Chronic subdural hematoma is a common disease in the field of neurosurgery, and the number of cases is expected to continue increasing in an aging society. At our hospital, minimally invasive percutaneous subdural perforation (the Aoki method) is the first-line treatment. We investigated the recurrence rate associated with the Aoki method, factors related to recurrence, and the complication risks. Among the cases treated with the Aoki method between June 2007 and December 2020, 383 (431 lesions) for which image analysis and recurrence tracking were possible were included. On the basis of the preoperative patient background (sex, age, history of taking antiplatelet and anticoagulant drugs, preoperative neurological findings, imaging findings (preoperative hematoma volume and hematoma density), surgical details, and postoperative use of concomitant drugs), we retrospectively analyzed the recurrence rate, factors related to recurrence, and complication risk. The recurrence rate was 23.7%, which is within the same range as that of burr-hole hematoma irrigation. Multivariate analysis showed that age and a large preoperative hematoma volume were associated with recurrence. One of the 3 cases with postoperative epidural and 2 of the 3 cases with subdural hematomas required craniotomy. The incidence of complications requiring additional surgery was approximately 1%, which is comparable to that of burr-hole irrigation. The Aoki method is efficient because it is minimally invasive and has a therapeutic effect equivalent to that of burr-hole irrigation, which is the current standard of care.

Posterior reversible encephalopathy syndrome (PRES) is a relatively rare central nerve condition. Here, we report a case of PRES that developed during acute pancreatitis in a previously healthy man in his 40s. On the third day, his respiratory status worsened during management of acute pancreatitis, requiring sedated ventilatory support. During ventilator management, his blood pressure was well-controlled, and no electrolyte abnormalities were observed; however, the patient was in a state of marked systemic inflammation. On the 12th day, after improvement in acute pancreatitis and respiratory status, with discontinuation of mechanical ventilation, the patient presented with mild disturbance of consciousness and visual field disturbance. Magnetic resonance imaging (MRI) showed diffuse vasogenic cerebral edema, mainly in the bilateral occipital and parietal white matter. The patient was provisionally diagnosed with PRES and was administered oral verapamil, along with supportive care. On the 23rd day, his neurological symptoms disappeared. Cerebral edema completely disappeared on MRI four months later. In the present case, it was speculated that endothelial dysfunction secondary to the severe inflammatory state accompanying acute pancreatitis caused PRES.

Basilar artery (BA) fenestration and its occlusion are relatively rare conditions. Mechanical thrombectomy for fenestrated BA occlusion has a high risk of complications. One limb occlusion or partial occlusion of fenestration mimics arterial stenosis or dissection. We present the case of a 75-year-old woman who presented with slight dysarthria, which subsequently worsened. Magnetic resonance imaging, magnetic resonance angiography, and basi-parallel anatomical scanning (BPAS) revealed BA fenestration and occlusion of the larger limb of the fenestrated BA, for which we performed thrombectomy with aspiration and achieved Thrombolysis in Cerebral Infarction Grade 3 flow restoration without procedure-related complications. If BA occlusion occurs at a site where a thrombus does not normally occur, confirming the anatomy of the BA before thrombectomy is desirable. As we obtained information on BA fenestration and occluded limb diameter using preoperative BPAS, we were able to safely achieve effective recanalization by guiding a relatively large-diameter aspiration catheter to the thrombus coaxially with a micro-guidewire and microcatheter.

Trigeminal neuralgia (TN) associated with a primitive trigeminal artery variant (PTAV) is a rare condition that causes severe facial pain. We report the case of an 81-year-old woman presenting with right facial pain. Brain magnetic resonance imaging revealed an aberrant artery originating from the cavernous portion of the right internal carotid artery (ICA), coursing laterally around the posterior clinoid process and running toward the anterior inferior cerebellar artery (AICA) territory, suggesting a PTAV. Although the pain subsided with carbamazepine, liver dysfunction developed; microvascular decompression was performed. Transposition of the PTAV in a lateral direction revealed a marked indentation at the root of the right trigeminal nerve. The PTAV was surgically transposed laterally and fixed to the pyramidal bone surface using a Teflon sling, whereas the proximal part was fixed downward to the brainstem. There was immediate facial pain relief, following surgery. We reviewed 27 cases of TN associated with PTA or PTAV reported in the literature, which showed that the average age of onset was similar to our case, at 56.5 years, with a male-to-female ratio of 1:2.85. The proportion of patients with PTAV with V2 region affected was highest (91.3%), with PTAV (AICA) being the most common aberrant blood vessel (40.7%). In cases of TN associated with PTA or PTAV, it is crucial to identify blood vessels that are compressing or contacting the nerve and transpose these arteries from the nerve. It is also critical to plan movement direction in order to prevent ischemia of perforators to the brainstem or internal auditory artery.

鹿児島県離島における輸血医療に関して院内血(warm fresh whole blood)の使用を含めて実態調査を行った.

Thrombolytic therapy using heparin, urokinase, and tissue plasminogen activator (tPA) has been the standard treatment for hyperacute ischemic stroke (HIS) with worsening carotid artery stenosis. In recent years, endovascular treatments (thrombectomy and carotid artery stenting) have attracted attention, and neurosurgeons are increasingly participating in these treatments. A 70-year-old Japanese male presented to our hospital with aphasia and right hemiparesis. Emergency computed tomography ([CT] CT angiography and perfusion CT) revealed a small infarct core and a large hemiparesis due to occlusion near the left common carotid artery orifice. Because of hemorrhagic sequelae, tPA was not administered, and emergency endovascular treatment failed. Therefore, a bilateral common carotid artery bypass surgery was performed. Revascularization was performed within 51 min of the start of the surgery, and the time from onset to revascularization was 5 h. Aphasia and right hemiparesis resolved immediately after surgery. The only sequela observed was mild dyskinesia. Our report is the first to show that bilateral common carotid artery bypass is a novel and effective treatment for HIS.

Hemorrhagic pilocytic astrocytomas (PAs) are rare, accounting for 1.1%-8.0% of all PA cases. They are reported to occur more frequently in older populations, with a male predominance. In this study, we report a case of a 14-year-old boy who presented with a headache, vertigo, and diplopia. As per his brain computed tomography scan, a small hematoma was observed in the left inferior cerebellar peduncle. Follow-up magnetic resonance imaging (MRI) revealed repeated minor bleeding from the lesion and mild expansion, with no neurological deficits. Four years later, the patient developed nausea, vomiting, and left abducens palsy. MRI revealed a mulberry-shaped mass surrounded by a hypointense rim, suggesting a cavernous angioma. The lesion was surgically resected via midline occipital craniotomy with the opening of the cerebellomedullary fissure. Histopathological examination of the lesion revealed PA. Next-generation sequencing analyses revealed that PAs harbored mutations in the ARID1A, ATM, and POLE genes but not in the BRAF gene. To the best of our knowledge, there are yet no reported studies on these mutations in PAs to date. Thus, PA should be considered in the differential diagnosis of cerebellar hemorrhage, especially in young adults and children．.

Background Prior studies indicated a decrease in the incidences of aneurysmal subarachnoid haemorrhage (aSAH) during the early stages of the COVID-19 pandemic. We evaluated differences in the incidence, severity of aSAH presentation, and ruptured aneurysm treatment modality during the first year of the COVID-19 pandemic compared with the preceding year. Methods We conducted a cross-sectional study including 49 countries and 187 centres. We recorded volumes for COVID-19 hospitalisations, aSAH hospitalisations, Hunt-Hess grade, coiling, clipping and aSAH in-hospital mortality. Diagnoses were identified by International Classification of Diseases, 10th Revision, codes or stroke databases from January 2019 to May 2021. Results Over the study period, there were 16 247 aSAH admissions, 344 491 COVID-19 admissions, 8300 ruptured aneurysm coiling and 4240 ruptured aneurysm clipping procedures. Declines were observed in aSAH admissions (−6.4% (95% CI −7.0% to −5.8%), p=0.0001) during the first year of the pandemic compared with the prior year, most pronounced in high-volume SAH and high-volume COVID-19 hospitals. There was a trend towards a decline in mild and moderate presentations of subarachnoid haemorrhage (SAH) (mild: −5% (95% CI −5.9% to –4.3%), p=0.06; moderate: −8.3% (95% CI −10.2% to –6.7%), p=0.06) but no difference in higher SAH severity. The ruptured aneurysm clipping rate remained unchanged (30.7% vs 31.2%, p=0.58), whereas ruptured aneurysm coiling increased (53.97% vs 56.5%, p=0.009). There was no difference in aSAH in-hospital mortality rate (19.1% vs 20.1%, p=0.12). Conclusion During the first year of the pandemic, there was a decrease in aSAH admissions volume, driven by a decrease in mild to moderate presentation of aSAH. There was an increase in the ruptured aneurysm coiling rate but neither change in the ruptured aneurysm clipping rate nor change in aSAH in-hospital mortality. Trial registration number NCT04934020.

Background:Cerebrospinal fluid (CSF) leakage is a common complication of ventriculoperitoneal shunt (VPS) and has the potential to induce shunt infection. Especially in infants and children, these are serious complications. DuraGen is a collagen matrix dural substitute used to reduce the risk of CSF leakage in various neurosurgeries. We report our VPS procedure with DuraGen for preventing postoperative CSF leakage in patients aged <1 year.Methods:We used DuraGen to prevent postoperative CSF leakage in six VPS surgeries. Antibiotic-impregnated shunt catheters and programmable valves with anti-siphon devices were also used in all cases. DuraGen was placed inside and atop the burr hole. All cases had an initial shunt pressure of 5 cmH2O. Fibrin glue was not used.Results:The patients underwent follow-up for a year after VPS surgery. There was no postoperative subcutaneous CSF collection or leakage after all six VPS surgeries. Furthermore, no postoperative shunt infections or DuraGen-induced adverse events were noted.Conclusion:We speculate that DuraGen has a preventive effect on postoperative CSF leakage in VPS cases aged <1 year.

Summary: Among middle cerebral artery aneurysms, those at the M1 portion of the middle cerebral artery have a lower incidence of occurrence. We retrospectively analyzed and reported the clinical features and management of 12 M1 aneurysms in 12 patients treated with direct clipping. Aneurysms arising at the M1 portion were mostly smaller in size and prevalent in older women, on the left side, with more intracerebral hematoma and less accompanied than those at the bifurcation. Ruptured aneurysms comprised 80% of the aneurysms and were larger than 5 mm in size, while 14.3% of those smaller than 5 mm in size were unruptured. Aneurysms were located in the upper (n=5), downward (n=5), anterior (n=1), and posterior (n=1) directions. Of the five aneurysms in the upper direction, three were in the early frontal branch, one was in the early temporal branch, and one was in the len-ticulostriate artery. Two of the aneurysms in the upper direction had an intracerebral hematoma (ICH) in the frontal and temporal lobes, while one aneurysm in the downward direction had an ICH in the temporal lobe. The preoperative clinical grade of M1 aneurysms with ICH was worse than that of bifurcation aneurysms; however, the outcome was equal to that of bifurcation aneurysms. Aneurysms arising at the M1 portion should be treated with a preoperative meticulous investigation for their anatomical complexity, not only with direct clipping but also with endovascular techniques. computed angiography aneurysm the bifurcation of early frontal Operative photograph an aneurysm through the bifurcation of the middle cerebral sev-eral attempts of temporary occlusion and Motor no by infarction

Background During the COVID-19 pandemic, decreased volumes of stroke admissions and mechanical thrombectomy were reported. The study’s objective was to examine whether subarachnoid haemorrhage (SAH) hospitalisations and ruptured aneurysm coiling interventions demonstrated similar declines.Methods We conducted a cross-sectional, retrospective, observational study across 6 continents, 37 countries and 140 comprehensive stroke centres. Patients with the diagnosis of SAH, aneurysmal SAH, ruptured aneurysm coiling interventions and COVID-19 were identified by prospective aneurysm databases or by International Classification of Diseases, 10th Revision, codes. The 3-month cumulative volume, monthly volumes for SAH hospitalisations and ruptured aneurysm coiling procedures were compared for the period before (1 year and immediately before) and during the pandemic, defined as 1 March–31 May 2020. The prior 1-year control period (1 March–31 May 2019) was obtained to account for seasonal variation.Findings There was a significant decline in SAH hospitalisations, with 2044 admissions in the 3 months immediately before and 1585 admissions during the pandemic, representing a relative decline of 22.5% (95% CI −24.3% to −20.7%, p<0.0001). Embolisation of ruptured aneurysms declined with 1170–1035 procedures, respectively, representing an 11.5% (95%CI −13.5% to −9.8%, p=0.002) relative drop. Subgroup analysis was noted for aneurysmal SAH hospitalisation decline from 834 to 626 hospitalisations, a 24.9% relative decline (95% CI −28.0% to −22.1%, p<0.0001). A relative increase in ruptured aneurysm coiling was noted in low coiling volume hospitals of 41.1% (95% CI 32.3% to 50.6%, p=0.008) despite a decrease in SAH admissions in this tertile.Interpretation There was a relative decrease in the volume of SAH hospitalisations, aneurysmal SAH hospitalisations and ruptured aneurysm embolisations during the COVID-19 pandemic. These findings in SAH are consistent with a decrease in other emergencies, such as stroke and myocardial infarction.

Background: As previously reported, inhibitory low frequency repetitive transcranial magnetic stimulation (rTMS) targeting the triangular part of the right inferior frontal gyrus can be useful for enhancing recovery in aphasic patients. In this study, we applied low and high frequency rTMS targeting the bilateral hemispheres. The purpose of this study is to evaluate the efficacy of two types of rTMS for post-stroke motor aphasia.

Background: Early recognition of stroke symptoms, pre-notification to the hospital, and rapid transport of the patients has been associated with faster intervention and better outcomes. We studied the impact of continuous monthly educational intervention to the emergency medical services (EMS) members on the therapeutic time till mechanical thrombectomy in acute ischemic stroke.

Deep Sylvian meningiomas are rare, accounting for 0.3-0.4% of all meningiomas, and mostly present in young adults and children. We report on a 32-year-old man who presented with headache but had no neurological deficits. Computed tomography of brain revealed a 24 × 19 × 21 mm3 mass lesion in the right Sylvian fissure with calcification. Magnetic resonance imaging showed that the lesion was isointense on T1- and T2-weighted images (WI), with homogenous enhancement on post-gadolinium T1WI. The lesion was surgically removed via right fronto-temporal craniotomy. The tumor was located in deep Sylvian fissure and had no dural attachment. Histopathological examination of the lesion revealed both meningothelial and fibroblastic features, thereby suggesting the diagnosis of transitional meningioma (WHO grade I), with Ki-67 labeling index of 6.9%. Thus, meningioma should be considered as a differential diagnosis of enhancing mass lesions in the Sylvian fissure even in the absence of dural tail sign, especially in young adults and children.

【目的】急性期脳塞栓症に対し,血栓回収術を行い再開通が得られた後,中大脳動脈の窓形成が判明した稀な症例を経験したので報告する.【症例】症例は65 歳男性.突然の左片麻痺を認め,MRI により右内頸動脈閉塞症と診断された.血栓溶解療法後に,脳血管撮影を行うとMRA 上閉塞していた内頸動脈は一部再開通しており中大脳動脈に血栓様陰影を認めた.引き続いて行った血栓回収術により再開通が得られたが,窓形成を伴った中大脳動脈を認めた.患者は術後に症状の改善がみられ発症11 日目に自宅退院となった.【結論】中大脳動脈の窓形成は非常に稀であるが,血栓回収術を行うときには念頭に置き治療を行う必要がある.