Postoperative Infarction Research Articles

Anatomical variations of dominant anastomotic veins in the superficial cortical venous system

BackgroundUnderstanding the anatomy of the anastomotic veins (AV) of the superficial cortical venous system (SCVS), viz. Superficial Sylvian vein (SSV) - also known as the superficial middle cerebral vein; vein of Labbe (VL) and vein of Trolard (VT), are imperative for neurosurgical procedures. This study aimed to investigate variant anatomical patterns of dominance of the AV, to elucidate the haemodynamically balanced SCVS, by reporting variations between the presence, diameter and dominant patterns of the AV. MethodsTwo hundred lateral angiograms were included, depicting left and right cerebral hemispheres of the same patient (n = 100 patients). Angiograms were analysed and variations recorded. Results were statistically compared against laterality, age, sex and ethnicity. ResultsPresence of the VL had the highest occurrence (96.5%), whereas the SSV and VT had an occurrence of 75.5% and 64.5%, respectively. This study reports presence of double veins of the AV: SSV (12.0%), VL (22.0%) and VT (19.5%). Furthermore, presence of a triple vein for each AV is reported. Diameters for the SSV, VL and VT were 1.99 ± 0.500 mm, 2.18 ± 0.579 mm and 2.14 ± 0.472 mm, respectively. Statistically significant relationships were established between diameters and the SSV, VL, VT and VT2 (double VT). Seven types of dominant patterns were recorded: Equilibrium; singular dominance of SSV, VL and VT; co-dominance of SSV/VL, SSV/VT and VL/VT. The Equilibrium dominant pattern of drainage had the highest occurrence (54.5%). ConclusionPatterns of dominance of these AV can aid the neurosurgeon in curbing the risk of iatrogenic injury and postoperative infarcts even after an otherwise successful surgery.

Single direct right axillary artery cannulation using a modified Seldinger technique in minimally invasive cardiac surgery.

Single direct right axillary artery cannulation is uncommon in minimally invasive cardiac surgery; however, the risk of cerebral infarction due to retrograde perfusion using the femoral artery remains high in patients with thoracoabdominal aortic atheroma. In our institution, we perform right axillary artery cannulation using a modified Seldinger technique in patients with atherosclerotic disease. This study aimed to evaluate the safety and effectiveness of this technique in minimally invasive cardiac surgery. Data of all peripheral cannulation cases in patients who underwent minimally invasive cardiac surgery between March 2014 and December 2019 were obtained from our institutional database. Right axillary artery cannulation was successfully performed in 175 patients, 112 of whom underwent magnetic resonance imaging. Procedures comprised single-valve 86.3% (n = 151, 86.3%), double-valve (n = 21, 12%), and triple-valve (n = 3, 1.7%) surgeries. In-hospital mortality rate was 1.7% (n = 3). Stroke rate was 1.1% (n = 2); these 2 patients developed stroke at 3 and 5days postoperatively. Forty-one (36.9%) patients were diagnosed with silent brain infarction on postoperative magnetic resonance imaging. There were no instances of intraoperative local axillary arterial injury, dissection, rupture, or surgical wound infection. Two patients had axillary wound hematoma and 2 had temporary right limb neuropathy, which resolved before discharge. No cases of pseudoaneurysm were found at the cannulation site. Limb ischemia and compartment syndrome were not reported. There were no complications of postoperative symptomatic cerebral infarction following minimally invasive cardiac surgery with single direct right axillary artery cannulation using a modified Seldinger technique, even though patients had significant atherosclerotic vascular disease.

Evolocumab administration prior to Coronary Artery Bypass Grafting in patients with multivessel coronary artery disease (EVOCABG): study protocol for a randomized controlled clinical trial

BackgroundDespite advances in surgical and postoperative care, myocardial injury or infarction (MI) is still a common complication in patients undergoing coronary artery bypass surgery (CABG). Several studies that aimed to reduce postoperative myocardial injury, including those investigating statin loading, have been conducted but did not indicate any clear benefits. Evolocumab, a PCSK9 inhibitor, has been reported to lower lipids and prevent ischemic events in various medical conditions. However, the effect of evolocumab in cardiovascular surgery has not been evaluated. The objective of this trial is to evaluate the cardioprotective effects of evolocumab in elective CABG patients with multivessel coronary artery disease.MethodsEVOCABG is a prospective, randomized, open, controlled, multicenter, superiority, phase III clinical trial. Patients with multivessel coronary artery disease without initial cardiac enzyme elevation will be recruited (n=100). Participants will be randomly allocated into two groups: a test group (evolocumab (140mg) administration once within 72 h before CABG) and a control group (no administration). The primary outcome is the change in peak levels of serum cardiac marker (troponin-I) within 3 days of CABG surgery compared to the baseline. Secondary outcomes include post-operative clinical events including death, myocardial infarction, heart failure, stroke, and atrial fibrillation.DiscussionThis trial is the first prospective randomized controlled trial to demonstrate the efficacy of evolocumab in reducing ischemic-reperfusion injury in patients undergoing CABG. This trial will provide the first high-quality evidence for preoperative use of evolocumab in mitigating or preventing ischemic-reperfusion-related myocardial injury during the surgery.Trial registrationClinical Research Information Service (CRIS) of the Republic of Korea KCT0005577. Registered on 4 November 2020.

Postoperative cerebral infarction after evacuation of traumatic epidural hematoma in children younger than two years: Single-center experience.

Background: Epidural hematoma (EDH) forms about 2–3% of all head injuries in the pediatric population. We evaluated clinical data and risk factors for postoperative infarction in children younger than 2 years presented with traumatic EDH.Methods: We retrospectively reviewed and analyzed the data of 28 children with traumatic EDH operated in our institute during a period of 26 months (from December 2016 to Febuary 2019).Results: Nineteen children were boys (68%) and nine were girls (32%), the mean age was 15 months (range from 5 to 24 months). Postoperative cerebral infarction was detected in seven cases (25%). Factors could be linked to postoperative cerebral: preoperative pediatric Glasgow Coma Scale (P = 0.036), neurological deficit on admission (P = 0.023), size of hematoma (P < 0.001), time between trauma and surgery (P = 0.004), midline shift (MLS) (P = 0.001), and basal cistern compression (P = 0.004).Conclusion: Traumatic EDH in young children represents a neurosurgical challenge that needs rapid surgical intervention for the best surgical outcome. Delay in the time of surgery for more than 6 h, large hematoma volume >100 ml3, MLS >10 mm, and basal cisterns compression will push the intracranial pressure to the point of decompensation and the resultant ischemic sequel occurs.

The preservation of accessory renal arteries should be considered the treatment of choice in complex endovascular aortic repair

ObjectiveThe objective of this study was to evaluate renal function and renal parenchymal length changes secondary to the coverage or preservation of accessory renal arteries (ARAs) in complex aortic repair. MethodsThis was a single-center retrospective study identifying all patients undergoing fenestrated or branched endovascular aortic repair (f-b EVAR) who presented with ARAs. Two groups were created, a preserved ARA group, with incorporation of the vessel as a dedicated fenestration or branch in the endograft plan, and a non-preserved ARA group, without incorporation of them. Early >30% decline of glomerular filtration rate (GFR), kidney infarcts, and endoleaks were evaluated. Mid-term results with freedom from kidney shrinkage (defined as length decrease >10%) at follow-up, freedom from GFR decrease >30%, or need for postoperative dialysis at follow-up were also analyzed. Primary assisted patency of incorporated ARAs was calculated. ResultsFrom 2011 through 2020, 145 patients undergoing complex aortic repair presented with an ARA. After excluding ruptured aneurysms, 33 patients had the ARA preserved with their incorporation into the stent graft (preserved ARA group), and 99 did not have preservation of them (not-preserved ARA group). There were no statistical differences in demographics or type of aneurysm. Patients in the ARA-preserved group had more ARAs (median of two per patient vs one in the non-preserved ARA group; P = .01) and bigger ARAs (median 4 vs 3 mm in the non-preserved ARA group; P = .001). Early postoperative worsening >30% of GFR (23% vs 6%; P = .03) as well as postoperative renal infarction (57% vs 6%; P = .001) and ARA-related endoleaks (20% vs 0%; P = .01) were statistically higher for the not-preserved ARA group. Mid-term kidney length showed significant shrinkage in the not-preserved ARA group compared with the ARA preserved group (9.7% vs 0%; P = .001). Freedom from >30% GFR decline at 2 years was significantly higher for the preserved ARA group (83% vs 47%; P = .01).Two-year primary assisted patency of incorporated ARA was 94%. ConclusionsComplex aortic repair incorporation of ARA is feasible, with low complications and good primary assisted patency at 2 years. It leads to less postoperative early renal dysfunction as well as higher freedom for mid-term renal disfunction and kidney shrinkage.

301 1000 Cases of Surgically Treated Aneurysmal Subarachnoid Haemorrhage: Changes in Practice and Clinical Outcomes

INTRODUCTION: Aneurysmal subarachnoid haemorrhage (aSAH) remains a complex and multidisciplinary pathology. With endovascular methods expanding fewer patients are treated surgically. METHODS: All patients following surgery for aSAH between 2007 - 2019 were included. Baseline characteristics outcomes were analysed. We compared outcomes between experienced (=50 independent cases) and non-experienced surgeons (&lt;50 independent cases), and high-volume (=20 cases/year) and low-volume surgeons (&lt;20 cases/year). RESULTS: 970 patients with 1003 aneurysms were identified with median age 56. 73.8% were WFNS grade 1 or 2. The majority of aneurysm were on the middle cerebral artery (41.4%), anterior communicating artery (27.6%) and posterior communicating artery (17.5%). 37.4% of aneurysm were &lt;7 mm in size. Technical error rate was 6%, resulting in a post-operative infarct in 4.9% of patients. 19 patients (2%) died within 30 days of admission. There were no significant changes in technical error rates or post-operative infarcts or death (p = 0.79 and p = 0.77 respectively) over the study period. There was no difference in post-operative infarctions between experienced and non-experienced surgeons (p = 0.28), but there was a difference when comparing high-volume vs. low-volume surgeons (p = 028). CONCLUSION: We present real world data on surgical indications and outcomes after aSAH. We believe that this constitutes important data demonstrating good retention of skills and good clinical outcomes in a very dynamic field of cerebrovascular surgery. We also demonstrate a relationship between surgical case volume and outcomes.

Quantitative angiographic haemodynamic evaluation of bypasses for complex aneurysms: a preliminary study

ObjectiveOpen microsurgery, often with bypass techniques, is indispensable for complex aneurysms. To date, it remains unknown whether arterial anatomy or quantitative blood flow measurements can predict insufficient flow-related stroke (IRS)....

Choroidal artery ischemic events after temporal lobe epilepsy surgery: clinical outcome, quality of life, and surgical pitfalls.

Ischemic events within the territory of the choroidal artery are an important cause of morbidity after temporal lobe epilepsy (TLE) surgery. The aim of the present study was to evaluate the rate of these ischemic events, their clinical presentation, and impact on patients' health-related quality of life (HRQoL) after TLE surgery. Four hundred twenty-two consecutive patients undergoing temporal resections for drug-resistant TLE were retrospectively analyzed. All patients underwent presurgical multidisciplinary assessment using a standard protocol comprising clinical, neuroradiological, neuropsychological, and EEG data. Postoperative complications with corresponding imaging, neurological deficits, and disease-specific HRQoL questionnaires were evaluated. The overall complication rate was 7.8% (n = 33). Fourteen patients (3.3%) suffered from ischemic events causing 6 permanent motor deficits, 3 with permanent aphasias, and 6 visual field defects that exceeded quadrantanopia. In 8 patients with anterior choroidal artery infarction, accounting for 57% of all ischemic events, infarction volume correlated positively with the occurrence of new permanent neurological deficits (8666 vs 1692 mm3, p = 0.032). Despite the occurrence of ischemic events, HRQoL improved in 71% of patients. However, infarction volume showed a negative correlation trend with HRQoL (Pearson's r = -0.390, p = 0.094). There was a trend toward increased risk for ischemic events in patients who underwent selective amygdalohippocampectomy compared to patients who underwent anterior temporal lobectomy or temporal lesionectomy (RR 0.96, 95% CI 0.93-0.99, p = 0.08). Choroidal artery infarctions are rare but relevant complications after TLE surgery, presenting with variable clinical courses ranging from devastating neurological deterioration to complete recovery. Despite the occurrence of postoperative infarction, most patients report improvement of HRQoL after TLE surgery. This study showed that the type of surgery appears to modulate the risk for these ischemic events.

Low-profile visualized intraluminal support stent for the endovascular treatment of traumatic intracranial internal carotid artery pseudoaneurysms.

Optimal treatment strategies for traumatic intracranial internal carotid artery (ICA) pseudoaneurysms are controversial. The low-profile visualized intraluminal support (LVIS) device is a braided stent with a metal coverage rate between traditional laser cut stents and flow diversion devices. We report here our therapy strategy using the LVIS stent-assisted coiling for treatment of traumatic intracranial ICA pseudoaneurysms. Patients with traumatic intracranial ICA pseudoaneurysms treated by the LVIS stent-assisted coiling in our center between January 2015 and June 2021 were reviewed. The complications, radiographic, and clinical outcomes of these patients were analyzed. A total of 12 patients with 12 pseudoaneurysms were included. The mean maximum aneurysm diameter was 6.2 ± 3.1mm. Nine patients had a subarachnoid hemorrhage; five patients with Hunt-Hess grade III and four patients with grade IV. All procedures were successfully performed without intraoperative complications. Immediate postoperative angiogram showed that six (50%) aneurysms were Raymond grade 1, four (33.3%) were grade 2, and two (16.7%) were grade 3. Postoperative multiple cerebral infarction occurred in two patients because of vasospasm. Of the ten patients with angiographic follow-up (mean, 29.9months), two received additional coiling because of recanalization of the pseudoaneurysm, and all aneurysms were completely obliterated at the last examination of the patients. During the clinical follow-up period (mean, 26.8months), the overall mortality and morbidity were 25% (3/12) and 8.3% (1/12), respectively. LVIS stent-assisted coiling was a feasible approach for the treatment of traumatic ICA pseudoaneurysms.

Intraoperative risk factors for peritumoral infarctions following glioma surgery

BackgroundSurgical intraoperative risk factors for peritumoral infarctions are not much studied. In the present study, we explore the possible association between intraoperative factors and infarctions diagnosed from early postoperative MRIs. MethodsWe screened all adult patients operated for newly diagnosed or recurrent diffuse gliomas at out department from December 2015 to October 2020 with available postoperative MRI including DWI sequences. Patient data was prospectively collected in a local tumor registry. Immediately after surgery, the surgeon completed a questionnaire on tumor vascularization, tumor stiffness, delineation of tumor from normal brain tissue, which surgical tool(s) were used, and if they had sacrificed a functional artery or a significant vein. ResultsData from 175 operations were included for analysis. Of these, 66 cases (38%) had postoperative peritumoral infarctions. 24 (36%) were rim-shaped and 42 (64%) infarctions were sector-shaped. The median infarction volume was 2.4 ​cm3. Surgeon reported sacrifice of a significant vein was associated with infarctions, but we found no clear “dose-response”, as “perhaps” was associated with fewer infarctions than “no”. None of the other studied factors reached statistical significance. However, there was a trend for more infarctions when an ultrasonic aspirator was used for tumor resection. Subgroup analyses were done for rim-shaped and sector-shaped infarctions, and ultrasonic aspirator was associated with sector-shaped infarctions (p ​= ​0.032). Infarction rates differed across surgeons (range 15%–67%), p ​= ​0.021). ConclusionIn this single center study, no clear relationships between surgeon reported intraoperative factors and postoperative infarctions were observed. Still, risks seem to be surgeon dependent.

Microsurgical Treatment of Vertebral Artery Dissection: Surgical Strategies and Treatment Outcomes

Vertebral artery dissection (VAD) is a rare cerebrovascular disease that can lead to permanent morbidity or mortality. Open surgery for VAD is challenging; therefore, most cases are managed via endovascular techniques. There are several surgical methods for VAD treatment, including trapping or proximal occlusion with or without bypass; however, the standard treatment protocol is not well established. The aims of this study were to demonstrate surgical strategies, surgical outcomes, and complications of each method and to propose an algorithm to select the appropriate procedure. This study included 22 patients with VAD who underwent open surgical treatment between January 2015 and December 2019 and were retrospectively reviewed and evaluated for postoperative outcomes and complications. Proximal occlusion, trapping, occipital artery-posterior inferior cerebellar artery (PICA) bypass with blind-alley formation, and occipital artery-PICA with trapping were performed in 13, 2, 5, and 2 patients. The surgical procedure depended on the type of VAD: pre-PICA, PICA, post-PICA, and non-PICA. All VADs were completely obliterated after surgery. Obliteration occurred immediately for 18 patients (81.8%) and within 1 week for 4 patients (18.2%). There was no postoperative bleeding or PICA infarction. Favorable outcome at 3 months after operation was achieved in 100% for good-grade patients and 86.4% overall. Open surgery can be a safe and effective treatment of VAD when surgical strategies are carefully selected. Angioarchitecture and the type of VAD influence the selection of the surgical method.

STMO-9 Maximal safe glioma resection using high resolution exoscope

INTRODUCTION: Maximal safe glioma resection should be achieved using neuronavigation, electrophysiological monitoring, fluorescence visual system, and so on. Heads-up surgery with exoscope is suitable for the multimodal glioma surgery because multi-monitors come in our sights simultaneously. We introduce our glioma surgery using a latest exoscope and neuronavigation system. METHODS: We attempted maximal safe resection for the patients with high grade glioma using 3D/4K exoscope with 5-ALA-induced fluorescence, neuronavigation, and electrophysiological monitoring or awake mapping. An extent of resection, morbidity, and postoperative infarction were retrospectively reviewed. RESULTS: Twenty-one patients (age 26–79, male 11/female 10, glioblastoma 10/lower grade glioma 11, general anesthesia 16/awake craniotomy 5) underwent exoscopic tumor removal. Neuronavigation and electrophysiological monitoring were displayed in sub-monitors close to the main screen. Navigation could be recognized continuously using electromagnetic navigation technology. Intraoperative fluorescence was observed in 100% of the tumor with gadolinium enhancement. Surrounding structures such as white matter, vessels and nerves were clearly visualized under blue light. Supra-total resection or gross total resection was achieved in 8 (80%) of the patients with glioblastoma. Surgical morbidity included hemiparesis in 1 (4.8%) patient, hemianopsia in 1 (4.8%) patient. Postoperative infarction was observed in 2 (9.5%) patients, which was significantly lower compared to 23 of 77 (29.9%) patients with glioblastoma who underwent tumor resection with fluorescence-equipped microscope (p<0.05). CONCLUSION: High resolution exoscope surgery is effective for patients undergoing glioma surgery with respect to higher extent of resection and lower ischemic complication. Further studies are needed to assess direct comparisons between exoscope and microscope glioma resection.

Endovascular repair of ruptured abdominal aortic aneurysms assisted by double balloon occlusion technique combined with intra-aneurysm fibrin binder injection technique

Objective: To investigate the long-term efficacy and safety of alternating double balloon occlusion combined with intra-aneurysm injection of human fibrin binder in the endovascular repair of ruptured abdominal aortic aneurysm (rAAA). Methods: The clinical data of 28 patients with rAAA admitted to Department of Vascular Surgery, the Fourth Affiliated Hospital of Guangxi Medical University from January 2015 to December 2019 were retrospectively analyzed. There were 23 males and 5 females, aged (62±5) years (range: 46 to 88 years).The maximum diameter of the tumors was (65.2±10.5) mm (range: 47.3 to 100.5 mm), all of which were subrenal rAAA. The intraoperative EVAR for abdominal aortic aneurysm was successfully performed under the emergency green channel procedure, and this surgery was assisted used the double balloon occlusion technique in aorta of inferior renal and superior renalcombined with intraoperative human fibrin binder injection technique. Observation indexes included: patients with preoperative preparation, operation time, hospitalization days, surgical treatment success rate and the incidence of postoperative complications, and aortic stent form during the follow-up period, the incidence of leakage, branch stents patency rate and infection rates. Results: The preoperative preparation time of 28 patients was (45.5±8.5) minutes (range:20 to 100 minutes). The operation time was (100.0±15.5) minutes (range:85 to 210 minutes), the ICU stay time was (7±2) days(range:1 to 17 days). The length of hospitalization was (13.5±2.5) days(range:5 to 43 days). The success rate of surgical treatment was 92.9% (26/28). Two patients died, 1 case died of postoperative multifocal lacunar cerebral infarction and massive gastrointestinal hemorrhage, and another elderly patient (84 years old) died of massive abdominal fluid due to preoperative abdominal aortic aneurysm rupture, postoperative complicated with significant abdominal compartment syndrome, and secondary multiple organ failure. Balloon occlusion of the upper renal aorta took (13±2)minutes (range:12 to 30 minutes). The intraoperative injection of fibrin adhesive was (14±2) ml(range:6 to 28 ml) in 22 cases. The incidence of major postoperative complications was 57.1% (16/28). Among the 26 patients who survived the surgery, 69.2% (18/26) completed the 3-year follow-up, and the follow-up time was (30±3) months(range:13 to 36 months). During the follow-up, the aortic stent was in good shape without obvious displacement. The incidence of leakage within 6 months after the operation was 10.7% (3/28), and there was no internal leakage in the patients who were followed up for 36 months after the operation. The patency rate of renal artery and iliac artery branch stents was 16/18. The incidence of stent infection was 7.7% (2/26), 1 case occurred at 1 month and another case at 6 months, respectively. All patients recovered after prolonged intensive anti-infection therapy. Conclusions: Under the standard emergency treatment process, the double balloon alternating occlusion technique combined with the intra-aneurysm injection of human fibrin adhesive technique can assist the successful completion of the endovascular repair of rAAA, effectively improve the success rate of treatment for patients, and reduce the incidence of postoperative leakage and serious complications. The mid-term and long-term results of EVAR for rAAA are good, safe and reliable.

FLGS-05. Maximal safe glioma resection using high resolution exoscope with 5-ALA-induced fluorescence

Abstract INTRODUCTION 5-aminolevulinic acid (5-ALA) guided surgery has been reported to prolong progression-free survival of patients with high grade glioma. Although blue-light capable microscope enables us to detect fluorescence intraoperatively, visualization of anatomy is difficult under blue-light microscope. On the other hand, exoscope permits to visualize both fluorescence and anatomy under blue-light conditions. We introduce our glioma surgery using an exoscope equipped with a 5-ALA fluorescence visual system. METHODS We attempted maximal safe resection for the patients with high grade glioma using 3D/4K exoscope with 5-ALA-induced fluorescence, neuronavigation, and electrophysiological monitoring or awake mapping. Visualization of fluorescence and anatomy under blue light, extent of resection, morbidity, and postoperative infarction were retrospectively reviewed. RESULTS Twenty patients (age 26–79, male 10/female 10, glioblastoma 11/lower grade glioma 9) underwent exoscopic tumor removal. Intraoperative fluorescence was observed in 100% of the tumor with gadolinium enhancement. Surrounding structures such as white matter, vessels and nerves were clearly visualized under blue light. Even perforators were visible and could be preserved. Supra-total resection and gross total resection of gadolinium-enhancing tumor was achieved in 6 (30%) and 10 (50%) patients, respectively. Surgical morbidity included hemianopsia in 1 patient and transient hemiparesis in 1 patient. Postoperative infarction was observed in 2 (10%) patients, which tended to be lower compared to 23 of 77 (29.9%) patients with glioblastoma who underwent tumor resection with fluorescence-equipped microscope(p=0.05). CONCLUSION Clear visualization of 5-ALA-indced tumor fluorescence and anatomical structures with use of high resolution exoscope help maximal safe tumor resection. Longer progression-free survival is expected as a result of greater extent of tumor resection.

Surgical outcomes of patients after treatment of ruptured anterior communicating artery aneurysms: \u201creal-world\u201d evidence from southern Thailand

BackgroundAnterior communicating artery (AComA) aneurysm rupture is the most common cause of subarachnoid hemorrhage worldwide. In this study, we aimed to determine the factors associated with a poor clinical outcome in patients with ruptured AComA aneurysms undergoing microsurgical clipping.MethodsWe retrospectively reviewed the clinical and radiologic features as well as clinical outcomes of 150 consecutive patients with ruptured AComA aneurysm who underwent surgical clipping during the 11-year study period. Logistic regression analysis was performed to identify independent factors associated with unfavorable clinical outcomes (defined as a modified Rankin scale score of 3–6).ResultsThe study included 83 male and 67 female patients, with a mean age of 51.3 ± 11.5 years. At admission, most of the patients had good neurological status, including 97 (64.7%) patients with a Hunt and Hess grade of 1 or 2 and 109 (72.6%) patients with a World Federation of Neurosurgical Societies grade of 1 or 2. Unfavorable outcomes at 6 months were observed in 23 (22.0%) patients, and the 6-month mortality rate was 8.0%. Multivariate analysis showed that preoperative intraventricular hemorrhage (odds ratio [OR], 19.66; 95% confidence interval [CI], 5.10–75.80; P < 0.001), A1 hypoplasia (OR, 8.90; 95% CI, 2.82–28.04; P < 0.001), and postoperative cerebral infarction (OR, 3.21; 95% CI, 1.16–8.88; P = 0.025) were strong independent risk factors for unfavorable outcomes.ConclusionsProper management of preoperative intraventricular hemorrhage, A1 hypoplasia, and intensive care for postoperative brain infarction are warranted for improved surgical outcomes in patients with ruptured AComA aneurysm undergoing surgical clipping.

Brain infarctions after glioma surgery: prevalence, radiological characteristics and risk factors

BackgroundPrevalence, radiological characteristics, and risk factors for peritumoral infarctions after glioma surgery are not much studied. In this study, we assessed shape, volume, and prevalence of peritumoral infarctions and investigated possible associated factors.MethodsIn a prospective single-center cohort study, we included all adult patients operated for diffuse gliomas from January 2007 to December 2018. Postoperative infarctions were segmented using early postoperative MRI images, and volume, shape, and location of postoperative infarctions were assessed. Heatmaps of the distribution of tumors and infarctions were created.ResultsMRIs from 238 (44%) of 539 operations showed restricted diffusion in relation to the operation cavity, interpreted as postoperative infarctions. Of these, 86 (36%) were rim-shaped, 103 (43%) were sector-shaped, 40 (17%) were a combination of rim- and sector-shaped, and six (3%) were remote infarctions. Median infarction volume was 1.7 cm3 (IQR 0.7–4.3, range 0.1–67.1). Infarctions were more common if the tumor was in the temporal lobe, and the map shows more infarctions in the periventricular watershed areas. Sector-shaped infarctions were more often seen in patients with known cerebrovascular disease (47.6% vs. 25.5%, p = 0.024). There was a positive correlation between infarction volume and tumor volume (r = 0.267, p < 0.001) and infarction volume and perioperative bleeding (r = 0.176, p = 0.014). Moreover, there was a significant positive association between age and larger infarction volumes (r = 0.193, p = 0.003). Infarction rates and infarction volumes varied across individual surgeons, p = 0.037 (range 32–72%) and p = 0.026.ConclusionsIn the present study, peritumoral infarctions occurred in 44% after diffuse glioma operations. Infarctions were more common in patients operated for tumors in the temporal lobe but were not more common following recurrent surgeries. Sector-shaped infarctions were more common in patients with known cerebrovascular disease. Increasing age, larger tumors, and more perioperative bleeding were factors associated with infarction volumes. The risk of infarctions and infarction volumes may also be surgeon-dependent.

Imaging Pattern and the Mechanisms of Postoperative Infarction After Indirect Revascularization in Patients with Moyamoya Disease

To develop preventive strategies against postoperative infarction after indirect revascularization surgery in patients with moyamoya disease (MMD), we evaluated clinical information, with a specific focus on the imaging pattern of postoperative infarction. We retrospectively evaluated 421 surgical procedures performed in 354 (262 pediatric and 159 adult) patients with MMD from April 1991 to March 2021 at our institute. In addition to clinical information, raw images of postoperative infarction were collected and categorized into subtypes by the location of the infarction. Symptomatic and asymptomatic postoperative infarction occurred in 47 and 12 patients (11.1% and 2.6%), respectively, and more than half (51.7%) of these cases of postoperative infarction occurred immediately or the day after the surgery. Cortical infarction around the craniotomy site was the most frequent pattern observed (50/59, 84.8%), and some of these cases seemed to occur under local compression from epidural or subdural hematomas (15/50, 30.0%). Ipsilateral white matter infarctions located in the watershed area (9/59, 15.3%) and contralateral infarctions (3/59, 5.1%) were also observed. Four patients (1.0%) showed sudden occlusions of ipsilateral or contralateral large intracranial arteries immediately after surgery. Postoperative infarction caused permanent neurologic deficits in 7 patients (1.7%), and all included the cortex outside the craniotomy site. Local cortical irritation, hemodynamic fluctuation, and thromboembolic events were suggested as possible mechanisms of postoperative infarction after indirect revascularization in patients with MMD. Minimizing cortical irritation, maintaining adequate cerebral blood flow, and perioperative antiplatelet agents might decrease the incidence of postoperative infarction.

Predictors of Neurological Outcome Following Infant Cardiac Surgery Without Deep Hypothermic Circulatory Arrest

The aim of this study is to describe the clinical characteristics, perioperative course and neuroimaging abnormalities of infants with congenital heart disease (CHD) undergoing heart surgery without deep hypothermic circulatory arrest (DHCA) and identify variables associated with neurological outcome. Infants with CHD undergoing open-heart surgery without DHCA between 2009 and 2017 were identified from a cardiac surgery database. Full-term infants < 10weeks of age at the time of surgery who had both a pre- and postoperative brain magnetic resonance imaging exam (MRI) were included. Clinical characteristics and perioperative variables were collected from the electronic medical record. Brain Injury Scores (BIS) were assigned to pre- and postoperative brain MRIs. Variables were examined for association with neurological outcome at 12months of age or greater. Forty-two infants were enrolled in the study, of whom 69% (n = 29) had a neurological assessment ≥ to 12months of age. Adverse neurological outcome was associated with longer intensive care unit (ICU) stay (P = 0.003), lengthier mechanical ventilation (P = 0.031), modified Blalock-Taussig (MBT) shunt procedure (P = 0.005) and postoperative seizures (P = 0.005). Total BIS scores did not predict outcome but postoperative infarction and/or intraparenchymal hemorrhage (IPH) was associated with worse outcome by multivariable analysis (P = 0.018). Infants with CHD undergoing open-heart surgery without DHCA are at increased risk of worse neurological outcome when their ICU stay is prolonged, mechanical ventilation is extended, MBT shunt is performed or when postoperative seizures are present. Cerebral infarctions and IPH on postoperative MRI are also associated with worse outcome.

Efficacy of Carotid Artery Stenting Performed under General Anesthesia with Somatosensory Evoked Potential Monitoring

ObjectivesDuring carotid artery stenting (CAS), hemodynamics may be affected by the carotid sinus reflex in some cases. Although general anesthesia has been reported to stabilize intraoperative hemodynamics, the patient's neurological condition must be assessed indirectly. Therefore, we investigated the changes in intraoperative hemodynamics and perioperative complications of CAS under general anesthesia and evaluated the efficacy of somatosensory evoked potential (SEP) monitoring in detecting a reduction in perfusion during CAS. Materials and methodsFrom April 2011 to August 2016,57 consecutive patients who underwent CAS under general anesthesia were evaluated. The follow-up period ranged from 3 to 8 years. During CAS, anesthesiologists monitored and managed the hemodynamics. SEP monitoring was performed during the CAS procedure in all patients. ResultsIntraoperative hypotension (systolic blood pressure ≤ 100 mmHg) was evident in 16 patients (28.1%), and 13 patients (22.8%) experienced intraoperative bradycardia; however, all of these cases were promptly managed under general anesthesia. None of the patients showed systolic blood pressure < 50 mmHg from baseline. Regarding perioperative complications, none of the patients exhibited myocardial infarction or postoperative hyperperfusion symptoms, and there was no mortality. Among 21 patients (36.8%) with a decrease in the intraoperative SEP, 3 (5.3%) exhibited transient ischemic symptoms and 1 (1.8%) had postoperative infarction. ConclusionsCAS under general anesthesia is a safe and effective management option in terms of intraoperative hemodynamic stability. In addition, our findings indicate that SEP monitoring could be helpful in evaluating transient postoperative cerebral ischemia or cerebral infarction after CAS.

Single-Institute Experience of Bypass Surgery for Complex Anterior Cerebral Artery Aneurysms: Paying Special Attention to the Spatial and Diameter Relationship Between the Efferent Arteries

To present a retrospective review of a single-institute experience with bypass surgery of complex anterior cerebral artery aneurysm. Eight patients (5 females and 3 males; mean age, 34.2 years) with complex anterior cerebral artery aneurysms were treated with bypass. There were 3 precommunicating aneurysms, 1 communicating artery aneurysm, and 4 postcommunicating aneurysms (2 in A2 and 2 in A3). A3-A3 side-to-side in situ bypass was performed in 6 cases. A3-radial artery-A3 interpositional bypass was performed in 1 case with A3 segments located far apart, and A3-A3 transplantation was performed in 1 case with nonparallel aligned A3 segments. Of the 8 aneurysms, 3 were secured with proximal clipping, 1 was secured with distal clipping, 1 was secured with direct clipping, 1 was secured with isolation, and 2 were secured with embolization. Aneurysm obliteration was achieved in all cases. Only 1 in situ bypass from a smaller donor artery to a larger recipient artery failed with minor postoperative infarction. Intraoperative bleeding from the site of anastomosis occurred in 1 case during embolization. All patients had complete recovery with normal neurological function during follow-up at outpatient clinics. We established a simplified surgical algorithm for complex anterior cerebral artery aneurysms based on the geometrical and spatial relationship between efferent arteries. The reasons for bypass failure and hemorrhagic complication were also discussed.