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Koji Kamijo and Toru Matsui

Object

Fragile aneurysm walls and poorly defined necks render the surgical treatment of blood blister–like aneurysms (BBAs) located at nonbranching sites of the supraclinoid internal carotid artery extremely challenging. Such aneurysms have a remarkable tendency to rupture during surgery, especially during the acute period. The authors describe the clinical course of patients with subarachnoid hemorrhage (SAH) caused by BBA rupture and emphasize the value of internal carotid artery trapping combined with high-flow extracranial-intracranial (trapping/EC-IC) bypass during the acute period following SAH.

Methods

The authors analyzed the clinical records of 7 consecutive female patients with a mean age of 61 years (range 51–77 years) who had been treated between January 2006 and December 2008 at their institute.

Results

All 7 patients presented with SAHs corresponding to Fisher Grade 3 and World Federation of Neurosurgical Societies Grades II, III, IV, and V in 3, 1, 2, and 1 patient, respectively. Surgery was postponed in the 3 patients, including 1 in whom the trapping/EC-IC bypass procedure was performed during the chronic period. Two of the 3 patients in whom surgery was postponed experienced preoperative rebleeding, and repeated angiography revealed remarkable enlargement of the aneurysm; both of these patients died before surgery could be performed. The remaining 4 patients underwent trapping/EC-IC bypass during the acute period following SAH. The outcome was excellent (Glasgow Outcome Scale Scores 5), and postoperative angiography demonstrated complete obliteration of the BBA as well as good graft patency in all 5 patients who underwent trapping/EC-IC bypass. Intraoperative bleeding from the BBAs never occurred in any of these 5 patients.

Conclusions

Ruptured BBAs were successfully treated with a trapping/EC-IC bypass during the acute SAH period. This surgical strategy for treating BBAs during the acute period might be a promising option for these rare but high-risk lesions.

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Hidehiko Kawabata, Toru Shibata, Yoshito Matsui and Natsuo Yasui

Object. The use of intercostal nerves (ICNs) for the neurotization of the musculocutaneous nerve (MCN) in adult patients with traumatic brachial plexus palsy has been well described. However, its use for brachial plexus palsy in infants has rarely been reported. The authors surgically created 31 ICN—MCN communications for birth-related brachial plexus palsy and present the surgical results.

Methods. Thirty-one neurotizations of the MCN, performed using ICNs, were conducted in 30 patients with birth-related brachial plexus palsy. In most cases other procedures were combined to reconstruct all upper-extremity function. The mean patient age at surgery was 5.8 months and the mean follow-up period was 5.2 years. Intercostal nerves were transected 1 cm distal to the mammary line and their stumps were transferred to the axilla, where they were coapted directly to the MCN. Two ICNs were used in 26 cases and three ICNs in five cases.

The power of the biceps muscle of the arm was rated Grade M4 in 26 (84%) of 31 patients. In the 12 patients who underwent surgery when they were younger than 5 months of age, all exhibited a grade of M4 (100%) in their biceps muscle power. These results are better than those previously reported in adults.

Conclusions. Neurotization of the MCN by surgically connecting ICNs is a safe, reliable, and effective procedure for reconstruction of the brachial plexus in patients suffering from birth-related palsy.

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Soichi Oya, Masahiro Indo, Masabumi Nagashima and Toru Matsui

Aneurysms at the distal portion of the superior cerebellar artery (SCA) are very rare. Because of the deep location and a propensity for nonsaccular morphology, aneurysm trapping or endovascular occlusion of the parent artery are the usual treatment options, which are associated with varying risks of ischemic complications. The authors report on a 60-year-old woman who had a 3.5-mm unruptured aneurysm in the lateral pontomesencephalic segment of the SCA with a significant interval growth to 8 mm. Direct surgical intervention comprising trapping of the aneurysm through a subtemporal approach and intradural anterior petrosectomy combined with revascularization of the distal SCA using the superficial temporal artery (STA) was performed. This approach provided sufficient space for the bypass instruments to be introduced into the deep surgical field at a more favorable angle to enhance microscopic visualization of the anastomosis with minimal retraction of the temporal lobe. The patient was discharged with no neurological deficit. Preservation of the blood flow in the distal SCA should be attempted to minimize the risk of ischemic injury, particularly when the aneurysms arise in the anterior or lateral segment of the SCA. The authors demonstrate the safety and effectiveness of the intradural anterior petrosectomy for STA-SCA bypass along with a relevant anatomical study.

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Han Soo Chang, Atsushi Nagai, Soichi Oya and Toru Matsui

An arachnoid web is an abnormal formation of the arachnoid membrane in the spinal subarachnoid space that blocks CSF flow and causes syringomyelia. Although the precise mechanism of syrinx formation is unknown, dissection of the arachnoid web shrinks the syrinx and improves symptoms. Precisely determining the location of the arachnoid web is difficult preoperatively, however, because the fine structure generally cannot be visualized in usual MRI sequences.

In this report the authors describe 2 cases of arachnoid web in which the web was preoperatively identified using quantitative CSF flow analysis of MRI. By analyzing cardiac-gated phase-contrast cine-mode MRI in multiple axial planes, the authors precisely localized the obstruction of CSF flow on the dorsal side of the spinal cord in both patients. This technique also revealed a 1-way valve-like function of the arachnoid webs. Imaging led to the early diagnosis of myelopathy related to the derangement of CSF flow and allowed the authors to successfully excise the webs through limited surgical exposure.

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Han Soo Chang, Tsukasa Tsuchiya and Toru Matsui

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Masahiro Indo, Soichi Oya, Michihiro Tanaka and Toru Matsui

Object

Surgery for aneurysms at the anterior wall of the internal carotid artery (ICA), which are also referred to as ICA anterior wall aneurysms, is often challenging. A treatment strategy needs to be determined according to the pathology of the aneurysm—namely, whether the aneurysm is a saccular aneurysm with firm neck walls that would tolerate clipping or coiling, a dissecting aneurysm, or a blood blister–like aneurysm. However, it is not always possible to properly evaluate the condition of the aneurysm before surgery solely based on angiographic findings.

Methods

The authors focused on the location of the ophthalmic artery (OA) in determining the pathology of ICA anterior wall aneurysms. Between January 2006 and December 2012, diagnostic cerebral angiography, for any reason, was performed on 1643 ICAs in 855 patients at Saitama Medical Center. The authors also investigated the relationship between the origin of the OA and the incidence of ICA anterior wall aneurysms. The pathogenesis was also evaluated for each aneurysm based on findings from both angiography and open surgery to identify any correlation between the location where the OA originated and the conditions of the aneurysm walls.

Results

Among 1643 ICAs, 31 arteries (1.89%) were accompanied by an anomalous origin of the OA, including 26 OAs originating from the C3 portion, 3 originating from the C4 portion, and 2 originating from the anterior cerebral artery. The incidence of an anomalous origin of the OA had no relationship to age, sex, or side. Internal carotid artery anterior wall aneurysms were observed in 16 (0.97%) of 1643 ICAs. Female patients had a significantly higher risk of having ICA anterior wall aneurysms (p = 0.026). The risk of ICA anterior wall aneurysm formation was approximately 50 times higher in patients with an anomalous origin of the OA (25.8% [8 of 31]) than in those with a normal OA (0.5% [8 of 1612], p < 0.0001). Based on angiographic classifications, saccular aneurysms were significantly more common in patients with an anomalous origin of the OA than in those with a normal OA (p = 0.041). Ten of 16 patients with ICA anterior wall aneurysms underwent craniotomies. Based on the intraoperative findings, all 6 aneurysms with normal OAs were dissecting or blood blister–like aneurysms, not saccular aneurysms.

Conclusions

There was a close relationship between the location of the OA origin and the predisposition to ICA anterior wall aneurysms. Developmental failure of the OA and subsequent weakness of the vessel wall might account for this phenomenon, as previously reported regarding other aneurysms related to the anomalous development of parent arteries. The data also appear to indicate that ICA anterior wall aneurysms in patients with an anomalous origin of the OA tend to be saccular aneurysms with normal neck walls. These findings provide critical information in determining therapeutic strategies for ICA anterior wall aneurysms.

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Toru Matsui, Hiroyuki Kaizu, Shoichi Iron and Takao Asano

✓ To evaluate the pathogenetic role of alterations in the physical properties of the arterial wall (the passive component) and of active smooth-muscle contraction (the active component) in the occurrence of chronic vasospasm, the temporal profiles of these events were examined using the canine “two-hemorrhage” model. In the in vivo study, the basilar artery was exposed via the transclival approach on Day 0, 2, 4, 7, or 14. Nicardipine, followed by the protein kinase C inhibitor H-7, then papaverine were administered in a cumulative fashion, and the change in the basilar artery diameter induced by the addition of each agent was recorded angiographically. Drug administration markedly reversed the arterial narrowing caused by chronic vasospasm. When the vasodilatory effect of each agent was compared, the dilation induced by nicardipine or papaverine progressively decreased from Day 2 to Day 7, whereas that induced by H-7 increased. The in vitro experiment using arterial segments excised from the basilar artery revealed a progressive increase in arterial stiffness from Day 2 to Day 7. Also, there was a significant decrease in the initial half-circumference of the arterial segment, which was at its maximum on Days 4 and 7. However, the alteration in the initial half-circumference was considerably less than that in the angiographic diameter following subarachnoid hemorrhage. These data indicate that the augmented spontaneous tonus of the smooth muscle plays the predominant role in the occurrence of chronic vasospasm. Thus, the involvement of the protein kinase C-mediated contractile system is strongly suggested.

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Yoshiki Obata, Junichi Takeda, Yohei Sato, Hiroyasu Ishikura, Toru Matsui and Eiji Isotani

OBJECT

Subarachnoid hemorrhage (SAH) is often accompanied by pulmonary complications, which may lead to poor outcomes and death. This study investigated the incidence and cause of pulmonary edema in patients with SAH by using hemodynamic monitoring with PiCCO-plus pulse contour analysis.

METHODS

A total of 204 patients with SAH were included in a multicenter prospective cohort study to investigate hemodynamic changes after surgical clipping or coil embolization of ruptured cerebral aneurysms by using a PiCCO-plus device. Changes in various hemodynamic parameters after SAH were analyzed statistically.

RESULTS

Fifty-two patients (25.5%) developed pulmonary edema. Patients with pulmonary edema (PE group) were significantly older than those without pulmonary edema (non-PE group) (p = 0.017). The mean extravascular lung water index was significantly higher in the PE group than in the non-PE group throughout the study period. The pulmonary vascular permeability index (PVPI) was significantly higher in the PE group than in the non-PE group on Day 6 (p = 0.029) and Day 10 (p = 0.011). The cardiac index of the PE group was significantly decreased biphasically on Days 2 and 10 compared with that of the non-PE group. In the early phase (Days 1–5 after SAH), the daily water balance of the PE group was slightly positive. In the delayed phase (Days 6–14 after SAH), the serum C-reactive protein level and the global end-diastolic volume index were significantly higher in the PE group than in the non-PE group, whereas the PVPI tended to be higher in the PE group.

CONCLUSIONS

Pulmonary edema that occurs in the early and delayed phases after SAH is caused by cardiac failure and inflammatory (i.e., noncardiogenic) conditions, respectively. Measurement of the extravascular lung water index, cardiac index, and PVPI by PiCCO-plus monitoring is useful for identifying pulmonary edema in patients with SAH.

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Tomasz Szmuda, Pawel Sloniewski, Marta Szmuda, Janusz Springer and Przemyslaw Waszak