Surgery for Cerebral Stroke
Online ISSN : 1880-4683
Print ISSN : 0914-5508
ISSN-L : 0914-5508
Volume 48, Issue 2
Displaying 1-11 of 11 articles from this issue
Carotid Artery Stenosis
Carotid Artery Stenosis-Review Article
  • Daisuke ANDO, Kazunori TOYODA
    2020 Volume 48 Issue 2 Pages 87-90
    Published: 2020
    Released on J-STAGE: September 15, 2020
    JOURNAL FREE ACCESS

    With the development of medical treatment in recent years, the incidence of stroke associated with carotid stenosis has continued to decrease. Treatment for carotid artery stenosis is intended to reduce the risk of thrombotic events and atherosclerotic changes to prevent future cardiovascular events. Antiplatelet therapy is routinely used for secondary prevention of ischemic stroke and is effective for the prevention of microembolism from the rupture or erosion of a carotid plaque. It is common to perform dual antiplatelet therapy in the acute to subacute stages of ischemic stroke. Lipid modification with statins is an essential element in the treatment of carotid artery stenosis. Statins are used to reduce the progression of carotid intima-media complex thickening and for plaque stabilization. Management of diabetes mellitus, lifestyle changes (including smoking cessation), physical activity, and weight management are also important for the prevention of carotid artery stenosis.

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Carotid Artery Stenosis-Original Article
  • Hajime YABUZAKI, Tohru MIZUTANI, Tatsuya SUGIYAMA, Kenji SUMI, Hirotak ...
    2020 Volume 48 Issue 2 Pages 91-95
    Published: 2020
    Released on J-STAGE: September 15, 2020
    JOURNAL FREE ACCESS

    Restenosis is a postoperative complication seen in patients who undergo carotid endarterectomy (CEA). The incidence of stroke and time course of restenosis are required information reported at follow-up assessment. In our institute, 477 CEA surgeries were performed from September 2006 to August 2014, and 32 restenoses were observed during the follow up period. The majority of restenosis cases (87%) developed within a year after CEA. No stroke events were observed in the restenosis cases. Our follow-up data indicate that short-term follow up is necessary, in particular within a year post surgery, and we report no incidence of stroke in the restenosis patients.

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Original Articles
  • Satoru TAKEUCHI, Kosuke KUMAGAI, Shou NISHIDA, Kojiro WADA, Naoki OTAN ...
    2020 Volume 48 Issue 2 Pages 96-102
    Published: 2020
    Released on J-STAGE: September 15, 2020
    JOURNAL FREE ACCESS

    In this study, we analyzed the causes of problems encountered during aneurysm surgery based on “the study of failure, ” which was originally devised for system engineering. We describe four problematic cases, which were all successfully managed by troubleshooting techniques. The majority of the problems (failures) were caused by the surgeon’s “carelessness and/or decision error”. Large vessel injury during aneurysm dissection is formidable but can be managed by troubleshooting techniques such as micro-suturing or a bypass procedure in the deep operative field. Prompt and secure micro-anastomotic suturing is one of the vital troubleshooting techniques during aneurysm surgery. Personal preparation of micro-suturing instruments and daily off-the-job training are essential to master such troubleshooting procedures.

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  • Takehiro MAKIZONO, Kimihiko ORITO, Gohsuke HATTORI, Takachika AOKI, Ya ...
    2020 Volume 48 Issue 2 Pages 103-109
    Published: 2020
    Released on J-STAGE: September 15, 2020
    JOURNAL FREE ACCESS

    Background and Purpose: Intraoperative angiography (IOA) and intraoperative interventional radiology (IO-IVR) are useful for surgical correction of neurovascular pathologies, such as dural arteriovenous fistula (DAVF), cerebral arteriovenous malformation (AVM), and spinal AVM. The development of a hybrid operating room allows evaluation and treatment with increased precision. Further, opportunities for simultaneous treatment of direct and intravascular surgeries are increasing, even without the use of hybrid operating rooms. However, the traditional femoral approach involves poor sterility at the access site, which may prove problematic during extended surgeries. In this study, we devised a method to enable effective IOA and IO-IVR in any surgical position with a long guiding sheath.

    Methods: Twenty-three patients (male:female=11:12; age, 17-73 years; mean, 49.0) who underwent IOA between April 2011 and April 2018 were included in the study. In each patient, the right femoral artery was punctured, and IOA was performed using a long guiding sheath. Then, patient positioning was maintained to ensure a sterile catheter system.

    Results: Twenty-three patients underwent surgeries: AVM, 11 (47.8%); DAVF, six (26.1%); aneurysm, three (13%); tumor, two (8.6%); and arteriovenous injury, one (4.3%). Surgeries were performed in the supine position for 13 patients (56.5%), prone position for seven (30.4%), and park-bench position for three (13.0%). All supra-aortic vessels were catheterized with a success rate of 100%. In some cases, we easily exchanged catheters, even in the prone and park-bench positions, by using the C-arm. In one patient with AVM who developed cerebral infarction, we did not perform our usual procedure.

    Conclusions: A long guiding sheath allows performance of angiography in various positions. Our method is useful even without a hybrid operating room.

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  • Hajime WADA, Masato SAITO, Takehiro SAGA, Nobuyuki MITSUI
    2020 Volume 48 Issue 2 Pages 110-115
    Published: 2020
    Released on J-STAGE: September 15, 2020
    JOURNAL FREE ACCESS

    Background: Trapping or neck bridge stent placement technique to preserve the parent artery has been performed as a treatment strategy for fusiform vertebral aneurysm. However, there is a concern that brain stem infarction will occur due to occlusion of the vertebral perforators. In this study, the treatment course of 17 cases in 3 years was retrospectively reviewed.

    Material and Method: Seventeen cases of fusiform vertebral aneurysm managed by an operator from 2015 were recorded, of which seven were ruptured and nine were unruptured aneurysms and one aneurysm was retreated after the first session because of recanalization. In ruptured cases, the entire aneurysm was treated with trapping. While in seven cases of unruptured aneurysm, stents were placed to preserve the parent artery, and coil embolization was performed.

    Result: In six ruptured cases (75%), in which trapping was performed, a high-signal lesion was detected by postoperative magnetic resonance imaging and diffusion-weighted imaging (DWI) of the brain stem (42.9%). However, in seven cases where stents (1 Enterprise VRD, 4 Lvis Jr, 2 NeuroformAtlas) were used, a high signal lesion was detected by DWI in one patient (14.3%) postoperatively, and no new neurological symptoms were observed. In all cases, postoperative bleeding was not observed. Previously, no regrowth of the aneurysm was observed, but in one patient, recanalization was performed in the acute phase after 3 weeks of treatment, and additional treatment was performed.

    Conclusion: As a treatment strategy for vertebral aneurysm of nonposterior inferior cerebellar artery involved type, presently, trapping in ruptured cases and stent-assisted coil treatment in unruptured cases are acceptable. Compared with open surgery, intravascular treatment without direct manipulation of the lower cranial nerve allows treatment with few complications. New imaging technologies, such as cone-beam computed tomography, seemed to be useful.

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  • Hirotaka HASEGAWA, Shunya HANAKITA, Masahiro SHIN, Yuki SHINYA, Mariko ...
    2020 Volume 48 Issue 2 Pages 116-121
    Published: 2020
    Released on J-STAGE: September 15, 2020
    JOURNAL FREE ACCESS

    The Spetzler-Martin grade (SMG) system is widely used to assess the treatment risk for arteriovenous malformations (AVMs). However, SMG II or III AVMs include diverse phenotypes, such as “large superficial” and “small deep” ones. Thus, it is worth analyzing the detailed treatment outcomes for each subtype. Among 724 consecutive patients who had AVM and were treated with stereotactic radiosurgery (SRS), 490 patients (238 with SMG II and 252 with SMG III AVMs) were included in the study. Upon classifying SMG II AVMs into S2, S1V1, and S1E1 and SMG III AVMs into S3, S2V1, S2E1, and S1V1E1, we analyzed the detailed treatment outcomes for each subtype. Significant neurological events (SNEs) were defined as any neurological events that caused > 1-point decrease in the modified Rankin Scale. The 5-year cumulative obliteration rates for SMG II and III AVMs were 88% and 77%, respectively. Among the subtypes, the rate was highest in S1E1 (91%) and lowest in S2E1 (66%). S2E1 demonstrated the highest, albeit well-acceptable, hemorrhage rate during the latency period (3.0%/year). The 12-year cumulative SNE rates were 1.6% and 6.0% in SMG II and III, respectively. Among the subtypes, the rate was highest in S2E1 (8.8%) and lowest in S2 (0%). The 12-year disease-specific mortality rates were 0.4% in SMG II and 2.2% in SMG III. Therefore, the outcomes of SRS for SMG II or III AVMs were different among the subtypes. S2E1 was associated with the lowest obliteration rate, which might be responsible for the highest hemorrhage rate, and, thus, the highest SNE rate. However, the outcomes seemed better than the estimated course of untreated cases and compatible with that of cases treated with direct surgery. SRS is an optimal therapeutic option for SMG II or III AVMs.

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Case Reports
  • Gakushi YOSHIKAWA, Kazuo TSUTSUMI
    2020 Volume 48 Issue 2 Pages 122-128
    Published: 2020
    Released on J-STAGE: September 15, 2020
    JOURNAL FREE ACCESS

    Accumulating evidence of surgical treatment for intracranial aneurysms, the usual surgical clipping of aneurysm will progress as planned throughout the microsurgical procedure. However, emergent revascularization is occasionally required to repair accidentally injured vessels during the surgery. We present four cases of unexpected bypasses (troubleshooting) during microsurgical surgery for ruptured intracranial aneurysm at the middle cerebral artery. The first case was treated with superficial temporal artery (STA)—the inferior trunk of the middle cerebral artery (M2 inferior trunk) anastomosis—because of a tear on the M2 inferior trunk by inappropriate clipping procedure. The second and third cases were revascularizations of the branch artery firmly attached to the aneurysm dome with the anterior temporal artery (end-to-end anastomosis and transposition, respectively). The fourth case, a giant aneurysm, was finally treated with excision and end-to-end anastomosis after the first surgery, which was performed with STA-M2 inferior trunk anastomosis. In addition to extracranial-intracranial bypass, in situ bypass is the alternative intervention of cerebral vascular reconstruction, which does not require harvesting an extracranial donor artery, though it technically requires various types of anastomosis under an emergent situation.

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  • Adam TUCKER, Shigeru MIYACHI, Hiroyuki OHNISHI, Ryo HIRAMATSU, Toshihi ...
    2020 Volume 48 Issue 2 Pages 129-133
    Published: 2020
    Released on J-STAGE: September 15, 2020
    JOURNAL FREE ACCESS

    Purpose: Intracerebral hemorrhage (ICH) that develops after treatment of unruptured intracerebral aneurysms is a rare complication. We present one case of ICH after endovascular treatment and discuss the possible pathophysiologic mechanisms and preventative strategies.

    Patient Case: A 51-year-old woman with left homonymous hemianopsia and a large paraclinoid (internal carotid-ophthalmic) aneurysm underwent flow diversion (FD) using the PipelineTM Embolization Device and coiling. Several hours postoperatively, she had motor aphasia with mild right hemiparesis, and head computed tomography revealed an ipsilateral frontotemporal hematoma. Magnetic resonance angiography and digital subtraction angiography suggested a form of hyperperfusion syndrome, and conservative management resulted in almost complete resolution of symptoms.

    Conclusions: The etiology of ICH acutely following FD may be multifactorial due to dual antiplatelet therapy (DAPT) hyper-response and flow modification related to hyperperfusion and the Windkessel effect. Conservative management resulted in a good outcome. However, for severe hemorrhagic cases, platelet transfusion, discontinuation of DAPT to single antiplatelet therapy, and surgical intervention should be considered. Perioperative monitoring indicating antiplatelet hyper-response or radiographic hyperperfusion should direct strict blood pressure control and risk reduction precautions.

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  • Yuta ARAKAKI, Nobuyuki SHIMIZU, Hidetoshi MURATA, Yuko GOBAYASHI, Hiro ...
    2020 Volume 48 Issue 2 Pages 134-138
    Published: 2020
    Released on J-STAGE: September 15, 2020
    JOURNAL FREE ACCESS

    We managed a patient with intracranial mycotic aneurysm (IMA) that was associated with infective endocarditis and treated with endovascular embolization under visual evoked potential (VEP) monitoring. Here, we report our experience with a review of the literature.

    A 31-year-old man with mitral valve regurgitation presented to our hospital. His chief complaint was fever and there was no neurological deficit. Cerebral angiography revealed a fusiform-shaped aneurysm, approximately 3.5 mm in size, at the origin of the left calcarine artery. The aneurysm enlarged gradually despite administering antibiotic therapy. We performed endovascular treatment of the aneurysm under general anesthesia and VEP monitoring. During balloon test occlusion (BTO) of the P3 portion of the left posterior cerebral artery, VEP amplitude of the left side was slightly reduced. Therefore, we embolized the fusiform aneurysm at the origin of the left calcarine artery and deployed the stent to the left parieto-occipital artery to preserve its patency. The VEP amplitude was not attenuated. After coil embolization of the aneurysm, there were no neurological deficits, including visual field defects.

    Coil embolization under VEP monitoring is useful for functional preservation when treating aneurysms of the posterior cerebral artery branches.

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  • Tsuyoshi ICHIKAWA, Kyouichi SUZUKI, Yoichi WATANABE, Yuya FURUKAWA
    2020 Volume 48 Issue 2 Pages 139-144
    Published: 2020
    Released on J-STAGE: September 15, 2020
    JOURNAL FREE ACCESS

    We report a rare case of intracranial cavernous malformation (CM) associated with transverse-sigmoid sinus dural arteriovenous fistula (T-SS DAVF). A 49-year old woman was admitted to our hospital with left motor weakness and seizure. Head computed tomography showed a mixed density mass lesion suggestive of CM in the right frontal lobe. She previously underwent head magnetic resonance imaging scans in another hospital, and no abnormalities were detected. De novo or radiographically occult CM was suspected. Cerebral angiography revealed right T-SS DAVF. The shunt flow disturbed normal venous return via the superior sagittal sinus and drained into the sphenoparietal sinus and superficial temporal vein. In order to normalize intracranial venous circulation, endovascular treatment of DAVF was performed first. The CM was removed following craniotomy. Although the relationship between CM and DAVF remains unclear, hemodynamic change caused by DAVF might affect de novo formation or growth of CM.

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  • Natsuki KOBAYASHI, Takashi SHUTO, Shigeo MATSUNAGA, Kosuke ISHIKAWA, Y ...
    2020 Volume 48 Issue 2 Pages 145-148
    Published: 2020
    Released on J-STAGE: September 15, 2020
    JOURNAL FREE ACCESS

    Cyst formation is a well-known complication of gamma knife surgery for the treatment of arteriovenous malformation (AVM). Surgical treatment for cysts is widely performed, but there is no common procedure for the surgery. We report a case of cyst recurrence after partial resection of a nodule that exhibited enhancement on magnetic resonance imaging (MRI). A 44-year-old man underwent surgery for a cyst that formed after gamma knife surgery for an AVM performed 5 years earlier. MRI performed after the surgery revealed an enhancing nodule. Six months later, a cyst formed around the nodule and grew steadily. Because of the cyst, the patient had a seizure. We decided to perform an operation to resect the cyst and nodule. After the second operation, enhanced MRI showed there was no remaining nodule. The patient had no recurrence until 15 months after surgery. The findings from this case suggest that total resection of the enhancing nodules must be performed during surgery for cysts that form after gamma knife surgery for AVM.

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