論文 - 堀口　崇

Silent MRA: arterial spin labeling magnetic resonant angiography with ultra-short time echo assessing cerebral arteriovenous malformation

Arai N., Akiyama T., Fujiwara K., Koike K., Takahashi S., Horiguchi T., Jinzaki M., Yoshida K.

Neuroradiology 62 （ 4 ） 455 - 461 2020年04月

ISSN  00283940

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Purpose: MR angiography using the silent MR angiography algorithm (silent MRA), which combines arterial spin labeling and an ultrashort time echo, has not been used for the evaluation of cerebral arteriovenous malformations (CAVMs). We aimed to determine the usefulness of silent MRA for the evaluation of CAVMs. Methods: Twenty-nine CAVMs of 28 consecutive patients diagnosed by 4D CT angiography or digital subtraction angiography, who underwent both time-of-flight (TOF) MRA and silent MRA, were enrolled. Two observers independently assessed the TOF-MRA and silent MRA images of CAVMs. Micro AVM was defined as AVM with a nidus diameter less than 10 mm. The detection rate, visualization of the components, and accuracy of Spetzler–Martin grade were evaluated with statistical software R. Results: For all 29 CAVMs, 23 (79%) lesions were detected for TOF-MRA and all for silent MRA. Of 10 micro AVMs, only 4 (40%) lesions were detectable on TOF-MRA and all (100%) on silent MRA. The visibility of the nidus and drainer was significantly better for silent MRA than TOF-MRA (p < 0.001), while there was no significant difference in the feeder between the two sequences. The accuracy rates of the Spetzler–Martin grade for the TOF and silent MRA were 38% (11/29) and 79.3% (23/29), respectively (p < 0.001). Conclusions: Silent MRA is useful for evaluating CAVM components and detecting micro AVM.

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Clipping versus coiling in unruptured anterior cerebral circulation aneurysms

Mohammad F., Horiguchi T., Mizutani K., Yoshida K.

Surgical Neurology International 11 （ 50 ） 50 2020年03月

ISSN  2229-5097

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Background: Unruptured intracranial aneurysms (UIAs) are not uncommon, especially in Japan. Treatment strategy for UIAs has evolved in the past decades in Western countries with the increased use of endovascular treatment as the primary option, but in Japan, clipping still has the upper hand. Methods: This study retrospectively included 200 patients treated by clipping or coiling for UIAs located in the anterior cerebral circulation. Postoperative angiographic and clinical outcomes were evaluated. Results: Of 200 UIAs, 147 and 53 were treated by surgery and coiling, respectively. The average follow-up duration was 30.2 ± 18.8 months for clipping and 29.3 ± 17.6 months for coiling. Complete occlusion was greater in the surgery group (78.9%) than the endovascular group (18.8%). Regrowth occurred in 1.4% of the clipping group and 13.2% of the coiling group. Ischemic events were encountered in both groups; asymptomatic ones were higher in the coiling group (24.5%) than in the clipping group (2%), while symptomatic ischemic complications were equal (7.5%) in both groups. The deterioration of modified Rankin scale was detected totally in 13 UIAs (6.5%) with no statistical difference between groups. Postoperative hospital period was longer in clipping (P = 0.01). Conclusion: Clipping and coiling were both safe and feasible in the treatment of unruptured aneurysms. The clipping was advantageous in durability, while the rate of morbidity was lower, and hospitalization period was shorter in the coiling group. The clipping and coiling should coexist while complementing each other by understanding the advantages and disadvantages of both.

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Loss of consciousness at ictus and/or poor World Federation of Neurosurgical Societies grade on admission reflects the impact of EBI and predicts poor outcome in patients with SAH

Takahashi S., Akiyama T., Horiguchi T., Miwa T., Takemura R., Yoshida K.

Surgical Neurology International 11 （ 40 ） 40 2020年03月

ISSN  2229-5097

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Background: There are many scores and markers that predict poor outcome in patients with subarachnoid hemorrhage (SAH). However, parameters that can predict outcomes in patients with SAH with high specificity and sensitivity, which can be identified in the early postictal state and utilized as a clinical marker of early brain injury (EBI) have not been identified so far. Methods: Thirty-nine patients with SAH due to a saccular intracranial aneurysm rupture were reviewed. We retrospectively analyzed the relationships between patients' baseline characteristics and patients' outcomes to identify parameters that could predict patient outcomes in the early postictal state. Results: In the univariate analysis, older age (>65), loss of consciousness (LOC) at ictus, poor initial World Federation of Neurosurgical Societies (WFNS) grade (3-5), and delayed cerebral ischemia (DCI) were associated with poor outcome (GOS 1-3). Statistical analyses revealed that combined LOC at ictus and/or poor initial WFNS grade (3-5) was a more powerful surrogate marker of outcome (OR 15.2 [95% CI 3.1-75.5]) than either LOC at ictus or the poor initial WFNS grade (3-5) alone. Multivariate logistic regression analyses revealed that older age, combined LOC at ictus and/or poor initial WFNS grade, and DCI were independently associated with poor outcome. Conclusion: Combined LOC at ictus and/or poor initial WFNS grade (3-5) reflects the impact of EBI and was a useful surrogate marker of poor prognosis in SAH patients, independent of patients' age and state of DCI.

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Altered expression of microRNAs in body fluids in after aneurysmal subarachnoid hemorrhage

Mihara, K; Takahasi, S; Yanagisawa, K; Mizutani, K; Akiyama, T; Katayama, M; Akaji, K; Horiguchi, T; Suga, S; Yoshida, K

JOURNAL OF CEREBRAL BLOOD FLOW AND METABOLISM 39   179 - 179 2019年07月

ISSN  0271-678X

Factors that predicts poor outcome in patients with subarachnoid hemorrhage

Takahashi, S; Akiyama, T; Horiguchi, T; Yoshida, K

JOURNAL OF CEREBRAL BLOOD FLOW AND METABOLISM 39   180 - 180 2019年07月

ISSN  0271-678X

Short-Term Spontaneous Resolution of Ruptured Peripheral Aneurysm in Moyamoya Disease

Yamada H., Saga I., Kojima A., Horiguchi T.

World Neurosurgery （World Neurosurgery）  126   247 - 251 2019年06月

ISSN  18788750

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© 2019 Elsevier Inc. Background: Peripheral aneurysms are known to be a source of intracranial hemorrhage in patients with moyamoya disease. However, the natural history of ruptured peripheral aneurysms remains unclear. Some regress spontaneously, whereas others may rebleed. Direct treatments, such as surgical or intravascular treatment of the peripheral aneurysm, can have a risk of severe neurologic complications owing to the depth of the operative field and the fragility of the parent artery. A careful treatment policy is required. Case Description: In a 29-year-old man with moyamoya disease with intraventricular hemorrhage, rupture of a right anterior choroidal artery aneurysm was diagnosed by cerebral angiography. The aneurysm was approximately 4 mm in size and existed in the plexal segment of the right anterior choroidal artery. Endovascular embolization of the aneurysm was planned. However, repeat angiography 3 weeks after aneurysm diagnosis demonstrated complete resolution of the aneurysm. Such short-term disappearance of an aneurysm is remarkably rare. We believe that the aneurysm was thrombosed for a brief period considering the slow blood flow detected inside the aneurysm during the initial angiography. The patient was discharged with no neurologic deficit and has remained recurrence-free for >1 year. Conclusions: Given that spontaneous resolution of an aneurysm may occur in a short period of time, we suggest that conservative treatment be considered as an option for ruptured peripheral aneurysms associated with moyamoya disease when direct treatment is risky.

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Pros and cons of using ORBEYE™ for microneurosurgery

Takahashi S., Toda M., Nishimoto M., Ishihara E., Miwa T., Akiyama T., Horiguchi T., Sasaki H., Yoshida K.

Clinical Neurology and Neurosurgery （Clinical Neurology and Neurosurgery）  174   57 - 62 2018年11月

ISSN  03038467

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© 2018 Elsevier B.V. Objective: To evaluate the pros and cons of using a newly developed microscope, ORBEYE™, during microneurosurgery. Patients and methods: ORBEYE™ use in 14 microneurosurgical procedures was retrospectively assessed by nine neurosurgeons after the procedure. A questionnaire comprising 20 questions was designed and used for evaluation. Results: Compared with the current gold standard, the binocular microscope, ease of setting up the equipment was scored the highest, whereas ease of conducting surgery in a position of an assistant was scored the lowest. Among characteristics of ORBEYE™ itself, the space-saving feature was scored the highest and was followed by the ability to perform procedures in a comfortable position. The only characteristic that was rated below average was ease of operation in a position of an assistant. Neurosurgeons with greater experience (more than five procedures using ORBEYE™) provided significantly higher scores (p = 0.0196) for characteristics of ORBEYE™ itself compared with neurosurgeon with fewer ORBEYE™ experience. Conclusions: The main benefits of the ORBEYETM are its compact size and freedom from focusing through the eye lens of a conventional binocular microscope. However, it appears to be disadvantageous for operating in a position of an assistant because the surgical field has a rotated view on the monitor from a position of an assistant. Nonetheless, because of certain advantages, we believe the ORBEYE™ could be of additional help to use of conventional binocular microscope at the moment and will facilitate microneurosurgery in the future.

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An analysis of the anatomic route of the hypoglossal nerve within the hypoglossal canal using dynamic computed tomography angiography in patients with anterior condylar arteriovenous fistulas

Oishi Y., Akiyama T., Mizutani K., Horiguchi T., Imanishi N., Yoshida K.

Clinical Neurology and Neurosurgery （Clinical Neurology and Neurosurgery）  174   207 - 213 2018年11月

ISSN  03038467

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© 2018 Elsevier B.V. Objective: The venous outlet of anterior condylar arteriovenous fistulas (AC-AVFs) often empties into the anterior condylar vein (ACV). Hypoglossal nerve palsy is one of the major complications after transvenous embolization (TVE) for the AC-AVF within the hypoglossal canal. However, no studies have investigated the route of the hypoglossal nerve within the hypoglossal canal in AC-AVF. The aim of the current study is to retrospectively verify the anatomical route of the hypoglossal nerve within its canal using dynamic computed tomography angiography (CTA) in order to facilitate the safe TVE for AC-AVF. Patients and methods: We included five patients with AC-AVF from 2011 to 2017. Dynamic CTA was performed on all patients. When the ACV was well-visualized by dynamic CTA, the hypoglossal nerve could be recognized as a less-intense structure within the surrounding enhanced vasculatures and the nerve route within the canal was analyzed. We also analyzed the location of the fistulas by digital subtraction angiography and cone-beam computed tomography. Results: In all five patients, the filling defect of the hypoglossal nerve ran through the most caudal portion of the hypoglossal canal. The fistulous pouches were located in the hypoglossal canal in three cases, and in the jugular tubercle venous complex in two cases. In all three cases with AC-AVF in the hypoglossal canal, the fistulous pouches were located in the superior wall of the hypoglossal canal, which means superior to the ACV. We performed TVE in four patients and none developed post-therapeutic hypoglossal nerve palsy. Conclusion: In the current study, dynamic CTA is useful for detecting the hypoglossal nerve within the hypoglossal canal. The hypoglossal nerve usually ran the bottom of its canal and the fistulous pouches were usually located at the superior aspect of the canal opposite side to the hypoglossal nerve. Accordingly, the selective embolization within the fistulous pouch located in the superior aspect of the ACV including jugular tubercle venous complex can reduce the risk of hypoglossal nerve palsy.

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Hybrid operating room(HOR)における複雑な脳血管障害に対する開頭および血管内複合治療の有用性　Hybrid operating room導入前後の検討

堀口 崇, 秋山 武紀, 高橋 里史, 大平 貴之, 吉田 一成

脳卒中の外科 （(一社)日本脳卒中の外科学会）  46 （ 6 ） 453 - 461 2018年11月

ISSN  0914-5508

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開頭手術と血管内複合治療(術中血管撮影を含む)を行った脳血管障害の症例を、手術台と血管撮影装置を兼ね備えたhybrid operating room(HOR)導入前後で比較し、HORの有用性について検討した。血管内治療医と共同で複合治療を行った脳血管障害の患者17例(男性10例、女性7例、平均49歳)を対象に、HOR導入前の前期11例、導入以後の後期6例に分類した。前期の11例中、部屋を移動して血管内治療を行ったのは4例であった。後期の6例はいずれも問題なく治療が終了した。転帰は原疾患の重症度が理由でsevere disabilityとなった症例を除き、全例でgood recoveryであったが、術後のminor strokeによる軽度顔面神経麻痺を1例に認めた。複雑な脳血管病変に対する開頭手術と血管内治療の複合治療は、HORを使用することで、より安全かつ円滑に完遂させることが可能であった。

Preoperative Assessment of Pathologic Subtypes of Meningioma and Solitary Fibrous Tumor/Hemangiopericytoma Using Dynamic Computed Tomography: A Clinical Research Study

Arai N., Mizutani K., Takahashi S., Morimoto Y., Akiyama T., Horiguchi T., Mami H., Yoshida K.

World Neurosurgery （World Neurosurgery）  115   e676 - e680 2018年07月

ISSN  18788750

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© 2018 Elsevier Inc. Background: Solitary fibrous tumors (SFTs)/hemangiopericytomas (HPCs) are highly vascularized tumors well known for malignant, invasive, and highly vascular features. To date, several studies have reported the preoperative imaging findings of SFTs/HPCs. In this study, computed tomography (CT) tumor values acquired from dynamic CT scan were selected to determine the tumor pathology of highly vascular tumors, such as SFTs/HPCs. Methods: We conducted a retrospective study on patients with pathologically diagnosed meningiomas and SFTs/HPCs who had undergone a dynamic contrast CT scan. We assessed and compared the CT values of these tumors according to the pathology. Results: From a total of 34 patients, 30 patients with meningiomas and 4 patients with HPCs were included. The mean CT values of SFTs/HPCs and angiomatous meningioma were statistically significantly higher than those of the other meningioma subtypes (P = 0.003). We also performed receiver operating characteristic curve analyses to detect an appropriate cutoff point for the CT value to differentiate tumor pathology, and the calculated threshold was 161 Hounsfield units (HU) (sensitivity, 100%; specificity, 75%; area under the curve, 0.87; 95%, CI 0.75–0.99). Conclusions: This study showed that obtaining a CT value is useful in determining highly vascular tumor pathology preoperatively. When considering neurosurgical extra-axial tumor removal, and when the CT value of tumors is >161 HU, then highly vascular tumors such as SFTs/HPCs or angiomatous meningiomas are likely, and this should be considered prior to surgical intervention and for risk assessment.

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Hyperperfusion after Clipping of Aneurysm: A Rare Entity

堀口 崇

Journal of Stroke and Cerebrovascular Diseases （Journal of Stroke and Cerebrovascular Diseases）  27 （ 5 ） 1425 - 1430 2018年01月

研究論文（学術雑誌）, 共著, 査読有り,  ISSN  10523057

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© 2018 National Stroke Association Background: Cerebral vasospasm is an uncontrollable and sometimes fatal complication occurring after subarachnoid hemorrhage. However, cerebral hyperperfusion syndrome is a rare complication after subarachnoid hemorrhage. Although plain computed tomography of cerebral hyperperfusion syndrome looks similar to cerebral infarction induced by cerebral vasospasm, they should be distinguished from each other because they require completely different treatments. Case Description: A 65-year-old man complained of severe headache and vomiting. A computed tomography scan of his head showed subarachnoid hemorrhage with acute hydrocephalus caused by intraventricular hematoma and aneurysm of the left middle cerebral artery. After endoscopic irrigation of the ventricular hematoma to decrease the intracranial pressure, we performed neck clipping for the ruptured aneurysm. We used a temporary clip to the proximal M1 segment twice for a total of 15 minutes. Five days after the clipping, a computed tomography scan of the patient's head showed a large low-density area in the left cerebral hemisphere. Although cerebral infarction caused by cerebral vasospasm was suspected, his perfusion computed tomography demonstrated a state of hyperperfusion corresponding to the low-density area. We started treatment to prevent vasodilation and excessive cerebral blood flow instead of treatment for cerebral vasospasm. After changing the treatment, the patient's symptoms gradually improved, and his perfusion computed tomography (8 days after surgery) showed no excessive increased blood flow. Conclusions: We present a case of cerebral hyperperfusion syndrome and its successful treatment, distinct from that of cerebral vasospasm, after ruptured aneurysm clipping. In addition, we discuss the mechanism of this rare syndrome based on previous reports.

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Hybrid operating room (HOR)における複雑な脳血管障害に対する開頭および 血管内複合治療の有用性ーHybrid operating room 導入前後の検討ー

堀口崇、秋山武紀、高橋里史、大平貴之、吉田一成

脳卒中の外科 46   453 - 461 2018年

研究論文（学術雑誌）, 共著, 査読有り

Hybrid operating room（HOR）における複雑な脳血管障害に対する開頭および血管内複合治療の有用性 ─Hybrid operating room導入前後の検討─

堀口 崇, 秋山 武紀, 高橋 里史, 大平 貴之, 吉田 一成

脳卒中の外科 （一般社団法人 日本脳卒中の外科学会）  46 （ 6 ） 453 - 461 2018年

ISSN  09145508

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Here we investigated the changes in utility and limits of combined microsurgical and endovascular treatment for complex cerebrovascular disease before and after the introduction of the hybrid operating room (HOR) in our department. Since 2006, a total of 17 patients (cerebral aneurysm in 12, cerebral arteriovenous malformation in 5) underwent integrated microsurgery with endovascular treatment. In 3 of 11 patients treated before the introduction of HOR, certain problems such as time consumption during patient transfer, disconnected workflow, and complicated operation due to poor quality of support equipment occurred. In contrast, all 6 operations in the HOR were uncomplicated. All therapeutic steps including anesthesia management were planned in a single session. In conclusion, HOR provides a safe and smooth workflow in combined microsurgical and endovascular treatment for complex cerebrovascular diseases.

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microRNA expression profiling in serum of patients with subarachnoid hemorrhage

Takahashi, S; Akiyama, T; Horiguchi, T; Mizutani, K; Mihara, K; Yanagisawa, K; Akaji, K; Mihara, B; Yoshida, K

CEREBROVASCULAR DISEASES 45   247 - 247 2018年

ISSN  1015-9770

　概要を見る

くも膜下出血患者の血清中でコントロールと比較して発現が1/4以下に低下している49種の（hsa-miR-223等）、2倍以上に上昇している27種のマイクロRNA（hsa-miR-451a等）を同定した。モデルマウスでは、頭蓋内圧上昇を5秒とすると、海馬でモデル作成後1日で微小血管基底膜が脱落し、アストロサイトの足突起が基底膜から剥がれた。3日後には基底膜周辺のアストロサイトのGFAP染色性が低下し、神経細胞自体の形態学的、数的変化は認めずに神経機能が障害された。くも膜下出血後のNVU統合性の崩壊は微小血管周囲に始まり、周辺アストロサイトの機能障害を介して、神経機能障害に至る可能性が考えられた。

再狭窄、最大内膜中膜複合体圧(max-IMT)、全身他臓器疾患合併から検討したCEAの長期成績

堀口　崇、秋山　武紀、高橋　里史、吉田　一成

脳卒中の外科 45 （ 5 ） 370 - 377 2017年10月

共著, 査読有り

再狭窄、最大内膜中膜複合体厚(max-IMT)、全身他臓器疾患合併から検討したCEAの長期成績

堀口 崇, 秋山 武紀, 高橋 里史, 吉田 一成

脳卒中の外科 （(一社)日本脳卒中の外科学会）  45 （ 5 ） 370 - 377 2017年09月

ISSN  0914-5508

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頸動脈内膜剥離術(CEA)施行後2年以上の経過観察が可能であった頸動脈狭窄症40例(男性36例、女性4例、平均72歳)、41病変(症候性35例、無症候性6例)を対象とした。定期的通院を中断した2例を除いた38例39病変において、31例が術前のmodified Rankin Scale(mRS)を維持できていたが、1例が転倒による急性硬膜下血腫を生じmRS 4となった。無症候性の6例全例の術後経過は良好であったが、1例が膵臓がんに罹患半年後に死亡した。最大内膜中膜複合体厚(max-IMT)の経時変化は、完全閉塞の1例を除き38病変で測定し、観察期間内における最大値は、平均2.0±1.1mm、1mm未満が6病変、1mm以上2mm未満が17病変、2mm以上3mm未満が8病変、3mm以上4mm未満3病変、4mm以上が4病変であった。術1ヵ月後よりも肥厚したのは15例で、全て術6ヵ月後に生じた。max-IMTが2mm以上になった群と2mm未満で留まった群において危険因子の有無と術後管理の成否を単項目で比較し、術後の糖尿病管理の成否のみに有意差を認めた。

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経過観察となった5 mm未満の未破裂脳動脈瘤に対する治療方針ー治療介入を決定する因子と時期についてー

堀口　崇、秋山　武紀、高橋　里史、吉田　一成

脳卒中の外科 44 （ 4 ） 276 - 282 2016年08月

共著, 査読有り

Marfan症候群に生じたくも膜下出血に対し開頭クリッピングを施行した1例ー症例報告と文献的考察ー

高橋里史、堀越知、金澤徳典、秋山武紀、堀口　崇、吉田一成

脳卒中の外科 44 （ 4 ） 307 - 310 2016年08月

共著, 査読有り

Marfan症候群の患者に生じたくも膜下出血に対し開頭クリッピングを施行した1例　症例報告と文献的考察

高橋 里史, 堀越 知, 金澤 徳典, 秋山 武紀, 堀口 崇, 吉田 一成

脳卒中の外科 （(一社)日本脳卒中の外科学会）  44 （ 4 ） 307 - 310 2016年07月

ISSN  0914-5508

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60歳代女性。Marfan症候群の既往に有する。今回、突然の激しい頭痛を主訴に近医を受診、CT所見でくも膜下出血を指摘され、治療目的で著者らの施設へ救急搬送となった。3D-CTA所見より右内頸動脈-後交通動脈分岐部の動脈瘤破裂と診断され、緊急で開頭クリッピング術を施行されることとなった。だが、全身麻酔、手術に先立ち、腰椎ドレナージの留置を検討したところ、Marfan症候群による脊椎の側彎が強く、正中確認が困難であった。そこで、術前3D-CTAから想定された動脈瘤は小さく、形状から解離も考えられたため、脆弱である可能性を念頭に、エダラボン点滴の上、右頭蓋内内頸動脈近位部を注意深くtemporary clipにて遮断し、瘤内の圧力を減じてから後交通動脈および近位側ネックを確認後、クリッピングした。その結果、術後経過は良好で、患者は後遺症なく第18病日目に独歩退院となった。尚、術後3ヵ月経過でのmRSは0で、動脈瘤の再発はみられていない。

経過観察となった5mm未満の未破裂脳動脈瘤に対する治療方針　治療介入を決定する因子と時期について

堀口 崇, 秋山 武紀, 高橋 里史, 吉田 一成

脳卒中の外科 （(一社)日本脳卒中の外科学会）  44 （ 4 ） 276 - 282 2016年07月

ISSN  0914-5508

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発見時の最大径が5mm未満で、経過観察となった未破裂脳動脈瘤316瘤を対象に、治療介入を決定する因子と的確な介入時期について検討した。その結果、1)本検討では局在(a-com、IC-PC)に加え、速い年間増大速度と形状変化(blebあるいは細長い変形)を伴う増大は破裂の危険が高く、迅速に治療介入を行う必要があると考えられた。2)治療介入時期を逃さないためには、2回目の検査は3ヵ月以内に実施し、その後も半年ごとの定期検査を2年間は継続する必要があると考えられた。