Preoperative evaluation of the microanatomy around an aneurysm is mandatory for safe clipping of a cerebral aneurysm. We assessed the usefulness of three-dimensional variable refocusing flip angle-turbo spin-echo (3D VRFA-TSE) in determining the microanatomy around aneurysms.

Between May 2015 and June 2017, 25 patients with 26 unruptured middle cerebral artery aneurysms were evaluated using MR T2-weighted imaging, 3D VRFA-TSE T2-weighted imaging, and cerebral angiography before surgery. All aneurysms were treated via neck clipping at our hospital. The high-intensity signal of the cerebrospinal fluid (CSF) was used as an indicator of the preserved CSF space without adhesion of an aneurysm to a surrounding structure. 3D VRFA-TSE T2-weighted imaging, conventional T2-weighted imaging, and cerebral angiography were used to assess the adhesion between the aneurysm and the artery. To assess the adhesion of the vein, we compared T2-weighted imaging findings to the intraoperative finding. Adhesion of the aneurysm to the artery, vein, or brain surface was confirmed during surgery.

3D VRFA-TSE T2 weighted-imaging was superior to conventional T2-weighted imaging or cerebral angiography in detecting the adhesion between an aneurysm and the brain surface or an artery. 3D VRFA-TSE T2 weighted-imaging detected lenticulostriate arteries even if cerebral angiography could not detect them. It could also identify large cerebral veins. However, 3D VRFA-TSE T2-weighted imaging could not identify narrow adhesion points. In such cases, a detailed evaluation is required.

3D VRFA-TSE can contribute to the preoperative evaluation of middle cerebral aneurysms by providing detailed anatomical information.

We report a case of a ruptured aneurysm originating from the posterior wall of the left internal carotid artery (ICA) that was treated with multi-clipping and radial artery graft (RAG) bypass. A 41-year-old man developed sudden-onset headache, followed by generalized convulsion. The initial computed tomography (CT) scan revealed subarachnoid hemorrhage (SAH), and CT angiogram (CTA) revealed aneurysmal dilatation of the posterior wall of the left ICA. Rebleeding near the lesion suggested a blood blister-like aneurysm causing SAH. On day 2, we performed an operation to insert multiclips to obliterate most of the lesion. The postoperative course was uneventful. Ischemic complications, rebleeding, or regrowth of the aneurysm was not observed for 1 year postoperatively.

Acute subdural hematoma without a history of trauma may be due to a ruptured aneurysm. We experienced a case of a ruptured aneurysm at the internal carotid artery-posterior communicating artery bifurcation that led to bilateral acute subdural hematoma without any accompanying subarachnoid hemorrhage. A 73-year-old woman suddenly developed severe headache while singing at karaoke. She also suffered from disorientation of consciousness accompanied by upper limb tension. There was no clear history of head injury. Upon arriving at the hospital, her consciousness disorder had improved. There were no pupil inconsistencies or neurological deficit symptoms. Computed tomography (CT) showed acute subdural hematoma on both sides of the dura and around the cerebral scalp and cerebellum tent. Her state of consciousness suddenly worsened, and her right pupil dilated. Three-dimensional CT showed an aneurysm projecting forward from the outside of the right internal carotid artery-posterior communicating artery bifurcation. CT further showed that the right-sided hematoma had increased in size, and midline shift was present. She underwent emergency aneurysm neck clipping and right craniotomy removal of hematoma with right external decompression. The intraoperative findings showed no traumatic changes or subarachnoid hemorrhage. Acute subdural hematoma without a history of trauma may be caused by a ruptured aneurysm, irrespective of its laterality.

Angiolymphoid hyperplasia with eosinophilia (ALHE) is an uncommon vasoproliferative disease. We report a case of ALHE revealed as a graft abnormality during bypass surgery. A 62-year-old man presented with right hemiparesis and dysarthria. He was at high risk of arteriosclerosis due to hypertension, diabetes, and smoking, and had undergone endovascular treatment for peripheral artery disease twice. Magnetic resonance imaging (MRI) at admission revealed ischemic lesions in the left corona radiata and an occlusion in the left middle cerebral artery (MCA). ¹²³I-IMP single-photon emission computed tomography demonstrated a marked decrease of uptake in the left MCA territory, and we planned to perform superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis. The parietal branch of the STA had a dissection in the wall, and the main vascular lumen was severely narrowed. We abandoned double bypass and performed single bypass surgery with the frontal branch of the STA. Histopathology of the parietal branch confirmed the diagnosis of ALHE. When planning treatment for a patient with systemic vascular impairment, the possibility of not only arteriosclerotic change but also inflammatory disease must be considered.

High flow bypass (HFB) surgery is often used to treat proximal large/giant aneurysms of the intracranial carotid artery followed by a parent artery occlusion (PAO). The authors report important key techniques for successful HFB including avoidance of graft twisting, use of double insurance bypass, and the proper PAO method.

Dolichoectatic and fusiform aneurysms of the posterior circulation represent a small subset of cerebral aneurysms and are often among the most difficult to treat. Various revascularization procedures are frequently performed. Among these techniques, occipital artery (OA) to posterior inferior cerebellar artery (PICA) anastomosis is the most frequently used. Thus, it is important to refine this surgical technique. In this technical note, we summarize optimized techniques of OA preparation and bypass for successful OA-PICA and OA to anterior inferior cerebellar artery (AICA) anastomoses.

Introduction: According to current guidelines, treatment for carotid stenosis with carotid endarterectomy (CEA) or carotid artery stenting (CAS) should be limited to patients with a life expectancy of ＞3-5 years. We aimed to assess the long-term survival after CEA and CAS in our institute and compare the survival rate with previous studies and the general Japanese population.

Methods: Between August 2006 and October 2016, 297 consecutive carotid revascularizations with either CEA (n=178) or CAS (n=119) were performed in our institute. The initial treatment was regarded as the starting point in patients who received treatment by bilateral carotid artery stenosis or retreatment. The final examinations were performed in December 2017. Therefore, only the patients who had undergone carotid revascularization at least 1 year before this date were included in the current study. Kaplan-Meier survival analysis was performed and a multivariate Cox hazard model was built for the analysis of long-term survival-associated risk factors.

Results: A total of 257 patients (CEA [n=158], CAS [n=99]; mean age, 72.3 ± 7.6 years), including 115 symptomatic patients, were enrolled in the current study with a mean follow-up period of 57 months. The perioperative stroke and death rate (within 30 days) was 2.5% for CEA and 6.1% for CAS. During follow-up, 41 patients (16%) died, with pneumonia (24%), cancer (17%), heart disease (15%) and senility (12%) as the most frequent causes. No death due to stroke occurred. Cumulative 5- and 7-year survival rates of all patients were 88% and 78%, respectively. Kaplan-Meier estimates of the 5-year survival rate were 91% for CEA and 83% for CAS, and those of the 7-year survival rate were 80% for CEA and 75% for CAS (p = 0.009). A Cox proportional hazard regression model showed the independent risk factors related to any death were age (Hazard ratio [HR], 1.07/year [95% CI, 1.03-1.13]; p = 0.003) and CAS (HR, 2.45 [95% CI, 1.30-14.61] compared with CEA; p = 0.006). The presence of symptoms and ischemic heart disease was not associated with long-term survival. Mean life-expectancy of an 80-year-old man after CEA was 9.5 years and after CAS was 8.0 years. These figures were not substantially different from the mean life expectancy of an 80-year-old man in the general Japanese population (8.95 years).

Conclusion: The life expectancy of patients in the current study satisfies the current guidelines. The life expectancy of men in the current study did not seem to be substantially different from that of men in the general Japanese population. Long-term survival after CEA and CAS was significantly associated with age and CAS. The inclusion of higher risk patients in the CAS group may have been the reason for CAS being a risk factor.

Background: Since the etiology of spinal cord cavernous malformations (CMs) is unclear, it is difficult to establish an optimal management strategy for spinal cord CMs.

Objective: To describe conservative and surgical management strategies for spinal cord CMs.

Materials and methods: We performed a retrospective study of patients diagnosed with spinal cord CMs. The neurological symptoms and Modified McCormick Scale scores of the selected patients were recorded. When patients experienced acute onset of hemorrhage or debilitating symptoms, the timing of surgery was determined by a shared decision-making process involving both physicians and patients.

Results: We identified a total of 12 patients (7 [58.3%] male; mean age of 38.0 years). Seven patients underwent microsurgical removal. During follow-up with conservative treatment, six patients underwent surgery for worsening of symptoms, one patient showed worsening of neurological symptoms but did not undergo surgery, and four patients showed no worsening of symptoms. The mean duration from presentation to subsequent hemorrhage or worsening of symptoms was 15.2 months, including asymptomatic recurrence. No patient experienced subsequent hemorrhage after surgical resection. Five patients (71.4%) within the surgical group showed improvements in their neurological state, two patients (28.6%) showed no change, and none experienced worsening of the symptoms.

Conclusions: Surgical treatment of spinal cord CMs did not lead to recurrence of hemorrhage or exacerbation of neurological symptoms.

Cerebral venous thrombosis (CVT) is a rare but devastating complication of inflammatory bowel disease, with an estimated incidence of 1.3%-6.4% of patients. Here, we report a case of CVT associated with ulcerative colitis (UC). A 52-year-old man developed sudden-onset headache and motor aphasia with trembling lips. Aphasia and trembling lips naturally improved in a short time. He had a medical history of UC (30 years) treated with mesalazine and prednisolone through enema administration. Additionally, he had developed deep vein thrombosis 10 years before and completed its anticoagulant treatment. Head magnetic resonance imaging (MRI) revealed hemorrhagic infarction in the right frontal lobe and superior cerebral vein thrombosis. The lower-extremity vein thrombosis was complicated. On the electroencephalogram, small, sharp waves were focused on the right frontal lobe. There were no blood coagulation disorders. Therefore, our diagnosis was CVT with simple partial seizure, lower-extremity vein thrombosis, and UC. Headache rapidly improved with the administration of heparin, and there was no deterioration of the hemorrhagic cerebral infarction. After 6 days of heparin administration, the medication was changed to edoxaban (60 mg/day). The disappearance of thrombosis from the vein was confirmed after 6 months. There were no adverse events. There is insufficient evidence to support the use of direct oral anticoagulants (DOACs) in CVT, although patients treated with dabigatran, rivaroxaban, apixaban, and edoxaban have shown favorable results. In the present case, edoxaban was chosen because there are fewer hemorrhagic complications with DOACs, and adherence is easily maintained through oral treatment once a day. Edoxaban may be a safe and effective option to treat CVT.

The dissecting procedure around the parotid gland (PG) from the anterior edge of the sternocleidomastoid muscle (SCM) is a crucial technique in high-positioned carotid endarterectomy. It facilitates exposure of the distal portion of the internal carotid artery, enabling retraction of PG anterosuperiorly and SCM posteriorly and wide opening of the retromandibular space. To dissect the PG safely, it is important to carefully dissect the cervical soft tissue based on an understanding of the anatomy. The layer structure around the internal carotid artery consists of the retromandibular space, containing the PG; deep cervical fascia (DCF), comprised of the superficial layer and carotid sheath; SCM; and lymph node wrapped with fat tissue on the internal jugular vein. The part of the PG lying on the SCM should be peeled from the SCM with the DCF attached because the PG and SCM are tightly connected via the DCF. The part of the PG hanging in the retromandibular space should be dissected between the DCF and the lymph node wrapped with fat tissue on the internal jugular vein. In this paper, we report the practical procedure in detail.