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Background and Objective Microsurgical clipping, along with endovascular treatment, has evolved in the treatment of unruptured intracranial aneurysms (UIA), and these developments have resulted in a reduction of the complication rate. We discuss the need for a central venous catheter (CVC) insertion as an anesthetic preparation for microsurgical clipping. Methods Between January 2019 and September 2019, 722 patients with UIA were treated at our institution. We excluded patients with a history of endovascular treatment or bypass surgery, recurrent aneurysms after coil embolization, brain tumors, or subarachnoid hemorrhages. A total of 272 patients were enrolled. Eighty-four patients underwent CVC insertion, and 188 patients underwent clipping surgery without CVC insertion. Outcome-related factors were compared between the 2 groups. We performed propensity score matching of the 2 groups to increase comparability. Results There were no significant differences in outcome, sex, aneurysm location, aneurysm multiplicity, aneurysm size, or comorbid disease between the 2 groups. The mean age at the time of surgery was higher in the non-CVC insertion group than in the CVC insertion group. There were no meaningful differences in primary outcomes, including premature rupture and intraoperative motor evoked potential/somatosensory evoked potential change, and secondary outcomes, including estimated blood loss, duration of intensive care unit stay, duration of hospitalization, and Glasgow Outcome Scale score at discharge. Conclusions CVC insertion for clipping surgery for UIA is not mandatory. Considering the possible complications associated with CVCs, we cautiously suggest aneurysm surgery with CVC insertion in patients with serious medical comorbidities, aneurysm sizes >10 mm, and difficult proximal parent artery control.

Postoperative ischemic complication results in neurological sequelae and longer hospitalization after unruptured middle cerebral artery (MCA) aneurysm clipping surgery. We evaluated the radiological and patient-related factors associated with ischemic complications after unruptured MCA aneurysm clipping surgery. Patient demographics, radiological findings, and intraoperative factors were compared between patients with and without postoperative ischemic complications. The clinical courses and outcomes of postoperative ischemic complications were compared according to the types of ischemic complication. Forty-two out of 2227 patients (1.9%) developed postoperative ischemic complications after MCA aneurysm clipping. Multivariate analysis revealed that diabetes mellitus (DM) was a patient-related factor. Intraarterial (IA) calcification of the distal internal carotid artery (ICA), preoperative M1 stenosis, and M1 aneurysm were radiological factors that increased the risk of postoperative ischemic complications. DM was significantly associated with divisional branch territory infarction (P = 0.04). The time to first presentation of ischemic complication was significantly longer in divisional branch territory infarction than perforator territory infarction (67.8 ± 75.9 h vs. 22 ± 20.7, P = 0.023). Twelve out of 42 patients with ischemic complications (28.6%) had unfavorable outcome (mRS > 3). Perforator territory infarction was significantly associated with an unfavorable outcome (mRS > 3, P = 0.019). IA calcification of the distal ICA, M1 stenosis and aneurysms, and DM were significantly associated with postoperative ischemic complications after unruptured MCA aneurysm clipping. Patients with DM should be closely monitored postoperatively to detect delayed occurrence of divisional branch infarction. Trial registration number: 2019-1002, Date of registration: January 1, 2005, "retrospectively registered".

Laminectomy followed by posterolateral fusion (PLF) is a standard procedure for thoracic and thoracolumbar (TL) compressive lesions. However, it is challenging to apply sufficient bone chips as the spinal cord is exposed after the laminectomy. Therefore, we performed posterior thoracic cage interbody fusion (PTCIF) as an alternative technique. A total of 25 patients operated with PTCIF technique between 2012 and 2017 were analyzed in our study. These patients required a posterior decompression and fusion in thoracic and TL spine for traumatic injury or degenerative disease. To evaluate the outcome of bone fusion, computed tomography (CT) was performed at least 3–4 months after PTCIF. The surgery was performed through insertion of screws and cages packed with autologous bone chips in a similar fashion to the posterior lumbar interbody fusion technique. Among 25 patients who underwent PTCIF, 22 patients were involved in our study. The mean age and follow-up interval were 58.6 (28–78) years and 27.1 (6–60) months, respectively. Traumatic spinal injury was diagnosed in 6 patients and degenerative disease in 16 patients. One level PTCIF was performed in 12 patients and 2 levels in 8 patients. After the operation, patients with degenerative disease showed neurological improvement, and trauma cases showed no neurological aggravation. Successful bone fusion was confirmed on CT for all patients. PTCIF is an effective treatment thereby we suggest this approach to be considered as an alternative procedure to decompression and fusion surgery in the thoracic and TL spine.

Microsurgical treatment of thrombosed middle cerebral artery (MCA) aneurysm is very complicated, especially in recurrent cases. A 48-year-old man presented with a recurrent thrombosed right MCA aneurysm. We performed MCA-to-MCA bypass using a superficial temporal artery (STA) interposition graft and proximal trapping. Initially, an STA-to-MCA bypass with aneurysm trapping was planned because 1 MCA branch of the superior trunk of the M2 segment needed flow replacement after aneurysm trapping. However, the blood flow from the proximal STA was insufficient because of the previous surgical trauma and redo clipping was not feasible. As the backflow from the distal STA segment was good, we used it as an interposition graft for the MCA-to-MCA bypass. The patient recovered well without any neurologic deficits. In this case, the recurrent aneurysm was a fusiform MCA-M2 segment aneurysm with clip slippage. Our initial surgical plan could not be executed. We changed our surgical plan to an MCA-interposition graft-MCA bypass considering the mobility of the M3 arteries. The options for interposition grafts included radial artery, saphenous vein, or ipsilateral or contralateral STA. The caliber discrepancy in the radial artery or saphenous vein grafts makes them less suitable. Further, harvesting the contralateral STA is time-consuming and tedious. Thus the ipsilateral STA interposition graft was used and showed promising results. We recommend this surgical technique in cases in which good STA backflow is guaranteed. In conclusion, revision surgery performed for a recurrent thrombosed MCA aneurysm with an MCA-STA interposition graft-MCA bypass with proximal trapping was successful. This technique is safe and effective for complex aneurysms with suboptimal condition of the STA, which could be due to reduced blood flow, previous surgery, or trauma.

To report a case of spinal intramedullary cysticercosis in thoracic spine. A 47-year old man living in Korea referred to our hospital with both feet tingling sensation for about a year. Laboratory evaluations, including serologic tests were not helpful. Magnetic resonance imaging revealed a 1.7 cm intramedullary mass at T10-11 level, which believed to be a tumor instead, rather than a cysticercosis preoperatively. Successful operation was done with a histopathological result confirmed it as cysticercosis. Even though the prevalence of intramedullary spinal cysticercosis is extremely rare, and radiologic exams mimic other common tumors like ependymoma or astrocytoma, the disease should be considered as differential diagnosis.