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Background Coil embolization of aneurysms of the ophthalmic segment of the internal carotid artery (ICA-OphA ANs) has potential risks of visual complications. We analyzed this risk and focused on the relationship of the ophthalmic artery (OphA) origin with the aneurysm neck. Methods From January 2003 to April 2018, 179 unruptured ICA-OphA ANs were treated with endovascular surgery in our institution. Two ruptured and four aneurysms with missing data were excluded. Finally, 173 unruptured aneurysms were included in this study. The aneurysms were classified into three groups according to the location of the OphA origin: Separate, Shared, and Dome type. We retrospectively assessed visual complications based on the relationship between types of aneurysm and postoperative angiographic findings for the OphA. Results Visual deficits remained permanent in eleven cases (6.4%). In the Dome type, visual complications were significantly more frequent compared to the Separate type. Change in the OphA flow was significantly associated with a higher complication rate of 2.9%, but patients with changed OphA flow had a significant rate of 7.5% ( p = 0.020). We found no significant difference in the incidence of visual complications concerning the use of perioperative antithrombotic therapy. Conclusions The location of OphA origin regarding the aneurysmal neck and postoperative OphA flow were significantly correlated with the visual outcome after coil embolization for ICA-OphA ANs. Post-procedural flow in the OphA was an important factor affecting the rate of ischemic retinal complications. Retinal embolic events occurred with preserved flow in the OphA, albeit at a lower rate.

Background Foramen magnum dural arteriovenous fistula (DAVF) is a rare disease, with some reported cases of successful treatment. We achieved complete obliteration of the foramen magnum DAVF through microsurgery after complications of endovascular embolization. We reviewed the treatment modalities and outcomes, focusing on pathologic and anatomic features from the literature. Case Description A 65-year-old man was admitted to our hospital with sudden diplopia. Magnetic resonance imaging revealed a subarachnoid hemorrhage around the right side of the prepontine cistern, and a foramen magnum DAVF was diagnosed by angiography. Subsequent angiography revealed that the fistula was supplied by the right neuromeningeal trunk of the ascending pharyngeal artery and the right posterior meningeal artery of the vertebral artery (VA), and the veins of the pouch via the fistula were retrogradely draining into the intracranial veins. We aimed to treat complete occlusion endovascularly with balloon-augmented transarterial Onyx injection via the posterior meningeal artery, but Onyx was refluxed to the VA through the anastomosis between the VA and posterior meningeal artery. Onyx subsequently migrated to the top of the basilar artery, causing occlusion, so we urgently removed the Onyx with a stent retriever (Trevo). Several weeks later, we performed complete obliteration of the foramen magnum DAVF via a lateral suboccipital approach with a C1 laminectomy. Conclusions Most foramen magnum DAVFs were obliterated completely with only endovascular treatment. Microsurgery is an effective and reliable treatment for incomplete occlusion and complications.

Objective Risk control of thromboembolic complications (TECs) during stent-assisted coil embolization (SACE) for unruptured intracranial aneurysms (UIAs) is crucial for satisfactory treatment outcomes. We retrospectively evaluated the data from our cohort of SACE for UIAs to analyze the role of anatomical, clinical, and stent type-related factors to determine the optimal preoperative values of light transmission aggregometry (LTA) for TEC prevention. Methods From July 2015 to May 2018, we retrospectively analyzed the data from 132 patients with SACE-treated UIAs at our hospital. Data regarding the aneurysm location, maximum diameter, stent type used, preoperative LTA value, and ischemic and hemorrhagic complications were collected. Aspirin 100 mg and clopidogrel 75 mg were started 7 days before surgery, with a “boost” dose (an additional 75 mg of clopidogrel for an LTA value >60%) added after August 2016 to address clopidogrel resistance. After multivariate analysis, we developed our original combined parameter termed the thromboembolic predictor (TEP). Receiver operating characteristic (ROC) analysis for TEP and each significant variable was performed. Results TECs were confirmed in 5 of the 132 patients (3.8%) and hemorrhagic complications in 9 of the 132 patients (6.8%). From the multivariate analysis results, the LTA value and maximum diameter were chosen as significant variables and included in the TEP. ROC analysis of the LTA value revealed a sensitivity and specificity of 0.866 and 0.600, respectively (area under the curve, 0.747), with a cutoff of 62%. TEP permitted the establishment of an optimal LTA value according to the aneurysm maximum diameter to predict for TECs. The complication rate for the Neuroform EZ, Enterprise, Neuroform Atlas, and LVIS stents was 2.9%, 10.5%, 1.4%, and 14.3%, respectively. Conclusions The preoperative LTA value contributes to the prediction of TECs after SACE for UIAs. The TEP (relating the LTA cutoff to aneurysm size) allows for improved antiplatelet therapy adjustment before SACE to reduce TECs.

Objective We report the clinical outcomes of stent-assisted coiling for wide-necked intracranial aneurysms using 3 low-profile laser-cut stents and compare the results according to stent type. Methods All patients treated with stent-assisted coiling for their intracranial aneurysms at our hospital between July 2010 and September 2019 were reviewed. We selected patients with Enterprise, Neuroform EZ, or Neuroform Atlas stents who underwent imaging follow-up and investigated aneurysm and stent features, stent-related complications, recanalization, and retreatment rates. We compared the retreatment risk among the patients treated with the 3 stent types using Kaplan-Meier survival analysis and Cox regression analysis. Results We evaluated 364 consecutive cases (103 Enterprise, 105 Neuroform EZ, and 156 Neuroform Atlas stents). Neuroform Atlas was more frequently used in distal vessels: 8 (7.8%) Enterprise, 2 (1.9%) Neuroform EZ, and 41 (26.3%) Neuroform Atlas cases, respectively. The median follow-up durations were 6.49, 4.91, and 1.24 years for the Enterprise, Neuroform EZ, and Neuroform Atlas cases, respectively, and retreatment was performed in 11 (10.1%), 9 (8.6%), and 6 (3.8%) cases. In the first 2 years of follow-up, the estimated retreatment risk ratios for Neuroform EZ and Neuroform Atlas with Enterprise as reference were 0.63 (95% confidence interval, 0.24–1.65; P = 0.35) and 0.54 (95% confidence interval, 0.18–1.59; P = 0.26), respectively. Conclusions Neuroform Atlas stents were more frequently deployed in small-caliber vessels compared with the other 2 types of stents. The complication rate and retreatment risk until at least 1 year after the aneurysm treatment appeared to be similar for the 3 stent types.

Objectives: Long term outcome of large / giant unruptured intracranial aneurysms (LG-UIAs) after endovascular therapy is still unknown. We retrospectively analyzed long-term results of patients with LG-UIAs who were followed up more than 5 years after endovascular therapy. Methods: We included patients from our complete database with UIAs greater than 10mm and treated at our hospital from January 2003 to December 2013. Retreatment rate of targeted aneurysms, rupture rate, and the modified Rankin scale (mRS) at last visit were evaluated till December 2018. Results: From 142 patients treated during the period were excluded 3 patients with perioperative rupture and 38 patients with less than 5 years follow-up period, finally analyzing 101 patients. The median aneurysm size was 12.0 mm (IQR 10.8-15). The median follow-up period was 9.4 years (IQR: 7-11), the longest being 13.3 years. Retreatment was performed on 36 patients (35.6%). Comparing cumulative re-treatment rates in groups with aneurysm sizes 20 mm, it was predominantly higher for aneurysms> 20 mm (P = 0.02, Figure1 ). Rupture of targeted aneurysms was observed in 2 cases (1.98%, Figure2 ), and the longest period from last treatment was up to 12 years. The mRS 0-1 at the first treatment and the final visit were 98% and 93%, respectively, and mRS deterioration remained at 5%. Conclusion: The retreatment rate tended to increase in proportion to the size of the aneurysm, however the final neurological outcome was favorable when considering the natural history of these aneurysms. Since aneurysmal rupture could occur after 12 years of treatment, long-term follow-up should be considered for LG-UIAs.

Background: Control of risks of thromboembolic complications (TEC) during stent assisted coil embolization (SACE) for unruptured intracranial aneurysm (UIA) is crucial for outcome. We evaluated retrospectively our cohort of SACE for UIA, analyzing the role of anatomical, clinical and stent type related factors to determine optimal presurgical values of light transmission aggregometry (LTA) for TEC prevention. Methods: From July 2015 to May 2018 we retrospectively analyzed 132 SACE treated UIA patients at our hospital. Aneurysm location and maximum diameter, preoperative LTA-value, ischemic and hemorrhagic complications, preoperative and discharge Modified Rankin scale (mRS) were collected. Aspirin 100 mg and clopidogrel 75 mg were started 7 days before operation, with “boost” therapy (additional 75mg clopidogrel in LTA-value >60) added after August 2016, addressing clopidogrel resistance. After multivariate analysis we developed our original combined parameter called TEC predictor (TEP). Receiver operating characteristic (ROC) analysis for TEP and each significant variable were performed. Results: TEC were confirmed in five (3.8%, 5/132) and hemorrhagic - in nine patients (6.8%, 9/132), with mRS deterioration post-operatively in five patients (5/132, 3.8%). By multivariate analysis, LTA-value and maximum diameter were chosen as significant variables, and included in TEP. ROC analysis of LTA-value showed sensitivity and specificity of 0.866 and 0.600 respectively (AUC=0.747) with cut-off point of 62. TEP permitted establishing optimal LTA-value according to the aneurysm maximum diameter to predict TEC. Neuroform-EZ, Enterprise, Neuroform-Atlas, and LVIS stents complications were 2.9%, 10.5%, 1.4%, and 14.3%, respectively. Conclusions: Preoperative LTA-value contributes to predicting TEC after SACE of UIA. TEP (relating LTA cutoff value to aneurysm size) provides improved antiplatelet therapy adjustment prior to SACE for TEC reduction.

Author(s): Misaki, Kouichi; Takao, Hiroyuki; Suzuki, Takashi; Nishimura, Kengo; Kan, Issei; Yuki, Ichiro; Ishibashi, Toshihiro; Yamamoto, Makoto; Murayama, Yuichi | Abstract: BACKGROUND:Hemodynamic factors play important roles in aneurysm recurrence after endovascular treatment. OBJECTIVE:Predicting the risk of recurrence by hemodynamic analysis using an untreated aneurysm model is important because such prediction is required before treatment. METHODS:We retrospectively analyzed hemodynamic factors associated with aneurysm recurrence from pretreatment models of five recurrent and five stable posterior communicating artery (Pcom) aneurysms with no significant differences in aneurysm volume, coil packing density, or sizes of the dome, neck, or Pcom. Hemodynamic factors of velocity ratio, flow rate, pressure ratio, and wall shear stress were investigated. RESULTS:Among the hemodynamic factors investigated, velocity ratio and flow rate of the Pcom showed significant differences between the recurrence group and stable group (0.630 ± 0.062 and 0.926 ± 0.051, P= 0.016; 56.4 ± 8.9 and 121.6 ± 6.7, P= 0.008, respectively). CONCLUSIONS:Our results suggest that hemodynamic factors may be associated with aneurysm recurrence among Pcom aneurysms. Velocity and flow rate in the Pcom may be a pretreatment prognostic factor for aneurysm recurrence after endovascular treatment.

Background Surgical treatment of vertebral artery (VA)-thrombosed giant aneurysms requires achieving both obliteration of the parent artery to prevent bleeding and dome thrombectomy to relieve the brain stem from mass effect. To secure both proximal and distal control of complex VA aneurysms, the contralateral approach to the aneurysm might be a useful alternative, as previously described. We successfully treated a case of VA-thrombosed giant aneurysm in a new, original way by combining craniotomy (ipsilateral and contralateral) and the endovascular technique. Case Description A 48-year-old man presented with a thrombosed giant aneurysm of the right VA compressing the brain stem. Treatment consisted of endovascular proximal ligation of the VA followed by 2-staged craniotomy for complete trapping of the aneurysm and intra-aneurysmal thrombectomy. The VA distal to the aneurysm was obliterated via contralateral craniotomy as only that provided adequate working space. Finally, intra-aneurysmal partial thrombectomy was performed through an ipsilateral craniotomy, which also made possible the obliteration of the eventually dangerous remaining vasa vasorum and additional proximal ligation of the VA. Conclusions Based on pathologic and surgical anatomical characteristics, a combination of an endovascular procedure with 2-staged craniotomy for complete trapping, thrombectomy, and vasa vasorum obliteration could be considered a feasible way to treat VA-thrombosed giant aneurysms located ventral to the brain stem and have their distal neck portions/patent vessel beyond the midline toward the contralateral side.

We report a very rare case of a ruptured abdominal aortic aneurysm (AAA) with an anomaly of the inferior vena cava (IVC). The AAA was covered with a large hematoma and an expanded vein was on its left side. It was not until we could not locate the IVC on the right side of AAA that we recognized the anomaly during the operation. Although we reviewed the findings on enhanced computed tomography, we were confused whether the case was a duplicated or left-sided IVC. Subsequently, a bifurcated vascular prosthesis was implanted without ligation of the left renal vein to join the left-sided IVC.

Deep femoral artery (DFA) aneurysms are rare. DFA is protected by the adductor canal, which may delay the diagnosis. Then, its early diagnosis may be difficult and it is possible to be misdiagnosis with incarcerated inguinal hernia, which occurs more often in elderly people. We report a very rare case of a treatment of an advanced elderly patient with an isolated ruptured DFA aneurysm that was preoperatively confused with an incarcerated inguinal hernia.A 97-year-old man was admitted to a neighboring hospital due to a painful mass of the right groin after transient consciousness loss and the patient was diagnosed with right incarcerated inguinal hernia by a nonenhanced computed tomography (CT). Although he was observed for 3 days, he suddenly lost consciousness again with a decrease in blood pressure. Thus, he was referred to our hospital due to the painful pulsatile inguinal mass after resuscitation from shock. As we diagnosed a ruptured DFA aneurysm by an enhanced CT, we emergently performed an excision of the aneurysm with revascularization of the right DFA. The postoperative course was uneventful without ischemic change of the lower leg.

Background and Purpose Precise stent deployment is important for successful treatment of intracranial aneurysms by stent-assisted coiling (SAC). We evaluated the accuracy of virtual stents generated using commercial stent planning software by comparing the length of virtual and actually deployed intracranial laser cut stents on three-dimensional digital subtraction angiography (3D-DSA) images. Methods We retrospectively analyzed the data of 75 consecutive cases of intracranial wide-necked aneurysms treated with the SAC technique using laser cut stents. Based on 3D-DSA images acquired by C-arm CT, stent sizing and placement were intraoperatively simulated by a commercial software application. The difference in length of the stents was estimated by measuring proximal discrepancies between the end points of the virtual and actually deployed stents on fused pre-procedural and post-procedural 3D-DSA images. Discrepancies between distal stent end points were manually minimized. The Kruskal–Wallis test was applied to test whether stent location, type, and length had an effect on difference in length between virtual and real stent. Results The median difference in length between virtual and real stents was 1.58 mm with interquartile range 1.12–2.12 mm. There was no evidence for an effect of stent location (p = 0.23), stent type (p = 0.33), or stent length (p = 0.53) on difference in length between virtual and real stents. Conclusions Stent planning software allows 3D simulation of laser cut stents overlain on 3D-DSA images of vessels and may thus be useful for stent selection and deployment of laser cut stents during stent-assisted coiling of intracranial aneurysms.

BackgroundStabilization of microcatheters during coiling after their optimal shaping are key factors for successful endovascular coil embolization of cerebral aneurysms. However, stabilization and optimal shaping of microcatheters are sometimes difficult. Our aim was to introduce "tailor-made" microcatheter shapes for coil embolization using three-dimensional (3D) printed vessel models. MethodSince August 2014, we have been investigating the use of 3D printed models of intracranial arterial aneurysms to produce optimally shaped microcatheters for endovascular coil embolization. Using Digital Imaging and Communication in Medicine data obtained from preoperative cerebral angiography, a vessel model was produced with a 3D printer using acrylic resin. Preoperative planning of microcatheter navigation and shaping were performed using the 3D vessel models. Before the procedure, microcatheter mandrels were bent manually to the intended angle, referring to the vessel model, and then sterilized. The 3D vessel models were also sterilized with plasma and used during the procedure. ResultsTwenty-six patients (27 aneurysms) were treated using a total of 48 microcatheters shaped while referring to the 3D printed vessel model. Of the 48 catheters, only 9 (19%) required modification of the initial shape due to inappropriate positioning of the catheter. Only 29% of the catheter placements required repositioning due to catheter kick back. There were no procedure-related complications, including aneurysm rupture. The responses from assistants to a questionnaire administered after the embolizations on the usefulness of the technique were favorable. ConclusionsTailor-made shaping of microcatheters may facilitate easier and safer procedures in coil embolization of intracranial aneurysm. 3D printed aneurysm models are simple and cheap to produce and apply.3D printed models make possible optimal "tailor-made" micro-catheter shapings."Tailor-made" micro-catheters permit easier access to aneurysms for coiling.

BACKGROUND Thin-walled regions (TWRs) of cerebral aneurysms are at high risk of rupture, and careful attention should be paid during surgical procedures. Despite this, an optimal imaging technique to estimate TWRs has not been established. Previously, pressure elevation at TWRs was reported with computational fluid dynamics (CFD) but not fully evaluated. OBJECTIVE To investigate the possibility of predicting aneurysmal TWRs at high-pressure areas with CFD. METHODS Fifty unruptured middle cerebral artery aneurysms were analyzed. Spatial and temporal maximum pressure (Pmax) areas were determined with a fluid-flow formula under pulsatile blood flow conditions. Intraoperatively, TWRs of aneurysm domes were identified as reddish areas relative to the healthy normal middle cerebral arteries; 5 neurosurgeons evaluated and divided these regions according to Pmax area and TWR correspondence. Pressure difference (PD) was defined as the degree of pressure elevation on the aneurysmal wall at Pmax and was calculated by subtracting the average pressure from the Pmax and dividing by the dynamic pressure at the aneurysm inlet side for normalization. RESULTS In 41 of the 50 cases (82.0%), the Pmax areas and TWRs corresponded. PD values were significantly higher in the correspondence group than in the noncorrespondence group (P = .008). A receiver-operating characteristic curve demonstrated that PD accurately predicted TWRs at Pmax areas (area under the curve, 0.764; 95% confidence interval, 0.574-0.955; cutoff value, 0.607; sensitivity, 66.7%; specificity, 82.9%). CONCLUSION A high PD may be a key parameter for predicting TWRs in unruptured cerebral aneurysms. ABBREVIATIONS CFD, computational fluid dynamicsMCA, middle cerebral arteryPave, average pressurePD, pressure differencePmax, maximum pressureTWR, thin-walled regionWSS, wall shear stress.

Purpose Antiplatelet management is essential in neuroendovascular treatment, especially with intracranial stent deployment, for thromboembolic complication reduction. There are few articles which described the use of light transmission aggregometry (LTA) as a platelet function test prior to deployment of intracranial stent. The aim of this study was to evaluate the usefulness of strict antiplatelet management in patients with stent assisted coil embolization. Method A total of 372 patients with intracranial aneurysms were treated with endovascular procedure from July 2015 to March 2018. During the period, 119 patients underwent stent-assisted coil embolization. All patients were measured platelet function test before procedure. Platelet function test was performed using LTA measuring adenosine diphosphate (ADP). We retrospectively analyzed thromboembolic complication based on two protocols (stages) of antiplatelet management for that period. In early stage, the patients were taken regular double antiplatelet therapy (aspirin 100 mg and clopidogrel 75 mg, daily) seven days before the procedure. In the late stage, we employed strict antiplatelet management described as follows: if ADP value is less than 60, additional clopidogrel 75 mg was administered in addition to the regular double antiplatelet therapy. Thromboembolic complications occurring from the date of the procedure until discharge were evaluated. Results In the early stage (July 2015 to August 2016), three thromboembolic complications were occurred out of 35 patients (8.6%). Patients with complications had significantly higher average ADP value than those without complication (60.7 versus 45.6; p=0.018). A cut-off value of ADP was 62 (AUC 0.807, Sensitivity 0.67, Specificity 0.93). In the late stage (August 2016 to March 2018), CLP boosting was conducted in nine patients out of 84 patients (10.7%). The rate of thromboembolic complication was significantly lower in late stage than that in the early stage (1.2% versus 8.6%; p=0.04). Conclusion Strict antiplatelet management using platelet aggregation test may reduce thromboembolic complication in patients with stent assisted coil embolization. Disclosures I. Kan: None. T. Ishibashi: None. I. Yuki: None. K. Sakuta: None. T. Kodama: None. S. Kaku: None. N. Kato: None. K. Nishimura: None. K. Aoki: None. Y. Murayama: None.

Purpose: Little is known about the long term clinical outcomes of middle cerebral artery (MCA) stenosis / occlusion patients who are treated with medical therapy. The efficacy and safety of the medical treatment was evaluated by analyzing the clinical outcomes along and imaging analysis using CT Angiography (CTA) with an automatic measurement software. Methods: Patients who were diagnosed with middle artery stenosis or occlusion were prospectively enrolled in the study. Those who were diagnosed with moyamoya disease were excluded. Along with the rigorous medical treatment for atherosclerosis risk factors, Cilostazol 200mg/day was selected as the first line of medication, and switched to either aspirin 100mg/day or clopidogrel 75mg/day if necessary. CT Angiogram (CTA) was performed and a software for the measurement of stenosis on the stretched view was used for evaluating the degree of stenosis. The neurological findings as well as the degree of stenosis during the observation time were analyzed. Results: Of the 186 MCA stenosis / occlusion patients who visited our institution, 62 lesions in 60 patients who completed periodic CTA evaluation were selected for the study. 20 lesions (40.3%) were symptomatic at the time of diagnosis. 45 patients (75.0%) were treated with cilostazol and 22 (36.7%) underwent dual antiplatelet therapy. 7 patients (11.7%) were observed without any antiplatelet therapy. During the median observation time of 75.6 months, 24 patients (40.0%) showed angiographic improvement, and the median % area stenosis improved from 66.0% (IQR: 53.0 - 80.0) to 54.7% (48.6 - 77.5). Of the 29 patients who showed complete occlusion at the initial diagnosis, 17 (58.6%) showed any degree of recanalization. For those with symptomatic lesions, no patient developed major stroke on the ipsilateral side after completing the 3 months of initial treatment. Conclusions: Angiographic improvement of MCA stenosis was observed with successful prevention of major stroke associated with the disease. Majority of the patients who tolerated the complete occlusion at the time of initial treatment showed recanalization during the observation period. Medical treatment can be an effective therapeutic method for the MCA stenosis / occlusion patients.

Introduction: Prediction of ischemic core during the thrombectomy procedure can contribute to the treatment strategy. To evaluate if the Cone Beam CT CBV (CBCT-CBV) can predict the image findings of post procedure MRI, retrospective analysis was performed. Methods: A total of 14 ischemic stroke cases with major vessel occlusion underwent CBCT-CBV. A 4 French diagnostic catheter, which was placed in the guiding catheter, was positioned at the ascending aorta. Utilizing 6 seconds acquisition (6Sec Dyna PBV Neuro, Siemens Healthcare), 30% diluted contrast was injected with the speed of 6ml/sec. The reconstruction of the images with CBV color mapping was created immediately after the acquisition. The pre and post procedure CBCT-CBV data was compared with the corresponding MRI images and the results were retrospectively analyzed. Results: Of the 14 cases who showed major vessel occlusion, 6 underwent both pre and post CBCT-CBV. Location of the occluded vessels were internal carotid artery (ICA) (4 cases), middle cerebral artery (9 cases) and 1 basilar artery. No case showed increased CBV. Five cases showed a significant reduction of regional CBV (mean reduction; 72.65%) at the end of the procedure. All these cases showed DWI high regions in the post procedure MRI matched with the area of CBCT-CBV reduction (100%). Of the 6 cases who underwent both pre and post procedure CBCT-CBV, 3 showed decreased CBV in the pre-procedure CBV. After the recanalization of the occluded vessels, the regional CBV was normalized to the level of contra lateral side in every case. Conclusions: Intra-operative CBCT-CBV showed recovery of the reduced CBV after the recanalization in some cases. The area of reduced CBV at the end of procedure was matched with the DWI positive region in the post-procedure MRI (100%). Intra-operative CBCT-CBV may contribute to the prediction of post-operative ischemic core.

Case A 45-year-old man was brought to our hospital in pre-shock after falling from a motorcycle. As we diagnosed him with open fracture of the right femur with leg ischemia, we performed revascularization of injured popliteal artery and treated the leg. The pathological findings showed fragmentation and decrease of elastic fibers and fragmentation of collagen fibers, but no inflammatory cells or intimal hyperplasia, and no dissection. Outcome Unfortunately, amputation had to be carried out on the 29th postoperative day due to infection and leg dysfunction. The postoperative course was uneventful. The patient could walk with an artificial leg and was discharged approximately 5 months after popliteal artery replacement. Conclusions We report a case of revascularization involving a patient with open fracture of the right femur due to acute blunt popliteal artery injury.

Brachial artery (BA) aneurysms are rare, and most are false aneurysms. Although true BA aneurysms have been reported, most have been reported without symptoms. A 65-year-old man was referred due to a left upper limb mass with rest pain and slight ulceration of the left second and third fingers. As enhanced computed tomography revealed the patency of only the left proximal and distal BA as well as the thrombosed mass, excision of the aneurysm and BA replacement were performed with a great saphenous vein graft. The postoperative course was uneventful, and the rest pain and ulceration were resolved.

Superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis is a common procedure for the treatment of cerebral ischemia and is useful for cerebral aneurysms and tumors. The STA has to pass through the dura and the dura cannot be sutured tightly around the STA to prevent vessel narrowing, so subcutaneous cerebrospinal fluid (CSF) collection is common. This study analyzed the feasibility of using a synthetic dural sealant in the STA-MCA anastomosis to establish watertight closure. Twenty-four patients underwent STA-MCA anastomosis for cerebral ischemia or cerebral aneurysm. After creation of a standard STA-MCA anastomosis, the dura was reapproximated closely, leaving a small defect around the STA. Then, DuraSeal(TM) was sprayed over the dural defect, and a negative-pressure drain was positioned before closing the skin. Only two patients developed subcutaneous CSF collection, which was managed conservatively. The patency of the anastomosis was proven by magnetic resonance angiography in all cases, and no ischemic complication suggesting chemical spasm of the STA due to the sealant occurred. With DuraSeal(TM), watertight dural closure can be obtained easily and safely in bypass surgery.

For dural plasty, several kinds of substitute materials are used clinically. Among these materials, pericranium is often used as a dural substitute since it is autologous and easy to harvest. However, it is rather thin and fragile, which makes it difficult to suture onto peripheral dura mater, especially when the defect is large.We present a simple method of reinforcing the pericranium with fibrin sealant, which facilitates easier handling and suturing of the pericranium.Fifteen patients who underwent surgical removal of meningioma, metastatic brain tumor and glioma attached to the dura mater were included in this analysis. To close the defects, we use 'fibrin-sealed pericranium'. Herein we describe the method we employed in these cases. First, a standard skin flap is made by dissecting the subgaleal layer, leaving the periosteum on the bone. Second, fibrin sealant is evenly applied to the pericranium. Finally, the pericranium is cut along the reinforced area and dissected from the bone. The harvested pericranium is then used for closure of the dural defect. Some of these patients received further treatment as needed according to each pathology. The fibrin-sealed pericranium was examined histopathologically.Fibrin-sealing of pericranium made it durable enough to be handled and sutured easily. There were no significant complications or treatment failures, such as infection or CSF leakage.Reinforcement of the pericranium with fibrin sealant is a simple and easy method to reduce the stress of dural plasty.

This study examines the pathogenesis of abdominal aortic aneurysms (AAAs) with respect to pathological characteristics and expressions of matrix metalloproteinases (MMP)-2, MMP-9 and tissue inhibitor of metalloproteinases (TIMP)-1, in Tottori University Hospital, Japan. Thirty-four consecutive patients were operated on for (AAAs). During surgery, the anterior wall of the aneurysmal aorta was resected from the site of maximal diameter throughout the wall. AAA specimens consisted of the aneurysmal aortas, while control specimens consisted of the undulated aortas of autopsy cases. The expression of MMP-2, MMP-9 and TIMP-1 was evaluated by immunohistochemistry, Western blotting and competitive polymerase chain reaction (C-PCR). Immunohistochemistry showed MMP-2-positive cells and TIMP-1 positive cells mainly in the intima, and MMP-9-positive cells in the intima and adventitia. Western blotting revealed the expression of MMPs and TIMP-l variably in all the cases examined. C-PCR showed significantly higher elevation of MMP-2 mRNA in the small-diameter AAAs (30–45 mm), plus higher MMP-9 mRNA expression in both the small-diameter and the medium-large-diameter AAAs (45 < mm), than in controls. The ratio of MMP-2 to TIMP-1 mRNA levels in the small-diameter AAAs, and the ratio of MMP-9 to TIMP-1 mRNA levels in both the small-diameter and medium-large-diameter AAAs were significantly higher than in controls. The mRNA levels were significantly correlated between MMP-2 and MMP-9, between MMP-2 and TIMP-1, and between MMP-9 and TIMP-1 in the AAAs. This study demonstrates that increases in mRNA imbalanced expression of MMPs/TIMP, as well as increases of MMP-2 and MMP-9 expression, may play crucial roles in the development and growth of AAAs, and TIMP-1 may play an important rule of preventing the aortic expansion.

Patients who undergo thoracic aortic surgery with deep hypothermia frequently have postoperative respiratory failure as a complication. Severe lung injury in these patients results in a fatal outcome. A specific neutrophil elastase inhibitor, sivelestat sodium hydrate, is an innovative therapeutic drug for acute lung injury. We evaluated the protective effects of sivelestat sodium hydrate on severe lung injury after thoracic aortic surgery with deep hypothermia. From January 2002 to July 2007, 71 consecutive patients underwent thoracic aortic surgery with deep hypothermia. Of these patients, 22 had postoperative respiratory failure with PaO₂/FiO₂ ratios of less than 150. They were randomly assigned to one of two groups. The first group (Group S, n = 10) was administered sivelestat sodium hydrate continuously at 0.2 mg/kg/h until weaning from mechanical ventilation; the second group (Group C, n = 12) was not administered sivelestat sodium hydrate. The groups were comparable with respect to clinical data. There were no significant differences between the two groups in age, operation duration, total cardiopulmonary bypass time, circulatory ischemia time, cardiac arrest time, intraoperative blood loss, and total transfusion volume. The improvement of pulmonary function was observed in the both groups, but more marked in Group S by statistical analysis using analysis of variance for repeated measurements. Especially, in the early phase, pulmonary function improvement was more marked in Group S. The duration of mechanical ventilation, the length of stay in the intensive care unit, and the length of hospital stay were shorter in Group S, but not significantly. Sivelestat sodium hydrate is a specific neutrophil elastase inhibitor that improves pulmonary function in patients with severe postoperative respiratory failure following thoracic aortic surgery with deep hypothermia. The drug may shorten the duration of postoperative ventilation, intensive care unit stay, and hospital stay.

We report the successful treatment of thoracoabdominal dissection, which extended into the left iliac artery, despite two independent complications: graft infection and a relatively rare, delayed postoperative paraplegia. The paraplegia suddenly occurred on postoperative day 10, and after an intravenous infusion of heparin and methylprednisolone, it gradually subsided. Moreover, graft infection was diagnosed on postoperative day 27, and with continuous irrigation of antibiotic treatment it was cured without recurrence of infection. Although anticoagulation therapy is not indicated for paraplegia, we suppose that it might be used as an adjunct therapeutic.

The indication for aortic valve replacement (AVR) combined left ventricular (LV) plasty in the patient with aortic valve stenosis (AS) complicated by ischemic heart disease is controversial. We describe a case of AS with ischemic heart disease of a patient who underwent a successful surgical treatment, AVR combined with the endoventricular patch technique. The patient was an 82-year-old woman who suffered from heart failure, New York Heart Association (NYHA) class III. The heart failure derived from AS and ischemic heart disease with severely compromised LV function. She underwent AVR combined with the endoventricular patch technique and the postoperative course was uneventful. She has been well with NYHA class I for about 5 years after the operation without heart failure.

Objective With improvements in endovascular techniques, fewer aneurysms are treated by surgical clipping, and those aneurysms targeted for open surgery are often complex and difficult to treat. We devised a hollow, 3-dimensional (3D) model of individual cerebral aneurysms for preoperative simulation and surgical training. The methods and initial experience with this model system are presented. Methods The 3D hollow aneurysm models of 3 retrospective and 8 prospective cases were made with a prototyping technique according to data from 3D computed tomographic angiograms of each patient. Commercially available titanium clips used in our routine surgery were applied, and the internal lumen was observed with an endoscope to confirm the patency of parent vessels. The actual surgery was performed later. Results In the 8 prospective cases, the clips were applied during surgery in the same direction and configuration as in the preoperative simulation. Fine adjustments were necessary in each case, and 2 patients needed additional clips to occlude the atherosclerotic aneurysmal wall. With these 3D models, it was easy for neurosurgical trainees to grasp the vascular configuration and the concept of neck occlusion. Practicing surgery with these models also improved their handling of the instruments used during aneurysm surgery, such as clips and appliers. Conclusion Using the hollow 3D models to simulate clipping preoperatively, we could treat the aneurysms confidently during live surgery. These models allow easy and concrete recognition of the 3D configuration of aneurysms and parent vessels.

症例は75歳，男性．2008年4月頃より安静時にも前胸部痛を自覚していた．心臓カテーテル検査で左主幹部，前下行枝，回旋枝基部に優位狭窄を認めた．胸部レントゲン検査で右上肺野に約2cmの境界不明瞭な陰影を認め，胸部CT検査で右S2に胸膜陥入を伴う径20×35mmの結節影を認め肺癌を疑った．気管支擦過細胞診と肺胞洗浄液細胞診より扁平上皮癌と診断された．左主幹部病変による虚血性心疾患と全身麻酔のリスクおよび患者さんの負担や早期治癒を考慮して，狭心症と右上葉肺癌に対して拍動下冠動脈バイパス術（OPCAB）と右上葉切除術を一期的に施行する方針とし，胸骨正中切開アプローチにて手術を行った．第13病日に心臓カテーテル検査にてグラフトの開存を確認後，第15病日に退院した．病理組織検査は扁平上皮癌でpT1N0M0，IA期であった．早期治療という点で一期的手術も考慮されるべきであると思われた．

We experienced the case of a left ventricular-free wall rupture (LVFWR) following successful coronary intervention for acute myocardial infarction (AMI). A 73-year-old woman was hospitalized because of chest oppression that had been continuing for 8 days. She was diagnosed to have AMI, and percutaneous coronary intervention (PCI) was performed. PCI was successful. However, immediately following PCI, she developed electromechanical dissociation secondary to tamponade because of blow-out-type LVFWR. The perforation tear was initially closed by a direct suture, followed by reinforcement using bovine pericardium patches sealed with GRF glue. The patient died of irreversible brain damage on postoperative day 3, but no re-bleeding or aneurysmal dilatation was detected at autopsy.

We attempted to clarify the effect of different types of shear stress on endothelial cell (EC) proliferation and survival. Bovine aortic ECs were subjected to either steady laminar, 1 Hz pulsatile, or 1 Hz to and fro shear at 14 dyne/cm(2). % of BrdU positive EC was 14.3 +/- 1.6% in steady, 21.5 +/- 3.2% in pulsatile, and 11.4 +/- 2.4% in to and fro after 4 h, respectively (P < 0.05). Pulsatile shear compared with static control. Rapamycin reduced BrdU incorporation in all shear regimens (P < 0.001). However, it was still higher in EC exposed to pulsatile shear than the other regimens (P < 0.005). PD98059 completely abolished the increased BrdU incorporation in all shear regimens, including pulsatile shear. Pulsatile shear had significantly elevated ERK1/2 phosphorylation at 5 min compared with steady (P < 0.05) and to and fro shear (P < 0.01) while there was no significant difference in pp70(S6k) phosphorylation between any shear regimen. The ratio of apoptotic cells in serum deprived EC in the presence of steady laminar, pulsatile and to and fro shear for 4 h were 2.7 +/- 0.78%, 2.7 +/- 0.42%, and 2.9 +/- 0.62%, respectively while after the addition of serum for 4 h, it was 4.3 +/- 0.73%. All shear regimens phosphorylated AKT in a time-dependent manner with no significant difference between regimens. Our results demonstrate that different types of shear stress regimens have different effects on EC and may account for the variable response of EC to hemodynamics in the circulation.

Heparin-induced thrombocytopenia (HIT) is still a relatively uncommon condition and it is not well known how to administer argatroban during continuous hemodiafiltration (CHDF). A 72-year-old man required CHDF with heparin because of the oliguria and hyperpotassemia directly after the open repair of a juxtarenal abdominal aortic aneurysm. As the postoperative blood platelet count dropped and there was a thrombus in the CHDF circuit, HIT was suspected and nafamostat mesilate, but not heparin, was immediately administered for CHDF. As heparin-platelet factor 4 complex was positive, we diagnosed him with HIT and started argatroban while monitoring the activated clotting time (ACT), resulting in no further obstruction of the CHDF and an increase in the platelets. There was no disadvantage for administering nafamostat mesilate which we have commonly used instead of heparin, we should have used argatroban once we suspected HIT. It may be important to consider the history of heparin especially in administering heparin and it may be useful to monitor the ACT when initially starting argatroban for patients with HIT.

Purpose: Brain arteriovenous malformation (AVM) patients presented in our institution were divided into two groups based on the initial treatment strategy, “intervention” vs. “conservative management”, and the mid-term clinical outcomes of the two groups were compared. Methods: A total of 149 AVM patients were enrolled in this study. After thorough discussions with each patient on the risk and benefit of the treatment, 83 patients underwent either endovascular, surgical intervention, radiosurgery or combination of these different modalities (Group A). 66 patients chose conservative management until hemorrhage or clinical worsening from the AVM occurred (Group B). In each group, 1) the type of the initial presentation, 2) Spetzler-Martin (S-M) Grade, 3) modified Rankin Scale (mRS) and 4) symptomatic bleeding or neurological deterioration during the follow-ups were recorded. The clinical outcomes of each group was compared. Results: Group A; The type of initial presentation was, bleeding 45%, epilepsy 21%, incidental 18%, headache 8%, focal neurological deficit 5% and others 2%. During the average observation period of 1569 days, 42 patients (51%) showed angiographical obliteration. Overall complications were seen in 15 patients (18%). Complications with neurological deterioration (mRS≧3) was seen in 2 patients (2.4%). Group B; The type of initial presentation was, incidental 33%, epilepsy 23%, bleeding 18%, headache 17%, focal neurological symptoms 3% and others 6%. During the follow-ups (778 days), 7 patients (10%) had hemorrhage or neurological deterioration, and all of them underwent treatment. One patient died immediately before the surgery due to substantial re-bleeding. Rupture rate was 4.5% / year, and neurological sequela (mRS≧3) was seen in 2.7% in this group. Conclusion: The risk of neurological deterioration during the observation period was similar in both groups. Considering the “treatment group” has higher risk of bleeding, the intervention (s) might have contributed to the prevention of the neurological deterioration. However, given the limited magnitude of neurological sequela induced by the bleeding, caution should be exercised in determining the treatment indications especially for the asymptomatic patients.

We report a case of mycotic abdominal aortic pseudoaneurysm caused by a penetrating atherosclerotic ulcer (PAU). An 81-year-old woman was admitted to a local hospital with fever and abdominal pain, and when her symptoms were not improved by antibiotics, she was referred to our department. Computed tomography (CT) and angiography showed a saccular aneurysm below the renal arteries, and an emergency laparotomy was performed because we suspected a mycotic abdominal aortic pseudoaneurysm. An abscess was found on the proximal side of the jejunum, caused by an aneurysm penetrating the serosa. We diagnosed a mycotic pseudoaneurysm after finding the anterior wall of the aorta penetrated by intense calcification. The pseudoaneurysm was resected with the abscess and the area was covered with a pedicled omental flap to prevent infection. An axillofemoral bypass was also done. The patient recovered well.

乳腺腺様嚢胞癌は極めて稀な疾患であり,本邦報告例もわれわれの検索した限りでは71例の報告があるのみである.今回われわれは乳腺腺様嚢胞癌の1例を経験した.症例は62歳の女性,平成13年9月9日右乳房の腫瘤を自覚して来院した.触診では右乳房のC領域に1cm大の可動性良好な硬い腫瘤を認めた.マンモグラフィーにてカテゴリーIII,エコーにて扁平・境界明瞭,内部エコー均一な腫瘤が認められ,細胞診ではclass III bであった.腫瘤を摘出した結果,乳腺腺様嚢胞癌との診断であったため乳房温存術+腋窩郭清を施行し,現在まで再発は認めていない.

1980年から1997年に手術した腹部大動脈瘤(AAA)191例(非破裂161例,破裂30例)の遠隔期予後を検討した.30日死亡は非破裂群1.2%,破裂群36.6%,在院死亡はおのおの3.1%,53.3%であった.耐術例の累積生存率は5年76.3%,10年42.3%で,一般人口より低かった.非破裂群と破裂群に有意差はなかった.遠隔期の死因は心臓関連死が28.8%,脳血管障害19.2%,悪性腫瘍17.3%,大動脈腸管瘻や再発した真性動脈瘤(真性瘤),吻合部動脈瘤(吻合部瘤)など中枢側吻合部周囲大動脈病変の破裂が9.6%であった.遠隔期に中枢側吻合部周囲の大動脈病変を10%,胸部大動脈瘤を3.7%,大動脈解離を4.2%に認めた.グラフト累積開存率は10年97.4%,15年90.9%であった.AAA患者では術後遠隔期において,冠動脈疾患や大動脈瘤の再発などを早期に発見するために,長期的な経過観察が必要である.

特発性血気胸の臨床的特徴について検討した.1978年1月から2001年5月までに当院で経験した特発性血気胸は15例で, 同時期の自然気胸症例の1.4%であった.年齢は18～56歳で平均35.7歳, 15例中13例は男性で, 罹患側に左右差はなかった.15例中14例は気胸初発例であった.症状は, 全例に激しい胸痛があり, ショック症状を3例に認めた.総出血量は400～7, 100mlで平均1, 459mlであった.治療方針として, 1978年から1992年までの胸腔鏡導入前では保存的治療だけでは不十分であった11例中6例に開胸術を施行した.胸腔鏡導入後の1992年以降は, 4例全例に胸腔鏡手術を施行した.手術時間, 術後の在院日数, 手術までの時間, 術中出血量, 術後のドレーンの留置期間において胸腔鏡下手術例の方が, 開胸術例に比べ良好な結果であった.特発性血気胸に対して, 早期の胸腔鏡下手術が第一選択になりうると思われた.

Background Sporadic emergence of the highly pathogenic avian influenza (HPAI) H5N1 virus infection in humans is a serious concern because of the potential for a pandemic. Conventional or quantitative RT-PCR is the standard laboratory test to detect viral influenza infections. However, this technology requires well-equipped laboratories and highly trained personnel. A rapid, sensitive, and specific alternative screening method is needed. Methods By a luminescence-linked enzyme immunoassay, we have developed a H5N1 HPAI virus detection kit using anti-H5 hemagglutinin monoclonal antibodies in combination with the detection of a universal NP antigen of the type A influenza virus. The process takes 15 minutes by use of the fully automated luminescence analyzer, POCube. Resutls We tested this H5/A kit using 19 clinical specimens from 13 patients stored in Vietnam who were infected with clade 1.1 or clade 2.3.4 H5N1 HPAI virus. Approximately 80% of clinical specimens were H5-positive using the POCube system, whereas only 10% of the H5-positive samples were detected as influenza A-positive by an immunochromatography-based rapid diagnostic kit. Conclusions This novel H5/A kit using POCube is served as a rapid and sensitive screening test for H5N1 HPAI virus infection in humans.

BACKGROUND AND PURPOSE: The natural history and therapeutic management of dissecting vertebrobasilar aneurysms without ischemic or hemorrhagic stroke (nonstroke dissecting vertebrobasilar aneurysms) are not well-established. We conservatively followed patients with nonstroke dissecting vertebrobasilar aneurysms and evaluated the factors related to clinical and morphologic deterioration. MATERIALS AND METHODS: One hundred thirteen patients were enrolled and divided by clinical presentation at diagnosis: asymptomatic (group 1, n = 52), pain only (group 2, n = 56), and mass effect (group 3, n = 5). Patients were conservatively managed without intervention and antithrombotic therapy. Clinical outcomes and morphologic changes were analyzed. RESULTS: A total of 113 patients who were diagnosed with nonstroke dissecting vertebrobasilar aneurysm had a mean follow-up of 2.9 years (range, 27 days to 8 years). Throughout that period, 1 patient in group 1 (1.9%) and 1 patient in group 2 (1.8%) showed clinical deterioration due to mass effect, and 1 patient in group 3 (20%) developed ischemic stroke followed by subarachnoid hemorrhage. Most patients (97.3%) were clinically unchanged. Three patients who had clinical deterioration showed aneurysm enlargement (P < .001). Aneurysms remained morphologically unchanged in 91 patients (80.5%). Aneurysm enlargement was seen in 5 patients (4.4%); risk of enlargement was significantly associated with either maximum diameter (hazard ratio = 1.30; 95% CI, 1.11–11.52; P = .001) or aneurysm ≥10 mm (hazard ratio = 18.0; 95% CI, 1.95–167; P = .011). CONCLUSIONS: The natural course of these lesions suggests that acute intervention is not always required and close follow-up without antithrombotic therapy is reasonable. Patients with symptoms due to mass effect or aneurysms of >10 mm may require treatment.

A 69-year-old woman was admitted because of an abnormal solitary round shadow in the right lower lung on chest X-ray. However we could not make an accurate preoperative diagnosis using either transbronchial lung biopsy or CT guided needle biopsy. Since intraoperative thoracoscopic needle biopsy revealed malignant findings, right middle lobectomy with R 2a lymph node dissection was performed. Histological examination determined pulmonary mucoepidermoid carcinoma originating from the peripheral bronchus of B 5b. Pulmonary mucoepidermoid carcinoma commonly occurres in the bronchial glands of the central bronchus, and gradually invades the pulmonary parenchyma. Since mucoepidermoid carcinoma of the peripheral bronchus is very rare, the clinical features of this casewere reported.

We experienced a case of malignant fibrous histiocytoma (MFH) throughout the mesentery. A 65-year-old man was pointed out an abdominal tumor at anotherin hospital and was admitted to the hospital on September 10, 1997. The tumor was about 10×15cm in size and had poor movability with slight tenderness. Ferritin level increased in blood laboratory data. Computed tomogram showed that the tumor was composed of cystic and solid regions with an unclear border on the mesentery. Angiography visualized blocking and encasement at the ileal artery. Therefore he was diagnosed as malignant tumor arising from the mesentery. Tumor extirpation combined with partial resection of the ileum by 35cm in length and urinary bladder was performed on October 3, 1997. Histopathological diagnosis was MFH of ordinary type. He was discharged from the hospital after chemotherapy with cyclophosphamide, Adriamycin and DTIC (CDA therapy). There have been no signs of local recurrence and metastasis as of 11 months after the operation. We think that Ferritin is a usefull tumor marker.

症例は73歳男性である. 1994年2月14日, 突然背部痛が出現し, 近医にて急性大動脈解離IIIbと診断され, 降圧療法を開始された. 1995年6月7日腹部に拍動性腫瘤を自覚し, 圧痛が生じるため切迫破裂として入院となった. 入院時腹部には10×10cmの拍動性腫瘤があり, 圧痛が認められた. 血液検査にて血小板数, フィブリノゲンの低下, FDPの上昇を認め, 消費性凝固障害が疑われた. CTにより腹部大動脈の解離と多発性真性腸骨動脈瘤が判明した. 薬物療法では消費性凝固障害が正常化しないため手術適応とした. 術前に heparin の薬効を確認し, 術中に使用した. 手術所見では腹部大動脈終末部には交通孔があり, 解離腔には赤色血栓が存在していたが真性総腸骨動脈瘤内には赤色血栓はなかった. Y型人工血管で腎動脈下腹部大動脈から両側外腸骨動脈を置換し, 両側真性内腸骨動脈瘤は末梢側で結紮した. 術後は薬物療法することなく消費性凝固障害は軽快した.

BACKGROUND Magnetic resonance imaging (MRI) during surgery has been shown to improve surgical outcomes, but the current intraoperative MRI systems are too large to install in standard operating suites. Although 1 compact system is available, its imaging quality is not ideal. OBJECTIVE We developed a new compact intraoperative MRI system and evaluated its use for safety and efficacy. METHODS This new system has a magnetic gantry: a permanent magnet of 0.23 T and an interpolar distance of 32 cm. The gantry system weighs 2.8 tons and the 5-G line is within the circle of 2.6 m. We created a new field-of-view head coil and a canopy-style radiofrequency shield for this system. A clinical trial was initiated, and the system has been used in 44 patients. RESULTS This system is significantly smaller than previous intraoperative MRI systems. High-quality T2 images could discriminate tumor from normal brain tissue and identify anatomic landmarks for accurate surgery. The average imaging time was 45.5 minutes, and no clinical complications or MRI system failures occurred. Floating organisms or particles were minimal (1/200 L maximum). CONCLUSION This intraoperative, compact, low-magnetic-field MRI system can be installed in standard operating suites to provide relatively high-quality images without sacrificing safety. We believe that such a system facilitates the introduction of the intraoperative MRI.