patient selection is required.
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  • Yushin TAKEMOTO, Takayuki KAWANO, Yuki OHMORI, Takashi NAKAGAWA, Toshi ...
    2018 Volume 46 Issue 6 Pages 422-428
    Published: 2018
    Released on J-STAGE: December 22, 2018
    JOURNAL FREE ACCESS
    Delineating the distal end of the plaque in the internal carotid artery (ICA) is important in carotid endarterectomy. In general, a plaque's distal edges are estimated based on the degree of carotid artery stenosis. Sometimes, the plaque's distal end cannot be detected before surgery and additional arteriotomy of the ICA distal edge is needed. We retrospectively evaluated 33 patients with carotid artery stenosis treated at the Kumamoto University Hospital between April 2013 and September 2016. Of these, 2 (6.1%) patients needed additional arteriotomy at the ICA distal edge. They had soft and maldistributed elongated plaques. Distal plaque ends in the ICAs could not be detected accurately on three-dimensional computed tomography, magnetic resonance angiography, and digital subtraction angiography, but could be detected on coronal magnetic resonance imaging (MRI). The patients who needed additional arteriotomy of the distal edge of the ICA had soft, maldistributed and elongated plaques. Plaque coronal MRI may be an easy, effective, and practical method for evaluation of the distal plaque end in the ICA.
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Topics: Revascularization 1: CEA-Technical Note
  • Tsutomu ICHINOSE, Takashi TSURUNO, Masaki YOSHIMURA, Yohei ONISHI, Hir ...
    2018 Volume 46 Issue 6 Pages 429-434
    Published: 2018
    Released on J-STAGE: December 22, 2018
    JOURNAL FREE ACCESS
    Background: Cases of carotid stenosis with highly-calcified plaques are associated with less expansion and intraoperative hypotension during carotid artery stenting (CAS). Therefore, carotid endarterectomy is recommended for highly calcified lesions. However, there is a risk of adventitial injury in carotid endarterectomy for highly-calcified plaques. We report our experience with microsurgical endarterectomy for highly-calcified plaques and discuss the pathological considerations.
    Methods: To obtain complete resection of the plaque with a smooth distal edge, a bloodless surface, and minimal exposure of the media, the thickened intima is incised under high-magnification microscopy. We reported this novel technique as “interintimal dissection.” The plaques are usually resected in en bloc fashion. However, en bloc resection may lead to vessel injury, because the media is very thin in the highly calcified segment. Thus, we intentionally leave behind the highly-calcified segment at first and then perform piecemeal resection.
    Results: Between September 2009 and March 2017, 162 carotid endarterectomies (CEAs) were performed in 152 patients with carotid stenosis. Highly calcified plaques were observed in 46 lesions. Complete resection of plaques without tacking sutures was obtained in all procedures. No deaths occurred. Stroke was recorded in 1 case (2.2%). No restenosis was recorded during follow-up (range, 1-82 months; mean, 45 months).
    Conclusion: Microsurgical interintimal dissection with piecemeal resection for highly-calcified plaques can achieve a good surgical outcome, including absence of significant early restenosis and vessel injury.
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  • Daiki MURATA, Fumiaki ISAKA, Takuya NAKAKUKI, Yasuhiro MAEDA, Takaaki ...
    2018 Volume 46 Issue 6 Pages 435-438
    Published: 2018
    Released on J-STAGE: December 22, 2018
    JOURNAL FREE ACCESS
    High cervical internal carotid artery stenosis (ICS) is considered a high-risk factor treated with carotid endarterectomy (CEA). Mandibular subluxation is among several methods available to perform CEA in cases with high cervical ICS. We report a case of high cervical ICS that was treated with a CEA carried out using mandibular traction with a wire. Our patient was an 80-year-old man with symptomatic right ICS. The distal plaque end of the ICS was at the upper edge of the second cervical vertebral arch and vulnerable plaque was suspected. A percutaneous wire was passed through the tip of the mandible and the mandible was then pulled. This method enabled exposure of the surgical field around the distal internal carotid artery and our surgical procedure became easier. This method is useful for CEA in cases with high cervical ICS.
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Topics: Revascularization 2: Vascular Anastomosis
Topics: Revascularization 2: Vascular Anastomosis-Original Articles
  • Yoshio ARAKI, Sho OKAMOTO, Kinya YOKOYAMA, Shinji OTA, Kenji UDA, Shin ...
    2018 Volume 46 Issue 6 Pages 439-444
    Published: 2018
    Released on J-STAGE: December 22, 2018
    JOURNAL FREE ACCESS
    Transient neurological events (TNEs) are relatively common phenomena after superficial temporal artery-middle cerebral artery (STA-MCA) bypass for the surgical treatment of moyamoya disease. Cortical-sulcal hyperintensity (CSHI) signs in magnetic resonance imaging (MRI) fluid-attenuated inversion recovery (FLAIR) images during the acute stage after the surgery have also been reported. These symptoms and radiological findings are reportedly correlated; however, few studies have examined these characteristics after indirect vascularization surgery. Therefore, here we retrospectively investigated the incidence and correlation of this issue. The CSHI signs were observed in 10 of 16 hemispheres (62.5%), and TNEs after the surgery were recognized in nine (56.3%). This correlation was statistically significant (p = 0.01). Our findings indicate that CSHI signs are associated with direct and indirect bypass surgery and may be closely related to postoperative TNEs.
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Topics: Revascularization 2: Vascular Anastomosis-Case Report
  • Shinji NODA, Hideomi KITAJIMA, Daisuke MIZUTANI, Ryou MORISHIMA, Yasuh ...
    2018 Volume 46 Issue 6 Pages 445-448
    Published: 2018
    Released on J-STAGE: December 22, 2018
    JOURNAL FREE ACCESS
    Objective: Although superficial temporal artery (STA)-middle cerebral artery (MCA) bypass is an established cerebral revascularization procedure, injuries to the vascular wall and occlusion of the anastomoses have been reported as complications of the procedure. We performed histological examination of the cut edge of the STA obtained from an STA-MCA bypass and investigated the injury.
    Materials and Methods: Two STA specimens were obtained from two STA-MCA bypass procedures. One specimen was cut using micro-scissors. The other specimen was slightly long and was cut with micro- and macro-scissors and with a micro-knife on a cotton sheet. Each specimen was stained and examined using Elastica-Masson stain and hematoxylin-eosin stain.
    Results: In the specimen cut using micro-scissors alone, all layers of the vascular wall were thinned, and the media was injured. In the specimen cut using macro-scissors, the outer membrane was injured, and the intima and media were dissected. In the specimen placed on a cotton sheet and cut with a micro-knife, no thinning of the layers of the vascular wall or dissection between layers was noted.
    Conclusions: Applying pressure to the vascular wall using scissors can injure the vascular wall and result in dissection between layers.
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Topics: Revascularization 2: Vascular Anastomosis-Technical Note
  • Isao CHOKYU, Kimihiko CHOKYU, Shinichi YOSHIMURA
    2018 Volume 46 Issue 6 Pages 449-452
    Published: 2018
    Released on J-STAGE: December 22, 2018
    JOURNAL FREE ACCESS
    Deep-seated bypass is one of the most difficult procedures in cerebrovascular surgery. Creating an anastomosis between the superficial temporal artery (STA) and superior cerebellar artery (SCA) using a subtemporal approach is time consuming because the SCA is located deep within the ambient cistern and vein of Labbe and temporal lobe, making it difficult to achieve a wide operative field. We describe a modification of deep-seated bypass using a semi-prone park-bench position and presigmoid transtentorial approach to achieve a wide operative view without temporal lobe injury. This skull base approach may permit an STA-SCA anastomosis within 20 minutes using short forceps.
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Original Articles
  • Takashi HORIGUCHI, Takenori AKIYAMA, Satoshi TAKAHASHI, Takayuki OHIRA ...
    2018 Volume 46 Issue 6 Pages 453-461
    Published: 2018
    Released on J-STAGE: December 22, 2018
    JOURNAL FREE ACCESS
    Here we investigated the changes in utility and limits of combined microsurgical and endovascular treatment for complex cerebrovascular disease before and after the introduction of the hybrid operating room (HOR) in our department. Since 2006, a total of 17 patients (cerebral aneurysm in 12, cerebral arteriovenous malformation in 5) underwent integrated microsurgery with endovascular treatment. In 3 of 11 patients treated before the introduction of HOR, certain problems such as time consumption during patient transfer, disconnected workflow, and complicated operation due to poor quality of support equipment occurred. In contrast, all 6 operations in the HOR were uncomplicated. All therapeutic steps including anesthesia management were planned in a single session. In conclusion, HOR provides a safe and smooth workflow in combined microsurgical and endovascular treatment for complex cerebrovascular diseases.
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  • Atsushi SATO, Tetsuo SASAKI, Yota SUZUKI, Satoshi KITAMURA, Kazuhiro H ...
    2018 Volume 46 Issue 6 Pages 462-468
    Published: 2018
    Released on J-STAGE: December 22, 2018
    JOURNAL FREE ACCESS
    Although it has been suggested that intraoperative monitoring with off response (OFR) in visual evoked potential (VEP) is possible, a stimulus preparation device for recording is not yet available. This paper reports on a prototype of a stimulator allowing for OFR recording to be more widely possible. The stimulation device needs to have a function of allowing the light emitting diode (LED), a stimulation device, to emit a constant light amount for a certain period of time. However this stimulation is difficult with existing products. In the new stimulator, heat generation accompanying the extension of the light emission time needs to be considered. The stimulus range which is the most effective and safe is set accordingly, and effective OFR recording is considered possible. In order to effectively record OFR, a very large amount of light is not required, so it was necessary to ensure sufficient light-off time while setting it, as stimulation intensity in a range not accompanied by heat generation. For stimulation, we set an output limit of 3/4 or less of the capability of the light emitting device and provided a safety device and light emission check function. In addition, the shape of the light emitting device was newly devised. Recording with a new stimulator can be easily set in comparison to the conventional design. In addition, the response waveform was well depicted. Recording of VEP off response was thought to be much easier with this stimulator. Easy recording greatly contributes to the progress of monitoring and leads to an improvement in surgical results. Since it can contribute to widening the scope of the recording of off response, it is expected that studies employing this technique will be conducted for various diseases in the future.
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  • Shintaro ARAI, Tohru MIZUTANI, Masaki MATSUMOTO, Takahito NAKAJO, Kenj ...
    2018 Volume 46 Issue 6 Pages 469-472
    Published: 2018
    Released on J-STAGE: December 22, 2018
    JOURNAL FREE ACCESS
    With the development of interventional radiology and radiosurgery, the number of open surgery cases has decreased. Young neurosurgeons need to gain experience with fewer cases, so effective off-the-job training is important. We created a practice model for setting up the head fixation and retractor systems and for microscopic training. In addition, as the equipment can be placed in the medical office, easy access for practice anytime is possible. Our training method includes fixing the skull model to the Mayfield® frame for each approach, setting the Budde® halo ring, setting up the retractor, using the scissors, performing the blading technique, performing deep anastomosis, and so on. With continuous practice in an environment simulating various surgical fields, young neurosurgeons can eventually perform anterior circulation clipping and superficial temporal artery-to-middle cerebral artery bypass for arteriosclerotic disease and moyamoya disease. We believe that our training method is useful especially for young neurosurgeons aiming to establish steady skills for performing microsurgical techniques.
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