脳神経外科速報

私の座右の銘は「段取り八分」，手術を開始するときにはもうほとんど終わっているくらいの周到な術前準備が何よりも大切だと思っています．特にAVM と動脈瘤はそうですね．詳細な手術ストラテジーのスライドを作り，オペ室のモニタに掲げます．比較的容易な手術もありますが，どういうふうにアプローチするのか，どういうクリップを使うのかということを事前にある程度シミュレーションしておく．もちろん，実際にはそれと異なることもありますが，とにかく担当するすべての症例に関して，事前にスライドを作ります．教育的な意味もあるんですけれども，どういうストラテジーで手術するかということを事前にしっかり組み立てておくことが必要だと思います．

脊髄の腫脹や髄内T2 病変，造影病変を呈する神経疾患は，脊髄腫瘍との鑑別で重要である．多くは急性あるいは亜急性の経過で発症するが，慢性に経過することもある．それゆえ，発症様式やその後の経過，単峰性か再発性か，既往歴の内容，家族歴を詳細に聞き出す．脊髄症状だけでなく，他の神経部位の症状や所見，内科疾患の可能性を考えて他の臓器症状の有無も重要である．鑑別診断にあたり，longitudinally extensive transverse myelitis（LETM）を呈する各種疾患，特に頻度の高い炎症性疾患，なかでも，重篤な後遺症を残す可能性が高い，視神経脊髄炎（neuromyelitis optica：NMO）急性期では場合によっては時間単位で進行するので，早期に検索することが大切である．

Background: Although stenting has evolved as an effective treatment for stenosis of aortic arch vessels, this technique is often difficult because the large diameter and short length of the lesion result in instability of the catheter system and the need for a large sheath. Additionally, the need for protection devices to prevent peripheral embolism is controversial. We herein report the approach methods and outcomes of stenting of aortic arch vessel stenosis in our department. Material and Methods: We perform stenting for stenosis of aortic arch vessels when the lesions are symptomatic or there is an obvious difference in upper limb blood pressure. We examined such cases in our department from 2010 to 2017. Results: Sixteen patients (12 men, 4 women) were treated. Their mean age was 71 years (range, 60 - 82 years). The lesions were located in 10 left subclavian arteries, 5 right subclavian arteries, and 1 innominate artery. The etiology of all lesions was arteriosclerosis. Seven patients were symptomatic. Double antiplatelet therapy (aspirin 100 mg + clopidogrel 75 mg) was administered to all patients. Cilostazol was added for two patients with resistance to clopidogrel. Stents were successfully deployed in all cases. The approach was trans-femoral in 7 patients, trans-brachial in 2, the pull-through technique in 6, and the retrograde trans-common carotid artery(trans-CCA) direct approach in 1. Protection devices were used in 6 patients. The symptoms were improved in all 7 symptomatic patients after stenting. Percutaneous angioplasty or restenting was performed in 3 patients with restenosis. One patient had asymptomatic dissection. Lesions were detected by diffusion-weighted imaging in 7 patients, one of whom was symptomatic. In the symptomatic patient, stent-assisted coil embolization was simultaneously performed. When problems associated with instability of the catheter system and a large sheath due to a large-diameter lesion with a short length were encountered, the pull-through technique and retrograde trans-CCA direct approach were useful. In one patient, the innominate artery stenosis was treated by a retrograde trans-CCA direct approach. This approach facilitates approach to the lesion and proximal balloon protection in the distal innominate artery. Conclusion: Stenting for symptomatic stenosis of aortic arch vessels is useful. Appropriate approach methods should be selected for each case.

A 5-year-old boy was presented with transient ischemic attacks of paraparesis after crying. He was diagnosed as having moyamoya disease and underwent direct and indirect revascularization for the right cerebral hemisphere 10 months ago. Early imaging of 123I-iomazenil single-photon emission computed tomography (SPECT) showed hypoactivity in the left frontal lobe when compared with radio isotope (RI) activity in the right frontal lobe. Late imaging of 123I-iomazenil SPECT showed slight hypoactivity in the left frontal lobe when compared with RI activity in the right f rontal lobe. Late/early imaging of 123I-iomazenil SPECT showed high value in the left frontal lobe when compared with value in the right frontal lobe. He underwent direct and indirect revascularization for the left cerebral hemisphere so that the indirect revascularization covered the area with relatively high values on late/early imaging of 123I-iomazenil SPECT. Postoperative course was uneventful, and late/early imaging of 123I-iomazenil SPECT performed six months after surgery showed relative reduction of RI activity in the left frontal lobe.

Introduction: Intracranial fusiform aneurysms of the anterior choroidal artery (AChA) are relatively rare. We present a rare case of ruptured fusiform aneurysm of the AChA. Case presentation: A 35-year-old man was admitted to our hospital with sudden headache and vomiting. Neurological examination was normal. CT showed diffuse subarachnoid hemorrhage (SAH). The initial 3D-CTA showed a suspicion of dilatation morphological changes in the right AChA. However, the right AChA and aneurysm were not detected in the digital subtraction angiography (DSA), suggesting that occlusion of the AChA. The next day, second 3D-CTA showed recanalization of the AChA and thrombosed portion of the aneurysm. We decided to perform open surgery to prevent rebleeding. We identified the fusiform aneurysm at the proximal portion of the AChA. Furthermore, the AChA was seen arising from the tip of the aneurysm. The perforators, which originated from the aneurysmal sac, were not found. These finding suggested that this fusiform aneurysm was enlarged AChA itself. We performed trapping under the motor evoked potential (MEP) monitoring. MEP remained unchanged after trapping. The patient was discharged without any neurological deficits. Conclusion: We describe a rare case of ruptured fusiform aneurysm of the AChA, successfully treated with trapping of the AChA. Intraoperative MEP monitoring is useful and indispensable in the treatment of AChA aneurysms.