Touch imprint cytology is useful for the intraoperative pathological diagnosis of PitNETs' surgical margins

Touch imprint cytology (TIC) and frozen section (FS) procedures are essential for intraoperative pathological diagnosis (IPD). They are invaluable tools for therapeutic decision-making, helping surgeons avoid under or overtreatment of patients. Pituitary neuroendocrine tumors (PitNETs) are generally small, slow-growing tumors with low-grade malignancy located at the base of the skull where it is impossible to maintain a wide tumor margin. Therefore, transsphenoidal surgery (TSS) should be performed with necessary caution, and with sufficient and minimal resection. Thus, this study aimed to evaluate the diagnostic accuracy of TIC for the diagnosis of PitNET and determine its ability to accurately evaluate the surgical margin compared to the FS procedure. A total of 104 fresh specimens from 28 patients who underwent TSS for PitNETs were examined using TIC and FS. TIC specimens were categorized according to the cell imprinting pattern. All specimens with a large number of neuroendocrine cells diffusely attached to the glass surfaces had PitNET components. Contrarily, no rich or diffuse cell attachments were observed in any non-tumoral endocrine cells. In conclusion, recognizing a pattern of endocrine cell adherence to glass is highly effective in IPD to certify the existence of a PitNET component.

Long-term outcomes after surgery for brainstem cavernous malformations: analysis of 46 consecutive cases

OBJECTIVE

The objective of this study was to evaluate the long-term outcomes after resection of brainstem cavernous malformations (BSCMs) and to assess the usefulness of the Lawton grading system in these cases.

METHODS

This retrospective study analyzed 46 consecutive patients with BSCMs operated on between July 1990 and December 2020. Outcomes at the last follow-up were defined as favorable (modified Rankin Scale [mRS] score 0-2) or unfavorable (mRS score > 2).

RESULTS

The study cohort comprised 24 men (52%) and 22 women (48%), ranging in age from 8 to 78 years old (median 37 years). In 19 patients (41%), the preoperative mRS score was > 2. All patients had hemorrhagic BSCM. There were 12 (26%) mesencephalic, 19 (41%) pontine, 7 (15%) medullary, and 8 (17%) cerebellar peduncle lesions, with a maximal diameter ranging from 5 to 40 mm (median 15 mm). In total, 24 BSCMs (52%) had bilateral extension crossing the brainstem midline. Lawton grades of 0, I, II, III, IV, V, and VI were defined in 3 (7%), 2 (4%), 10 (22%), 11 (24%), 8 (17%), 7 (15%), and 5 (11%) cases, respectively. Total resection of BSCMs was attained in 43 patients (93%). There were no perioperative deaths. Excluding the 3 most recent cases, the length of follow-up ranged from 56 to 365 months. The majority of patients demonstrated good functional recovery, but regress of the preexisting oculomotor nerve deficit was usually incomplete. No new hemorrhagic events were noted after total resection of BSCMs. In 42 patients (91%), the mRS score at the time of last follow-up was ≤ 2 (favorable outcome), and in 18 (39%), it was 0 (absence of neurological symptoms). Forty-four patients (96%) demonstrated clinical improvement and 2 (4%) had no changes compared with the preoperative period. Multivariate analysis revealed that only lower Lawton grade had a statistically significant independent association (p = 0.0280) with favorable long-term outcome. The area under the receiver operating characteristic curve for prediction of favorable outcome with 7 available Lawton grades of BSCM was 0.93.

CONCLUSIONS

Resection of hemorrhagic BSCMs by an experienced neurosurgeon may be performed safely and effectively, even in severely disabled patients. In the authors' experience, preexisting oculomotor nerve palsy represents the main cause of permanent postoperative neurological morbidity. The Lawton grading system effectively predicts long-term outcome after surgery.

Resection of the Cavernous Sinus Medial Wall Improves Remission Rate in Functioning Pituitary Tumors: Retrospective Analysis of 248 Consecutive Cases

BACKGROUND

The purpose of transsphenoidal surgery (TSS) for a functioning pituitary tumor (FPT) is to achieve endocrinological remission. The biggest challenge is aggressive tumor resection invading the cavernous sinus (CS).

OBJECTIVE

To evaluate the effects of the medial wall of CS (MWCS) resection during FPT surgery.

METHODS

Consecutive FPTs were reviewed for CS invasion (CSI) between April 2018 and December 2021. We operated on more than 250 FPTs, including 134 somatotroph tumors, 70 corticotroph tumors, 35 lactotroph tumors, and 9 thyrotroph tumors.

RESULTS

The patients were classified into 3 groups based on the relationship between the tumor and the CS: group A (no clear wall invasion), in which MWCS was not removed because of no tumorous direct contact with MWCS (N = 92) and group B (possible wall invasion), where MWCS was removed because we were not confident of MWCS invasion (N = 102). Among these 102 patients, histological tumor invasion was confirmed in 45 of 79 patients (57%) for whom histology findings were available. Tumors invading the CS clearly during surgery were classified into the "clear CS invasion" (group C: N = 55) group. The overall complete remission rate in group B was 94%, which was as high as that in group A (87%). Moreover, we clarified that microscopic invasion of MWCS could not always be predicted from Knosp grading.

CONCLUSION

MWCS invasion occurred in 57% of cases confirmed histologically where it was unclear during surgery, and its resection can improve the overall complete remission rate in FPT cases.

Temozolomide and Capecitabine Treatment for an Aggressive Somatotroph Pituitary Tumor: A Case Report and Literature Review

Aggressive somatotroph pituitary tumor that causes acromegaly is extremely rare and resists conventional treatments such as multiple surgeries, radiotherapies, and various types of somatostatin analogs. Here, we propose a novel treatment option for these rare cases by discussing our case and reviewing the literature. We experienced an aggressive somatotroph tumor in a 52-year-old woman with acromegaly. Not only could a complete remission of growth hormone (GH) and insulin-like growth factor-1 (IGF-1) not be obtained, but the tumor continued to grow and eventually recurred around the brainstem despite multidisciplinary treatments. We employed immunohistochemistry and a three-dimensional (3D) spheroid ex vivo assay to determine the best treatment option for this case. Although histology showed strong O⁶-methylguanine DNA methyltransferase expression and high Ki-67 labeling index (22%), temozolomide (TMZ) combined with capecitabine (CAPTEM) treatment was performed based on the results of the patient-derived 3D spheroid ex vivo assay, which predicted more effective treatment with CAPTEM than with TMZ alone. Consequently, GH and IGF-1 levels were restored to normal range with remarkable tumor shrinkage after CAPTEM treatment. To the best of our knowledge, there have been even very few reports describing successful treatment for such aggressive and refractory somatotroph tumors and this is the first report showing the effectiveness of CAPTEM on refractory somatotroph tumor both ex vivo and in vivo.

Apoplexy in sellar metastasis from papillary thyroid cancer: A case report and literature review

Background:

Pituitary metastasis from papillary thyroid cancer (PTC) is rare and only a few cases have been reported.

Case Description:

We report the case of a patient who presented with visual dysfunction and panhypopituitarism. Magnetic resonance imaging revealed a pituitary tumor and hydrocephalus. Transsphenoidal surgery had been indicated, but his surgery had been postponed due to COVID-19 pandemic. During that waiting period, he showed pituitary apoplexy with consciousness disturbance, resulting in acute adrenal insufficiency and diabetes insipidus. He was urgently hospitalized and underwent transsphenoidal surgery. Rapid and permanent pathological examinations have confirmed metastasis of PTC to the pituitary. The patient also underwent serial thyroidectomy. He was also suspected to have secondary hydrocephalus and underwent lumboperitoneal shunting after excluding cerebrospinal fluid metastasis. Thereafter, his cognitive dysfunction and performance status improved dramatically.

Conclusion:

To the best of our knowledge, this is the first patient with PTC who developed pituitary apoplexy secondary to metastasis.

Revalidation of inferior petrosal sinus sampling: the latest results from a single-center experience

Cushing's disease (CD), which manifests as excess cortisol secretion, is caused by adrenocorticotrophic hormone (ACTH)-secreting pituitary adenomas. Such adenomas are occasionally difficult to identify on magnetic resonance imaging (MRI), and thorough endocrinological examination may be required to detect them. Inferior petrosal sinus (IPS) sampling (IPSS) has been the gold standard test for distinguishing CD from ectopic ACTH syndrome (EAS). However, IPSS is an invasive procedure, and proper catheterization is occasionally challenging due to anatomical variations. Thus, there have been ongoing debates regarding the necessity of this procedure. Here, we present our recent IPSS data derived from the analysis of 65 patients who were referred to us for possible CD between April 2018 and December 2020 after undergoing meticulous endocrinological testing. Even with detailed MRI, no obvious lesions were identified in 19 patients. IPSS performed on these 19 individuals identified an IPS-to-peripheral ACTH gradient in 15 of them. The four patients who lacked this gradient were subjected to a classical algorithm using concurrently measured prolactin levels, the results of which were consistent with their ultimately confirmed diagnoses: two true-positive and two true-negative diagnoses. These findings support the validity of the algorithm and demonstrate that the prolactin-adjusted IPS-to-peripheral ACTH ratio can improve the differentiation between CD and EAS. We had no false-negative results, but three patients were false-positive. Consequently, those three patients in which no apparent tumor was clarified during surgery could not have any endocrinological improvement postoperatively.

Treatment of an anterior cerebral artery pseudoaneurysm secondary to a transsphenoidal surgery using stent-assisted coiling

Background:

Injury of the internal carotid artery (ICA) during transsphenoidal surgery (TSS) is a rare but critical complication. There are several reports on endovascular treatment of ICA injury during TSS. With the recent flourishing of extended TSS, injuries to the distal arteries such as the anterior cerebral artery (ACA) are more likely to occur.

Case Description:

In the present case, we report a pseudoaneurysm of the right ACA due to injury during extended TSS for aggressive prolactinoma. Due to the absence of collateral vessels, the pseudoaneurysm had to be obliterated while preserving the parent artery. Hence, we decided to treat the pseudoaneurysm using stent-assisted coiling (SAC). The pseudoaneurysm was completely obliterated and he was discharged without any complications.

Conclusion:

To the best of our knowledge, this is the first case in which an ACA pseudoaneurysm caused by injury during the TSS was treated with SAC and the parent artery was preserved.

Surgery of Critically Located Intracranial Gliomas

Management of deep-seated and midline gliomas originating from thalamus, hypothalamus, basal ganglia, and brainstem presents significant challenges. Aggressive resection of such tumors is frequently impossible due to excessive morbidity and mortality rates; thus, combinations of both surgical and non-surgical treatment options should be always considered. In each individual case, there should be reasonable clinical judgment with regard to the optimal outcome providing the best possible prognosis for the patient, with high quality of life and minimal risk of complications.

Utility of crankshaft clips for middle cerebral artery aneurysms: A single-center experience of 150 cases

Background:

Applying more than one clip for a complicated-shaped aneurysm is an established strategy, particularly for middle cerebral arteries (MCA). However, obliterating the cleft of the internal elastic lamina with a single clip is theoretically possible because the line is usually on a single plane. Crankshaft clips were reformed for that purpose decades ago, but are not widely used and have been described in almost no report ever since.

Methods:

To reconsider and describe the utility of crankshaft clips for complicated MCA aneurysms and to articulate the advantages and limitations of the clips, we meticulously analyzed a series of more than 150 cases in which the crankshaft clips were used, predominantly for treatment of MCA aneurysms, at Moriyama Memorial Hospital between August 2010 and December 2015.

Results:

Readjustment of the clip was not necessary in almost all cases, and the first application was the final one. None of the patients had morbidity or mortality related to the surgical technique. To date, we have not experienced any trouble or recurrence.

Conclusions:

Crankshaft clips are useful and safe for clipping of complicated MCA aneurysms.

Impact of Endoscopic Indocyanine Green Fluorescence Imaging on Superselective Intra-arterial Chemotherapy for Recurrent Cancer of the Skull Base

BACKGROUND/AIM

For advanced paranasal sinus cancer, intra-arterial (I-A) chemotherapy has been applied for improving prognosis and organ preservation. While computed tomographic angiography (CTA) is useful for identifying the tumor-feeding artery, CTA cannot always detect the precise artery. The aim of this study was to assess the feasibility of endoscopic ICG (indocyanine green) fluorescence technique during I-A chemotherapy for recurrent skull-base cancer.

PATIENTS AND METHODS

Seven patients with recurrent skull-base cancer were included in this study. Conventional CTA followed by ICG was administered. Additional information regarding tumor-feeding arteries attained via ICG was evaluated.

RESULTS

Out of seven cases, the blood supply to the cancer was detected in three by CTA alone. By adding the endoscopic evaluation, the blood supply to the tumor was confirmed without difficulty in all cases. The information from endoscopic fluorescence imaging was helpful in making decisions concerning the administration of drugs for skull-base cancer.

CONCLUSION

Endoscopic ICG fluorescence imaging combined with I-A chemotherapy compensated for deficiencies of CTA and generated more useful information about the feeders to tumors than was previously available.

Rebleeding from clipped aneurysm after 35 years: Report of 2 cases

BACKGROUND

A successfully applied clip for a ruptured aneurysm keeps the aneurysm's neck closed, preventing rerupture throughout the patient's life. Unfortunately, rebleeding from a clipped aneurysm does occur, but the likelihood declines with time. Since relatively old people suffer from subarachnoid hemorrhage, they die from diseases other than rebleeding, such as cancer. Therefore, rebleeding from a clipped aneurysm after two decades is quite rare.

CASE DESCRIPTION

Here, we report 2 cases of rerupture after an extremely long time since the initial clipping. In both cases, the old clip was removed, and the regrown gourd-shaped aneurysm was successfully obliterated. The clips in both cases were submitted to their manufacturers and inspected thoroughly. They were found to be second-generation, stainless steel clips, and were almost intact, even keeping their closing forces. In both cases, the clip existed on the surface of the newly made dome, and the previous dome completely disappeared.

CONCLUSIONS

We experienced 2 cases of rebleeding from the clipped aneurysm after 35 years. In one of the cases, the clip was a Yasargil second generation stainless steel clip that retained its mechanical properties and surface elemental composition in vivo for a long time. These cases should be informative as they show extremely long-term course of a clip applied for a ruptured aneurysm.

Achievement of three year remission in a case of aggressive glioblastoma using a multidisciplinary treatment strategy: A case report

Glioblastoma (GB) is the most common type of malignant tumor of the central nervous system and, despite extensive research, its prognosis is poor. Although recent advances have been made in the treatment of GB with aggressive resection combined with radiochemotherapy, more than three-quarters of GB patients succumb to the disease within two years. The current study presents a highly aggressive case of small cell GB as diagnosed by histological features and immunohistochemistry for vimentin, glial fibrillary acidic protein, oligodendrocyte lineage transcription factor 2, isocitrate dehydrogenase 1-R132H and p53. The patient was treated using a multidisciplinary treatment strategy, which included temozolomide, CyberKnife radiotherapy and autologous formalin-fixed tumor vaccination. In addition, the patient developed radiation necrosis, which was treated with bevacizumab. In conclusion, three years following the initial diagnosis, the patient continues to experience a successful clinical course, and the observations of the current study demonstrate that a multidisciplinary treatment strategy may be effective for the treatment of aggressive GB.

Idiopathic carotid and coronary vasospasm: A case treated by carotid artery stenting

Background:

We previously reported a case of cerebral infarction complicated by myocardial infarction. The pathogenesis of both infarctions was thought to be vasospasm; thus, we named this condition ‘idiopathic carotid and coronary vasospasm’. Various medical treatments for the prevention of carotid vasospasm have been unsuccessfully tried. Thus, other effective treatments should be established for patients who frequently suffer cerebral ischemic attacks.

Case Description:

We treated the present case of ‘idiopathic carotid and coronary vasospasm’ by carotid artery stenting (CAS). The first stenting, of the carotid bifurcation, failed to prevent internal carotid artery (ICA) vasospasm. However, after an additional stent placement to the prepetrous portion, ischemic attacks were dramatically reduced.

Conclusion:

The effect of CAS for extracranial ICA vasospasm was dramatic and control of the spasm at the prepetrous portion seems to be essential. Further validation of the effectiveness and safety of CAS for ICA vasospasm will be necessary.

Dynamic changes in blood flow of a bypassed superficial temporal artery with unstable internal carotid artery stenosis

Background:

There are limited indications for superficial temporal artery to middle cerebral artery (STA–MCA) bypass in the treatment of cerebral atherosclerotic disease. However, recent reports emphasize that STA–MCA bypass may be beneficial for select patients. In this report, we describe a case in which a flow-dependent STA–MCA bypass was achieved in a patient with unstable internal carotid artery (ICA) stenosis.

Case Description:

A 51-year-old woman presented with left ICA occlusion. A severely elongated mean transit time (MTT) indicated misery perfusion. STA–MCA bypass was performed immediately and blood flow through the graft appeared excellent on magnetic resonance angiography (MRA). Two weeks later, MRA revealed normal anterograde ICA blood flow and the bypass graft was not visible. Three years later, the left ICA stenosis again became severe and the patient developed contralateral hemiparesis. She underwent endovascular surgery and the ipsilateral MCA became occluded during the procedure. The STA–MCA bypass graft appeared immediately after the MCA occlusion and became a major provider of blood flow to the ipsilateral MCA area. She recovered with almost no deficit.

Conclusion:

This is a rare case which shows that dynamic flow changes through an STA–MCA bypass can occur with variable ICA blood flow. STA–MCA bypass can be beneficial for the treatment of unstable ICA stenosis.

Cervical spontaneous spinal epidural hematoma with internal jugular vein thrombosis

Spontaneous spinal epidural hematoma (SSEH) is a rare condition, and its etiology remains unclear. Spinal venous wall instability due to intravenous pressure changes and the resultant venous rupture seem to be the underlying pathophysiological mechanisms. Here, the authors report a case of posterior SSEH at the C3-5 level causing mild left hemiparesis in a previously healthy 56-year-old woman. Angiography performed at the time of admission showed left internal jugular vein (IJV) thrombotic occlusion and dilation of the surrounding venous plexus, strongly suggesting that these pathologies caused the SSEH. Furthermore, immediate MR imaging suggested severely impaired blood flow in the left IJV. The hematoma soon resolved after spontaneous IJV thrombolysis. The authors' radiological observations imply that idiopathic IJV thrombosis may cause cervical SSEH.

Usefulness of attenuated vein sign and T2*-weighted imaging for diagnosis of deep cerebral venous sign--case report

A 45-year-old woman presented with extensive deep cerebral venous thrombosis (DCVT) identified by typical direct thrombosed sign in the internal cerebral vein, vein of Galen, and straight sinus on both computed tomography and T(2)*-weighted magnetic resonance imaging. Moreover, rare direct sign, probably of the direct lateral vein, was also obtained. Direct sign of the thrombosed vein or sinus is important for the diagnosis of DCVT. The present case indicates the usefulness of attenuated vein sign and T(2)*-weighted imaging for the diagnosis of direct thrombosed vein in patients with DCVT.

Organized chronic subdural haematoma with a thick calcified inner membrane successfully treated by surgery: a case report

The optimal surgical procedure for patients with calcified and organized chronic subdural haematoma (CSDH), or "armoured brain", has not been established because it is difficult to obtain good re-expansion of the brain after surgery. We present herein the case of a 32-year-old woman with huge calcified CSDH manifesting as refractory headache, periods of unconsciousness, and unsteady gait who obtained favourable results after craniotomy. Thinning of the thick calcified inner membrane using high-speed air drilling was performed after removal of the organized CSDH. The patient obtained good re-expansion after surgery. This observation illustrates that it is possible to perform such a surgery even on a huge calcified CSDH.

Fully functional MR-compatible flexible operating table resolves the neurosurgeon's dilemma over use of intraoperative MRI

In February 2006, our hospital officially opened the Magnetic Resonance / X-ray / operation (MRXO) suite, which is the first hybrid neurosurgical procedure suite to combine magnetic resonance imaging (MRI), computed tomography and angiography with a neurosurgical operating room. For this suite, we have developed a specially designed fully functional magnetic resonance (MR)-compatible flexible operating table. Here, we describe the details of this operating table and discuss its advantages. Its MR-compatible tabletop can be bent during surgery. The specially designed MR-compatible flexible operating table for the MRXO suite reduces limitations on neurosurgeons during standard neurosurgical procedures. Also, it does not give rise to imaging artifacts on MRI. The specially designed MR-compatible flexible operating table resolves the neurosurgeon's dilemma over use of intraoperative MRI.

Mechanism of injury to the corpus callosum, with particular reference to the anatomical relationship between site of injury and adjacent brain structures

The location of corpus callosum injury was investigated using magnetic resonance imaging in 92 patients. The anatomical relationships in the region around the corpus callosum were also evaluated to clarify involvement in the mechanism of corpus callosum injury in 20 normal volunteers. Lesions in the posterior half of the corpus callosum accounted for 80% of corpus callosum injuries. The falx was increasingly elongated toward the posterior portion of the corpus callosum and the corpus callosum was thinnest at the body-splenium junction in the normal volunteers. The mechanism of corpus callosum injury apparently involves the following factors. The posterior half of the falx is closer to the corpus callosum than the anterior half. Therefore, the anterior part of the corpus callosum easily moves with lateral movement of the cerebral hemispheres, and the strain is likely to be concentrated in the posterior half of the corpus callosum, because the falx greatly limits lateral movement of the hemisphere in the posterior region. The corpus callosum is easily distorted at the thinnest part of the body-splenium junction. Therefore, corpus callosum injury predominantly occurs in the posterior half of the corpus callosum.

Acute oral selenium intoxication with ten times the lethal dose resulting in deep gastric ulcer

A 48-year-old woman presented after taking 2000 mg of selenium dioxide, corresponding to 10 times the experimental lethal dose in animals. She presented with mildly altered consciousness and hematemesis. Endoscopy revealed mucosal damage throughout the oral cavity, esophagus, and stomach. There was no evidence of perforation. After intubation and gastric lavage, hemodialysis was performed. The patient was discharged uneventfully on the 16(th) day. This case highlights a very rare acute selenium intoxication. Serum and urinary selenium levels and serum glutathione peroxidase activities during the patient's course were followed, as well as the mucosal corrosive damage caused by the selenium.

[The usefulness of MRI around the tentorial incisura for determining the mechanism of brain stem injury: a case report]

We report a case of isolated brain stem injury caused by the tentorium cerebelli. A 17-year-old male was admitted to our hospital. Thirty minutes before admission, he was struck by another motorcycle while driving his own motorcycle. The Glasgow Coma Scale (GCS) was 10. He had no extremity weakness and his pupils were normal. CT scan showed no evidence of intracranial lesions except for facial bone fractures. His consciousness level improved to GCS 13 at 6 hours after admission. Follow-up CT scan was normal, however MRI 3 days after admission showed a contusion at the left lateral midbrain. He was discharged without any neurological deficits on 6 days after admission. Analysis of the distance between the brain stem and the tentorial margin using MR cisternography showed that the left side was shorter than the right side. We presumed that an isolated lateral brain stem injury was caused by the direct impact of the tentorium cerebelli. Typically the location of this type of lesion is present in the same side as that of impact. However in this case the orientation was opposite to that. We considered that the distance between the brain stem and the tentorial margin affected the mechanism of this lesion.

Pupillary abnormality on admission and brain bulging during surgery as unfavourable predictors in patients treated with hypothermia: a retrospective review of 81 patients with severe head injury

BACKGROUND

To determine factors predicting outcome of patients with severe head injury, the authors retrospectively analyzed 81 patients, 3 to 70 years of age, who were treated by hypothermia.

METHOD

The initial Glasgow Coma Scale scores of the 81 patients ranged from 3 to 8. Outcome in each case was determined at six months after injury and was retrospectively analyzed with respect to patient characteristics, initial clinical status, laboratory data, computed tomographic findings, data from monitoring, intra-operative findings, and treatment methods. The significance of clinical and neuroradiological factors for predicting unfavorable outcome was analyzed by univariate logistic regression. Stepwise multiple logistic regression analysis was then used to identify independent predictors of outcome.

FINDINGS

Favorable outcome was observed in 27 of 81 patients treated by hypothermia. Independent factors predicting unfavorable outcome included pupillary abnormality on admission and brain bulging during surgery.

INTERPRETATION

Therapeutic effectiveness of hypothermia was thus limited in patients who presented with these grave symptoms.