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Periventricular collaterals are associated with high risk of hemorrhagic stroke in adult moyamoya disease (MMD). However, the clinical significance of the periventricular collateral enhancement sign (PCES), which indicates wall enhancement of periventricular collaterals on contrast-enhanced vessel wall imaging (VWI), has yet to be determined.Thirty-seven patients with MMD with acute neurological symptoms were consecutively recruited. Periventricular collaterals including lenticulostriatal artery, thalamic artery, and choroidal artery collaterals were evaluated on digital subtraction angiography, and then PCES was detected on pre- and postcontrast VWI. First, the association between PCES and hemorrhagic presentation was evaluated using multivariate analyses. Second, two raters investigated the culprit vessels responsible for bleeding in hemorrhagic MMD using the Cohen kappa statistic.Fifteen sites of PCES on postcontrast VWI were observed in 15 patients. Multivariate analysis revealed that hemorrhagic presentation was the only independent factor for PCES (OR = 37.3, 95%CI = 3.9-113, p =.002). In patients with hemorrhagic presentation (n = 20), the identification rate of the ruptured vessel was 80% by rater 1, with excellent agreement. (inter-rater, κ = 0.86, 95%CI = 0.59-1.00; intra-rater, κ = 0.83, 95%CI = 0.50-1.00). Choroidal (50%) and thalamic artery collaterals (15%) were the most common and the second most common types of culprit vessels. Inter-rater and intra-rater reliabilities for the classification of culprit vessels were also excellent (intra-rater, κ = 0.86, 95%CI = 0.67-1.00; inter-rater, κ = 0.93, 95%CI = 0.79-1).Acute hemorrhagic stroke in MMD is independently associated with PCES on postcontrast VWI. PCES can help to detect the culprit vessels that are responsible for hemorrhage in patients with MMD.

Tension pneumocephalus is a treatable emergency that is usually caused by trauma or surgery. We present a rare case of spontaneous tension pneumocephalus. A 64-year-old woman presented with a severe aggravating headache. Computed tomography revealed a large air collection in the brain parenchyma of the right frontal lobe, both lateral ventricles, and the subarachnoid space. Emergent craniotomy was performed because her headache got progressively worse. We found that an abnormal bony protrusion connected the frontal sinus mucosa and the intraparenchymal pneumocephalus. After removal of the bony mass and repair of the defect, the patient immediately recovered and there was no recurrence.

Periventricular anastomosis (PA), which is a novel term for extended collateral vessels in moyamoya disease (MMD), is reportedly associated with a high risk of intracranial hemorrhage in adult patients. The present study aimed to clarify the similarities and the differences in the development of PA between three MMD groups, classified by age at the time of diagnosis and clinical phenotype. This study included 232 hemispheres of 132 patients with MMD who underwent surgical revascularization. The subjects were classified into child ischemic (CI) group, adult ischemic (AI) group, and adult hemorrhagic (AH) group. We evaluated the lenticulostriate (LSA), thalamic (THA), choroidal (ChA), anterior choroidal (AChA), and posterior choroidal (PChA) anastomosis as well as the posterior cerebral artery (PCA) involvement. The PA scores and the sums of each grade of LSA, THA, and ChA anastomosis were also calculated in all of the cases. In a multiple comparison test, the PA scores (P

Actinomycosis of the central nervous system is extremely rare. A 73-year-old woman with a history of abdominal actinomycosis presented with sudden-onset headache. Magnetic resonance imaging demonstrated a nodular lesion at the left precentral gyrus. A cerebral angiogram confirmed a fusiform aneurysm arising from the precentral branch of the left middle cerebral artery. High-resolution vessel wall imaging revealed circumferential wall enhancement of the aneurysm and multifocal enhancement of the M3 and M4 segments of both middle cerebral arteries. The patient had received a 4-week course of antibiotics, but follow-up angiography demonstrated no shrinkage or resolution of the aneurysm. Trapping combined with revascularization was successfully performed for refractory mycotic aneurysms.

Objective Trigeminal neuralgia (TN) is a severe neuropathic condition that affects several elderly patients. It is characterized by uncontrolled pain that significantly impacts the quality of life of patients. Therefore, the condition should be treated as an emergency. In the majority of patients, pain can be controlled with medication; however, other treatment modalities are being explored in those who become refractory to drug treatment. The use of the trigeminal nerve block with a local anesthetic serves as an excellent adjunct to drug treatment. This technique rapidly relieves the patient of pain while medications are being titrated to effective levels. We report the efficacy and safety of percutaneous trigeminal nerve block in elderly patients with TN at our outpatient clinic. Methods Twenty-one patients older than 65 years with TN received percutaneous nerve block at our outpatient clinic. We used bupivacaine (1 mL/injection site) to block the supraorbital, infraorbital, superior alveolar, mental, and inferior alveolar nerves according to pain sites of patients. Results All patients reported relief from pain, which decreased by approximately 78% after 2 weeks of nerve block. The effect lasted for more than 4 weeks in 12 patients and for 6 weeks in two patients. There were no complications. Conclusion Percutaneous nerve block procedure performed at our outpatient clinic provided immediate relief from pain to elderly patients with TN. The procedure is simple, has no serious side effects, and is easy to apply.

Objective Intracranial aneurysm (IA) is the leading cause of subarachnoid hemorrhage. The pathomechanisms of IA are poorly understood but can be related to arterial tortuosity resulting from underlying systemic factors leading to arterial wall weakening. We aimed to analyze the tortuosity of the intracranial artery in a cohort with IA, hypothesizing that the tortuosity of intracranial arteries differs depending on the characteristics of the IA. Methods Patients with saccular IA were consecutively enrolled. Clinical factors and vascular tortuosity of the right and left middle cerebral arteries and basilar artery (BA) of all patients with IA were compared according to the characteristics of the IA: 1) ruptured versus unruptured, 2) multiple versus single, and 3) large (>5 cm) versus small (≤5 cm). Unruptured IAs were comparatively analyzed according to aneurysm size and aspect ratio, whereas ruptured IAs were analyzed according to aneurysm size. Results Two hundred eighty-five patients were enrolled (mean age, 59 years; 71.2% women). The tortuosity of the BA was higher in the large IA group (5.63 ± 6.26; n = 133; P = 0.009), large unruptured IA group (6.64 ± 6.32; n = 53; P = 0.039), and large ruptured IA group (5.50 ± 6.52; n = 80; P = 0.033) compared with the small IA, small unruptured IA, and small ruptured IA group. In multivariate analysis, increased BA tortuosity was significantly associated with large IAs (β = 1.066; P = 0.008), unruptured large IAs (β = 1.077; P = 0.033), and ruptured large IAs (β = 1.086; P = 0.025). Conclusions The BA tortuosity was higher in patients with large IAs, which may represent an imaging biomarker of aneurysm growth.

It is very difficult to predict some complications after subarachnoid hemorrhage (SAH), despite rapid advances in medical science. Herein, we introduce a label-free cellulose surface-enhanced Raman spectroscopy (SERS) biosensor chip with pH-functionalized, gold nanoparticle (AuNP)-enhanced localized surface plasmon resonance (LSPR) effects for identification of SAH-induced cerebral vasospasm and hydrocephalus caused by cerebrospinal fluid (CSF). The SERS biosensor chip was implemented by the synthesis reaction of the AuNPs, which were charged positively through pH level adjustment, onto a negatively-charged cellulose substrate with ξ = –30.7 mV. The zeta potential, nanostructural properties, nanocrystallinity, and computational calculation-based electric field distributions of the cellulose-originated AuNPs were optimized to maximize LSPR phenomena and then characterized. Additionally, the performance of the SERS biosensor was compared under two representative excitation laser sources in the visible region (532 nm) and near-infrared region (785 nm). The Raman activities of our SERS biosensor chip were evaluated by trace small molecules (crystal violet, 2 µL), and the biosensor achieved an enhancement factor of 3.29 × 109 for the analytic concept with an excellent reproducibility of 8.5% relative standard deviation and a detection limit of 0.74 pM. Furthermore, the experimental results revealed that the five proposed SERS-based biomarkers could provide important information for identifying and predicting SAH-induced cerebral vasospasm and hydrocephalus complications (91.1% reliability and 19.3% reproducibility). Therefore, this facile and effective principle of our SERS biosensor chip may inspire the basis and strategies for the development of sensing platforms to predict critical complications in various neurosurgical diagnoses.

Background Cranial defects following anterior cranial base surgery have been frequently reconstructed using the pericranial flap. Methods We present a simple technique for preparing the flap using injection of saline into the subgaleal space. Results We inserted a 20-gauge needle perpendicular to 8–10 spots in the frontal area and injected 5–7 mL of saline at each spot 10 minutes before skin incision. Distinctive swelling of the scalp was then observed. After the scalp was incised, the layers were dissected with a monopolar electrocautery device. The layer containing saline allowed us to better localize its exact position and harvest the flap without injury. Dissection in the subgaleal plane was performed mainly using the tip of a surgical blade. After the periosteum was stripped from the calvaria, the flap that had been considerably thickened by saline injection was harvested. Conclusions Because pericranium thickness in the frontal areas is reported to be thinner than in other areas, a beginning neurosurgeon may have difficulty harvesting an anteriorly based flap of sufficient size. The technique presented here can help increase awareness of the subgaleal layer, facilitate the dissection process, and reduce additional tissue injury resulting from electrocautery manipulation.

Although new imaging tools have been developed for the detection of smaller aneurysms, angiographically negative microaneurysms are still encountered during cerebral microsurgery. Currently, only limited information regarding incidence and efficacy of treatment of these microaneurysms is available.We investigated the incidence and treatment of incidental microaneurysms (IMAs) in the last 5 years. IMAs are unidentifiable and invisible on preoperative angiography, but are detected during microvascular surgery. The inclusion criteria were aneurysm cases treated with microsurgery via transsylvian approaches, and those undergoing preoperative digital subtraction angiography.This study enrolled 484 surgical cases (248 cases of subarachnoid hemorrhage and 236 cases of unruptured aneurysms) in 460 patients, and 33 tiny aneurysms were found in 31 operative cases (6.4% incidence per operation). The most typical type was located on another branching site of the middle cerebral artery found during neck clipping of the middle cerebral artery bifurcation aneurysm. A patient with multiple aneurysms presented a statistically significant risk (375/78 vs. 15/16; P0.001) of IMA identification. IMAs were treated by clipping and wrapping in 18 and 15 cases, respectively, without complications.This study revealed a 6.4% incidence of IMAs; however, this could be underestimated because of the limited range of inspection. Early detection of an IMA through careful inspection during microvascular surgery could be beneficial, especially in patients with multiple aneurysms.

AIM For endovascular embolization of paraclinoid aneurysms, superselection needs consideration of the complex anatomy around the carotid siphon. As no guideline or classification has been established for selecting proper microcatheters, pre-shaped microcatheters must be considered. We suggest a geometric classification of paraclinoid aneurysms for microcatheter selection. MATERIAL AND METHODS Clinical data from 76 patients (80 paraclinoid aneurysms) who underwent endovascular treatments were retrospectively reviewed. Paraclinoid aneurysms were classified according to the six directions where the aneurysm neck lies and simplified into three groups as follows: superior, medial, and lateral groups. The medial group was further divided into proximal, mid, and distal subgroups according to the location of the aneurysm neck on lateral angiography. Furthermore, we assessed the superselection success rate with the first-selected pre-shaped microcatheter per group. RESULTS According to the aneurysm direction, the medial group showed relatively lower superselection success rates (66.1%) than the superior (81.8%) and lateral groups (85.7%). The S-shaped microcatheter was the most frequently used in the superior (69.2%) and lateral groups (62.5%). Acute-angled J- and C-shaped microcatheters (88.5%) were preferred for proximal aneurysms; and obtuse-angled 45° - and 90°-angled microcatheters (75%), for distal aneurysms. The mid-portion group showed the lowest success rate (45.8%) and more difficulties in pre-shaped microcatheter superselection. CONCLUSION Medially directed mid-portion aneurysms were difficult to access using pre-shaped microcatheters; thus, tailored steam-shaping techniques may be considered. Superiorly and laterally directed aneurysms could be accessed using pre-S-shaped microcatheters. Acute-angled microcatheters may be considered for proximal aneurysms; and obtuse-angled microcatheters, for distal aneurysms.

Background Many methods for treating complex anterior cerebral artery (ACA) aneurysms are available; however, there is substantial variation among methods because of various aneurysm locations, the relationship of the aneurysm to arterial branches, aneurysm size and other morphologic characteristics, and the diameters of the parent or branching arteries. Methods We reviewed complex ACA aneurysms based on both our own experience and the available literature. Each unique case is analyzed in terms of the characteristics of the aneurysm, along with analysis and classification of the revascularization method used. Computer tablet–drawn illustrations of each unique technique are provided for comprehension and application in various situations. Results Over 6 years, we treated 5 cases of complex ACA aneurysms (1 precommunicating, 1 communicating, 1 postcommunicating, and 2 precallosal-supracallosal segment) with revascularization. Side-to-side anastomoses included pericallosal ACA segment-pericallosal ACA segment in 3 cases, supracallosal ACA segment-supracallosal ACA segment in 1 case, and ipsilateral callosomarginal artery-pericallosal artery in 1 case. Final modified Rankin scale score was 0 in 4 of 5 cases and 3 in 1 case. Six treatment strategies were used for the precommunicating aneurysm, 8 for the communicating aneurysm, 7 for the postcommunicating aneurysm, and 9 for the 2 precallosal-supracallosal segment aneurysms. Conclusions Treatment of complex ACA aneurysms should be tailored according to the location and nature of the aneurysm and collateral circulation. Viable and feasible treatment strategies must be established by the neurovascular surgeon.

In situ side-to-side (STS) anastomosis is a unique technique used for intracranial artery-intracranial artery revascularization. Over a 7-year period, 7 STS anastomoses were performed for anterior cerebral artery aneurysms in 6 patients and a posteroinferior cerebellar artery aneurysm in 1 patient. We provide a step-by-step guide for suturing techniques from arteriotomy to vessel wall sutures based on clinical experiences, with detailed illustrations. Technical considerations in each stage are also discussed. The current technique provides a viable option for treatment of complex aneurysms.

A relevant irrigating and flushing maneuver during cerebral microsurgical procedures allows for a neat and optimal operative field. However, when operating on the deep region of the brain, a delicately created slim surgical corridor could unintentionally hinder the assisting surgeon from properly performing this routine maneuver. To address this problem, the authors devised a useful and convenient irrigation system that can be used during cerebral microsurgery. This system only necessitates a readily available silastic feeding tube and a malleable wire. The advantages of our devised system include the convenience of free molding, good endurance of the molded contour, and easy control over the amount of irrigation. In this report, the authors demonstrated technical tips for using this newly devised system.

Pseudoaneurysm on the distal anterior cerebral artery (ACA) is rare but potentially fatal. It usually cannot be treated with typical treatment modalities. A 47-year-old female patient was diagnosed with a ruptured aneurysm on the pericallosal artery (PerA). During surgical exploration, it was found to be a pseudoaneurysm and could not be treated with clipping. We performed surgical trapping of the involved segment of the proximal PerA followed by side-to-side anastomosis between the ipsilateral PerA and the callosomarginal artery. The patient recovered without any neurologic deficit. This new method of anastomosis could be an alternative option.

Objective To provide detailed information about how to realize a self-training laboratory with cost-effective microsurgical instruments, especially pertinent for the novice trainee. Methods Our training model is designed to allow the practice of the microsurgery skills in an efficient and cost-effective manner. A used stereoscopic microscope is prepared for microsurgical training. A sufficient working distance for microsurgical practice is obtained by attaching an auxiliary objective lens. The minimum instrument list includes 2 jeweler's forceps, iris scissors, and alligator clips. The iris scissors and alligator clip provide good alternatives to micro-scissors and microvascular clamp. Results The short time needed to set up the microscope and suture the gauze with micro-forceps makes the training model suitable for daily practice. It takes about 15 minutes to suture 10 neighboring fibers of the gauze with 10-0 nylon; thus, training can be completed more quickly. Conclusions We have developed an inexpensive and efficient micro-anastomosis training system using a stereoscopic microscope and minimal micro-instruments. Especially useful for novice trainees, this system provides high accessibility for microsurgical training.

Introduction Deep bypass surgery remains a challenging operative procedure. For novice trainees, there is a high barrier to improving the microsurgical skills needed for this procedure because of the relatively low number of cases and the high cost of microsurgical instruments. Here, the authors introduce a training model that includes highly accessible devices and does not require a microscope. Materials and Methods The surgical environment consisted of two 15.5-cm straight serrated forceps with a 1-mm tip width (Medicon, Tuttlingen, Germany), 9-cm curved iris scissors (Medicon), 4-0 black silk suture, gauze, and a 15 × 10.5 × 3.5-cm-sized box with a transparent cover. These materials are affordable even in low-income countries. Procedure To understand and learn the hand positioning used in the deep surgical field, suturing practice was performed as follows: the forceps and a needle were placed in a slanted position, with hand position maintained at a 50° angle between the 2 forceps. This was also performed above the desk, without wrist support. Conclusions Our training system will be helpful, especially for deep bypass surgery, since training with similar muscle effort and fatigue can improve surgical skills. This system is economic, highly accessible, and available even for portable training.

Purpose This report describes the need for a tailored approach for intracranial vascular occlusive disease and introduces the usefulness of the OA as a donor artery for interposition graft. Materials and Methods A 65-year-old male patient suffered from repeated transient ischemic attack (TIA). Imaging studies revealed complete occlusion of the proximal left side of the internal carotid artery (ICA) and multiple infarction in the watershed zone. We planned superficial temporal artery-middle cerebral artery (STA-MCA) bypass to restore cerebral blood flow and to prevent the progression of infarction. However, the parietal branch of the STA was too small in diameter and not suitable as a single donor for the bypass in order to supply sufficient blood flow. Moreover, the frontal branch of the STA had collateral channels through the periorbital anastomosis into the cerebral cortex that could result in infarction during clamping for anastomosis. Results We determined that tailored treatment planning was necessary for successful revascularization under these conditions. Thus, we performed a bypass between the parietal branch of the STA and a cortical branch of the MCA as an “insurance bypass.” Then we performed another bypass between the frontal branch of the STA and a cortical branch of the MCA using an ipsilateral occipital artery (OA) interposition graft. The patient had no perioperative complications, and postoperative imaging confirmed the restoration of cerebral blood flow. Conclusion When end-to-side anastomosis in single-branch bypass is not appropriate for cerebral revascularization, a tailored double-barrel “insurance bypass” with an OA interposed graft could be a good alternative treatment modality. In addition, an OA interposition graft is a useful option for double-barrel bypass surgery in such cases of intracranial vascular occlusive disease.

Objective Isolated dissections that develop on the posterior inferior cerebellar artery (PICA) require intensive treatment because of their potential fatality. However, because of the rarity of these dissections, the optimal treatment has not yet been established. Methods We retrospectively reviewed the clinical records of all patients who underwent any PICA dissection treatment in our institute over the last 4 years. Ten patients were enrolled, including 7 patients with subarachnoid hemorrhage (SAH) and 3 with PICA territory infarction. Dissection was seen at the proximal portion in 8 patients, whereas the remaining 2 patients showed distal PICA dissecting aneurysms. Results Among the 7 patients with hemorrhage, 5 were actively treated (trapping and bypass, 2 patients; surgical clipping, 1 patient; coil embolization, 2 patients). Conservative management was performed in the other 2 patients. Among the 3 patients with infarction, 2 received conservative treatment. Endovascular treatment was performed in 1 patient, who showed rapid progression, aneurysm formation, and conversion to massive SAH within 10 days after the initial attack. Although 7 patients showed relatively good outcomes (modified Rankin Scale score, ≤2) after 30 days of follow-up, 1 patient had a final modified Rankin Scale score of 3. In addition, the other 2 patients (1 in each group) died as a result of major SAH. Conclusions Given the dynamic clinical course and potential fatality of PICA dissection, meticulous evaluation, intensive treatment with a diverse range of modalities, and proper follow-up are required for patients with PICA dissection to achieve favorable outcomes.

Background Venous infarction in the brainstem caused by venous congestion is an extremely rare complication of traumatic carotid cavernous fistulas (CCFs). This condition requires immediate treatment and a multimodal treatment strategy is needed to prevent recurrence. Case Description A 24-year-old man presented with exophthalmos and chemosis after a bicycle accident. Cerebral angiography showed an engorged right superior ophthalmic vein and a right carotid cavernous fistula. Transvenous coil embolization was successfully performed without severe complications. Two months later, a decline in mental status occurred. Follow-up angiography showed recanalization of the CCF. The patient underwent radial artery graft bypass surgery combined with endovascular trapping of the internal carotid artery. Sylvian veins and other cortical veins became intraoperatively arterialized and we observed marked brain edema after high-flow CCF. After surgery, the patient's mental status recovered and angiography showed good patency of the bypass graft and complete obliteration of the recurrent CCF. Conclusions To ensure prevention of recurrent CCF, internal carotid artery trapping combined with high-flow bypass surgery can be a good salvage treatment for urgent cases in which an endovascular approach already failed.