This 44-year-old woman presented with a ruptured anterior communicating artery aneurysm. Intraoperative indocyanine green (ICG) videoangiography demonstrated the aneurysm neck and dome, which were buried in subarachnoid clots. Dissection and aspiration of the clots around the neck were safely performed without touching the ruptured points. The aneurysm was successfully clipped. The patient's postoperative course was excellent. This case illustrates the use of intraoperative ICG videoangiography to provide information about the anatomical location of the aneurysm neck and dome despite their being completely obscured by subarachnoid clots. Intraoperative ICG videoangiography allowed safer dissection of the ruptured aneurysm from the blood clots.
Katsuhiro Kuroda, Hiroyuki Kinouchi, Kazuya Kanemaru, Takuma Wakai, Nobuo Senbokuya and Toru Horikoshi
Nobuo Senbokuya, Hideyuki Yoshioka, Takashi Yagi, Yuji Owada and Hiroyuki Kinouchi
Elucidating the mechanisms of neuronal injury is crucial for the development of spinal cord injury (SCI) treatments. Brain-type fatty acid–binding protein 7 (FABP7) is expressed in the adult rodent brain, especially in astrocytes, and has been reported to play a role in astrocyte function in various types of brain damage; however, its role after SCI has not been well studied. In this study, the authors evaluated the expression change of FABP7 after SCI using a mouse spinal cord compression model and observed the effect of FABP7 gene knockout on neuronal damage and functional recovery after SCI.
Female FABP7 knockout (KO) mice with a C57BL/6 background and their respective wild-type littermates were subjected to SCI with a vascular clip. The expression of FABP7, neuronal injury, and functional recovery after SCI were analyzed in both groups of mice.
Western blot analysis revealed upregulation of FABP7 in the wild-type mice, which reached its peak 14 days after SCI, with a significant difference in comparison to the control mice. Immunohistochemistry also showed upregulation of FABP7 at the same time points, mainly in proliferative astrocytes. The number of surviving ventral neurons in the FABP7-KO mice at 28 days after SCI was significantly lower than that observed in the wild-type mice. In addition, motor functional recovery in the FABP7-KO mice was significantly worse than that of the wild-type mice.
The findings of this study indicate that FABP7 could have a neuroprotective role that might be associated with modulation of astrocytes after SCI. FABP7 could potentially be a therapeutic target in the treatment of SCI.
Yoshihisa Nishiyama, Hiroyuki Kinouchi, Nobuo Senbokuya, Tatsuya Kato, Kazuya Kanemaru, Hideyuki Yoshioka and Toru Horikoshi
Recently, intraoperative fluorescence video angiography using indocyanine green (ICG) has been widely used in aneurysm surgery. This is a simple and useful method to confirm complete occlusion of the aneurysm lumen and preservation of blood flow in the arteries around the aneurysm. However, the observation field of ICG video angiography is limited under a microscope, making it difficult to confirm the flow in the arteries behind the parent arteries or aneurysm. The authors developed a new technique of intraoperative endoscopic ICG video angiography to assess the blood flow in perforating arteries hidden by the parent arteries or aneurysm. The endoscope emits excitation light with a wavelength of approximately 800 nm, and video images were obtained through a cut filter. The authors used this ICG fluorescence endoscope in treating 3 patients with unruptured cerebral aneurysms. During clip placement, the endoscope was inserted to confirm aneurysm occlusion. Then, ICG was intravenously administered, and the fluorescence in the vessels was observed via the endoscope as well as under the microscope. The blood flow in the perforating arteries was clearly identified, and no procedural complication occurred. The authors conclude that the technique is very useful and facilitates intraoperative real-time assessment of the patency of perforating arteries behind parent arteries or aneurysms.
Nobuyasu Takeuchi, Toru Horikoshi, Hiroyuki Kinouchi, Arata Watanabe, Takashi Yagi, Kentaro Mitsuka and Nobuo Senbokuya
The size of the subarachnoid space in the optic nerve sheath (ONS) on MR images is thought to reflect intracranial pressure. The diagnostic value of this space was investigated in patients with spontaneous intracranial hypotension (SIH) syndrome.
Coronal fat-saturated T2-weighted MRI of the orbit was performed in 15 patients with SIH fulfilling the diagnostic criteria for headache caused by low CSF pressure of the International Classification of Headache Disorders or the criteria for spontaneous spinal CSF leaks and intracranial hypotension. The size of the subarachnoid space in the ONS was measured in 2 slices behind the eyeballs. The images were compared before and after treatment. The CSF pressure was measured by lumbar puncture.
Before treatment, the diameter of the ONS subarachnoid space ranged from 2.58 to 4.21 mm (mean 3.34 mm) and the thickness from 0 to 0.48 mm (mean 0.15 mm). Both measurements showed significant correlations with CSF opening pressure, and 8 patients had no CSF space before treatment. The size of CSF space increased in many patients after effective treatment.
Disappearance of the CSF space in the ONS was frequently observed in patients with SIH. This characteristic finding may be useful in the diagnosis of SIH as well as in the evaluation of treatment effectiveness.
Nobuo Senbokuya, Hiroyuki Kinouchi, Kazuya Kanemaru, Yasuhiro Ohashi, Akira Fukamachi, Shinichi Yagi, Tsuneo Shimizu, Koro Furuya, Mikito Uchida, Nobuyasu Takeuchi, Shin Nakano, Hidehito Koizumi, Chikashi Kobayashi, Isao Fukasawa, Teruo Takahashi, Katsuhiro Kuroda, Yoshihisa Nishiyama, Hideyuki Yoshioka and Toru Horikoshi
Cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH) is a major cause of subsequent morbidity and mortality. Cilostazol, a selective inhibitor of phosphodiesterase 3, may attenuate cerebral vasospasm because of its antiplatelet and vasodilatory effects. A multicenter prospective randomized trial was conducted to investigate the effect of cilostazol on cerebral vasospasm.
Patients admitted with SAH caused by a ruptured anterior circulation aneurysm who were in Hunt and Kosnik Grades I to IV and were treated by clipping within 72 hours of SAH onset were enrolled at 7 neurosurgical sites in Japan. These patients were assigned to one of 2 groups: the usual therapy group (control group) or the add-on 100 mg cilostazol twice daily group (cilostazol group). The group assignments were done by a computer-generated randomization sequence. The primary study end point was the onset of symptomatic vasospasm. Secondary end points were the onset of angiographic vasospasm and new cerebral infarctions related to cerebral vasospasm, clinical outcome as assessed by the modified Rankin scale, and length of hospitalization. All end points were assessed for the intention-to-treat population.
Between November 2009 and December 2010, 114 patients with SAH were treated by clipping within 72 hours from the onset of SAH and were screened. Five patients were excluded because no consent was given. Thus, 109 patients were randomly assigned to the cilostazol group (n = 54) or the control group (n = 55). Symptomatic vasospasm occurred in 13% (n = 7) of the cilostazol group and in 40% (n = 22) of the control group (p = 0.0021, Fisher exact test). The incidence of angiographic vasospasm was significantly lower in the cilostazol group than in the control group (50% vs 77%; p = 0.0055, Fisher exact test). Multiple logistic analyses demonstrated that nonuse of cilostazol is an independent factor for symptomatic and angiographic vasospasm. The incidence of new cerebral infarctions was also significantly lower in the cilostazol group than in the control group (11% vs 29%; p = 0.0304, Fisher exact test). Clinical outcomes at 1, 3, and 6 months after SAH in the cilostazol group were better than those in the control group, although a significant difference was not shown. There was also no significant difference in the length of hospitalization between the groups. No severe adverse event occurred during the study period.
Oral administration of cilostazol is effective in preventing cerebral vasospasm with a low risk of severe adverse events. Clinical trial registration no. UMIN000004347, University Hospital Medical Information Network Clinical Trials Registry.