Background Although endovascular parent artery occlusion (PAO) of the intracranial artery is a well‐established treatment option, the long‐term stability of cerebral blood flow remains a concern. This study aimed to evaluate the long‐term clinical and radiological outcomes of patients who underwent PAO. Methods The patients who underwent endovascular PAO of their internal carotid or vertebral artery (VA) between April 2011 and March 2022 were included in this observational study. Information about patient characteristics, details of the endovascular treatment, and clinical and radiological follow‐up were collected. Results The study included a total of 104 cases (average age, 52.9±12.6 years old; men, 73 [70.2%] cases; 95 [91.3%] VA PAO cases) from 8 centers. Most cases were performed in an emergency condition, such as ruptured VA dissecting aneurysm (73 cases [70.2%]). PAO was successful in all cases. Early stroke (within 30 days) occurred in 33 (31.7%) cases (31 cases in VA PAO and 2 cases in internal carotid PAO) with ischemic stroke (29 cases) comprising the largest group. Clinical follow‐up over 1 month was available in 85 cases. During an average follow‐up period of 45.8±25.8 months, 1 case of VA PAO experienced a stroke without functional deterioration. Imaging follow‐up was performed in 75 cases. Recanalization of the occluded VA was observed in 2 cases. The remaining image change was contralateral VA stenosis after VA PAO. The incidence of clinical and radiological events was 1.2% and 1.1% per patient‐year, respectively. Conclusion Once the patients surpass the acute phase after PAO, their mid‐ to long‐term course was stable. The risk of late stroke or de novo aneurysm formation was lower than expected in the literature, and the direct comparison to novel reconstructive techniques is warranted in future studies. Clinical Trial Registration information: https://www.umin.ac.jp/ctr/index.html , trial ID: UMIN000045160.
Surgical treatment of pontine cavernous malformations (CMs) is challenging due to the anatomical difficulties and potential risks involved. We successfully applied an anterior transpetrosal approach (ATPA) to remove a lower ventral pontine CM, and herein we discuss the outline of our procedure accompanied by a surgical video.A 50-year-old woman presenting with progressively worsening diplopia was urgently admitted to our hospital. Preoperative images showed a lower ventral pontine CM compressing the corticospinal tract posteriorly. Considering the location of the CM, we determined that an ATPA was the appropriate approach to achieve a more anterolateral trajectory. We performed extradural anteromedial petrosectomy and penetrated the brainstem from the point just below the anterior inferior cerebellar artery and above the root exit zone of the abducens nerve, which might be located in the somewhat lowest border of actual maneuverability in the ATPA. Maneuverability through this corridor was sufficient without hindering and darkening the high magnification microscopic view, as demonstrated in our surgical video.This report demonstrates surgical treatment of a lower ventral pontine CM using the ATPA. The surgical video we present provides information that is useful for understanding this technique's maneuverability and working window.
Objective Because of their anatomical features, treatment for paraclinoid aneurysms has remained to be challenging. Thus, the aim of this report is to prove the validity of our surgical method for unruptured paraclinoid aneurysms, together with surgical videos. Study Design Between August 2017 and November 2019, we were able to perform surgical clipping for 11 patients with unruptured paraclinoid aneurysm using a completely unified method. This study investigated the effect of surgery on multiple measures, including visual impairment, brain contusion, temporalis muscle atrophy, and multiple neurocognitive functions. Results Of the 67 unruptured aneurysms treated at our hospital, 17 were identified to be paraclinoid aneurysm, and 11 of them were treated by direct clipping using anterior clinoidectomy. Three were ophthalmic artery aneurysms, three were superior hypophyseal artery aneurysms, and five were anterior carotid wall aneurysms without branch projection. Only one patient had asymptomatic mild enlargement of the Marriott blind spots postoperatively. No brain contusion and temporalis muscle atrophy were observed in any cases. Only the Trail Making test (TMT) showed a significant worsening in the acute postoperative period: mean pre- and postoperative TMT scores were 59.1 ± 29.1 and 72.7 ± 37.3 for Part A ( p = 0.018) and 80.5 ± 35.5 and 93.8 ± 39.9 for Part B ( p = 0.030), respectively. However, it improved in the chronic phase. Conclusion We can conclude that our surgical method is safe and can be considered an acceptable treatment. Although surgical stress can cause temporary executive dysfunction shortly after surgery, this decline is temporary.
Operative management of clinoidal meningiomas remains challenging. Several techniques to safely treat this tumor have been reported. Damage to the surrounding structures, such as major vessels, could be fatal; therefore, it is preferable to avoid total resection for the patient's safety. Thus, subtotal resection with gamma knife radiosurgery (GKRS) is an alternative method. It is crucial to remove the tumor around the optic nerve, relieve the nerve from tumor compression, and maintain good tumor control after GKRS. This report proposes an adjunctive operative management technique for clinoidal meningioma. The patient was a 62-year-old-woman with a right clinoidal meningioma who was referred to our department. Magnetic resonance imaging (MRI) revealed a mass lesion in the middle cranial fossa, with infiltration and compression of surrounding structures. Therefore, we planned a subtotal resection with superficial temporal artery-middle cerebral artery (STA-MCA) bypass and additional GKRS. Considering operative complications and postoperative GKRS, anterior clinoidectomy, optic canal unroofing, and aggressive resection around the optic nerves were similarly planned. The operation was performed safely, and the bypassed artery worked as long-term insurance for ischemic complications. We planned a subtotal resection followed by GKRS to prevent major operative complications. In our case, we additionally adopted three specific measures to ensure the safety of the procedure. Notably, STA-MCA bypass was also beneficial as long-term management, as it serves a supportive role for providing collateral flow in cases of vascular stenosis that the patient may experience in the future.
During treatment of vertebral artery (VA) fusiform aneurysms, it is critical to preserve peripheral perforators and anterograde blood flow of the VA and to reduce hemodynamic load to the contralateral VA. Even in the era of endovascular treatment, there are still many benefits to using microsurgical treatments with appropriate clip application and preservation of the perforators around the aneurysm, in conjunction with various bypass techniques. The ideal microsurgical technique involves reconstructive clipping that obliterates the aneurysm but preserves anterograde blood flow of the VA, followed by isolation of the aneurysm and VA reconstruction. If these two methods are unavailable, proximal clipping of the aneurysm combined with flow-augmentation bypass to the distal branch can be considered as an alternative surgical management. We discuss the microsurgical treatment of unruptured VA fusiform aneurysms in our surgical cases on the basis of a review of the current literature.
Abstract Background Although endovascular parent artery occlusion (PAO) of the intracranial artery is a well-established treatment option, the long-term stability of cerebral blood flow remains a concern. This study aimed to evaluate the long-term clinical and radiological outcomes of patients who underwent PAO. Methods The patients who underwent endovascular PAO of their internal carotid or vertebral artery (VA) between April 2011 and March 2022 were included in this observational study. Information about patient characteristics, details of the endovascular treatment, and clinical and radiological follow-up were collected. Results The study included a total of 104 cases (average age 52.9±12.6 years old, male 73 (70.2%) cases, 95 (91.3%) VA PAO cases) from eight centers. Most cases were performed in an emergency condition, such as ruptured vertebral artery dissecting aneurysm (73 cases [70.2%]). PAO was successful in all cases. Early stroke (within 30 days) occurred in 33 (31.7%) cases (31 cases in VA PAO and two cases in internal carotid PAO) with ischemic stroke (29 cases) comprising the largest group. Clinical follow-up over 12 months was available in 78 cases. During an average follow-up period of 49.5 ± 24.3 months, one case in VA PAO experienced a stroke without functional deterioration. Imaging follow-up was performed in 73 cases. Recanalization of the occluded VA was observed in two cases. The remaining image change was contralateral VA stenosis after VA PAO. The incidence of clinical and radiological events was 0.95 and 1.1% per patient-year, respectively. Conclusions Once the patients surpass the acute phase after PAO, their mid-to-long term course was stable. The risk of late stroke or de novo aneurysm formation was lower than expected in the literature, and the direct comparison to novel reconstructiv techniques is warranted in future studies. Registration https://www.umin.ac.jp/ctr/index.html , trial ID: UMIN000045160
Adult patients with moyamoya disease (MMD) may present with mild cognitive dysfunction, even those without evidence of conspicuous brain parenchymal damage. This cognitive dysfunction might be caused by local frontal lobe ischemia.To explore the relationship between frontal lobe hemodynamic insufficiency and cognitive dysfunction in patients with MMD.Thirty adult patients with MMD without conspicuous brain parenchymal damage were retrospectively examined. Patients with MMD with frontal lobe intracerebral steal phenomenon on single photon emission computed tomography were defined as group S (n = 13) and those without it were defined as group P (n = 17). A comparative group comprising patients with unruptured intracranial aneurysm was defined as group C (n = 30). The results of various cognitive and intelligence tests and a composite cognitive score were compared between groups.The digit span test forward version ( P = .041), frontal assessment battery ( P = .022), and composite cognitive score ( P = .015) z-scores were significantly lower in group S than group C. Adjusting for sex and age, patients in group S had a significantly lower composite cognitive score compared with those in group C in multiple regression analysis ( P = .037). Executive dysfunction and working memory dysfunction may be involved in the cognitive decline observed in group S.Mild cognitive dysfunction in MMD was associated with frontal lobe hemodynamic insufficiency. Future studies should examine whether revascularization can improve cerebral hypoperfusion and neurocognitive function in these patients.
Angiography is essential to diagnosis and treatment for the patients with ruptured intracranial aneurysm in early stage, but on the other hand angiography always involves a risk that extravasation (EV) occurs from the aneurysm during angiography. Once EV occurs, the patient's outcome is poor and, in general, the patient tends to be regard as hopeless of recovery. Over the past 5 years, in 154 patients with ruptured intracranial aneurysm angiography was performed, and in 7 of them EV occurred. We performed neck clipping for ruptured aneurysm in 3 of 7 patients and were able to save the life of 2 patients. We investigated factors to cause EV and to decide outcome in 7 cases and 75 cases of literature, totally 82 cases. Following results were obtained. Occurrence of EV seems to be related to the causal factors of the time interval (within 6 hours) from SAH to angiography and the severity of disturbance of consciousness prior to angiography. It is considered that the patient's outcome is related to age, pre-angiographic severity of disturbance of consciousness, and also time interval from SAH to angiography, but the extent of EV and the number of past history of SAH are not important as the factors related to the outcome. Consequently, the utmost care must be taken for cerebral angiography particularly in patients within 6 hours after the onset of SAH, and in patients with severe disturbance of consciousness. Even if EV should occur, there is a fair chance for life-saving by an emergency surgery in cases with mild disturbance of cerebral function before angiography.
