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Toshihiko Nakashima, Noriyuki Nakayama, Masahiro Furuichi, Jouji Kokuzawa, Takatsugu Murakawa and Noboru Sakai

The authors report two rare cases of arteriovenous malformation (AVM) associated with moyamoya disease. An AVM, supplied by transdural communicating arteries, was located in the right occipital lobe in one patient who presented with ischemia. The second AVM, which was supplied by basal moyamoya vessels, was located in the posterior part of the left frontal lobe in a patient who developed intracerebral hemorrhage that occupied the left basal ganglion.

A review of the literature revealed a total of 12 AVMs in 11 patients with moyamoya disease including our cases. All AVMs were cerebral and two were supplied by normal cerebral arteries, whereas six AVMs were supplied by basal moyamoya vessels at the base of the brain and four AVMs were supplied by external carotid arteries through the transdural communicating arteries. Every AVM drained into deep or cortical cerebral veins. These findings suggest that the hyperangiogenic character of moyamoya disease occasionally induces the development of acquired arteriovenous shunts that mimic AVM.

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Jouji Kokuzawa, Shinichi Yoshimura, Yasuhiko Kaku and Noboru Sakai

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Yasuhiko Kaku, Kentaro Yamashita, Jouji Kokuzawa, Kiyomitsu Kanou and Masanori Tsujimoto

Object

Superficial temporal artery (STA)–middle cerebral artery (MCA) bypasses have continually evolved, and new strategies have been advocated for reducing anesthetic or surgical morbidity and mortality. Further simplifying, and decreasing the invasiveness of, STA-MCA bypass by performing this operation without endotracheal general anesthesia was believed to be feasible in certain subsets of patients.

Methods

The authors performed STA-MCA bypass using local anesthesia with a sedative in 10 patients with hemodynamically compromised occlusive cerebrovascular disease, as well as multiple comorbidities, between February 2010 and September 2011. The technique is based on the preoperative identification of the point at which the donor and recipient vessels are in closest proximity. Preoperative use of CT angiography allowed the authors to identify the target point precisely and use a minimally invasive procedure. All patients received dexmedetomidine as the sole sedative agent, together with scalp-blocking local anesthesia, with an unsecured airway.

Results

Successful STA-MCA bypass surgeries were achieved via a preselected minimally invasive approach in all cases. There was good hemodynamic stability throughout surgery. No airway or ventilation complications occurred, and no patients were converted to general anesthesia. Subjectively, patients tolerated the technique well with a high rate of satisfaction. There were no perioperative morbidities or deaths. Postoperative MR angiography confirmed a patent bypass in all patients. All patients remained symptom free and returned to normal daily life following the operation.

Conclusions

This initial experience confirms the feasibility of performing STA-MCA bypass without endotracheal general anesthesia. This novel technique produced a high degree of patient satisfaction.