Toshikazu Kimura, Chikayuki Ochiai, Kensuke Kawai, Akio Morita and Nobuhito Saito
To investigate the risk of bleeding from unruptured cerebral aneurysms (UCAs), previous studies have used Kaplan-Meier analyses without treating the definitive treatment as a competing risk event, which may underestimate the rupture rate. The authors analyzed the survival of patients with UCAs alongside the occurrence of aneurysm bleeding and its competing risk events.
A retrospective analysis was conducted on 722 patients diagnosed with UCAs in the period from 2000 to 2009 using an institution’s electronic medical records and telephone interviews. The cumulative incidence of aneurysm rupture was examined, and factors contributing to rupture were assessed using regression analyses.
By 2014, 19 patients had experienced aneurysm rupture, with an overall rupture rate of 0.57% per year over 3320.8 person-years. However, cumulative incidence analysis indicated that 1.3% of all patients had a rupture within 2 years after aneurysm identification, and 38.4% of the patients underwent definitive treatment in the same period. Among the patients who experienced rupture, regression analysis revealed that an aneurysm size greater than 5 mm, a location in the anterior or posterior communicating arteries, and an irregular shape contributed to aneurysm rupture, with HRs of 4.4 (95% CI 1.2–15.7), 3.5 (95% CI 1.4–8.7), and 2.1 (95% CI 0.7–6.0), respectively.
Rupture rate analyses using the person-year or standard Kaplan-Meier method are not as informative without consideration of the competing risks. The incidence of aneurysm rupture should be presented clearly with those of competing risks.
Keisuke Maruyama, Masahiro Shin, Masao Tago, Hiroki Kurita, Nobutaka Kawahara, Akio Morita and Nobuhito Saito
Appropriate management of hemorrhage after Gamma Knife surgery (GKS) for arteriovenous malformations (AVMs) of the brain is poorly understood, although a certain proportion of patients suffer from hemorrhage.
Among 500 patients observed for 1 to 183 months (median 70 months) after GKS, 32 patients (6.4%) suffered a hemorrhage. Hemorrhage developed even after angiographically documented obliteration of the AVM in five (2%) of 250 patients followed for 1 to 133 months (median 75 months) post-GKS. These patients had been treated according to their pathological condition. Treatment of these patients and their outcomes were retrospectively reviewed. As a management strategy in patients with preobliteration hemorrhage, the intracerebral hematoma and the AVM nidus were removed in four patients, and chronic encapsulated hematoma was removed in three. Among 11 patients who were conservatively treated, AVMs were ultimately obliterated in five, including three patients who underwent repeated GKS. Intracerebral hematoma from angiographically documented obliterated AVMs was radically resected in two patients, including one who also underwent aspiration of an accompanying symptomatic cyst. Intraoperative bleeding was easily controlled in these patients. Outcomes after hemorrhage, measured with the modified Rankin Scale, were significantly better in patients with postobliteration hemorrhage than in those with preobliteration hemorrhage (p < 0.05).
Various types of hemorrhagic complications after GKS for AVMs can be properly managed based on an understanding of each pathological condition. Although a small risk of bleeding remains after angiographically demonstrated obliteration, surgery for such AVMs is safe, and the patient outcomes are more favorable. Radical resection to prevent further hemorrhage is recommended for ruptured AVMs after obliteration because such AVMs can cause repeated hemorrhages.
Kyousuke Kamada, Tomoki Todo, Yoshitaka Masutani, Shigeki Aoki, Kenji Ino, R.T., Akio Morita and Nobuhito Saito
There is continuous interest in the monitoring of language function during tumor resection around the fron-totemporal regions of the dominant hemisphere. The aim of this study was to visualize language-related subcortical connections, such as the arcuate fasciculus (AF) by diffusion tensor (DT) imaging–based tractography.
Twenty-two patients with brain lesions adjacent to the AF in the frontotemporal regions of the dominant hemisphere were studied. The AF tractography was accomplished by placing initiation and termination sites (seed and target points) in the frontal and temporal regions, which were functionally identified by using functional magnetic resonance (fMR) imaging in conjunction with a verb generation task and magnetoencephalography (MEG) in conjunction with a reading task. The combination of fMR imaging and MEG data clearly demonstrated the hemispheric dominance of language functions, which was confirmed by an intracranial amobarbital test (Wada procedure). In all 22 patients, the authors were able to consistently visualize the AF by DT imaging–based tractography, using the functionally identified seed and target points and a fractional anisotropy value of 0.16. In two of 22 cases investigated, the functional information, including the results of AF tractography, fMR imaging, and MEG, was imported to a neuronavigation system and was validated by bipolar electric stimulation of the cortical and subcortical areas during awake surgery. The cortical stimulation to the gyrus that included the area of activation identified in fMR imaging with the language task evoked speech arrest, while the subcortical stimulation close to the AF reproducibly caused paranomia without speech arrest. Postoperative AF tractography showed that the distances between the stimulus points and the AF were within 6 mm.
The combination of these techniques facilitated accurate identification of the location of the AF and verification of the language fibers.
Sunho Ko, Atsushi Nakazawa, Yusuke Kurose, Kanako Harada, Mamoru Mitsuishi, Shigeo Sora, Naoyuki Shono, Hirofumi Nakatomi, Nobuhito Saito and Akio Morita
Advanced and intelligent robotic control is necessary for neurosurgical robots, which require great accuracy and precision. In this article, the authors propose methods for dynamically and automatically controlling the motion-scaling ratio of a master-slave neurosurgical robotic system to reduce the task completion time.
Three dynamic motion-scaling modes were proposed and compared with the conventional fixed motion-scaling mode. These 3 modes were defined as follows: 1) the distance between a target point and the tip of the slave manipulator, 2) the distance between the tips of the slave manipulators, and 3) the velocity of the master manipulator. Five test subjects, 2 of whom were neurosurgeons, sutured 0.3-mm artificial blood vessels using the MM-3 neurosurgical robot in each mode.
The task time, total path length, and helpfulness score were evaluated. Although no statistically significant differences were observed, the mode using the distance between the tips of the slave manipulators improves the suturing performance.
Dynamic motion scaling has great potential for the intelligent and accurate control of neurosurgical robots.