Neurologia medico-chirurgica
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Neurol. Med. Chir. (Tokyo) · Jan 2012
Case ReportsIschemic events due to intraoperative microemboli developing in the cerebral hemisphere contralateral to carotid endarterectomy in a patient with preoperative cerebral hemodynamic impairment.
A 74-year-old man with a history of asymptomatic right internal carotid artery (ICA) occlusion experienced amaurosis fugax in the left eye. Angiography showed left cervical ICA stenosis in addition to right cervical ICA occlusion. The right anterior and middle cerebral artery (MCA) territories were perfused from the left ICA via the anterior communicating artery. ⋯ Transient and slight motor weakness of the left upper extremity was noted on recovery from anesthesia. Diffusion-weighted magnetic resonance imaging demonstrated the development of new spotty ischemic lesions only in the right cerebral hemisphere. The present case suggests that intraoperative cerebral embolism causing postoperative neurological deficits can develop exclusively in the cerebral hemisphere contralateral to CEA if the hemisphere has preoperative hemodynamic impairment and collateral circulation via the anterior communicating artery from the ICA ipsilateral to CEA.
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Neurol. Med. Chir. (Tokyo) · Jan 2012
Surgical treatment of Spetzler-Martin grade III to V cerebral arteriovenous malformations: 10 years experience in Kyoto University.
Cerebral arteriovenous malformations (AVMs) are abnormal connections between arteries and veins leading to arteriovenous shunting with nidus formation. This study reviewed the clinical outcomes of surgical treatment for AVMs of Spetzler-Martin grades III to V in our institute. ⋯ Excellent outcomes were obtained, but about 40% of all patients with AVMs could not receive surgical treatment. Multimodality approach including Onyx embolization may extend the surgical indications.
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Neurol. Med. Chir. (Tokyo) · Jan 2012
Lessons learned from moyamoya disease: outcome of direct/indirect revascularization surgery for 150 affected hemispheres.
Moyamoya disease is a chronic, occlusive cerebrovascular disease with unknown etiology characterized by bilateral steno-occlusive changes at the terminal portion of the internal carotid artery and an abnormal vascular network at the base of the brain. Recent advances in molecular biology and genetic research have provided better understanding of the pathophysiology of moyamoya disease, but surgical revascularization still remains the preferred treatment for this entity. The present study investigated the clinical course of 106 consecutive patients with moyamoya disease who underwent superficial temporal artery-middle cerebral artery anastomosis with indirect pial synangiosis in 150 hemispheres. ⋯ Despite the favorable long-term outcome, the incidence of temporary neurological deterioration due to cerebral hyperperfusion was 18.0% (27/150), but no patients suffered permanent neurological deterioration directly caused by hyperperfusion. In conclusion, direct/indirect revascularization surgery is a safe and effective treatment for moyamoya disease, although the issue of bleeding/re-bleeding remains to be solved. Postoperative cerebral hyperperfusion and peri-operative infarction are potential complications of this procedure, so we recommend intensive postoperative care and cerebral blood flow measurement in the acute stage, because the management of hyperperfusion is contradictory to that of ischemia.
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Neurol. Med. Chir. (Tokyo) · Jan 2012
External carotid artery stenting and superficial temporal artery to middle cerebral artery anastomosis for internal carotid artery occlusion with external carotid artery severe stenosis: case report.
Superficial temporal artery (STA) to middle cerebral artery (MCA) anastomosis may have inadequate effects in patients with internal carotid artery (ICA) occlusion and severe stenosis of the ipsilateral external carotid artery (ECA), because poor blood flow in the STA leads to insufficient flow to the MCA. In these patients, dilation of the stenotic ECA is required to improve the blood flow in the STA before STA-MCA anastomosis. A 71-year-old man presented with left hemiparesis and dysarthria. ⋯ Postoperative SPECT demonstrated marked improvement of hemodynamic insufficiency in the right MCA territory. After treatment, the patient had no ischemic events. This case suggests external CAS together with STA-MCA anastomosis is a good therapeutic option for a patient with symptomatic ICA occlusion and severe stenosis of the ipsilateral ECA if external CEA is difficult to perform.