Innovative approach in the diagnosis of medulloblastoma in which the 123I-metaiodobenzylguanidine single-positron emission computerized tomography is used
Toshio Sasajima, Hiroyuki Kinouchi, Noriaki Tomura, Jiro Watarai, and Kazuo Mizoi
Anterior paraclinoid aneurysms
Hiroyuki Kinouchi, Kazuo Mizoi, Yoshihide Nagamine, Noritaka Yanagida, Shigeki Mikawa, Akira Suzuki, Toshio Sasajima, and Takashi Yoshimoto
Object. The characteristics of a previously unclassified paraclinoid aneurysm arising from the anterolateral (dorsal) wall of the proximal internal carotid artery were retrospectively analyzed in seven patients (five women and two men) who were treated surgically for an aneurysm in this unusual location.
Methods. One patient presented with subarachnoid hemorrhage (SAH) caused by rupture of this aneurysm. The lesions were found incidentally (five cases) or during investigation of SAH due to another aneurysm (one case). There was a female predominance in this series; all female patients harbored multiple aneurysms. All patients underwent surgery. Removal of the anterior clinoid process was necessary because the proximal neck of the aneurysm was closely adjacent to the dural ring.
Conclusions. This special group of aneurysms is very rare, is located exclusively in the intradural space, and carries the risk of SAH. The results of surgical treatment for this aneurysm are quite satisfactory.
Direct repair of a blisterlike aneurysm on the internal carotid artery with vascular closure staple clips
Toshiharu Yanagisawa, Kazuo Mizoi, Taku Sugawara, Akira Suzuki, Tohru Ohta, Naoki Higashiyama, Masataka Takahashi, Toshio Sasajima, and Hiroyuki Kinouchi
✓ Vascular closure staple clips made of titanium were originally developed for microvascular anastomosis. Clinical applications for these clips include arteriotomy closure for carotid endarterectomy, extracranial—intracranial bypass, and dural closure. This is the first report in which vascular closure staple clips have been used successfully for direct repair of a tear on the internal carotid artery (ICA). This report involves a 65-year-old man who presented with sudden onset of headache. Admission computerized tomography scans demonstrated a diffuse and thick subarachnoid hemorrhage in the basal cisterns. Cerebral angiograms demonstrated a broad-based, small bulge on the superomedial wall of the left ICA. Intraoperatively, an extremely thin-walled aneurysm was seen on the segment of the ICA at the C-2 vertebral level. The aneurysm ruptured abruptly, although no surgical manipulation was being performed on the aneurysm itself. After temporary clips were applied on the vessel, a large tear of the ICA was repaired with vascular closure staple clips. Reconstruction with the vascular closure staple clips required only a short period of temporary occlusion of the ICA. Postoperative angiograms revealed reduction of the aneurysm bulge and good patency of the ICA. The postoperative course was uneventful, and the patient has been free of symptoms. The vascular closure staple clipping procedure is useful for urgent repair of an aneurysm tear. This method is a new treatment option for these fragile aneurysms in cases in which other options, such as encircling clips or bypass procedures, may have drawbacks or be impossible.
Simultaneous microscopic and endoscopic monitoring during surgery for internal carotid artery aneurysms
Hiroyuki Kinouchi, Toshiharu Yanagisawa, Akira Suzuki, Tohru Ohta, Yoshitaka Hirano, Taku Sugawara, Toshio Sasajima, and Kazuo Mizoi
Object. The authors of this study evaluated the efficacy of simultaneous microscopic and endoscopic monitoring during surgery for internal carotid artery (ICA) aneurysms.
Methods. The endoscopic technique was applied during microsurgery in 11 patients with 13 aneurysms. Nine of these lesions were located on the posterior communicating artery (PCoA), three in the paraclinoid region, and one on the anterior choroidal artery (AChA). Eight patients had unruptured aneurysms and three had ruptured aneurysms. The endoscope was introduced after first exposing the aneurysm through the microscope and was gripped firmly by an air-locked holding arm fitted with a steering system throughout the entire surgery, including dissection of the perforating arteries and application of the aneurysm clips.
Regarding paraclinoid aneurysms, clips were applied through direct visualization of the ophthalmic artery and the proximal neck. In a case involving a superior hypophyseal artery aneurysm in the paraclinoid segment, a ring clip was applied without removing the bone structure around the optic canal. In all aneurysms of the PCoA and the AChA, perforating arteries behind the lesion were identified and dissected using endoscopic control. The aneurysm clip was applied in the best position in a single attempt in 10 of 11 patients. There was no surgical complication related to the endoscopic procedures.
Conclusions. Simultaneous monitoring with the microscope and endoscope is extremely useful in applying clips to ICA aneurysms. This combined method allows for direct dissection of the aneurysm, perforating vessels, and the main trunk in an area not visible through the microscope's eyepiece and promises better surgical results.