Variations and management for patients with craniocervical junction arteriovenous fistulas: Comparison of dural, radicular, and epidural arteriovenous fistulas.

BACKGROUND: Craniocervical junction arteriovenous fistulas (CCJAVFs) are known to be rare, but variations and clinical behaviors remain controversial. METHODS: A total of 11 CCJAVF patients (M: F=9:2, age 54-77 years) were investigated. Based on the radiological and intraoperative findings, they were categorized into three types: dural AVF (DAVF), radicular AVF (RAVF), and epidural AVF (EDAVF). RESULTS: There were four symptomatic patients (subarachnoid hemorrhage in two, myelopathy in one, and tinnitus in one) and seven asymptomatic patients in whom coincidental CCJAVFs were discovered on imaging studies for other vascular diseases (arteriovenous malformation in one, intracranial DAVF in two, ruptured cerebral aneurysm in two, and carotid artery stenosis in two). Of these 11 patients, 2 (18.2%) had multiple CCJAVFs. Of 14 lesions, the diagnoses were DAVF in 5, RAVF in 3, and EDAVF in 6 (C1-C2 level ratio =5:0, 2:1, 3:3). Patients with DAVF/RAVF in four lesions with intradural venous reflux underwent surgery, although an RAVF remained in one lesion after embolization/radiation. Since all six EDAVFs, two DAVFs, and one RAVF had neither feeder aneurysms nor significant symptoms, no treatment was provided; of these nine lesions, one DAVF and one RAVF remained unchanged, whereas six EDAVFs showed spontaneous obliteration within a year. Unfortunately, however, one DAVF bled before elective surgery. CONCLUSION: CCJAVFs have many variations of shunting site, angioarchitecture, and multiplicity, and they were frequently associated with coincidental vascular lesions. For symptomatic DAVF/RAVF lesions with intradural drainage, surgery is preferred, whereas asymptomatic EDAVFs without dangerous drainage may obliterate during their natural course.

Determining if Cerebrospinal Fluid Prevents Recurrence of Chronic Subdural Hematoma: A Multi-Center Prospective Randomized Clinical Trial.

Over the decades, the problem of postoperative recurrence of chronic subdural hematoma (CSDH) has not been resolved. The objective of our study was to investigate whether the recurrence rate of CSDH is decreased when artificial cerebrospinal fluid (ACF) is used as irrigation solution for CSDH surgery. The present study was a multi-center, prospective, randomized, open parallel group comparison test of patients enrolled from 10 hospitals in Japan. Eligible patients with CSDH were randomly assigned to undergo burr hole drainage with either normal saline (NS) or ACF irrigation. The primary end-point was postoperative recurrence of ipsilateral CSDH. A total of 402 patients with newly diagnosed CSDH were enrolled during the study period. After applying inclusion and exclusion criteria, and taking into consideration cases lost to follow-up, our final study cohorts consisted of 177 ACF patients and 165 NS patients, representing 85.7% of the initial cohort. The overall recurrence rate was 11.4%, occurring in 39 of the 342 analyzed patients during 90 days of follow-up. Recurrence rates in the ACF and NS groups were 11.9% (21 of 177) and 10.9% (18 of 165), respectively. No significant difference was evident between groups (p = 0.87). In addition, no significant difference in time to recurrence was seen between groups (p = 0.74). No serious adverse effects related to irrigation fluid were seen in either group. Regarding the irrigation fluid for CSDH surgery, no differences in recurrence rate or time to recurrence were seen between the ACF and NS groups. However, ACF offers sufficient safety as irrigation fluid for CSDH.

Plaque Characteristics of Patients with Symptomatic Mild Carotid Artery Stenosis.

BACKGROUND: Carotid revascularization may be considered for severe stenosis, but its use for symptomatic mild stenosis (<50%) with vulnerable plaque or ulcer remains uncertain. The characteristics of patients with symptomatic mild stenosis who underwent revascularization are reviewed. METHODS: The subjects of this study were 18 patients with symptomatic mild stenosis (<50%) on angiography from among 175 patients who underwent revascularization in our department. The plaques were evaluated by black-blood magnetic resonance imaging (BB-MRI) and ultrasonography (US) and classified into 2 types: type 1 (n = 15), a lesion with an ulcer or mobile plaque or thrombosis on angiography or US; and type 2 (n = 3), a lesion without any of the above. Fourteen patients underwent carotid endarterectomy (CEA), and 4 patients underwent carotid artery stenting. RESULTS: The stenosis on angiography was 27.2% ± 10.7 (5%-41%), and the area carotid artery stenosis rate on US was 69.8 ± 14.5% (44.5%-97%). The stenosis rate of these 2 methods was not at all correlated. In type 1 plaque that underwent CEA, 10 of 11 patients had vulnerable plaque by histopathology, and 1 patient had thrombus on the plaque by operative findings. In type 2 plaque that underwent CEA, all patients had vulnerable plaque by histopathology. During the follow-up period, none of the patients had restenosis or stroke. CONCLUSIONS: The findings of US and BB-MRI in patients with symptomatic mild stenosis (<50%) on angiography are important for determining treatment. If BB-MRI or US shows the findings of vulnerable plaque in mild stenosis, surgical treatment may be considered for these patients.

Present epidemiology of chronic subdural hematoma in Japan: analysis of 63,358 cases recorded in a national administrative database.

OBJECTIVE Aging of the population may lead to epidemiological changes with respect to chronic subdural hematoma (CSDH). The objectives of this study were to elucidate the current epidemiology and changing trends of CSDH in Japan. The authors analyzed patient information based on reports using a Japanese administrative database associated with the diagnosis procedure combination (DPC) system. METHODS This study included patients with newly diagnosed CSDH who were treated in hospitals participating in the DPC system. The authors collected data from the administrative database on the following clinical and demographic characteristics: patient age, sex, and level of consciousness on admission; treatment procedure; and outcome at discharge. RESULTS A total of 63,358 patients with newly diagnosed CSDH and treated in 1750 DPC participation hospitals were included in this study. Analysis according to patient age showed that the most common age range for these patients was the 9th decade of life (in their 80s). More than half of patients 70 years old or older presented with some kind of disturbance of consciousness. Functional outcomes at discharge were good in 71.6% (modified Rankin Scale [mRS] score 0-2) of cases and poor in 28.4% (mRS score 3-6). The percentage of poor outcomes tended to be higher in elderly patients. Approximately 40% of patients 90 years old or older could not be discharged to home. The overall recurrence rate for CSDH was 13.1%. CONCLUSIONS This study shows a chronological change in the age distribution of CSDH among Japanese patients, which may be affecting the prognosis of this condition. In the aging population of contemporary Japan, patients in their 80s were affected more often than patients in other age categories, and approximately 30% of patients with CSDH required some help at discharge. CSDH thus may no longer have as good a prognosis as had been thought.

Utility of Indocyanine Green Video Angiography for Sylvian Fissure Dissection in Subarachnoid Hemorrhage Patients - Sylvian ICG Technique.

Indocyanine green (ICG) emits fluorescence in the far-red domain under light excitation. ICG video angiography (ICG-VA) has been established as a useful method to evaluate blood flow in the operative field. We report the usefulness of ICG-VA for Sylvian fissure dissection in patients with subarachnoid hemorrhage (SAH). Subjects comprised 7 patients who underwent ICG-VA before opening the Sylvian fissure during neck clipping for ruptured cerebral aneurysm. We observed contrasted Sylvian veins before opening the Sylvian fissure using surgical microscopes. This procedure was termed "Sylvian ICG". We observed ICG fluorescence quickly in all cases. Sylvian veins that appeared unclear in the standard microscopic operative field covered with subarachnoid hemorrhage were extremely clearly depicted. These Sylvian ICG findings were helpful in identifying entry points and the dissecting course of the Sylvian fissure. At the time of clipping, no residual fluorescence from Sylvian ICG was present, and aneurysm clipping was not impeded. Sylvian ICG for SAH patients is a novel technique to facilitate dissection of the Sylvian fissure. We believe that this technique will contribute to improved safety of clipping surgery for ruptured aneurysms.

[A Case of an Orbital Angioleiomyoma].

A 70-year-old woman presented with a 4-year history of painless conjunctival congestion and proptosis of the right eye. Computed tomography and magnetic resonance imaging revealed a 48-mm lesion in the right medial orbit. As the symptoms progressed, the tumor was resected by performing fronto-orbital craniotomy. Histopathological examination revealed a vascular tumor surrounded by smooth muscle fibers and immunohistochemistry demonstrated tumor positivity for smooth muscle actin and desmin. The tumor was diagnosed as an angioleiomyoma, and no recurrence has been observed as of 5 years postoperatively. Angioleiomyomas in the orbit are extremely rare;thus, we have reported this case with reference to the literature.

Chronic Subdural Hematoma in Elderly Patients: Is This Disease Benign?

As the world population becomes progressively older, the overall incidence of chronic subdural hematoma (CSDH) is increasing. Peak age of onset for CSDH has also increased, and recently the 80-year-old level has a peak. Many patients with CSDH have had prior treatment with anticoagulants and antiplatelet drugs, which have an accompanying risk of CSDH. In elderly patients with CSDH, symptoms of cognitive change (memory disturbance, urinary incontinence, and decreased activity) and disturbance of consciousness at admission were more frequent compared to younger patients with CSDH. The literature actually offers conflicting advice regarding CSDH treatment; however, burr hole surgery with drainage under local anesthesia is the most common surgical procedure, even in elderly patients. The recurrence rate of CSDH has not decreased over recent decades, and it has ranged from 0.36-33.3%. Outcomes in patients over 75 years old was significantly worse than for those younger than 75. Moreover, long-term outcomes for elderly patients with CSDH are poor. CSDH in the elderly is no longer a benign disease. In the future, it will be important for us to understand the mechanisms of onset and recurrence of CSDH and to develop more effective medical treatments and noninvasive surgical techniques for elderly patients.

Bamboo Leaf Sign as a Sensitive Magnetic Resonance Imaging Finding in Spinal Subependymoma: Case Report and Literature Review.

Background and Importance. Subependymoma occurs very rarely in the spinal cord. We report another case of spinal subependymoma along with a review of the literature and discussion of a radiological finding that is useful for preoperative diagnosis of this tumor. Clinical Presentation. A 51-year-old man presented with a 2-year history of progressive muscle weakness in the right lower extremity. Sagittal magnetic resonance imaging (MRI) showed spinal cord expansion at the Th7-12 vertebral level. Surgical resection was performed and the tumor was found to involve predominantly subpial growth. Histological diagnosis was subependymoma, classified as Grade I according to criteria of World Health Organization. We made an important discovery of what seems to be a characteristic appearance for spinal subependymoma on sagittal MRI. Swelling of the spinal cord is extremely steep, providing unusually large fusiform dilatation resembling a bamboo leaf. We have termed this characteristic MRI appearance as the "bamboo leaf sign." This characteristic was apparent in 76.2% of cases of spinal subependymoma for which MRI findings were reported. Conclusion. The bamboo leaf sign on spinal MRI is useful for differentiating between subependymoma and other intramedullary tumors. Neurosurgeons encountering the bamboo leaf sign on spinal MRI should consider the possibility of subependymoma.

Endoscopic hematoma evacuation for acute and subacute subdural hematoma in elderly patients.

OBJECT: Endoscopic surgery was performed for acute or subacute subdural hematoma (SDH), and its effectiveness and safety in elderly patients were evaluated. METHODS: Between September 2007 and November 2013, endoscopic surgery was performed in 11 elderly patients with acute SDH (8 patients) and subacute SDH (3 patients). The criteria for surgery were as follows: 1) the presence of clinical symptoms; 2) age older than 70 years; 3) no brain injury (intracerebral hematoma, brain contusion); 4) absence of an enlarging SDH; and 5) no high risk of bleeding. Hematoma evacuation was performed with a 4-mm rigid endoscope with a 0° lens and a malleable irrigation suction cannula. RESULTS: Endoscopic surgery was performed under local anesthesia. The mean age of the patients was 82.6 years (range 73-91 years). There were 5 female and 6 male patients. The mean preoperative Glasgow Coma Scale score was 12, and 5 patients had been receiving antithrombotic drug therapy. The mean operation time was 85 minutes. Only 1 patient had rebleeding, and reoperation with the same technique was performed uneventfully in this individual. A total of 7 patients had a good recovery (modified Rankin Scale Score 0-2) at discharge. CONCLUSIONS: Endoscopic hematoma evacuation of acute and subacute SDH is a safe and effective method of clot removal that minimizes operative complications. This technique may be a less invasive method for treating elderly patients with acute and subacute SDHs.

[A mixed germ cell tumor that underwent dramatic size changes].

This report describes a mixed germ cell tumor that underwent dramatic size changes. A 12-year-old boy presented to our hospital with a headache that had persisted for two months. Initial magnetic resonance imaging (MRI) revealed a pineal tumor and hydrocephalus. The patient required external ventricular drainage and underwent two endoscopic biopsies. His evaluation involved a total of nine computed tomography (CT) scans prior to the second biopsy;the tumor size had decreased before the second endoscopic biopsy. The tumor consisted of both a germinoma and a teratoma component. The patient was treated with three courses of carboplatin-etoposide (CBDCA-VP) chemotherapy and whole-ventricle radiotherapy (32.1 Gy). However, during the adjuvant therapy, the tumor size increased, necessitating total tumor resection. We speculate that the tumor's initial size reduction was caused by leakage of the cyst component and exposure to the brain CT irradiation. The tumor's subsequent increase in size was due to the recollection of the cystic components and intracranial growing teratoma syndrome (iGTS). Therefore, frequent brain CTs and angiography should be avoided before definitive pathological diagnosis is achieved. Further, the tumor size should be considered, with surgical resection being performed at the optimal time.

Surgical results of lumbar interbody fusion using calcium phosphate cement.

Clinical and radiological outcomes of lumbar interbody fusion using artificial fusion cages filled with calcium phosphate cements (CPCs) were retrospectively reviewed. Between 2002 and 2011, 25 patients underwent lumbar interbody fusion at Tokushima University Hospital, and 22 patients were enrolled in this study. Of these, 5 patients received autologous local bone grafts and 17 received CPC. Japan Orthopedic Association (JOA) score was used for clinical outcome assessments. Lumbar radiography and computed tomography (CT) were performed at 12, 24 months and last follow-up period to assess bony fusion. The mean JOA score of all patients improved from 9.3 before surgery to 21.0 at 24 months after surgery. Fusion had occurred in 5 of 5 patients in the local bone graft group and in 16 of 17 patients in CPC group at 24 months postoperatively. No surgically related complication was occurred in both groups. CPC is a useful and safe graft material for lumbar interbody fusion.

Chronic encapsulated intracerebral hematoma: Three case reports and a literature review.

BACKGROUND: Chronic encapsulated intracerebral hematoma (CEIH) is one type of intracerebral hematoma that sometimes grows progressively while forming a capsule and presenting with neurological deficits. Although many cases of CEIH have been reported, correct preoperative diagnosis is very difficult. Only around 20% of cases are diagnosed preoperatively. CASE DESCRIPTION: We encountered three cases of CEIH in which causes were unidentified and difficult to diagnose. All three cases were treated surgically. In the first case, a 59-year-old male was diagnosed preoperatively with metastatic brain tumor. In the second case, a 62-year-old female was diagnosed preoperatively with glioblastoma. The third case involved a 58-year-old female diagnosed preoperatively with CEIH. CONCLUSION: We should keep in mind that CEIH is a differential diagnosis for intracerebral space-occupying lesions. This report describes these three cases and discusses imaging findings and characteristics of CEIH.

Prediction of cerebral vasospasm using early stage transcranial Doppler.

Transcranial Doppler (TCD) is widely used to monitor vasospasm after subarachnoid hemorrhage (SAH), but its ability to predict the future occurrence of the symptomatic vasospasm (SVS) remains controversial. We investigated the utility of TCD for predicting the future occurrence of SVS after SAH in 45 patients with aneurysmal SAH. TCD was performed on days 1, 3, 5, 7, 10, and 14 after SAH. The mean flow velocity (MFV) of the horizontal portion of the middle cerebral artery (M1) was recorded. SVS occurred in 24.4% of patients (n = 11). MFV of M1 increased progressively in patients with SVS, but did not increase in patients without SVS. The mean MFV values were significantly higher in patients with SVS than in patients without SVS (p = 0.031). The mean MFV value on day 3 was already significantly higher in patients with SVS than in patients without SVS (88.5 cm/sec versus 62.7 cm/sec, respectively) (p = 0.018). The receiver operating characteristic curve of MFV on day 3 showed the threshold of 72.5 cm/sec for predictive value of SVS in the future (sensitivity 71.4%, specificity 68.1%, and accuracy 82.3%). Increased MFV of M1 during the early stage of SAH may predict the future occurrence of SVS. The threshold value of 72.5 cm/sec MFV of M1 on SAH day 3 was one of the best predictor of future SVS. To prevent delayed cerebral ischemia, aggressive treatment for vasospasm is needed for patients with increased MFV in the early stages of SAH.

Microbleeds as a prognostic factor for acute subdural hematoma.

This study investigated the frequency of poor outcome at discharge of acute subdural hematoma (SDH) patients with and without microbleeds. We retrospectively examined the records of 37 patients with acute SDH who were surgically treated with hematoma removal and received magnetic resonance (MR) imaging within 2 weeks of head injury onset. MR images were used to determine the presence or absence of microbleeds and contusional hemorrhage (CH). Patient outcome was categorized as good (moderate disability or good recovery) or poor (severely disability, vegetative state, or dead) according to the Glasgow Outcome Scale at discharge. Microbleeds were found in 23 patients (62%) and CH was found in 26 patients (70%). Fifteen patients (41%) had both microbleeds and CH. Poor outcome at discharge was more common in SDH patients with both microbleeds and CH than in SDH patients with neither microbleeds nor CH (14/15, 93% vs. 14/22, 64%; p = 0.04). Poor outcome at discharge was more common in SDH patients under 60 years of age with microbleeds (6/8, 75%) than patients under 60 years of age without microbleeds (0/4, 0%; p = 0.03). The location of the microbleed was not related to the outcome at discharge. These results suggest that the presence of microbleeds and CH on MR images may indicate poor prognosis in patients with acute SDH.

Ruptured distal accessory anterior cerebral artery aneurysm--case report.

A 48-year-old man presented with an extremely rare aneurysm arising from an accessory anterior cerebral artery (ACA) manifesting as sudden onset of headache lasting for 5 days. Neurological examination on admission revealed no abnormalities. Computed tomography showed subarachnoid hemorrhage of the interhemispheric fissure and intraparenchymal hematoma of the left cingulate gyrus. Magnetic resonance and cerebral angiography revealed a saccular aneurysm of the distal portion of the accessory ACA classified as the bihemispheric type. Neck clipping of the aneurysm was performed via an interhemispheric approach 17 days after symptom onset. The patient made a good postoperative recovery without neurological deficit. Distal accessory ACA aneurysms tend to arise from the first bifurcation and supply parietal branches. The aneurysms tend to occur on the bihemispheric type of distal accessory ACA. Hemodynamic stress may contribute to formation or development of these aneurysms.

Paraspinal arteriovenous fistula presenting with subarachnoid hemorrhage and acute progressive myelopathy--case report.

A 60-year-old man presented with paraspinal arteriovenous fistula (AVF) manifesting as subarachnoid hemorrhage (SAH) and acute progressive myelopathy. The patient presented with sudden onset of low back pain and paraparesis. Spinal magnetic resonance imaging revealed a vascular malformation on the lumbar spinal canal. Three-dimensional computed tomography angiography demonstrated a paraspinal AVF in the sacral ventral pelvis. The clinical symptoms were progressing rapidly, so transarterial embolization and surgical drainage ligation were performed. Paraspinal AVF may present with SAH and cause acute progressive myelopathy. Prompt examination and treatment are necessary.

Freehand technique for putaminal hemorrhage--technical note.

We designed a new endoscopic surgical procedure for putaminal hemorrhage (freehand technique) and evaluated its effectiveness and safety in patients with putaminal hemorrhage. Computed tomography (CT) data sets from 40 healthy patients were used. The CT data were transformed into three-dimensional images using AZE VirtualPlace(TM) Plus. The nasion and external auditory foramen were the intraoperative reference points. The median point from medial of the globus pallidus to the insula was the target point. The location of the burr hole point was 80-125 mm above and 27.5 mm lateral to the nasion, and the direction was parallel to the midline and a line drawn from the burr hole to the ipsilateral external auditory foramen. This point was used for 15 patients with putaminal hemorrhage. In all cases, only one puncture was required, and there were no complications. The median surgical time was 91.7 minutes, and the median hematoma removal rate was 95.9%. No recurrent bleeding or operative complications occurred. The freehand technique is a simple and safe technique for patients with putaminal hemorrhage. We believe that this technique of endoscopic hematoma evacuation may provide a less-invasive method for treating patients with putaminal hemorrhage.

[Rapid recurrence of chronic subdural hematoma by CSF entrapment].

A case of chronic subdural hematoma with multiple rapid recurrences is reported. A 41-year-old woman was admitted to hospital because of a traumatic subarachnoid hemorrhage and an intracerebral hematoma in the left frontal lobe. Both regions were conservatively treated, and she was discharged with no neurological deficit. Four months after this injury, she was readmitted to our clinic with complaints of severe headache and mild left hemiparesis. A CT scan showed a right chronic subdural hematoma. A burr hole and irrigation was performed, and the hematoma cavity disappeared on the following day. However, a deterioration of consciousness and left hemiparesis appeared ten days after the first operation. A second CT scan showed the recurrence of a left chronic subdural hematoma, so a second operation was performed. The patient showed a good postoperative course, and once again the hematoma cavity disappeared on the day following the operation. Nevertheless, a deterioration of consciousness and left hemiparesis appeared eight days after the second operation. A CT scan showed a second recurrence with low-density findings. Intraoperative findings during the third operation showed an almost water-like subdural fluid, and entrapment of cerebrospinal fluid by the inner membrane was suspected. A craniotomy and the removal of the outer and inner membranes were performed. Macroscopically, the inner membrane was intact and showed no signs of injury. No further recurrences occurred after the craniotomy. The suspected cause of the multiple subdural hematomas was the flow and entrapment of cerebrospinal fluid in some area of the inner membrane.

Boron neutron capture therapy using mixed epithermal and thermal neutron beams in patients with malignant glioma-correlation between radiation dose and radiation injury and clinical outcome.

PURPOSE: To clarify the correlation between the radiation dose and clinical outcome of sodium borocaptate-based intraoperative boron neutron capture therapy in patients with malignant glioma. METHODS AND MATERIALS: The first protocol (P1998, n = 8) prescribed a maximal gross tumor volume (GTV) dose of 15 Gy. In 2001, a dose-escalated protocol was introduced (P2001, n = 11), which prescribed a maximal vascular volume dose of 15 Gy or, alternatively, a clinical target volume (CTV) dose of 18 Gy. RESULTS: The GTV and CTV doses in P2001 were 1.1-1.3 times greater than those in P1998. The maximal vascular volume dose of those with acute radiation injury was 15.8 Gy. The mean GTV and CTV dose in long-term survivors with glioblastoma was 26.4 and 16.5 Gy, respectively. A statistically significant correlation between the GTV dose and median survival time was found. In the 11 glioblastoma patients in P2001, the median survival time was 19.5 months and 1- and 2-year survival rate was 60.6% and 37.9%, respectively. CONCLUSION: Dose escalation contributed to the improvement in clinical outcome. To avoid radiation injury, the maximal vascular volume dose should be <12 Gy. For long-term survival in patients with glioblastoma after boron neutron capture therapy, the optimal mean dose of the GTV and CTV was 26 and 16 Gy, respectively.