A novel predictor of ischemic complications in the treatment of ruptured middle cerebral artery aneurysms: Neck-branching angle

Objective

The risk factors of procedural cerebral ischemia (CI) in ruptured middle cerebral artery (MCA) aneurysms are unclear. This study proposed the neck-branching angle (NBA), a simple quantitative indicator of the aneurysm neck and branch vessels, and analyzed its usefulness as a predictor of procedural CI in ruptured MCA aneurysms.

Methods

We retrospectively analyzed 128 patients with ruptured saccular MCA aneurysms who underwent surgical or endovascular treatment between January 2014 and June 2021. We defined the NBA as the angle formed by the MCA aneurysm neck and M2 superior or inferior branch vessel line. The superior and inferior NBA were measured on admission via three-dimensional computed tomography angiography on admission. We divided the patients into clipping (106 patients) and coiling (22 patients) groups according to the treatment. Risk factors associated with procedural CI were analyzed in each group.

Results

Both groups showed that an enlarged superior NBA was a significant risk factor for procedural CI (clipping, P < 0.0005; coiling group, P = 0.007). The receiver operating characteristic curve showed the closed thresholds of the superior NBA with procedural CI in both groups (clipping group, 128.5°, sensitivity and specificity of 0.667 and 0.848, respectively; coiling group, 130.9°, sensitivity and specificity of 1 and 0.889, respectively).

Conclusion

The NBA can estimate the procedural risk of ruptured MCA aneurysms. In addition, an enlarged superior NBA is a risk factor for procedural CI in both clipping and coiling techniques.

Safety and Efficacy of Prasugrel Administration in Emergent Endovascular Treatment for Intracranial Atherosclerotic Disease

Objective

Intracranial atherosclerosis disease (ICAD) is one of the most common causes of acute ischemic stroke. In endovascular treatment (EVT) for acute large vessel occlusion stroke-related ICAD, reocclusion of the recanalized artery due to in situ thrombosis is problematic. In this study, the safety and efficacy of prasugrel administration to avoid reocclusion of emergent EVT for ICAD was investigated.

Methods

All consecutive emergent EVTs for ICAD between September 2019 and December 2022 were included in this study. The procedures were divided into two groups as receiving periprocedural prasugrel (PSG group) or not (non-PSG group). Target vessel patency on follow-up, postprocedural intracranial hemorrhage (ICH), and clinical outcome were compared between PSG and non-PSG groups.

Results

A total of 27 procedures were included in this analysis. Nineteen target vessels were patent on follow-up and eight were non-patent. Fifteen patients received prasugrel (18.75 mg: 11 cases, 11.25 mg: 4 cases), and twelve patients did not receive prasugrel. The target vessel patency rate was better in the PSG group vs. non-PSG group (100% vs. 33.3%, respectively; p = 0.0002). The postprocedural ICH rate was not different between the groups (PSG: 40.0% vs. non-PSG: 25.0%; p = 0.68), and all ICHs were asymptomatic. Good clinical outcome (modified Rankin Scale score of 0 to 3 at discharge) was more frequent in the PSG group than that in the non-PSG group (66.7% vs. 16.7%, respectively; p = 0.019).

Conclusion

Prasugrel administration was significantly associated with target vessel patency and good clinical outcome after emergent EVT for ICAD without increasing the symptomatic ICH rate. Prasugrel administration might be safe and effective to avoid reocclusion during and after emergent EVT for ICAD.

Intra-arterial infusion of fasudil hydrochloride to treat post-traumatic cerebral vasospasm

Background

The effect of intra‐arterial infusion of fasudil hydrochloride in patients with post‐traumatic cerebral vasospasm remains unclear. Here we report a case of intra‐arterial infusion of fasudil hydrochloride for post‐traumatic cerebral vasospasm.

Case presentation

A 47‐year‐old man was transferred to our hospital with a fractured skull and traumatic subarachnoid hemorrhage. As rhinorrhea of cerebrospinal fluid had not improved, repair surgery was carried out on day 4. Aphasia appeared on day 13. Magnetic resonance imaging and angiography showed an ischemic region in the left temporal lobe and vasospasm of the left middle cerebral artery. We immediately carried out angiography and diagnosed severe vasospasm of the M1 region of the left middle cerebral artery. After placing a microcatheter into the proximal middle cerebral artery, we injected fasudil hydrochloride intra‐arterially. Vasospasm improved and aphasia resolved.

Conclusion

In this case, intra‐arterial infusion of fasudil hydrochloride was effective against post‐traumatic cerebral vasospasm.

Life-Threatening Hemorrhagic Moyamoya Disease: Report of Rare Case of Atraumatic Acute Subdural Hematoma Due to Ruptured Transdural Anastomosis

BACKGROUND

Atraumatic acute subdural hematoma (ASDH) associated with moyamoya disease (MMD) is rare, and only a few studies have reported the bleeding origin. We present a case of atraumatic ASDH attributable to a transdural anastomosis that developed owing to the compensatory mechanisms involved in the pathogenesis of advanced MMD. This is the first case of life-threatening atraumatic ASDH associated with MMD in which the rupture point was clearly visualized using a 3-dimensional rotational reconstructed image.

CASE DESCRIPTION

A 37-year-old woman presented with sudden-onset, serious, atraumatic ASDH requiring emergency decompressive craniectomy. The cerebral angiograms revealed that she had advanced MMD with transdural anastomosis that was classified as Suzuki stage V with a 5-mm saccular aneurysm in the middle meningeal artery on the affected side, which was suggested as the bleeding origin. Follow-up angiograms demonstrated that the aneurysm spontaneously disappeared and was inferred to be a pseudoaneurysm. We performed a left extraintracranial bypass to prevent recurrent hemorrhage. With intensive rehabilitation, the patient accordingly achieved stroke-free survival with a modified Rankin Scale score of 3 for 1 year.

CONCLUSIONS

Atraumatic ASDH associated with MMD is a rare type of hemorrhagic MMD, and a 3-dimensional-rotational reconstructed image was useful to confirm the origin of the bleeding. The transdural anastomosis development most likely correlates with the occurrence of any type of hemorrhagic MMD. We should consider that the transdural anastomosis collapse can cause a life-threatening atraumatic ASDH and should plan a surgical strategy carefully so as not to destroy collateral supply through the transdural anastomosis in such cases.

Small Hyperintensities in the Area of the Perforating Arteries in Patients with Seizure

Background/Aim: We previously observed spotty hyperintense lesions in the region of the perforating arteries on peri-ictal diffusion-weighted imaging (DWI); however, no report has formally described these findings. The aim of this study was to investigate focal intensities on peri-ictal DWI, and to evaluate the clinical significance of these lesions. Methods: We conducted a retrospective review of 677 consecutive patients with seizure who completed peri-ictal DWI within 24 h after seizure onset. Patients were grouped according to the presence or absence of diffusion hyperintense lesions (DHLs) in the region of the perforating arteries. We compared clinical and imaging characteristics between these 2 groups. Results: Among 677 patients, 23 patients (3.4%) had DHLs. Analyses of apparent diffusion coefficient values and fluid attenuated inversion recovery images suggested that DHLs were acute or subacute ischemic lesions that had appeared prior to seizure onset. Patients with DHLs were more likely to be older in age, have atrial fibrillation, and coronary artery disease, and have more severe deep white matter hyperintensity or leukoaraiosis compared to patients without DHLs. Conclusion: DHLs detected on peri-ictal DWI may represent incidental acute cerebral microinfarcts in the aging brain, especially in patients with small vessel disease.

Spontaneous Regression of Inflammatory Pseudotumor in the Cauda Equina: A Case Report

Spinal intradural extramedullary inflammatory pseudotumor (IPT) is an extremely rare entity. Spontaneous shrinking of a spinal IPT has never been reported. A case of an IPT of the cauda equina that regressed spontaneously is presented. A 78-year-old woman presented with hypoesthesia of both lower legs in the L4 nerve root distribution and motor weakness of the right leg. Preoperative CT myelography and MRI showed two tumor-like lesions located at T12-L1 and L2-3. The lesion at the T12-L1 level appeared to encase several nerve roots. The preoperative diagnosis was ependymoma, schwannoma, or malignant lymphoma. The tumors were biopsied. In the operation, the lesion turned out to consist of swollen and adherent nerve roots. On histopathological examination of the biopsied nerve roots, they were diagnosed as IPT. The patient's symptoms improved gradually without any treatment after the operation. The IPTs regressed on the postoperative MR images and disappeared at one year. This is the first report of spontaneous regression of an IPT in the spinal region. IPT should be considered in the differential diagnosis of a tumor that appears to involve several nerve roots on preoperative imaging, but surgery is necessary for diagnosis. Complete resection is not absolutely required if an intraoperative pathological diagnosis of the frozen section reveals IPT.

Decompressive Craniectomy in Conjunction With Evacuation of Intracranial Hemorrhagic Lesions Is Associated With Worse Outcomes in Elderly Patients With Traumatic Brain Injury: A Propensity Score Analysis

BACKGROUND

When it comes to evacuating intracranial hemorrhagic lesions in patients with traumatic brain injury (TBI), neurosurgeons perform either a craniotomy or a decompressive craniectomy (DC). The aim of the present study was to estimate the impact of DC on outcomes in elderly patients.

METHODS

This retrospective cohort study, conducted in a neurosurgical institute in Japan from April 2009 to June 2014, included 91 consecutive patients with TBI (aged 60 years or older) who underwent evacuation of intracranial hemorrhagic lesions. Patients were divided into 2 groups: craniotomy only or DC. We set the primary endpoint as an unfavorable outcome (death or vegetative state), as evaluated on the Glasgow Outcome Scale at 6 months after injury. The secondary endpoints included existence of delayed hemorrhage and occurrence of hydrocephalus requiring shunt placement. The inverse probability of treatment weighting method was used to develop a propensity model to adjust for baseline imbalances between groups.

RESULTS

The DC group exhibited greater severity both in clinical and computed tomography findings according to baseline characteristics. After we adjusted for these differences by inverse probability of treatment weighting using the propensity score, DC was significantly associated with unfavorable outcomes (adjusted odds ratio, 8.00; 95% confidential interval, 2.30-27.84; P = 0.002) and delayed hemorrhage (adjusted odds ratio, 13.42; 95% confidential interval, 1.52-118.89; P = 0.022). There was no significant difference in the occurrence of hydrocephalus requiring shunt placement.

CONCLUSIONS

DC in conjunction with evacuation of intracranial hemorrhagic lesions was associated with worse functional outcome in elderly patients with TBI.

Retreatment of Recurrent Internal Carotid-Posterior Communicating Artery Aneurysm after Coil Embolization

Internal carotid-posterior communicating artery (IC-PC) aneurysms account for more than 20% of all intracranial aneurysms. As a result of the increase in coiling, there has also been an increase in recurrent IC-PC aneurysms after coiling. We present our experience of 10 recurrent IC-PC aneurysms after coiling that were retreated using surgical or endovascular techniques in order to discuss the choice of treatment and the points of clipping without removal of coils. From 2007 to 2014, 10 recurrent IC-PC aneurysms after coiling were retreated. When the previous frames covered the aneurysms all around or almost around except a part of the neck, coiling was chosen. In other cases, clipping was chosen. Clipping was attempted without removal of coils when it was technically feasible. Among the 10 IC-PC aneurysms retreated, 3 were retreated with coiling and 7 were retreated with clipping. In all three cases retreated with coiling, almost complete occlusion was accomplished. In the seven cases retreated with clipping, coil extrusion was observed during surgery in six cases. In most of them, it was necessary to dissect strong adhesions around the coiled aneurysms and to utilize temporary occlusion of the internal carotid artery. In all seven cases, neck clipping was accomplished without the removal of coils. There were no neurological complications in any cases. The management of recurrent lesions of embolized IC-PC aneurysms requires appropriate choice of treatment using both coiling and clipping. Clipping, especially without the removal of coils, plays an important role in safe treatment.

Superior turbinectomy: role for a two-surgeon technique in endoscopic endonasal transsphenoidal surgery--technical note

We describe a practical technique of superior turbinectomy followed by posterior ethmoidectomy as a less invasive procedure for two-surgeon technique on endoscopic endonasal transsphenoidal surgery. After identification of the superior turbinate and the sphenoid ostium, the inferior third portion of the superior turbinate was coagulated and resected. This partial superior turbinectomy procedure exposed the posterior ethmoidal sinus. Resection of the bony walls between the sphenoid and posterior ethmoid sinuses provided more lateral and superior exposure of the sphenoid sinus. This technique was performed in 56 patients with midline skull base lesions, including 49 pituitary adenomas and 7 other lesions. Meticulous manipulation of instruments was performed in all cases without surgical complications such as permanent hyposmia/anosmia or nasal bleeding. Our findings suggested that the partial superior turbinectomy followed by retrograde posterior ethmoidectomy is a simple and safe technique providing a sufficient surgical corridor for two-surgeon technique to approaching midline skull base regions, mainly involving pituitary adenomas.

Unruptured internal carotid-posterior communicating artery aneurysm splitting the oculomotor nerve: a case report and literature review

Objective To report a rare case of unruptured internal carotid-posterior communicating artery (IC-PC) aneurysm splitting the oculomotor nerve treated by clipping and to review the previously published cases.

Case Presentation A 42-year-old man suddenly presented with left oculomotor paresis. Three-dimensional digital subtraction angiography (3D DSA) demonstrated a left IC-PC aneurysm with a bulging part. During surgery, it was confirmed that the bulging part split the oculomotor nerve. After the fenestrated oculomotor nerve was dissected from the bulging part with a careful microsurgical technique, neck clipping was performed. After the operation, the symptoms of oculomotor nerve paresis disappeared within 2 weeks.

Conclusions We must keep in mind the possibility of an anomaly of the oculomotor nerve, including fenestration, and careful observation and manipulation should be performed to preserve the nerve function during surgery, even though it is very rare.

Modified hemostatic technique using microfibrillar collagen hemostat in endoscopic endonasal transsphenoidal surgery: technical note

Microfibrillar collagen hemostat (MCH) is accepted as an effective topical hemostatic agent during endoscopic endonasal transsphenoidal surgery (EETS), particularly to achieve venous hemostasis; however, handling MCH may be troublesome because of its adherence to gloves and instruments. We describe here a method of “injection” of MCH suspension using a syringe applicator. This technique allows a rapid and precise delivery of MCH to the bleeding points and thereby results in effective hemostasis; in addition, it is easy to prepare and it is also inexpensive.

[A case of culture-negative brain abscess caused by Streptococcus intermedius infection diagnosed by broad-range PCR of 16S ribosomal RNA]

A 50-year-old man presented with altered mental status during hospitalization for pneumonia. MRI showed multifocal ring-enhanced lesions, which consisted of multiple cerebral abscesses. We started empirical antibiotic therapy, but the following morning, his condition rapidly deteriorated and a CT scan revealed acute hydrocephalus, which required ventricular drainage. Gram staining of cerebro-spinal fluid from the ventricular drainage showed gram-positive cocci in chains, but culture results were negative. 16S ribosomal RNA sequencing with broad-range PCR of the cerebro-spinal fluid identified Streptococcus intermedius. On the basis of this identification, the antibiotic regimen was changed to ampicillin monotherapy. After 1 year of antibiotic therapy, all the abscesses had disappeared and the patient was discharged without any sequelae. Bacterial 16S rRNA gene analysis with broad-range PCR is a very useful method for facilitating the etiological diagnosis and selection of appropriate treatment for culture-negative infections.

Impact of energy intake on the survival rate of patients with severely ill stroke

INTRODUCTION

Stroke accounts for approximately 10% of all deaths. We examined whether energy intake influences the survival rate of severely ill stroke patients.

METHODS

We analyzed 86 consecutive severely ill stroke patients. Patients' background was compared between survivors and non-survivors. Average energy intakes in seven different periods from day one to seven following neurosurgical care unit (NCU) admission were compared between two groups, to examine which period is proper to show an energy difference. Groups were stratified by average total energy intake (group E-I, -II, -III, and -IV; ≤.25, 8.25-16.5, 16.5-25, and >25kcal/kg/day, respectively), and cumulative survival rate for 90 days after NCU admission was analyzed. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated to examine the effect of confounder factors.

RESULT

Patients' background did not differ significantly between the two groups. Average daily energy intake for the first seven NCU days of non-survivors was significantly lower than that of survivors (p=0.034). The survival rate of group E-II was significantly higher than that of group E-I, which was set as a reference (p=0.030). The adjusted HR of E-II was also significantly lower than that of group E-I (HR=0.19, p=0.047), although E-III did not show significance (HR=0.52, p=0.279).

CONCLUSION

Energy intake assessment should be conducted for at least seven days following NCU admission. An average total energy intake ranging from 8.25 to 16.5 kcal/kg/day and enteral feeding increases survival rate in severely ill stroke patients.

Superior sagittal sinus dural arteriovenous fistulas treated by stent placement for an occluded sinus and transarterial embolization. A case report

We describe a case of dural arteriovenous fistulas (DAVFs) involving the superior sagittal sinus (SSS) successfully treated with stent placement for an occluded sinus and transarterial embolization. A 61-year-old man who had been treated with anticoagulation for a known SSS thrombosis presented with a sudden onset of headache. CT scan revealed an intraventricular hemorrhage and cerebral angiography revealed DAVFs involving the SSS which had severe venous congestion and sinus occlusion. We treated this case with a staged endovascular approach which consisted of stent placement for the occluded sinus and transarterial intravenous embolization resulting in complete eradication of DAVFs. Recanalization of an occluded sinus by stent placement can reduce venous congestion and transarterial intravenous embolization can obliterate dural arteriovenous shunts. This staged strategy is feasible and should be considered a first option of treatment, especially for DAVFs which presented with intracranial hemorrhage and aggressive venous hypertension.

Direct percutaneous carotid artery stenting for a patient with absence of the common carotid artery

A 54-year-old man with symptomatic internal carotid artery stenosis with absence of the common carotid artery (CCA), who had been treated with surgery and postoperative radiotherapy for tonsillar carcinoma, underwent direct percutaneous carotid artery stenting (CAS). To our knowledge, this is the first report of direct percutaneous carotid artery stenting (CAS) for a patient with absent CCA.

Transient total mesencephalic locked-in syndrome after bilateral ptosis due to basilar artery thrombosis

Locked-in syndrome (LIS) usually occurs as a result of pontine lesions and has been classified into various categories on the basis of neurologic conditions, of which transient total mesencephalic LIS is extremely rare. A 53-year-old man presented with bilateral ptosis followed by a total locked-in state. In the clinical course, the patient successfully recovered with only left slight hemiparesis and skew deviation remaining. Magnetic resonance imaging revealed multiple ischemic lesions caused by thrombosis at the top of basilar artery, including the bilateral cerebral peduncles, tegmentum of the midbrain, and the right cerebellar hemisphere. Antecedent bilateral ptosis before the locked-in state may be related to ischemia in the central caudal nucleus of the oculomotor nuclei. We should pay attention to this easily missed condition during the treatment of ischemic stroke involving the basilar artery.

Detection of the microcatheter tip using a novel microguidewire during coil embolization of cerebral aneurysms - technical note -

Detection of the position of the microcatheter tip is important for safe and effective coil embolization of cerebral aneurysms, but is sometimes difficult, especially in the final stage with a high density of embolized coils. We report a new technique to deduce the position of the microcatheter tip using a novel microguidewire during coil embolization of cerebral aneurysms. The novel microguidewire (ASAHI CHIKAI 10; Asahi Intecc, Nagoya, Aichi), with a radiopaque portion of 30 mm, is advanced into the microcatheter until the distal end of the radiopaque portion reaches the coil mass edge at the neck of the aneurysm. The distance between the second marker of the microcatheter and the proximal end of the radiopaque portion of the microguidewire is checked. The position of the microcatheter tip is deduced from the distance and curve of the microguidewire. Microcatheter tips can be easily detected with this technique without complications. This technique is safe, simple, and useful for deducing the position of the microcatheter tip during coil embolization of cerebral aneurysms.

Primary intracranial leiomyosarcoma in an immunocompetent patient: case report

We report a case of intracranial leiomyosarcoma (LMS) arising after resection of neurofibroma at the cerebellopontine angle. A 45-year-old immunocompetent woman presented with recurrence of a tumor 9 years after resection performed in another hospital. Magnetic resonance imaging demonstrated a heterogeneously enhancing, dura-based mass at the left cerebellopontine angle. The tumor was subtotally removed via lateral suboccipital craniotomy. LMS was diagnosed based on histological and immunohistochemical findings. Postoperatively, although the patient was treated using local radiotherapy, she died due to rapid regrowth of the tumor. Reevaluation of the specimen obtained in the first operation led to a diagnosis of neurofibroma. Both LMS and neurofibroma rarely occur intracranially. LMS is generally thought to arise from smooth muscle cells of the blood vessels or pluripotent mesenchymal cells. In this case, LMS might also have originated from smooth muscle cells of the vessels in the neurofibroma, possibly associated with mechanical and/or heat stimulation during the previous surgery.

Fixation and protective method for the interposition graft in bonnet bypass--technical note

Bonnet bypass is recommended for the rare patients in whom no alternative revascularization procedure is available. Fixation and protection of the interposition graft are important for stable anastomosis, and to avoid mechanical injury after operation. Here, we describe a new technique for fixation and protection of the interposition graft in bonnet bypass. The interposition graft is passed through a bone groove created in the skull, and covered with microplates, temporal fascia, and muscle. The method prevents the interposition graft from slipping out during the anastomosis, and can also protect the graft from mechanical injury after the operation.

Technique for shaping microcatheter tips in coil embolization of paraclinoid aneurysms using full-scale volume rendering images of 3D rotational angiography

INTRODUCTION

In coil embolization of paraclinoid aneurysms, it is sometimes difficult to introduce and stabilize microcatheter tips in the aneurysms. We report a new technique for shaping microcatheter tips in the coil embolization of paraclinoid aneurysms.

METHODS

From May 2007 to May 2008, this new technique was applied to 10 paraclinoid aneurysms undergoing coil embolization. Before coil embolization, 3D rotational angiography was performed, and volume-rendering images were reconstructed. Vinyl-coated handicraft wire was shaped 3-dimensionally to fit full-scale volume-rendering images on the monitor, from the C5 portion of the internal carotid artery to the center of the dome of the aneurysm from various angles. The microcatheter tip was then shaped with steam to fit the vinyl-coated wire. Thereafter, the microcatheter tip was introduced into the aneurysm and coil embolization was performed.

RESULTS

Microcatheter tips could be easily shaped and could be introduced smoothly into aneurysms, and were stable during coil embolization.

CONCLUSION

This technique is feasible for shaping microcatheter tips precisely for coil embolization of paraclinoid aneurysms.

Complete Cure of Superior Sagittal Sinus Dural Arteriovenous Fistulas by Transvenous Embolization through the Thrombosed Sinus in a Single Therapeutic Session. A Case Report

SUMMARY

Endovascular treatment often fails to completely eliminate dural arteriovenous fistulas (dural AVFs) involving the superior sagittal sinus (SSS). We report a successful case of dural AVF involving the SSS using transvenous embolization through the thrombosed sinus in a single therapeutic session.

Technique to detect coil migration using mask images of rotational angiography during stent-assisted coil embolization for ultra-wide necked aneurysms: technical note

A novel technique was developed to detect coil migration to the stent interior using mask images of rotational angiography. Stent-assisted coil embolization under x-ray fluoroscopy control was simulated with a hand-made vessel model. The stent interior was observed with a rigid endoscope during coil embolization. After insertion of the coil, mask images using rotational angiography were acquired and multi-planar reformation (MPR) images were reconstructed on a workstation. The stent interior could be observed during coil embolization. Longitudinal MPR images showed the positional relationships between the stent, coil, and tip of the microcatheter. This technique was successfully employed in a patient to detect displacement of the tip of the microcatheter inside the stent. This technique is useful for monitoring stent-assisted coil embolization of an ultra-wide necked aneurysm, but requires extra time and increased radiation exposure, so we recommend use only if coil migration is strongly suspected.

Dissecting aneurysm of the radiculomedullary artery originating from extracranial vertebral artery dissection in a patient with rheumatoid cervical spine disease: an unusual cause of subarachnoid hemorrhage

✓The authors report the case of a 65-year-old woman with atlantoaxial subluxation caused by rheumatoid arthritis. The patient had been hospitalized because of an infection after a total-knee replacement, when she suddenly lost consciousness and became apneic after an episode of intractable neck pain. Cranial computed tomography scanning demonstrated subarachnoid hemorrhage (SAH), and angiography revealed a dissecting aneurysm of the radiculomedullary artery that had originated from an extracranial vertebral artery dissection at the level of the atlantoaxial joint. Although coil embolization for the parent artery, including the dissecting aneurysm, was performed successfully, the patient died of worsening infection. The authors believe that the SAH occurred because of a ruptured dissecting aneurysm in the intradural portion of the radiculomedullary artery.

Magnetoencephalographic analysis of cortical oscillatory activity in patients with brain tumors: Synthetic aperture magnetometry (SAM) functional imaging of delta band activity

Abnormal focal slow wave activity on electroencephalography and magnetoencephalography (MEG) is often seen in patients with various brain pathologies and MEG is capable of localizing cortical oscillatory activity with enhanced accuracy. In addition, MEG with synthetic aperture magnetometry (SAM) can depict changes in cortical oscillatory activity tomographically. Using SAM, we recorded cortical rhythms in patients with a brain tumor and evaluated the tomographic appearance of focal slow wave activity in relation to clinical signs and symptoms. Spontaneous MEG recordings were obtained in 15 patients with brain tumors. Statistically-determined power distributions in the delta-, theta-, and alpha-frequency bands were displayed tomographically and overlaid on individual magnetic resonance images. The location, strength and volume of enhanced activity were analyzed. Delta and theta band activities were significantly more intense in the cortex adjacent to tumors and in the surrounding edematous cortical areas than in other portions of the cortex. In 13 of the 15 patients, spatial distribution of enhanced focal delta activity coincided with the area responsible for the presenting signs and symptoms. Volumetric analysis revealed that emergence of tumor-related focal delta band activity in the cortex adjacent to a tumor, or with peritumoral edema, was greater for intra-axial tumors involving subcortical fibers than for extra-axial tumors. Patients with an increased volume of enhanced delta activity exhibited poor recovery of function in the early postoperative period. It is concluded that SAM imaging of focal delta activity can reveal functional alterations in cortical activity in patients with brain tumors and is useful for assessing cortical states associated with the existing pathology.

Spinal lipomas in children--surgical management and long-term follow-up

Since its introduction, MR imaging has been easy to perform on all children with lumbosacral cutaneous stigmata, and has enabled the phenomenal refinement of spinal pathology. We investigated the overall outcomes of children with spinal lipomas at the Osaka Medical Center and Research Institute for Maternal and Child Health in Osaka, Japan. Between 1991 and 2003, 76 children with a tethered cord underwent a total of 90 surgical procedures at our institutes. Of this cohort, 67 cases had spinal lipomas. The mean age of patients at first operation for asymptomatic lipoma was 22.4 months (range: 1 month to 16 years, trim mean: 10.1 months, mode: 5 months), except 4 cases. The mean total follow-up for the cohort since the first surgical procedure was 7.2 years (trim mean: 7.9 years). Since the introduction of MR imaging, the reoperation rate for symptoms or signs in our series was 16.4% (11 cases). Regarding the 13 subsequent reoperations (2 patients had 2 operations), 3 patients were reoperated on due to multiplication of the lipomas after untethering, 3 due to urologic symptoms and 5 due to orthopedic signs. There were 2 cases who also had to undergo reoperation early due to CSF leakage. Filum and conus lipomas have similar tethering pathologies, but differ in the outcome following surgery. Filum lipomas are benign, and therefore surgery is safe and effective. Conus lipomas are more difficult to manage.

Intraoperative three-dimensional reconstruction of power Doppler vascular images

We have developed a simple method for reconstructing a three-dimensional (3D) image in the operating room from sequentially scanned intraoperative two-dimensional (2D) power Doppler images using a personal computer and commercially available software. During three operations, 2 for cerebral aneurysm and 1 for cerebral tumor, intracranial vessel images were digitally transferred to a personal computer by freehand scanning over the dura mater or surface of the brain with a 7.5-MHz linear probe. A series of 2D images were converted to a smaller file, and 3D image was reconstructed with volume-rendering software. It took about 15 minutes to reconstruct of the initial 3D image. In the cases of cerebral aneurysm, the vessels connected to the lesion or running nearby were easily identified on the image. In the tumor case, the anatomical relation between the vascular structures and the tumor was clear. This simple 3D reconstruction method provides spatial information about intracranial vascular structures that is useful in intraoperative surgical planning.

Multiplication of infantile spinal lipomas after surgical untethering. Report of two cases

The authors reviewed 63 cases of patients with spinal lipomas who had undergone surgical untethering in childhood and found two infants in whom multiplication of the lipomas occurred within 1 year postoperatively. More importantly, the lipomas dramatically increased in size during infancy. In each case, the pathological findings on reoperation were identical to those in the first surgery. Subsequent imaging revealed no change in size of the lesions by 10 and 7 years after reoperation, respectively. This potential for growth of the lipomas should be kept in mind in infants with spinal lipomas who should undergo follow-up neuroimaging.

Tethered cord associated with anorectal malformation

Ten children with a tethered cord and also an anorectal malformation are reported in this document. The anorectal malformations comprised 5 vesicointestinal fissures, 2 cloacal exstrophies, 2 rectovesical fistulas and 1 rectobulbar fistula. All of the patients underwent colostomy in advance of surgery for untethering of the spinal cord. Although their neurologic deficits had previously been considered static, they were subjected to radiographic examination of the caudal spine and found to have a tethered cord. These 10 children were among 55 children with a tethered cord surgically treated at the Division of Neurosurgery of the Osaka Medical Center and Research Institute for Maternal and Child Health during the last 11 years. Data were obtained for these 10 children (6 boys and 4 girls, mean age 1.7 years) who underwent surgical untethering. Several hypotheses are offered to explain this association. Anorectal malformations are related to underlying spinal cord anomalies, which may be amenable to neurosurgical correction. Eight of our patients had no skin stigma of the lumbosacral region, in contrast to an ordinary tethered cord. Spinal cord imaging is necessary to closely scrutinize these children.

[Effect of stimulus size on binocular summation within the binocular visual field]

PURPOSE

To study the influence of stimulus sizes on binocular summation using the modified Octopus 201 combined with a space synoptophore.

METHODS

Four normal subjects, aged 21 to 26 were tested. Using the SARGON program, we designed a new program to test 37 points in the central 6 degrees visual field. Sensitivity of the central 6 degrees visual field under monocular and binocular conditions was measured while the fusion patterns were displayed on the space synoptophore. The visual fields were measured at stimulus sizes 1, 3, and 5.

RESULTS

The visual sensitivity under binocular conditions was higher than under monocular conditions for all the stimulus sizes. Binocular summation for stimulus size 1 was present in a flat form, for stimulus size 3 in a convex form, and for stimulus size 5 in a concave form in the central 6 degrees visual field.

CONCLUSION

Binocular summation differed in stimulus size and retinal eccentricity. Binocular summation for stimulus size 3 increased in the fovea and it increased for stimulus size 5 in the peripheral area in the central 6 degrees visual field.

Vitamin E supplementation attenuates leakage of enzymes following 6 successive days of running training

The purpose of this study was to examine whether vitamin E supplementation in humans would attenuate an increase of serum enzymes as an indirect marker of muscle damage following a sudden large increase in the running distance in a 6-day running training or not. A randomized and placebo-controlled study was carried out on fourteen male runners who were supplied vitamin E (alpha-tocopherol 1200 IU x day(-1); E) or placebo (P) 4 weeks prior to (T1) and during 6 successive days of running training (48.3 +/- 5.7 km x day(-1), means +/- SD). Resting venous blood samples were obtained before maximal treadmill running, at T1, the day immediately before (T2), the next day (T3), and three weeks (T4) after the running training. Serum levels of alpha-tocopherol, lipid peroxidation products (thiobarbituric acid; TBA), creatine kinase (CK), lactate dehydrogenase (LDH), and LDH isozyme 1-5 were quantitatively analyzed. No significant difference was found in maximal oxygen uptake (VO2max) and maximal heart rates following the exhaustive exercise between the P and E group during the experiments. Vitamin E supplementation significantly increased serum alpha-tocopherol (p<0.001) and decreased TBA levels (p < 0.001) compared with pre-supplementation levels. Although serum CK and LDH activities increased significantly at T3 in either group, significantly lower CK (p < 0.05) and LDH (p < 0.001) levels were observed in the E group compared with the P group. The ratio of LDH1 to LDH2 (LDH1/LDH2) decreased significantly at T3 in either group compared with the T1 levels, since there was no significant difference in the LDH1/LDH2 between the P and E group throughout the experiments. These results indicate that vitamin E supplementation can reduce the leakage of CK and LDH following 6 successive days of endurance running. The protective effect of vitamin E against free radicals probably inhibits free-radical-induced muscle damage caused by a sudden large increase in the running distance.

Purely laparoscopic pylorus-preserving gastrectomy with extraperigastric lymphadenectomy for early gastric cancer: a case and technical report

For the purpose of prevention of postgastrectomy syndrome and a less invasive and yet curative oncological resection, a purely laparoscopic pylorus-preserving gastrectomy with extraperigastric lymphadenectomy was performed for a patient with early gastric cancer located in the middle third of the stomach. The patient's postoperative course was uneventful. During his postoperative recovery, the patient experienced very little pain and used analgesic medication only one time. This operation appeared to be oncologically adequate. As of the seventh postoperative month, the patient never experienced dumping syndrome or alkaline reflux gastritis. This procedure is technically feasible and an excellent option because of its reduced surgical invasiveness and better postoperative quality of life.

[Spinal lipoma in children: analysis of magnetic resonance image for upward displacement of medullary-conus on 44 consecutive surgical cases]

Medullary conus-untethering operation was conducted on 52 infants with spinal lipoma. Magnetic resonance (MR) image was used in order to evaluate the untethering results in 44 out of these 52 patients who could be followed-up after Osaka Medical Center & Research Institute for Maternal & Child Health was opened. Talking into account the changes in vertebral body during the growth period of infants, the authors studied the upward displacement of the conus-lipoma interface by four fractional MR sagittal image, using the vertebral body-intervertebral disc space as the baseline. Upward displacement was confirmed in 27 of 44 (61.4%). The mean, median and trimmed mean of upward displacement were 1.78 +/- 0.80, 2.0, 1.70 fractions, respectively. Sixteen (59.3%) were caudal type, 10 (37.0%) were transitional type and 1 (3.7%) was dorsal type. By type of spinal lipoma, upward displacement was observed in 16 of 23 caudal type patients (69.6%), 10 of 16 transitional type patients (62.5%) and 1 of 5 dorsal type patients (20%). While the rate of upward displacement was almost equal between the caudal and transitional type, that of dorsal type was lower. However, statistical analysis for the difference in population percentage of the three groups showed that significant difference existed only in the caudal type group.

Decrease in N-acetylaspartate without commensurate accumulation of acetate in focal cerebral ischemia in rat

N-acetylaspartate (NAA) is a plausible marker of neuronal viability which decreases in a variety of neurodestructive conditions. To elucidate the mechanism that leads to NAA decline in two different types of cerebral ischemia in rats, we simultaneously determined cortical concentrations of NAA and its hydrolytic metabolites, aspartate, and acetate by high-resolution 1H-NMR spectroscopy. NAA decreased almost linearly up to 24 h in both decapitation induced global cerebral ischemia, and in ischemic cortices of focal ischemia. Acetate was increased continuously for up to 24 h of global ischemia, while in focal cerebral ischemia it was increased transiently at 6 h. Aspartate did not show any change in global ischemia, while it was decreased in focal ischemia. Although NAA decreased similarly in the brain with global and focal ischemia, temporal changes of two NAA hydrolytic metabolites were different in each type of ischemia. The present results suggest hydrolytic degradation of NAA may be modified alternatively under each pathophysiologic condition.

[Vein of Galen aneurysmal malformation: multi-staged feeder clipping in two neonatal cases with intractable heart failure]

The authors reported the surgical experience of two cases of vein of Galen aneurysmal malformation in the newborn, whose congestive high-output cardiac failure was intractable. Along with the intensive care to clinical manifestations of the heart failure, multi-staged feeder clipping was carried out to decrease the high-flow shunt of the malformation. As stages going on, heart failure was relieved gradually and cathecolamines were weaned. Although certain retardation became apparent in both cases, they are showing satisfactory development in the long-term follow up. By the recent advancement of the embolization technique, the embolization appears to have already taken place the treatment of choice for this malformation. According to the neonatal evaluation score of Lasjaunias, the embolization would no longer be recommendation in neonates, whose general condition scored less than eight points. The authors believe, based on our two cases, that multi-staged feeder clipping is one of the effective modality of treatment in neonates of the vein of Galen aneurysmal malformation with severe multiorgan failure.

[Urodynamic studies on the untethering of spinal lipoma in the children]

We performed conus untethering on 44 children with spinal lipoma. In this retrospective study, we studied urological examinations obtained in 36 consecutive patients. Urological examinations were ultrasonography of bladder and kidney, voiding cystourethrography (VCG), and urodynamic cystometry. In those of them, 6 patients had already had urinary dysfunction at preoperative stage, but 4 patients' spinal lipoma was one complication of cloaca exstrophy and 2 patients' spinal lipoma after repairment of their myelomeningocele. In the remaining 30 cases, 18 patients (60.0%) as the group 1 did not have urinary dysfunction and abnormality in any urological examinations. Another 7 patients (23.3%) as group 2 also did not have urinary dysfunction, but abnormal vesicoureteral reflux (VUR) was found out in their VCG examination. At postoperative stage, abnormal VUR resolved or improved in all these 7 cases, but one of them showed transient urinary retention. Two patients of 18 in the group 1 had to require clean intermittent self-catheterization at postoperative stage. These observations confirmed that children with spinal lipoma were more likely to present with urological findings, and so it was imperative that a diagnosis be made and treatment be instituted as early as possible.

Combined transfrontal and endonasal endoscopic surgery of epidural abscess following frontal sinusitis. A case report

A large epidural abscess secondary to frontal sinusitis in a previously healthy 19-year-old man was successfully treated with a small eyebrow incision using combined transfrontal and endonasal endoscopic technique. The abscess was resolved with concomitant pneumatization of the paranasal sinuses. The present case illustrates the promising use of endoscopy in the merging fields of neurosurgery and otorhinolaryngology.

Identification of a receptor tyrosine kinase involved in germ cell differentiation in planarians

To investigate external signals involved in germ cell differentiation from somatic stem cells, we have tried to identify protein kinases whose expression is regulated during the process of sexualization of asexual-state planarians. It is known that in planarians germ cells differentiate from totipotent somatic stem cells called "neoblasts" during sexualization. As a first step, we have isolated twelve protein kinase genes from cDNAs of sexual-state planarians, including three non-receptor tyrosine kinases, three receptor-tyrosine kinases and three non-receptor serine/threonine kinases, and then analyzed their expression patterns during sexualization. One of them, the DjPTK1 gene, is specifically expressed in germ cells of sexual-state planarians. DjPTK1-positive cells were also detected in the mesenchymal space during the process of sexualization, and it appears that these cells migrate to the dorsal side and then differentiate into spermatogonia/spermatocytes in testis. Sequence analysis indicated that the DjPTK1 gene encodes a receptor protein tyrosine kinase belonging to the FGFR/PDGF family. These results suggest that a receptor tyrosine kinase system may be involved both at an early stage of germ cell differentiation and in a step of germ cell maturation in planarians.

Changes in brain organic osmolytes in experimental cerebral ischemia

The cell volume is regulated not only by inorganic ions, but also by organic osmolytes, such as amino acids, methylamines, and polyhydric alcohols (polyols). Using proton nuclear magnetic resonance spectroscopy (1H-NMR), we measured the tissue concentrations of amino acids (alanine, aspartate, gamma-aminobutyric acid (GABA), glutamate, glutamine, N-acetyl-aspartate (NAA), taurine), methylamines (glycerophosphorylcholine (GPC), creatine+phosphocreatine (total creatine, tCr)), and polyols (myo-inositol) in the rat brain after middle cerebral artery occlusion (incomplete focal ischemia) or after decapitation (complete global ischemia). The total osmolytes expressed as a sum of total amino acids, total methylamines, and total polyols were significantly decreased at 24 h of focal ischemia (58.7% of control value, P=0.0025) whereas they were not changed following decapitation. The water content was increased from control value of 77.9%-84.1% after focal ischemia (P<0.0001) but not after decapitation. These results suggest that the brain organic osmolytes are involved in the process of edema formation following focal cerebral ischemia. Further elucidation of the cellular mechanisms regulating these organic osmolytes in cerebral ischemia may promote greater understanding of the pathophysiology involved in the evolution of brain edema.

[Anesthetic and perioperative management of a neonatal vein of Galen malformation with multiple organ failure]

We treated a neonate in intractable cardiac failure due to a vein of Galen malformation. She manifested severe multiple organ failure. Perioperative problems are cardiac failure, respiratory failure, renal as well as hepatic dysfunction, and coagulopathy. Direct clipping of the feeding arteries improved her symptoms. Anesthetic problems encountered in this patient are massive bleeding and drastic circulatory changes while clipping the feeding arteries, increased intracranial pressure and brain ischemia, and other underlying complications; hepatic and renal dysfunction, respiratory failure and coagulopathy.

[Clinical and electroencephalographic studies in children with hemimegalencephaly]

Clinical and electroencephalographic (EEG) studies were performed in two children with hemimegalencephaly. The ages of seizure onset were 44 hours after birth in one infant and 33 days of postnatal life in the other patient. In both children, infantile spasms (IS) associated with hemihypsarrhythmia, developed at 1.5 months and 4 months, respectively. The subsequent clinical courses in these children were notable for frequent, intractable seizures. The seizures consisted of either generalized or partial seizures which originated from not only the hemimegalic hemisphere but also the contralateral one. Later, the clinical and EEG findings in one child indicated the development of Lennox-Gastaut syndrome (LGS). These findings suggested that the lesions of epileptogenesis in patients with hemimegalencephaly involved not only the pathological hemisphere, but also the contralateral hemisphere and subcortical structures. A detailed neurophysiological investigation in hemimegalencephaly could help the elucidation of the pathophysiology of intractable epilepsies, such as IS or LGS.

Serial IMP-SPECT and EEG studies in an infant with hemimegalencephaly

An 8-month-old girl of hypomelanosis of Ito associated with hemimegalencephaly had frequent seizures beginning 44 h after birth. The seizures were secondarily generalized or unilateral initially, followed by infantile spasms at about 1.5 months of age. Frequent partial seizures appeared at 4 months of age. [123I]N-Isopropyl-p-iodoamphetamine (IMP) single photon emission computed tomography (SPECT) was performed serially during an interictal period at 1, 3 and 7 months of age. At 1 and 3 months, IMP-SPECT showed a marked increase of IMP uptake in the pathological left hemisphere and electroencephalography (EEG) revealed left-sided dominant hypsarrhythmia. At 7 months of age, a reversal was seen, there being decreased uptake on SPECT in the pathological hemisphere and abundant high amplitude background activity mingled with epileptic discharges on EEG in the non-pathological hemisphere. These serial changes of IMP uptake on SPECT seemed to reflect either changes in epileptic activity or maturational changes in cerebral perfusion in hemimegalencephaly.

Evaluation of masked neurological disorders in the chronic stage after middle cerebral artery occlusion in rats--methamphetamine-induced rotation and regional glucose metabolism in basal ganglia

Neurofunctional changes in rats in the chronic stage of focal cerebral ischemia induced by left middle cerebral artery (MCA) occlusion were examined. Neurological disorders and behavioral changes were observed with or without methamphetamine administration. Metabolic changes in the basal ganglia following methamphetamine intraperitoneal injection were evaluated by [14C]deoxyglucose autoradiography 30 days after occlusion. Neurological examination revealed persistent spontaneous rotation to the lesioned side in two of 18 rats, and forelimb flexion to the lesioned side in nine of 18 rats during a 28-day observation period after occlusion. Intraperitoneal administration of methamphetamine (4 mg/kg) induced full 360 degrees rotation toward the lesion side in 14 of 17 rats. The number of rotations was inversely correlated with the size of the intact striatum on the lesion side, especially in rats with cerebral infarct located only in the striatum. Rats with extensive cortical lesion in addition to striatal lesion did not demonstrate this relationship. Deoxyglucose autoradiography in methamphetamine-untreated rats showed symmetrical local cerebral glucose utilization in the basal ganglia except for the subthalamic nucleus, striatum and sensorimotor cortex. Autoradiography in methamphetamine-treated and MCA-occluded rats showed a remarkable increase in glucose utilization in the anterior striatum, entopeduncular nucleus, substantia nigra pars reticulata, and sensorimotor cortex contralateral to the occlusion side, but not on the lesioned side. Rotational movements observed in methamphetamine-treated rats are related to lack of stimulation of the basal ganglia system on the ischemic side.(ABSTRACT TRUNCATED AT 250 WORDS)

Two-step procedure for early neonatal surgery of fetal hydrocephalus

This retrospective study analyzed the diagnosis and treatment of 36 infants with central nervous system anomalies diagnosed antenatally by ultrasonographic studies between December, 1987 and December, 1990. Magnetic resonance imaging of the fetuses without maternal or fetal sedation/anesthesia was very useful, as the fetal ventricular system was depicted clearly. Twenty-three infants with hydrocephalus underwent early postnatal surgical emplacement of a miniature Ommaya's reservoir. Continuous cerebrospinal fluid aspiration was combined with intracranial pressure monitoring. Observation of the ventricular size used ultrasonography through the anterior fontanelle. This technique controlled the intracranial pressure during the early neonatal period without serious complications. A ventriculoperitoneal shunt was emplaced 1 month later as the second, more permanent treatment. This two-step procedure achieves brain reconstitution and prevents irreversible neurological damages. Clinical and radiographic findings are presented to illustrate the effectiveness of this approach.

[Perinatal neurosurgical care for one fetal hydrocephalus on twin gestation]

Twin gestations are responsible for a disproportionate amount of perinatal mortality and morbidity. Such gestations may impose greater demands on maternal and child physiologic systems than singleton pregnancies. The most common antenatal complications were preterm labor. The clinical record of myelomeningocele infant presenting with overt hydrocephalus in utero at 27 weeks of twin gestation and operated miniature Ommaya's reservoir placement early after birth and intentional delayed back closure for myelomeningocele was reported. Although perinatal neurosurgical care for one fetal hydrocephalus on twin gestation is clearly advantageous, it alone is relatively ineffective in reducing the incidence of the complication, preterm labor.

Changes in somatosensory circuits after subcortical infarct in rats

We compared the functional and anatomical alterations of somatosensory circuits in the acute (1-3 days after infarct) and chronic (3 months after infarct) stage after subcortical striatal infarct in Wistar rats. Occlusion of the left middle cerebral artery produced subcortical striatal infarct in approximately 69% of the rats. The others developed cortical infarct. The function of the somatosensory circuits was evaluated by [14C]2-deoxyglucose autoradiography during physiological stimulation of the right vibrissae and face. In rats with subcortical infarct, the areas activated by sensory stimulation of the right vibrissae and face, applied 1 and 3 days after occlusion, were reduced compared to sham-operated controls (P < 0.05). In the chronic stage of subcortical infarct, the areas of metabolic activation of the left anterior vibrissal and facial sensory area were increased compared to rats with acute subcortical infarct (P < 0.05). To evaluate the anatomical changes in the somatosensory pathway, at 1 day and 3 months after occlusion, we injected wheat germ agglutinin-horseradish peroxidase solution as an axonal transport substance bilaterally into the anterior vibrissal and facial sensory area. Tract tracing studies in both the acute and chronic stage of subcortical infarct showed a reduction in the peroxidase-positive area in the left thalamus compared to the control hemispheres (P < 0.01). The functional disturbance and recovery of the somatosensory circuits after subcortical infarct are discussed.

[Extremely low birth-weight infant with hydrocephalus; management of hydrocephalus using a miniature Ommaya's reservoir]

Use of the miniature Ommaya's reservoir in the treatment of extremely low birth-infant (under 1,000 mg) with hydrocephalus was studied in a series of five patients. The reservoir has a small-caliber with a 3 cm ventricular catheter. For these infants, this miniature Ommaya's reservoir is extremely useful for protection of the cortical mantle until a definitive procedure can be carried out after increase of body weight. The clinical course in five cases are summarized.