✓ A technique is described for removing previously placed aneurysm clips and applying new aneurysm clips for the treatment of regrown or reruptured cerebral aneurysms in patients more than 10 years after the original clipping of the aneurysm neck. The adherent tissue covering previously placed clips is cut just on and alongside the clips themselves using a small scalpel. Using the clip applicator, gentle pressure is applied to open the clip blade as little as possible. The aneurysm clip is carefully slid out along the line where the clip blade has resided, and a new aneurysm clip is applied. The procedure was successfully accomplished in four patients. Whereas three of these patients had an uneventful postoperative course, the remaining patient experienced transient right oculomotor nerve palsy and left-sided motor weakness. The present technique is a useful procedure for treatment of regrown or reruptured cerebral aneurysms occurring a significantly long time after initial clipping of an aneurysm neck.
Hiroshi Kashimura, Kuniaki Ogasawara, Yoshitaka Kubo, Yasunari Otawara and Akira Ogawa
Hiroshi Kashimura, Takashi Inoue, Kuniaki Ogasawara, Hiroshi Arai, Yasunari Otawara, Yoshiyuki Kanbara and Akira Ogawa
Preoperative planning for meningiomas requires information about tumor consistency as well as location and size. In the present study the authors aimed to determine whether the fractional anisotropy (FA) value calculated on the basis of preoperative magnetic resonance (MR) diffusion tensor (DT) imaging could predict meningioma consistency.
In 29 patients with intracranial meningiomas, MR DT imaging was performed preoperatively, and the FA values of the tumors were calculated. Tumor consistency was intraoperatively determined as hard or soft, and the histological diagnosis of the tumor was established.
Of the 29 tumors, 11 were classified as hard and 18 as soft. The FA values of fibroblastic meningiomas were significantly higher than those of meningothelial meningiomas (p = 0.002). The FA values of hard tumors were significantly higher than those of soft tumors (p = 0.0003). Logistic regression analysis demonstrated that the FA value was a significant independent predictor of tumor consistency (p = 0.007).
The FA value calculated from preoperative MR DT imaging predicts meningioma consistency.
Yasunari Otawara, Kuniaki Ogasawara, Hiroshi Kashimura, Yoshitaka Kubo, Akira Ogawa and Kouichi Watanabe
The mechanical properties of titanium-alloy aneurysm clips after long-term implantation in the human cranium are unclear. The characteristics of a Yasargil titanium aneurysm clip were evaluated after long-term implantation for 12 years in a patient with a cerebral aneurysm. The closing forces of the retrieved clip before and after implantation were approximately equal. The bending test showed no differences between the retrieved and control clips. Titanium oxide and calcium were identified on the surface of the retrieved clip, which indicated the formation of corrosion-resistant layers. Titanium-alloy clips retain their mechanical properties in the human cranium for a long time.
Yoshitaka Kubo, Takahiro Koji, Hiroshi Kashimura, Yasunari Otawara, Akira Ogawa and Kuniaki Ogasawara
The prevalence of patients with asymptomatic unruptured intracranial aneurysms (UIAs) increases with the advancing age of the general population. The goal of the present study was to identify risk factors for the growth of UIAs detected with serial MR angiography (MRA) in patients 70 years of age or older.
This prospective study enrolled 79 patients (age range 70–84 years) with 98 UIAs. Patients were followed up every 4 months, including an assessment of the aneurysm diameter and morphological changes on MRA, neurological status, and other medical conditions. Aneurysm growth was categorized into two different patterns on the basis of the MRA findings: 1) maximum increase in aneurysm diameter of 2 mm or more; and 2) obvious morphological change, such as the appearance of a bleb.
The mean duration of follow-up was 38.5 months (250.2 patient-years). Aneurysm rupture did not occur, but aneurysm growth was observed in 8 aneurysms (8 patients) during the study period. Univariate analysis showed that female sex, patient age ≥ 75 years, and an aneurysm location in the internal carotid artery (ICA) or middle cerebral artery (MCA) were associated with aneurysm growth (p = 0.04, p = 0.04, and p < 0.001, respectively). Multivariate analysis demonstrated that female sex was the only independent predictor of aneurysm growth (p = 0.0313, OR 2.3, 95% CI 1.3–30.2).
Female sex is an independent risk factor for the growth of UIAs in elderly patients. In addition, an age ≥ 75 years and aneurysm location in the ICA or MCA are characteristics that may warrant additional attention during follow-up imaging.
Shunsuke Kakino, Kuniaki Ogasawara, Yoshitaka Kubo, Hiroshi Kashimura, Hiromu Konno, Atsushi Sugawara, Masakazu Kobayashi, Makoto Sasaki and Akira Ogawa
Although angioplasty and stent placement for vertebral artery (VA)–origin stenosis have been performed using endovascular techniques, a high likelihood of restenosis has been observed in the long term. Therefore, the authors assessed the long-term clinical and angiographic outcomes in patients after VA–subclavian artery (SA) transposition.
Thirty-six patients (31 men, 5 women; mean age 64.3 years, range 46–76 years) underwent clinical evaluation (modified Rankin Scale [mRS]) and cervical angiographic evaluation preoperatively and within 1 month of and 6 months after VA-SA transposition undertaken to treat symptomatic stenosis of VA origin.
Postoperative neurological deficits due to intraoperative brain ischemia did not occur, and MR imaging demonstrated no new postoperative ischemic lesions in any of the patients. One patient died of acute myocardial infarction 2 months after surgery and another developed a left thalamic hemorrhage (mRS score of 5) at 42 months postsurgery. None of the remaining 34 patients experienced further ischemic events, and the mRS score in all of these patients remained unchanged during a mean follow-up period of 54 months. The degree of VA-origin stenosis (preoperative mean 84%) was reduced to ≤ 30% after surgery (mean 2%). Long-term follow-up angiography in 29 patients (81%) revealed the absence of restenosis, defined as > 50% luminal narrowing, in all of them.
The clinical and angiographic long-term outcomes demonstrated here suggest that VA-SA transposition will be useful in patients with symptomatic stenosis of VA origin.
Hiroshi Kashimura, Kuniaki Ogasawara, Yoshitaka Kubo, Shunsuke Kakino, Kenji Yoshida, Masayuki Sasoh, Hajime Takahashi, Kenji Suzuki and Akira Ogawa
✓ A technique for exposing the vertebrobasilar junction with traction of the dentate ligament is described for treatment of large vertebral artery (VA) aneurysms via the far lateral suboccipital approach with partial condylar resection. The most rostral attachment of the dentate ligament is divided above the site where the VA pierces the dura mater. A traction suture is placed into the dentate ligament and gently retracted using mosquito forceps. As a result, the medulla oblongata is lifted dorsally and slightly rotated by the divided and retracted dentate ligament, allowing an approach from a more superior or inferior direction. The present technique is useful for the treatment of large thrombosed VA aneurysms.