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Object. Although the spontaneous occurrence of an unruptured vertebral artery (VA) dissection has increasingly been recognized as a relatively common cause of stroke, and the clinical aspects of this lesion have gradually been determined, its natural course remains obscure. The main goal of this study was to clarify the management protocol for this condition by examining serial angiographic changes in patients with unruptured VA dissections.Methods. Seventeen patients with unruptured VA dissections, including 13 men and four women, were clinically and angiographically examined between 1993 and 1998. All patients were observed using serial angiography studies. The initial angiography examinations most frequently revealed stenotic lesions (appearance of a pearl-andstring sign or string sign) in eight (47.1%) of 17 cases. In 15 cases (88.2%), changes in the lesions were evident on follow-up angiography studies. Stenotic lesions resulted in occlusion in four cases, normalization in three, and subsequent formation of an aneurysm in one case, which was treated successfully by proximal occlusion of the affected vessel performed using a detachable balloon. Occluded lesions, which were initially observed in three patients, recanalized in two patients and remained unchanged in one patient. Fusiform dilation alone was demonstrated in three patients during the initial angiography session; these lesions became normalized or were unchanged on follow-up studies. Saccular aneurysms were observed in two patients. In one of these cases, proximal ligation of the parent artery was successfully performed because of subsequent aneurysm enlargement. A double lumen, which appeared in one patient with an extradural VA dissection, became occluded. Magnetic resonance T2-weighted imaging studies revealed infarction corresponding to the posterior circulation in seven cases. During long-term observation in this series, good or excellent recovery was obtained in 14 (87.5%) of 16 patients, and moderate or severe disability in two (12.5%); one patient was lost to follow up after the second angiography study.Conclusions. A follow-up angiography study must be performed during the early stage (within approximately 3 weeks after onset of symptoms) to confirm the formation or enlargement of an aneurysm, because such conditions may be amenable to surgical treatment. Unruptured VA dissection could otherwise be treated and followed conservatively. Although the majority of dissected lesions seem likely to stabilize within a few months, as evidenced on angiography, in some cases a longer observation period is required.

Background Encephalomyosynangiosis is one of the indirect method in which ischemic brain surface is covered by temporal muscle for the treatment of moyamoya disease. Case Descriptions A 14-year-old girl who had been treated with bilateral STA-MCA anastomosis and EMS in 1999 was admitted on January 5, 2005. She showed transient incomplete palsy on the left side of the face and the ipsilateral upper extremity. On the day of admission, MRIs/MRA and 3-dimensional regional CBF measurement using stable xenon and CT scanning were conducted after performance of plain CT scanning. The MRI and CT studies showed that ossified and hypertrophied temporal muscle used for EMS to the right MCA territory compressed the brain just under the muscle. MRA demonstrated well-developed collaterals to the territories of the bilateral MCAs via the previously performed anastomosis. The CBF studies disclosed a low CBF value just under ossified and hypertrophied muscle used for EMS on the right side. She showed same transient ischemic attacks repetitively after January 5, 2005. Conclusions The repetitive attacks with the transient motor palsy on her left side was thought to be caused by direct compression of the brain by the ossified and hypertrophied muscle used for EMS and decrease in CBF just under it, and its removal was thought to be the treatment of choices. However, the patient and her parents refused the surgical procedure, and she is treated conservatively at present.

BACKGROUND Acute subdural hematomas caused by meningiomas have been rarely encountered. Pathophysiologic mechanisms and clinical considerations in these patients have not been sufficiently explored. We addressed the possible mechanism of spontaneous hemorrhage in our case and briefly discuss the optimal treatment. CASE DESCRIPTION This case of falx meningioma presenting as an acute subdural hematoma in a 78-year-old woman is described. On initial computed tomography (CT), an enhancing tumor of the falx appeared to be the cause of hemorrhage. Only faint contrast staining in the periphery of the tumor was seen on right external carotid arteriograms, with no evidence of other vascular supply. Extravasation of contrast material during the procedure occurred suddenly and was successfully treated by endovascular embolization using a microcatheter. The hematoma was emergently evacuated with gross total removal of the tumor. Pathologic examination confirmed a transitional meningioma with abundant hyalinized structures. Disruption of a thin-walled vessel adjacent to the tumor capsule was assumed to be the site of hemorrhage. CONCLUSIONS The longstanding ischemia of the tumor was considered to have produced the deposition of hyalin in the tissue, which changed the hemodynamics within the tumor, producing vascular stress leading to rupture. The prognosis of patients with meningiomas complicated by acute subdural hematoma is generally poor, with mortality reported in approximately one-half of such patients. Surgical exploration is the most effective treatment and should be conducted before irreversible brain damage has occurred.

Carotid rete mirabile is a physiological vascular network between the external carotid and internal carotid systems present in some vertebrate species, but rarely observed in humans. We describe a 17-year-old girl with rete mirabile who presented with subarachnoid hemorrhage. Angiography disclosed the bilateral internal carotid arteries (ICAs) ended at the cavernous portion, and abnormal arterial networks visualized via the ICAs and the external carotid arteries in the paracavernous region. The distal ICAs were visualized via the abnormal arterial networks. After 18 years of follow-up she is leading a normal life without neurological problems. Rete mirabile in humans may present with hemorrhage or ischemic symptoms, but the prognosis appears to be good.

線維筋性異形成による脳虚血性疾患患者の浅側頭動脈-中大脳動脈吻合術の麻酔管理に観血的動脈ラインの代用としてトノメトリーと大腿動脈単回穿刺による採血を採用し良好に管理し得た症例を経験した.脳外科領域の麻酔管理において動脈ラインは有用だがトノメトリー,パルスオキシメトリ,カプノグラフなどの非観血的方法により代用できることも多く非侵襲的である恩恵が動脈ライン有用性を上回る場合もあり,またこれらの非侵襲的代用手段を選択しなければならないときもあると思われる.

BACKGROUND A new technique using intravascular ultrasound has been used for diagnosis of coronary artery in order to obtain intravascular echo images. In this study, an intracisternally positioned ultrasound catheter was introduced obtaining serial echo images of the first segment (M1) of the middle cerebral artery in order to detect cerebral vasospasm following subarachnoid hemorrhage (SAH). METHODS Thirteen patients were admitted to Osaka Neurological Institute with SAH due to ruptured intracranial aneurysm. All patients underwent surgical neck clipping on the day of admission. In each patient, an 8 Fr. ultrasound imaging catheter (Cardiovascular Imaging Systems, Inc. (CVIS), Sunnyvale, CA) was detained intracisternally adjacent to the Ml segment following neck clipping of the aneurysm and placement of cisternal drainage(s) in the prepontine and/or distal portion of the Sylvian fissure. In order to detain the mirror device near the M1 segment, the tip of a 2.0 cm cisternal drainage tube (SILASCON®, E-3L-12, Kaneka Medix Co, Osaka, Japan) was attached to the tip of the intravascular ultrasound catheter with 3-0 silk suture. The tip was placed in the prechiasmal cistern. RESULTS Angiographic evidence of delayed vasospasm was obtained for three (23.1%) of the 13 patients. In one (33.3%) of the three patients who had angiographic evidence of vasospasm (25% stenosis), decrease in the inner diameter of the M1 segment was detected on the echo images, but in the other two (66.7%), no such decrease was noted on echo images. Angiographically identified vasospasm in the latter patients was associated with only 10% stenosis. CONCLUSIONS Intracisternally positioned ultrasound catheter can be used for intermittent measurement of the diameter of a target artery for detection of cerebral vasospasm after SAH.

BACKGROUND Percutaneous transluminal angioplasty (PTA) and super-selective intra-arterial infusion of papaverine have recently been performed for the treatment of cerebral arterial vasospasm, with generally favorable results in patients with delayed symptomatic cerebral vasospasm. METHODS We used dynamic digital subtraction angiography (dynamic DSA) to measure local transit time before and after endovascular treatment (EVT) for the treatment of ruptured intracranial aneurysm and delayed symptomatic cerebral vasospasm. Mean transit time (MTT) was measured by dynamic DSA in 19 patients with ruptured intracranial aneurysm and delayed symptomatic cerebral vasospasm and 6 patients without symptomatic cerebral vasospasm (group III) just after surgery, immediately prior to EVT, just after EVT, and in the chronic stage of disease more than 1 month after onset of subarachnoid hemorrhage. EVT included PTA using a silicone nondetachable balloon and/or superselective infusion of 0.2% papaverine. RESULTS Symptomatic vasospasm occurred between days 7 and 11 after onset of subarachnoid hemorrhage. The MTT just after the onset of neurologic deterioration in these 10 patients with complete neurologic recovery during the chronic stage of disease (group I) and the other 9 patients without complete recovery (group II) were respectively 6.92 +/- 0.42 seconds and 7.66 +/- 0.78 seconds. The latter value was significantly larger than the former (p < 0.02). MTT just after EVT in group II were also significantly greater than the corresponding MTT in group I (p < 0.002). In addition, immediately prior to EVT the MTT in group I and group II was significantly longer than that in group III (p < 0.0001). CONCLUSIONS Functional analysis with dynamic DSA can be used to detect hemodynamic disturbances, and can be used for hemodynamic evaluation during the treatment of symptomatic cerebral vasospasm.

BACKGROUND Perimedullary arteriovenous fistulas (AVFs) are abnormal vascular connections between medullary arteries and veins without an intervening nidus. It is thought to be difficult to treat Type II AVFs which have multiple feeding branches. We performed intraoperative transvenous embolization to treat Type II AVFs. CASE REPORT A 30-year-old man with Type II perimedullary arteriovenous fistulas (AVFs), present at the level of the L-1 vertebral body, underwent surgical and endovascular treatment. The patient displayed slight motor weakness (4/5) and slight hypesthesia in the right lower extremity. Angiograms demonstrated that an anterior spinal artery and posterior spinal arteries were feeding arteries for the perimedullary AVFs. The patient underwent surgical occlusion of the fistulas three times. Fistulas present on the dorsal surface of the spinal cord were occluded with hemoclips, while those located on the ventral and ventolateral aspect of the spinal cord were occluded transvenously with isobuthyl-2-cyanoacrylate (IBCA) during surgery. Total occlusion of the perimedullary AVFs was achieved with these procedures, and no change was noted postsurgically in the patient's symptoms. CONCLUSIONS In summary, Type II perimedullary AVFs are sometimes difficult to treat using either embolization or open surgery. In such cases, both open surgery and intraoperative transvenous embolization should be performed in order to obtain occlusion of multiple fistulas.

An ultra-thin-walled 4-French catheter was used for angiography and as a guiding catheter for the Tracker-18 microcatheter in patients with intracranial dural arteriovenous fistulas (AVFs), spinal dural AVFs, spinal epidural AVF, meningioma, and acute embolic occlusion of major cerebral vessels. The 4-French guiding catheter was introduced through the transfemoral or transbrachial route. The guiding catheter and the guidewire were advanced to the aortic arch and then turned over just above the aortic valves, and finally the catheter was introduced into the external carotid artery or vertebral artery when the transbrachial approach was selected. Images of the intracranial vessels and spinal dural branches obtained were excellent in all cases. The Tracker-18 could smoothly be advanced to the target artery through the 4-French catheter in all patients. Endovascular treatment with the Tracker-18 can be performed using an ultra-thin 4-French guiding catheter, and safely via the transbrachial route.

This preliminary study investigated local hemodynamic changes in intramedullary spinal arteriovenous malformation (AVM) before and after embolization. 99mTcO4- was injected into the anterior spinal artery feeding the AVM via a Tracker-10 or MAGIC microcatheter. Time-dependent radioisotope images were sequentially obtained in the anteroposterior plane every 0.2 sec before and just after embolization. Local mean transit time (MTT) was then calculated for both the nidus and draining vein and compared before and after embolization. Prior to embolization, MTTs in the nidus and in the draining vein were 1.84 +/- 0.62 (mean +/- SD) and 2.80 +/- 0.69 sec for the five patients, respectively. MTTs in both the nidus and the draining vein were significantly prolonged after embolization to 3.32 +/- 1.14 and 4.90 +/- 0.93 sec, respectively (p < 0.02 and p < 0.005, respectively). In vivo measurements of local hemodynamic changes in the spinal cord during the treatment of spinal AVMs could be achieved. This method may allow investigation of the hemodynamic mechanisms which induce ischemic symptoms in patients with spinal AVM.

Moyamoya disease (MMD) is a rare cerebrovascular disease characterized by progressive occlusion of the terminal portion of the internal carotid arteries and their branches. A genetic background was under speculation, because of the high incidence of familial occurrence. Sibling cases usually exhibit a similar clinical course. Recently, RNF213 was identified as the first MMD susceptibility gene. The c.14576G>A variant of RNF213 significantly increases the MMD risk, with an odds ratio of 190.8. Furthermore, there is a strong association between clinical phenotype and the dosage of this variant. The present study described sibling MMD cases having homozygous and heterozygous c.14576G>A variant in RNF213, as well as different clinical course and disease severity. The homozygote of c.14576G>A variant showed an early onset age and rapid disease progress, which resulted in significant neurological deficits with severe and wide distribution of vasculopathy. In contrast, the heterozygote of the variant showed a relatively late-onset age and mild clinical course without irreversible brain lesions with limited distribution of vasculopathy. This is the first report of sibling MMD cases with different doses of the RNF213 variant, showing its genetic impact on clinical phenotype even in members with similar genetic background.

Preparation of a scalp artery as a donor is the first step in the procedure of direct anastomosis for the treatment of ischemic type moyamoya disease. In some cases, the scalp artery is not visualized well on cerebral angiograms. Another scalp artery must be used as a donor or it is interposed between the proximal portion of the firstly selected scalp artery and a branch of the middle cerebral artery in that condition. Skin incision should be planned to include multiple scalp arteries. On cerebral angiograms, in the present two cases, the diameter and length of branches of the STA was thought to be too small and short to anastomose, but direct anastomosis was successfully performed with a single STA branch. In conclusion, skin flap should include multiple scalp arteries prepared for interposition, and each branch of the scalp arteries should be carefully inspected intraoperatively to determine whether an angiographically small and short branch of the scalp can be used to anastomose.

A 37-year-old woman was admitted to Osaka Neurological Institute after the sudden onset of left hemiplegia, hemihypesthesia, and ipsilateral hemianopia on February 4, 1992. Computed tomography (CT) disclosed the presence of hemorrhage in the right thalamus extending to the ipsilateral internal capsule. Cerebral angiography after CT scanning disclosed the presence of a cerebral arteriovenous malformation (AVM) fed by copsulothalamic and lateral geniculate body arteries originating from the right anterior choroidal artery. She was operated on with removal of the AVM using a right orbito-fronto-malar approach (OFM approach), which did not require transection of the cerebral parenchyma. The anterior choroidal artery could be followed distally from its origin and small feeding branches originating from the parent artery were easily identified, and the cerebral base could be examined in greater detail than with the conventional frontotemporal approach. The nidus could be excised in its entirety without difficulty. Postoperative angiography confirmed total excision of the AVM. She was transferred to another hospital for rehabilitation on April 13, 1992. Motor strength on the left side had improved to 3 / 5 by that time. The OFM approach appears to be potentially useful for the resection of inferolateral thalamic AVMs, because it does not require corticotomy and feeding branches can be identified and dealt with prior to other surgical manipulations.

Serial measurements of local cerebral blood flow were obtained with inhalation of stable xenon and computed tomography prior to and during induced hypertension with continuous infusion of dopamine (7-15 micrograms/kg/min) in 34 patients who underwent surgery for treatment of subarachnoid hemorrhage due to ruptured intracranial aneurysm. Cerebral vasospasm was detected angiographically in all but one of the patients studied. Vasospasm was not symptomatic in 19 patients, but was in the other 15 patients. Disturbance of autoregulation was observed just after surgical operation. In the latter group, local cerebral blood flow in the territory of the middle cerebral artery and the corona radiata on the craniotomy side reached their lowest values, 25.1 +/- 6.8 mL/100 g/min and 15.7 +/- 1.8 mL/100 g/min, respectively, on days 10-14, and each subsequently increased significantly, to 34.3 +/- 7.3 mL/100 g/min and 19.9 +/- 2.0 mL/100 g/min, respectively, during induced hypertension. In conclusion, cortical dysfunction and motor palsy in the patients studied here were thought to be due to significant reduction in local cerebral blood flow in the cortical territories of the middle cerebral artery and corona radiata, respectively.

A 27-year-old man was admitted to our institution with the sudden development of right hemiparesis and dysarthria beginning an hour after the onset of symptoms on August 9, 1992. The patient was found on admission to have right hemiparesis ( 2 5 ) , hemihypesthesia, hemianopia, dysarthria; he had transient atrial fibrillation. No abnormalities were detected on computed tomography (CT) scans, and cerebral blood flow studies undertaken following conventional CT scans revealed no low flow regions in the left cerebral hemisphere. But cerebral angiography disclosed an occlusion of the left internal carotid artery with well-developed cross-circulation via the anterior communicating artery and embolus lodged at the level of the anterior choroidal artery. Superselective fibrinolysis using Tracker-18 and 420,000 units of urokinase resulting in complete recanalization of the left anterior choroidal artery without distal migration of the embolus. Immediately after the procedure, his neurologic disturbance underwent complete resolution. In summary, fibrinolysis could be performed but limited to anterior choroidal artery in a case with an occlusion of the internal carotid artery with well-developed cross-flow via the anterior communicating artery; the patient's neurologic condition may deteriorate suddenly if fibrinolysis is incomplete and the embolus migrates to the internal carotid artery.

Most ependymal cysts occur intracerebrally, with a few cases situated in the subarachnoid space. The cerebellopontine angle is a common site for arachnoid cysts, but a very rare site for ependymal cysts. A case is described here of a large ependymal cyst in the cerebellopontine angle. A 12-year-old girl with left hearing disturbance was admitted. CT and MRI revealed a cystic tumor in the left cerebellopontine angle. At operation, we obtained a discrete thin-walled cyst which had arisen from a continuation of the choroid plexus of the lateral foramen of Luschka, which had no connection with the arachnoid. The cyst proved to be an ependymal cyst.

A 76-year-old female presented with vertebrobasilar insufficiency due to a severe stenosis of the right primitive hypoglossal artery (an unusual carotid-basilar anastomosis) manifesting as recurrent transient ischemic attacks (TIA) associated with quadriparesis and cerebellar ataxia with vertigo, nausea, and vomiting. She had been treated with 100 mg of aspirin per day, but TIA associated with the same symptoms persisted. Cerebral blood flow (CBF) studies disclosed a region of moderately low flow in the posterior fossa. Cerebral angiography demonstrated that the posterior fossa was supplied via the right primitive hypoglossal artery, which was severely stenotic at its origin. Percutaneous transluminal angioplasty using a Stealth catheter, 3.0-mm diameter and 10-mm long, successfully dilated the stenosis. No TIA occurred postoperatively, and a marked increase in CBF was demonstrated in the posterior fossa.

A 40-year-old male, treated with radiotherapy and supraophthalmic intracarotid artery (ICA) ACNU infusion for glioblastoma in the right occipital lobe, developed cerebral infarction secondary to vasculopathy manifesting as hemiparesis 3 months after a second ICA injection. The initial diagnosis was focal neurotoxicity, but angiography revealed severe vasospasm of the anterior choroidal artery. The symptoms improved gradually with therapy for the vasospasm. Angiography is required to discriminate vasospasm and focal neurotoxicity as a complication of ICA injection of antineoplastic agents.

A lateral approach, consisting of a modified transversectomy, hemilaminectomy, and adequate transversectomy with costectomy of 7-8 cm, was used to treat four cases of anterior or anterolateral thoracic lesions, including two cases of thoracic disc herniations, one of thoracic meningioma, and one of hypertrophic pachymeningitis. All patients presented with gait disturbance, but recovered well postoperatively except for one who needed rehabilitation of the lower extremities. This approach provides a greater access to the anterior thoracic canal, and can achieve effective anterior decompression, and a good outcome for thoracic spinal disease if recognized early.

Twenty-three patients with epileptic type moyamoya disease are reviewed among 200 moyamoya disease patients. Ten boys and 13 girls aged 5 months to 12 years were followed over 6 months to 17.3 years. Six had generalized seizure and 17 had focal seizure. Operations were performed within 1 year in eight patients, within 1-3 years in five, and more than 3 years after onset in 10. Nineteen patients improved and suffered no seizure without receiving antiepileptic drugs, but four patients developed true epilepsy and three of these suffered cerebral infarction. Multivariate analyses showed that toddlers aged less than 1 year and mild or severe abnormal computed tomographic (CT) findings correlated with a bad outcome. This study showed that epileptic type moyamoya disease has the same clinical features as transient ischemic attack or infarction type. Age under 1 year and CT abnormalities indicate a poor prognosis and necessity for early reconstructive surgery.

Treatment for moyamoya disease includes direct and indirect anastomosis. During surgery, acute and massive brain swelling has been encountered infrequently just after opening of the dura mater, while mild or moderate brain swelling is frequently found just after opening of the dura mater. Four out of 866 cases operated on by the first author in the last twenty-two years showed acute and massive brain swelling and the operation had to be completed as soon as possible. In the present study, we investigated the cause of acute brain swelling just after opening of the dura mater. Partial pressure of end-tidal carbon dioxide gas (ETCO(2), mmHg) was measured and recorded just before induction of general anesthesia (preETCO(2)) and just after opening of the dura mater (postETCO(2)) in fourteen patients operated on for moyamoya disease. The distance between the opened dural edge and the top of the swelled brain surface (dbs, mm) was also measured. The relationship between increase in ETCO(2) (x, defined as postETCO(2) minus preETCO(2)) and dbs (y) was investigated and it was revealed that there was a significant positive correlation between the two parameters (y=2.59+0.31x, n=14, r=0.65048, p=0.011770.05). It means that decrease in carbon dioxide gas tension in various degrees before operation was normalized abruptly by the anesthesiologist and the increase in carbon dioxide gas tension was thought to increase in cerebral blood flow abruptly, resulting in acute brain swelling.

Moyamoya disease is a chronically progressive and occlusive cerebrovascular disease. Steno-occlusion of the terminal portion of the internal carotid artery occurs bilaterally, and fine vascular network gradually develops at the base of the brain and they act as collaterals to the distal portion of the anterior and middle cerebral arteries. Steno-occlusion of the posterior cerebral artery develops in accord with progression of the disease. Intracranial omental transplantation is one of the indirect bypass surgeries for the treatment of cerebral ischemia, especially in the territories of the anterior/posterior cerebral artery in moyamoya disease. In the present report, one of sixty-seven moyamoya disease patients who had been treated with intracranial omental transplantation, showed chronological change of the mass of the transplanted omentum in accord with decrease/increase in the patient's body weight. In addition, the patient experienced headache which appeared and disappeared in accord with increase and decrease in the patient's body weight, respectively. The transplanted omentum was thought to act in the same way as fat tissue in other portions of the body. Measurement of body weight is thought to be as important as radiological examination using computed tomography/magnetic resonance imaging in the follow-up period after intracranial omental transplantation in moyamoya disease.

The neurosurgical application was evaluated of a flow-directed oximetry thermodilution catheter for measurement of oxygen saturation in the jugular vein, which reflects cerebral blood flow (CBF). The catheter allows estimation of changes in CBF during carotid endarterectomy and therapeutically induced hypertension in the management of delayed vasospasm after subarachnoid hemorrhage.

Oxygen consumption calculated by the direct Fick method using a Swan-Ganz catheter (D-VO2) and indirect calorimetry using a metabolic computer (ID-VO2), carbon dioxide production calculated by the latter method, and respiratory quotient were determined pre- and postoperatively in 12 patients with acute hypertensive intracerebral hemorrhage and eight patients with acute ruptured intracranial aneurysm. The mean D-VO2 value was slightly lower than the mean ID-VO2 value, but had a significantly positive correlation. The regression curve was very close to the line of identity. The total metabolic expenditure can be calculated from D-VO2 and daily urinary nitrogen excretion. Direct calorimetry using a Swan-Ganz catheter is a simple method to evaluate metabolic expenditure in acute hemorrhagic cardiovascular disease.

Surgery for the treatment of moyamoya disease includes direct and indirect anastomosis. In the present study, three cases with moyamoya disease, in which acute brain swelling in the operative field occurred just after opening of the dura mater and indirect anastomosis was performed as a substitute for direct anastomosis to terminate the operation earlier than originally planned. They all waked immediately from general anesthesia and showed no neurological deterioration. Computed tomographay of the brain performed just after the operation showed no abnormalities such as acute infarction, hemorrhage, global brain swelling, and local brain swelling. One of the three cases showed signs of having caught a cold before the operation, another manifested allergic rhinitis just before the operation, and the other had taken a long walk and experienced hyperventilation resulting in TIA associated with quadriparesis a day before the operation. Abrupt return from hypocapnea to normocapnea during the induction of general anesthesia was thought to be the cause of the acute brain swelling. It was thought desirable that correction of hypocapnea needed to be performed gradually during the operation in those cases.

Oxygen consumption (VO2), carbon dioxide production, respiratory quotient, urinary nitrogen excretion (UN), resting energy expenditure (REE), REE rate (%REE) and consumption rates of carbohydrate (%C), fat (%F) and protein (%P) were pre- and postoperatively measured in the acute stage of 17 patients with cerebrovascular diseases. They included six of ruptured intracranial aneurysms, six of cerebrovascular occlusion, and five of hypertensive intracerebral hemorrhage. Preoperative VO2, UN, REE, and %REE were 185.1 ml/min, 7.1 gm/day, 1280 cal/day, and 132.6, respectively. %C, %F, and %P were 40.9, 38.5, and 20.6, respectively. Especially the preoperative %P had markedly increased. Postoperatively, %C significantly decreased to 28.3, and %P showed a significant increase up to 30.3. Patients with ruptured intracranial aneurysms manifested a significant increase of %P and %F and a decrease of %C, postoperatively. In summary, the catabolism of fat and protein increases in the acute stage, especially postoperatively, and this hypermetabolic state should be considered when caring for patients with cerebrovascular diseases as malnutrition might prevent wound healing and cause weight loss and a decrease in immunity.

Background Simple indirect anastomosis was introduced for the treatment of moyamoya disease with cerebral ischemia in the territory of anterior cerebral arteries (ACAs) or middle cerebral arteries (MCAs), and its clinical usefulness was discussed. Methods The study included 19 patients with childhood moyamoya disease who were operated on with subcutaneous tissue graft including a scalp artery and a relevant vein (group 1). They all had repetitive transient ischemic attacks (TIAs) in the territory of ACAs or MCAs. To compare age, sex, and the time required for the operation, 34 patients with childhood moyamoya disease with direct anastomosis were also included in the (group 2). Results No TIAs were observed in 19 of 21 operative sides during the follow-up period in group 1. The remaining 2 sides continued to have TIAs postsurgically, but with a marked decrease in frequency. There were no significant differences in age and sex between group 1 and group 2. Required time for surgical procedure in group 1 ranged from 103 to 270 minutes (mean ± SD, 167.4 ± 38.8 minutes), and in group 2 from 140 to 320 minutes (215.0 ± 36.2 minutes). The former was significantly shorter than the latter (unpaired t test, t = 4.8773, P = .000007). Conclusions Subcutaneous tissue graft including a scalp artery and a relevant vein is recommended for the treatment of moyamoya disease presenting ischemia in the territory of the ACAs or MCAs.

Cerebral angiography is performed for diagnosis and management of moyamoya disease and in childhood moyamoya disease is usually carried out under general anesthesia after tracheal intubation. Mechanical irritation to trachea resulting in pain,cough,and increase in secretion after termination of the general anesthesia sometimes occurs and it sometimes causes hyperventilation resulting in hypocapnea. Continuous hypocapnea sometimes causes appearance of ischemic attacks in moyamoya disease. In the present study, we examine cerebral angiography conducted under general anesthesia using face mask ventilation in fourteen children with moyamoya disease. Sevoflurane was used as inhalation anesthetics. Face mask anesthesia was sixteen times in total in the 14 patients. Cerebral angiography terminated uneventfully in these patients except one patient who showed bronchospasm after induction of anesthesia and required tracheal intubation. However, the patient showed uneventful course after termination of the angiography. Tracheal irritation did not appear and all the patients were asleep just after termination of face mask anesthesia except for the patient who required tracheal intubation. In the latter case, the patient frequently coughed out phlegm after general anesthesia with tracheal intubation. In conclusion, general anesthesia with face mask ventilation was thought to be one of the suitable anesthetic methods introduced for cerebral angiography in childhood moyamoya disease.

BACKGROUND: Selective angiography of the vertebral arteries has not been performed in rabbit models. We used a tracker-10 microcatheter for selective vertebral artery angiography. METHODS: Five Japanese male rabbits weighing 2.0 to 2.5 kg were used. The right femoral artery was identified and an 18-gauge Teflon catheter was introduced into the iliac artery. A Tracker-10 microcatheter was introduced through the 18-gauge Teflon catheter into the right vertebral artery under fluoroscopic guidance. RESULTS: Selective angiograms of the right vertebral artery were obtained using a bolus injection of 0.1 mL of iopamidol in all five rabbits. CONCLUSIONS: Selective vertebral artery angiograms could be obtained via the transfemoral route with the use of Tracker-10, and intraarterial selective administration of vasodilators will be achieved using our technique.

Intracranial omental transplantation is sometimes indicated for treatment of ischemia in the territory both of the anterior cerebral artery and of the posterior cerebral artery in certain cases with moyamoya disease. The surgical process for omental transplantation is thought to be complicated and time-consuming. For this reason some technical improvements for intracranial omental transplantation are presented in this report. 1) Technique for harvest of omentum. 2) A gastroepiploic artery is anastomosed to a scalp artery in an end-to-side fashion, or in an end-to-end fashion. 3) A gastroepiploic vein is anastomosed to a cortical vein in an end-to-side fashion.