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Although the recurrence of chronic subdural hematoma (CSDH) after surgical treatment significantly affects the patients' quality of life, the recurrence rate has not improved in decades. Goreisan, a Japanese herbal Kampo medicine, promotes the hydragogue effect and has been empirically used in the treatment of CSDH in Japan. We conducted a prospective randomized study to investigate whether Goreisan treatment decreases the recurrence rate of CSDH. Between March 2013 and December 2018, a total of 224 patients who underwent initial burr hole surgery for CSDH were randomly assigned to receive Goreisan for 3 months (Group G) or no medication (Group N). The primary endpoint was symptomatic recurrence within 3 months postoperatively, and the secondary endpoint was complications, including the adverse effects of Goreisan. Of 224 randomized patients, 208 were included in the final analysis (104 in Group G and 104 in Group N). The overall recurrence rate was 9.1% (19/208). The recurrence rate of Group G was lower than that of Group N (5.8% vs 12.5%, P = 0.09), but the difference was not statistically significant. However, a significant preventive effect of Goreisan was found in 145 patients with high-risk computed tomography (CT) features, namely, homogeneous and separated types (5.6% vs 17.6%, P = 0.04). Although the present study did not prove the beneficial effect of Goreisan treatment, it suggested the importance of selecting patients with an increased risk of recurrence. A subset of patients whose hematoma showed homogeneous and separated patterns on CT image might benefit from Goreisan treatment.

Dissemination of histologically benign hemangioblastoma is rare; approximately 30 cases have previously been reported, and all cases occurred several months to years after surgical resection. Herein, we report a case of hemangioblastoma in which leptomeningeal dissemination occurred 2 years after hypofractionated radiation therapy (39 Gy/13 fractions). The tumor was treated primarily with radiation without surgical resection. Biopsy of the disseminated lesion confirmed histological diagnosis as histologically benign hemangioblastoma. Ki67 index was not remarkably elevated for hemangioblastomas. In addition, the methylation class determined by the methylation profiling classifier developed by the German Cancer Research Center (DKFZ)/University Hospital Heidelberg/German Consortium for Translational Cancer Research was consistent with that of common hemangioblastomas. However, genetic analyses showed significant gains and losses throughout the whole genome, indicating that highly aberrant copy number profiles may be the key to elucidating this rare but life-threatening clinical entity. Accumulation of more detailed case reports based on the comparison of specimens obtained before and after surgery or radiation is necessary to better understand the pathophysiology of the dissemination phenotype of hemangioblastoma.

The therapeutic effect of carotid endarterectomy (CEA) on visual disturbance caused by chronic ocular ischemia due to carotid artery stenosis has not been validated. This prospective observational study aims to investigate whether CEA is associated with an increase in ocular blood flow (OBF) and postoperative visual improvement. In total, 41 patients with carotid artery stenosis treated by CEA between March 2015 and September 2018 were enrolled in this study. OBF was evaluated by laser speckle flowgraphy, which can measure the mean blur ratio (MBR) which is well correlated to the absolute retinal blood flow. Visual acuity was assessed before and after CEA by subjective improvement and objective visual assessment using CSV-1000, an instrument used to test contrast sensitivity. OBF increased after CEA on the operated side (mean MBR 33.5 vs 38.2, p

Background Vertebral artery injuries (VAIs) caused by cervical trauma include irregularities with narrowing of the arterial wall, dissection, pseudoaneurysm formation, occlusion, and transection. Although recent guidelines have recommended anticoagulant or antiplatelet therapy to prevent subsequent stroke in patients with traumatic VAIs, regardless of the type of vascular injury, the clinical role of endovascular surgery in the treatment of traumatic VAIs remains to be elucidated. Methods We retrospectively evaluated the treatment outcomes of 23 patients with cervical fracture and vertebral artery occlusion (VAO) who had required cervical surgery in the acute stage. Results No patient received antiplatelet or anticoagulant therapy, because the VAs had already become occluded. After cervical surgery, 5 of the 23 patients developed radiologically confirmed thromboembolic stroke after cervical surgery. None of these 5 patients with postoperative infarction had undergone preoperative VA embolization. Univariate analysis revealed that only the implementation of preoperative VA embolization was associated with the prevention of postoperative infarction (P = 0.004). Factors such as age, reduction, level of VAO, and diabetes mellitus did not correlate with increased risk. Conclusions The clinical role of endovascular surgery for traumatic VAI has not been previously established; however, a more specific selection of patients according to the VAI type might be necessary. Our data have indicated that preoperative embolization of the occluded VA significantly reduces the risk of postoperative infarction in a specific cohort of patients with traumatic VAI (i.e., patients with post-traumatic VAO who require cervical surgery).

Aneurysms at the distal portion of the superior cerebellar artery (SCA) are very rare. Because of the deep location and a propensity for nonsaccular morphology, aneurysm trapping or endovascular occlusion of the parent artery are the usual treatment options, which are associated with varying risks of ischemic complications. The authors report on a 60-year-old woman who had a 3.5-mm unruptured aneurysm in the lateral pontomesencephalic segment of the SCA with a significant interval growth to 8 mm. Direct surgical intervention comprising trapping of the aneurysm through a subtemporal approach and intradural anterior petrosectomy combined with revascularization of the distal SCA using the superficial temporal artery (STA) was performed. This approach provided sufficient space for the bypass instruments to be introduced into the deep surgical field at a more favorable angle to enhance microscopic visualization of the anastomosis with minimal retraction of the temporal lobe. The patient was discharged with no neurological deficit. Preservation of the blood flow in the distal SCA should be attempted to minimize the risk of ischemic injury, particularly when the aneurysms arise in the anterior or lateral segment of the SCA. The authors demonstrate the safety and effectiveness of the intradural anterior petrosectomy for STA-SCA bypass along with a relevant anatomical study.

Object Surgery for aneurysms at the anterior wall of the internal carotid artery (ICA), which are also referred to as ICA anterior wall aneurysms, is often challenging. A treatment strategy needs to be determined according to the pathology of the aneurysm—namely, whether the aneurysm is a saccular aneurysm with firm neck walls that would tolerate clipping or coiling, a dissecting aneurysm, or a blood blister–like aneurysm. However, it is not always possible to properly evaluate the condition of the aneurysm before surgery solely based on angiographic findings. Methods The authors focused on the location of the ophthalmic artery (OA) in determining the pathology of ICA anterior wall aneurysms. Between January 2006 and December 2012, diagnostic cerebral angiography, for any reason, was performed on 1643 ICAs in 855 patients at Saitama Medical Center. The authors also investigated the relationship between the origin of the OA and the incidence of ICA anterior wall aneurysms. The pathogenesis was also evaluated for each aneurysm based on findings from both angiography and open surgery to identify any correlation between the location where the OA originated and the conditions of the aneurysm walls. Results Among 1643 ICAs, 31 arteries (1.89%) were accompanied by an anomalous origin of the OA, including 26 OAs originating from the C3 portion, 3 originating from the C4 portion, and 2 originating from the anterior cerebral artery. The incidence of an anomalous origin of the OA had no relationship to age, sex, or side. Internal carotid artery anterior wall aneurysms were observed in 16 (0.97%) of 1643 ICAs. Female patients had a significantly higher risk of having ICA anterior wall aneurysms (p = 0.026). The risk of ICA anterior wall aneurysm formation was approximately 50 times higher in patients with an anomalous origin of the OA (25.8% [8 of 31]) than in those with a normal OA (0.5% [8 of 1612], p < 0.0001). Based on angiographic classifications, saccular aneurysms were significantly more common in patients with an anomalous origin of the OA than in those with a normal OA (p = 0.041). Ten of 16 patients with ICA anterior wall aneurysms underwent craniotomies. Based on the intraoperative findings, all 6 aneurysms with normal OAs were dissecting or blood blister–like aneurysms, not saccular aneurysms. Conclusions There was a close relationship between the location of the OA origin and the predisposition to ICA anterior wall aneurysms. Developmental failure of the OA and subsequent weakness of the vessel wall might account for this phenomenon, as previously reported regarding other aneurysms related to the anomalous development of parent arteries. The data also appear to indicate that ICA anterior wall aneurysms in patients with an anomalous origin of the OA tend to be saccular aneurysms with normal neck walls. These findings provide critical information in determining therapeutic strategies for ICA anterior wall aneurysms.

OBJECTIVE. Not much is known about surgical management of patients with chronic subdural haematoma (CSDH) treated with antiplatelet or anticoagulant therapy. The aims of this study were to review the surgical outcomes of patients with CSDH and assess the risks of antiplatelet in their surgical management. METHODS. We retrospectively analysed 448 consecutive patients with CSDH treated by one burr hole surgery at our institution. Among them, 58 patients had been on antiplatelet therapy. We discontinued the antiplatelet agents before surgery for all 58 patients. For 51 of these 58 patients (87.9%), early surgery was performed within 0-2 days from admission. We analysed the association between recurrence and patient characteristics, including history of antiplatelet or anticoagulant therapy; age (< 70 years or ≥ 70 years); side; history of angiotensin receptor II blocker, angiotensin converting enzyme blocker, or statin therapy; and previous medical history of head trauma, infarction, hypertension, diabetes mellitus, haemodialysis, seizure, cancer, or liver cirrhosis. RESULTS. Recurrence occurred in 40 patients (8.9%), which was one of the lowest rates in the literature. Univariate analysis showed that only the presence of bilateral haematomas was associated with increased recurrence rate while antiplatelet or anticoagulant therapy did not significantly increase recurrence risk. Also, the recurrence rate from early surgery (0-2 days from drug cessation) for patients on antiplatelet therapy was not significantly higher than that from elective surgery (5 days or more after drug cessation). However, multivariate analysis revealed that previous history of cerebral infarction was an independent risk factor for CSDH recurrence. CONCLUSIOns. Our overall data support the safety of early surgery for patients on the preoperative antiplatelet therapy without drug cessation or platelet infusion. Patients with a previous history of infarction may need to be closely followed regardless of antiplatelet or anticoagulant therapy.

Pilomyxoid astrocytoma (PMA) was recently classified as a variant of pilocytic astrocytoma (PA) with significantly more aggressive clinical features than those of PA. Like PAs, PMAs frequently arise in the chiasmatic/hypothalamic regions. The cerebellum is also a common site of occurrence for PAs but not for PMAs. We present the case of a 31-month-old boy with cerebellar PMA that showed rapid regrowth during the 3 months following the first subtotal resection. Gross total resection was achieved in the second surgery, followed by radiation to the tumor bed. During follow-up over the next 12 years, there has been no evidence of recurrence on magnetic resonance imaging. Although the prognosis of cerebellar PMAs remains unknown because of the paucity of cases, the relevant literature reports a more favorable outcome for cerebellar PMAs than for PMAs occurring at other locations. The results of this case study and a review of the relevant literature advocate radical resection, sometimes involving multiple surgeries, for cerebellar PMAs because gross total or near total resection is more feasible in the cerebellum than in other locations.

We describe microsurgical training methods for novice operators using gauze and tubes. Seven training methods were designed, and a neurosurgeon without microsurgical experience practiced these methods every day for about 3 years. After completing training, the neurosurgeon performed superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis, A3-A3 bypass, and occipital artery-posterior inferior cerebellar artery (OA-PICA) bypass. These training methods contribute to improving microsurgical technique, especially microvascular anastomosis, of novice operators.

Anorexia and emaciation result from various conditions, including digestive diseases, metabolic disorders, chronic inflammation, chronic infections, malignancies, and psychiatric problems. Intracranial tumors can also cause a reduction in food intake, thus mimicking anorexia nervosa, through various mechanisms. Fourth ventricular tumors, particularly hemangioblastomas, can cause prolonged appetite loss and extreme body weight loss, without any apparent focal neurologic deficits.

Background Cerebral ischemia associated with chronic CCA occlusion is a rare condition and raises strategic dilemma when the revascularization is needed. Methods Two patients with CCA occlusion presented with ischemic symptom associated with the affected side. Both patients underwent vascular reconstruction by direct carotid endarterectomy to achieve primary restoration of CCA to ICA flow. Results Successful reopening of the vessels was obtained in both patients without the evidence of postsurgical ischemic event. Follow-up MRA was obtained at later than 6 months after surgery, which demonstrated patent CCA-ICA in both patients. Conclusions Direct carotid endarterectomy of the occluded CCA can be safely performed if the preoperative angiography suggest still patent vessels distal to carotid bifurcation and the substantial “back flow” is obtained from ICA during arteriotomy.

Introduction We report a training technique of microvascular anastomosis readily accessible for trainees engaged in busy day-to-day clinical practice. Method A table-top microscope is prepared on a table and 10-0 nylon suture (nonsterile) is used to tie two adjacent gauze fibers to form successive knots. In a second step, the knots are untied using the suture needle, which we call the knots untying technique (KUT). As the tied knots face different directions, it is difficult to guide the needle accurately through the knots without damaging or breaking the suture. And to untie all the knots within a certain time period, high controllability is required. Results The practice of KUT will allow surgeons to improve their ability to accurately guide the needle from any direction and carry out precise suturing swiftly, which will prevent vascular wall dissection during microvascular anastomosis or inability to guide the needle to a target point because of physiologic tremor. Conclusions In our experience of training young neurosurgeons, practice of KUT contributes to shortening the duration of blood-flow blockage and helps mastering the technique of successful microvascular anastomosis.

Intracranial abscesses account for 2% of the intracranial mass even in advanced countries. Because of the variety of causative organisms and symptoms, a standard treatment for intracranial abscess has not yet been established.We retrospectively reviewed the treatment outcomes for intracranial brain abscess and subdural abscess to assess the risk factors for poor prognosis and problems related to treatment.In total, 28 patients were included in this study. Preceding craniocervical infections were found in 35.7% of patients. In 39.3% of patients, causative organisms were not identified. The treatment outcome evaluated using the modified Rankin Scale was 0 in 17 patients, 1 in 1 patient, 2 in 2 patients, 4 in 3 patients, 5 in 1 patient, and 6 in 4 patients. All mortality was noted in patients older than 60 years. Advanced age and the development of ventriculitis were significantly associated with poor outcome, i.e., a modified Rankin Scale score of 4 or worse. In contrast, the presence of fever or headache as initial symptoms, severity of neurological deficit, location of the abscess, and lack of identification of causative organism were not related to poor outcome. Compared with our previous treatment results, diffusion-weighted MR imaging has significantly contributed to the improvement of outcomes.Early administration of antibiotic therapy based on MR findings was critical in obtaining a good outcome in the treatment of brain abscess. Based on our experience, treatment should be continued, even for patients in a critical condition.

We envisage the efficacy and safety of intra-arterial infusion of fasudil hydrochloride (IAF) for symptomatic vasospasm (SVS) after subarachnoid hemorrhage (SAH). We compared results obtained from the groups that received selective IAF (a microcatheter inserted in intracranial arteries) and nonselective IAF (a microcatheter inserted in the cervical arteries). Glasgow Outcome Scale (GOS) value and computed tomographic (CT) score were used to evaluate clinical outcome and the extent of infarction due to delayed vasospasm.Over 2 years, 113 patients with SAH underwent clipping or coiling. Among them, 31 patients (27.4%) developed SVS. We performed nonselective IAF in 10 patients and selective IAF in 10 other patients. Eleven patients with SVS were treated without IAF. The data were statistically analyzed.By univariate linear regression analysis, IAF negatively correlated with CT score (p = 0.016), but IAF was significantly correlated with GOS (p = 0.035). By multiple regression analysis, Hunt and Kosnik grade and CT score significantly correlated with GOS.CT score significantly correlated with functional outcome. Although IAF, both selective and nonselective, was significantly effective for the treatment of delayed vasospasm, the former seemed to be more beneficial.

Background Some ruptured intracranial aneurysms concomitant with major artery occlusion may not be amenable for standard clipping or coiling due to the specific hemodynamic conditions. The long-term effect of flow reduction therapy for such aneurysms is largely unknown. Case Presentation A 45-year-old woman presented with subarachnoid hemorrhage due to a ruptured basilar tip aneurysm. Angiography revealed that the bilateral internal carotid arteries were hypoplastic and that the anterior circulation was fed by the collateral flow through the bilateral posterior communicating arteries and the posterior choroidal arteries. Endovascular treatment failed because it was extremely difficult to secure the catheter at the neck of the aneurysm and insert the coil safely because it was a small aneurysm with a wide neck. In addition, direct clipping was risky due to the location and projection of the aneurysm. We therefore adopted the 2-stage bilateral superficial temporal artery–middle cerebral artery bypass to alleviate the vascular demand on the anterior circulation, with the aim of reducing the hemodynamic stress to the basilar bifurcation. The patient had no rebleeding for 4 years after surgery, with gradual shrinkage of the aneurysm. Conclusion All the possible treatment options should be carefully assessed because the long-term effect of the flow alternation method to prevent rebleeding has not been proved. However, our case suggests that the strategy of reducing the hemodynamic stress at the parent artery may be effective even in selected cases of ruptured aneurysms for which standard clipping or coiling is not feasible.

Background: It is difficult to intraoperatively confirm the total disappearance of arteriovenous (AV) shunts during surgery for microarteriovenous malformations (micro-AVMs), especially when the nidus is extremely small or diffuse on preoperative angiography. Although intraoperative angiography is effective for evaluating residual shunts, procedure-related risks raise important concerns. The purpose of this study was to assess the usefulness of intraoperative indocyanine green-based videoangiography (ICG–VA) to determine complete disappearance of micro-AVMs during surgery. Methods: We retrospectively analyzed eight patients with ruptured micro-AVMs who were treated using craniotomy with ICG–VA at our institution. Results: Two patients underwent emergency partial evacuation of hematoma and external decompression before the diagnostic angiography. While three patients had a nidus smaller than 1 cm, five patients had only early draining veins without an appreciable nidus. The draining veins were superficial in six cases and deep in two cases. The average interval from onset to surgery was 33 days (range, 2–57). ICG–VA was repetitively conducted until disappearance of the AV shunt was confirmed. No residual AV shunt was observed on postoperative radiological examinations. In all cases, the diagnosis of AVM was confirmed from the results of postoperative pathological examination. Conclusions: ICG–VA could detect early draining veins more clearly in situ than diagnostic angiography. Although it is not as effective for visualizing lesions with deep draining veins, repetitive ICG–VA was safe and effective for confirming the disappearance of AV shunts with superficial drainage.