Vascular Neurosurgery Research Articles

A simple bracing technique to correct kinking of arterial branches to avoid ischemic sequelae during neurovascular surgery.

Background:During microscopic procedures for neurovascular disease, we sometimes encounter kinking of arterial branches resulting in ischemic sequelae. A simple and useful technique that involves inserting a small, ball-like prosthesis made of oxidized cellulose or shredded Teflon with fibrin glue that corrects the arterial branch kinking and avoids subsequent compromise is reported.Methods:Between January and December 2014, three patients developed arterial kinking during microscopic procedures, including two in the caudal loop of the posterior inferior cerebellar artery during microvascular decompression for glossopharyngeal neuralgia and one in a branch of the middle cerebral artery (MCA) during clipping for an unruptured MCA aneurysm. Blood flow insufficiency was confirmed by microvascular Doppler ultrasonography (MDU) and indocyanine green (ICG) videoangiography. The prosthesis, which was made of shredded Teflon in two cases and oxidized cellulose in one case, was inserted into the crotch of the kinked arteries to correct the kinking of the arteries and restore the proper vascular shape and normal blood flow.Results:The small, ball-shaped prosthesis corrected the kinked arteries and maintained the proper shape, which was confirmed by ICG videoangiography and MDU during the operation and three-dimensional computerized tomography angiography postoperatively. Postoperatively, the patients did not manifest any ischemic sequelae related to the kinked arteries.Conclusion:The insertion of prostheses with fibrin glue into the crotch of a kinked artery for repair is considered a simple and useful method for correcting a kinked artery that avoids ischemic sequelae.

Intraoperative indocyanine green videoangiography to guide decision making regarding need for vessel bypass: A case report and technical note.

Background:Indocyanine green (ICG) videoangiography is an intraoperative technique recently used in vascular neurosurgery to assess the presence or absence of blood flow during critical times of a procedure. These include, but are not limited to, detecting whether daughter branches or perforators are patent after placing a vascular clip or determining whether an aneurysm has been completely isolated from the cerebral circulation after clipping. We present a case of a less-commonly reported application of ICG videoangiography involving the selection of a vessel to act as the bypass recipient once the need is identified during the surgical treatment of a complex intracranial aneurysm.Case Description:A 51-year-old male presented with a ruptured dissecting superior cerebellar artery (SCA) aneurysm that had two branches arising from the dome. Due to the difficult morphology of this aneurysm, a superficial temporal artery to SCA bypass was planned. We used ICG videoangiography to identify the branch that had insufficient retrograde flow via collateral circulation, to which the bypass was performed, followed by the isolation of the aneurysm from the cerebral circulation using permanent surgical clips.Conclusion:Our case represents a possible use of ICG videoangiography during the operative treatment of a difficult aneurysm. Our patient suffered no infarcts postoperatively. In the correct clinical context, this method represents a possible treatment option for complex aneurysms requiring a bypass.

A retrospective review of cryoprecipitate transfusion practice in Kuala Lumpur Hospital.

Background:Cryoprecipitate is generally used to treat bleeding patients with hypofibrinogenemia, and the transfusion decision is guided based on published guidelines.Aim:This study aimed to evaluate the practice appropriateness in accordance to cryoprecipitate transfusion guidelines in Hospital Kuala Lumpur.Methodology:This cross-sectional study of 117 cryoprecipitates transfused adult patients was conducted in Kuala Lumpur Hospital from January to June 2012. The compliance of the indication of cryoprecipitate was considered as appropriate if indicated for patients who have hypofibrinogenemia (<1.0 g/L) with bleeding, or otherwise inappropriate if pretransfusion fibrinogen level was more than 1.0 g/L, pretransfusion fibrinogen level was not examined and posttransfusion fibrinogen level more than 1.5 g/L.Results:Most of the cryoprecipitate prescriptions were found to be inappropriate, which read 81.2% (95% confidence interval = 0.740, 0.880). Patients who underwent neurovascular surgery were the major recipient of cryoprecipitate, but majority of the prescription was found not appropriate. The decision to transfuse cryoprecipitate was found mostly appropriate when was guided by fibrinogen (52.2%), but the percentage dropped to 10.6% when pretransfusion fibrinogen test was not performed. Regrettably, only 19.7% of total cryoprecipitate were given based on pretransfusion fibrinogen level.

Is aneurysm surgery too exciting for our own good?

Bunevicius and colleagues present an observational study on hemodynamic changes recorded from four experienced vascular neurosurgeons during 42 aneurysm clippings (ref). With this rather novel approach studying surgeons instead of patients, they found that heart rates and blood pressures rose during surgery and peaked after aneurysm neck dissection and clipping relative to at rest. They also observed that clipping un-ruptured aneurysms was associated with greater hemodynamic responses than clipping ruptured aneurysms. Although they are to be congratulated for conducting an interesting and different study, it may hardly come as a surprise to the reader that aneurysm surgery can be more stressful than resting in a chair. It also seems reasonable that un-ruptured aneurysms trigger greater hemodynamic responses since only perfect results are acceptable when patients undergo prophylactic neurovascular surgery, while treatment results in patients with subarachnoid hemorrhage are not entirely up to the surgeon. Although too much stress may increase tremor, impair judgment and therefore be undesirable for our patients during complex microneurosurgical procedures, the authors also speculate that aneurysm surgery may pose an occupational threat to our own health. Despite stressful surgeries, the mortality rates of surgeons luckily do not appear to be higher than in other medical specialties, and there is no excess of ischemic heart disease [1, 17]. In Norway, the life expectancy of male doctors is among the highest of all professions; only priests, college/university teachers and architects beat us by a fewmonths (www.ssb.no). US data also confirm that the life expectancy is higher for physicians than for example lawyers and other examined professionals [3]. But are neurovascular surgeons perhaps special? Although neurovascular surgery is both technically and mentally demanding, dealing with as well as controlling stress is part of the drill. Many neurovascular surgeons thrive on stress and may therefore represent a selection of individuals who are more comfortable with stressful situations. With human responses there is often a response shift with repeated exposures over time. With experience many neurovascular surgeons may therefore become more resistant to the adverse reactions from stress, as also suggested in the current study. This is presumably good for our patients. Among the four experienced neurovascular surgeons included in the present study, recorded hemodynamic responses were quite modest with observed heart rates 180/ 110 mmHg) 28 % of the time during observation. Also, abnormal blood pressure was more common during surgery than during vigorous physical exercise [14]. Even so, based on what we know from these two studies, aneurysm surgery does not seem to trigger extreme hemodynamic responses compared to other procedures or life situations. Similar hemodynamic responses have for example been seen during hallux valgus surgery, but with larger responses in trainees than in trainers [5]. Also in healthy men watching (Scottish!) football hemodynamic responses similar to performing aneurysm * Ole Solheim ole.solheim@ntnu.no

Intracranial-to-intracranial bypass for posterior inferior cerebellar artery aneurysms: options, technical challenges, and results in 35 patients.

OBJECT Intracranial-to-intracranial (IC-IC) bypasses are alternatives to traditional extracranial-to-intracranial (EC-IC) bypasses to reanastomose parent arteries, reimplant efferent branches, revascularize branches with in situ donor arteries, and reconstruct bifurcations with interposition grafts that are entirely intracranial. These bypasses represent an evolution in bypass surgery from using scalp arteries and remote donor sites toward a more local and reconstructive approach. IC-IC bypass can be utilized preferentially when revascularization is needed in the management of complex aneurysms. Experiences using IC-IC bypass, as applied to posterior inferior cerebellar artery (PICA) aneurysms in 35 patients, were reviewed. METHODS Patients with PICA aneurysms and vertebral artery (VA) aneurysms involving the PICA's origin were identified from a prospectively maintained database of the Vascular Neurosurgery Service, and patients who underwent bypass procedures for PICA revascularization were included. RESULTS During a 17-year period in which 129 PICA aneurysms in 125 patients were treated microsurgically, 35 IC-IC bypasses were performed as part of PICA aneurysm management, including in situ p3-p3 PICA-PICA bypass in 11 patients (31%), PICA reimplantation in 9 patients (26%), reanastomosis in 14 patients (40%), and 1 V3 VA-to-PICA bypass with an interposition graft (3%). All aneurysms were completely or nearly completely obliterated, 94% of bypasses were patent, 77% of patients were improved or unchanged after treatment, and good outcomes (modified Rankin Scale ≤ 2) were observed in 76% of patients. Two patients died expectantly. Ischemic complications were limited to 2 patients in whom the bypasses occluded, and permanent lower cranial nerve morbidity was limited to 3 patients and did not compromise independent function in any of the patients. CONCLUSIONS PICA aneurysms receive the application of IC-IC bypass better than any other aneurysm, with nearly one-quarter of all PICA aneurysms treated microsurgically at our center requiring bypass without a single EC-IC bypass. The selection of PICA bypass is almost algorithmic: trapped aneurysms at the PICA origin or p1 segment are revascularized with a PICA-PICA bypass, with PICA reimplantation as an alternative; trapped p2 segment aneurysms are reanastomosed, bypassed in situ, or reimplanted; distal p3 segment aneurysms are reanastomosed or revascularized with a PICA-PICA bypass; and aneurysms of the p4 segment that are too distal for PICA-PICA bypass are reanastomosed. Interposition grafts are reserved for when these 3 primary options are unsuitable. A constructive approach that preserves the PICA with direct clipping or replaces flow with a bypass when sacrificed should remain an alternative to deconstructive PICA occlusion and endovascular coiling when complete aneurysm occlusion is unlikely.

Risk factors for meningitis after craniotomy in patients with subarachnoid hemorrhage due to anterior circulation aneurysms rupture

ObjectivesPostoperative meningitis is a serious complication occurring after neurosurgical interventions. However, few investigations have focused specifically on the risk factors that predispose patients to meningitis after major craniotomy. This study identified the risk factors for postoperative meningitis after neurovascular surgery, and investigated the relationship between postoperative meningitis and clinical outcome. Patients and methodsA total of 148 consecutive patients with subarachnoid hemorrhage (SAH) who underwent clipping surgery through a pterional approach within 72h between January 2007 and September 2011 were retrospectively analyzed. The treatment strategy of our hospital for patients with SAH was based on the findings of digital subtraction angiography in the acute phase. Coil embolization was firstly considered, and clipping through craniotomy if indicated was performed as soon as possible. Prophylactic antibiotics were administered before beginning craniotomy and for at least 3 days after. Hydrocortisone was used to prevent hyponatremia if allowed by the medical condition of the patient. Intrathecal administration of nicardipine hydrochloride was given if required for vasospasm treatment. Meningitis was clinically diagnosed from the blood samplings and cerebrospinal fluid (CSF) examinations. Data were collected from the electronic and paper charts. The status of modified Rankin scale (mRS) 0–2 at discharge was defined as favorable outcome. ResultsA total of 14 patients (9.5%) had meningitis during this study period. Symptomatic vasospasm was detected in 33 patients (22.3%), and 12 patients (8.1%) had permanent neurological deficits caused by vasospasm. Overall, 109 patients (73.6%) had favorable outcome. The longer duration of drainage placement, presence of CSF leakage, and intrathecal administration of vasodilatory agent showed significantly higher incidence of postoperative meningitis in univariate analysis (p=0.0093, 0.0017, and 0.0090, respectively). The proportion of favorable outcome patients at discharge (mRS 0–2) was significantly lower in patients with postoperative meningitis (35.7%) than in patients without it (77.6%) (p=0.0004). The duration of in-hospital stay was significantly longer in patients with postoperative meningitis (median 58.5, range 28–115 days) than in patients without it (median 38.5, range 19–149 days) (p<0.001). Multivariate logistic regression analysis showed that only presence of CSF leakage was associated with postoperative meningitis (p=0.0299). ConclusionMeningitis after surgery is still a serious complication that requires preventative intervention. The clinical outcome of patients with postoperative meningitis after neurovascular surgery is not still satisfactory.

Neurovascular imaging: seeing the future more clearly

I am very happy to present the new journal titled Neurovascular Imaging (NVI), published by BioMed Central. The field of neurovascular imaging is a pivotal point at the intersection of neuroradiology, vascular neurology and vascular neurosurgery. Neurovascular research is a growing field and it is my opinion that a dedicated space for research in this field is necessary. In recent years, research in the field of neurovascular imaging has grown and changed through the exploration of both the morphological features associated with the pathology [1–3] and the pathways that lead to the early development of pathological conditions [4, 5]. In particular, the introduction of new CT and MR technologies opened new territories in the neurovascular imaging field [6–8]. Epidemiological analyses have shown that stroke is the third leading cause of death in the western world [9] and several recently published studies have underlined the link between the vessel (small and medium size) and brain disorders [10, 11]. The purpose of this journal will be to publish the latest research and educational papers about the key topics in neurovascular imaging. The main topics of focus for NVI include (but are not limited to): (1) Basis of pathology and technique (2) Carotid and vertebral artery, (3) Intracranial arterial circulation, (4) Stroke imaging, (5) Veins imaging, (6) Spine circulation, (7) Pediatric vascular disease. The journal will publish not only articles that cover “how to image” or “how to identify” some specific anatomy part or disease, but mainly scientific studies that explore the diagnostic process by using imaging. The vision is to consider the use of imaging as an advanced tool to perform the diagnosis of a disease and to identify associations between pathological conditions. The modality of publication of the articles in NVI is the open access publishing model [12, 13]; this approach has several advantages, including a wide readership resulting from unrestricted access. In the past, the traditional business model for scientific publishers relied on restricting access to published research in order to recoup the costs of the publication process. This approach was proven to work in the past but it is becoming apparent that the reality is rapidly changing and the necessity of restricting access to published research nowadays is debatable. It is well demonstrated that to produce “science,” it is important for the unrestricted flow of information in order to develop the necessary critical mass of new ideas to make a “quantum leap” the research [14]. The Editorial Board is composed by world-renowned leaders in the various fields of neurovascular imaging, some of whom are some of the fathers of this topic. Readers can be assured that NVI will be home to highquality research submitted and reviewed by the leading people in the field. In conclusion, I have high hopes for Neurovascular Imaging; its duty is complex, but I am sure that NVI will achieve its goals in the best way.

Magnetic resonance susceptibility weighted imaging in neurosurgery: current applications and future perspectives.

Susceptibility weighted imaging (SWI) is a relatively new imaging technique. Its high sensitivity to hemorrhagic components and ability to depict microvasculature by means of susceptibility effects within the veins allow for the accurate detection, grading, and monitoring of brain tumors. This imaging modality can also detect changes in blood flow to monitor stroke recovery and reveal specific subtypes of vascular malformations. In addition, small punctate lesions can be demonstrated with SWI, suggesting diffuse axonal injury, and the location of these lesions can help predict neurological outcome in patients. This imaging technique is also beneficial for applications in functional neurosurgery given its ability to clearly depict and differentiate deep midbrain nuclei and close submillimeter veins, both of which are necessary for presurgical planning of deep brain stimulation. By exploiting the magnetic susceptibilities of substances within the body, such as deoxyhemoglobin, calcium, and iron, SWI can clearly visualize the vasculature and hemorrhagic components even without the use of contrast agents. The high sensitivity of SWI relative to other imaging techniques in showing tumor vasculature and microhemorrhages suggests that it is an effective imaging modality that provides additional information not shown using conventional MRI. Despite SWI's clinical advantages, its implementation in MRI protocols is still far from consistent in clinical usage. To develop a deeper appreciation for SWI, the authors here review the clinical applications in 4 major fields of neurosurgery: neurooncology, vascular neurosurgery, neurotraumatology, and functional neurosurgery. Finally, they address the limitations of and future perspectives on SWI in neurosurgery.

Development of a new high-resolution intraoperative imaging system (dual-image videoangiography, DIVA) to simultaneously visualize light and near-infrared fluorescence images of indocyanine green angiography.

Intraoperative indocyanine green videoangiography (ICG-VA) has been widely used in vascular surgery, where vessels are clearly shown as white on a black background. However, other structures cannot be observed during ICG-VA. We have developed a new, high-resolution intraoperative imaging system (dual-image VA [DIVA]) to simultaneously visualize both light and near-infrared (NIR) fluorescence images from ICG-VA, allowing observation of other structures. The operative field was illuminated via an operating microscope by halogen and xenon lamps with a filter to eliminate wavelengths over 780 nm. In the camera unit, visible light was filtered to 400-700 nm and NIR fluorescence emission light was filtered to 800-900 nm using a special sensor unit with an optical filter. Light and NIR fluorescence images were simultaneously visualized on a single monitor. Our system clearly visualized the operative field together with fluorescence-enhanced blood flow. In aneurysm surgeries, we could confirm incomplete clipping with the neck remnant or with remnant flow into the aneurysm. In cases of arteriovenous malformation or arteriovenous fistula, feeding arteries and draining veins were easily distinguished. This system allows observation of the operative field and enhanced blood flow by ICG together in real time and may facilitate various types of neurovascular surgery.

Application of indocyanine green video angiography in surgical treatment of intracranial aneurysms.

Indocyanine green (ICG) video angiography has been used for several medical indications in the last decades. It allows a real time evaluation of vascular structures during the surgery. This study describes the surgical results of a senior vascular neurosurgeon. We retrospectively searched our database for all aneurysm cases treated with the aid of intraoperative ICG from 2009 to 2014. A total of 61 aneurysms in 56 patients were surgically clipped using intraoperative ICG. Clip reposition after ICG happened in 2 patients (3.2%). Generally, highly variable clip adjustment rates of 2%-38% following ICG have been reported since the introduction of this imaging technique. The application of ICG in vascular neurosurgery is still an emerging challenge. It is an adjunctive strategy which facilitates aneurismal evaluation and treatment in experienced hands. Nevertheless, a qualified vascular neurosurgeon is still the most important component of a high quality work.

Visualization of declamping procedure during carotid endarterectomy by ICG videoangiography

Background. ICG videoangiography (ICG-VAG) is widely used in neurovascular surgery. In carotid artery disease, it has been used to assess the extent of the plaque and to confirm the removal of the plaque and patency of the artery. We introduce a novel usage of the ICG-VAG to confirm the patency of the external carotid artery (ECA) and superior thyroid artery (STA), which should work as a drainage system of possible debris in the lumen. Method. Consecutive 27 patients with severe internal carotid artery stenosis were employed. Carotid endarterectomy (CEA) was done in the usual fashion. After suturing the arteriotomy, ICG was injected intravenously before reperfusion. Before declamping procedure, ICG-VAG mode was started. As the declamping procedure went on, the assistant judged whether the STA and the ECA were patent by watching the ICG flow on the monitor. After confirming the patency of the ECA–CCA system, the ICA was reperfused. Result. The back flow from the STA was not confirmed in two cases. The back flow from the ECA was confirmed in all 27 cases. In four cases, the ICG-VAG showed air bubbles in the lumen; these bubbles were washed away to the ECA or STA. Conclusion. Using ICG-VAG during the reperfusion procedure of CEA, the patency of the ECA and the STA can be confirmed. It may contribute to reduce embolic complication during reperfusion procedure.

Fluorescence in neurosurgery: Its diagnostic and therapeutic use. Review of the literature

Fluorescent agents, e.g. 5-aminolevulinic acid (5-ALA), fluorescein and indocyanine green (ICG) are in common use in neurosurgery for tumor resection and neurovascular surgery. Protoporphyrine IX (PPIX) as major metabolite of 5-ALA is a strong fluorescent substance accumulated within malignant glioma tissue and a very sensitive and specific tool for visualizing high grade glioma tissue during surgery. Furthermore, 5-ALA or rather PPIX also offers an intratumoral therapeutic option stimulated by laser light in specific wavelength. Fluorescein was demonstrated to show similar fluorescent reactions in neurosurgery, but is controversial in its use, especially in high grade tumor surgery. Intraoperative angiography during resection of arterio-venous malformations, extracranial–intracranial-bypass or aneurysm surgery is supported by ICG fluorescence. Generally ICG will provide beneficial information for both, exposure of the pathology and illustration of healthy structures. This manuscript shows an overview of the literature focussing fluorescence in neurosurgery.

Middle Cerebral Artery Bifurcation Aneurysms: When and How to Treat Asymptomatic Unruptured Aneurysms

Management of unruptured asymptomatic cerebral aneurysms is one of the most highly controversial and most discussed topics in vascular neurosurgery. The increasing availability and use of imaging modalities, including computed tomography with and without angiography, magnetic resonance imaging, magnetic resonance angiography, and digital subtraction angiography, has resulted in an increased number of diagnosed unruptured aneurysms. This trend has led more patients to ask if their vascular lesion should be treated and if so when should such treatment be done. The current medical literature shows conflicting data regarding the natural history of unruptured cerebral aneurysms and the risks associated with their management. In 2003, the International Study of Unruptured Intracranial Aneurysms (ISUIA) (11) showed that aneurysms in the anterior circulation measuring <7 mm had a 5-year cumulative risk of rupture of 0% in patients with no history of subarachnoid hemorrhage and that aneurysms measuring 7e12 mm had a 5-year cumulative risk of 2.6%, making the risk associated with any treatment modality

MP62-10 LESS (LAPAROENDOSCOPIC SINGLE SITE SURGERY) RADICAL PROSTATECTOMY USING NEEDLE FORCEPS (ENDO RELIEF)

You have accessJournal of UrologyProstate Cancer: Localized V1 Apr 2015MP62-10 LESS (LAPAROENDOSCOPIC SINGLE SITE SURGERY) RADICAL PROSTATECTOMY USING NEEDLE FORCEPS (ENDO RELIEF) Hidetoshi Akita, Akihiro Nakane, Takahiro Kobayashi, Kenji Yamada, Ryosuke Ando, Yutaro Tanaka, Takehiko Okamura, Takahiro Yasui, and Kenjiro Kohri Hidetoshi AkitaHidetoshi Akita More articles by this author , Akihiro NakaneAkihiro Nakane More articles by this author , Takahiro KobayashiTakahiro Kobayashi More articles by this author , Kenji YamadaKenji Yamada More articles by this author , Ryosuke AndoRyosuke Ando More articles by this author , Yutaro TanakaYutaro Tanaka More articles by this author , Takehiko OkamuraTakehiko Okamura More articles by this author , Takahiro YasuiTakahiro Yasui More articles by this author , and Kenjiro KohriKenjiro Kohri More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2384AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES While 5-port laparoendoscopic radical prostatectomy(RP) is standard practice, efforts have been focused in developing a single port surgery, but this is still in the pioneering stage. We had therefore focused on reduced port surgery, using only 2-ports and reported. Endo Relief (Hope Denshi, Chiba, Japan), the new forceps, enabling to attach and remove the handle of needle forceps, has the same shape, size and sort as that of conventional 5-mm forceps and 2.4-mm diameter shaft. Using this forceps, we introduced LESS (laparoendoscopic single site surgery) radical prostatectomy for clinically localized prostate carcinoma and reported this surgical results in this study. METHODS From August 2012 to July 2014, A total 54 patients with clinically localized prostate cancer (cT1c, cT2, cT3aN0M0) were operated on and included in this analysis. A multichannel port (EZ ACCESS, Hakko, Nagano, Japan) with three 5-mm trocars, providing easier instrument handling, was inserted extraperitoneally through a 2.5-cm lower umbilical □gU□h incision. An additional needle forceps was inserted into the left fossa to allow an adequate working angle. RESULTS The operation was successfully completed in all patients. No patient required an additional port and open conversion. One patient (1.9%) had neurovascular bundle preservation surgery and 52 patients (96.3%) had Lymph Node dissection. The median operation time was 205.5(143-396) min, and the blood loss, including urine, was 402.5(2-1517) ml. The median Foley catheter indwelling period was 4 (3-55) days after surgery. Positive Surgical Margin rate was 18.5% (n=10). No intraoperative complications were occurred. CONCLUSIONS Judging from this initial trial, this procedure can be safely carried out, with cosmetic advantages and reduction in post surgical pain. Clinical characteristics and surgical results LESS-RP(n=54) Mean age (range) 69(49-75) BMI 23.4(16.8-30.2) Median PSA (ng/ml) 6.4(4.2-22.2) Clinical T stage cT1c 18(33.3%) cT2 33(61.1%) cT3a 3(5.6%) Biopsy Gleason score 6 or less 17(31.5%) 7 25(46.3%) 8 or more 12(22.2%) Pathological stage pT2 50(98.0%) pT3a 2(3.7%) pT3b 2(3.7%) Pathological Gleason score 6 or less 9(17.7%) 7 29(56.9%) 8 or more 13(25.5%) Extraprostatic extention 4(7.4%) Seminal vesicle invasion 2(3.7%) Positive Surgical margin 10(18.5%) operating time (min) 205.5(143-396) blood loss including urine (ml) 402.5(2-1517) Prostate volume (g) 41.5(21-80) Neuovascular preservation 1(1.9%) Lymph Node Dissection 52(96.3%) Indwelling catheter (day) 4(3-55) PAD Free Rate 1M (M:month) 15.8% 3M 44.7% 6M 78.9% © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e783-e784 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hidetoshi Akita More articles by this author Akihiro Nakane More articles by this author Takahiro Kobayashi More articles by this author Kenji Yamada More articles by this author Ryosuke Ando More articles by this author Yutaro Tanaka More articles by this author Takehiko Okamura More articles by this author Takahiro Yasui More articles by this author Kenjiro Kohri More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Impact of routine cerebral CT angiography on treatment decisions in infective endocarditis.

BackgroundInfective endocarditis (IE) is commonly complicated by cerebral embolization and hemorrhage secondary to intracranial mycotic aneurysms (ICMAs). These complications are associated with poor outcome and may require diagnostic and therapeutic plans to be modified. However, routine screening by brain CT and CT angiography (CTA) is not standard practice. We aimed to study the impact of routine cerebral CTA on treatment decisions for patients with IE.MethodsFrom July 2007 to December 2012, we prospectively recruited 81 consecutive patients with definite left-sided IE according to modified Duke’s criteria. All patients had routine brain CTA conducted within one week of admission. All patients with ICMA underwent four-vessel conventional angiography. Invasive treatment was performed for ruptured aneurysms, aneurysms ≥5 mm, and persistent aneurysms despite appropriate therapy. Surgical clipping was performed for leaking aneurysms if not amenable to intervention. Results: The mean age was 30.43±8.8 years and 60.5% were males. Staph aureus was the most common organism (32.3%). Among the patients, 37% had underlying rheumatic heart disease, 26% had prosthetic valves, 23.5% developed IE on top of a structurally normal heart and 8.6% had underlying congenital heart disease. Brain CT/CTA revealed that 51 patients had evidence of cerebral embolization, of them 17 were clinically silent. Twenty-six patients (32%) had ICMA, of whom 15 were clinically silent. Among the patients with ICMAs, 11 underwent endovascular treatment and 2 underwent neurovascular surgery. The brain CTA findings prompted different treatment choices in 21 patients (25.6%). The choices were aneurysm treatment before cardiac surgery rather than at follow-up, valve replacement by biological valve instead of mechanical valve, and withholding anticoagulation in patients with prosthetic valve endocarditis for fear of aneurysm rupture.ConclusionsRoutine brain CT/CTA resulted in changes in the treatment plan in a significant proportion of patients with IE, even those without clinically evident neurological disease. Routine brain CT/CTA may be indicated in all hospitalized patients with IE.

Surgery of brain aneurysm in a BrainSuite® theater: A review of 105 cases

IntroductionThe BrainSuite® is a highly integrated operating theater designed mainly for brain tumor surgery. The issues concerning its routine use in vascular neurosurgery have not been discussed in literature to date.We report our experience of surgical treatment of cerebral aneurysms in the BrainSuite®, with a view to evaluating safety, feasibility, advantages, disadvantages, and contraindications. Material and methodsRetrospectively, we reviewed all the patients affected by ruptured and unruptured aneurysms that underwent craniotomy with clipping between January 2007 and May 2013 and a subsequent minimum 12-month follow up. Intraoperative DWI, MRA, and volumetric MRI were always performed in order to evaluate vessel patency and early ischemic lesions. The usefulness of navigation was also evaluated in terms of loss/gain of time and its effectiveness as a surgical aid to both the localization of small distal aneurysms and the preoperative planning of the clipping strategies to adopt. ResultsA total of 105 patients were included in this report. Of these, 39 and 66 were affected, respectively, by ruptured and unruptured aneurysms. The mean age was 56.1 and the male-to-female ratio was 1:2.9. The aneurysms affected, with progressively descending incidence, the MCA, ACoA, ICA bifurcation, PComA, A2, A1–A2, and C6 segment of the ICA in 40 (38.1%), 23 (22%), 15 (14.3%), 7 (6.6%), 7 (6.6%), 7 (6.6%), and 6 (5.8%) cases, respectively. The aneurysms were clipped and completely excluded from blood circulation in all cases and no difficulty was encountered in positioning and fixing the patients’ heads, despite the particular head holder of the BrainSuite®. MRI created no interference or problems in cases of carotid exposure at the neck, while harvesting of the lower-limb saphenous vein was not feasible due to the vicinity of the operating field to the magnet. Intraoperative angiography was never performed since an angiogram is not compatible with the BrainSuite. Intraoperative DWI, MRA, and volumetric MRI proved to be effective tools for post-clipping evaluation of the patency of the parent vessels and their collateral branches as well as of aneurismal occlusion. This was also checked doubly by availing also of intraoperative micro Doppler ultrasonography. Intraoperative DWI also permitted us to evaluate the presence of initial ischemic lesions as possible consequences of both direct arterial occlusion and early vasospasm related to surgical manipulation. Intraoperative navigation of brain aneurysm with 3D-model reconstructions may be of some use to younger surgeons when planning the clipping strategies and localizing the aneurysm particularly in cases, respectively, of large-complex aneurysms where the sac involves collateral branches and small aneurisms affecting both distal ACA and MCA aneurysms. The outcomes for patients, evaluated according to the GOS (Glasgow outcome score), associated significantly with the preoperative HH (Hunt and Hess) scale grading. Patients with high HH scores (IV and V) in particular showed the highest incidence of unfavorable outcome (GOS=1 or 2) ConclusionsThe BrainSuite® theater is completely suited to brain aneurysm surgery but only in cases where a combined endovascular approach may be required. It provides some advantages and few limitations compared to a normally-equipped neurosurgical operating theater; our experience shows that the technological advances of this complex operating room are useful though not essential in aneurysm surgery.

Integration of Indocyanine Green Videoangiography With Operative Microscope

Preservation of adequate blood flow and exclusion of flow from lesions are key concepts of vascular neurosurgery. Indocyanine green (ICG) fluorescence videoangiography is now widely used for the intraoperative assessment of vessel patency. Here, we present a proof-of-concept investigation of fluorescence angiography with augmented microscopy enhancement: real-time overlay of fluorescence videoangiography within the white light field of view of conventional operative microscopy. The femoral artery was exposed in 7 anesthetized rats. The dissection microscope was augmented to integrate real-time electronically processed near-infrared filtered images with conventional white light images seen through the standard oculars. This was accomplished by using an integrated organic light-emitting diode display to yield superimposition of white light and processed near-infrared images. ICG solution was injected into the jugular vein, and fluorescent femoral artery flow was observed. Fluorescence angiography with augmented microscopy enhancement was able to detect ICG fluorescence in a small artery of interest. Fluorescence appeared as a bright-green signal in the ocular overlaid with the anatomic image and limited to the anatomic borders of the femoral artery and its branches. Surrounding anatomic structures were clearly visualized. Observation of ICG within the vessel lumens permitted visualization of the blood flow. Recorded video loops could be reviewed in an offline mode for more detailed assessment of the vasculature. The overlay of fluorescence videoangiography within the field of view of the white light operative microscope allows real-time assessment of the blood flow within vessels during simultaneous surgical manipulation. This technique could improve intraoperative decision making during complex neurovascular procedures.

The use of barbiturate-induced coma during cerebrovascular neurosurgery procedures: A review of the literature

Barbiturates are indicated for use during vascular neurosurgery procedures such as carotid surgery, arteriovenous malformation (AVM) surgery, cerebral aneurysm surgery, extracranial-intracranial bypass, and following significant bleeding due to AVMs or subarachnoid hemorrhage (SAH). These drugs are commonly used for their neuroprotective effects during focal cerebral ischemia and for their ability to treat intractable intracranial hypertension. Currently, thiopental and pentobarbital are the most frequently used barbiturates for these purposes, although methohexital and phenobarbital have been studied as well. Depending on the drug used and the desired effect, the dose administered may vary. Additionally, barbiturates are known to cause significant, severe side effects including depression of cardiac output, increased liver enzymes, increased risk of cardiac arrhythmia, lowered immune threshold, adversely affected brain temperature, systemic hypotension, and dyskalemia. For these reasons, these drugs should be monitored carefully and only used in circumstances of clear benefit. Finally, in order to evaluate barbiturates use during these procedures, information was gathered via an extensive PubMed literature review in addition to reviewing the resources of previous reviews on this topic or similar, relevant topics.

Intraoperative indocyanine green fluorescence angiography in surgery of brain aneurysms. The first experience with using the technique and literature review

Intraoperative blood flow assessment after aneurysm clipping has become a standard procedure in vascular neurosurgery worldwide. Intraoperative indacyanine green angiography (ICG) has recently been certified in Russia. Fifteen patients with aneurysms operated with ICG control in Burdenko NSI are described in present publication. ICG advantages and weaknesses are discussed along with alternative flow control techniques available now.

Impact of a Vascular Neurosurgery Simulation-Based Course on Cognitive Knowledge and Technical Skills in European Neurosurgical Trainees

To assess microsurgical and diagnostic cerebral angiography modules and their corresponding objective assessment scales as educational tools for European neurosurgical residents at the European Association of Neurosurgical Societies Resident Vascular Neurosurgery course, which was held in Prague, Czech Republic, on September 2013. Microsurgical skills and cerebral angiography are fundamental skills in vascular neurosurgery. There is a need to develop a simulation-based curriculum focusing on these skills for neurosurgical trainees worldwide. The course consisted of 2 modules: microanastomosis and diagnostic cerebral angiography. In addition to an initial screening survey, each module was divided into 3 components: 1) a before didactic cognitive knowledge and technical skills testing, 2) a didactic lecture, and 3) an after didactic cognitive knowledge and technical skills testing. We compared the trainees' cognitive and technical scores from the before and after testing phases. Wilcoxon sum rank test was used to test statistical significance. The knowledge test median scores increased from 63% and 68% to 80% and 88% (P < 0.01) on the microanastomosis and cerebral angiography modules, respectively. The practical hands-on simulation assessment median scores increased from 42% and 50% to 50.5% and 68% (P < 0.01) on the microanastomosis and cerebral angiography modules, respectively. Our course suggests that a simulation-based vascular neurosurgery curriculum is feasible and may enhance resident knowledge and technical proficiency.