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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.
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.
We report a case of synchronous double cancer involving the left lung and esophagus treated with a minimally invasive one-stage procedure combining thoracoscopic lobectomy and mediastinoscopic esophagectomy. Although a two-stage approach is often selected due to the technical complexity and invasiveness of simultaneous surgery, both tumors in this case were advanced, and a single-stage resection was considered the most appropriate option to avoid losing the opportunity for curative treatment. The postoperative course was complicated by anastomotic leakage, which was managed conservatively;however, early recurrence of esophageal cancer occurred, followed by multiple brain metastases from small cell lung carcinoma. These recurrences may have been related to limited mediastinal lymph node dissection, performed to preserve bronchial blood flow, and to the delayed initiation of adjuvant therapy due to treatment for esophageal recurrence. This case demonstrates not only the feasibility and advantage of a less invasive simultaneous approach but also emphasizes the need to optimize lymph node dissection strategies and the timing of postoperative therapy in complex synchronous malignancies.
Cerebral vasospasm after aneurysmal subarachnoid hemorrhage (aSAH) is a major cause of delayed cerebral ischemia (DCI) and remains a critical determinant of neurological outcomes. DCI pathophysiology is multifactorial and involves large artery vasospasm and microcirculatory dysfunction, including endothelial injury, microthrombosis, impaired autoregulation, and cortical spreading depolarization. In Japan, pharmacological management has traditionally included fasudil hydrochloride and other agents targeting the vascular tone or platelet aggregation, often combined with strategies to remove subarachnoid blood. The recent approval of clazosentan, a selective endothelin A receptor antagonist, has introduced a new therapeutic approach to prevent vasospasm after aSAH. Clinical trials conducted in Japan have demonstrated that clazosentan reduces vasospasm-related morbidity and mortality, as well as improves clinical outcomes. However, large international trials have shown reductions in angiographic vasospasms without consistent improvements in functional outcomes, highlighting DCI's complex pathophysiology beyond large vessel narrowing. In clinical practice, clazosentan has been associated with favorable outcomes, but requires careful management because of adverse events such as fluid retention and pulmonary complications. Future strategies should focus on optimizing treatment protocols centered on clazosentan and identifying effective combination therapies that target multiple mechanisms underlying DCI.
The patient is a 69-year-old woman who underwent surgery for rectal cancer in January 202X. In July 202X+2, computed tomography (CT) revealed a nodule shadow with a maximum diameter of 4 mm in S1 of the right lung. After three months, the nodule increased in size. Based on the patient's history, a metastatic lung tumor was suspected, and the patient underwent surgical resection. Preoperative CT revealed the presence of B1 tracheobronchus and abnormal running of A1. B 1 was more centrally located than usual and branched directly from the trachea, whereas A1 branched from the main pulmonary artery trunk. S1 segmentectomy was performed for suspected metastatic lung tumor nodule in S1. Abnormal running of the pulmonary artery poses a risk of vascular injury during surgery. In the case of abnormal bronchial branching, the pulmonary vessels may be abnormal, and it is important to recognize such abnormalities using contrast-enhanced or three-dimensional CT preoperatively.
Here, we report a case of catamenial pneumothorax that occurred during endometriosis treatment. A 46-year-old woman presented with a history of right pneumothorax. At 43 years of age, the patient was diagnosed with endometriosis and progesterone therapy was initiated. The patient developed rightsided chest pain and was diagnosed with right-sided pneumothorax. Video-assisted thoracoscopic surgery was performed, because of persistent air leakage. Intraoperative findings revealed a suspected pleural defect in the right upper lobe and multiple perforations around the central tendon of the right diaphragm. The pleural defect was resected, and the diaphragm surface was covered with a polyglycolic acid sheet. Pathologically, the diagnosis was associated with thoracic endometriotic pneumothorax, including immunostaining findings. Hormonal therapy was continued after discharge. The patient has remained free of recurrence for one year postoperatively.
Emergency management of acute stroke involves various clinical scenarios, and determining the optimal treatment can sometimes be challenging. However, rapid diagnosis and timely intervention are essential to achieve favorable outcomes. Therefore, a structured summary of emergency evaluation and management of patients with stroke is necessary to support physicians. At the same time, recent advances in stroke research have significantly changed management strategy. In brain hemorrhage, reversal agents have become available, and the concept of door-to-needle time is also adapted to brain hemorrhage. In cerebral infarction, the ischemic core is now recognized as heterogeneous, and new concepts for evaluating viable regions have emerged. Accordingly, it is important to integrate these evolving concepts into clinical practice. This article reviews current strategies for emergency stroke management, highlights common pitfalls in critical care, and illustrates practical approaches through representative clinical cases.
In recent years, endovascular aortic repair has become one of the standard treatments for aortic aneurysms. However, when the aneurysm involves the branches of the abdominal aorta or the aortic arch, the procedure becomes more complex and often necessitates surgical reconstruction of the involved branches. To address these challenges, the use of physician-modified endografts in which fenestrations are manually created by physicians has been reported. This approach, known as fenestrated and branched endovascular aortic repair, involves the placement of small-diameter bridging stent grafts through the fenestrations, and its utility has recently been highlighted. Herein, we report a case of successful fenestrated and branched endovascular aortic repair using physician-modified endografts in a patient with both thoracoabdominal and aortic arch aneurysms.
Emergency surgery remains the standard of treatment for acute Stanford type A aortic dissection(AAAD), Nevertheless, in real-world practice a minority of patients do not undergo immediate surgery due to clinical constraints, We sought to delineate the outcomes and practical limits of such nonoperative management under strict protocols, Methods:Of 668 consecutive AAAD patients(Jan 2019~Mar 2025), we retrospectively analyzed 100 who did not receive immediate surgery after excluding 13 with cardiopulmonary arrest, Patients were stratified into a criteria group(C;thrombosed/occluded false lumen in the ascending aorta with ascending diameter≦50 mm and false lumen≦11 mm;n=59)and a non-criteria group(NC;outside these criteria;n=41), The primary endpoint was in-hospital mortality;secondary endpoints included aortic-related death, post-discharge events, and associations with imaging/clinical indices, Results:NC patients were older and more often female, with larger ascending aortas and false lumens(both p<0.001), In-hospital mortality was 31.7% in NC vs 1.7% in C(p<0.001);48-hour mortality in NC was 12.2%, and aortic-related deaths clustered within 4.56±2.99 days(range 1~12), Seven patients underwent delayed surgery for imaging changes;all survived, Discharge alive occurred in 98.3%(C)and 68.3%(NC), Among those discharged alive, survival up to 2 years was similar, Low body mass index(BMI)and hemodynamically significant tamponade were associated with in-hospital death in NC, Conclusions:These data support surgery as the default strategy for AAAD, When surgery is unavoidably deferred, conservative management should be considered only in strictly selected patients, with early hemodynamic/computed tomography(CT)triggers for conversion, In NC patients, the first hospital week is the highest-risk window, and low BMI or tamponade should prompt heightened vigilance and a low threshold for intervention.
Adverse events associated with neurosurgery remain a major concern in clinical practices. Most morbidity and mortality events are directly related to surgical procedures and can be broadly classified as avoidable or unavoidable. Based on our experience, morbidity and mortality conferences can significantly reduce avoidable morbidity among both residents and experienced neurosurgeons. The ultimate goal of surgical education is to enhance patient safety and improve outcomes by systematically identifying problems and developing appropriate solutions. Morbidity and mortality conferences therefore represent an essential component of neurosurgical education, contributing to better neurosurgical practice and improved patient safety.
A 75-year-old man, who had undergone total arch replacement for a thoracic aortic aneurysm 4 years earlier, presented with transient left hemiplegia and right upper extremity weakness. Contrast-enhanced computed tomography (CT) revealed a large pseudoaneurysm at the proximal anastomosis of the ascending aortic graft, compressing and occluding the brachiocephalic graft. Surgical resection of the pseudoaneurysm and ascending aortic graft replacement with a 1-branched graft were performed. Cardiopulmonary bypass was established via peripheral vessels prior to re-median sternotomy. Thrombi were removed from the brachiocephalic graft, followed by replacement of the ascending aorta with a branched artificial graft for the brachiocephalic artery. The patient was discharged without complications. We report a rare case of transient hemiplegia due to brachiocephalic graft compression by a pseudoaneurysm.
We report a rare case of a non-anastomotic pseudoaneurysm following ascending aortic replacement. A 73-year-old woman presented with anterior chest swelling after undergoing sternal wire removal due to suspected metal allergy. A pseudoaneurysm was identified on computed tomography (CT) at the site where the removed sternal wire had been in contact with the anterior surface of the vascular graft. Surgical repair with cardiopulmonary bypass identified a bleeding pinhole at the graft surface, successfully closed with a 4-0 monofilament mattress suture. This case suggests that prevention of such complications requires protective coverage of the graft with autologous tissue prior to chest closure, careful selection and handling of sternal wires, and thorough preoperative imaging evaluation before wire removal.
In the management of traumatic brain injury (TBI), even when the injury initially appears isolated to the head, occult injuries may be present; therefore, a comprehensive evaluation in accordance with the Japan Advanced Trauma Evaluation and Care is essential. Traumatic coagulopathy is frequently observed in patients with TBI, particularly in severe cases. In addition, the aging population has increased in recent years, and many elderly patients are taking antithrombotic medications. Patients with a tendency to bleed may develop severe symptoms due to hematoma growth or challenging surgical hemostasis, necessitating appropriate perioperative measures. Traditionally, large craniotomies were performed to achieve adequate hemostasis and decompression. However, mini-craniotomy combined with neuroendoscopy has recently been adopted to minimize surgical invasiveness, particularly in elderly patients. Postoperative management focuses on visualizing intracranial pathology through neuromonitoring and implementing neurocritical care to prevent secondary brain injury through optimal systemic management. Although the number of severe TBI cases has decreased in recent years and opportunities for clinical experiences may be limited, understanding the fundamental principles of severe TBI management remains essential for neurosurgeons.
A 67-year-old female, diagnosed with atrial fibrillation over 35 years ago, presented with mild heart failure symptoms. However, due to mild mitral regurgitation, she had been managed conservatively at local hospital. Recently, she developed severe dyspnea and was referred to our institution for surgical intervention. Comprehensive evaluation revealed significant enlargement of both atria, leading to a restrictive ventilatory impairment. The surgical procedure included mitral annulus repair, tricuspid annulus repair, maze procedure, and extensive cylindrical resection of the left atrium, along with right atrial repair, all performed under cardiopulmonary bypass. Post-surgery, her atrial volume decreased from 830 ml to 275 ml, and her vital capacity improved from 1.28 l to 1.77 l. Following the procedure, she maintained sinus rhythm, with complete resolution of her dyspnea. These improvements have been sustained for three years postoperatively.
A lung hernia is a rare condition in which the lung parenchyma protrudes beyond its normal thoracic cavity boundaries. Traditionally, lung hernias have been associated with chest trauma or congenital weakness of the chest wall. However, in recent years, there have been increasing reports of lung hernias developing at small surgical wound sites, such as those created by minimally invasive cardiac surgery or thoracoscopic procedures. Here, we present a case of a lung hernia that occurred at the port site following a thoracoscopic partial lung resection. The hernia was successfully repaired using a thoracoscopic approach with prosthetic reinforcement. We also discuss relevant literature on the etiology, diagnosis, and treatment of port-site lung hernias, highlighting the importance of careful surgical technique and appropriate wound closure to prevent this rare but significant complication.
Superior mesenteric artery(SMA)malperfusion in acute aortic dissection(AAD)is a highly lethal complication with no established treatment strategy, We introduced a "perfusion-first strategy," prioritizing SMA revascularization via laparotomy for patients with preoperative computed tomography(CT)evidence of SMA obstruction, Methods:Our strategy involves an initial laparotomy for direct visual assessment of intestinal ischemia, After identifying the occluded segment of the SMA with vascular ultrasound, a bypass is created to the distal SMA using a heparin-coated expanded polytetrafluoroethylene(ePTFE)graft, Initial reperfusion is established via a side branch of the extracorporeal circulation circuit from the femoral artery, This is followed by a median sternotomy for central aortic repair, Finally, the SMA bypass graft is anastomosed to the central aortic graft to complete the revascularization, Results:Between April 2024 and May 2025, this strategy was performed on six consecutive patients, All six patients survived to discharge without requiring bowel resection, Postoperative CT scans confirmed the patency of all SMA bypass grafts, Conclusion:Our perfusion-first strategy, a single-stage hybrid approach, was shown to be a safe and effective treatment for AAD complicated by SMA malperfusion in this initial series, This approach allows for accurate assessment of intestinal ischemia and reliable revascularization while avoiding the risks of delaying central aortic repair, It represents a promising new therapeutic option for this fatal condition.
Awake craniotomy requires comprehensive preoperative preparation that differs fundamentally from conventional tumor resection performed under general anesthesia. Successful awake surgery depends not only on the technical expertise of the neurosurgeon but also on close multidisciplinary collaboration among anesthesiologists, neuropsychologists, nurses, and technical staffs, as well as active patient participation. Preoperative planning plays a crucial role in ensuring intraoperative safety and preserving neurological function. Careful patient selection is essential and includes assessment of neurological status, seizure history, age, and anesthetic risk factors. Detailed neuropsychological evaluation is required to establish baseline cognitive function, select appropriate intraoperative tasks, and define functional targets for preservation. Integration of structural imaging, diffusion tensor tractography, and functional magnetic resonance imaging enables individualized surgical planning based on functional brain networks. Preoperative simulation in the operating room setting enhances team coordination and reduces patient anxiety. Anesthetic strategies should prioritize airway safety, reliable awakening, and seizure prevention. As intraoperative electrical stimulation carries a risk of seizures, appropriate antiepileptic management and troubleshooting strategies are necessary. Through systematic preparation, task selection, imaging integration, and multidisciplinary communication, awake craniotomy can achieve maximal tumor resection while preserving critical cognitive and functional networks. This review summarizes key preoperative considerations for neurosurgeons beginning to perform awake craniotomy.
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.
The patient was a 54-year-old male. He underwent invasive seminoma resection, bypass grafting from the left subclavian vein to the right atrial appendage, and patch plasty of the superior vena cava( SVC) 18 years ago in 1990. In 1992, graft obstruction was demonstrated, and in 1994, subsequent downhill esophageal varices developed. Varices deteriorated to grade F3 with a red-colored sign in 2008. Therefore, bypass grafting from bilateral subclavian veins to the right atrial appendage was performed to prevent rupture. Endoscopy performed two weeks after surgery showed that the varices had improved to grade F1. The patient was discharged without adverse events. In 2023, the graft remained patent and the varices did not worsen. After SVC reconstruction, strict follow-up is necessary because fatal event in esophageal varices can occur owing to graft obstruction.
Left main coronary artery (LMCA) malperfusion due to acute aortic dissection (AAD) is relatively rare but life-threatening. Almost all such patients suffer from cardiogenic shock, and cardiopulmonary arrest occurs in approximately half of them. A 64-year-old man with chest pain was taken to our hospital by ambulance. Acute coronary syndrome was suspected as electrocardiography showed changes in ST segment. Coronary angiography revealed severely stenotic LMCA. Percutaneous cardiopulmonary support was initiated for subsequent cardiogenic shock. Dissection in the LMCA on intravascular ultrasonography suggested that AAD occurred and dissection extended into the LMCA. Percutaneous coronary intervention (PCI) to the LMCA was performed with a drug-eluting stent. Post-PCI contrast-enhanced computed tomography (CT) scan demonstrated Stanford type A AAD. Subsequently, ascending-aortic replacement was successfully carried out. Postoperative echocardiography showed well preserved cardiac contraction. Primary PCI under percutaneous cardiopulmonary support for AAD and LMCA malperfusion shortens myocardial ischemic time and improves prognosis.