No Shinkei Geka. Neurological Surgery[JOURNAL]
Sun
200 papers
[Transcranial and Endonasal Skull Base Approaches for Cerebello-Pontine Angle Lesions].
Morisako H, Nagahama A, Goto T
No Shinkei Geka · 2025 Jul · PMID 40831106 · Publisher ↗
Cerebellopontine angle lesions should be reduced as much as possible while preserving the cranial nerve and brainstem functions. However, because the lesion is located deep and surrounded by various important structures,...
Cerebellopontine angle lesions should be reduced as much as possible while preserving the cranial nerve and brainstem functions. However, because the lesion is located deep and surrounded by various important structures, surgical procedure is difficult to perform, and a surgical strategy is important to avoid complications. Surgical outcomes have dramatically improved with the development of skull bases and microsurgical techniques. The main surgical approaches for cerebellopontine angle lesions include the anterior and posterior combined transpetrosal, anterior transpetrosal, lateral suboccipital, and endoscopic endonasal approaches. With the recent developments in endoscopic keyhole surgery, such as the endoscopic keyhole anterior transpetrosal approach, minimally invasive surgery for skull-base lesions has gradually begun. Here, we describe the preoperative checkpoints, selection of surgical approaches, and surgical techniques for the resection of cerebellopontine angle lesions.
[Lateral Suboccipital Approach].
Higuchi Y, Origuchi S, Nakano S
No Shinkei Geka · 2025 Jul · PMID 40831105 · Publisher ↗
The lateral suboccipital approach is a fundamental surgical method for accessing the cerebellopontine angle. This article outlines critical aspects, including anatomical landmarks, surgical positioning, and techniques fo...
The lateral suboccipital approach is a fundamental surgical method for accessing the cerebellopontine angle. This article outlines critical aspects, including anatomical landmarks, surgical positioning, and techniques for craniotomy and dural opening, based on practices at our institution. Important landmarks include the mastoid process, asterion, and suboccipital triangle, which contains critical structures such as the vertebral artery. Preoperative three-dimensional computed tomography imaging significantly aids surgical planning through visualizing bone landmarks and venous sinus positioning. Optimal patient positioning, involving careful head flexion and rotation in the park-bench position, is essential to minimize complications such as airway edema. Accurate muscle dissection and careful handling of the mastoid emissary vein are detailed to prevent venous sinus occlusion. Significant complications associated with this procedure include cerebrospinal fluid (CSF) leakage, vertebral artery injury, and venous sinus injury. Strategies for preventing CSF leakage include meticulous dural closure using artificial dura and fat grafts. While rare, vertebral artery injury demands precise handling to prevent severe ischemic complications. Overall, careful anatomical understanding, rigorous preoperative planning, and a meticulous surgical technique are paramount to minimize complications associated with the lateral suboccipital approach.
[Hemostasis].
Oya S
No Shinkei Geka · 2025 Jul · PMID 40831104 · Publisher ↗
Hemostasis is a critical skill in cerebellopontine angle (CPA) tumor surgery given its deep anatomical location, narrow surgical corridor, and proximity to vital neurovascular structures. Inadequate bleeding control can...
Hemostasis is a critical skill in cerebellopontine angle (CPA) tumor surgery given its deep anatomical location, narrow surgical corridor, and proximity to vital neurovascular structures. Inadequate bleeding control can obscure the operative field, increase the risk of cranial nerve injury, and lead to life-threatening complications, such as brainstem infarction or cerebellar swelling. This article outlines the key principles of hemostasis at each step of CPA tumor resection, from the preoperative setting and craniotomy to tumor debulking and dissection. Based on our surgical experience, we present detailed technical strategies for achieving safe and effective hemostasis during meningioma, vestibular schwannoma, and hemangioblastoma resection. Practical tips include the management of emissary veins; the preservation of draining veins, such as the petrosal vein; and staged tumor resection adapted to the vascular supply. Videos of representative cases are included to demonstrate hemostatic techniques in real surgical settings. Through emphasizing complete bleeding control at each stage before proceeding to the next, this article aims to provide practical guidance for neurosurgeons in training and promote safer skull base tumor surgery.
[Preoperative Embolization for Cerebellopontine Angle Tumors].
Hashimoto T
No Shinkei Geka · 2025 Jul · PMID 40831103 · Publisher ↗
Preoperative embolization of brain tumors has been reported to be useful in reducing blood loss during resection, softening the tumor, and shortening the operation time by occluding blood-rich tumor nutrient vessels. Thi...
Preoperative embolization of brain tumors has been reported to be useful in reducing blood loss during resection, softening the tumor, and shortening the operation time by occluding blood-rich tumor nutrient vessels. This applies to skull base tumors, which are deep and difficult to expand in the operative field. Cerebellopontine angle tumors often have the petrosal branch of the middle dural artery, ascending pharyngeal artery, meningohypophyseal trunk, and inferolateral trunk as feeding vessels. Caution is required because these blood vessels are involved in the vasa nervorum and dangerous anastomosis. Embolization of these vessels can be performed safely and effectively by guiding a small catheter as far as possible to the periphery without wedging and injecting a high dilution of Embosphere 500-700µm.
[Intraoperative Monitoring During Cerebellopontine Angle Tumor Removal].
Fukuda M, Hiraishi T, Oishi M
No Shinkei Geka · 2025 Jul · PMID 40831102 · Publisher ↗
Two types of intraoperative monitoring of the cranial nerve motor function have been widely used during the removal of cerebellopontine angle tumors. The first type involves anatomical mapping through directly stimulatin...
Two types of intraoperative monitoring of the cranial nerve motor function have been widely used during the removal of cerebellopontine angle tumors. The first type involves anatomical mapping through directly stimulating the cranial nerve to confirm its location. The second type involves monitoring motor function preservation through direct stimulation-compound muscle action potential (Ds-CMAP), motor-evoked potential (MEP) using transcranial electrical stimulation, and free-run electromyography (EMG). Particularly for patients with vestibular schwannomas, anatomical mapping is important to confirm the location of the facial nerve, which is likely to be deviated or compressed by a tumor. Ds-CMAP monitoring adjacent to the root exit zone of the facial nerve is useful for detecting facial nerve damage. Monitoring facial MEP, induced using transcranial electrical stimulation, is also useful in predicting postoperative facial motor function. Free-run electromyography EMG provides real-time monitoring of facial motor function; however, objective evaluation is challenging intraoperatively. Brainstem auditory evoked potential monitoring has been widely used to preserve hearing during the removal of cerebellopontine angle tumors. Cochlear nerve action potentials recorded directly from the cochlear nerve provide more useful monitoring for predicting postoperative hearing function. To preserve the motor function of the glossopharyngeal and vagus nerves, both pharyngeal MEP recorded from the swallowing muscle and vagus nerve MEP recorded from the vocal cord using transcranial electrical stimulation are useful in predicting postoperative swallowing function. A clear understanding of the purposes, methods, and evaluations of various types of cranial nerve monitoring during the removal of cerebellopontine angle tumors is essential.
[Preoperative Virtual Reality Surgical Simulation].
Kin T
No Shinkei Geka · 2025 Jul · PMID 40831101 · Publisher ↗
In this study, the application of virtual reality (VR) neurosurgical simulation using 3-dimensional image fusion for preoperative planning of cerebellopontine angle meningiomas is described. Fusion 3-dimensional images a...
In this study, the application of virtual reality (VR) neurosurgical simulation using 3-dimensional image fusion for preoperative planning of cerebellopontine angle meningiomas is described. Fusion 3-dimensional images are reconstructed from medical imaging modalities, such as computed tomography and magnetic resonance imaging, allowing precise visualization of tumors and adjacent anatomical structures. Surgical planning involves identifying a tumor's location, extent, dural attachment, and the feeding center, in particular, which is a vascular entry point that correlates with the tumor's dural attachment. Early feeding center identification and coagulation can significantly reduce intraoperative bleeding, facilitate tumor resection, and preserve surrounding healthy tissues. A medical device certificated application, namely 'GRID,'was used for preoperative simulation. Two clinical cases showed how VR simulation clarified the tumor's spatial relationship with the cranial nerves and major vessels, enabling safe and effective surgical strategies. The simulation process helped identify critical neurovascular structures, such as the trigeminal nerve, and optimized the craniotomy and approach routes. VR surgical simulation is a valuable tool for improving both operative safety and efficiency and as an educational method for neurosurgical planning and anatomical understanding.
[Preoperative Examination:Neuro-Otological Examination and Its Significance].
Inagaki T
No Shinkei Geka · 2025 Jul · PMID 40831100 · Publisher ↗
Neuro-otologic examinations are essential to identify lesion sites in patients with hearing and balance disorders. These tests assess the functions from the peripheral sensory organs to the central auditory and vestibula...
Neuro-otologic examinations are essential to identify lesion sites in patients with hearing and balance disorders. These tests assess the functions from the peripheral sensory organs to the central auditory and vestibular pathways. They are valuable for evaluating inner ear function and detecting central nervous system involvement. Auditory tests, such as pure-tone audiometry and auditory brainstem response, help localize lesions along the auditory neural pathway. Vestibular function can be assessed using the caloric test, video head impulse test, and vestibular evoked myogenic potentials, which individually evaluate the semicircular canals and otolith organs. Additionally, eye movement recordings using the ENG or VOG during visual stimulation aid in the detection of central vestibular dysfunction. Cerebellopontine angle (CPA) tumors vary in size and extent, from small lesions within the internal auditory canal to large masses compressing the brainstem and cerebellum. Preoperative neuro-otologic assessment provides insight into the extent of the tumor and affected functional areas. This is valuable for understanding the pathophysiology of CPA tumors and contributes to surgical planning and prognosis.
[Preoperative Neuroimaging of Cerebellopontine Angle Tumors with an Emphasis on Techniques and Differential Diagnosis].
Tsuchiya K
No Shinkei Geka · 2025 Jul · PMID 40831099 · Publisher ↗
MRI is the most effective imaging tool for diagnosing cerebellopontine angle tumors, although CT is also useful for evaluating bone changes and detecting calcification. Regarding MRI, it is recommended to efficiently use...
MRI is the most effective imaging tool for diagnosing cerebellopontine angle tumors, although CT is also useful for evaluating bone changes and detecting calcification. Regarding MRI, it is recommended to efficiently use MR cisternography, a small imaging field of view, and a thin slice thickness. The most common tumor type is acoustic schwannoma, followed by meningioma, trigeminal, facial nerve, jugular foramen schwannoma, paraganglioma, and others. Many of these tumor types can be effectively differentiated by combining various CT and MRI techniques, as stated above, as well as MRA, perfusion imaging, MR digital subtraction angiography, MR spectroscopy, and bone imaging. This article discusses the key MRI and CT findings of major cerebellopontine angle tumors, as well as some representative cases and the corresponding differential diagnoses.
[Overview of Cerebellopontine Angle Tumors].
Kohno M
No Shinkei Geka · 2025 Jul · PMID 40831098 · Publisher ↗
Cerebellopontine angle tumors are rare, and surgeries for these tumors are challenging. Vestibular schwannomas, which account for 70-80% of cerebellopontine angle tumors, are managed by surgery, stereotactic radiosurgery...
Cerebellopontine angle tumors are rare, and surgeries for these tumors are challenging. Vestibular schwannomas, which account for 70-80% of cerebellopontine angle tumors, are managed by surgery, stereotactic radiosurgery or radiotherapy, and watchful observation. Surgery for vestibular schwannoma aims for maximal tumor resection while preserving facial and/or hearing function through strict intraoperative neuromonitoring. Surgical outcomes have markedly improved since the centralization of vestibular schwannoma surgery through the Internet and mass media. This chapter outlines the surgical approaches for cerebellopontine angle tumors, including vestibular schwannomas, meningiomas, epidermoid cysts, trigeminal schwannomas, jugular foramen schwannomas, facial nerve schwannomas, hypoglossal schwannomas, and glomus jugulare tumors.
[Evidence for Antiplatelet Drug Therapy for Moyamoya Disease].
Takahashi S
No Shinkei Geka · 2025 May · PMID 40438024 · Publisher ↗
Currently, no randomized clinical trials have investigated the use of antiplatelet drugs to prevent stroke in patients with Moyamoya disease(MMD). Notably, most of these studies were retrospective observational or prospe...
Currently, no randomized clinical trials have investigated the use of antiplatelet drugs to prevent stroke in patients with Moyamoya disease(MMD). Notably, most of these studies were retrospective observational or prospective with small cohorts. Although the effectiveness of antiplatelet drug administration for ischemic MMD is limited, patients with microembolic signals detected using transcranial Doppler ultrasound may benefit from the prevention of cerebral infarction. There are no data that the administration of antiplatelet drugs increases the risk of hemorrhagic stroke in patients with MMD. However, administration of antiplatelet drugs may increase the patency rate of bypass blood vessels after bypass surgery. Among antiplatelet drugs, cilostazol has a clinically beneficial effect in patients with MMD through its multifaceted effects, such as increasing cerebral blood flow and inhibiting cognitive decline.
[Natural History of Asymptomatic Moyamoya Disease].
Yamamoto S, Kuroda S
No Shinkei Geka · 2025 May · PMID 40438023 · Publisher ↗
Emerging evidence obtained as a result of recent advancements in non-invasive diagnostic modalities indicates that the incidence of asymptomatic moyamoya disease may be much higher than previously reported. However, ther...
Emerging evidence obtained as a result of recent advancements in non-invasive diagnostic modalities indicates that the incidence of asymptomatic moyamoya disease may be much higher than previously reported. However, there are currently no established guidelines for managing asymptomatic moyamoya disease because of the lack of sufficient information regarding its clinical features, prognosis, and treatment strategies. To address these issues, we conducted a multicenter prospective cohort study, the Asymptomatic Moyamoya Registry(AMORE), in Japan. The interim analysis of the AMORE revealed that affected hemispheres may carry a 1.0% annual risk of stroke, mainly hemorrhagic stroke, in asymptomatic moyamoya disease. Grade-2 choroidal anastomosis was found to be an independent predictor of stroke, whereas microbleeds and Grade-2 choroidal anastomosis were independent predictors of hemorrhagic stroke. The annual risk of disease progression, transient ischemic stroke(TIA), and de novo microbleeds were 5.9%, 2.3%, and 2.3%, respectively. Younger age and hypercholesterolemia were predictors of disease progression; disease progression prior to TIA was a significant predictor of TIA, and microbleeds at the time of enrollment were significant predictors of de novo microbleeds. Further research on the impact of genetic mutations and cerebral hemodynamics on the prognosis of asymptomatic moyamoya disease is warranted.
[Adult Hemorrhagic Moyamoya Disease: Physiopathology and Treatment].
Funaki T, Chihara H
No Shinkei Geka · 2025 May · PMID 40438022 · Publisher ↗
The Japan Adult Moyamoya(JAM) Trial revealed the preventive effect of direct bypass on rebleeding in patients with hemorrhagic moyamoya disease. Subsequent studies have elucidated the significance of periventricular anas...
The Japan Adult Moyamoya(JAM) Trial revealed the preventive effect of direct bypass on rebleeding in patients with hemorrhagic moyamoya disease. Subsequent studies have elucidated the significance of periventricular anastomosis, a fragile periventricular collateral manifestation, as a source and predictor of hemorrhage. Practitioners should confirm the reduction in periventricular anastomosis after bypass surgery for hemorrhagic moyamoya disease through optimal imaging assessments.
[Association between Moyamoya Disease and Autoimmune Thyroid Disorders].
Hamano E, Kataoka H
No Shinkei Geka · 2025 May · PMID 40438021 · Publisher ↗
Moyamoya disease(MMD) is a progressive cerebrovascular disorder characterized by stenosis or occlusion of the terminal portion of the internal carotid arteries and development of abnormal collateral vessels. Recent studi...
Moyamoya disease(MMD) is a progressive cerebrovascular disorder characterized by stenosis or occlusion of the terminal portion of the internal carotid arteries and development of abnormal collateral vessels. Recent studies have suggested a clinical association between MMD and autoimmune thyroid disorders or antithyroid antibodies. In patients with concurrent Graves'disease, thyrotoxicosis may precipitate ischemic cerebrovascular events, and normalization of thyroid function is crucial before revascularization surgery. Notably, elevated levels of antithyroid autoantibodies, such as antithyroid peroxidase and anti-thyroglobulin, are frequently observed in patients with MMD, despite the absence of clinically overt thyroid dysfunction. Genetic susceptibility, including variants and immunological factors, might contribute to the pathophysiology of MMD and autoimmune thyroid disorders. The presence of thyroid autoantibodies may be associated with the pathological extension and cerebrovascular events in MMD. However, the underlying mechanisms linking thyroid autoimmunity and moyamoya angiopathy remain unclear. Further investigation is warranted to elucidate these associations and establish appropriate diagnostic and therapeutic approaches.
[Cognitive Impairment in Adult Patients with Moyamoya Disease].
Miyamoto T, Takagi Y
No Shinkei Geka · 2025 May · PMID 40438020 · Publisher ↗
Moyamoya disease is characterized by stenosis of the terminal region of the internal carotid artery and the development of collateral blood vessels with a smoke-like appearance. It causes cerebral infarction and hemorrha...
Moyamoya disease is characterized by stenosis of the terminal region of the internal carotid artery and the development of collateral blood vessels with a smoke-like appearance. It causes cerebral infarction and hemorrhage. However, the occurrence of cognitive impairment in patients with moyamoya disease has been insufficiently addressed. Many patients with moyamoya disease experience difficulties in social life, such as schooling and employment, due to cognitive impairment. This article describes the current cognitive impairment status in patients with moyamoya disease, focusing on the COSMO-Japan Study, a multicenter study on patients with moyamoya disease.
[Cognitive Dysfunction of Pediatric Moyamoya Disease].
Hara S, Nariai T
No Shinkei Geka · 2025 May · PMID 40438019 · Publisher ↗
Moyamoya disease is rare and affects children and young adults. A substantial proportion of children with this disease experience cognitive dysfunction in some domains even in the absence of ischemic or hemorrhagic strok...
Moyamoya disease is rare and affects children and young adults. A substantial proportion of children with this disease experience cognitive dysfunction in some domains even in the absence of ischemic or hemorrhagic stroke. A characteristic feature is a decline in working memory, which is believed to be associated with reduced blood flow and disrupted microstructure in the frontal and parietal lobes. However, the involvement of the temporo-parietal-occipital lobes has also been reported. While successful bypass surgery can improve cognitive decline in some domains, especially the visual-motor processing ability, some patients still suffer from cognitive decline, which negatively affects school learning. As a primary physician of pediatric patients with moyamoya disease, it is essential to assess not only neurological symptoms but also their educational situation and need for support at each school stage. Furthermore, since children with moyamoya disease will have a long life after initial treatment, it is crucial to transmit our knowledge and current challenges to healthcare providers in the next generation to ensure appropriate support throughout the patients' lives.
[Pregnancy and Delivery of Patients with Moyamoya Disease].
Tsurane K, Fudono A, Hara S … +1 more , Miyasaka N
No Shinkei Geka · 2025 May · PMID 40438018 · Publisher ↗
Pregnancy and delivery management in patients with moyamoya disease requires careful attention because of the increased risk of cerebrovascular events. Prepregnancy evaluation, including radiological imaging, neurologica...
Pregnancy and delivery management in patients with moyamoya disease requires careful attention because of the increased risk of cerebrovascular events. Prepregnancy evaluation, including radiological imaging, neurological assessment, and medication adjustment, is essential. During pregnancy, blood pressure(BP) should be monitored closely to prevent complications, because patients are prone to developing high BP. Delivery should be planned based on the patient's cerebrovascular condition, with vaginal delivery under epidural analgesia management or cesarean section in high-risk cases. Postpartum care includes managing BP and monitoring stroke symptoms. Multidisciplinary collaboration between obstetricians, neurologists, and anesthesiologists is crucial for optimizing outcomes.
[Long-term Outcome of Bypass Surgery for Moyamoya Disease].
Yamaguchi K, Kawamata T
No Shinkei Geka · 2025 May · PMID 40438017 · Publisher ↗
Moyamoya disease(MMD) is a progressive cerebrovascular disorder characterized by the stenosis or occlusion of the terminal portion of the internal carotid artery and its major branches. Surgical revascularization is impo...
Moyamoya disease(MMD) is a progressive cerebrovascular disorder characterized by the stenosis or occlusion of the terminal portion of the internal carotid artery and its major branches. Surgical revascularization is important in the management of patients with MMD. This report compared the long-term outcomes of direct, indirect, and combined bypass techniques focusing on stroke recurrence rates and functional prognosis. Recent meta-analyses and clinical reports suggest that combined bypass provide the best long-term outcomes, reducing the risk of stroke recurrence and improving hemodynamic stability. These findings are crucial for neurosurgeons in selecting the optimal surgical approach for adult patients with MMD.
[Perioperative Management and Complications of Moyamoya Disease].
Muraoka S, Saito R
No Shinkei Geka · 2025 May · PMID 40438016 · Publisher ↗
Moyamoya disease is a chronic cerebrovascular disorder characterized by progressive stenosis or occlusion of the terminal portion of the internal carotid artery around the circle of Willis, thereby forming fragile collat...
Moyamoya disease is a chronic cerebrovascular disorder characterized by progressive stenosis or occlusion of the terminal portion of the internal carotid artery around the circle of Willis, thereby forming fragile collateral vessels(moyamoya vessels). Although ischemic symptoms predominate in pediatric cases, adult cases often involve ischemic and hemorrhagic events. Surgical revascularization effectively improves long-term outcomes; however, perioperative complications, such as ischemic events, hyperperfusion syndrome, and hemorrhagic complications, remain challenging. Perioperative management aims to minimize the risk of ischemia and hemorrhage by stabilizing blood pressure, maintaining fluid and electrolyte balance, and implementing optimal ventilation strategies. Intraoperative management aims to prevent ischemic events by ensuring careful hemodynamic and respiratory monitoring and maintaining adequate cerebral perfusion during bypass procedures. Postoperative care emphasizes the early detection and management of hyperperfusion syndrome using imaging modalities, such as PET and SPECT, together with tailored blood pressure control and pharmacological interventions. Meta-analyses and systematic reviews have underscored the importance of selecting the appropriate surgical technique(direct, indirect, or combined bypass) to minimize complications. Although combined bypass techniques may offer long-term outcomes, particularly in pediatric patients, individualized management strategies are essential to address the complex perioperative risks associated with moyamoya disease. Further research is needed to refine surgical approaches and optimize patient outcomes.
[Direct Bypass for Moyamoya Disease].
Yoshikawa K, Ota N, Noda K … +2 more , Kamiyama H, Tanikawa R
No Shinkei Geka · 2025 May · PMID 40438015 · Publisher ↗
We performed direct bypass in adult moyamoya disease and combined direct and indirect bypasses in pediatric cases. Our surgical approach was based on techniques learned from Dr. Hiroyasu Kamiyama, which we refined over t...
We performed direct bypass in adult moyamoya disease and combined direct and indirect bypasses in pediatric cases. Our surgical approach was based on techniques learned from Dr. Hiroyasu Kamiyama, which we refined over time. This paper provides an overview of our method, including its technical modifications and rationale. We performed multiple direct bypasses using the superficial temporal artery(STA) in the anterior and middle cerebral artery territories. Bypass of the anterior cerebral artery is routinely performed in pediatric patients to improve cognitive function. Because secondary bypass using the STA is often unfeasible, we primarily used available resources for the initial surgery. Key procedural refinements include an optimized skin incision to reduce flap ischemia and STA dissection and preparation. Bypass suturing techniques emphasize intima-to-intima anastomosis, which is achieved by optimal stitching to enhance patency and reduce the risk of occlusion. Fish-mouth trimming can achieve a wider orifice while minimizing ischemic time because of the precision of the procedure. Surgical advancements improve the safety and efficacy of moyamoya bypass procedures. Understanding and refining these techniques through continuous training is essential to achieve optimal outcomes.
[History and Current Status of Direct or Combined Revascularization Surgery for Moyamoya Disease].
Kanoke A, Endo H
No Shinkei Geka · 2025 May · PMID 40438014 · Publisher ↗
We reviewed the history and development of revascularization surgery for moyamoya disease, particularly STA-MCA bypass. In the early stages, medical treatments, such as vasodilators, were ineffective. In the 1970s, indir...
We reviewed the history and development of revascularization surgery for moyamoya disease, particularly STA-MCA bypass. In the early stages, medical treatments, such as vasodilators, were ineffective. In the 1970s, indirect surgical methods were introduced but have shown limited success. Direct bypass techniques have evolved with advancements in microsurgery, and STA-MCA bypass has become the standard treatment. Surgery improves the collateral blood flow and reduces the risk of stroke, especially in patients with ischemia. Despite being generally safe, perioperative complications, such as cerebral infarction and hyperperfusion syndrome, may occur. Adult and pediatric patients show different hemodynamic responses that require tailored postoperative care. Long-term studies have shown high graft patency and reduced risk of stroke, although late cerebrovascular events may occur. Meta-analyses support revascularization, especially in cases of hemorrhage. The optimal timing of surgery remains controversial. The risk factors for postoperative stroke include age < 5 years, diabetes, and a higher Suzuki grade. Continued research is needed to refine individual treatment strategies.
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