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Background: The microsurgical treatment of large and giant aneurysms poses a challenge and direct clipping is still prefferred: this is very dificulttask withrisksofintraoperativerupture. Microsurgical clipping with angioplastic arrangement of clips at the neck along with retrograde suction evacuation of the blood from the proximal internal carotid artery and aneurysm have been advocated in order to avoid these problems. Methods: This is a retrospective study of 13 patients with 13 large/ giant internal carotid artery aneurysms, who were managed surgically with retrograde suction decompression assisted clipping at our center over a period of last 2 years. The clinical profile, details of surgical management, complications and outcome of these patients were analysed. In the preoperative assessment, MRI/MR Angiography brain, 3Dimensional- Computed Tomography scan along with diagnostic angiography and balloon occlusion test were performed. The surgical technique has been described in detail. Results: The age ranged from 36-79 years old. There were 7 males and 6 females. 11 patients had unruptured aneurysms, while 2 presented with subarachnoid hemmorrhage. There were no peri-operative complications. In the post-operative period, one patient had severe disabilty with right sided hemiparesis due to the thrombo-embolic phenomenon, while the rest had an excellent outcom, with no mortality. Conclusions: Retrograde suction decompression is an effective aid in surgical management of large and giant aneurysms with many advantages. It is certainly an extremely useful adjunct for obtaining early proximal control so that safe clip application can be achieved. Intra-operative angiography can be performed easily to check adequacy of aneurysm clipping. Integration of endovascular techniques in management of complex aneurysms has made posible the advancement of the therapeutic armentarium.

Even with the use of most sophisticated microscope sometimes the relationship between the aneurysm and the adjacent structures are not clearly defined. The straight line of view by microscope results in inadequate visualization of structures that lie immediately behind other structures like the neck, branches or perforators of the aneurysm. Hence exposure of these structures may require risky retraction either of the parent artery or the aneurysm itself, which can be overcome by clear anatomical information obtained by the use of endoscope instead of attempting extensive manipulation under the microscope. The endoscope permits close up, wide angled views of regional anatomic features and verification of the optimal clip position. Visual conformation of regional anatomy achieved using the rigid endoscope provides valuable information for subsequent microsurgical procedures and enhances the safety and reliability. Endoscopic-assisted microsurgery is an exceptional aid and using the PIP (picture-in picture) technology, simultaneous observation of microscope and endoscopic images can be viewed through the ocular system of microscope. The advantages of neuroendoscope include the ability to look around corners and behind obstructions. With less brain retraction, smaller operative exposures and better visualization, neuroendoscopy may reduce operative morbidity. However the surgeon should be familiar with this technique and be prepared for the inconveniences and risks during the procedure.

We previously demonstrated that the inflammatory cytokine interleukin-6 (IL-6) activates the Janus kinase (JAK)-signal transducer and activator of transcription (STAT) signaling pathway in fibroblasts within the outer membranes of chronic subdural hematomas (CSDHs), and the activation of this pathway may induce CSDH outer membrane growth. The inhibitory system for this signal transduction pathway is unknown. CSDH fluids were obtained from 10 patients during trepanation surgery as the case group, and cerebrospinal fluid (CSF) samples were obtained from seven patients suffering from subarachnoid hemorrhage (SAH) on Day 1 as the control group. The concentrations of IL-6, soluble IL-6 receptor (sIL-6R), and soluble gp130 (sgp130) in CSDH fluid and CSF were measured using enzyme immunoassay kits. The co-localization of IL-6 and sgp130 in CSDH fluid was examined by immunoprecipitation. The expression levels of STAT3, JAK2, suppressor of cytokine signaling 3 (SOCS3), and protein inhibitor of activated Stat3 (PIAS3) in the outer membranes of CSDHs were examined by immunostaining. Soluble IL-6R and sgp130 concentrations in CSDH fluid were significantly higher than those in CSF after SAH. Sgp130 and IL-6 were co-immunoprecipitated from CSDH fluid. Immunostaining revealed STAT3, JAK2, SOCS3, and PIAS3 expression in fibroblasts located in the outer membranes of CSDHs. Soluble gp130 binds to IL-6/sIL-6R and acts as an antagonist of the JAK/STAT signaling pathway. SOCS3 also binds to JAK and inhibits its signaling pathway. In addition, PIAS3 regulates STAT3 activation. These factors might down-regulate the IL-6/JAK/STAT signaling pathway in fibroblasts within CSDH outer membranes. Therefore, these molecules may be novel therapeutic targets for the inhibition of CSDH growth.

Intraoperative rerupture (IOR) during clipping of cerebral aneurysms is a difficult complication of microneurosurgery. The aim of this study was to evaluate the incidence of IOR and analyze the strategies for controlling profound hemorrhage. A total of 165 patients with unruptured intracranial aneurysms and 46 patients with subarachnoid hemorrhage (SAH) treated surgically between April 2010 and March 2011, were reviewed. The data were collected with regard to age, sex, presence of symptoms, confounding factors and strategy for controlling intraoperative hemorrhage was analyzed in terms of location of aneurysms, timing of rupture and severity of IOR. 211 patients with 228 aneurysms were treated in this series. There were a total of six IORs which represented an IOR rate of 2.84% per patient and 2.63% per aneurysm. The highest ruptures rates occurred in patients with internal carotid artery aneurysms (25%). Surgeries in the group with ruptured aneurysms had a much higher rate of IOR compared with surgeries in the group with unruptured aneurysms. Of the six IOR aneurysms, one occurred during predissection, four during microdissection and one during clipping. One was major IOR, three were moderate and two were minor. Intraoperative rupture of an intracranial aneurysm can be potentially devastating in vascular neurosurgery. Aneurysm location, presence of SAH and surgical experience of the operating surgeon seem to be important factors affecting the incidence of IOR.

We present our experience with elective microsurgical clipping of unruptured intracranial aneurysms (UIA) and analyze this management. A total of 150 patients with UIA were reviewed and data were collected with regard to age, sex, presence of symptoms, location and size of the aneurysms, surgical complications and postoperative 1 year outcomes. Aneurysm size was assessed either by three-dimensional CT angiography or digital subtraction angiogram. Glasgow Outcome Scale was used to assess clinical outcomes. One hundred and fifty patients with 165 aneurysms were treated in this series. The mean size of the UIA was 5.6mm. Eighty aneurysms (48.5%) were less than 5mm in size, and 73 (44.2%) were from 5 to 10mm. Ten (6.1%) of the aneurysms were large and two (1.2%) were giant. One hundred and forty-three were asymptomatic and seven were symptomatic before surgery. The outcome was good in 147 patients (98%), and only three patients (2%) had a treatment-related unfavorable outcome. Five patients experienced transient neurological deficits and one patient experienced permanent neurological deficits. Overall 98.7% of the treated aneurysms were satisfactorily obliterated. Wound complications were seen only in three patients. In conclusion, UIA pose a significant challenge for neurosurgeons, where a delicate balance between benefits and possible risks must be weighed. If the requisite expertise is available, they can be treated surgically with low morbidity and a good outcome at specialized neurovascular centers.

Neurogenic pulmonary edema (NPE) occurs frequently after aneurysmal subarachnoid hemorrhage (SAH), and excessive release of catecholamines (epinephrine/norepinephrine) has been suggested as its principal cause. The objective of this retrospective study is to evaluate the relative contribution of each catecholamine in the pathogenesis of NPE associated with SAH. Records of 63 SAH patients (20 men/43 women) whose plasma catecholamine levels were measured within 48 h of SAH onset were reviewed, and the clinical characteristics and laboratory data of those who developed early-onset NPE were analyzed thoroughly. Seven patients (11 %) were diagnosed with NPE on admission. Demographic comparison revealed that the NPE+ group sustained more severe SAH than the NPE− group. Cardiac dysfunction was also significantly more profound in the former, and the great majority of the NPE+ group sustained concomitant cardiac wall motion abnormality. There was no significant difference in the plasma epinephrine levels between NPE+ and NPE− group (324.6 ± 172.8 vs 163.1 ± 257.2 pg/ml, p = 0.11). By contrast, plasma norepinephrine levels were significantly higher in the NPE+ group (2977.6 ± 2034.5 vs 847.9 ± 535.6 pg/ml, p

Chronic subdural hematoma (CSDH) is fundamentally treatable through surgery, although CSDH recurs in some cases. We have observed several cases of spontaneous resolution of CSDH outer membranes, including in trabecular CSDH, after trepanation surgery. In this study, we examined the expression of molecules involved in caspase signaling in CSDH outer membranes. Eight patients whose outer membranes were obtained successfully during trepanation surgery were included in this study. The expression of Fas; Fas-associated death domain (FADD); tumor necrosis factor receptor type 1-associated death domain (TRADD); receptor-interacting protein (RIP); caspases 3, 7, 8, and 9; poly-(ADP-ribose) polymerase (PARP); DNA fragmentation factor 45 (DFF45) and β-actin was examined by Western blot analysis. The expression levels of PARP, caspase-3, and cleaved caspase-3 were also examined by immunohistochemistry. Fas; FADD; TRADD; RIP; caspases 3, 7, 8, and 9; PARP, and DFF45 were detected in nearly all samples. Caspase-3 and PARP were localized in the endothelial cells of vessels and in fibroblasts in CSDH outer membranes. In addition, cleaved caspase-3 was detected in fibroblasts. We detected molecules of the caspase signaling pathway in CSDH outer membranes. In particular, cleaved caspase-3 was detected, which suggests that apoptosis may occur within these membranes. Thus, during the growth of CSDH outer membranes, the caspase signaling pathway may be restrained. Once the pathway is activated, gradual resolution of CSDH outer membranes may occur. Therefore, these molecules may be novel therapeutic targets for intractable CSDH.

The vascular type of Ehlers-Danlos syndrome (vEDS) is an autosomal dominant hereditary disease characterized by connective tissue fragility throughout the body, including the arteries, viscera, and gastrointestinal tract. We report a case in which we performed transvenous embolization (TVE) via direct superior ophthalmic vein (SOV) approach to treat a direct carotid-cavernous fistula (CCF) in a patient with Ehlers-Danlos syndrome (EDS). The patient was a 37-year-old woman who developed tinnitus in her left ear and a headache during examination in the outpatient clinic of another hospital in order to make a definitive diagnosis of vEDS, and she was referred to our hospital and examined. Based on the results of all of the studies she was diagnosed with a CCF. Conservative treatment was attempted, but was not very effective. Because of progressing aphasia, TVE was performed via the SOV direct cut. There were no intraoperative or postoperative complications. It has been reported that cerebral angiography is generally contraindicated in vEDS and that the morbimortality associated with endovascular treatment is very high. When performing treatment it is necessary to be sufficiently aware of the risks it entails.

Background Malignant hemispheric infarction is a life-threatening condition with a high mortality rate. Decompressive hemicraniectomy (DHC) is frequently a life-saving procedure that has shown the highest grade of evidence for patients 18 to 60 years of age. However, the efficacy of DHC in patients >60 years of age has rarely been investigated. Methods A retrospective study was conducted in a single academic institution. Surrogates of patients with clinical signs of impending brain herniation despite standard medical therapy were offered the option of DHC regardless of age or the side of the lesion. The clinical data from 18 patients >60 years of age who underwent DHC for malignant hemispheric infarction in our institution were analyzed. Patients were classified into the following 2 groups: 61-70 and >70 years of age, and their demographics and surgical outcomes were compared. The variables compared included the male:female ratio, side of the lesion, type of stroke, site of vascular occlusion, use of thrombolytic therapy, National Institutes of Health Stroke Scale score, stroke onset-to-DHC interval, duration of hospital stay, infectious complications, and 90-day mortality rate. Results There were no significant intergroup differences in any of the demographic variables evaluated. However, the 30-day mortality rate was significantly higher in the group that was >70 years of age (0% v 60%; P = .01) than in the group that was 61 to 70 years of age. Conclusions We suggest that the efficacy of DHC in malignant hemispheric stroke patients between 61 and 70 years of age be further investigated in future randomized trials. By contrast, it appears unlikely that patients >70 years of age would benefit from DHC.

Stereotactic biopsy has been validated for tissue sampling of deep-seated lesions that cannot be easily resected via open craniotomy. However, some inherent problems including the inability to directly observe the lesion and difficulty in confirming hemostasis limit its usefulness. To overcome these issues, we used the endoscope in brain tumor biopsy, for not only intraventricular tumors but also intraparenchymal tumors. The rigid scope was used in association with a surgical navigation system for intraparenchymal lesions via a transcortical route. There were no useful anatomical landmarks when the trajectory to the lesions was decided; therefore, surgical navigation system was required for the transcortical procedures. The endoscopic procedure described here was attempted in 21 cases of intraparenchymal lesions between January 2007 and February 2012. A definitive diagnosis was obtained in all cases, and genetic analysis was performed when required. Serious postsurgical hemorrhage or neurological deficits were not observed in any cases. Endoscopic surgery provides a clear view of the target and makes it easier to differentiate tumor tissue from normal brain tissue. Moreover, the endoscope helped to confirm hemostasis during the procedure. Thus, endoscopic biopsy has the potential to contribute toward safe and reliable diagnosis of brain tumors.

Background Interleukin-6 (IL-6), an inflammatory cytokine, plays important roles in cerebrospinal fluid (CSF) after subarachnoid hemorrhage (SAH). Chemokines are chemoattractant cytokines that regulate trafficking of monocytes/macrophages and lymphocytes to sites of inflammation. However, no studies have been reported regarding the temporal expression of these cytokines in CSF after SAH. Findings The concentrations of IL-6, monocyte chemoattractant protein-1 (MCP-1), interferon-γ-inducible protein-10 (IP-10), and monokine induced by interferon-γ (MIG) in the CSF of ten patients with SAH were measured using ELISA kits over a period of 14 days. All aneurysms were located in the anterior circulation. CSF samples from patients with unruptured aneurysms were used as controls. The concentration of IL-6 significantly increased during the acute stage of the disease. The concentration of MCP-1 increased from days 1 to 5, peaking on day 3, and decreased thereafter. The concentrations of IP-10 and MIG progressively increased, peaked on day 5, and then gradually decreased. There were strong correlations between the maximum levels of IL-6 and MCP-1 and IP-10 and MIG on day 5. The maximum level of IL-6 was much higher in poor outcome patients than in good outcome patients. Conclusions The present investigation demonstrated that increases in IL-6 levels may induce the expression of MCP-1 in CSF after SAH, followed by increases in the expression of IP-10 and MIG. Dynamic changes in the levels of these cytokines may induce inflammation and may be closely associated with the development of delayed ischemic neurological deficits after SAH. Electronic supplementary material The online version of this article (doi:10.1186/s12974-016-0675-7) contains supplementary material, which is available to authorized users.

Objective Chronic subdural hematoma (CSDH) is considered an angiogenic and inflammatory disease. Interleukin-6, a well-known inflammatory cytokine, activates the Janus kinase/signal transducer and activator of transcription (JAK/STAT) signaling pathway. We previously reported that the JAK/STAT pathway is activated in fibroblasts in the outer membrane of CSDH. More recently, signal transducer and activator of transcription 3 (STAT3) has been shown to have a role in angiogenesis. We examined the expression of STAT3 in endothelial cells in the outer membrane of CSDH. Methods This study included 7 patients whose outer membranes were successfully obtained during trephination surgery. The expression of STAT3 and phosphorylated STAT3 was examined by Western blot analysis and immunohistochemistry. We also examined whether CSDH fluid could activate STAT3 in cultured endothelial cells in vitro. Results STAT3 and phosphorylated STAT3 were detected in all cases. Immunostaining showed that STAT3 and phosphorylated STAT3 were expressed not only in fibroblasts but also in vascular endothelium. Expression of phosphorylated STAT3 in endothelial cells was significantly induced immediately after treatment of CSDH fluid in vitro. The activation of STAT3 was significantly inhibited by treatment with antibodies that were directed against interleukin-6; however, this was suppressed by antibodies that were directed against vascular endothelial growth factor, but not significantly. Conclusions Interleukin-6 might dominantly activate STAT3 in endothelial cells, which might have a central role in endothelial cell proliferation and angiogenesis of CSDH outer membranes.

Statistical analysis comparing the good recovery (GR) group (n = 5) and the moderate disability (MD) plus vegetative state (VS) group (n = 5) via the Mann-Whitney U test. (DOC 28 kb)

Correlation coefficients showing the relationships among the levels of interleukin-6 (IL-6), monocyte chemoattractant protein-1 (MCP-1), interferon-Îł-inducible protein-10 (IP-10), and monokine induced by interferon-Îł (MIG). The maximum value of each cytokine or chemokine was adopted as its peak value. (DOC 28 kb)

Objective To evaluate the feasibility and limitations of the contralateral approach to unruptured superior hypophyseal artery (SHA) aneurysms. Methods Data regarding eight cases of superior hypophyseal artery aneurysms operated on by a contralateral pterional approach at our center from January 2008 to September 2010 were collected and evaluated retrospectively. Of these eight cases, six were male and two were female. The mean age was 57.1 years (range 28 years to 77 years). All the aneurysms were unruptured; five were on right side and three were on left side. The surgical technique and outcome of patients were reviewed. Results All aneurysms were successfully clipped without complication and patency of all superior hypophyseal arteries was preserved. Postoperative three-dimensional computed tomography angiography revealed residual aneurysm in only one case. None of the patients had deterioration of visual acuity or field after surgery. The contralateral pterional approach was found to be appropriate for fully exposing the aneurysmal dome and neck without retraction of the optic nerve or the carotid artery in five cases. Slight retraction of the optic nerve was required in two cases, and significant manipulation of the optic nerve was required in one case. Conclusions The contralateral pterional approach for clipping of unruptured superior hypophyseal artery aneurysms is technically feasible and safe in a select group of patients where optimal results can be achieved without significant retraction of near by neurovascular structures.

Sub-arachnoid hemorrhage (SAH) has been easily one of the most debilitating neurosurgical entities as far as stroke related case mortality and morbidity rates are concerned. To date, it has case fatality rates ranging from 32-67%. Advances in the diagnostic accuracy of the available imaging methods have contributed significantly in reducing morbidity associated with this deadly disease. We currently have computed tomography angiography (CTA), magnetic resonance angiography (MRA) and the digital subtraction angiography (DSA) including three dimensional DSA as the mainstay diagnostic techniques. The non-invasive angiography in the form of CTA and MRA has evolved in the last decade as rapid, easily available, and economical means of diagnosing the cause of SAH. The role of three dimensional computed tomography angiography (3D-CTA) in management of aneurysms has been fairly acknowledged in the past. There have been numerous articles in the literature regarding its potential threat to the conventional "gold standard" DSA. The most recent addition has been the introduction of the fourth dimension to the established 3D-CT angiography (4D-CTA). At many centers, DSA is still treated as the first choice of investigation. Although, CT angiography still has some limitations, it can provide an unmatched multi-directional view of the aneurysmal morphology and its surroundings including relations with the skull base and blood vessels. We study the recent advances in the diagnostic approaches to SAH with special emphasis on 3D-CTA and 4D-CTA as the upcoming technologies.

This case report presents the unusual holospinal dissemination of a neurenteric cyst, which was successfully treated by fenestration and placement of a subarachnoid-peritoneal (SP) shunt. The patient was a 46-year-old Japanese woman with a history of fourth ventricle neurenteric cysts, which were managed with cyst fenestration in 1996 and 2005. She had been doing well until January 2006, when she developed dizziness and an unsteady gait. A neurological examination revealed a disturbance in the deep sensation of the feet. A neuroimaging evaluation demonstrated multiple cystic lesions in the whole spinal canal, which significantly distorted the spinal cord. Because the spinal cord distortion was the most severe in the lower cervical to upper thoracic areas, a unilateral osteoplastic laminotomy with an endoscopic cyst fenestration was performed in these areas, followed by placement of an SP shunt. The pathological diagnosis was a disseminated neurenteric cyst. There was no malignancy, and the patient has been well, with an improved gait and no signs of peritoneal dissemination, for > 1 year. The present case showed a unique extent of dissemination, which was most likely a secondary characteristic. Neurenteric cysts are well known for their tendency to recur, and total removal is usually difficult because of adhesion of the cyst membrane to important structures. The lesion also compromises cerebrospinal fluid circulation. Cyst fenestration combined with SP shunt placement might be a treatment option in such a case.

OBJECTIVE We present a rare case of neurosarcoidosis mimicking an intramedullary tumor in the medulla oblongata. The features of the clinical presentation, magnetic resonance (MRI) appearances, and management strategy are discussed. CASE PRESENTATION A 59-year-old man without evidence of systemic sarcoidosis was presented with a history of progressive numbness and deep sensation disturbance in bilateral lower extremities. MR imaging revealed an enhanced intra-axial mass lesion on the dorsal side of medulla. Under neurophysiological monitoring, tumor biopsy was performed. Pathologic evaluation revealed noncaseating granuloma composed of large epithelioid cells with multinucleated giant cells, suggesting sarcoidosis. Findings of comprehensive hematologic laboratory studies; cerebrospinal fluid examination; and examinations for bacteria, fungi, and acid fast bacilli were all negative. This mass lesion was diagnosed as medullary neurosarcoidosis, and then high-dose steroid therapy was tried. On follow-up, nearly complete resolution of the neurosarcoidosis on MRI was revealed. CONCLUSION To our knowledge, this is the first reported case of neurosarcoidosis manifested in the medulla oblongata. A biopsy is sufficient for a diagnosis and high-dose steroid is recommended.

A 67-year-old woman with neurofibromatosis type 1 presented with progressive dyspnea. Radiologic evaluation and magnetic resonance imaging revealed progression of a giant meningocele associated with hydrothorax. Laminoplasty with incision of the meningocele and dural plasty was performed, although nerve rootlets were killed. Microsurgical incision of the neck of the meningocele is a favorable operation even in large meningoceles such as the present case.

To assess the importance of pre-operative embolisation, 27 cases of cerebral artriovenous malformation (AVM) treated in this institute between July 1994 and October 1998 were analysed. The patients' ages ranged from 3 to 70 years (average 36.9) with a follow-up period of 1-41 months (average 19.2). The patient presented with haemorrhage in 21 cases and seizure in five. In 21 of 27 cases, surgical resection of a nidus was performed, gamma knife therapy was applied in three and conservative therapy was chosen in three. Of 21 cases treated surgically, total removal was achieved in 19 cases and a residual nidus was seen in one (a large basal ganglia AVM). In the remaining case, postoperative angiography was not available. Pre-operative embolisation followed by surgical resection of the nidus was performed in seven cases in which there was a large AVM. A volume index was calculated to indicate the size of the nidus using X x Y x Z, where X is the maximum diameter (cm) of the nidus on the lateral angiogram, Y is the diameter (cm) perpendicular to X and Z is the maximum diameter (cm) on the anteroposter or angiogram. The index averaged 45.9 for the cases in which pre-operative embolisation was performed, while it was 5.6 in the cases without embolisation. Pre-operative embolisation was performed to reduce the nidus flow as much as possible, to prevent overload to the surrounding structures. At surgery, the nidus was resected from the surrounding tissue and care was taken not to enter the nidus. Postoperatively, the systolic blood pressure was maintained at 90-100 mmHg for several days in the intensive care unit. The results were excellent in 15 cases, good in three (hemiparesis due to the initial haemorrhage remained in all three), fair in one (a patient with a severe subarachnoid haemorrhage). Two patients died (acute pulmonary oedema and severe meningitis). Minor postoperative bleeding or oozing was seen in three cases. In conclusion, reducing the shunt flow through a nidus in a step-wise fashion with pre-operative embolisation of a large AVM seems to be quite helpful in preventing postoperative haemodynamic overload to the surrounding brain. It is also important not to enter the nidus when it is removed at surgery. This helps to prevent intraoperative and/or postoperative bleeding, and led to successful total removal of the nidus with a good postoperative course.

Seizures occurring after clipping of unruptured cerebral aneurysms have rarely been documented in the literature. The objective of this retrospective study is to clarify whether the frequency of early seizures, i.e., seizures occurring within 14 days of surgery, is influenced by patient- or aneurysm-specific characteristics. Data on 1,000 consecutive patients who underwent clipping of unruptured anterior circulation aneurysms were reviewed. They consisted of 387 men and 613 women with mean age of 59.8 ± 9.7 years. Fifty-one patients (5.1 %) developed early seizures. Interestingly, the frequency was similar to that occurring after clipping of unruptured posterior circulation aneurysms (n = 20, 5.0 %). Multivariate regression analysis revealed that younger age was correlated with early seizures (odds ratio (OR) 0.902; 95 % confidence interval (CI) 0.891–0.989). However, other variables, including aneurysm size and operation length, were not correlated. Although patients with history of epilepsy exhibited relatively high frequency of early seizures, the difference was not statistically significant. The frequency was unaffected by location or multiplicity of aneurysms. Thirty-one patients (61 %) developed seizures within 24 h of clipping. Regarding seizure types, 34 (67 %) developed generalized seizures and the other 17 (33 %) experienced partial seizures. Patients with generalized seizures were significantly more likely to harbor an iatrogenic brain lesion than those with partial seizures (47 vs. 18 %; OR 4.148; 95 % CI 1.005–17.113). Among 40 patients with follow-up period >12 months, seizures were temporary without recurrence in 38 (95 %). Although early seizures are mostly benign, a small possibility of them becoming a permanent morbidity needs to be explained to patients undergoing elective clipping.

Chronic subdural haematoma (CSDH) is an uncommon but potentially serious complication of clipping unruptured cerebral aneurysms. We conducted a study to identify the patients who are at risk of developing postoperative CSDH. The data from 713 consecutive patients who underwent clipping of unruptured anterior circulation aneurysms were reviewed, and risk factors correlated with CSDH were identified by multivariate regression analysis of demographic variables. Fifteen patients (2.1%) developed CSDH after the surgery. Advanced age (odds ratio [OR] 1.151, 95% confidence interval [CI] 1.051-1.261) and male gender (OR 3.167, 95% CI 1.028-9.751) were correlated with CSDH. Subsequently, all 713 patients were quadrichotomized on the basis of gender and age, with 70 years as the cut-off value for age. The frequency of CSDH in men70 years of age was 1.3% and that in men ≥70 years of age was 15.1%, with risk of CSDH was significantly higher in the older men (OR 13.39; 95% CI: 3.42-52.44). The frequency of CSDH in women70 years of age was 0.6% and that in women ≥70 years of age was 3.7%. As in men, the risk of CSDH was significantly higher in the older women (OR 6.69, 95% CI 1.10-40.73). The interval between the aneurysm clipping and CSDH development was 0.5-6 months, suggesting that clinical observation should be continued up to 6 months after surgery. Although prognosis for patients with a postoperative CSDH complication is generally favourable, the risk of CSDH should be taken into account when considering elective clipping of unruptured aneurysms in patients ≥70 years of age.

Objective: To discuss the role of FLOW 800 innovative software for analytical color visualization and objective evaluation of fluorescence videos obtained by microscope-integrated intraoperative indocyanine green (ICG) fluorescence angiography in arteriovenous malformations (AVM) surgery. Materials and Methods: Microscope-integrated intraoperative FLOW 800 was used and evaluated in three consecutive AVM surgeries over a period of two months. The role of FLOW 800 to distinguish feeding arteries from arterialized veins and other arteries was evaluated. Its advantages and limitations over conventional intraoperative ICG angiography were evaluated. Results: This software was found to be useful in identifying arterial feeders, arterialized veins and other arteries in all the three patients and it gives additional information on the status of AVM before and after clipping suspected feeders which is sometimes difficult to interpret on conventional ICG angiography. Conclusion: Flow 800 is a reliable and useful addition to microscope-integrated color ICG video angiography. Although its role is limited in deep-seated AVMs, if properly dissected and exposed it can give useful information which can be easily interpretable and reproducible.

OBJECTIVE: The aim of this study was to present our experience with retrograde suction decompression in clipping of large and giant cerebral aneurysms and analyze its advantages and pitfalls. METHODS: A retrospective analysis of 27 patients with large and giant intracranial aneurysms treated by suction decompression assisted clipping between November 2005 and February 2010 was done. The surgical technique and the outcome of patients were reviewed. RESULTS: All aneurysms were successfully clipped, and postoperative 3-D CTA or DSA revealed no major branch occlusion or residual aneurysm. There was no surgical mortality in both giant and large aneurysm groups. CONCLUSION: Retrograde suction decompression is a successful adjunct to clipping of large and giant cerebral aneurysms.

We present our preliminary experience with intraoperative near-infrared indocyanine green-videoangiography (ICG-VA) and analysis of blood flow dynamics using fluorescence intensity assessment in cerebral aneurysm clipping surgery. Thirty-nine patients with 43 intracranial aneurysms underwent microsurgical clipping. Intraoperative ICG-VA was performed before and after clip application. An infrared fluorescence module integrated into a surgical microscope was used to visualize fluorescence in the surgical field and we recorded the emitted fluorescent light. An integrated analytical visualization tool simultaneously analyzed the video sequence and converted it into an intensity diagram, which allowed an objective evaluation of the results rather than the subjective assessment of fluorescence using ICG-VA. Overall, ICG-VA was performed 137 times. Incomplete clipping was detected in four patients, which allowed suitable adjustment to completely obliterate the aneurysm. In 12 patients, perforators arising close to, or from, the aneurysmal neck were identified in the surgical field. In three patients, the ICG-VA intensity diagram provided valuable information leading to modification of the primary surgical maneuver. ICG-VA provides high resolution images allowing real-time assessment of the blood flow in the parent artery and arterial branches, including the perforators. The intensity diagram is useful for providing a more objective record of the hemodynamics than the traditional ICG-VA, which relies more on subjective assessment and may allow interobserver variability. We conclude that ICG-VA, combined with the intensity diagram, can reduce the morbidity and complications associated with aneurysm clipping and improve patient outcomes.

This case report presents the unusual holospinal dissemination of a neurenteric cyst, which was successfully treated by fenestration and placement of a subarachnoid-peritoneal (SP) shunt. The patient was a 46-year-old Japanese woman with a history of fourth ventricle neurenteric cysts, which were managed with cyst fenestration in 1996 and 2005. She had been doing well until January 2006, when she developed dizziness and an unsteady gait. A neurological examination revealed a disturbance in the deep sensation of the feet. A neuroimaging evaluation demonstrated multiple cystic lesions in the whole spinal canal, which significantly distorted the spinal cord. Because the spinal cord distortion was the most severe in the lower cervical to upper thoracic areas, a unilateral osteoplastic laminotomy with an endoscopic cyst fenestration was performed in these areas, followed by placement of an SP shunt. The pathological diagnosis was a disseminated neurenteric cyst. There was no malignancy, and the patient has been well, with an improved gait and no signs of peritoneal dissemination, for1 year. The present case showed a unique extent of dissemination, which was most likely a secondary characteristic. Neurenteric cysts are well known for their tendency to recur, and total removal is usually difficult because of adhesion of the cyst membrane to important structures. The lesion also compromises cerebrospinal fluid circulation. Cyst fenestration combined with SP shunt placement might be a treatment option in such a case.

The authors report a case of severe fracture-dislocation of C6-C7 with dural and spinal cord damage causing quadriplegia. The patient was treated surgically with circumferential stabilisation. Intense spinal instrumentation with pedicle screw fixation in addition to anterior decompression and plate fixation was essential for restoring the original vertebral column. This technique of internal fixation provided a more rigid anchor, however the risk to the neurovascular structures could not be completely eliminated. Therefore, the combined anterior and posterior stabilisation assisted with a navigation system was a safer and reasonable surgical treatment for this patient with severe cervical injuries.

We report a rare case of a non-ruptured basilar bifurcation aneurysm presenting as a third ventricular mass producing unilateral obstructive hydrocephalus. This is the first reported case of its kind. A 70 year old woman presented with a giant basilar bifurcation aneurysm in which the aneurysm protruded into the third ventricle as a mass causing unilateral left hydrocephalus. The patient gradually became disoriented and developed a right hemiparesis and global aphasia. The right vertebral artery was occluded by placing coils intravascularly followed by an endoscopic septostomy. The patient's neurological state dramatically improved immediately. One month after the septostomy, however, the aneurysm ruptured and the patient eventually died. Treatment of the hydrocephalus only was selected instead of direct surgery or an intravascular procedure on the aneurysm, which eventually ruptured. The mechanisms for the unilateral hydrocephalus and the rupture of the aneurysm are described. The treatment strategy for these lesions is also discussed.

A 63-year-old woman presenting with temporal lower quadrantanopsia of the right eye was found to have a large dorsal internal carotid artery aneurysm. Large dorsal aneurysms of the internal carotid artery are rare. Lateral compression of the optic nerve by the aneurysm might damage the optic nerve at the medial side of the right optic foramen. Direct clipping surgery was performed uneventfully. Since the dome of the aneurysm was buried in the frontal lobe and also attached to the anterior skull base, a careful approach to the aneurysm with removal of the anterior clinoid process and drilling into the planum sphenoidale around the aneurysm dome was needed. The surgical strategy is discussed.

The authors report a case of spontaneous spinal epidural haematoma causing paraplegia secondary to thrombocytopaenia and consumptive coagulopathy from Kasabach-Merritt syndrome. The patient had long-standing multiple subcutaneous and visceral haemangiomas from childhood and developed lumbago and subsequent paraplegia. Evacuation of a spinal epidural haematoma was performed, however, the patient's neurological symptoms did not improve significantly. This case describes the potential risk of bleeding in the spinal column in patients with Kasabach-Merritt syndrome. Prompt diagnosis and management are crucial for an optimal outcome.

Objective To evaluate the usefulness and limitations of the intraoperative near-infrared (NIR) indocyanine green videoangiography (ICG-VA) and analysis of fluorescence intensity in cerebrovascular surgery. Methods Forty-eight patients received ICG-VA during various surgical procedures from May 2010 to August 2010. Included among them were 45 cases of cerebral aneurysms and 3 cases of cerebral arteriovenous malformations (AVMs). The infrared fluorescence module integrated into the surgical microscope was used to visualize fluorescent areas in the surgical field. An integrated analytical visualization tool constantly analyzed the fluorescence video sequence and generated it in the form of an intensity diagram for objective interpretation. Results Overall, the procedure of ICG VA was done 158 times in 48 patients. There was no adverse effect of ICG dye. In cerebral aneurysm cases, the images obtained were of high resolution. In 4 cases, incomplete clipping was detected by ICG-VA and allowed suitable adjustment to completely obliterate the aneurysm. In 3 aneurysm cases, the intensity diagram of ICG VA provided valuable information. ICG-VA identified the feeding arteries, the draining veins, and nidus in all 3 AVM cases, which was confirmed by an immediate analysis of fluorescence intensity. Conclusions ICG-VA provides high resolution images allowing real-time assessment of the blood flow in surgical field. The intensity analysis function, in addition, is a useful adjunct to improve the accuracy of the clipping and decrease the complication rates in cerebral aneurysm cases. In cerebral AVM cases, with the help of color map and intensity diagram function, the superficial feeders, drainers, and nidus can be identified easily.