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Tetsuyoshi Horiuchi, Yuichiro Tanaka, Hisayoshi Takasawa, Takahiro Murata, Takehiro Yako and Kazuhiro Hongo

Object. Ruptured distal middle cerebral artery (MCA) aneurysms are uncommon, and their clinical and radiological features are poorly understood. To clarify characteristics of these lesions, the authors undertook a retrospective analysis of nine patients with ruptured distal MCA aneurysms.

Methods. The medical records of patients who underwent surgical repair of ruptured intracranial aneurysms between 1988 and 2002 at Shinshu University Hospital and its affiliated hospitals were retrospectively evaluated. The authors found only nine patients with a ruptured distal MCA aneurysm, and their clinical, neuroimaging, and intraoperative findings were evaluated.

Conclusions. This study of nine patients with distal MCA aneurysms is the largest series to date. Eight lesions were saccular aneurysms that were clipped and the remaining one was a mycotic aneurysm that was trapped. Eight of the nine patients suffered cerebral hematomas with subarachnoid hemorrhage. All patients had good outcomes after obliteration of their aneurysm, although their preoperative condition was not good.

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Mitsunori Matsumae, Jun Koizumi, Haruo Fukuyama, Hideo Ishizaka, Yoshihito Mizokami, Tanefumi Baba, Hideki Atsumi, Atsushi Tsugu, Shinri Oda, Yutaka Tanaka, Takahiro Osada, Masaaki Imai, Tomoko Ishiguro, Minako Yamamoto, Jiro Tominaga, Masami Shimoda and Yutaka Imai

Object

In February 2006, the magnetic resonance/x-ray/operating room (MRXO) suite opened at the authors' institution. This is the first hybrid neurosurgical procedure suite to combine magnetic resonance (MR) imaging, computed tomography (CT), and angiography within a neurosurgical operating room (OR). In the present paper the authors describe the concept of the MRXO as well as their first 10 months of experience using this suite, and discuss its advantages and limitations.

Methods

In the MRXO suite, the combined OR and angiography (OR–angiography) station is located in the middle of the suite, and the MR imaging and CT scanning stations are each installed in an adjoining bay connected to the OR–angiography station by shielded sliding doors. The surgical, MR imaging, angiography, and CT tables are positioned in order of use. The patient lies on a fully MR imaging– and radiography-compatible mobile patient tabletop that is used to move the patient quickly and safely among the tables in the imaging and operating components of the MRXO suite.

Results

The authors performed all interventional procedures safely. The specially designed operating tabletop of the MRXO suite reduced the limitations on neurosurgeons during standard neurosurgical procedures. This hybrid suite helps to provide high-quality intraoperative imaging, greatly reducing the risk of unexpected events during the procedure.

Conclusions

The MRXO suite, which combines OR and imaging equipment, represents a significant milestone in the improvement of neurosurgical diagnosis and treatment and other interventional procedures. Another advantage of the MRXO suite is its cost-effectiveness, which is partly due to its streamlined imaging procedure.

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Keisuke Takai, Toshiki Endo, Takao Yasuhara, Toshitaka Seki, Kei Watanabe, Yuki Tanaka, Ryu Kurokawa, Hideaki Kanaya, Fumiaki Honda, Takashi Itabashi, Osamu Ishikawa, Hidetoshi Murata, Takahiro Tanaka, Yusuke Nishimura, Kaoru Eguchi, Toshihiro Takami, Yusuke Watanabe, Takeo Nishida, Masafumi Hiramatsu, Tatsuya Ohtonari, Satoshi Yamaguchi, Takafumi Mitsuhara, Seishi Matsui, Hisaaki Uchikado, Gohsuke Hattori, Nobutaka Horie, Hitoshi Yamahata and Makoto Taniguchi

OBJECTIVE

Spinal arteriovenous shunts are rare vascular lesions and are classified into 4 types (types I–IV). Due to rapid advances in neuroimaging, spinal epidural AVFs (edAVFs), which are similar to type I spinal dural AVFs (dAVFs), have recently been increasingly reported. These 2 entities have several important differences that influence the treatment strategy selected. The purposes of the present study were to compare angiographic and clinical differences between edAVFs and dAVFs and to provide treatment strategies for edAVFs based on a multicenter cohort.

METHODS

A total of 280 consecutive patients with thoracic and lumbosacral spinal dural arteriovenous fistulas (dAVFs) and edAVFs with intradural venous drainage were collected from 19 centers. After angiographic and clinical comparisons, the treatment failure rate by procedure, risk factors for treatment failure, and neurological outcomes were statistically analyzed in edAVF cases.

RESULTS

Final diagnoses after an angiographic review included 199 dAVFs and 81 edAVFs. At individual centers, 29 patients (36%) with edAVFs were misdiagnosed with dAVFs. Spinal edAVFs were commonly fed by multiple feeding arteries (54%) shunted into a single or multiple intradural vein(s) (91% and 9%) through a dilated epidural venous plexus. Preoperative modified Rankin Scale (mRS) and Aminoff-Logue gait and micturition grades were worse in patients with edAVFs than in those with dAVFs. Among the microsurgical (n = 42), endovascular (n = 36), and combined (n = 3) treatment groups of edAVFs, the treatment failure rate was significantly higher in the index endovascular treatment group (7.5%, 31%, and 0%, respectively). Endovascular treatment was found to be associated with significantly higher odds of initial treatment failure (OR 5.72, 95% CI 1.45–22.6). In edAVFs, the independent risk factor for treatment failure after microsurgery was the number of intradural draining veins (OR 17.9, 95% CI 1.56–207), while that for treatment failure after the endovascular treatment was the number of feeders (OR 4.11, 95% CI 1.23–13.8). Postoperatively, mRS score and Aminoff-Logue gait and micturition grades significantly improved in edAVFs with a median follow-up of 31 months.

CONCLUSIONS

Spinal epidural AVFs with intradural venous drainage are a distinct entity and may be classified as type V spinal vascular malformations. Based on the largest multicenter cohort, this study showed that primary microsurgery was superior to endovascular treatment for initial treatment success in patients with spinal edAVFs.