For malperfusion in Stanford type A acute aortic dissection, we resolve static intestinal ischemia prior to central repair, rapidly unload the left ventricle for myocardial ischemia, and resolve cerebral or lower limb ischemia using cardiopulmonary bypass, We evaluated the validity of this strategy, Subjects:Among 165 emergency surgeries for Stanford type A acute aortic dissection performed since 2009, malperfusion was present in 52 cases(brain 23/heart 9/kidney 8/intestine 4/lower extremity 21)[overlap present], Results:Mean age was 63±12 years;29 patients were male;1 case had Marfan syndrome, The median time from onset to extracorporeal circulation initiation was 5 hours(range 2~51), Postoperative extracorporeal membrane oxygenation(ECMO)was used in 5 cases;in-hospital mortality occurred in 8 cases;and 8 cases had residual sequelae of cerebral infarction(controlled reperfusion in 1), Conclusion:Strategies for treating coronary malperfusion require improvement, In cerebral malperfusion, controlled reperfusion may be effective, with fewer residual sequelae in treated cases.
Japan faces significant challenges, including an aging population, rising healthcare costs, and strained healthcare sustainability. Digital health is an indispensable strategic imperative. Telemedicine, such as telestroke networks, reduces regional care disparities for acute stroke and is supported by national guidelines and reimbursement policies. Evidence-based digital therapeutics and software-based treatments are approved for conditions, such as hypertension and nicotine dependency, aiding chronic disease management by fostering sustained behavioral change. Artificial intelligence-driven data analysis improves prognostic accuracy and offers insights into more precise preventive interventions. However, systemic barriers hinder the widespread adoption of digital health, including 1) limited resources for implementation and maintenance, 2) stakeholder resistance because of low digital literacy, lack of confidence, and "change fatigue," 3) persistent technical and ethical challenges, including data interoperability issues, and 4) inadequate insurance reimbursement for digital health services. Achieving "digital maturity" requires moving beyond technological acquisitions. It is measured by how well systems use technology to improve patient and provider experiences and population health and reduce costs. Therefore, government, industry, and clinical stakeholders must collaborate to create a resilient and sustainable future for Japan.
Neuroendovascular therapy is a minimally invasive treatment for various cerebrovascular diseases; however, its outcomes depend heavily on perioperative management. Antithrombotic control is particularly important in procedures using high-metal-burden devices such as stents and flow diverters. Although dual antiplatelet therapy (DAPT) is the standard strategy, variability in the clopidogrel response, especially due to CYP2C19 polymorphisms, necessitates individualized management supported by platelet function testing. Careful access evaluation and ultrasound-guided femoral puncture can also reduce access-site complications. Overall, a tailored and risk-balanced perioperative approach is essential to improve safety and outcomes.
This single-center retrospective study evaluated postoperative outcomes in Stanford type A acute aortic dissection(AAAD)patients presenting with preoperative cardiopulmonary arrest(CPA)between January 2021 and May 2025, Methods:Among 390 consecutive AAAD cases undergoing emergency surgery, 18(4.6%)presented with CPA, We assessed 30-day mortality, return of spontaneous circulation(ROSC), and use of preoperative veno-arterial extracorporeal membrane oxygenation(VA-ECMO), Results:The 30-day mortality was 72.2%, ROSC occurred in 4 cases(22.2%), and ROSC-positive patients had significantly lower mortality(p=0.022), Preoperative VA-ECMO was used in 7 cases(38.9%), none of whom survived(p=0.013), Conclusions:AAAD with preoperative CPA carries extremely high mortality, but patients achieving ROSC may benefit from urgent surgical intervention, VA-ECMO appears to confer no survival advantage, Early survivors often achieve favorable long-term outcomes, in line with prior literature.
A man in his 60s presented with an abnormal shadow on chest radiography. Computed tomography (CT) showed a tumor, measuring 6.1 cm, in the right upper lobe and an anomalous bronchus arising from the trachea. Following transbronchial biopsy and examinations, the patient was diagnosed with stageⅡB lung adenocarcinoma. The patient underwent a multiport thoracoscopic right upper lobectomy and lymph node dissection. Preoperatively, the information of the tracheal bronchus was shared in the surgical team. During the procedure, the tracheal bronchus was detected behind the azygos arch. The azygos arch and tracheal bronchus were dissected by a stapler. The tracheal bronchus stump was covered by a pedicled pericardial fat pad. No complications were observed perioperatively. Information of anomalies should be shared in the surgical team, including anesthesiologists preoperatively.
A 76-year-old woman underwent percutaneous coronary intervention (PCI) to the right coronary artery for subacute myocardial infarction six months earlier. Subsequently, PCI was also performed for a residual lesion in the left anterior descending artery. On follow-up transthoracic echocardiography, performed six months later, a localized bulging of the inferior wall of the left ventricle was observed, which had markedly enlarged compared to the previous study, leading to the decision for surgical intervention. Intraoperatively, there were no significant adhesions between the aneurysm and the pericardium. A saccular aneurysm was identified in the inferior wall of the left ventricle. A thin layer of myocardial tissue was observed beneath the epicardium, suggesting the diagnosis of a pseudopseudoaneurysm. The aneurysm was incised, and patch closure was performed at the aneurysmal orifice. The postoperative course was uneventful. Left ventricular pseudo-pseudoaneurysm is an extremely rare entity. We report this case to highlight the effectiveness of surgical patch closure in the management of this condition.
Vascular lesions, including aneurysms, are rare but well-documented complications of von Recklinghausen's disease. Although aneurysms associated with this condition are often asymptomatic, rupture can lead to life-threatening events such as hemothorax. We report a 63-year-old male with von Recklinghausen's disease who presented with sudden onset of chest pain. Imaging revealed left-side hemothorax, and contrast-enhanced computed tomography( CT) suggested rupture of the left 10th intercostal artery. Given his hemodynamic stability, percutaneous coil embolization was performed. Angiography revealed two adjacent aneurysms at the origin of the left 10th intercostal artery, both of which were successfully embolized. Postoperative course was uneventful, and the patient was discharged on postoperative day 6. This case highlights the importance of considering vascular complications in von Recklinghausen's disease and supports the efficacy and safety of coil embolization in managing ruptured intercostal artery aneurysms.
Brain tumors are relatively rare when compared with other malignancies. However, because the central nervous system governs the functions of the entire body, brain tumors can lead to significant morbidity and, ultimately, mortality if they are not treated appropriately and in a timely manner. These conditions are referred to as "neuro-oncologic emergencies," in which neurosurgeons play a central role in management. This review outlines the pathophysiological mechanisms underlying neuro-oncologic emergencies and discusses the role of emergent surgical intervention in supratentorial tumors, infratentorial tumors, and pituitary apoplexy, with reference to the current literature.
Craniotomy is a fundamental procedure in neurosurgical practice, and optimal perioperative management is essential for improving surgical outcomes and minimizing complications. Comprehensive care requires meticulous attention to intracranial pressure control, cerebral edema management, fluid and electrolyte homeostasis, hemodynamic stability, infection prophylaxis, and nutritional support. Adequate preoperative evaluation and correction of systemic conditions, optimization of antithrombotic therapy, and appropriate use of osmotic agents and corticosteroids are critical for ensuring safe surgical intervention. Prompt neurological assessment, timely neuroimaging, and close monitoring of intracranial dynamics are essential for the early detection of postoperative complications. Electrolyte disturbances, particularly hyponatremia, caused by the inappropriate antidiuretic hormone secretion or cerebral salt-wasting syndrome, remain common and require accurate differentiation and tailored management. Glycemic control, blood pressure regulation, prevention of postoperative seizures, and antimicrobial prophylaxis play pivotal roles in reducing postoperative morbidity. In elderly patients, preoperative assessment of sarcopenia and nutritional status is increasingly recognized as a key determinant of functional recovery. This review provides a practical, evidence-based framework for the perioperative management of craniotomy, integrating current guidelines and clinical experience, and aims to serve as a comprehensive reference for neurosurgeons in routine clinical practice.
In the era of advanced three-dimensional imaging technologies, cerebral angiography remains a fundamental modality for understanding dynamic cerebral hemodynamics. Although computed tomography angiography (CTA), magnetic resonance angiography (MRA), and 3D reconstruction techniques have markedly improved anatomical visualization, the ability to interpret two-dimensional angiographic images and mentally reconstruct vascular structures is increasingly important. This article revisits the core principles of diagnostic cerebral angiography, with an emphasis on practical insights that are often under-recognized in routine training. Key topics include preprocedural risk assessment, evaluation of vascular access route, radiation safety, optimal imaging angles for aneurysms visualization and mechanical thrombectomy planning, assessment of dural arteriovenous fistulas, and dynamic assessment of collateral circulation. By reorganizing these fundamental concepts, we highlight practical "Kandokoro" that bridge basic angiographic technique with therapeutic decision-making. This review aims to support the development of clinical judgment and angiographic interpretation skills in the era of advanced 3D imaging.
Intraoperative neuromonitoring is an indispensable surgical support tool for safe neurosurgical procedures. Although various monitoring techniques exist, motor-evoked potentials (MEPs) and somatosensory-evoked potentials (SSEPs) are the most commonly used. MEPs are classified into transcranial, direct cortical, and subcortical stimulation, which require case-specific selection based on each case. Furthermore, to ensure proper intraoperative monitoring, it is desirable to share information beforehand with the monitoring technician regarding which monitoring techniques should be used and which procedures carry a higher risk. This article describes the practical applications of intraoperative neuromonitoring, including its classification and intraoperative troubleshooting.
The patient was a 79-year-old male, During the course of treatment for eosinophilic pneumonia, he developed left-sided pneumothorax, Despite the implementation of thoracic drainage, air leakage persisted, Computed tomography(CT)revealed a left pneumatocele, which was deemed to be the underlying cause of pneumothorax, Consequently, thoracoscopy-assisted operation was performed, Six months postoperatively, no recurrence of pneumothorax was observed, and the pneumatocele had significantly decreased in size, Surgical intervention for refractory pneumothorax associated with pneumatocele is therefore considered to be an appropriate and effective therapeutic approach.
Stanford type A acute aortic dissection(AAAD)is a life-threatening cardiovascular emergency, Early surgical repair is essential to prevent fatal outcomes, According to the 2023 Annual Report of the Japanese Association for Thoracic Surgery, AAAD cases increased by 4.4% in 2022, with an in-hospital mortality of 10% for AAAD, Although surgical outcomes have improved with advances in cerebral protection techniques, patients with cerebral malperfusion remain at high risk of poor neurological outcomes and mortality, with postoperative death rates reported between 15~30%, Antegrade selective cerebral perfusion(ASCP)is the standard method for cerebral protection during circulatory arrest, However, in AAAD patients with carotid artery occlusion or severe stenosis, conventional ASCP may result in uneven cerebral perfusion, risking ischemia in the affected hemisphere, To address this, we introduced a two-roller pump technique, in which each carotid artery(affected and non-affected)is perfused independently using separate ASCP circuits, Cerebral perfusion was monitored with transcranial Doppler and regional cerebral oxygen saturation(rSO2), The common carotid artery(CCA)was exposed via median sternotomy without additional neck incision, and direct cannulation was performed to establish targeted perfusion, The two-roller pump technique allowed independent regulation of flow and pressure for each carotid artery, Intraoperative monitoring confirmed stable perfusion to all cerebral vessels, including the previously occluded CCA, The two-pump technique prevented uneven blood distribution, reduced cerebral ischemia time, and was associated with improved immediate neurological outcomes, It enables immediate, controlled reperfusion of the affected hemisphere, potentially improving neurological outcomes, and offers a practical option for urgent surgical management of severe cerebral malperfusion in AAAD.
An 82-year-old man receiving anticoagulants was referred to our hospital with dyspnea and back pain. One day earlier, he bruised his back in his house. On arrival, the hemoglobin value was 5.6 g/dl, and computed tomography( CT) showed bilateral pleural effusion along with left lower rib fractures. In the left hemithorax, irregular high-density lesion which was surrounded by a low-density stripe was observed. He was initially diagnosed with left traumatic hemothorax, and managed through inpatient care with bed rest and blood transfusion. Although anemia was improved, bilateral compression atelectasis was observed compromising cardiopulmonary function. We therefore performed surgical treatment on the 14th hospital day. Under general anesthesia, a chest tube was inserted into the right thoracic cavity, removing 1,000 ml of serous pleural effusion. We subsequently performed a left-sided thoracotomy. After suctioning 400 ml of bloody pleural effusion, we found a pleural bulge in the posterior chest wall. Hematoma was accumulated in the extrapleural space. The parietal pleura was opened and the extrapleural hematoma was bluntly curetted and evacuated. The deviated rib fracture was repaired. Postoperative course was uneventful. He was discharged home after rehabilitation on postoperative day 54.
Neurological emergencies are time-sensitive conditions in which rapid diagnosis and early intervention critically influence survival and functional outcomes. This review summarizes essential diagnostic strategies for neurosurgeons involved in acute care, guided by the principles of Emergency Neurological Life Support (ENLS). Initial management prioritizes stabilization of the airway, breathing, and circulation, followed by focused neurological assessment, with particular attention to pupillary findings and quantitative monitoring such as the Neurological Pupil index. Laboratory evaluation aims to promptly identify reversible systemic causes, including metabolic disturbances and coagulation abnormalities that directly affect treatment decisions in acute ischemic stroke and intracerebral hemorrhage, particularly in patients receiving anticoagulants. Neuroimaging plays a central role; non-contrast computed tomography (CT) remains the first-line modality, while CT angiography, perfusion imaging, and magnetic resonance imaging (MRI) provide complementary information for therapeutic decision-making. Imaging markers of hematoma expansion and etiological evaluation are essential in hemorrhagic stroke. Electroencephalography (EEG) is crucial for detecting nonconvulsive status epilepticus in patients with unexplained persistent impaired consciousness. Integrating clinical, laboratory, and imaging findings while recognizing common diagnostic pitfalls is essential for optimizing early neurocritical care management.
Advances in neurosurgical techniques and perioperative management have improved survival and neurological outcomes in several neurosurgical diseases. Nonetheless, even when objective functional scales, such as the modified Rankin Scale or Karnofsky Performance Status, indicate favorable outcomes, patients may experience persistent impairments in quality of life (QOL) and higher brain function, affecting daily activities, social participation, and treatment satisfaction. Conventional neurological examinations and imaging often fail to capture subtle cognitive, emotional, and psychosocial difficulties. Moreover, patient-reported outcomes and health-related QOL assessments provide a complementary perspective that reflects patients'subjective experiences, including fatigue, attention deficits, anxiety, and depressive symptoms. This review outlines a practical framework for incorporating QOL and higher brain function assessments into routine neurosurgical practice. Appropriate timing for preoperative and postoperative evaluations, commonly used general and disease-specific QOL instruments, and brief cognitive screening tools applicable in busy clinical settings are discussed. Notably, emphasis is placed on stepwise assessment strategies and multidisciplinary collaboration due to limited manpower. Integrating objective functional measures with patient-centered QOL evaluations enables a more comprehensive understanding of treatment outcomes and supports individualized clinical decision-making aimed at optimizing long-term patient well-being.
Advances in neuroimaging have improved the diagnosis and management of structural brain diseases, including cerebrovascular disorders and brain tumors. Although conventional computed tomography and magnetic resonance imaging (MRI) provide essential morphological information, functional and metabolic imaging enables the qualitative assessment of tissue physiology. Integrating morphological and qualitative imaging has become increasingly important for optimizing diagnostic strategies, treatment selection, and therapeutic response evaluation. However, excessive imaging may increase cost and complexity without improving clinical outcomes, thereby necessitating appropriate modality selection. This review summarizes perfusion and metabolic imaging modalities, including MRI-based arterial spin labeling, and nuclear medicine techniques. These techniques enable the evaluation of cerebral blood flow, oxygen metabolism, and tumor metabolic characteristics. Clinical applications include differentiating tumor from non-tumor lesions, predicting glioma grade and infiltration, performing preoperative functional mapping, distinguishing tumor recurrence from radiation necrosis, assessing the ischemic penumbra in acute stroke, evaluating chronic cerebral ischemia, and localizing epileptic foci. Qualitative imaging complements morphological imaging and is crucial in modern neurodiagnostic techniques. Appropriate selection and interpretation of these modalities are crucial in improving patient management in clinical practice.
This retrospective analysis assessed surgical outcomes in patients aged 85 years or older who underwent emergency open thoracic aortic surgery for acute Stanford type A dissection between 2012 and 2025. Among 352 patients, 27 were classified as very elderly. Compared to younger cohorts, this group exhibited a higher prevalence of DeBakey typeⅡ dissection and thrombotic false lumen occlusion, with a lower incidence of malperfusion. The majority underwent hemiarch replacement. In-hospital mortality was low at 3.7%, and postoperative complication rates were comparable to the control group. Due to slow functional recovery, the proportion of patients discharged directly home was reduced. Despite a limited follow-up rate, three-year outcomes-including overall survival (77.4%), freedom from aortic-related mortality( 91.7%), and distal reoperation-free survival( 91.7%)-were favorable. The implementation of advanced techniques, such as staged thoracic endovascular aortic repair (TEVAR) and zone 0 TEVAR utilizing the retrograde in-situ branched stent graft (RIBS) method, effectively minimized the necessity for reintervention via thoracotomy or laparotomy. These findings underscore the clinical viability of surgical intervention in selected very elderly patients, notwithstanding inherent limitations such as referral bias and incomplete longitudinal data.
Perioperative seizure management is an important component of neurosurgical care. Antiseizure medications (ASMs) have historically been used prophylactically in many neurosurgical patients; however, current evidence does not support routine prophylaxis in seizure-naïve individuals. Recent guidelines recommend ASM administration primarily for patients with a history of seizures or for short-term use during the immediate perioperative period in selected high-risk conditions. Accordingly, prophylactic treatment should be individualized based on seizure risk and generally limited to short-term use to avoid unnecessary long-term exposure. This review summarizes three clinically relevant areas. First, we summarize evidence-based strategies for perioperative seizure prophylaxis in major neurosurgical conditions, including brain tumors, traumatic brain injury, and cerebrovascular disease. Second, we review the pharmacological properties of newer ASMs commonly used in neurosurgical practice, including levetiracetam, lacosamide, brivaracetam, and perampanel, with emphasis on their mechanisms of action, adverse-effect profiles, and practical advantages in perioperative settings, such as the availability of intravenous formulations. Finally, we discuss the clinical applications of long-term video electroencephalographic monitoring (VEEG), including evaluation for epilepsy surgery, detection of nonconvulsive status epilepticus, and differential diagnosis of seizure-like events such as syncope and functional/dissociative seizures. Risk-based ASM management combined with appropriate utilization of VEEG is essential for optimizing perioperative neurological care.
Recent advances in neuroimaging have made radiological evaluations indispensable for preoperative assessment and surgical planning in the field of neurosurgery. Recent improvements in imaging resolution and three-dimensional visualization now allow the detailed anatomical structures encountered during surgery to be recognized preoperatively. This enables e design of surgical approaches, avoidance of critical neurovascular structures, and function-preserving strategies. In this chapter, imaging modalities are organized according to the major anatomical structures relevant to the surgical anatomy, including the bone structures, cerebrospinal fluid spaces, arteries, perforating arteries, veins, venous sinuses, and white matter fiber tracts. The advantages and limitations of each modality are discussed, together with their practical applications in tumor and vascular surgeries. Particular emphasis is placed on the integration of multimodal images. When combined with a thorough understanding of anatomy, these imaging datasets facilitate three-dimensional reconstruction and interpretation of complex anatomical relationships. Recent developments in 3D reconstruction and fusion imaging technologies have made preoperative simulations increasingly accessible, providing valuable educational opportunities, particularly for young neurosurgeons. Integrating anatomical knowledge with multimodal imaging interpretation improves the intraoperative orientation and contributes to safer and more reliable surgical outcomes.