Detecting passive and active response in patients with behaviourally diagnosed unresponsive wakefulness syndrome.

The diagnosis of unresponsive wakefulness syndrome depends mostly on the motor response following verbal commands. However, there is a potential for misdiagnosis in patients who understand verbal commands (passive response) but cannot perform voluntary movements (active response). To evaluate passive and active responses in such patients, this study used an approach combining functional magnetic resonance imaging and passive listening tasks to evaluate the level of speech comprehension, with portable brain-computer interface modalities that were applied to elicit an active response to attentional modulation tasks at the bedside. We included ten patients who were clinically diagnosed as unresponsive wakefulness syndrome. Two of ten patients showed no significant activation, while limited activation in the auditory cortex was found in six patients. The remaining two patients showed significant activation in language areas, and were able to control the brain-computer interface with reliable accuracy. Using a combined passive/active approach, we identified unresponsive wakefulness syndrome patients who showed both active and passive neural responses. This suggests that some patients with unresponsive wakefulness syndrome diagnosed behaviourally are both wakeful and responsive, and the combined approach is useful for distinguishing a minimally conscious state from unresponsive wakefulness syndrome physiologically.

Feasibility study of finalizing the extended adjuvant temozolomide based on methionine positron emission tomography (Met-PET) findings in patients with glioblastoma.

In the management of patients with newly diagnosed glioblastoma, there is no standard duration for adjuvant temozolomide treatment. This study aimed to assess the feasibility of finalizing adjuvant temozolomide treatment on the basis of methionine uptake in methionine positron emission tomography (Met-PET). We conducted a retrospective review of glioblastoma patients who underwent more than twelve cycles of temozolomide (extended temozolomide) treatment after resection and concomitant chemoradiotherapy with no evidence of recurrence on MRI. In addition to the methionine uptake value at the completion of extended temozolomide, local and distant recurrence and progression-free survival were also analyzed. Forty-four patients completed the extended temozolomide treatment. Among these, 18 experienced some type of tumor recurrence within one year. A Tmax/Nave value of 2.0 was the optimal cut-off value indicating progression. More than 80% of the patients with low methionine uptake completed the temozolomide treatment, and subsequent basic MRI observations showed no recurrence within one year after Met-PET. Subgroups with high uptake (≥2.0), even with continuation of temozolomide treatment, showed more frequent tumor progression than patients with low uptake (<2.0) who completed the extended temozolomide treatment (p < 0.001, odds ratio 14.7, 95% CI 3.46-62.3). The tumor recurrence rate increased in stepwise manner according to methionine uptake. Finalization of the extended temozolomide treatment on the basis of low uptake value was feasible with a low recurrence rate. Compared to MRI, Met-PET shows better ability to predict tumor progression in long-term glioblastoma survivors with extended temozolomide use.

Increased brain glucose metabolism in chronic severe traumatic brain injury as determined by longitudinal 18F-FDG PET/CT.

Little is known about changes in glucose metabolism in patients with chronic severe traumatic brain injury (sTBI). It remains to be elucidated how neurological manifestations of sTBI are associated with brain glucose metabolism during longitudinal follow-up. We show here that neurological manifestations are associated with changes of brain glucose metabolism by using two serial 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) images. In this longitudinal observational study, two serial 18F-FDG PET/CT images from each of 45 patients were analyzed for whole-brain maximum standardized uptake values (SUVmax). For clinical assessment, we applied two different scales: the coma recovery scale-revised and the original Chiba score with additional information regarding nutrition, excretion, facial expression, and position change of the patient's relative immobility and bedridden state. As a result, the increased FDG uptake group was associated with a high level of wakefulness (first PET, p = 0.04; second PET, p = 0.01) and small ventricular size (first PET, p = 0.01; second PET, p = 0.01). In addition, anticonvulsant withdrawal (p = 0.001), improvement of total Chiba score (p = 0.01), language expression (p = 0.03), position change (p = 0.03), and communication (p = 0.03) were accelerated in the increased FDG uptake group. Spearman's rank correlation coefficients of change in SUVmax and language expression between the first and second PET were 0.4 (p = 0.01). Our results indicate that chronic severe traumatic head injury patients have changed brain glucose metabolism.

Molecular imaging of 1p/19q deletion in oligodendroglial tumours with 11C-methionine positron emission tomography.

OBJECTIVE: Chromosome 1p/19q deletion is an established prognostic and predictive marker in the WHO grade III oligodendroglial tumours (OT). To estimate the genetic status preoperatively, the authors investigated the correlation between the uptake of (11)C-methionine in positron emission tomography (PET) and the 1p/19q status in grades II and III OT. METHODS: We retrospectively reviewed 144 patients with gliomas who received (11)C-methionine PET. 66 cases with grades II-III oligodendrogliomas or oligoastrocytomas underwent fluorescence in situ hybridisation to determine the 1p/19q status. The tissue uptake of (11)C-methionine was expressed as the ratio of the maximum standardised uptake value (SUVmax) in tumour areas to the mean SUV (SUVmean) in the contralateral normal brain (tumour-to-normal tissue (T/N) ratio). RESULTS: The T/N ratio in (11)C-methionine PET was significantly higher in grade III OT than in grade II tumours. The mean T/N ratio of the grade II tumours without 1p/19q deletion was significantly higher than that of the grade II tumours with 1p/19q deletion (mean 2.67 vs 1.94, respectively; p=0.0457). In grade III tumours, the mean T/N ratio of the tumours without 1p/19q deletion was also significantly higher than that of the tumours with 1p/19q deletion (mean 4.83 vs 3.49, respectively; p=0.0261). The rate of IDH1 mutation was lower and the rate of contrast enhancement on MRIs was higher in the 1p/19q non-deleted OT than those with 1p/19q deletion, which may contribute to the high T/N ratio. CONCLUSIONS: Among suspected OT, (11)C-methionine PET may help us preoperatively discriminate tumours with and without 1p/19q deletion.

Methionine Uptake and Required Radiation Dose to Control Glioblastoma.

PURPOSE: The purpose of this study was to retrospectively assess the feasibility of radiation therapy planning for glioblastoma multiforme (GBM) based on the use of methionine (MET) positron emission tomography (PET), and the correlation among MET uptake, radiation dose, and tumor control. METHODS AND MATERIALS: Twenty-two patients with GBM who underwent MET-PET prior to radiation therapy were enrolled. MET uptake in 30 regions of interest (ROIs) from 22 GBMs, biologically effective doses (BEDs) for the ROIs and their ratios (MET uptake:BED) were compared in terms of whether the ROIs were controlled for >12 months. RESULTS: MET uptake was significantly correlated with tumor control (odds ratio [OR], 10.0; P = .005); however, there was a higher level of correlation between MET uptake:BED ratio and tumor control (OR, 40.0; P < .0001). These data indicated that the required BEDs for controlling the ROIs could be predicted in terms of MET uptake; BED could be calculated as [34.0 × MET uptake] Gy from the optimal threshold of the MET uptake:BED ratio for tumor control. CONCLUSIONS: Target delineation based on MET-PET was demonstrated to be feasible for radiation therapy treatment planning. MET-PET could not only provide precise visualization of infiltrating tumor cells but also predict the required radiation doses to control target regions.

Differences between otolith- and semicircular canal-activated neural circuitry in the vestibular system.

In the last two decades, we have focused on establishing a reliable technique for focal stimulation of vestibular receptors to evaluate neural connectivity. Here, we summarize the vestibular-related neuronal circuits for the vestibulo-ocular reflex, vestibulocollic reflex, and vestibulospinal reflex arcs. The focal stimulating technique also uncovered some hidden neural mechanisms. In the otolith system, we identified two hidden neural mechanisms that enhance otolith receptor sensitivity. The first is commissural inhibition, which boosts sensitivity by incorporating inputs from bilateral otolith receptors, the existence of which was in contradiction to the classical understanding of the otolith system but was observed in the utricular system. The second mechanism, cross-striolar inhibition, intensifies the sensitivity of inputs from both sides of receptive cells across the striola in a single otolith sensor. This was an entirely novel finding and is typically observed in the saccular system. We discuss the possible functional meaning of commissural and cross-striolar inhibition. Finally, our focal stimulating technique was applied to elucidate the different constructions of axonal projections from each vestibular receptor to the spinal cord. We also discuss the possible function of the unique neural connectivity observed in each vestibular receptor system.

Discrimination between low-grade oligodendrogliomas and diffuse astrocytoma with the aid of 11C-methionine positron emission tomography.

OBJECT: The diagnostic usefulness of (11)C-methionine PET scans in gliomas is still controversial. The authors investigated the clinical significance of (11)C-methionine PET findings in preoperative diagnosis of histological type and grade. METHODS: The tissue uptake of (11)C-methionine was assessed using PET in 70 patients with histologically confirmed intracerebral gliomas. The ratio of maximum standard uptake values in tumor areas to the mean standard uptake values in the contralateral normal brain tissue (tumor/normal tissue [T/N] ratio) was calculated and correlated with tumor type, histological grade, contrast enhancement on MR imaging, Ki 67 labeling index, and 1p/19q status. RESULTS: The T/N ratio was significantly increased as tumor grade advanced in astrocytic tumors (WHO Grade II vs Grade III, p = 0.0011; Grade III vs Grade IV, p = 0.0007). Among Grade II gliomas, the mean T/N ratio was significantly higher in oligodendroglial tumors than in diffuse astrocytomas (DAs) (p < 0.0001). All T/N ratios for oligodendroglial tumors were ≥ 1.46, and those for DA were consistently < 1.46, with the exception of 2 cases of gemistocytic astrocytoma. The Ki 67 labeling index significantly correlated with T/N ratio in astrocytic tumors, but not in oligodendrogliomas. Oligodendroglial tumors without 1p/19q deletion had a significantly higher T/N ratio than those with the codeletion. In combination with Gd-enhanced MR imaging, 67% of nonenhanced tumors with a T/N ratio of ≥ 1.46 were proved to be Grade II oligodendrogliomas. CONCLUSIONS: These results clearly show that (11)C-methionine PET T/N ratios in Grade II oligodendrogliomas were higher than those in DAs independently of their proliferative activity. This information contributes to preoperative differential diagnoses of histological type, especially in suspected low-grade gliomas.

Properties and axonal trajectories of posterior semicircular canal nerve-activated vestibulospinal neurons.

We studied the axonal projections of vestibulospinal neurons activated from the posterior semicircular canal. The axonal projection level, axonal pathway, and location of the vestibulospinal neurons originating from the PC were investigated in seven decerebrated cats. Selective electrical stimulation was applied to the PC nerve, and extracellular recordings in the vestibular nuclei were performed. The properties of the PC nerve-activated vestibulospinal neurons were then studied. To estimate the neural pathway in the spinal cord, floating electrodes were placed at the ipsilateral (i) and contralateral (c) lateral vestibulospinal tract (LVST) and medial vestibulospinal tract (MVST) at the C1/C2 junction. To elucidate the projection level, floating electrodes were placed at i-LVST and MVST at the C3, T1, and L3 segments in the spinal cord. Collision block test between orthodromic inputs from the PC nerve and antidromic inputs from the spinal cord verified the existence of the vestibulospinal neurons in the vestibular nuclei. Most (44/47) of the PC nerve-activated vestibulospinal neurons responded to orthodromic stimulation to the PC nerve with a short (<1.4 ms) latency, indicating that they were second-order vestibulospinal neurons. The rest (3/47) responded with a longer (>/=1.4 ms) latency, indicating the existence of polysynaptic connections. In 36/47 PC nerve-activated vestibulospinal neurons, the axonal pathway was histologically verified to lie in the spinal cord. The axons of 17/36 vestibulospinal neurons projected to the i-LVST, whereas 14 neurons projected to the MVST, and 5 to the c-LVST. The spinal segment levels of projection of these neurons elucidated that the axons of most (15/17) of vestibulospinal neurons passing through the i-LVST reached the L3 segment level; none (0/14) of the neurons passing through the MVST extended to the L3 segment level; most (13/14) of them did not descend lower than the C3 segment level. In relation to the latency and the pathway, 33/36 PC nerve-activated vestibulospinal neurons were second-order neurons, whereas the remaining three were polysynaptic neurons. Of these, 33 second-order vestibulospinal neurons, 16 passed through the i-LVST, while 13 and 4 descended through the MVST and c-LVST, respectively. The remaining three were polysynaptic neurons. Histological analysis showed that most of the PC nerve-activated vestibulospinal neurons were located within a specific area in the medial part of the lateral vestibular nucleus and the rostral part of the descending vestibular nucleus. In conclusion, it was suggested that PC nerve-activated vestibulospinal neurons that were located within a focal area of the vestibular nuclei have strong connections with the lower segments of the spinal cord and are related to postural stability that is maintained by the short latency vestibulospinal reflex.

[Usefulness of FDG-PET for the diagnosis of copper deficiency at an early stage: a case report].

For the patients under long-term tube feeding, copper deficiency is known to be a cause of neutropenia and/or anemia. It is recognized as reversible myelodysplasia, since the condition improves by giving a copper supplementation. Myelodysplasia caused by copper deficiency is difficult to be diagnosed because it is not so common, and often it takes a long time to reach correct diagnosis. We reported usefulness of FDG-PET for the diagnosis of myelodysplasia caused by copper deficiency in early stage. The case was 46 y.o. male patient in vegetative state for 2 years after traumatic brain injury. Laboratory examination revealed slight leukopenia. PET/CT demonstrated high and diffuse FDG accumulation mainly in the vertebral bone marrow. Based on the lower levels of serum copper and ceruloprasmin, the patient was diagnosed as copper deficiency. After treatment of copper supplementation, FDG accumulation of the bone marrow disappeared, and the serum copper level has normalized. From the FDG-PET findings, even in the early stage of copper deficiency, high glucose metabolism of bone marrow was shown.

Axonal pathways and projection levels of anterior semicircular canal nerve-activated vestibulospinal neurons in cats.

Using collision tests of orthodromically and antidromically generated spikes, we studied the axonal pathways, axonal projection levels, and soma location of anterior semicircular canal (AC) nerve-activated vestibulospinal neurons in decerebrate cats. AC nerve-activated vestibulospinal neurons (n=74) were mainly located in the ventral portion of the lateral vestibular nuclei and the rostral portion of the descending vestibular nucleus, which is consistent with previous studies. Of these neurons, 15% projected through the ipsilateral (i-) lateral vestibulospinal tract (LVST), 74% projected through the medial vestibulospinal tract (MVST), and 11% projected through the contralateral (c-) LVST. The vast majority (78%) of AC nerve-activated vestibulospinal neurons were activated antidromically only from the cervical segment of the spinal cord; 15% of neurons were activated from the T1 segment and only one neuron was activated from the L3 segment. AC nerve-activated vestibulospinal neurons may primarily target the neck muscles and thus contribute to the vestibulocollic reflex. Most of the c-LVST neurons were also activated antidromically from the oculomotor nucleus, suggesting that they are closely related to the control of combined eye-head movements.

MR imaging of normal perivascular space expansion at midbrain.

BACKGROUND AND PURPOSE: A previous investigation of the MR imaging findings in the midbrain reported expanded perivascular (PV) spaces in only the ponto-mesencepalic junction (PMJ) in 20% of healthy subjects, whereas pathologically expanding PV spaces have been reported at the mesencephalo-diencephalic junction (MDJ) as multi-lobulated, cystic lesions with signal intensity compatible with that of CSF that cause aqueductal stenosis. To clarify the anatomical distinctions between normally expanded and pathologically expanding PV spaces, we defined their distribution in the normal midbrain by using high-spatial-resolution MR imaging. METHODS: Heavily T2-weighted MR imaging was performed in 115 adult subjects with neurologic complaints without cerebral disease. Histologic studies were performed from two normal midbrain blocks. RESULTS: Expanded PV spaces were visible at the PMJ in 87% of subjects and at the MDJ in 63% of subjects. On axial images, ovoid or linear lesions with signal intensity compatible to CSF were present behind the cerebral peduncle at both the PMJ and MDJ. These areas varied from less than 1 mm to 5 mm (maximum diameter on coronal sections). Histologic studies confirmed the distribution of expanded PV spaces, as noted on MR images. CONCLUSION: This study, by using high-spatial-resolution MR imaging, revealed that expanded PV spaces were visible at the PMJ and MDJ. Our finding of expanded PV spaces normally present at the MDJ may be related to pathologically expanding PV spaces, which should be kept in mind as a differential diagnosis for intraparenchymal cystic lesions in the midbrain with signal intensity compatible to CSF.

Recurrent meningitis associated with a petrous apex cephalocele.

We present the case of a 6-year-old girl with recurrent bacterial meningitis and cerebrospinal fluid (CSF) rhinorrhea associated with a petrous apex cephalocele (PAC). We diagnosed her by means of three-dimensional computed tomography (CT) and heavily T2-weighted magnetic resonance imaging (MRI). Petrous apex cephaloceles are usually an asymptomatic incidental finding in adults; however, they should be considered as a possible cause of CSF rhinorrhea, otorrhea, and recurrent meningitis in children.

Eye movements evoked by selective saccular nerve stimulation in cats.

OBJECTIVE: Because of technical obstacles in controlling current spread to adjacent peripheral nerve, eye movements evoked by activation of the otolith organs have not been investigated in detail compared to eye movements evoked by activation of the canal organs. We attempted to solve this problem by applying more sensitive methods using fine needle and strictly controlling stimulus current intensity compare with filed potential for selective stimulation. METHODS: Eye movements evoked by selective, unilateral saccular (SAC) nerve stimulation were investigated using both electrooculography (EOG) and video recording in decerebrated cats in the presence or absence of anesthesia. Electrical stimulation was applied to the SAC nerve through implanted acupuncture needles. RESULTS: In the absence of anesthesia and with stimulus intensities less than (3.1 +/- 2.7) x N(1)T, we found supraduction in both eyes or in either the ipsilateral or contralateral eye of different cats. We observed downward eye movements using a stronger stimulus intensity ((6.2 +/- 2.9)) x N(1)T). The threshold for downward eye movements was significantly greater than that for upward eye movements (P < 0.05). In anesthetized cats, only downward eye movements were observed when stimulus intensities less than 10 x N(1)T ((7.8 +/- 2.3) x N(1)T) were used. CONCLUSION: These results confirm the known sacculo-ocular anatomical connections, which are involved predominantly in vertical eye movements. Because the sacculo-ocular connections are relatively weak, the normal supraduction evoked by SAC activation can be easily modified by factors such as level of anesthesia and the method of stimulation.

Histologic characteristics of normal perivascular spaces along the optic tract: new pathogenetic mechanism for edema in tumors in the pituitary region.

BACKGROUND AND PURPOSE: Perivascular (PV) spaces are known to distend and cause edema along the optic tract (OT) in pituitary-region tumors. Interstitial fluid may be retained in PV spaces when tumors block their drainage outlets to subarachnoid spaces. However, these spaces and their outlets have not been anatomically elucidated. Our purpose was to evaluate how often large PV spaces are present along the OT and demonstrate their superficial communication points to adjacent subarachnoid spaces. METHODS: We examined serial histologic sections of 10 hemispheric blocks obtained from cadavers without cerebral abnormality. RESULTS: Large PV spaces, 0.5-1.5 mm in maximum height, were always present along the middle portion of the OT. Perforation points of the largest spaces were noted at the medial sulcus of the OT in seven hemispheres and through the OT in three. CONCLUSION: Large PV spaces are present along the middle portion of the OT. Their communication point to adjacent subarachnoid spaces was histologically demonstrated. The locations and variations of the outlet of large PV spaces explain the clinical features of edemas; these findings anatomically support the hypothesis that blockage of the outlets to subarachnoid spaces may play a role in distending the PV spaces and in causing edema in pituitary-region tumors. Only MR imaging has revealed this change; further pathologic investigations are awaited.

Properties of horizontal semicircular canal nerve-activated vestibulospinal neurons in cats.

Axonal pathways, projection levels, and locations of horizontal semicircular canal (HC) nerve-activated vestibulospinal neurons were studied. The HC nerve was selectively stimulated. Vestibulospinal neurons were activated antidromically with four stimulating electrodes, inserted bilaterally into the lateral vestibulospinal tracts (LVST) and medial vestibulospinal tracts (MVST) at the C1/C2 junction. Stimulating electrodes were also positioned in the C3, T1, and L3 segments and in the oculomotor nuclei. Most HC nerve-activated vestibulospinal neurons were located in the ventral portion of the medial, lateral, and the descending nuclei. Among the 157 HC nerve-activated vestibular neurons, 83 were antidromically activated by stimulation at the C1/C2 junction. Of these 83 neurons, axonal pathways of 56 HC nerve-activated vestibulospinal neurons were determined. Most (48/56) of these had axons that descended through the MVST, with the remainder (8 neurons) having axons that descended through the ipsilateral (i-) LVST. Laterality of the axons' trajectories through the MVST was investigated. The majority of vestibulospinal neurons (24/28) with axons descending through the contralateral MVST were also antidromically activated from the oculomotor nucleus, whereas almost all vestibulospinal neurons (19/20) with axons descending through the i-MVST were not. Most HC nerve-activated vestibulospinal neurons were activated antidromically only from the C1/C2 or C3 segments. Only one neuron that was antidromically activated from the T1 segment had an axon that descended through the i-LVST. None of the HC nerve-activated vestibulospinal neurons were antidromically activated from the L3 segment. It is likely that the majority of HC nerve-activated vestibulospinal neurons terminate in the cervical cord and have strong connections with neck motoneurons.

Role of cross-striolar and commissural inhibition in the vestibulocollic reflex.

In the otolith system, there are two types of neuronal circuitry that can enhance response sensitivity during linear acceleration and tilt of the head. One produces cross-striolar inhibition and the other commissural inhibition. Cross-striolar inhibition can be observed in over 50% of saccular-activated, second-order vestibular neurons. In contrast, it is seen in less than 33% of utricular-activated, second-order vestibular neurons. The majority of vestibular neurons that receive cross-striolar inhibition have axons that project to the spinal cord. Over 50% of the utricular-activated, second-order vestibular neurons received commissural inhibition from the contralateral utricular nerve. On the other hand, almost all the saccular-activated, second-order vestibular neurons exhibit no response to stimulation of the contralateral saccular nerve. The majority of vestibular neurons receiving commissural inhibition also have axons that project to the spinal cord. These results suggest that cross-striolar inhibition is important for increasing the sensitivity of the saccular system, whereas commissural inhibition is more important in the utricular system.

Eye movements evoked by the selective stimulation of the utricular nerve in cats.

OBJECTIVE: Eye movements evoked by otolith organ are not well-investigated compare with canal related eye movements due to the technical difficulties. We try to solve this problem by means of our methods. METHODS: Eye movements evoked by selective utricular (UT) nerve stimulation were investigated using both electrooculography (EOG) and video recording in decerebrated cats in the presence or absence of anesthesia. Electrical stimulation was applied to the UT nerve through implanted acupuncture needles. RESULTS: In the absence of anesthesia and with stimulus intensities less than 2.6+/-0.7 x N(1)T, we found ipsilaterally directed horizontal eye movements in both eyes in one cat, abduction in the ipsilateral eye in two cats, and adduction in the contralateral eye in another cat. Other types of eye movements (e.g., supraduction or diagonal eye movements) were observed in both eyes of cats in the absence of anesthesia at a stimulus intensity of 12.2+/-7.6 x N(1)T, an intensity in which current spread to the adjacent nerve could not be ruled out. In the presence of anesthesia, UT nerve stimulation alone failed to evoke horizontal eye movements, but with an intensity 13.8+/-6.4 x N(1)T, supraduction or diagonal eye movements were evoked. UT nerve stimulation at 2-3 x N(1)T facilitated horizontal eye movements induced by ipsilateral abducens (AB) nucleus stimulation or contralateral horizontal canal nerve stimulation. CONCLUSION: This is the first report to our knowledge in which UT nerve-evoked horizontal eye movements are documented. These results confirm the known monosynaptic and disynaptic anatomical connections from utricular primary afferents to the ipsilateral AB nucleus neurons.

Conservative management, gamma-knife radiosurgery, and microsurgery for acoustic neurinomas: a systematic review of outcome and risk of three therapeutic options.

Conservative management, gamma-knife (GK) radiosurgery, and microsurgery are therapeutic options for acoustic neurinomas (ANs). To determine the outcomes and risks of these methods this systematic review analyzed data from 903 patients with conservative management, 1475 with GK radiosurgery, and 5005 with microsurgery from 38 studies identified in MEDLINE searches. Conservative management over a 3.1-year period showed that 51% of ANs showed a tumor growth, an average tumor growth rate was 1.87 mm year-1, 20% of ANs ultimately required surgical intervention, and a third of the patients lost useful hearing. GK radiosurgery significantly reduced the percentage of ANs that enlarged, to 8%, and reduced the percentage that underwent microsurgery to 4.6% over a 3.8-year period. Microsurgery removed 96% of ANs totally, with tumor recurrence, mortality, and major disability rates of 1.8%, 0.63%, and 2.9%, respectively. The majority of ANs grow slowly, but ultimately require intervention. Carrying the risk of hearing loss, conservative management should be supplemented with close follow-up. With a low rate of morbidity, GK radiosurgery suppresses tumor growth and provides good tumor control. Microsurgery provides the best tumor control, although mortality and morbidity are not completely eliminated.

Computed tomography evaluation of air cells in the petrous bone--relationship with postoperative cerebrospinal fluid rhinorrhea.

The anatomy of air cells in the petrous bone was investigated using thin-slice bone-window computed tomography (CT) of 168 petrous bones in 84 patients. Air cells in the petrous bone were classified into mastoid and petrous cells. Petrous cells were subdivided into perilabyrinthine and apical cells. Perilabyrinthine cells comprised supralabyrinthine and infralabyrinthine cells. Supralabyrinthine cells were subdivided into posterosuperior, posteromedial, and subarcuate cells. The mastoid was classified as eburnated (11%) or pneumatized (89%) by the extent of the mastoid cells. The mastoid cells were classified into presinusoidal (14%), sinusoidal (44%), and postsinusoidal (42%) according to the relationship with the sigmoid sulcus. The extent of the mastoid cells was significantly correlated with the pneumatization of the petrous apex, i.e. the apical cells (p < 0.01). CT precisely depicted the complex anatomy of the air cells in the petrous bone. Cerebrospinal fluid (CSF) rhinorrhea is the most common complication after skull base surgery for cerebellopontine angle tumors. Air cells in the petrous bone provide the route for CSF rhinorrhea. Therefore, CT assessment of the air cells is useful for preventing this complication.

MR imaging study of edema-like change along the optic tract in patients with pituitary region tumors.

BACKGROUND AND PURPOSE: Edema-like change along the optic tract commonly occurs in association with craniopharyngiomas. The aim of this study was to clarify whether it occurs in association with other common pituitary region tumors and to elucidate its mechanism as seen on MR images. METHODS: Fifty patients with pituitary region tumors that were touching or compressing the optic pathway underwent heavily T2-weighted MR imaging before and after treatment. RESULTS: Edema-like change along the optic tract was visible on the images of four of 25 pituitary adenomas, eight of 11 craniopharyngiomas, one germ cell tumor, and one malignant lymphoma and was not visible on the images of seven meningiomas and five Rathke's cleft cysts. After therapeutic decompression of the optic pathway, the edema-like change disappeared and large Virchow-Robin spaces, present under normal conditions, became visible along the optic tract. Comparison of pre- and post-treatment coronal and axial view MR images revealed that the edema-like change had been located at, along, and/or around the large Virchow-Robin spaces along the optic tract. CONCLUSION: Edema-like change occurs in association with pituitary region tumors other than craniopharyngiomas. It is related with distension of normally present large Virchow-Robin spaces adjacent to the optic tract. Because Virchow-Robin spaces are speculated to be a drainage route of interstitial fluid into the subarachnoid space, their distension may be related to the fluid retention in and along the Virchow-Robin spaces, the outlet of which into the subpial and/or subarachnoid space(s) is blocked by pituitary region tumors.