Any quantitative assessment of blood flow using conventional angiography remains impossible with current technology. Physicians decide the clinical end point of a procedure by subjective interpretation. Color-coded digital subtraction angiography has been invented to meet this demand and is used primarily in neuroradiology. This report presents the endovascular treatment of a rare complex combination of peripheral artery disease and arteriovenous fistula using guidance of blood flow parameters, such as area under the curve.

The preoperative assessment of cerebral veins is important to avoid unexpected cerebral venous infarction in the neurosurgical setting. However, information is particularly limited regarding deep Sylvian veins, which occasionally disturb surgical procedures for cerebral anterior circulation aneurysms. The predictability of detecting deep Sylvian veins and their tributaries using a modern multimodal fusion image was aimed to be evaluated. Moreover, 51 patients who underwent microsurgery for unruptured cerebral aneurysms with Sylvian fissure dissection were retrospectively reviewed. The visualization of the four components of the deep Sylvian veins in conventional computed tomography (CT) venography and multimodal fusion images was evaluated. To compare the detection accuracy among these radiological images, the sensitivity and specificity for the detection of each of the four venous structures were calculated in comparison with those of intraoperative inspections. The kappa coefficients were also measured and the inter-rater agreement for each venous structure in each radiological image was examined. In all veins, the multimodal fusion image exhibited a high detection rate without statistical difference from intraoperative inspections (P = 1.0). However, CT venography exhibited a low detection rate with a significant difference from intraoperative inspections in the common vertical trunk (P = 0.006) and attached vein (P = 0.008). The kappa coefficients of the fusion image ranged from 0.73 to 0.91 and were superior to those of CT venography for all venous structures. This is the first report to indicate the usefulness of a multimodal fusion image in evaluating deep Sylvian veins, especially for the detection of nontypical, relatively small veins with large individual variability.

Background:Although recent development of screw instrumentation techniques for rigid fixation of the atlantoaxial joint has increased surgical options, patients in whom screws of any type cannot be safely placed are sometimes encountered. We present a unique surgical technique for C1-2 transarticular screw placement utilizing a novel trajectory.Methods:A 35-year-old male with a history of Down's syndrome and cognitive dysfunction with hyperkinesis spontaneously developed rapid onset of tetraparesis and gait disturbance. Radiographs of the cervical spine revealed atlantoaxial subluxation (AAS) that could not be reduced. Computed tomography (CT) of the head showed multiple subacute cerebral infarctions in the territory of the right vertebral artery (VA). Three-dimensional CT angiography of the craniovertebral junction additionally confirmed right VA occlusion at the C2/3 level, a left C2 origin of the posterior inferior cerebellar artery, and hypoplasia of the bilateral C2 pedicles/C2 lamina. Because traditional screw-placement was not feasible, we performed a unique atlantoaxial fusion utilizing a C2 transverse foramen-penetrating screw with iliac bone grafting performed under neuronavigation.Results:The postoperative course was uneventful, and the patient regained the ability to ambulate, returning to his previous level of function. The CT of the cervical spine 12 months postoperatively showed rigid bony C1-C2 fusion, without recurrence of stroke.Conclusion:We introduced a novel C1-C2 transarticular screw-placement technique in which the trajectory went through the ipsilateral VA foramen due to already extent VA occlusion.

Background：3-dimensional(3D)multi-fusion medical imaging for neurosurgical planning is a newly developing technique, in which images taken from different radiological modality are superimposed and reconstructed to a high-resolution 3D image. The aim of this study is to describe our experience with this technique while applying it to spinal disorders and to discuss its usefulness and operational issues. Methods：The patients who underwent surgery for any spinal disorders using 3D multi-fusion medical imaging for preoperative neurosurgical planning at our institution between 2015 and 2018 were included in the study. These images were described using a medical workstation, which had broad utility, by radiation technologists and a neurosurgeon. Patients characteristics, required time, usefulness for pre-surgical planning, and encountered issues were analyzed. Results：Thirty-three patients were included in this study. Mean age of the patients was 57.5± 18.5 years. The underlying pathophysiologic disorders included various diseases, specifically spinal tumors for 20 patients. Two and 3 radiological modalities were incorporated in 26 and 7 patients, respectively. Mean required time for turning off the image was 95 minutes. The 3D image provided less useful information for pre-surgical simulation in the case of common neurospinal degenerative disorders, such as cervical or lumbar disc herniation. On the other hand, in cases of rare pathophysiological conditions, especially diseases that affect the craniovertebral junction or adhesive arachnoiditis, novel information provided from 3D fusion image helped surgeons to raise spatial cognition. However, as reciprocal deviation between each radiological modality was an insoluble problem, additional attempts to make the deviation smaller was needed. Conclusions：We presented our experience with the use of 3D multi-fusion medical imaging for neurosurgical planning in the area of spinal disorders and discussed its usefulness and operational issues. This technique might make the surgery much easier for surgeons by raising their spatial ability. However, the reciprocal deviation between each radiological modality is an unsolvable issue. Therefore, this technique must be operated based on this characteristic feature in cases with spinal disorders.