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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: 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: 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.)

Background: In vascular reconstructive surgery, intraoperative confirmation of patency is performed by angiography, Doppler, or indocyanine videoangiography, but it is sometimes insufficient., Objective: Using the FLOW 800 system (Carl Zeiss, Oberkochen, Germany), we confirmed patency in a quantitative relative evaluation of the timing of the luminance change of the regions of interest (ROIs) on the donor and recipient., Methods: Thirty-seven patients (58 anastomoses) were divided into 2 groups: those with arteriosclerotic ischemic disease (CI group; n = 23) and those with cerebral aneurysm (AN group; n = 14). Four ROIs were set: the donor, proximal, and distal sides of the recipient middle cerebral artery (MCA) and cortical MCA (control MCA). The half-life for fluorescence intensity was calculated by using the FLOW 800 system. A delay map analysis was also performed., Results: In the CI group, there were statistically significant differences (P < 0.05) between the donor vessel and control MCA, proximal MCA and MCA control, and distal MCA and control MCA. The investigation with the delay map showed red tones in 20/22 patients in the CI group and in 2/17 patients in the AN group., Conclusions: In the CI group, the transit time of the donor vessel was shown relatively early as red T. When good patency has been achieved, the FLOW 800 system can be used to confirm patency more reliably, especially in ischemic regions. The unique point of this research is that the patency of anastomotic vessels was evaluated as a quantitative value of its rendering time rather than as a change in fluorescence intensity., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Bilateral vertebral artery dissection (VAD) may result in subarachnoid hemorrhage (SAH). However, a variety of factors contribute to the difficulties with treating SAH. We report a case of bilateral VAD with SAH, as well as a literature review., Case Description: A 32-year-old woman developed headache. Computed tomography demonstrated diffuse SAH, and 3-dimensional computed tomography indicated bilateral VAD. Her left vertebral artery was severely stenosed, and the basilar artery retrogradely flowed via the posterior communicating artery. Her bilateral VAD was trapped with the use of staged craniotomy. The postoperative course was uneventful for 13 days; however, severe neurologic deterioration remained in the area of the cerebral infarction, due to vasospasm of the internal carotid artery. This is the first report of hemorrhagic bilateral VAD treated with bilateral trapping and aggressive spasm treatment in the acute phase. However, the treatment was not successful., Conclusions: Because of the increasing use of stent therapy, there has been a shift toward this treatment choice. For cases in which stents cannot be used, treatment methods based on prestenting protocols are helpful. A literature review indicated that conservative treatment for 2 weeks, in which vasospasm and rebleeding are controlled, may be considered compared with acute-stage stent treatment. Following our literature review, in situations in which stents cannot be used, only the ruptured side should be trapped with strict blood pressure control and detailed radiological images should be observed for 2 weeks. In conclusion, patient selection is essential to subject the patient to open surgery in such cases., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Few reports of delirium-related risk factors have focused on environmental risk factors and clinical risk factors, such as white matter signal abnormalities on magnetic resonance imaging fluid attenuated inversion recovery images., Methods: We prospectively enrolled 253 patients admitted to our neurosurgical center between December 2014 and June 2015 and analyzed 220 patients (100 male patients; mean age, 64.1 years; age range, 17-92 years). An Intensive Care Delirium Screening Checklist score ≥4 points indicated delirium. We evaluated patient factors consisting of baseline characteristics and related factors, such as white matter lesions (WMLs), as well as the surrounding environment., Results: Delirium occurred in 29/220 cases (13.2%). Regarding baseline characteristics, there were significant statistical correlations between delirium and age (P = 0.0187), Hasegawa Dementia Scale-Revised score (P = 0.0022) on admission, and WMLs (P < 0.0001). WMLs were related to age (P < 0.0001) and atherosclerotic disease (P = 0.004). Regarding related factors, there were significant statistical correlations between delirium and stay in a neurosurgical care unit (P = 0.0245). Multivariate logistic regression analyses showed statistically significant correlations of delirium with WMLs (P < 0.0001) and surrounding patients with delirium (P = 0.026)., Conclusions: WMLs in patients and the surrounding environment are risk factors for delirium in a neurosurgical center. To prevent delirium, clinicians must recognize risk factors, such as high-grade WMLs, and manage environmental factors., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: Large or giant internal carotid artery (ICA) aneurysms often cause visual deficits and cranial nerve palsy. The aim of this study was to investigate the efficacy of ligation of the ICA with high-flow bypass., Methods: We retrospectively analyzed the findings from patients with visual deficit and ophthalmologic symptoms due to ICA aneurysms. In addition, we analyzed the recovery factors associated with the visual deficit and ophthalmologic symptoms postoperatively, focusing on the type of cranial nerve palsy, aneurysm size, location, and the time to treatment from first symptoms., Results: We identified 38 patients (35 women, 3 men) with a mean age at surgery of 63.6 years (range, 24-81 years) with visual and ophthalmologic symptoms due to large or giant internal carotid aneurysm. Aneurysms ranged in size from 15-50 mm (mean, 25.2 mm). Visual disturbance (7 cases, 18%) and ophthalmoplegia (31 cases, 82%) were the only preoperative cranial nerve palsies. Aneurysms were completely thrombosed in 94.7% of cases (36/38). Visual disturbance improved in 28.5% of cases (2/7), and ophthalmoplegia improved in 87.1% of cases (27/31). Time to therapy from developing a visual disturbance was longer than time to therapy from developing ophthalmoplegia (P = 0.001). Time to therapy was significantly associated with recovery from cranial nerve palsy (P < 0.0001). The recovery of visual disturbance was worse than that of ophthalmoplegia (P = 0.001)., Conclusion: Early treatment is recommended when the visual and ophthalmologic symptoms are present because treatment delay is a risk factor for nonimprovement of symptoms., (Copyright © 2016 Elsevier Inc. All rights reserved.)

In neurosurgical procedures, avoiding damage of surrounding tissues such as muscle and periosteum during a craniotomy is important for esthetic and other reasons. We devised a protection tool by using an amputated syringe barrel to cover the perforating drill and protect temporal muscle damage. This device made it possible to prevent damage to surrounding tissues, such as the muscle and periosteum, during cranial perforation. This method could be useful as it is cost-effective, simple, and versatile., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Few reports have been published discussing surgical outcomes of paraclinoid aneurysms using multifarious treatments such as high-flow bypass., Material and Methods: We retrospectively analyzed findings from 127 consecutive patients (19 males, mean age at surgery: 56.8 years, range: 19-81 years) at our hospital. The size of aneurysms ranged from 2.7-43.2 mm (mean: 6.9 mm). Extradural anterior clinoidectomy was used to clip small aneurysms. As large or giant aneurysms required a longer temporal occlusion period and often could not undergo simple clipping, high-flow bypass with anterior clinoidectomy or cervical internal carotid ligation was performed to reduce aneurysm blood flow and induce thrombosis. We reviewed a postoperative modified Rankin Scale (mRS), radiographic outcomes, cerebral infarction, and visual disturbance. In addition, we analyzed factors relating to the outcomes and complications, with focus on the aneurysm size, location, and type of surgical treatment., Results: Good outcomes were achieved in all patients, as follows: mRS 0:100, mRS 1:16, mRS 2:11, and mRS 3-6:0. Among the 127 patients, complete exclusion of aneurysm was achieved in 119 cases (93.7%). Postoperative morbidity included ischemic lesions in 11 (8.6%) and visual disturbance in 24 (18.8%). Significant statistical differences were observed between ischemic complication and aneurysm size and location (P = 0.0001) and surgical treatment (P < 0.0001)., Conclusion: Surgical treatment of unruptured paraclinoid aneurysm has high efficacy with good outcomes and a high rate of complete exclusion. However, the rate of visual disturbance is relatively high. Careful surgical techniques and intraoperative monitoring are therefore required., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: We report a case of an internal carotid artery (ICA) aneurysm anomalously originating from the posterior communicating artery (PComA)., Case Description: Preoperative radiologic findings revealed a paraclinoid carotid artery aneurysm at the level of the distal dural ring. Because of the low rupture risk, there are no treatment indications for small paraclinoid or ICA-superior hypophyseal artery unruptured aneurysms. In this case, because of the patient's age and the irregular shape of the aneurysm, treatment was considered necessary. Intraoperative findings using microscopic and endoscopic angiography showed that the aneurysm originated from the proximal branched PComA. The PComA originated from the same level as the ophthalmic artery, and the superior hypophyseal artery originated from the distal side of the PComA., Conclusions: According to numerous reports, small incidental paraclinoid aneurysms have a lower risk of rupture and growth than PComA aneurysms. Preoperative radiologic examination of unruptured small aneurysms was performed using magnetic resonance angiography and three-dimensional computed tomography angiography. Because the ability of magnetic resonance angiography and three-dimensional computed tomography angiography to detect small branches of the ICA is inferior to digital subtraction angiography, the location of an unruptured ICA aneurysm should be evaluated with other diagnostic modalities besides magnetic resonance angiography and three-dimensional computed tomography angiography., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Object: Only a few studies have reported the risk of ischemic complications occurring when superficial temporal artery (STA) to middle cerebral artery (MCA) anastomosis is performed during surgery for complex MCA aneurysms., Subjects and Methods: This is a retrospective study of 10 patients (age 52-73) with MCA aneurysms treated with revascularization surgery. The aneurysms were 10-50mm in size (mean: 21mm). We studied the causes and frequency of ischemic complications by analyzing postoperative magnetic resonance imaging., Results: Postoperative diffusion-imaging confirmed ischemic complications in six of the 10 patients (in two of the five ruptured aneurysms and in four of the five unruptured). The ischemic complications that observed were infarction of the lenticulostriate artery territory in three cases, cortical infarction in two cases, and cerebral infarction that was likely to be due to cerebral vasospasm in one case. In one case, both cortical infarction and infarction of the lenticulostriate artery territory were observed. The Glasgow Outcome Scale (GOS) scores at the time of discharge indicated good recovery (GR) and moderate disability (MD) in seven cases, severe disability (SD) in two cases, and death (D) in one case., Conclusions: The present study suggests the possibility that STA-MCA anastamosis in surgeries for MCA aneurysms can be performed with comparatively better safety. However, the temporary occlusion time with this surgery is longer than that with a temporary clipping for aneurysmal surgery; thus, we believe that adequate countermeasures are required to prevent ischemic complications., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Objective: The aim of the present study was to assess a new technique of surgical microscope-based indocyanine green (ICG) videoangiography (VAG) to confirm the patency of the anterior communicating artery (AcomA) after clipping AcomA aneurysms., Methods: Aneurysmal clipping of five cases of unruptured, broad-neck AcomA aneurysm was performed using the Carl Zeiss Surgical Microscope OPMI Pentero INFRARED 800., Results: In all five patients, after clipping AcomA aneurysms, the patency of AcomA was confirmed using ICGVAG findings and temporary unilateral occlusion of the A1 segment of the anterior cerebral artery using temporary clips. Images were excellent and enabled a real-time surgical assessment because the structures of interest, including vessels, perforating arteries, or residual aneurysm neck, were visible to the surgeon's eye under the microscope in all five patients., Conclusions: ICGVAG and temporary unilateral occlusion with clips provides a simple, reliable, real-time, and rapid intraoperative assessment of the patency of AcomA. This technique may help to improve the quality of neurosurgical procedures., (Copyright © 2011 Elsevier Inc. All rights reserved.)