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Rainfall can trigger flow-like mass movements characterised by different percentages of solid and water (debris flows, hyperconcentrated flows, and flash floods). They exhibit different magnitude (volume), run-out distance and consequence, due to both distinct triggering mechanisms and kinematic features. Indeed, discriminating among these phenomena for appropriate risk analysis and zoning is a relevant issue also considering that the volume of the flow may sudden increase along the propagation path. The paper deals with September 2010 combined types of flows occurred at Atrani village (Amalfi coast, southern Italy), and originated by heavy rainstorm in the catchment located upslope to the urban centre. The events were reconstructed by using multi-source information. Field surveys, geological analysis, elaboration of videos recorded during the events and numerical modelling were combined. A 40 minutes lasting water flood abruptly combined to a relatively small-sized high-discharge hyperconcentrated flow, with the consequence of an abnormal flow that invaded the narrow main street of the urban area in few minutes. The peak discharge at the catchment outlet was increased by erosion and/or other rainfall-induced slope instabilities occurred in the whole catchment. As main conclusion, the multidisciplinary analysis has resulted effective to enhance the understanding of the complex flow-like mass movements. [ABSTRACT FROM AUTHOR]

Bagnoli-Coroglio is a Site of National Interest (SNI) facing the Pozzuoli Bay that has been the place of an industrial activity for more than a century (1854-1985). The modern coastal geology of this area results from the recent evolution of an antecedent volcanic landscape that originated after a caldera collapse following the eruption of Neapolitan Yellow Tuff (NYT) of Campi Flegrei (15 ka). After the NYT eruption, a shallow marine depression formed within the caldera collapse area that underwent progressive filling-up, due to volcaniclastic sediment input from the caldera borders, within a semi-enclosed source-to-sink system. The integrated interpretation of the Digital Terrain Model (DTM) of the Bagnoli-Coroglio area and the high resolution reflection seismic profiles acquired off the Pozzuoli Bay suggests that the present-day coastal plain of Bagnoli-Fuorigrotta and conterminous continental shelf represent the latest infilling phase of the annular depression (caldera 'collar') between the structural border of the NYT caldera and the inner caldera resurgent dome. The stratigraphic architecture and morpho-bathymetry of the Bagnoli inner shelf provide a record of the complex interplay between eustatic sea level changes, volcano-tectonic (ground/seafloor) deformation, and supply of volcaniclastic sediments, with associated coastline shifts over the last millennia. [ABSTRACT FROM AUTHOR]

The amount of coastal subsidence on the Sele River coastal plain has been examined and measured with local vertical land movement data. The vertical displacements, derived by satellite radar differential interferometry processing (Ps‐InSAR), show that the analysed coastal sector is characterised by a south‐eastward decrease of vertical subsidence rates. These results have been coupled with sea‐level rise (SLR) scenarios, in order to identify the most critical areas. In general, the subsidence mostly affects areas where alluvial deposits are thicker, the back‐dune areas and the Sele River mouth, all late Holocene in age. Five local SLR scenarios allow identifying zones in the plain potentially prone to inundation and the shoreline retreat for the years 2065 and 2100. For these dates, 2.2% and 7.06% of the investigated area will have a topography lower than the estimated future sea level. Moreover, results show that the extent of the areas potentially exposed to inundation and erosion increases moving from south to north. [ABSTRACT FROM AUTHOR]

Campi Flegrei is an active volcanic district located along the Eastern Tyrrhenian continental margin, Italy, and is worldwide known for dramatic ground deformation phenomena (bradyseism) recorded over the last centuries. The purpose of this article is to present the annual rates of ground deformation fields (average velocity, average acceleration, and combined annual velocity/acceleration) at Campi Flegrei, during almost two decades (years 1993–2010). The research work was conducted based on a temporal analysis and advanced mapping of Persistent Scatterer Pair (PSP) data, obtained from interferometric processing of radar satellite European Remote Sensing-1/2 and Environmental Satellite (ENVISAT) scenes of the study area. Patterns and trends of annual PSP velocity have provided a reconstruction of the spatial and temporal variability of ground deformation in terms of uplift and/or subsidence along the satellite line of sight (LOS). The analysis of annual PSP velocity and acceleration has revealed an intense dynamics of the Campi Flegrei caldera collapse-resurgence system, testified by the high PSP velocity and acceleration values, as well as the significant changes in the rates of ground deformation through time. The main results of this research indicate that the largest ground deformation is localized within and around the structural border of the Campi Flegrei caldera and suggest a systematic recurrence of opposite trends (upliftvs. subsidence) in the ground deformation of the inner caldera region with respect to the surrounding areas throughout the analysed time period. [ABSTRACT FROM PUBLISHER]

Objective: Bifrontal craniotomy often involves the bony opening and mucosal disruption of the frontal sinus (FS), which can lead to cerebrospinal fluid (CSF) leakage and meningitis. These complications are particularly associated with surgical treatments for skull base tumors and anterior cerebral artery aneurysms. The authors initially reported on the basic technique in 2014 with 51 cases. This study presents a detailed description of their technique and postoperative management for sealing the exposed FS during bifrontal craniotomy, including long-term follow-up results and outcomes. To objectively evaluate the effectiveness of suturing FS mucosa in preventing CSF leakage during bilateral frontal craniotomy, the authors focused only on anterior cerebral artery aneurysms. This limitation was necessary as other conditions, like extensive tumors or trauma, might lack intact FS mucosa or require its removal due to infection., Methods: The records of 34 consecutive patients (median age 62.0 years, mean 60.4 years, range 33-78 years) who underwent bifrontal craniotomy for anterior cerebral artery aneurysms between January 2014 and December 2023 were retrospectively analyzed. All patients had bony opening and mucosal injury of the FS (with exposure to the nasal cavity) that required mucosal suturing. This technique for sealing the exposed FS involves careful dissection of the mucosa from the entire sinus, sterilization with iodine-soaked surgical cotton, and preparation for closure. After the microsurgical procedure is completed, the exposed mucosa is sealed with 6-0 nylon sutures and further secured with fibrin glue-soaked Gelfoam. The bony exposure is covered with an autologous bone flap created from the inner table of the craniotomy bone flap. Finally, the frontal periosteal flap is sutured to the frontal base dura mater. Patients were instructed not to blow their noses for 2 months postoperatively., Results: Two patients experienced transient non-CSF leakage from the nasal cavity, likely due to irrigation fluid, which resolved within 2 days postoperatively. No recurrence was observed during a mean follow-up period of 52.8 ± 41.7 months (median 49 months, range 3-127 months). No cases of meningitis or other intracranial infections were reported., Conclusions: The long-term results demonstrate the sustained effectiveness of this technique in preventing postoperative complications related to FS exposure during bifrontal craniotomy.

We report a case of distal anterior cerebral artery (DACA) aneurysm presenting with subdural hematoma (SDH) without subarachnoid hemorrhage (SAH). A patient in his fifties presented with headache. Fluid-attenuated inversion recovery magnetic resonance imaging revealed SDH in the interhemispheric fissure and left frontotemporal region. SAH was not detected. Computed tomographic angiography revealed aneurysms in the left internal carotid artery (ICA) and DACA. The patient underwent frontotemporal craniotomy, which confirmed an unruptured ICA aneurysm, followed by bilateral frontal craniotomy for clipping of DACA aneurysm. The left DACA aneurysm was identified as the source of the SDH. Intraoperative findings showed adhesion between the aneurysm body and falx cerebri, explaining the SDH formation. Literature review identified only six reported cases of SDH without SAH due to DACA aneurysm. Evidence suggests that DACA aneurysms have a relatively higher propensity to cause SDH without SAH, likely due to the anatomical characteristics of the parent vessel and aneurysm projection., Competing Interests: The authors have no conflict of interest to declare., (Published by Oxford University Press and JSCR Publishing Ltd. © The Author(s) 2025.)

Background: Because of ischemic symptoms, intracranial internal carotid artery (IICA) dissection has no established treatment guidelines. The authors report a case of IICA dissection in which an emergency superficial temporal artery-middle cerebral artery (STA-MCA) bypass was performed., Observations: A 46-year-old woman presented with a headache and left hemiplegia. Her cortical symptoms appeared on day 10, and an STA-MCA bypass was performed because of cerebral hypoperfusion. Her postoperative patency was good, and cortical symptoms improved. Contrast-enhanced magnetic resonance imaging (MRI) was performed in the acute phase with wall contrast. From day 18, the internal carotid artery delineation improved, and the patient was transferred for rehabilitation without worsening symptoms. A literature review of spontaneous IICA dissection with revascularization procedures was conducted to discuss the indications, timing, treatment modalities, and surgical outcomes., Lessons: The STA-MCA bypass provides supplemental cerebral blood flow and can prevent critical complications. Contrast-enhanced MRI in the acute phase of dissection can show a wall contrast effect and assist in predicting disease progression. https://thejns.org/doi/10.3171/CASE24332.

Background: Fat is commonly used for preventing cerebrospinal fluid (CSF) leakage during endoscopic transsphenoidal surgery (ETSS). However, fat is soft, slippery, and sometimes not easy to handle. The present study aimed to examine the efficacy of our Surgicel ® wrapping method, which allows for better fat handling, in preventing the occurrence of CSF leakage among patients undergoing ETSS., Methods: We used fat tissues removed from the abdomen. The fat was cut with scissors into pieces that were approximately 5 mm in size. Surgicel ® was also cut into 2.5 cm 2 . The fat tissues were encased with these Surgicel ® squares and slightly moistened with a saline solution., Results: Between January 2023 and August 2024, 34 patients aged 18-86 years (average 54.9 years) underwent ETSS. Among these patients, 20 had pituitary tumors, 6 had Rathke's cysts, and 8 had other conditions. None of the patients had CSF leakage postoperatively. The use of Surgicel ® -wrapped fat during ETSS is better than the use of fat alone., Conclusion: The Surgicel ® wrapping method allows for better fat handling during ETSS., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Surgical Neurology International.)

Background:  Gentian violet ink is used as a skin marker in various surgical procedures, including neurosurgery. The dye is also used to visualize the edges of blood vessels during bypass surgery. However, gentian violet ink carries the risks of carcinogenicity and venous injury, which causes microvascular thrombosis. In this study, we compare the gentian violet-free dye C.I. Basic Violet 4 (BV4) and gentian violet. The usefulness, in terms of color, and formation of microvascular thrombosis in anastomosis were compared., Methods:  We used the gentian violet-free dye in 20 cases involving 3 vascular anastomoses. The bone cutting lines on the bone surface, superior temporal artery, and middle cerebral artery were drawn using BV4 and gentian violet ink., Results:  The colors of BV4 and gentian violet ink were similar. No thrombus formation was observed at the vascular anastomosis when using BV4., Conclusion:  BV4 can be used similarly to gentian violet ink. No adverse effects such as thrombus formation in microvascular anastomosis were experienced when BV4 was used., Competing Interests: None declared., (Thieme. All rights reserved.)

(1) Background Cerebral revascularization is necessary to treat intracranial arterial stenosis caused by moyamoya disease, atherosclerosis, or large complex aneurysms. Although various donor vascular harvesting methods have been reported safe, there are no reports on the histological evaluation of donor vessels for each disease, despite the variety of diseases wherein vascular anastomosis is required. (2) Methods Pathological findings of the superficial temporal artery (STA), radial artery (RA), occipital artery (OA), and saphenous vein (SV) harvested at the institution were analyzed. Patients classified according to aneurysm, atherosclerosis, and moyamoya disease were assessed for pathological abnormalities, medical history, age, sex, smoking, and postoperative anastomosis patency. (3) Results There were 38 cases of atherosclerosis, 15 cases of moyamoya disease, and 30 cases of aneurysm in 98 donor vessels (mean age 57.2) taken after 2006. Of the 84 STA, 11 RA, 2 OA, and 1 SV arteries that were harvested, 71.4% had atherosclerosis, 11.2% had dissection, and 10.2% had inflammation. There was no significant difference in the proportion of pathological findings according to the disease. A history of hypertension is associated with atherosclerosis in donor vessels. (4) Conclusions This is the first study to histologically evaluate the pathological findings of donor vessels according to disease. The proportion of dissection findings indicative of vascular damage due to surgical manipulation was not statistically different between the different conditions.

Moyamoya disease (MMD) is a cerebrovascular disorder that is predominantly observed in women of East Asian descent, and is characterized by progressive stenosis of the internal carotid artery, beginning in early childhood, and a distinctive network of collateral vessels known as "moyamoya vessels" in the basal ganglia. Additionally, a prevalent genetic variant found in most MMD cases is the p.R4810K polymorphism of RNF213 on chromosome 17q25.3. Recent studies have revealed that RNF213 mutations are associated not only with MMD, but also with other systemic vascular disorders, including intracranial atherosclerosis and systemic vascular abnormalities such as pulmonary artery stenosis and coronary artery diseases. Therefore, the concept of "RNF213-related vasculopathy" has been proposed. This review focuses on polymorphisms in the RNF213 gene and describes a wide range of clinical and genetic phenotypes associated with RNF213-related vasculopathy. The RNF213 gene has been suggested to play an important role in the pathogenesis of vascular diseases and developing new therapies. Therefore, further research and knowledge sharing through collaboration between clinicians and researchers are required.

A patient with trigeminal neuralgia due to venous compression was successfully treated by transposition achieved by drilling the suprameatal tubercle. A 53-year-old woman presented with classical trigeminal neuralgia affecting the maxillary division of the right trigeminal nerve. MRI and CT revealed a bony prominence, called the suprameatal tubercle, above the opening of the internal acoustic meatus. MRI showed a thick venous flow void interposed between the suprameatal tubercle and trigeminal nerve. The patient underwent retrosigmoid craniotomy. The bony prominence restricted transposition of the compressed vein, so the compressed vein was successfully transposed after drilling the prominence. The patient's symptoms resolved completely. Drilling the suprameatal tubercle is useful for transposing sandwiched compression vessels.

Ruptured cerebral aneurysms that occur in the anterior wall of the internal carotid artery (ICA) are known as blood blister-like aneurysms (BBAs); they have been reported to account for 0.3% to 1% of all ruptured ICA aneurysms. In this report, we describe the treatment of an unusual traumatic BBA (tBBA) with high-flow bypass using a radial artery graft, which resulted in a favorable outcome. A 59-year-old female suffered from an acute epidural hematoma, traumatic subarachnoid hemorrhage, and traumatic carotid-cavernous sinus fistula (tCCF) after being involved in a motor vehicle accident. Her angiography results showed tCCF and a tBBA on the anterior wall of the right ICA. On the fourth day after injury, we found rebleeding from the tBBA and performed an emergency high-flow bypass using a radial artery graft with lesion trapping as a curative procedure for the tCCF and tBBA. Postoperatively, right abducens nerve palsy appeared, but no other neurological symptoms were noted; the patient was thereafter transferred to a rehabilitation hospital 49 days after injury. Traumatic ICA aneurysms commonly occur close to the anterior clinoid process, form within 1 to 2 weeks of injury, and often rupture around 2 weeks after trauma. This case was considered rare as the ICA was likely injured and bleeding at the time of injury, resulting in a form of tBBA; this allowed early detection and appropriate treatment that resulted in a good outcome., Competing Interests: The authors and all co-authors have no conflicts of interest to declare. Authors who are members of the Japan Neurosurgical Society have registered online for self-reported COI Disclosure Statement Forms., (© 2023 The Japan Neurosurgical Society.)

Middle cerebral artery (MCA) dissection is rare, and various clinical presentations, including hemorrhage, ischemia, or comorbidities, and the changes in imaging findings over time hinder treatment decisions. The European Stroke Organization guidelines exclude MCA dissection. Few cases have been reported with no review of the relevant literature. Therefore, we reviewed the relevant literature and our own experience with non-traumatic MCA dissection cases to determine appropriate treatment strategies. At our institution and affiliated institutions, we encountered six cases of MCA dissection-five with infarction and one with hemorrhage. Two patients underwent revascularization, and one underwent an aneurysmectomy. We reviewed English and Japanese articles in PubMed and Medical Journal Web and summarized the results based on the relationships among age, sex, location, the presence of an aneurysm, the presence of angiography, history, treatment, and mode of onset. The clinical course, changes in imaging, treatment strategies, and prognosis were discussed. Eighty cases were included in the review. Cerebral aneurysms were more common distal to the M2 area (p = 0.00) and were correlated with hemorrhage (p < 0.001). Most hemorrhagic cases with aneurysms were treated surgically, while ischemic cases were treated with antithrombotic agents, and both had a similar neurological prognosis. There were some cases of rebleeding after antithrombotic therapy, especially in older adults.Surgical treatment is recommended in cases of hemorrhage and confirmed aneurysms, particularly for lesions distal to the M2 area. Patients with aneurysm-associated ischemia should be followed up, and antithrombotic treatment should be considered with particular care in older adults., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Transorbital endoscopic approaches have been described for pathologies of anterior and middle fossae. Standard lateral orbitotomy gives access to mesial temporal lobe, but the axis of work is partially obscured by the temporal pole and working corridor is limited., Objective: To evaluate the usefulness of an inferolateral orbitotomy to provide a more direct corridor to perform a transuncal selective amygdalohippocampectomy., Methods: Three adult cadaveric specimens were used for a total of 6 dissections. A step-by-step description and illustration of the transuncal corridor for a selective amygdalohippocampectomy were performed using the inferolateral orbitotomy through an inferior eyelid conjunctival incision. The anatomic landmarks were demonstrated in detail. Orbitotomies and angles of work were measured from computed tomography scans, and the area of resection was illustrated by postdissection MRI., Results: Inferior eyelid conjunctival incision was made for exposure of the inferior orbital rim. Inferolateral transorbital approach was performed to access the transuncal corridor. Endoscopic selective amygdalohippocampectomy was performed through the entorhinal cortex without damage to the temporal neocortex or Meyer's loop. The mean horizontal diameter of the osteotomy was 14.4 mm, and the vertical one was 13.6 mm. The mean angles of work were 65° and 35.5° in the axial and sagittal planes, respectively. Complete amygdalohippocampectomy was achieved in all 6 dissections., Conclusion: Transuncal selective amygdalohippocampectomy was feasible in cadaveric specimens using the inferolateral transorbital endoscopic approach avoiding damage to the temporal neocortex and Meyer's loop. The inferior eyelid conjunctival incision may result in an excellent cosmetic outcome., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Crystal violet (CV) ink has been used as a skin marker worldwide. It has been reported to be useful for vessel wall visualization of microvascular anastomoses. Contrastingly, it has been found to be carcinogenic and inhibit migration and proliferation of venous cells. In some countries, its use in the medical field has been restricted. Therefore, it is necessary to consider alternatives to CV. In this present study, we compared the time required for the anastomosis of a 0.8-1 mm diameter vessel in the chicken wrist artery using CV and a CV-free dye (ethyl violet; EV). The surgeon, microscope, and anastomosis microsurgical tools were standardized for comparison. CV and EV were changed for each anastomosis. The same surgeon performed 30 anastomoses using each dye. No visually obvious differences were noted in the vascular transections with CV and EV. As per the results, no statistically significant difference was observed in the time required for anastomosis using CV and EV. EV conforming to California Proposition 65 may be an effective alternative to CV for vascular visualization of microvascular anastomoses. However, further studies on the effectiveness of the EV in clinical cases are needed.

Background: Few studies have used simulation models to examine long-term improvement in microsurgical technique. We investigated whether improvement in surgical technique could be assessed by continuous, objective, contest-format evaluation of the same microsurgical task., Methods: Since 2014, neurosurgeons with 1-10 years of experience participated in a biannual competition-format test. The task involved creating as many sutures as possible during the 5-minute interval after arteriotomy of a 1-mm artificial vessel. A modified version of the Objective Structured Assessment of Technical Skills examination was created and used. Changes and differences in scores over time were examined for each evaluator., Results: Overall, 103 neurosurgeons participated in the study at least once, and those who participated more than once were divided into two groups: those who had the highest score in each contest and those who had the lowest score. The linear regression equations for the highest and lowest scorers were y=7.62x+81.56 (R 2 =0.628) and y=1.94x+67.93 (R 2 =0.0433), respectively. High scorers had high scores from the first time they participated, and their scores tended to increase further, while scores for low scorers tended not to increase with additional experience. Scores for the four evaluators did not significantly differ., Conclusions: Our results suggest that technical improvement in surgery can be assessed by long-term, continuous evaluation of microsurgical technique and that the present evaluation system might help increase surgical safety.

Objective: Concerns about the approach-related morbidity of the extradural anterior petrosal approach (EAPA) have been raised, especially regarding temporal lobe and venous injuries, hearing impairment, facial nerve palsy, cerebrospinal fluid fistula, and seizures. There is lack in the literature of studies with detailed analysis of surgical complications. The authors have presented a large series of patients who were treated with EAPA, focusing on complications and their avoidance., Methods: The authors carried out a retrospective review of patients who underwent EAPA at their institution between 2012 and 2021. They collected preoperative clinical characteristics, operative reports, operative videos, findings on neuroimaging, histological diagnosis, postoperative course, and clinical status at last follow-up. For pathologies without petrous bone invasion, the amount of petrous apex drilling was calculated and classified as low (< 70% of the volume) or high (≥ 70%). Complications were dichotomized as approach related and resection related., Results: This study included 49 patients: 26 with meningiomas, 10 brainstem cavernomas, 4 chondrosarcomas, 4 chordomas, 2 schwannomas, 1 epidermoid cyst, 1 cholesterol granuloma, and 1 osteoblastoma. The most common approach-related complications were temporal lobe injury (6.1% of patients), seizures (6.1%), pseudomeningocele (6.1%), hearing impairment (4.1%), and dry eye (4.1%). Approach-related complications occurred most commonly in patients with a meningioma (p = 0.02) and Meckel's cave invasion (p = 0.02). Gross-total or near-total resection was correlated with a higher rate of tumor resection-related complications (p = 0.02) but not approach-related complications (p = 0.76). Inferior, lateral, and superior tumoral extension were not correlated with a higher rate of tumor resection-related complications. No correlation was found between high amount of petrous bone drilling and approach- or resection-related complications., Conclusions: EAPA is a challenging approach that deals with critical neurovascular structures and demands specific skills to be safely performed. Contrary to general belief, its approach-related morbidity seems to be acceptable at dedicated skull base centers. Morbidity can be lowered with careful examination of the preoperative neuroradiological workup, appropriate patient selection, and attention to technical details.

The extended endoscopic endonasal approach(EEA)has been expanding in recent years with the development of instruments and surgical techniques. Basically, sela, extradural, and intranasal lesions such as pituitary tumor, craniopharyngioma, chordoma, chondrosarcoma, and cholesterol granuloma are indicated. Intradural lesions or lesions that extend laterally or downward to the craniocervical junction are more difficult to operate. In addition, cases of hard tumor with calcification of the tumor, cases in which the tumor involves important blood vessels, re-operative cases, and cases after radiotherapy are also difficult cases and should be considered preoperatively. In recent years, we have been trying to keep the nasal structures as much as possible without removing nasal structure, but in cases where the tumor has invaded and destroyed the nasal structures, extended EEA is necessary. The anatomy of the extended EEA is complicated and not common among neurosurgeons. In this chapter, we present the basic anatomy and surgical cases to be understood in extended EEA and explain the pitfalls.

•The transorbital approach combining eyebrow incision and crescent-shaped craniotomy increases the surgical freedom to access the anterior and middle skull-base.•The technic allows the use of both endoscope and microscope.•The concept is at the crossroad between the supraorbital keyhole and endoscopic trans-orbital approach., (© 2022 Published by Elsevier B.V. on behalf of EUROSPINE, the Spine Society of Europe, EANS, the European Association of Neurosurgical Societies.)

Background: Maintaining the patency of extracranial-to-intracranial (EC-IC) bypass is critical for long-term stroke prevention. However, reports on the factors influencing long-term bypass patency and quantitative assessments of bypass patency are limited., Objective: To quantitatively evaluate blood flow in EC-IC bypass using four-dimensional (4D) flow magnetic resonance imaging (MRI) and investigate factors influencing the long-term patency of EC-IC bypass., Methods: Thirty-six adult Japanese patients who underwent EC-IC bypass for symptomatic internal carotid or middle cerebral artery occlusive disease were included. We examined the relationships between decreased superficial temporal artery (STA) blood flow volume and perioperative complications, long-term ischemic complications, patient background, and postoperative antithrombotic medications in patients for whom STA flow could be quantitatively assessed for at least 5 months using 4D flow MRI., Results: The mean follow-up time was 54.7 ± 6.1 months. One patient presented with a stroke during the acute postoperative period that affected postoperative outcomes. No recurrent strokes were recorded during long-term follow-up. Two patients died of malignant disease. Seven cases of reduced flow occurred in the STA, which were correlated with single bypass (P = .0294) and nonuse of cilostazol (P = .0294). STA occlusion was observed in 1 patient during the follow-up period. Hypertension, age, smoking, dyslipidemia, and diabetes mellitus were not correlated with reduced blood flow in the STA., Conclusion: Double anastomoses and cilostazol resulted in long-term STA blood flow preservation. No recurrence of cerebral infarction was noted in either STA hypoperfusion or occlusion cases., (Copyright © Congress of Neurological Surgeons 2022. All rights reserved.)

Background: Large basilar trunk aneurysm caused by bilateral occlusion of the proximal common carotid artery is rare. We treated one case with vertebral V3 portion-radial artery-distal common carotid artery (V3-RA-dCCA) bypass., Case Description: Basilar trunk aneurysm and bilateral occlusion of the proximal CCA were found incidentally in a 70-year-old woman. During the next 5 years, the aneurysm gradually enlarged to 12 mm, and blood flow of the anterior circulation was supplied through the posterior communicating artery. V3-RA-dCCA bypass was performed to reduce the stress of blood flow and prevent aneurysm growth and rupture. After exposing the neck portion, forearm of RA, and V3 portion of the vertebral artery, we created a space just below the sternocleidomastoid muscle to bypass the RA. We flushed the RA with albumin to stiffen the artery and temporarily clamped the bilateral sides of the RA to prevent twisting. We anastomosed the V3 and RA with a 9-0 thread and temporarily clamped the V3. After flushing the RA with albumin to prevent twisting, we clamped the external and internal carotid arteries, opened the dCCA with a vascular punch to prevent arterial dissection, and anastomosed the RA to the dCCA. The patency of the bypass was confirmed with Doppler and indocyanine green video angiography. The postoperative course was uneventful, bypass patency was good, and the aneurysm did not expand further., Conclusion: V3-RA-dCCA bypass may be an effective and low-risk treatment for large basilar trunk aneurysms with bilateral occlusion of the proximal common carotid artery., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Background: The combined transpetrosal approach (CTPA) is a versatile technique suitable for challenging skull base pathologies. Despite the advantages provided by a wide surgical exposure, the soft tissue trauma, complex and time-consuming bony work, and cosmetic issues make it far from patient expectations. In this study, the authors describe a less invasive modification of the CTPA, the mini-combined transpetrosal approach (mini-CTPA), and perform a quantitative comparison between these two approaches., Methods: Five human specimens were used for this study. CTPA was performed on one side and mini-CTPA on the opposite side. The surgical freedom, petroclival and brainstem area of exposure, and maneuverability for 6 anatomical targets, provided by the CTPA and mini-CTPA, were calculated and statistically compared. The bony volumes corresponding to each anterior petrosectomy were also measured and compared. Three clinical cases with an operative video are also reported to illustrate the effectiveness of the approach., Results: The question-mark skin incision done along the muscle attachments permits an optimal cosmetic result. Even though the limited incision, the smaller craniotomy, and the less extensive bone drilling of mini-CTPA provide a smaller area of surgical freedom, the areas of exposure of petroclival region and brainstem were not statistically different between the two approaches. The antero-posterior maneuverability for the oculomotor foramen (OF), Meckel's cave (MC) and the REZ of trigeminal nerve, and the supero-inferior maneuverability for OF, MC, Dorello's canal, and REZ of CN VII are significantly reduced by the smaller opening. The bony volume of anterior petrosectomy resulted similar among the approaches., Conclusions: The mini-CTPA is an interesting alternative to the CTPA, providing comparable surgical exposure both for petroclival region and for brainstem. Although the lesser soft tissue dissection and bony opening decrease the surgical maneuverability, the mini-CTPA may reduce surgical time, potential approach-related morbidities, and improve cosmetic and functional outcomes for the patients., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

The use of an endoscope in exoscopic transcranial neurosurgery for skull-base lesions has not yet been investigated. Thus, this study aimed to investigate the advantages, disadvantages, and safety of "simultaneous temporary use of an endoscope during exoscopic surgery" (exo-endoscopic surgery (EES)). Consecutive exo-endoscopic surgeries performed by experienced neurosurgeons and assistants were analyzed. Surgical complications and time were compared with previous consecutive microsurgeries performed by the same surgeon. A questionnaire survey was conducted on 16 neurosurgeons with experience in both "temporary simultaneous use of endoscope during microscopic surgery" (micro-endoscopic surgery (MES)) and EES. EES was performed in 18 of 76 exoscopic surgeries, including tumor removal ( n = 10), aneurysm clipping ( n = 5), and others ( n = 3). There were no significant differences in operative time, anesthesia time, or complications from microsurgery by the same operator. According to the questionnaire survey results, compared with MES, EES had a wider field of view due to its lack of an eyepiece, was easier when loading and unloading instruments into and out of the surgical field, and was more suitable for the simultaneous observation of two fields of view. Overall, 79.2% of surgeons indicated that EES may be better suited than MES to simultaneously observe two fields of view.

The ring finger protein 213 (RNF213) susceptibility gene has been detected in more than 80% of Japanese and Korean patients with moyamoya disease (MMD), a bilateral internal carotid artery (ICA) occlusion. Furthermore, RNF213 has been detected in more than 20% of East Asians with atherosclerotic ICA stenosis. In this study, we evaluated the frequency of RNF213 mutations in congenital occlusive lesions of the ICA system. This case series was conducted jointly at four university hospitals. Patients with a family history of MMD, quasi-MMD, or related diseases were excluded. Ten patients were diagnosed with abnormal ICA or middle cerebral artery (MCA) angiogenesis. Patients with neurofibromatosis were excluded. Finally, nine patients with congenital vascular abnormalities were selected; of these, five had ICA deficiency and four had twig-like MCA. The RNF213 c.14576G > A mutation was absent in all patients. Therefore, the RNF213 c.14576G > A mutation may not be associated with ICA and MCA congenital dysplasia-rare vascular anomalies making it difficult to study a large number of cases. However, an accumulation of cases is required for accurate determination. The results of this study may help differentiate congenital vascular diseases from MMD., (© 2021. The Author(s).)

To the best of our knowledge, we report a case of MEN2A complicated by moyamoya syndrome. A 52-year-old woman presented with vertigo. Magnetic resonance angiography (MRA) revealed bilateral supraclinoid stenosis of the internal carotid artery and abnormal moyamoya-like vessels around the basal ganglia. She had a heterozygous variant of RNF213 , which is the susceptibility gene for moyamoya disease. She had also previously received diagnoses of medullary thyroid carcinoma (MTC) at age 23 and left-sided pheochromocytoma (PHEO) at age 41. Genetic testing revealed heterozygosity for a mutation at codon 634 in exon 11 (TGC-TTC mutation; p.Cys634Phe) of the Ret gene. Intracranial vascular stenosis may have been caused by a genetic mutation of RNF213 and hypersecretion of catecholamines by MEN2A. Physicians should recognize that MEN2A can be present with moyamoya syndrome., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Matano, Murai, Watanabe, Shirokane, Igarashi, Shimizu, Shimada and Morita.)

Objectives: Intraoperative fluorescence imaging is currently used in a variety of surgical fields for four main purposes: assessing tissue perfusion; identifying/localizing cancer; mapping lymphatic systems; and visualizing anatomy. To establish evidence-based guidance for research and practice, understanding the state of research on fluorescence imaging in different surgical fields is needed. We evaluated the evidence on fluorescence imaging for perfusion assessments using the Idea, Development, Exploration, Assessment, Long Term Study (IDEAL) framework, which was designed for describing the stages of innovation in surgery and other interventional procedures., Design: Narrative literature review with analysis of IDEAL stage of each field of study., Setting: All publications on intraoperative fluorescence imaging for perfusion assessments reported in PubMed through 2019 were identified for six surgical procedures: coronary artery bypass grafting (CABG), upper gastrointestinal (GI) surgery, colorectal surgery, solid organ transplantation, reconstructive surgery, and cerebral aneurysm surgery., Main Outcome Measures: The IDEAL stage of research evidence was determined for each specialty field using a previously described approach., Results: 196 articles (15 003 cases) were selected for analysis. Current status of research evidence was determined to be IDEAL Stage 2a for upper GI and transplantation surgery, IDEAL 2b for CABG, colorectal and cerebral aneurysm surgery, and IDEAL Stage 3 for reconstructive surgery. Using the technique resulted in a high (up to 50%) rate of revisions among surgical procedures, but its efficacy improving postoperative outcomes has not yet been demonstrated by randomized controlled trials in any discipline. Only one possible adverse reaction to intravenous indocyanine green was reported., Conclusions: Using fluorescence imaging intraoperatively to assess perfusion is feasible and appears useful for surgical decision making across a range of disciplines. Identifying the IDEAL stage of current research knowledge aids in planning further studies to establish the potential for patient benefit., Competing Interests: Competing interests: TI (associate editor), PMC (editor in chief), NK and RJR are editorial board members of BMJ Surgery, Interventions, & Health Technologies. The other authors have no competing interests to declare., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The hemodynamic changes after superficial temporal artery (STA) to middle cerebral artery (MCA) bypass surgery are unclear., Objective: To clarify the hemodynamics by comparing flow parameters obtained by 4-dimensional (4D) flow magnetic resonance imaging (MRI) and intraoperative MCA pressure measurement., Methods: We recruited 23 patients who underwent STA-MCA bypass surgery for internal carotid artery (ICA) or MCA stenosis. We monitored intraoperative MCA, STA, and radial artery (RA) pressure. All patients underwent 4D flow MRI preoperatively and 3 wk after surgery to quantify the blood flow volume (BFV) of the ipsilateral ICA (BFViICA), contralateral ICA (BFVcICA), basilar artery (BFVBA), ipsilateral STA (BFViSTA), and contralateral STA (BFVcSTA). The sum of intracranial BFV was defined as BFVtotal. We compared BFV parameters and intraoperative pressure., Results: BFViSTA significantly increased after surgery (P < .001). BFViICA and BFVBA significantly decreased after surgery (BFViICAP = .005; BFVBAP = .02). No significant difference was observed between BFVcICA before and after surgery. As a result, BFVtotal postoperatively increased by 6.8%; however, no significant difference was observed. Flow direction at M1 changed from antegrade to unclear after surgery in 5 patients. Intraoperative MCA pressure and MCA/RA pressure ratio significantly increased after surgery (P < .001). We found a stronger positive correlation between MCA pressure increase ratio and BFVtotal increase ratio in patients with lower pre-MCA pressure (r = 0.907, P < .001)., Conclusion: The visual and quantitative assessment of 4D flow MRI revealed that intracranial blood flow changes complementarily after STA-MCA bypass surgery. 4D flow MRI may detect the improvement of cerebral perfusion pressure., (© Congress of Neurological Surgeons 2021.)

A mutation in RNF213 (c.14576G>A), a gene associated with moyamoya disease (>80%), plays a role in terminal internal carotid artery (ICA) stenosis (>15%) (ICS). Studies on RNF213 and cerebral aneurysms (AN), which did not focus on the site of origin or morphology, could not elucidate the relationship between the two. However, a report suggested a relationship between RNF213 and AN in French-Canadians. Here, we investigated the relationship between ICA saccular aneurysm (ICA-AN) and RNF213 . We analyzed RNF213 expression in subjects with ICA-AN and atherosclerotic ICS. Cases with a family history of moyamoya disease were excluded. AN smaller than 4 mm were confirmed as AN only by surgical or angiographic findings. RNF213 was detected in 12.2% of patients with ICA-AN and 13.6% of patients with ICS; patients with ICA-AN and ICS had a similar risk of RNF213 mutation expression (odds ratio, 0.884; 95% confidence interval, 0.199-3.91; p = 0.871). The relationship between ICA-AN and RNF213 (c.14576G>A) was not correlated with the location of the ICA and bifurcation, presence of rupture, or multiplicity. When the etiology and location of AN were more restricted, the incidence of RNF213 mutations in ICA-AN was higher than that reported in previous studies. Our results suggest that strict maternal vessel selection and pathological selection of AN morphology may reveal an association between genetic mutations and ICA-AN development. The results of this study may form a basis for further research on systemic vascular diseases, in which the RNF213 (c.14576G>A) mutation has been implicated.

Objective: Quasi-moyamoya disease (QMMD) is moyamoya disease (MMD) associated with additional underlying diseases. Although the ring finger protein 213 (RNF213) c.14576G>A mutation is highly correlated with MMD in the Asian population, its relationship to QMMD is unclear. Therefore, in this study the authors sought to investigate the RNF213 c.14576G>A mutation in the genetic diagnosis and classification of QMMD., Methods: This case-control study was conducted among four core hospitals. A screening system for the RNF213 c.14576G>A mutation based on high-resolution melting curve analysis was designed. The prevalence of RNF213 c.14576G>A was investigated in 76 patients with MMD and 10 patients with QMMD., Results: There were no significant differences in age, sex, family history, and mode of onset between the two groups. Underlying diseases presenting in patients with QMMD were hyperthyroidism (n = 6), neurofibromatosis type 1 (n = 2), Sjögren's syndrome (n = 1), and meningitis (n =1). The RNF213 c.14576G>A mutation was found in 64 patients (84.2%) with MMD and 8 patients (80%) with QMMD; no significant difference in mutation frequency was observed between cohorts., Conclusions: There are two forms of QMMD, one in which the vascular abnormality is associated with an underlying disease, and the other in which MMD is coincidentally complicated by an unrelated underlying disease. It has been suggested that the presence or absence of the RNF213 c.14576G>A mutation may be useful in distinguishing between these disease types.

Objective: To examine the relationship between trap location and cerebral infarction in the anterior choroidal artery (AChA) region and associated risks in ruptured internal carotid artery blood blister-like aneurysm (BLA) treatment with high-flow bypass and lesion trapping., Methods: We included 26 patients diagnosed with BLAs and treated with high-flow bypass and trapping. We examined clinical characteristics including age, aneurysm trap location, final prognosis, cerebral infarction on postoperative magnetic resonance imaging, and modified Rankin Scale score at discharge. We also searched the literature for similar studies., Results: The modified Rankin Scale score at discharge was 0-2 in 20 patients, 3-5 in 2 patients, and 6 in 2 patients. In 19/26 patients (73.1%), the trapped segment was between the posterior communicating (PcomA) and the ophthalmic arteries. In 2 patients (7.7%), the trapped segment included the PcomA and the AChA; in 4 patients (15.4%), the trapped segment was within the PcomA. In these patients, the PcomA was occluded, and blood from the high-flow bypass flowed out to the AChA alone. No patient showed cerebral infarction. Our systematic review identified 70 patients. Of all 96 patients, 12 had AChA cerebral infarction; however, the infarction affected the prognosis of only 2 patients., Conclusions: When treating BLAs with high-flow bypass and lesion trapping, the frequency of AChA cerebral infarction is low even when the PcomA is occluded, leaving the AChA as the only outflow vessel during high-flow bypass. However, PcomA occlusion may be associated with risks when treating patients with advanced arteriosclerosis near C1-2., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Initial management of severe traumatic brain injury is important and includes treatment decision-making and prediction of prognosis. We examined whether biomarkers at admission could be useful prognostic predictors. We focused on electrolytes and blood glucose, which can be measured easily at any facility and for which results can be obtained promptly, before those of other biomarkers, such as D-dimer., Methods: All trauma patients with head injuries treated at Chiba Hokusoh Hospital between 2014 and 2017 were investigated. Cases of multiple trauma accompanied by fatal trauma, hemorrhagic shock, or cardiopulmonary arrest, and pediatric cases, were excluded from this study. Blood gas data at the initial hospital visit were reviewed retrospectively. A poor outcome was defined as death during hospitalization or a vegetative state due to head injury. Factors related to poor outcomes were analyzed., Results: Of the 185 male and 79 female patients studied, 34 had poor outcomes. Poor outcome was significantly correlated with potassium (P = 0.003), glucose (P < 0.001), and glucose-to-potassium ratio (P < 0.001) at arrival. The odds ratio was 4.079 for a glucose-to-potassium ratio of ≥50., Conclusions: We evaluated blood gas data at the initial hospital visit, as these results can be obtained more quickly than those of other biomarkers assessed previously. Serum glucose-to-potassium ratio at admission may be a potential predictor of prognosis for severe traumatic brain injury.

Background and Importance: In cardiogenic cerebral embolism, early recanalization is the most important factor for good prognosis. However, endovascular thrombectomy often fails to achieve recanalization. We present an open surgical embolectomy technique and discuss its advantages., Clinical Presentation: A 79-year-old woman developed right hemiparesis and severe aphasia. Magnetic resonance imaging revealed an acute cerebral infarction caused by left middle cerebral artery (MCA) occlusion. We attempted endovascular thrombectomy but failed because it was impossible to guide the catheter to the occlusion site. Hence, we converted to open surgical embolectomy. Sylvian fissure was widely opened. After confirming the range of thrombosis using indocyanine green videoangiography (ICGVAG), the proximal and distal arteries were secured, and a temporary clip was placed on the distal M2 to prevent distal thrombosis migration. MCA was cut approximately 3 mm from the bifurcation, and thrombosis was removed using micro-forceps. The proximal clip was simultaneously inserted but was not clamped because the thrombus was extruded by proximal vascular flow. Immediately after removing the thrombus, intense bleeding occurred from the proximal flow. An assistant clamped the proximal artery using the prepared clip, and the incised area of MCA was sutured using 9-0 threads. We finally confirmed blood flow after recanalization using ICGVAG. The time from skin incision to recanalization was 27 min. After the procedure, the patient developed slight aphasia but had no hemiparesis and was later transferred to a rehabilitation hospital., Conclusion: Open surgical embolectomy may be a secondary rescue treatment option in the case of endovascular thrombectomy failure., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Introduction: We aimed to identify the risk factors for surgical treatment of unruptured intracranial aneurysms (UIAs) in individuals aged >60 years, particularly focusing on white matter lesions (WMLs)., Material and Methods: We investigated a total of 214 patients with UIAs. The patient group comprised 53 males and 151 females with an average age of 68.2 years. UIA size ranged from 2.7 to 26 (mean: 7.3) mm. The primary endpoint of the study was patient prognosis evaluated at the time of discharge using the modified Rankin Scale. We examined the risk factors for poor outcome and WMLs using magnetic resonance imaging., Results: Poor outcome was observed in 23 (10.7%) patients. Significant correlations were observed between poor outcome and UIA size (P < 0.0001), UIAs located posteriorly (P = 0.0204), UIA thrombosis (P = 0.0002), and presence of WMLs (P < 0.0001) in univariate regression analysis. However, no significant correlations were noted between poor outcome and age (P = 0.1438). Multivariate logistic regression analyses showed significant correlations between poor outcome and UIA size (P < 0.0001), presence of WMLs (P = 0.001). Severe WMLs based on the Fazekas classification was correlated to age (P < 0.0001) and atherosclerosis (P = 0.0001). Severe WMLs were associated with ischemia (P < 0.001) and epilepsy (P = 0.0502) as well as length of hospitalization (P < 0.0001)., Conclusion: Severe WMLs are risk factors for surgical treatment of UIAs in the elderly. Surgical indications must be considered and caution should be taken when managing patients with severe WMLs., Competing Interests: Declaration of Competing Interest None of authors have any conflicts of interest., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: Petrous internal carotid aneurysm (PA) concomitant with a mass lesion and cranial nerve palsy is relatively rare. Flow-diverter stent implantation is now widely used as an alternative treatment for PA. However, alternative treatments sometimes cannot be used because of tortuosity of the carotid artery, allergies to contrast material, and high costs. The outcomes of different treatment methods should therefore be assessed. Here, we review the available literature on treatments for PA., Methods: In a search using the terms "aneurysm", "carotid artery", and "petrous" on PubMed, MEDLINE, and databases such as OvidSP, 221 articles were identified. We also performed a literature review and discuss and compare the causes, symptoms, treatment methods, and clinical outcomes of PA., Results and Conclusions: Onset of secondary aneurysm was generally heralded by bleeding (p<0.001), while onset of primary aneurysm was heralded by cranial nerve deficit (p= 0.0014). Outcomes after treatment of 34 cranial nerve palsies in 25 patients are reported.

Background: We present a patient who underwent left superior temporal artery (STA)-to-right middle cerebral artery (MCA) bypass using a radial artery (RA) graft with resection of a giant right cervical common carotid artery (CCA) pseudoaneurysm after carotid artery stenting (CAS) and discuss the treatment strategy and surgical procedure in detail., Case Description: An 86-year-old male presented with sudden onset of altered consciousness and complete left hemiparesis. Magnetic resonance angiography and catheter angiography of the brain revealed occlusion of the right cervical ICA. Endovascular thrombectomy and stenting of the cervical segment of the ICA were performed. Thirty-two days after CAS, the patient developed a high fever and rapid swelling of the neck. Catheter angiography showed a giant right CCA pseudoaneurysm that had a fistula just proximal to the carotid stent, and the aneurysm extended to the neck entirely. Because of the expanding neck infection, stent placement long lesion, and lack of distal collateral flow on angiography, we performed aneurysm and stent removal and left STA-to-right MCA bypass using an RA graft. The harvested RA graft was anastomosed side to end to both the M2 segment of the right MCA and the left STA. Bypass patency was confirmed before neck exposure. The pseudoaneurysm and proximal portion area of the stent were resected. The patient recovered well postoperatively, and follow-up catheter angiography showed patency of the bypass., Conclusions: Left STA-RA-right MCA bypass with aneurysm resection is a good treatment option for giant CCA pseudoaneurysms that occur after CAS., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Tumors arising from oculomotor nerve are rare, with few cases reported in the literature. Generally, whereas schwannomas are well encapsulated tumors, neurofibromas tend to invade the entire nerve fibers. These differences influence surgical resection and neurological clinical outcome, with neurofibroma often requiring the sacrifice of the nerve. Accordingly, an incorrect preoperative diagnosis can lead to incomplete patient counseling before surgery., Case Description: We report 2 cases: a patient with oculomotor schwannoma and a patient with oculomotor neurofibroma. After tumor resection, the patient with a diagnosis of schwannoma recovered with 3rd nerve palsy, while patient with the neurofibroma developed a complete oculomotor nerve deficit. For each patient, surgical strategy and neurological outcome are elucidated in relation with differences in preoperative magnetic resonance imaging and histology., Conclusions: To the best of our knowledge, this is the first report of an oculomotor neurofibroma. When an oculomotor nerve tumor is suspected, a careful preoperative evaluation of magnetic resonance imaging guides in distinguishing the different histology, in selecting the treatment strategy, and in correctly informing the patient on expected postoperative neurologic outcome., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: Japan has the largest elderly population in the world. As data on the clinical outcomes in elderly patients with aneurysmal subarachnoid hemorrhage (aSAH), including those older than 80 years, are lacking, we analyzed the characteristics of 54,805 aSAH patients and recorded their treatments and clinical outcomes using a Japanese nationwide inpatient database., Methods: Using the Japanese Diagnostic Procedure Combination database, we identified aSAH patients aged 18 years or older who were hospitalized between July 1, 2010 and March 31, 2016. They were categorized as less than or equal to 60-, 61-70-, 71-80-, 81-90-, and greater than or equal to 91 years of age. The primary outcome was the modified Rankin Scale (mRS) score at discharge. Multivariable logistic regression analysis was performed to examine factors affecting the mRS score at discharge., Results: Of 54,805 patients, 37.5% were aged less than or equal to 60 years; 24.8% were 61-70-, 21.8% were 71-80-, 13.9% were 81-90-, and 2.0% were greater than or equal to 91 years old at the time of the insult. Among 46,107 patients younger than 81 years, 58.9% underwent surgical clipping (SC), 22.9% endovascular coiling (EC), and 18.2% were treated conservatively. There were 8,698 patients aged 81 years or older, 32.4% underwent SC, 23.2% EC, and 44.4% were treated conservatively. A poor mRS score (3-6) at discharge was recorded in 87.2% of patients older than 80 years. Multivariable logistic regression was used to compare their estimated odds ratio (OR) for a poor mRS score at discharge with that of patients aged less than or equal to 60 years. The OR increased by 87% in patients between 61 and 70 years of age (P < .001; OR, 1.87; 95% confidence interval (CI), 1.77-1.98), by 358% in patients aged from 71 to 80 years (P < .001; OR, 4.58; 95%CI, 4.29-4.89), by 1,035% in patients between 81 and 90 years (P < .001; OR, 11.35; 95%CI, 10.32-12.49), and by 1,710% in patients aged more than or equal to 91 years (P < .001; OR, 18.10; 95%CI, 13.96-23.46)., Conclusions: As the treatment outcomes in elderly aSAH patients, especially those 80 years old or older, were poor, the appropriate therapy decisions must be made on a case-by-case basis., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: There have been reports on postoperative ischemic complications with vascular reconstructive surgery. However, various factors, such as lesions, operative technique, and perioperative treatment, prevent analyzing the causes of ischemic complications in vascular reconstruction surgeries. In the present study, we analyzed the cause of ischemic complications for vascular reconstruction surgeries with the same operator, surgical procedure, and perioperative treatment and without focusing on the lesions., Patients and Methods: We retrospectively reviewed 66 patients, including 24 aneurysm cases and 42 ischemic disease cases, between 2008 and 2018. The patient group comprised 35 males and 31 females, and the patient mean age was 63.3 (23-87) years. We investigated the postoperative presence of symptomatic and asymptomatic cerebral ischemia on MRIDWI performed within 4 postoperative days. We conducted a statistical analysis of the ischemic complications and clinical and treatment factors., Results: Symptomatic cerebral ischemia was detected in 3 cases, whereas asymptomatic ischemic findings were identified in 8 cases. All cases of symptomatic cerebral ischemia involved cerebral aneurysms. Results of a univariate analysis revealed an association between symptomatic cerebral ischemia and preoperative antithrombotic therapy (OR, 0.07; p =  0.049 (95 %CI; 0.007-0.8794)), clipping (OR, 4.8; p =  0.0501 (95 %CI; 1.641-342.9)), and aneurysm (OR, 14.16; p =  0.0423 (95 %CI; 0.6991-286.9)). Significant associations were found between asymptomatic cerebral ischemia and preoperative antithrombotic therapy [OR, 0.2941; p =  0.0514 (95 %CI; 0.08335-1.038)], aneurysms [OR, 7.8; p =  0.0146 (95 %CI; 1.414-43.04)] and radial artery grafts (RAGs) [OR, 6.8; p =  0.0192 (95 %CI; 1.410-32.98)]. Multivariate analysis identified clipping [OR, 5.462; p =  0.045 (95 %CI; 1.01-78.25] and preoperative antithrombotic therapy [OR, 0.187; p =  0.037 (95 %CI; 0.004-0.813)] as the risk factors for symptomatic cerebral ischemia. Further, a correlation was found between asymptomatic cerebral ischemia and RAGs [OR, 9.244; p =  0.00013 (95 %CI; 2.34-29.44)]., Conclusion: Ischemic complications associated with combined vascular reconstruction surgeries for cerebral aneurysms are possibly associated with procedures related to aneurysmal occlusions. Thus, vascular reconstruction surgeries can be performed relatively safely. Further, preoperative antithrombotic treatment should be considered, and caution is required for asymptomatic cerebral ischemia in RAG cases., Competing Interests: Declaration of Competing Interest None of the authors have any conflicts of interest., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: This study aimed to clarify the risk factors of treatment for unruptured cerebral aneurysms (UCAs) in elderly patients by comparing the morbidity at discharge between surgical clipping and endovascular coiling in nonelderly (<65 years) and elderly (≥65 years) patients based on a national database in Japan., Methods: A total of 36,017, including 15,671 patients with UCA after exclusion of unknown location, were registered in the Diagnosis Procedure Combination, the nationwide database, from 2010 to 2015 in Japan. Outcome of Barthel Index at discharge was investigated and multivariate logistic regression analysis identified risk factors for morbidity of Barthel Index <90 at discharge in nonelderly and elderly patient groups., Results: Risk factors for morbidity at discharge were basilar artery aneurysm compared with internal carotid artery (ICA), diabetes mellitus (odds ratio [OR], 2.0-2.5; 95% confidence interval [CI], 1.6-3.7), antiplatelet drug, and anticoagulation drug; however, highest hospital volume compared with lowest was an inverse risk factor in both age groups. Endovascular coiling (OR, 0.4; 95% CI, 0.3-0.5) was a significantly inverse risk in the elderly group. Anterior communicating artery aneurysm compared with ICA was a significant risk (OR, 1.6; 95% CI, 1.0-2.6) in the nonelderly group; on the other hand, anterior communicating artery aneurysm (OR, 0.7; 95% CI, 0.5-0.95) and middle cerebral artery aneurysm (OR, 0.6; 95% CI, 0.5-0.8) compared with ICA were significantly inverse risks in the elderly group., Conclusions: Endovascular coiling after control of diabetes mellitus was recommended for the treatment of UCA in elderly patients. The ICA location of aneurysm in the elderly should be paid attention as the treatment risk., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Surgical clipping of an internal carotid artery (ICA)-posterior communicating artery (ICPC) aneurysm is often difficult in cases involving limited space to insert a clip at the proximal aneurysm neck hidden by the tent. In such cases, we perform incision of the anterior petroclinoidal fold to secure the proximal space for clip insertion. Between April 2013 and March 2018, we treated 89 ICPC aneurysm cases by clipping. Incision of the anterior petroclinoidal fold was performed in 15 of the 89 cases (16.8%). Fast imaging employing steady-state acquisition (FIESTA) magnetic resonance imaging (MRI) can indicate the locations of the aneurysm and tent and can help assess the need for tent incision. We widely dissected the distal sylvian fissure and sufficiently exposed around the aneurysmal space. We coagulated and cut the anterior petroclinoidal fold supra between the ICA and proximal neck of the aneurysm using a low-power bipolar system and needles or micro-scissors with care to avoid injury around structures such as the ICA, aneurysm, and oculomotor nerve. When using this strategy, we often select the Yasargil FT717 clip that has a curve along the skull base because of easy insertion. All cases showed complete aneurysm exclusion on three-dimensional computed tomography angiography, and there was no cerebral infarction, neurological deficit (such as hemiparesis), or oculomotor nerve palsy. Therefore, our strategy of incision of the anterior petroclinoidal fold during clipping for securing the proximal space of an ICA aneurysm is effective and safe.

Objective: Cerebral vasospasm is associated with poor prognosis in patients with aneurysmal subarachnoid hemorrhage (SAH), and biomarkers for predicting poor prognosis have not yet been established. We attempted to clarify the relationship between serum glucose/potassium ratio and cerebral vasospasm in patients with aneurysmal SAH., Methods: We studied 333 of 535 aneurysmal SAH patients treated between 2006 and 2016 (123 males, 210 females; mean age 59.7 years; range 24-93). We retrospectively analyzed the relationship between cerebral vasospasm grade and clinical risk factors, including serum glucose/potassium ratio., Results: Postoperative angiography revealed cerebral vasospasm in 112 patients (33.6%). Significant correlations existed between the ischemic complication due to cerebral vasospasm and glucose/potassium ratio (P < .0001), glucose (P = .016), and potassium (P = .0017). Serum glucose/potassium ratio was elevated in the cerebral vasospasm grade dependent manner (Spearman's r = 0.1207, P = .0279). According to the Glasgow Outcome Scale (GOS) score at discharge, 185 patients (55.5%) had a poor outcome (GOS scores 1-3). Serum glucose/potassium ratio was significantly correlated between poor outcome (GOS scores 1-3) and age (P < .0001), serum glucose/potassium ratio (P < .0001), glucose (P < .0001), potassium (P = .0004), white blood cell count (P = .0012), and cerebral infarction due to cerebral vasospasm (P < .0001). Multivariate logistic regression analyzes showed significant correlations between cerebral infarction due to cerebral vasospasm and serum glucose/potassium ratio (P = .018), glucose (P = .027), and potassium (P = .052)., Conclusions: Serum glucose/potassium ratio in cases of aneurysmal SAH was significantly associated with cerebral infarction due to cerebral vasospasm and GOS at discharge. Therefore, this factor was useful to predict prognosis in patients with cerebral vasospasm and aneurysmal SAH., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: The efficacy of thyrotropin-releasing hormone tartrate (TRH-T) for treating prolonged disturbance of consciousness due to aneurysmal subarachnoid hemorrhage (SAH) remains unclear. The purpose of the present study was to determine whether TRH-T was really effective, and what was the recovery factor when it was valid. This was a retrospective study of a single facility., Methods: We treated 208 patients with aneurysmal SAH at our hospital between 2011 and 2017. Among them, we investigated 97 cases in which TRH-T was administered to prolonged disturbance of consciousness. Thirty one patients with Hasegawa dementia rating scale-revised (HDS-R) score less than 20 were included. Patients' HDS-R scores were evaluated 7 days after clipping the aneurysm and 2 days after completing a course of TRH-T treatment. HDS-R score increases of greater than or over equal to 8 and less than 8 were defined as good and poor outcomes, respectively. Outcomes were compared to 11 patients who did not receive TRH-T treatment., Results: Average initial and post-treatment HDS-R scores were 9 ± 6.6 and 19 ± 9.5, respectively. The good outcome group included 19 patients. Statistically significant differences in HDS-R score changes were observed between the group with initial HDS-R scores of 0-4 and the other groups. Poor outcomes were significantly correlated with age of greater than 60 years and initial HDS-R scores less than oroverequal to 4 points. The improvement in HDS-R score was significantly greater in the TRH-T administration group than the control group., Conclusions: TRH-T was effective for treating prolonged disturbance of consciousness due to aneurysmal SAH, especially in young patients with HDS-R scores between 5 and 20., (Copyright © 2018. Published by Elsevier Inc.)

Tumors of the skull base, such as meningiomas, tend to recur. With progress in free vascularized flap surgery, an increasing number of studies are investigating skull base reconstruction with free flaps after tumor removal. In this report, we discuss the results of second free flap surgery after skull base reconstructive surgery. We retrospectively analyzed data from patients treated at our center during the period from 2013 through 2017. All four patients identified had skull base anaplastic meningioma and had undergone radiotherapy. In all cases, the flap and donor blood vessel were sourced from sites that differed from those used in the previous surgeries. No complications developed, such as cerebrospinal fluid leakage, meningitis, wound infection, wound hemorrhage, or flap necrosis. Because the first flap was found to be unviable, it was difficult to preserve and was removed. Essential points in preventing complications are anchoring at the appropriate site, pinprick testing of the created flap, and use of multilayered countermeasures to prevent cerebrospinal fluid leakage.