Guglielmi detachable coil embolization for ruptured lower-midbasilar trunk aneurysms - a report of five cases

Detachable coil embolization currently plays an essential role for patients with ruptured basilar artery aneurysms, even though it may have an unfavorable outcome and there may be some technical problems of embolization. We describe Guglielmi detachable coil (GDC) embolization for five ruptured lower-mid basilar trunk aneurysms, using a variety of techniques. The patients' ages ranged from 61 to 78 years; Hunt and Kosnik grade was distributed from 2 to 4, and three patients were found to have fenestrations of the lower basilar arteries. All patients underwent aneurysmal embolization at the subacute or chronic stage. The transfemoral route was used in three patients--one of whom, with a wide-necked aneurysm, was treated by the balloon remodeling technique. The transbrachial approach was chosen for the fourth patient, while vertebral artery origin exposure followed by a direct puncture was achieved in the fifth. All patients were assessed with 80-100% aneurysmal obliteration. No patient re-bled after the embolization. Small cerebellar infarction, possibly due to embolism from the obliterated aneurysmal sac, occurred 11 days after the treatment. Of the five patients, four achieved a good recovery, and one became severely disabled. Ruptured basilar trunk aneurysms can be successfully treated with GDC embolization. In addition to the routine transfemoral route, the transbrachial route, direct vertebral artery puncture, and balloon remodeling technique are also useful for the embolization of this location of aneurysm.


Combined therapeutic approach of intra-arterial thrombolysis and carotid endarterectomy in selected patients with acute thrombotic carotid occlusion

The feasibility and clinical outcome of intra-arterial thrombolysis followed by carotid endarterectomy (CEA) for acute thrombotic occlusion of the internal carotid artery (ICA) were evaluated. Intra-arterial thrombolysis and CEA were performed in four patients with acute thrombotic ICA occlusion. Computed tomography scans, cerebral angiograms, and the severity of carotid plaques were examined, and the patients' clinical outcome was evaluated. All 4 patients had severe hemiparesis; 3 patients were alert, and 1 patient was lethargic at the time of hospital admission. New lesions were not shown by means of the initial computed tomography scan. ICA occlusion was indicated in all four patients by means of cerebral angiograms; in three patients, middle cerebral artery occlusion was noted. Collateral circulation was manifested in all patients. Partial recanalization of the occluded ICA was obtained in all patients. Two patients with severe residual ICA stenosis underwent an emergency CEA soon after thrombolysis; the other two patients were treated by means of CEA in the subacute or chromic stage. Plaque rupture and intraplaque hemorrhage were seen in all four patients. All four patients recovered completely, and restenosis of the ICA was not shown by means of follow-up angiograms. Intra-arterial thrombolysis followed by CEA may be an effective therapeutic approach for treating acute thrombotic ICA occlusion. The optimal timing of CEA remains controversial.


Quantitative evaluation of cerebral metabolites and cerebral blood flow in patients with carotid stenosis

We examined the metabolic and hemodynamic status of patients with severe carotid stenosis and evaluated the effectiveness of carotid endarterectomy (CEA) by comparing pre- and post-operative results of quantitative proton magnetic resonance spectroscopy (1H-MRS) and single-photon emission computed tomography (SPECT). Quantitative 1H-MRS and SPECT were performed in 17 patients with severe carotid stenosis before CEA; in 10 patients the examinations were repeated after CEA. There was a significant correlation between the degree of internal carotid artery (ICA) stenosis and the N-acetyl-aspartate (NAA) concentration, and between CBFand NAA in the basal ganglia. In 10 of the 17 patients (58.8%) we noted a decrease of NAA on 1H-MRS. After CEA in these patients, NAA was significantly increased, and in 7 of 8 patients whose pre-operative SPECT had indicated impairment of cerebral vasoreactivity, it was improved. Quantitative 1H-MRS and CBF measurements can indicate the severity of metabolic and hemodynamic impairment in patients with severe carotid stenosis, and can help to assess the effectiveness of CEA.


Anterior Ischemic Optic Neuropathy After Combined Ophthalmic Artery Embolization and Craniofacial Surgery --- Case Report

A 57-year-old man developed visual loss following craniofacial surgery for an inflammatory ethmoidal sinus mass. Surgery was preceded by endovascular occlusion of the ophthalmic artery distal to central retinal artery (CRA). Routine angiography obtained immediately after endovascular ophthalmic artery occlusion showed patency of the CRA. He complained of visual loss one day after craniofacial surgery (2 days after embolization). Repeat emergency angiography confirmed the patent CRA. Ophthalmic examination and fluorescein angiography showed that the visual loss was due to anterior ischemic optic neuropathy (AION). Preservation of the CRA is critical during ophthalmic artery embolization to avoid visual complications. Neurosurgeons should be aware of the possibility of AION as a complication of ophthalmic artery embolization.


Event related Potentials in a patient with word meaning aphasia with special referencce to topography --- とくにそのトポグラフィーについて

語義失語症例の事象関連電位 --- とくにそのトポグラフィーについて

外傷による語義失語と正常対照群および典型失語群の漢字，仮名課題における事象関連電位(ERP)とそのトポグラフィーを比較検討した．語義失語例では漢字·かなともにコントロール群，典型失語群に比べP200が高振幅であったが，P300は不明瞭であった．P200振幅は受症36ヶ月では漢字課題において，課題正答率の増大とともに減衰した．またトポグラフィーでこのP200は左右頭頂後頭部に特異的な分布を示した．


Carotid Endarterectomy with External Shunt: A New Device and Indication for Use: Technical Note

We designed a new external shunt system and evaluated its indications and efficacy in patients undergoing carotid endarterectomy (CEA). In 8 of 332 CEA procedures, external shunts were placed between the common carotid artery and the internal carotid artery (ICA). This procedure was implemented for one of two indications: 1) a change in electroencephalographic and/or somatosensory evoked potential readings immediately after ICA occlusion, or 2) elongation of the ICA made safe insertion of an internal shunt impossible. In addition, a shunt was placed between the common carotid artery and the external carotid artery to establish collateral circulation from the external carotid artery to the intracranial circulation, which is essential during ICA occlusion. All external shunts were functional, and electroencephalography and somatosensory evoked potentials demonstrated no significant abnormalities during the CEAs. All patients awoke from surgery without manifestation of new neurological deficits. Our new external shunt device proved safe and efficacious in cases that did not permit the placement of an internal shunt.


Cerebellar hemorrhage caused by dural arteriovenous fistula: a review of five cases

In this study the authors performed a retrospective analysis of five cases in which the patients (three women and two men) were treated for intracranial dural arteriovenous fistulas (AVFs) associated with cerebellar hemorrhage. On the basis of their findings, the authors evaluated the characteristics of this unusual symptom. The dural AVFs were located in the right cavernous sinus in one patient, the left transverse-sigmoid sinus in three patients, and the right superior petrosal sinus (SPS) in one patient. All patients presented with severe headache and/or loss of consciousness. Computerized tomography scans revealed a small cerebellar hemorrhage near the fourth ventricle and hydrocephalus in four cases, and a massive hemispheric cerebellar hemorrhage in the remaining case. The four patients with small hemorrhages underwent ventriculostomy and endovascular treatment; all recovered. The patient suffering from a massive hemorrhage because of a dural AVF in the SPS was treated by suboccipital craniectomy, hematoma evacuation, and removal of the vascular anomaly. This patient remains in a persistent vegetative state. In four cases, results of angiography demonstrated retrograde leptomeningeal venous drainage through the SPS to the anastomotic lateral mesencephalic vein (ALMV) and/or to the vein of the lateral recess of the fourth ventricle (VLR4V). Retrograde leptomeningeal venous drainage to the ALMV and/or VLR4V was responsible for cerebellar hemorrhage in these cases. Thus, it is important to consider dural AVF in cases in which there is even a small hemorrhage near the fourth ventricle accompanied by intraventricular perforation and a decreased level of consciousness.


頚動脈プラークおよび血漿中の酸化LDLの定量とその意義

頚動脈プラークおよび血漿中の酸化LDLの定量とその意義


Phenotypic modulation of smooth muscle cells in human cerebral aneurysmal walls

We used immunohistochemical methods to analyze the phenotypes of smooth muscle cells (SMCs) in human cerebral arteries and aneurysmal walls. Thirty-two aneurysmal walls were studied; 31 aneurysmal walls were resected at operation and 1 aneurysm was obtained at autopsy. Seven control arteries were obtained at autopsy. Semiserial sections were subjected to immunohistochemical staining with antibodies to alpha-smooth muscle actin (alpha-SMA), desmin and smooth muscle myosin heavy chain isoforms: SM1, SM2 and SMemb. In control cerebral arteries, SMCs in the media were strongly immunostained for alpha-SMA, desmin, SM1 and SM2; immunoreactivity for SMemb was faint or weakly positive. SMCs in both non-ruptured and ruptured aneurysmal walls showed no staining for desmin; the expression of alpha-SMA was well preserved. Compared with control cerebral arteries, in 4 of 11 non-ruptured aneurysmal walls, the staining intensity of SMCs for SMemb was clearly increased. In ruptured aneurysmal walls, the expression of SM2 was lower than in control cerebral arteries and non-ruptured aneurysmal walls. Our study suggests that the phenotype of SMCs in aneurysmal walls is different from the contractile type in the media of normal cerebral arteries, at least partially changing to the synthetic type in some non-ruptured aneurysms. SMCs in ruptured aneurysmal walls may have lost both phenotypes before rupture. Phenotypic modulation of SMCs in the aneurysmal walls appears to be related to a remodeling of the aneurysmal wall and to a rupture mechanism.


Transvenous Embolization for Cavernous Sinus Dural Arteriovenous Malformations

海綿静脈洞部硬膜動静脈奇形に対する経静脈的塞栓術


Coronary artery stenosis evaluated by combined carotid and coronary angiography in patients undergoing carotid endarterectomy

The relationship between coronary artery stenosis and the postoperative outcome was investigated in patients who underwent carotid endarterectomy (CEA). The benefit of combined carotid and coronary angiography was also evaluated. Combined carotid and coronary angiography was performed in 72 patients treated with CEA (mean age 64.0 years). Fourteen patients with a history of ischemic heart disease (IHD) had a higher Gensini score for coronary artery stenosis than patients with no history of IHD (37.9 +/- 36.8 vs. 7.9 +/- 12.5, p < 0.0001). However, 39.7% of patients with no history of IHD had a Gensini score exceeding 6. Patients with diabetes mellitus had a significantly higher Gensini score than nondiabetic patients. Eleven patients (15.3%) underwent percutaneous transluminal coronary angioplasty and three (4.2%) underwent coronary artery bypass grafting during the CEA perioperative period. None of the patients who underwent combined angiography showed signs of IHD during or after CEA (mean follow-up period 30 months). Combined angiography was not performed in 189 previous patients. Of these, two died of acute myocardial infarction in the postoperative period, 11 manifested nonfatal IHD, and 18 succumbed to IHD (mean follow-up period 8 years). Although patients with a history of IHD manifested more severe coronary artery stenosis than patients without such a history, the possibility of coronary artery stenosis must be considered in patients with no history of IHD, especially those with diabetes mellitus. Combined carotid and coronary angiography and careful management of coronary artery stenosis can be expected to decrease the mortality and morbidity in patients treated with CEA.


頚部頚動脈狭窄性病変に対する頚動脈内膜剥離術の手術成績および冠動脈病変合併例の予後の検討


Posterior circulation aneurysmに対するdetachable coilを用いた血管内治療


Endovascular treatment using detachable coils for non-ruptured intracranial aneurysm


頚動脈狭窄症に対するSPECTおよび1H-MRSによる脳血流，脳代謝の評価

頚動脈狭窄症に対するSPECTおよび1H-MRSによる脳血流，脳代謝の評価


Hyperperfusion syndrome after extracranial-intracranial bypass in a patient with moyamoya disease case report


Mesurement of volume ratio to predict coil compaction, on aneurysmal embolization


Carotid endoarterectomy for radiation-induced carotid artery stenosis Case report


症例報告 第17回若手奨励賞受賞論文 遅発性ジストニア(tardive dystonia)に対して脳深部刺激術を施行した5例

We assessed the efficiency of pallidal deep brain stimulation for tardive dystonia. This search was carried out in Electronic chart of Tokushima University Hospital. 5 patients with tardive dystonia were enrolled. GPi(internal segment of globus pallidus)was the target in all patients. The motor part of Burke-Fahn-Marsden Dystonia Rating Scale(BFMDRS)was improved by 78．4% on average when compared to preoperative BFMDRS scores. The performed analysis indicates that GPi-DBS is an effective and safe treatment for tardive dystonia.


Usefulness of a novel higher brain dysfunction screening test for evaluating higher brain function in healthy persons.

To accurately and rapidly screen for higher brain dysfunction, we developed a screening test named the "higher brain dysfunction screening test" (HIBRID-ST). Previous studies have reported a decrease in higher brain function with age. However, whether HIBRID-ST can detect a decrease in higher brain function in healthy persons remains unclear. We aimed to assess the usefulness of HIBRID-ST for evaluating higher brain function in healthy persons. We recruited 60 persons without physiological abnormalities and divided them into six equal groups based on their age (20s-70s). HIBRID-ST addresses orientation, short-term memory, word recall, situational awareness, visual short-term memory, and graphic replication and includes the Trail Making and Kana-hiroi tests. There was a significant negative correlation between the participants' age and their total HIBRID-ST score (ϱ = -0.68, p < 0.01). The total HIBRID-ST score of participants in their 70s was significantly lower than that of participants in their 20s-60s; the total HIBRID-ST score of participants in their 60s was significantly lower than that of participants in their 20s-50s. Our findings show that HIBRID-ST accurately detects an age-related decline in higher brain function. Further studies are needed to examine the usefulness of HIBRID-ST in patients with higher brain dysfunction. J. Med. Invest. 64: 280-285, August, 2017.

The Journal of Medical Investigation : JMI


脳神経外科医がリハビリテーションに期待するもの

脳神経外科医がリハビリテーションに期待するもの

The Japanese Journal of Rehabilitation Medicine


高齢者における頭蓋内多発性病変

高齢者における頭蓋内多発性病変


Treatment strategy for acute ischemic stroke with internal carotid artery occlusion in the stroke care unit of Tokushima University Hospital

徳島大学病院脳卒中センターでの内頚動脈急性閉塞に対する治療戦略

Objective : Strokes related to acute internal carotid artery (ICA) occlusion are associated with extremely poor prognosis. Recently, some studies have reported that the prognosis has been getting better by treating with intra-arterial endovascular therapy. We sought to evaluate clinical outcomes in patients with acute ischemic stroke attributable to ICA occlusion treated with intraarterial endovascular therapy or otherwise. Methods : We reviewed 44 patients who underwent treatment with intra-arterial endovascular therapy or otherwise in our stroke care unit (SCU) from January, 2011 to May, 2014. We compared the prognosis of patients in the 2 treatment groups (endovascular group, n＝23 vs nonendovascular group, n＝21). Results : The rate of good prognosis (modified Rankin Score of ≦2) was significantly higher in the endovascular group than non-endovascular group (17．4% vs0%，p＝0．045). The rate of patients who had extreme improvements of National Institutes of Health Stroke Scale (NIHSS) ≧8 was higher in the endovascular group than non-endovascular group (30．4% vs14．3%). Concerning the improvement of NIHSS ≧8, recombinant tissue-type plasminogen activator (rt-PA) or the left side ICA occlusion were associated significantly (p＝0．019, p＝0．042, respectively). Although the hypothesis that endovascular therapy could contribute to extreme improvements of NIHSS wasn't proved (p＝0．202), there was one case that NIHSS was dramatically improved from 22 to 0 by endovascular therapy. Conclusions : Intra-arterial endovascular therapy of ICA occlusion might result in improved clinical outcomes for indicated cases.


徳島大学病院脳卒中センターでの内頚動脈急性閉塞に対する治療戦略

徳島大学病院脳卒中センターでの内頚動脈急性閉塞に対する治療戦略

第249回徳島医学会学術集会

第249回徳島医学会学術集会


Atypical teratoid rhabdoid tumor in the cavernous sinus of a toddler presenting with oculomotor nerve palsy.

Atypical teratoid rhabdoid tumor (ATRT) is a rare, highly malignant, and aggressive tumor of infancy. Although the prognosis of ATRT has been extremely poor, recently, the first prospective study for ATRT demonstrated improvement of prognosis. On the other hands, oculomotor nerve palsy is rare in children and the most frequent etiology is congenital. To our knowledge, only a few ATRT cases presenting with oculomotor nerve palsy have been reported, but ATRT originating from the cavernous sinus (CS) has not yet been reported. An 18-month-old girl with right oculomotor nerve palsy was admitted, and a small mass in the right CS was detected with brain MRI. Although she received steroid pulse therapy and antimicrobial therapy, the mass continued to enlarge. One month after admission, the mass was partially resected and diagnosed as ATRT. Multimodal therapy including anthracycline-based chemotherapy, intrathecal therapy, and cranial irradiation was performed. Twenty-nine months after resection, she was alive without tumor relapse, but the oculomotor nerve palsy persisted. This is the first reported case of ATRT located in the CS presenting with oculomotor nerve palsy. This case was successfully treated with partial removal of the tumor, a new chemotherapy regimen for ATRT and cranial X-ray irradiation.


Revised organ transplant act and neurosurgeons


Conservative treatment strategy in patients with dystonia

薬物療法を中心としたジストニア治療戦略


Bilateral pallidal stimulation in Meige syndrome

原発性 Meige 症候群に対する両側淡蒼球刺激術 : 罹患部位による反応の相違


Clinical characteristics of X-linked dystonia-parkinsonism


Bilateral subthalamic stimulation for dropped head syndrome in Parkinson's disease

パーキンソン病における dropped head syndrome に対する両側視床下核刺激術の治療効果


Meige症候群に対する両側淡蒼球刺激術

Meige症候群に対する両側淡蒼球刺激術


Microscopic Carpal Tunnel Release usinga Minimal Skin Incision : Technique and Outcomes

手根管症候群に対する顕微鏡下小切開手根管解放術:手技と成績


Long-term suppression of Meige syndrome after pallidal stimulation: a 10-year follow-up study.


進行性に増悪をきたし血管内治療を施行した右内頸動脈閉塞の1例

進行性に増悪をきたし血管内治療を施行した右内頸動脈閉塞の1例


Vo-complex thalamotomy and pallidal stimulation in focal hand dystonia

Focal hand dystonia に対する視床 Vo-complex 破壊術と淡蒼球刺激術


Involuntary movements due to cerebrovascular disease : Three case reports

その他の不随意運動 脳血管障害による不随意運動の3症例


Depression in X-linked dystonia-parkinsonism:A case-control study