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1.  Emergency In Situ Bypass during Middle Cerebral Artery Aneurysm Surgery: Middle Cerebral Artery-Superficial Temporal Artery Interposition Graft-Middle Cerebral Artery Anastomosis 
Many reports have been published on complications related to middle cerebral artery (MCA) aneurysm surgical clipping procedures. We report an emergency intracranial in situ bypass surgery case which was performed as a rescue procedure after aneurysmal neck laceration during clipping of an MCA large aneurysm. In this case, we performed in situ M3-superficial temporal artery (STA) interposition graft-M3 bypass procedure. If a STA-MCA anastomosis is not available under MCA flow obstruction, we can consider an emergency in situ MCA-MCA bypass procedure with or without an STA interposition graft.
PMCID: PMC3393865  PMID: 22792427
Middle cerebral artery aneurysm; Clipping; In situ bypass
2.  Intra-Arterial Thrombolysis Using Double Devices: Mechanicomechanical or Chemicomechanical Techniques 
To optimize the recanalization of acute cerebral stroke that were not effectively resolved by conventional intraarterial thrombolysis (IAT), we designed a double device technique to allow for rapid and effective reopening. In this article, we describe the feasibility and efficacy of this technique.
From January 2008 to September 2009, twenty patients with acute cerebral arterial occlusion (middle cerebral artery : n=12; internal carotid artery terminus : n=5; basilar artery : n=3) were treated by the double device technique. This technique was applied when conventional thrombolytic methods using drug, microwires, microcatheters and balloons did not result in recanalization. In the double device technique, two devices are simultaneously placed at the lesion (for example, one microcatheter and one balloon or two microcatheters). Chemicomechanical or mechanicomechanical thrombolysis was performed simultaneously using various combinations of two devices. Recanalization rates, procedural time, complications, and clinical outcomes were analyzed.
The initial median National Institute of Health Stroke Scale (NIHSS) was 16 (range 5-26). The double device technique was applied after conventional IAT methods failed. Recanalization was achieved in 18 patients (90%). Among them, 55% (11 cases) were complete (thrombolysis in cerebral infarction 2B, 3). The median thrombolytic procedural time including the conventional technique was 135±83.7 minutes (range 75-427). Major symptomatic hemorrhages (neurological deterioration ≥4 points in NIHSS) developed in two patients (10%). Good long term outcomes (modified Rankin Scale ≤2 at 90 days) occurred in 25% (n=5) of the cases. Mortality within 90 days developed in two cases (10%).
The double device technique is a feasible and effective technical option for large vessel occlusion refractory to conventional thrombolysis.
PMCID: PMC3322211  PMID: 22500197
Acute; Stroke; Thrombolysis; Double devices
3.  The Prognostic Factors That Influence Long-Term Survival in Acute Large Cerebral Infarction 
We retrospectively evaluated the prognostic factors that can influence long-term survival in patients who suffered acute large cerebral infarction.
Between June 2003 and October 2008, a total of 178 patients were diagnosed with a large cerebral infarction, and, among them, 122 patients were alive one month after the onset of stroke. We investigated the multiple factors that might have influenced the life expectancies of these 122 patients.
The mean age of the patients was 70±13.4 years and the mean survival was 41.7±2.8 months. The mean survival of the poor functional outcome group (mRS≥4) was 33.9±3.3 months, whereas that of the good functional outcome group (mRS≤3) was 58.6±2.6 months (p value =0.000). The mean survival of the older patients (≥70 years) was 29.7±3.4 months, whereas that of the younger patients (<70 years) was much better as 58.9±3.2 months (p value=0.000). Involvement of ACA or PCA territory in MCA infarction is also a poor prognostic factor (p value=0.021). But, other factors that are also known as significant predictors of poor survival (male gender, hypertension, heart failure, atrial fibrillation, diabetes mellitus, a previous history of stroke, smoking, and dyslipidemia) did not significantly influence the mean survival time in the current study.
Age (older versus younger than 70 years old) and functional outcome at one month could be critical prognostic factors for survival after acute large cerebral infarction. Involvement of ACA or PCA territory is also an important poor prognostic factor in patients with MCA territorial infarction.
PMCID: PMC3079105  PMID: 21519496
Age; Functional outcome; Large cerebral infarction; Prognostic factors
4.  Comparison of Different Microanastomosis Training Models : Model Accuracy and Practicality 
The authors evaluated the accuracies and ease of use of several commonly used microanastomosis training models (synthetic tube, chicken wing, and living rat model).
A survey was conducted among neurosurgeons and neurosurgery residents at a workshop held in 2009 at the authors' institute. Questions addressed model accuracy (similarity to real vessels and actual procedures) and practicality (availability of materials and ease of application in daily practice). Answers to each question were rated using a 5-point scale. Participants were also asked what types of training methods they would chose to improve their skills and to introduce the topic to other neurosurgeons or neurosurgery residents.
Of the 24 participants, 20 (83.3%) responded to the survey. The living rat model was favored for model accuracy (p < 0.001; synthetic tube -0.95 ± 0.686, chicken wing, 0.15 ± 0.587, and rat, 1.75 ± 0.444) and the chicken wing model for practicality (p < 0.001; synthetic tube -1.55 ± 0.605, chicken wing, 1.80 ± 0.523, and rat, 1.30 ± 0.923). All (100%) chose the living rat model for improving their skills, and for introducing the subject to other neurosurgeons or neurosurgery residents, the chicken wing and living rat models were selected by 18 (90%) and 20 (100%), respectively.
Of 3 methods examined, the chicken wing model was found to be the most practical, but the living rat model was found to represent reality the best. We recommend the chicken wing model to train surgeons who have mastered basic techniques, and the living rat model for experienced surgeons to maintain skill levels.
PMCID: PMC2864822  PMID: 20461170
Cerebral revascularization; Microsurgery; Training
5.  A Case of Ruptured Peripheral Aneurysm of the Anterior Inferior Cerebellar Artery Associated with an Arteriovenous Malformation : A Less Invasive Image-Guided Transcortical Approach 
A 47-year-old man presented with a subarachnoid hemorrhage (SAH) and right cerebellar hematoma was referred for evaluation. Cerebral angiography revealed a distal anterior inferior cerebellar artery (AICA) aneurysm associated with an arteriovenous malformation (AVM). Successful obliteration and complete removal of the aneurysm and AVM were obtained using transcortical approach under the guidance of neuronavigation system. The association of a peripheral AICA aneurysm and a cerebellar AVM by the same artery is unique. The reported cases of conventional surgery for this disease complex are not common and their results are variable. Less invasive surgery using image-guided neuronavigation system would be helpful and feasible for a peripheral aneurysm combining an AVM of the posterior fossa in selective cases.
PMCID: PMC2803276  PMID: 20062576
Aneurysm; Anterior inferior cerebellar artery; Arteriovenous malformation; Neuronavigation
6.  Enhancing Box Sign : Enhancement Pattern of Acute Osteoprotic Compression Fracture 
Although gadolinium enhancement of compression fractures is well known, the enhancement pattern of the acute stage of a fracture is not completely understood. Here, we investigated the enhancement pattern of acute vertebral compression fractures (VCFs).
We conducted a retrospective study of patients with acute osteoporotic VCFs admitted to hospital between January 2004 and December 2005. The demographic details, stage of the fracture, management data, and results were analyzed. There were nine men and 22 women, and the mean age was 71 years (range, 53-92 years). According to the onset of pain, patients were divided into the following four groups : Group I (less than 3 days), Group II (4-7 days), Group III (8-14 days), and Group IV (14-30 days).
All patients had central low-signal intensity of the nonenhancing part of vertebral bodies on T1 images. Enhancing box sign (EBS) was seen 7 days of VCF development. After 7 days of onset (Groups III and IV), patch or Kummell's enhancements occurred. EBS has been statistically correlated with stage of compression fracture (Pearson's correlation = -0.774). However, EBS had no statistically significant correlation with prognosis in our study (Pearson's correlation = 0.059).
EBS represents a characteristic sign 7 days of VCF development.
PMCID: PMC2803267  PMID: 20062567
Compression fracture; Magnetic resonance imaging; Gadolinium
7.  Extensive Tension Pneumocephalus Caused by Spinal Tapping in a Patient with Basal Skull Fracture and Pneumothorax 
Tension pneumocephalus may follow a cerebrospinal fluid (CSF) leak communicating with extensive extradural air. However, it rarely occurs after diagnostic lumbar puncture, and its treatment and pathophysiology are uncertain. Tension pneumocephalus can develop even after diagnostic lumbar puncture in a special condition. This extremely rare condition and underlying pathophysiology will be presented and discussed. The authors report the case of a 44-year-old man with a basal skull fracture accompanied by pneumothorax necessitating chest tube suction drainage, who underwent an uneventful lumbar tapping that was complicated by postprocedural tension pneumocephalus resulting in an altered mental status. The patient was managed by burr hole trephination and saline infusion following chest tube disengagement. He recovered well with no neurologic deficits after the operation, and a follow-up computed tomography (CT) scan demonstrated that the pneumocephalus had completely resolved. Tension pneumocephalus is a rare but serious complication of lumbar puncture in patients with basal skull fractures accompanied by pneumothorax, which requires continuous chest tube drainage. Thus, when there is a need for lumbar tapping in these patients, it should be performed after the negative pressure is disengaged.
PMCID: PMC2693797  PMID: 19516955
Pneumocephalus; Pneumothorax; Spinal tapping
8.  Ruptured Aneurysm Arising from the Distal End of a Proximal A1 Fenestration : Case Report and Review of the Literature 
A 75-year-old female presented with subarachnoid hemorrhage. Angiography revealed a partial duplication (fenestration) in the proximal A1 segment and a ruptured aneurysm at the distal end of A1 fenestration. This congenital anomaly accompanying an aneurysm was associated with duplicated ipsilateral middle cerebral artery (MCA). Congenital defect of the arterial wall and hemodynamic factors at the fenestrated A1 are considered to play a significant role in the development of this aneurysm. The present case is peculiar because not only the ruptured A1 aneurysm was related with the anterior and middle cerebral artery duplication but also the location of A1 fenestration and the origin of A1 aneurysm in a fenestration are quite unusual.
PMCID: PMC2640827  PMID: 19242571
Subarachnoid hemorrhage; Aneurysm; A1 fenestration; Hemodynamic factors
9.  Three-Dimensional Angiographic Demonstration of Plexiform Fenestrations of the Proximal Anterior Cerebral Artery Associated with a Ruptured Aneurysm 
A rare case of ruptured aneurysm associated with multiple A1 fenestrations resembling plexiform network was demonstrated by 3D angiography. A 56-year-old female presented with a ruptured aneurysm in the A2 segment of the left distal anterior cerebral artery associated with the right A1 fenestration. The ruptured aneurysm was occluded with surgical neck clipping via interhemispheric approach without neurological deficit. Plexiform fenestrations of the right distal A1, opposite side to the left ruptured A2 aneurysm, were clearly visible on postoperative 3D angiography. Our case may strongly support the theory described by Paget, namely that a remnant of the plexiform anastomosis between the primitive olfactory artery and A1 segment is the source of such fenestration.
PMCID: PMC2612573  PMID: 19119472
Anterior cerebral artery fenestration; Aneurysm; Three-dimensional angiography
10.  Distal Middle Cerebral Artery M4 Aneurysm Surgery Using Navigation-CT Angiography 
Unruptured non-traumatic dissecting aneurysm in the M4 segment of the middle cerebral artery (MCA) accompanied by complete occlusion of the ipsilateral internal cerebral artery (ICA) has never been reported. A 41-year-old man presented with an infarction manifesting as left-sided weakness and dysarthria. Magnetic resonance angiography revealed a subacute stage infarction in the right MCA territory and complete occlusion of the right ICA. Angiography demonstrated aneurysmal dilatation of the M4 segment of the right MCA. Surgery was performed to prevent hemorrhage from the aneurysm. The aneurysm was proximally clipped guided by Navigation-CT angiography and flow to the distal MCA was restored by superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis. We report this rare case with literature review.
PMCID: PMC2588183  PMID: 19096593
Middle cerebral artery aneurysm; Navigation; Dissecting aneurysm

Results 1-10 (10)