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Objective: Facet articular irregularity is associated with rapidly progressive degenerative cervical myelopathy (DCM). However, its significance compared with other known risk factors remains unknown. Therefore, this retrospective study aimed to clarify the potential impact of facet articular irregularity as a risk factor for rapid DCM progression.Methods: This study included 141 consecutive patients with DCM who underwent surgical treatment at our institution. Clinical variables and radiological findings related to DCM progression were collected. Imaging findings were analyzed at the segmental level of myelopathy in each case. The patients were divided into 2 groups based on the presence or absence of rapid DCM progression, and independent risk factors were determined using logistic regression analyses.Results: Overall, 131 patients with a mean age of 63.9 ± 12.6 years were analyzed; 27 patients (20.6%) were classified into the rapid DCM progression group. The mean age was significantly higher in the rapid progression group than in the slow progression group (72.4 ± 9.6 vs. 61.7 ± 12.4, p < 0.001). According to univariate analysis, facet articular irregularity, dynamic segmental translation (≥ 1.6 mm), upper cervical spine involvement above C4–5, history of cerebrovascular events, preceding minor trauma, local lordotic angle (≥ 4.5°), diabetes, hypertension, ligamentum flavum hypertrophy, and age were independent risk factors. Additionally, multivariate analysis showed that facet articular irregularity was the highest risk factor for rapid DCM progression (p = 0.001).Conclusion: Facet articular irregularity is the most clinically significant finding among the known risk factors in patients with rapid DCM progression.

Closure of the ventral dura mater of the thoracic spinal cord is challenging because it requires both avoiding spinal cord damage and obtaining sufficient working space in an anatomically narrow area. We report a case of superficial siderosis (SS) due to chronic bleeding from a thoracic ventral dural defect in which we preformed dural repair using as a simple sutureless method and obtained good results.A 75-year-old man complained of slowly progressive gait, speech, and hearing disturbances over 5 years. Magnetic resonance imaging (MRI) showed SS in the brain and the spinal cord and a dural defect ventral to the spinal cord at the T2 level. Neurological examination revealed bilateral cerebellar ataxia and mild motor weakness in left iliopsoas muscle. T2 and T3 hemi-laminectomy was performed in the prone position. Transdurally, a dural defect on the ventral side of the spinal cord and a fluid-filled space beyond it could be observed. With endoscopic assistance, a blood clot in the space was confirmed. For dural closure, we performed a simple manipulation using a collagen-based dural graft. The graft was cut into pieces, softened with saline, and simply packed into the space with minimal strain on the spinal cord despite the narrow space. The postoperative clinical course was uneventful. Postoperative MRI at 1 year showed the space had disappeared.In patients with SS, sutureless dural closure using a collagen-based dural graft allows for effective, minimally invasive dural closure, even for thoracic ventral lesions.

Carotid near occlusions show a lower risk of stroke than other types of severe stenosis. However, emerging evidence suggests that near occlusion with full collapse differs from that without full collapse. The results of treatment with carotid artery stenting for near occlusion with full collapse are presented.Between March 2007 and December 2020, 18 of 477 carotid artery stenting procedures were performed in patients with near occlusion with full collapse (3.8%). A total of 17 men and one woman with a mean age of 76.1 years were included. Eleven patients (61%) were symptomatic. The technical success rate, incidence of symptomatic stroke within 30 days, new ipsilateral ischemic lesions on diffusion tensor imaging within 48 hours after carotid artery stenting, and follow-up results (ipsilateral stroke rate and restenosis rate) were retrospectively assessed.The technical success rate was 100%. All carotid artery stenting procedures were performed using embolic protection devices. No symptomatic stroke occurred within 30 days. New ipsilateral ischemic lesions on magnetic resonance imaging were observed in 16.7% (3/18) of patients. Asymptomatic minor cerebral hemorrhage occurred in 2 patients (11.1%) with cerebral hyperperfusion syndrome. The median follow-up period was 77 months. Asymptomatic restenosis of 50% occurred in one patient (5.5%), and asymptomatic occlusion occurred in one patient (5.5%). During follow-up, no patients experienced ipsilateral stroke. Three patients (16.7%) died from nonneurological causes.Carotid artery stenting for near occlusion with full collapse seems to be a feasible and safe procedure that can be performed by an experienced neuro-interventional team.

Objective: To evaluate cervical facet joint degeneration using a newly developed classification, investigate its prevalence and relationship with cervical degenerative spondylolisthesis, and clarify its clinical significance in patients with degenerative cervical myelopathy (DCM).Methods: This study included 145 consecutive patients with DCM who underwent surgical treatment. Clinical variables and radiological findings were analyzed. A new 6-grade computed tomography (CT) classification for cervical facet joint degeneration was adapted, and its prevalence was evaluated by categorizing the joints into those at responsible and those at nonresponsible spinal segmental levels. We evaluated the association between rapidly progressive myelopathy and the presence of significant facet joint degeneration or spondylolisthesis at the responsible segmental level.Results: Finally, 140 patients with a mean age of 64.1 ± 12.8 years were analyzed. The prevalence of grade 1, 2, 3, 4, 5A, and 5B classification in all facet joints was 72.0%, 9.5%, 10.9%, 4.3%, 2.9%, and 0.4%, respectively. There was a statistically significant difference in the distribution of CT grades between the joints at the responsible and nonresponsible segmental levels (p < 0.001), with a high prevalence of grade 4 or 5B degeneration at the responsible segmental level, reflecting articular irregularity. There was also a statistically significant relationship between rapidly progressive myelopathy and grade 4 or 5B degeneration at the responsible segmental level (p < 0.001), but not between rapidly progressive myelopathy and spondylolisthesis (p = 0.255).Conclusion: This novel CT classification for facet joints deserves additional evaluation in patients with DCM. Abnormal findings on the articular surfaces might be related to the progression of myelopathy.

To evaluate the safety profile of bis-chloroethyl-nitrosourea (BCNU) wafer implantation after malignant glioma resection with or without ventricular opening (VO).This single-center retrospective study included 66 consecutive patients with BCNU wafer implantation after malignant glioma resection between March 2013 and August 2021. The patients were categorized into two groups based on whether VO occurred during the malignant glioma resection. Fifty-eight patients had glioblastoma, and eight had anaplastic astrocytoma or oligodendroglioma. Forty-eight patients underwent an initial treatment, and 18 underwent recurrent surgeries. Infection, hydrocephalus, subcutaneous fluid collection, chronic subdural hematoma, early seizure after surgery within one month, symptomatic edema surrounding the resected cavity, cyst formation, and postoperative hemorrhage were defined as adverse events (AEs).Thirty-three patients underwent resection with VO, and 33 without. The median survival time was 28 months in the initial treatment group and 11.5 months in the recurrent treatment group. The with and without VO groups had similar median survival times. Postoperative AEs occurred in 7/33 patients (21.2%) with VO and 10/33 (30.3%) without VO, with no difference between them (p = 0.574).This study showed that VO during surgery with BCNU wafer implantation might not influence the occurrence of postoperative AEs. If VO happens, BCNU wafer implantation can be performed safely with accurate closing of the ventricle.

The preoperative assessment of cerebral veins is important to avoid unexpected cerebral venous infarction in the neurosurgical setting. However, information is particularly limited regarding deep Sylvian veins, which occasionally disturb surgical procedures for cerebral anterior circulation aneurysms. The predictability of detecting deep Sylvian veins and their tributaries using a modern multimodal fusion image was aimed to be evaluated. Moreover, 51 patients who underwent microsurgery for unruptured cerebral aneurysms with Sylvian fissure dissection were retrospectively reviewed. The visualization of the four components of the deep Sylvian veins in conventional computed tomography (CT) venography and multimodal fusion images was evaluated. To compare the detection accuracy among these radiological images, the sensitivity and specificity for the detection of each of the four venous structures were calculated in comparison with those of intraoperative inspections. The kappa coefficients were also measured and the inter-rater agreement for each venous structure in each radiological image was examined. In all veins, the multimodal fusion image exhibited a high detection rate without statistical difference from intraoperative inspections (P = 1.0). However, CT venography exhibited a low detection rate with a significant difference from intraoperative inspections in the common vertical trunk (P = 0.006) and attached vein (P = 0.008). The kappa coefficients of the fusion image ranged from 0.73 to 0.91 and were superior to those of CT venography for all venous structures. This is the first report to indicate the usefulness of a multimodal fusion image in evaluating deep Sylvian veins, especially for the detection of nontypical, relatively small veins with large individual variability.

Each year, the Japan Neurosurgical Society (JNS) reports up-to-date statistics from the Japan Neurosurgical Database regarding case volume, patient demographics, and in-hospital outcomes of the overall cohort and neurosurgical subgroup according to the major classifications of main diagnosis. We hereby report patient demographics, in-hospital mortality, length of hospital stay, purpose of admission, number of medical management, direct surgery, endovascular treatment, and radiosurgery of the patients based on the major classifications and/or main diagnosis registered in 2018 and 2019 in the overall cohort (523283 and 571143 patients, respectively) and neurosurgical subgroup (177184 and 191595 patients, respectively). The patient demographics, disease severity, proportion of purpose of admission (e.g., operation, 33.9-33.5%) and emergent admission (68.4-67.8%), and in-hospital mortality (e.g., cerebrovascular diseases, 6.3-6.5%; brain tumor, 3.1-3%; and neurotrauma, 4.3%) in the overall cohort were comparable between 2018 and 2019. In total, 207783 and 225217 neurosurgical procedures were performed in the neurosurgical subgroup in 2018 and 2019, respectively, of which endovascular treatment comprised 19.1% and 20.3%, respectively. Neurosurgical management of chronic subdural hematoma (19.4-18.9%) and cerebral aneurysm (15.4-14.8%) was most common. Notably, the proportion of management of ischemic stroke/transient ischemic attack, including recombinant tissue plasminogen activator infusion and endovascular acute reperfusion therapy, increased from 7.5% in 2018 to 8.8% in 2019. The JNS statistical update represents a critical resource for the lay public, policy makers, media professionals, neurosurgeons, healthcare administrators, researchers, health advocates, and others seeking the best available data on neurosurgical practice.

Cranioplasty complications after decompressive craniectomy (DC) in infants are not fully recognized. We aimed to devise and assess the efficacy of a hinge and floating DC (HFDC) technique for treating infantile acute subdural hematoma. Five infants, aged 2-20 months, were included. Intracranial pressure was controlled below 20 mmHg, no additional surgery was required, and there was no incidence of surgical site infection or bone graft resorption.

Balloon test occlusion (BTO) is a useful examination for evaluating ischemic tolerance to internal carotid artery (ICA) occlusion. The aim of this study was to investigate the relationships between intraoperative motor evoked potential (MEP) monitoring and the results of preoperative BTO. Between 2013 and 2017, 32 patients undergoing surgery under general anesthesia with intraoperative MEP monitoring, in whom preoperative BTO was performed, were identified. A receiver operator characteristic (ROC) analysis was performed to determine the appropriate cutoff value of MEP amplitude for BTO-positive. Furthermore, the accuracy of MEP monitoring for BTO-positive was compared with electroencephalogram (EEG) and somatosensory evoked potential (SEP) monitoring. Four of 32 (12.5%) patients were BTO-positive. The cutoff value of MEP amplitude for BTO-positive was a > 80% reduction from the baseline level, which showed sensitivity of 100% and specificity of 100%. Thus, the sensitivity and specificity for BTO-positive were significantly higher for MEP than for EEG (100% and 72.0%, p = 0.02) in 28 patients, but they were not significantly different compared with SEP (33.3% and 100%, p = 0.48) in 21 patients. MEP monitoring might be one of the alternatives for evaluating ischemic tolerance to ICA occlusion during surgery. The cutoff value of MEP amplitude was a > 80% reduction.

The present study aimed to determine the incidence of intraprocedural motor-evoked potential (MEP) changes and to correlate them with intraprocedural ischemic complications and postprocedural neurological deficits in patients after endovascular intracranial aneurysm treatment. This study analyzed data from 164 consecutive patients who underwent endovascular coil embolization to treat intracranial aneurysms under transcranial MEP monitoring. We analyzed associations between significant changes in MEP defined as > 50% decrease in amplitude, and intraprocedural complications as well as postoperative neurological deficits. Factors associated with postprocedural neurological deficits were also assessed. The treated aneurysms were predominantly located in the anterior circulation (71%). Fourteen (9%) were located at perforators or branches that supplied the pyramidal tract. Intraprocedural complications developed in eight (5%) patients, and four of eight (50%) patients occurred postprocedural neurological deficits. Significant intraprocedural MEP changes occurred during seven of eight endovascular procedures associated with intraprocedural complications and salvage procedures were performed immediately. Among these changes, four transient MEP changes, recovered within 10 min, were not associated with postprocedural neurological deficits, whereas three permanent MEP changes were associated with postprocedural neurological deficits and mRS ≥ 1 at discharge. Aneurysms located at perforators/branches supplying the pyramidal tract, and permanent intraprocedural MEP changes were associated with postprocedural neurological deficits. We conclude that intraprocedural transcranial MEP monitoring can reliably identify ischemic changes and can initiate prompt salvage procedures during endovascular aneurysm treatment.

We describe a rare case of extradural schwannoma in the upper cervical spine compressing the dominant internal jugular vein (IJV) presenting with atypical headaches. A 50-year-old woman complained of a subcutaneous neck mass associated with atypical headaches. Radiological examinations revealed the right IJV was compressed anteriorly by C2 extradural mass and occluded with markedly dilated collateral cerebral venous drainage through deep cervical veins. Subtotal removal was performed via the posterolateral approach and the atypical headaches resolved immediately. This case demonstrates that extradural schwannoma in the upper cervical spine could compress the IJV and manifest as cerebral venous circulation disturbances.

Acute basilar artery occlusion (BAO) is associated with major morbidities and a high mortality rate. The prevalence of acute BAO is 10.4% among patients treated with thrombectomy for acute large vessel occlusion. Vertebral artery stump syndrome (VASS) reportedly causes ischemic stroke with tandem occlusions as vertebral artery (VA) origin occlusion and BAO. The pathogenesis of ischemic stroke due to VASS can be attributed to thrombi or emboli. Acute embolic BAO due to VASS accounted for 2 of 25 cases (8.0%) of BAO treated using thrombectomy between April 2014 and May 2019 in our registry. VASS must be considered as one cause of BAO. With the initial Magnetic resonance angiography on arrival, it is difficult to distinguish between BAO due to simple cardiogenic embolus and due to embolus caused by VASS rapidly. In patients suffering from acute embolic BAO due to VASS, the presence of VA origin occlusion makes endovascular therapy (EVT) difficult to perform. Here, we report consecutive cases of thrombectomy for acute embolic BAO due to VASS, showing markedly different outcomes. VA origin occlusion severely limits the technical options for EVT. Visualization or conjecture of the origin of both or dominant VAs conceivably offers the possibility of successful EVT and may allow good outcomes.

Background Overshunting-associated myelopathy (OSAM) is a rare complication of cerebrospinal fluid shunt placement. Previous reports have recommended removal or ligation of the shunt and use or revision of a pressure programmable valve to treat OSAM. We present a rare case of OSAM successfully treated with endoscopic third ventriculostomy (ETV). Case Description A 67-year-old female who had undergone ventriculoperitoneal shunting with a constant pressure valve for long-standing overt ventriculomegaly in adults 42 years ago presented to our department with bilateral hand numbness. Magnetic resonance imaging of the cervical spine showed spinal canal stenosis and dilatation of the paravertebral venous plexus with spinal cord compression. Cervical laminoplasty was temporarily effective, but her symptoms reoccurred and worsened. ETV was performed, and a programmable shunt valve adjusted to maximum pressure was also interposed as a safety device. Her symptoms immediately improved after this operation. Cervical magnetic resonance imaging and computed tomography showed that the cervical paravertebral venous dilatation had also resolved immediately. Clinical improvement was maintained with no recurrence of hydrocephalus or paravertebral venous dilatation for 2 years postoperatively. Conclusions This is the first case of OSAM treated with ETV. ETV might be a useful treatment option for OSAM after treatment for obstructive hydrocephalus.

BackgroundPeriprocedural lipid core plaque (LCP) has been detected in carotid arteries assessed by catheter-based near-infrared spectroscopy (NIRS). High LCP is associated with cerebral embolism after carotid artery stenting (CAS) using a first-generation stent. We aimed to evaluate whether dual-layered stents reduce embolic infarcts in patients with high LCP and change of lipid signal as assessed by NIRS during CAS.MethodsParticipants comprised 210 consecutive patients undergoing CAS. The study was divided into two distinct periods, with first-generation closed-cell stents used in the earlier period and dual-layered stents used in the later period. NIRS was performed at baseline, after stent implantation, and after balloon post-dilatation to analyze maximal lipid core burden index at minimal luminal area (max-LCBIMLA).ResultsThe ipsilateral cerebral embolism rate was significantly lower with dual-layered stents (9%) than with first-generation stents (33%, pMLAdecreased significantly after stenting in both groups (both pMLAafter balloon post-dilatation was significantly lower with dual-layered stents (22.4±65.6) than with first-generation stents (124.2±208.2; p=0.006).ConclusionsDual-layered stents reduce embolic infarcts in patients with highly lipidic plaque lesions as assessed by NIRS who undergo CAS. Dual-layered stents significantly reduced NIRS-derived lipid signals after stenting.

Background: Superselective shunt occlusion (SSSO) for cavernous sinus dural arteriovenous fistula (CSDAVF) avoids the risk of cranial nerve palsy, unlike entire sinus packing, but requires paying attention to recurrence. Distinguishing between true and paradoxical worsening of postoperative ophthalmic symptoms using a less-invasive modality is often difficult. Here, we report a case of true worsening of neuro-ophthalmic symptom by recurrent CSDAVF detected by venous-arterial spin labeling (ASL) on magnetic resonance imaging. Case Description: A 55-year-old woman with neither contributory medical history nor previous head trauma presented with neuro-ophthalmic symptoms and pulsatile tinnitus. Digital subtraction angiography (DSA) revealed CSDAVF with multiple shunted pouches. She underwent successful transvenous SSSO, but neuroophthalmic symptom worsened after SSSO and venous-ASL revealed increased signal intensity in the right superior orbital vein (SOV). DSA confirmed recurrent CSDAVF and additional transvenous embolization was performed. Neuro-ophthalmic symptoms and venous-ASL hyperintensity on SOV improved postoperatively. Conclusion: Venous-ASL is noninvasive and seems useful for detecting true worsening of neuro-ophthalmic symptoms of recurrent CSDAVF.

Objective To evaluate the safety profile of bis-chloroethyl-nitrosourea (BCNU) wafer implantation after malignant glioma resection with or without ventricular opening (VO). Methods This single-center retrospective study included 61 consecutive patients with BCNU wafer implantation after malignant glioma resection between March 2013 and April 2021. The patients were categorized into two groups based on whether VO occurred during the malignant glioma resection. Fifty-three patients had glioblastoma, and eight had anaplastic astrocytoma or oligodendroglioma. Forty-five patients underwent an initial treatment, and 16 underwent recurrent surgeries. Symptomatic edema, newly occurring seizures within one month of the surgery, wound infection, brain abscess, hydrocephalus, cerebrospinal fluid leak, postoperative hemorrhage, and cyst formation were defined as adverse events (AEs). Results Twenty-nine patients underwent resection with VO, and 32 without. The median survival time was 28 months in the initial treatment group and 11.5 months in the recurrent treatment group. The with and without VO groups had similar median survival times. Postoperative AEs occurred in 7/29 patients (24.1%) with VO and 11/32 (34.4%) without VO, with no difference between them (p = 0.414). Conclusions This study showed that VO during surgery with BCNU wafer implantation might not influence the occurrence of postoperative AEs. If VO happens, BCNU wafer implantation can be performed safely with accurate closing of the ventricle.

Background: Large and giant aneurysms are known to involve intra-aneurysmal thrombosis and present a poor prognosis because of compression of the surrounding brain tissue with enlargement of the aneurysm. These aneurysms are difficult to cure by endovascular treatment due to involvement of the vasa vasorum in their pathology. We report this technical note to describe stent-assisted jam-packed coil embolization for the treatment of a giant thrombosed aneurysm. Case Description: A 62-year-old man presented with right homonymous hemianopsia, and magnetic resonance imaging (MRI) showed a giant thrombosed aneurysm with poor wall contrast enhancement, which indicates little involvement of the vasa vasorum, at the terminal part of the left internal carotid artery. To block blood flow into the aneurysmal dome, stent-assisted “jam-packed” coil embolization was performed. For this, a braided stent was shortened to enhance metal coverage ratio and tight aneurysmal coil packing was performed using a hydrogel coil. Our technique resulted in complete obliteration of the aneurysm, and MRI performed 1 year later showed remarkable shrinkage of the aneurysm dome. Conclusion: Stent-assisted jam-packed coil embolization technique might be effective in shrinking the dome of giant thrombosed aneurysms with poor wall contrast enhancement.

Background To assess the neuroimaging and clinical outcomes in patients with brainstem metastasis (BSM) treated with linac-based fractionated stereotactic radiotherapy (fSRT) with a micro-multileaf collimator. Methods Between May 2007 and January 2017, 24 patients (15 male and 9 female) with BSM (25 lesions: midbrain, 10; pons, 13; and medulla oblongata, 2) were consecutively treated with linac-based fSRT. BSM originated from the lung (n = 18, 75.0%), colon (n = 3, 12.5%), and breast (n = 3, 12.5%). The median patient age was 67.0 (range: 42–80) years. Recursive partition analysis classified 2 patients as class I, 17 as class II, and 5 as class III. Overall survival was calculated using the Kaplan–Meier method. Results Tumor volume ranged from 0.01 to 7.49 cm3 (median: 0.233 cm3), and patients were treated with a dose of 24–40 Gy in 7–13 fractions. The median OS was 9 months after fSRT (95% confidence interval 4.104–13.896). Large tumor volume, presence of brainstem-related symptoms, poor pretreatment Karnofsky performance status, and recursive partition analysis class III were significantly associated with low overall survival. Tumor volume decreased in 18 metastatic lesions, remained stable in 6, and increased in 1. No patient exhibited permanent radiation injury. Grade 2 nausea and vomiting according to the Common Terminology Criteria for Adverse Events 4.0 occurred in 1 patient who received corticosteroids. Conclusions Linac-based fSRT with a micro-multileaf collimator delivered in the doses of 24–40 Gy in 7–13 fractions is a safe and effective local therapy for patients with BSM.

Ruptured blood-blister aneurysms (RBBAs) of the intracranial internal carotid artery (ICA) are associated with high morbidity and mortality. RBBA has been treated with trapping with high-flow bypass avoiding manipulation of RBBA. In case of the presence of persistent primitive trigeminal artery (PPTA), it is necessary to preserve the antegrade blood flow of PPTA because avoiding ischemic complications. Here, we present a case of RBBA concomitant with ipsilateral PPTA successfully treated with multistaged overlapping braided stents maintaining PPTA flow. A 30-year-old woman suffered from headache and was diagnosed RBBA of the intracranial ICA concomitant with ipsilateral PPTA. A reconstructive endovascular treatment using low-profile visualized intraluminal support (LVIS) stent was performed. However, it has recurred, and RBBA has finally been occluded after overlapping LVIS stents with coil sandwich that is not yet reported in the literature. We report the first case of overlapping LVIS stents with coil sandwich for RBBA.

Background With the recent advances in endovascular treatment devices, it has become standard in wide-neck or large intracranial aneurysms to perform coil embolization with adjunctive techniques. However, device-related perioperative complications have been reported because of the use of more complex systems. Objective To investigate patients who developed multiple parenchymal lesions after undergoing coil embolization for treating an unruptured intracranial aneurysm. Methods This study investigated 305 consecutive patients who underwent coil embolization of unruptured intracranial aneurysms between 2015 and 2017. Delayed inflammatory changes referred to the delayed observation of multiple cerebral white matter lesions on follow-up magnetic resonance imaging at an area corresponding to the perfused area of the treatment target vessel. The timing and pattern of onset, device used, the combined use of adjunctive techniques, and the clinical course after steroid treatment were retrospectively investigated. Results The 7 patients (2.3%) who showed delayed inflammatory changes were all women with a mean age of 59 yr. A mean duration from treatment to onset was 28 d. Symptoms were convulsions in 3 patients, hemiplegia in 2 patients, and homonymous hemianopia in 1 patient. All 7 patients were treated with adjunctive technique including stents, double catheter method, and balloon assist. Response to steroid treatment was satisfactory both clinically and on imaging in all 7 patients. Skin patch test was positive for nickel allergy in 2 patients. Conclusion Clinicians must be fully aware of symptomatic delayed inflammatory changes may occur after endovascular aneurysmal treatment with the use of various devices.

Background Medullary infarction (MI) occasionally occurs after treatment of ruptured vertebral artery dissection (VAD). The aim of this study was to validate whether flow reduction for ruptured unilateral VAD by proximal clipping prevents rebleeding and MI in comparison with trapping. Methods Thirty-one patients who underwent direct surgery or endovascular procedures for unilateral ruptured VAD and postoperative magnetic resonance imaging (MRI), including 9 patients treated with trapping and 22 patients treated with proximal clipping, were enrolled. For posterior inferior cerebellar artery (PICA)–involved type VAD, occipital artery to PICA anastomosis was added as needed to isolate the rupture point. The rate of rebleeding and the occurrence of MI on MRI were compared between the 2 groups. Results There was no rebleeding after treatment in all 31 patients. However, 5 patients had MI on postoperative MRI (16.1%, κ = 0.903). In 5 of the 9 patients treated with trapping, MI was seen on MRI after treatment (55.6%). On the other hand, 0 of the 22 patients treated with proximal clipping developed MI (P Conclusions Appropriate flow reduction for ruptured unilateral VAD by proximal clipping is thought to be effective for preventing rebleeding and avoiding MI.

Objective To study clinical significance of augmentation of intraoperative motor evoked potentials (MEPs) during direct open surgery for middle cerebral artery (MCA) aneurysms. Methods Between 2009 and 2017, 134 MCA aneurysm surgeries were performed with intraoperative MEP monitoring. The frequency and cause of augmentation with >50% increase of MEP amplitude from baseline were studied. Factors associated with MEP augmentation were investigated. Results MEP augmentation was demonstrated in 9 patients. All 9 events were observed just after application of the temporary clip to the parent artery. The ratio of the maximum amplitude to baseline was 2.6 ± 1.1 at an mean of 2.4 ± 1.1 minutes after parent artery occlusion. Ten patients who did not show MEP augmentation after parent artery occlusion were compared with the patients showing MEP augmentation. The distance of the temporary clip point from the midline was smaller in patients with MEP augmentation compared with patients without MEP augmentation (P = 0.033). Conclusions MEP augmentation was thought to be an early ischemic sign preceding a significant decrease in MEPs during MCA aneurysm surgery. Transient augmentation of MEPs was more frequently observed in cases with a temporary clip applied to the more proximal part of the MCA.

OBJECTIVELumbar spinal drainage (LSD) during neurosurgery can have an important effect by facilitating a smooth procedure when needed. However, LSD is quite invasive, and the pathology of brain herniation associated with LSD has become known recently. The objective of this study was to determine the risk of postoperative brain herniation after craniotomy with LSD in neurosurgery overall.METHODSIncluded were 239 patients who underwent craniotomy with LSD for various types of neurological diseases between January 2007 and December 2016. The authors performed propensity score matching to establish a proper control group taken from among 1424 patients who underwent craniotomy and met the inclusion criteria during the same period. The incidences of postoperative brain herniation between the patients who underwent craniotomy with LSD (group A, n = 239) and the matched patients who underwent craniotomy without LSD (group B, n = 239) were compared.RESULTSBrain herniation was observed in 24 patients in group A and 8 patients in group B (OR 3.21, 95% CI 1.36–8.46, p = 0.005), but the rate of favorable outcomes was higher in group A (OR 1.79, 95% CI 1.18–2.76, p = 0.005). Of the 24 patients, 18 had uncal herniation, 5 had central herniation, and 1 had uncal and subfalcine herniation; 8 patients with other than subarachnoid hemorrhage were included. Significant differences in the rates of deep approach (OR 5.12, 95% CI 1.8–14.5, p = 0.002) and temporal craniotomy (OR 10.2, 95% CI 2.3–44.8, p = 0.002) were found between the 2 subgroups (those with and those without herniation) in group A. In 5 patients, brain herniation proceeded even after external decompression (ED). Cox regression analysis revealed that the risk of brain herniation related to LSD increased with ED (hazard ratio 3.326, 95% CI 1.491–7.422, p < 0.001). Among all 1424 patients, ED resulted in progression or deterioration of brain herniation more frequently in those who underwent LSD than it did in those who did not undergo LSD (OR 9.127, 95% CI 1.82–62.1, p = 0.004).CONCLUSIONSBrain herniation downward to the tentorial hiatus is more likely to occur after craniotomy with LSD than after craniotomy without LSD. Using a deep approach and craniotomy involving the temporal areas are risk factors for brain herniation related to LSD. Additional ED would aggravate brain herniation after LSD. The risk of brain herniation after placement of a lumbar spinal drain during neurosurgery must be considered even when LSD is essential.

Background Cerebral venous sinus thrombosis (CVST) is a relatively uncommon cause of stroke in pediatric patients and young adults. The clinical course of CVST is also highly variable. In particular, coma has been noted as a predictor of poor outcome. The standard treatment for CVST in adults is systemic anticoagulation, which can lead to recanalization. Endovascular mechanical thrombectomy (EMT) is considered as possibly indicated in the event of failure to respond to anticoagulation or a comatose state. However, the role of endovascular therapy in the management of pediatric and young adult CVST is unclear. Here, we describe 3 cases of successful emergent EMT for pediatric and young adult CVST presenting in a comatose state. Case Description A 17-year-old boy presented with rapid deterioration and a comatose state despite anticoagulation using heparin. Emergent EMT was performed for CVST. Balloon percutaneous transmural angioplasty and catheter aspiration were repeatedly performed, and partial recanalization of the superior sagittal sinus was achieved by the end of the procedure. The child was discharged without neurologic deficits. Another 2 comatose cases with CVST underwent emergent EMT with balloon percutaneous transmural angioplasty and catheter aspiration, and partial recanalization was again achieved. These patients finally showed complete superior sagittal sinus recanalization and were discharged without neurologic deficits. Conclusion Pediatric and young comatose CVST warrants endovascular mechanical thrombectomy as soon as possible.

Various guidelines regarding surgical site infection (SSI) have recently been established. However, perioperative management of the wound and use of antibiotics have never been standardized completely in departments of neurosurgery in Japan. This survey investigated current perioperative management and administration of surgical antibiotic prophylaxis (SAP) and compared with guidelines intended to reduce SSI associated with neurosurgery in Japan. Questionnaires were distributed to members of the conference on Neurosurgical Techniques and Tools and the Japan Society of Aesthetic Neurosurgery via internet. The questionnaires asked about methods of perioperative management. A total of 255 members returned answers to the questionnaires. The questionnaires revealed that partial or no removal of the hair and hair shampooing at the day before surgery were performed in 96.1% and 88.1% of each institute following the World Health Organization (WHO) guidelines. Use of SAP at just before, during, and after surgery were 65.0%, 86.2%, and 63.0%, respectively. The postoperative period of use of intravenous SAP prolonged beyond 24 h in 80.0% against the recommendation of WHO. Perioperative management of wounds and use of SAP varies in institutes in Japan and some procedures were far different from the WHO guidelines. Japanese neurosurgeons should notice the prolonged SAP and comply with the WHO guidelines.

The results of recent clinical and experimental studies suggest that the most important factor associated with the pathogenesis of dural arteriovenous fistula (AVF) is sinus thrombosis and subsequent venous or intrasinus hypertension. Here, we describe two patients who each developed a dural AVF after a posterior fossa craniotomy on the side of the nondominant or hypoplastic transverse (TS)-sigmoid (SS) sinuses. A 63-year-old female underwent surgical resection of a meningioma in the left cerebellopontine angle. Preoperative subtraction digital angiography (DSA) revealed a hypoplastic, ipsilateral left TS-SS and the sinus occlusion was revealed after surgery. Sixteen months later, she presented with a progressive left retroauricular, pulse-synchronous bruit. An AVF in the left TS-SS region was diagnosed by DSA and treated with transvenous coil embolization. The patient recovered without neurological deterioration. A 56-year-old female underwent surgical removal of an epidermoid tumor in the right cerebellopontine angle. Preoperative DSA revealed severe, ipsilateral right TS stenosis and the sinus occlusion was revealed after surgery. Two years later, she presented with the progressive right retroauricular, pulse-synchronous bruit, which was diagnosed by DSA as dural AVF in the right TS-SS region. She was treated with transvenous coil embolization and recovered without neurological deterioration. Sinus manipulation during intracranial surgery carries a potential risk of dural AVF development and this should be carefully considered, even when the ipsilateral TS-SS is nondominant or appears hypoplastic.

Background: Vertebral artery stump syndrome (VASS) involves repeated acute ischemic stroke (AIS) in the posterior circulation following vertebral artery (VA) orifice occlusion. The presence of VA orifice occlusion makes endovascular thrombectomy (EVT) difficult to achieve and leads to posterior circulation stroke with unfavorable functional outcomes. Here, we report a case of endovascular VA orifice angioplasty for the right VA pseudo-occlusion to prevent AIS following VASS pathology. Case Description: In a 76-year-old man presenting with dizziness, angiography revealed right pseudo-occluded VA at the origin concomitant with the left VA occlusion. The posterior circulation depended on the right VA through collateral flow to the distal portion. Prophylactic endovascular VA angioplasty for the right pseudo-occluded VA at the orifice was achieved to prevent AIS with tandem lesions. In the present case, endovascular VA angioplasty can prevent acute embolic stroke in the posterior circulation following EVT-resistant VASS pathology. Conclusion: Clinicians should be aware that EVT is not easy in AIS following VASS due to access difficulties and the treatment strategy should be carefully considered.

Background: Prosopagnosia is a rare form of apraxia, in which a person has normal memory and vision, but has impaired cognition of human faces that are manifested through symptoms such as not being able to recognize the face of a familiar person, one has known or not being able to remember the face of a person. Here, we report the case of a patient with transient prosopagnosia associated with brain metastasis from epidermal growth factor receptor (EGFR)-mutated lung adenocarcinoma who was treated with tyrosine kinase inhibitors (TKIs). Case Description: A 52-year-old right-handed man with lung adenocarcinoma was introduced to our department because brain metastasis. On admission, he complained that he could not recognize his wife’s face, but he could recall her face based on her voice. MRI revealed a right temporo-occipital enhancing lesion with perifocal edema and dissemination that were indicative of brain metastasis from lung adenocarcinoma. Two weeks after open biopsy, he was started on TKI therapy with osimertinib at a dosage of 80 mg/day. An MRI scan taken 1 month later revealed shrinkage of the metastasis. In addition, he had recovered from transient prosopagnosia and returned to normal life. Conclusion: In this study, the TKI osimertinib was administered to a patient with brain metastasis of EGFR-mutated lung adenocarcinoma who presented with prosopagnosia, and the patient’s lesion shrunk and his symptoms were reversed with this treatment.

A 45-year-old man suffered multiple cerebral infarctions in the vertebrobasilar artery territory, followed by second stroke against conservative treatment. Radiological examinations revealed intra-arterial defect in left persistent 1st intersegmental artery (PFIA) at C1 level, suggesting mural thrombus, and mechanical compression of left PFIA at the level with head rotation to the right clearly revealed by reconstructed 3-dimensional radiological images, but no findings of atlantoaxial instability. One month after the second stroke, posterior fixation was performed. Postoperative course was uneventful without subsequent stroke for 24 months. This unique case demonstrated that PFIA might associate with cerebral stroke as a clinical condition of bow hunter's stroke even in middle age. Reconstructed 3-dimensional radiological images might be useful for clear demonstration of the pathophysiology in this complex clinical entity.

Several basic experimental studies have demonstrated that statins have beneficial effects for intracranial aneurysm (IA). Clinical studies on unruptured IAs, however, remain limited to four retrospective studies that have reached different conclusions. This study was the first open-label, multicenter, randomized controlled trial to assess the preventive effects of atorvastatin. Patients with unruptured small saccular IAs were randomly assigned to statin and control groups. The primary endpoint was a composite of aneurysm growth of ≥0.5 mm, new bleb formation confirmed from magnetic resonance (MR) angiography, and rupture. Enrollment was prematurely terminated due to unexpectedly slow enrollment. Of 231 patients (275 target IAs), 110 patients (128 IAs) were randomly assigned to the statin group and 121 patients (147 IAs) to the control group. After excluding 22 dropout patients, 107 IAs in the 93 statin group patients and 140 IAs in the 116 control group patients were finally analyzed. No significant differences of basic characteristics were evident between groups, except for significantly higher systolic pressure in the statin group (P = 0.03). The primary endpoint occurred in 28 IAs (20.0%) in the control group and in 17 IAs (15.9%) in the statin group. No aneurysm rupture was confirmed in either group. Significant beneficial effects of statin for IAs were not demonstrated for the primary endpoint (log-rank P = 0.359). This randomized trial did not establish any preventive effects of atorvastatin for unruptured small IAs. Further studies of larger cohorts are required to clarify the efficacy of statins for patients with unruptured IAs. Clinical trial registration: UMIN000005135.

BackgroundIt is vital to identify a surrogate last-known-well time to perform proper endovascular thrombectomy in acute ischemic stroke; however, no established imaging biomarker can easily and quickly identify eligibility for endovascular thrombectomy and predict good clinical prognosis.ObjectiveTo investigate whether low relative diffusion-weighted imaging (DWI) signal intensity can be used as a predictor of good clinical outcome after endovascular thrombectomy in patients with acute ischemic stroke.MethodsWe retrospectively identified consecutive patients with acute ischemic stroke who were treated with endovascular thrombectomy within 24 hours of the last-known-well time and achieved successful recanalization (modified Thrombolysis in Cerebral Infarction score ≥2b). Relative DWI signal intensity was calculated as DWI signal intensity in the infarcted area divided by DWI signal intensity in the contralateral hemisphere. Good prognosis was defined as a modified Rankin Scale score of 0–2 at 90 days after stroke onset (good prognosis group).Results49 patients were included in the analysis. Relative DWI signal intensity was significantly lower in the group with good prognosis than in the those with poor prognosis (median (IQR) 1.32 (1.27–1.44) vs 1.56 (1.43–1.66); pConclusionsLow relative DWI signal intensity was associated with good prognosis after endovascular thrombectomy. Its ability to predict good clinical outcome shows potential for determining patient suitability for endovascular thrombectomy.

BackgroundPlatelet function tests have been increasingly adopted to measure patient responses to antiplatelet drugs, and to predict complications. However, no established optimal antiplatelet management for stent-assisted coil embolization (SAC) have been established. The purpose of the present study was to investigate the efficacy and feasibility of clopidogrel dose adjustment for active target P2Y12 reaction unit (PRU).MethodsA total of 202 consecutive patients undergoing SAC to treat unruptured intracranial aneurysms were prospectively recruited. All patients were given two antiplatelet agents starting 7 days prior to the procedure, and platelet function was measured with the VerifyNow test. Clopidogrel hyper-responsive patients received reduced dosing according to the values of follow-up PRUs before and 7, 14, 30, and 90 days after the procedure. Patients were divided into three groups according to clopidogrel responsiveness before treatment, and clinical outcomes and time in target PRU ranges (TTR) were analyzed.ResultsNo delayed ischemic or hemorrhagic events occurred that were associated with out-of-range PRU. PRU values in the hypo-responsive and hyper-responsive groups significantly improved 7 days after treatment with active target PRU management (p=0.05,ConclusionActive target PRU management can achieve control of optimal PRU values and may decrease perioperative ischemic and hemorrhagic events among patients undergoing SAC.