脳神経外科速報

脳神経外科では，マイクロ手術・血管内治療用はもちろん，モニタリングや画像診断，シミュレーションなど，新しいIT，デバイスが誕生し続けています．急患や長時間手術など，忙しい科であるのは確かですが，決して3Kだけではない．新しい発見と発展が常に目の前に現れる刺激的な領域で，日々,やり甲斐を感じています．

①適切なrecipientを選択するためによく観察し，かつ考える．　・その患者の脳の還流を改善するにはどうしたらいいか？　・バイパスからたくさんの血流を流すためにはどうするべきなのか？②血管の内膜同士がきちんと向き合った姿で縫合する．　・最初のstay sutureのあとの鈍角側の1針を，意識して捻って縫う．　・ はじめの1，2 針の縫い方で内膜同士が最初にきちんと合わさると，次の針を通すポイントが次々に明らかになっていく．　・ 正確なポイントに針を通すために、動作を割り、早く縫うために動作を重層化させる．

近年，小脳の研究の発展に伴い，小脳が運動のバランスと協調を司るという単なる運動調整機構としての認識から，学習記憶，言語，精神状態などの機能にも重要な役割を果たす，高次脳機能をも司る重要な臓器として再認識されてきている．小脳への関心はジストニアにおいても例外ではなく，さまざまな異常が小脳においても明らかとなってきた．ジストニアにおける小脳の所見は，症状に対する代償性の二次的変化だとの指摘もあるが，多くの動物実験が，ジストニアにおける一次的な小脳の関与を示唆している．このような研究により，古くから代表的な大脳基底核疾患として考えられてきたジストニアが，その病態に小脳や脳幹などを包含する広範囲なネットワーク障害によって表出されているとの新しい概念が広まりつつある．また，小脳を治療ターゲットとしてジストニアを治療する試みも始まっており，ジストニアにおける小脳の研究は今後さらなる発展が期待される

開頭手術中の予期せぬ虚血合併症を回避するためには，各種のモニタリングの併用が重要となる．そうしたモニタリングのひとつとして，蛍光脳血管撮影（FCAG）が施行され，その有用性が報告されている．蛍光色素には，インドシアニン・グリーン（ICG）とフルオレセインNa（fluorescein）が使用されているが，それぞれ長所と限界とがあり，それを理解して使用することが求められる．本稿では，fluorescein-FCAGの原理と実際の手技を概説し，臨床症例を呈示する．

Video recording is useful for looking back on surgeries and as an educational tool. However not a ll hospitals have an astral lamp-mounted video recording camera. Here, we report our experience with the use of a wearable camera during neurosurgery and discuss its effectiveness in surgical education. The wearable camera used was a Panasonic(R) HX-A100. (1) Chronic subdural hematoma (CSDH) : The surgical field and technique were visualized well; however, the surgical field was not visible on the screen when the surgeon approached the field to change the direction of his gaze. The dura mater and outer membrane of the CSDH were identified but the microbleeding point was not. The process of irrigation was observed well. (2) External ventricular drainage: A good view of the direction of catheter insertion into the ventricle and ventricular tap was obtained. (3) Acute subdural hematoma: A good view of the surgical field was obtained; however, one side of the surgical field was imaged obliquely when operating from the opposite side. The surgical field was not visible when the surgeon looked away. The deep parts of the surgical field were also visible when dissecting the dura mater adherent to the bone flap, rongeuring the sphenoid wing, and evacuating a residual hematoma. The microbleeding point was not identified. A wearable camera enables us to record surgical videos from the surgeon's point of view without disturbances between the camera and the surgical field. This in turn enables the observation of deep parts of the surgical field by camera, although it may be difficult to obtain the required detail. We think that greatest benefit of using wearable cameras is the ability to record surgeries without an astral lamp-mounted video recording camera. Furthermore, the videos of surgeries include discussions and teaching occurring during the surgery, which imparts high quality surgical education to their viewers. We believe that video recording of surgical procedures using wearable cameras might be useful for looking back on surgeries and macrosurgical education.

Objectives: To present the surgical devise of the Lumbosubarachnoid- Lumboepidural (L-L) shunt performed as treatment for idiopathic normal pressue hydrocephalus (iNPH) and decision of initial set-up pressure. Subject, Surgical procedure and Method: The subjects were 17 patients with probable iNPH (aged 66 to 98 yrs., mean age:83.5 yrs., male-female ratio 11: 6) who were judged to be at high risk from general or lumbar anesthesia due to their systemic complications, abdominal desease and age. The L-L shunt operation was performed for all the patients under local anesthesia using CHPV. The surgical procedure is as follows. 1) An approximately 5 cm groom longitudinal skin incision is made at the midline of the spine. 2) The catheters are inserted into the lumbar subarach space and lumbar epidural space. 3) Each catheters are connected to the shunt valve. 4) The catheters are looped and then the valve and catheters are fixed to the fascia. 5) Suturing of the skin. The evaluation of shunt efficacy were performed both 1 mo. and each follow-up period (5 to 32 mos.) after operation and the lumbar epidural space CSF absorption test (injection of contrast media into epidural space) were performed both the operation day and the 1 mo. after operation. Postoperative complications were also inveatigated. Results: The shunt operation was judged to be effective (shunt responder) in 14 out of 17 patients. No improvement in symptoms were seen in 3 patients (shunt non-responder) where the shunting had no effect after the initial pressure was changed to low pressure. The lumbar epidural space CSF absorption test both on the operation day and the 1 mo. after operation confirmed absorption in all patients. Postoperative subcutaneous CSE collection (PSCC) were seen in 4 patients. But all PSCC disappeard by changed to high pressure. Conclusions: 1) The L-L shunting is useful for patients with probable iNPH who are at high risk from general or lumbar anesthesia due to their systemic complications, abdominal desease and age. 2) Cerebrospinal fluid was continuously absorped in the lumbar epidural space during postoprative follow-up peri 3) Initial set-up pressure of L-L shunting should be setted 20 cmH2O on CHPV shunt system.