It is not an easy task to imagine what will happen to cerebrovascular surgery in the twenty-first century, considering the tremendous developments that have occurred during the past decades. This review paper is attempted to address the present and future of cerebrovascular surgery on the basis of author's experience of cerebrovascular diseases during the past 30 years. Cerebrovascular surgery has been recognized as a subspecialty of neurosurgery that requires utmost technical challenge and precision in all of medicine. Cerebrovascular surgery has achieved much that we can proud of. However, as forward-thinking cerebrovascular surgeons, our concern isn't with past glories. They would tackle questions of natural history, scientific assessment of therapy, outcomes sciences, and molecular basis of cerebrovascular disease. They would remain at the forefront of research in stroke and brain protection, and would succeed at the integration of endovascular, radiosurgical, and pharmacological tools into a truly multidisciplinary armamentarium.
Aneurysm ; Brain ; Cerebral Hemorrhage ; Natural History ; Neurosurgery ; Stroke ; Vascular Malformations

The advent of endovascular treatment offers an alternate strategy for the management of cerebral aneurysms. This procedure can provide immediate protection from rebleeding of ruptured aneurysm or rupture of an unruptured aneurysm in cases with advanced age, poor medical condition, difficult surgical anatomy, and attempted surgery. This review article was designed to address current and future roles of neurosurgeons in the era of intra-aneurysmal treatment on the basis of author's experience of more than 200 cases during the past 6 years. The role of neurosurgeons in the era of endovascular treatment could be defined as follows. Close collaboration between neurosurgeons and neurointerventionists is essential to obtaining favorable outcome. Neurointerventionists should be capable of evaluating the benefits and risks of open surgery as well as those of endovascular treatment. It is vitally important not only that neurosurgeons be involved in the evolution of new subspecialty, but also that neurosurgical program directors continue to train young neurosurgeons in the microsurgical management of cerebral aneurysms. Neurosurgeons should maintain a leadership role in the management of cerebral aneurysms.
Aneurysm ; Aneurysm, Ruptured ; Cooperative Behavior ; Intracranial Aneurysm ; Leadership ; Risk Assessment ; Rupture

Microvascular decompression is the gold standard for the treatment of trigeminal neuralgia (TN). However, percutaneous techniques still play a role in treating patients with TN and offer several important advantages and efficiency in obtaining immediate pain relief, which is also durable in a less invasive and safe manner. Patients’ preference for a less invasive method can influence the procedure they will undergo. Neurovascular conflict is not always a prerequisite for patients with TN. In addition, recurrence and failure of the previous procedure can influence the decision to follow the treatment. Therefore, indications for percutaneous procedures for TN persist when patients experience idiopathic and episodic sharp shooting pain. In this review, we provide an overview of percutaneous procedures for TN and its outcome and complication.

Mice ; Animals ; Actins/metabolism* ; Actin Depolymerizing Factors/metabolism* ; TRPM Cation Channels ; Actin Cytoskeleton/metabolism* ; Nervous System/metabolism*

PURPOSE: Reduced brain glucose metabolism and basal forebrain cholinergic neuron degeneration are common features of Alzheimer's disease and have been correlated with memory function. Although regions representing glucose hypometabolism in patients with Alzheimer's disease are targets of cholinergic basal forebrain neurons, the interaction between cholinergic denervation and glucose hypometabolism is still unclear. The aim of the present study was to evaluate glucose metabolism changes caused by cholinergic deficits. MATERIALS AND METHODS: We lesioned basal forebrain cholinergic neurons in rats using 192 immunoglobulin G-saporin. After 3 weeks, lesioned animals underwent water maze testing or were analyzed by 18F-2-fluoro-2-deoxyglucose positron emission tomography. RESULTS: During water maze probe testing, performance of the lesioned group decreased with respect to time spent in the target quadrant and platform zone. Cingulate cortex glucose metabolism in the lesioned group decreased, compared with the normal group. Additionally, acetylcholinesterase activity and glutamate decarboxylase 65/67 expression declined in the cingulate cortex. CONCLUSION: Our results reveal that spatial memory impairment in animals with selective basal forebrain cholinergic neuron damage is associated with a functional decline in the GABAergic and cholinergic system associated with cingulate cortex glucose hypometabolism.
Acetylcholine/metabolism ; Alzheimer Disease ; Animals ; Antibodies, Monoclonal/*pharmacology ; Basal Forebrain/*drug effects/metabolism ; Cholinergic Agents/administration & dosage/*pharmacology ; Cholinergic Neurons/*drug effects/metabolism ; Fluorodeoxyglucose F18 ; GABAergic Neurons/*drug effects/metabolism ; Glucose/*metabolism ; Gyrus Cinguli/*drug effects/metabolism ; Humans ; Injections ; Maze Learning ; Motor Activity/physiology ; Positron-Emission Tomography ; Rats ; Ribosome Inactivating Proteins, Type 1/*pharmacology

OBJECTIVE: Subthalamic nucleus (STN) deep brain stimulation (DBS) is an effective treatment of choice for patients with advanced idiopathic Parkinson's disease (PD) who have motor complication with medication. The objectives of this study are to analyze long-term follow-up data of STN DBS cases and to identify the factors related to outcomes. METHODS: Fifty-two PD patients who underwent STN DBS were followed-up for more than 3 years. The Unified Parkinsons Disease Rating Scale (UPDRS) and other clinical profiles were assessed preoperatively and during follow-up. A linear regression model was used to analyze whether factors predict the results of STN DBS. We divided the study individuals into subgroups according to several factors and compared subgroups. RESULTS: Preoperative activity of daily living (ADL) and the magnitude of preoperative levodopa response were shown to predict the improvement in UPDRS part II without medication, and preoperative ADL and levodopa equivalent dose (LED) were shown to predict the improvement in UPDRS part II with medication. In UPDRS part III with medication, the magnitude of preoperative levodopa response was a predicting factor. CONCLUSION: The intensity of preoperative levodopa response was a strong factor for motor outcome. And preoperative ADL and LED were strong factors for ADL improvement. More vigorous studies should be conducted to elucidate how levodopa-induced motor complications are ameliorated after STN DBS.
Activities of Daily Living ; Deep Brain Stimulation ; Follow-Up Studies ; Humans ; Levodopa ; Linear Models ; Parkinson Disease ; Subthalamic Nucleus

Objective: : The blood-brain barrier (BBB) is an obstacle for molecules to pass through from blood to the brain. Focused ultrasound is a new method which temporarily opens the BBB, which makes pharmaceutical delivery or removal of neurodegenerative proteins possible. This study was demonstrated to review our BBB opening procedure with magnetic resonance guided images and find specific patterns in the BBB opening. Methods: : In this study, we reviewed the procedures and results of two clinical studies on BBB opening using focused ultrasound regarding its safety and clinical efficacy. Magnetic resonance images were also reviewed to discover any specific findings. Results: : Two clinical trials showed clinical benefits. All clinical trials demonstrated safe BBB opening, with no specific side effects. Magnetic resonance imaging showed temporary T1 contrast enhancement in the sonication area, verifying the BBB opening. Several low-signal intensity spots were observed in the T2 susceptibility-weighted angiography images, which were also reversible and temporary. Although these spots can be considered as microbleeding, evidence suggests these are not ordinary microbleeding but an indicator for adequate BBB opening. Conclusion : Magnetic resonance images proved safe and efficient BBB opening in humans, using focused ultrasound.

Both hydropathy plot and in vitro translation results predict the topology of SR-BI; the receptor is an integral membrane protein of 509 amino acids, consisting of a short cytoplasmic N-terminus of 9 amino acids followed by a first transmembrane domain of 22 amino acids, the extracellular domain of 408 amino acids, the second transmembrane domain of 22 amino acids, and the cytoplasmic C-terminus of 47 amino acids. The immunoblot of rBBMV in the presence or absence of pAb589 peptide antigen (the C-terminal 22 amino acid residues of SR-BI) confirmed that the bands at apparent molecular weight of 140 and 210 kDa are SR-BI related protein which might be multimeric forms of SR-BI. 125I apo A-I overlay analysis showed that SR-BI can bind to its ligand, apo A-I, only when it is thoroughly matured - glycosylated and dimerized. The antibody which was generated against extracellular domain of SR-BI (pAb230) not only prevented 125I-labeled apo A-I from binding to 140 kDa band but also inhibited the esterified cholesterol uptake of rabbit BBMV with its IC50 value of 40 microgram/ml of IgG. In contrast, the antibody generated against the C-terminal domain of SR-BI (pAb589) did not show any effect either on cholesterol uptake of rabbit BBMV or 125I-labeled apo A-I binding to 140 kDa band. Overall results show that the ligand binding site of SR-BI in rabbit BBMV is located in extracellular domain, and SR-BI is only functional when it is part of dimeric forms which rationalize the previously found cooperative nature of the binding interaction and maybe a fundamental finding towards the so far poorly understood mechanism of SR-BI function.
Amino Acid Sequence ; Animals ; Antigens, CD36/*metabolism ; Apolipoprotein A-I/metabolism ; Binding Sites/physiology ; Blotting, Western ; Caco-2 Cells ; Cholesterol Esters/metabolism ; Humans ; Intestinal Mucosa/metabolism ; Intestine, Small/*metabolism/ultrastructure ; Iodine Radioisotopes ; Membrane Proteins/*metabolism ; Microvilli/metabolism ; Molecular Sequence Data ; Rabbits ; *Receptors, Immunologic ; Receptors, Lipoprotein/*metabolism ; Receptors, Scavenger ; Scavenger Receptors, Class B ; Surface Properties

The spontaneous dissecting aneurysm of the anterior cerebral artery is very rare and shows difference in nature and clinical presentation. The authors present 2 cases of spontaneous dissecting aneurysms localized to the anterior cerebral artery. Both patients experienced severe headache and ischemic symptoms. The lesions were repaired successfully with wrapping and clipping.
Aneurysm, Dissecting* ; Anterior Cerebral Artery* ; Cerebral Angiography ; Cerebral Infarction ; Headache ; Humans

OBJECTIVES: The goal of surgical management of cerebral arteriovenous malformations (AVMs) is elimination of the lesions without development of new neurological deficits. To improve the surgical management of results of cerebral AVMs in the future, this article discusses about surgical complications of the AVMs and their preventive methods. METHODS: We investigate the methods to avoid the surgical complications of the AVMs based on the our experiences and review of literatures. RESULTS: Accurate anatomical knowledge about location of AVMs, proper reduction of nidus size by preoperative embolization, accurate dissection of peripheral margin of AVMs during surgery, and understanding and proper management of peculiar pathophysiological events of AVMs which occur during surgery and postoperative period are the key points for avoiding surgical complications of the AVMs. CONCLUSION: We conclude that refined skill for endovascular and microsurgical techniques are required to successful surgical treatment of cerebral AVMs.
Arteriovenous Malformations* ; Intracranial Arteriovenous Malformations ; Postoperative Period