S ubarachnoid hemorrhage (SAH) from a ruptured aneurysm is accompanied by several complications, including electrolyte abnormalities, vasospasm, hydrocephalus, cardiac dysfunction, and pulmonary edema. 15,16,18 Among these complications, delayed cerebral ischemia (DCI) remains an important cause of morbidity and death. 15 Many studies have investigated the prevention or treatment of DCI after SAH.Triple-H therapy (i.e., hypertension, hypervolemia, and hemodilution) has reportedly been an effective approach abbreviatioNs CI = cardiac index; CRP = C-reactive protein; DCI = delayed cerebral ischemia; ELWI = extravascular lung water index; GEDI = global end-diastolic volume index; PVPI = pulmonary vascular permeability index; SAH = subarachnoid hemorrhage; SVRI = systemic vascular resistance index; WFNS = World Federation of Neurosurgical Societies. obJective Subarachnoid hemorrhage (SAH) is often accompanied by pulmonary complications, which may lead to poor outcomes and death. This study investigated the incidence and cause of pulmonary edema in patients with SAH by using hemodynamic monitoring with PiCCO-plus pulse contour analysis. methods A total of 204 patients with SAH were included in a multicenter prospective cohort study to investigate hemodynamic changes after surgical clipping or coil embolization of ruptured cerebral aneurysms by using a PiCCO-plus device. Changes in various hemodynamic parameters after SAH were analyzed statistically. results Fifty-two patients (25.5%) developed pulmonary edema. Patients with pulmonary edema (PE group) were significantly older than those without pulmonary edema (non-PE group) (p = 0.017). The mean extravascular lung water index was significantly higher in the PE group than in the non-PE group throughout the study period. The pulmonary vascular permeability index (PVPI) was significantly higher in the PE group than in the non-PE group on Day 6 (p = 0.029) and Day 10 (p = 0.011). The cardiac index of the PE group was significantly decreased biphasically on Days 2 and 10 compared with that of the non-PE group. In the early phase (Days 1-5 after SAH), the daily water balance of the PE group was slightly positive. In the delayed phase (Days 6-14 after SAH), the serum C-reactive protein level and the global end-diastolic volume index were significantly higher in the PE group than in the non-PE group, whereas the PVPI tended to be higher in the PE group. coNclusioNs Pulmonary edema that occurs in the early and delayed phases after SAH is caused by cardiac failure and inflammatory (i.e., noncardiogenic) conditions, respectively. Measurement of the extravascular lung water index, cardiac index, and PVPI by PiCCO-plus monitoring is useful for identifying pulmonary edema in patients with SAH.Clinical trial registration no.: UMIN000003794 (clinicaltrials.gov)http://thejns.org/doi/abs/10.3171/2015.6.JNS1519

The aim of this study was to evaluate the importance of pre- and post-operative volumetric measurement of the cerebellopontine angle (CPA) using 3 Tesla (3T) magnetic resonance imaging (MRI). Between April 2012 and December 2015, a total of 87 consecutive patients underwent microvascular decompression (MVD) for trigeminal neuralgia (TN), of whom 51 with primary TN caused by arterial compression were enrolled in this study. Bilateral CPA cistern volume was evaluated using 3T MRI before and after surgery; the Cistern Deviation Index was used to represent the degree of deviation of the CPA cistern. The relationships between CPA cistern volume and the etiology of TN were assessed, and post-operative changes in anatomical parameters were examined to determine differences between recurrent and non-recurrent patients with TN. The mean volume of the CPA cistern on the affected side was significantly smaller than the unaffected side (P < 0.001). Five of 51 (10%) patients experienced TN recurrence. The recurrent cases demonstrated significantly lower pre-operative Cistern Deviation Index scores than non-recurrent cases (P = 0.035). On the unaffected side—but not the affected side—post-operative volume reduction was significantly greater in the recurrence group than in the non-recurrence group (P = 0.004). The pre-operative Cistern Deviation Index was a useful parameter to predict the recurrence of TN. In recurrent patients, post-operative inflammatory reaction may extend to not only the operated side but also the healthy side and reduce the volume of the CPA cistern.

Background: Quality indicators (QIs) are an accepted tool for measuring a hospital’s performance in routine care. We examined national trends in adherence to the QIs developed by the Close The Gap-Stroke program by combining data from the health insurance claims database and electronic medical records, and the association between adherence to these QIs and early outcomes in patients with acute ischemic stroke in Japan. Methods: In the present study, patients with acute ischemic stroke who received acute reperfusion therapy in 351 Close The Gap-Stroke-participating hospitals were analyzed retrospectively. The primary outcomes were changes in trends for adherence to the defined QIs by difference-in-difference analysis and the effects of adherence to distinct QIs on in-hospital outcomes at the individual level. A mixed logistic regression model was adjusted for patient and hospital characteristics (eg, age, sex, number of beds) and hospital units as random effects. Results: Between 2013 and 2017, 21 651 patients (median age, 77 years; 43.0% female) were assessed. Of the 25 defined measures, marked and sustainable improvement in the adherence rates was observed for door-to-needle time, door-to-puncture time, proper use of endovascular thrombectomy, and successful revascularization. The in-hospital mortality rate was 11.6%. Adherence to 14 QIs lowered the odds of in-hospital mortality (odds ratio [95% CI], door-to-needle <60 min, 0.80 [0.69–0.93], door-to-puncture <90 min, 0.80 [0.67–0.96], successful revascularization, 0.40 [0.34–0.48]), and adherence to 11 QIs increased the odds of functional independence (modified Rankin Scale score 0–2) at discharge. Conclusions: We demonstrated national marked and sustainable improvement in adherence to door-to-needle time, door-to-puncture time, and successful reperfusion from 2013 to 2017 in Japan in patients with acute ischemic stroke. Adhering to the key QIs substantially affected in-hospital outcomes, underlining the importance of monitoring the quality of care using evidence-based QIs and the nationwide Close The Gap-Stroke program.

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The far lateral approach includes exposure of the C1 transverse process, vertebral artery, posterior arch of the atlas, and occipital condyle. We designed a method for systematic muscular-stage dissection and present our experience with this approach. We used a horseshoe scalp flap that was reflected downward and medially. The lateral muscle layers were separated layer to layer to expose the suboccipital triangle. The medial muscle layers were separated in the midline and reflected in a single layer. At this stage, the midline of the C1 process and the foramen magnum were identified. The rectus capitis posterior major muscle was reflected to expose the posterior arch of the atlas. The C1 transverse process and vertebral artery were identified by reflection of the superior oblique muscle. The occipital condyle was separated accordingly. We used this method of muscular dissection in 10 patients (foramen magnum meningioma, = 5; hypoglossal schwannoma, = 2; others, = 3). Systematic muscular-stage dissection facilitates identification of the anatomical landmarks with no vertebral artery injury. Gross total removal was obtained in all 9 patients with complex tumors. The patient with vertebral artery dissection successfully underwent proximal clipping. Our muscular-stage dissection could contribute to safe and effective surgery for the far lateral approach.