Neuroport® makes brain biopsy less invasive and easy even in eloquent areas.

Tissue diagnosis of brain tumours in eloquent is often done via needle biopsy but this method yields small samples that may not be representative of the whole tumour. The Neuroport® system enables a larger tumour biopsy to be taken via a burr hole. We report our experience on 5 cases October 2017 and June 2018. Brainlab® navigation was used. The diagnosis in all patients was made without worsening of their modified Rankin scale scores.

Absence of Microbleeds Reduces the Risk for Recurrent Intracerebral Hemorrhage.

BACKGROUND: Many known risk factors, including hypertension and hyperlipidemia cause intracerebral hemorrhage (ICH). Recently, microbleeds have been identified as one of the factors leading to ICH. While some patients have been found to have recurrent ICH, risk factors for recurrent ICH are scarcely reported. We conducted an observational study on the risk-factors of recurrent ICH, comparing stroke patients with a single hemorrhagic episode and those with recurrent ICH. METHODS: A retrospective analysis of a single-center database was performed to analyze the clinical presentation and characteristics of patients with a single and recurrent ICH. From January 2016 to December 2017, a total of 317 patients were analyzed based on suspected factors including patients' sex, age, medical history, antiplatelet therapy use, and presence of microbleeds on images. RESULTS: Of the 317 patients, 36 patients (11.4%) developed a second episode of cerebral hemorrhage. Brain magnetic resonance imaging (MRI) of the patients without microbleeds, predicted reduced risk of recurrence. This is the first report strongly associating the presence of microbleeds with the possibility of a recurrent ICH. Other factors under study did not show an apparent association with recurrent ICH probably because of the high statistical significance obtained with the presence of microbleeds. CONCLUSION: Our findings revealed that the absence of microbleeds on images is a factor that strongly predicts a reduced risk for recurrent ICH and that the detection of microbleeds on MRI performed in patients with a single hemorrhagic episode, is useful in defining further therapeutic management. These findings may benefit physicians treating stroke patients.

Differentiating between Mycotic and Dissecting Aneurysms in a Case of Ruptured Distal Superior Cerebral Artery Aneurysm.

Objective: We present a case of subarachnoid hemorrhage (SAH) due to ruptured mycotic aneurysm found in the distal superior cerebellar artery (SCA). Case Presentation: A 64-year-old man was admitted to our hospital with sudden unconsciousness. He had a history of alcoholism but no family history of SAH. Computed tomography (CT) showed apparent SAH; however, CT angiography (CTA) showed no apparent cause of SAH except for two small aneurysms in the same branch of the left distal SCA. We suspected mycotic aneurysm and prescribed antibiotics. It was difficult to diagnose the condition as mycotic aneurysm because there were no vegetations or caries at the time of admission. Because there were two aneurysms in the same branch with partial dilatation and stenosis, we suspected dissecting aneurysm, but continued to administer antibiotics for possible mycotic aneurysm. After the first operation, we diagnosed mycotic aneurysm because a vegetation and valve degeneration was found. Conclusion: It is difficult to distinguish mycotic aneurysms from dissecting aneurysms because of similar appearance on imaging, especially if no vegetation is found. Nevertheless, it is important to start treatment for mycotic aneurysm. If there is the possibility of mycotic aneurysm, appropriate antibiotics should be administered, and endovascular treatment could be considered for patients with deteriorating conditions.

Trigeminal Neuralgia Caused by a Persistent Primitive Trigeminal Artery Variant and Superior Cerebellar Artery.

Trigeminal neuralgia is caused by compression of the trigeminal nerve by arteries or veins in the posterior fossa. A persistent primitive trigeminal artery variant (PPTAv) is an anomalous artery that may cause trigeminal neuralgia. A 65-year-old man presented with left facial pain. Brain magnetic resonance imaging revealed a PPTAv. Constructive interference in steady state showed that both the PPTAv and the superior cerebellar artery (SCA) compressed the trigeminal nerve. Thus, we performed microvascular decompression and the patient's symptoms improved. PPTAv is a rare anomaly in the posterior fossa that can cause trigeminal neuralgia. Dual compression of the trigeminal nerve by the SCA and PPTAv demonstrates that trigeminal neuralgia may originate from multiple sources. It is therefore important to check preoperative images to adequately treat trigeminal neuralgia.

How to Remove a Penetrating Intracranial Large Nail.

BACKGROUND: The incidence of penetrating intracranial foreign bodies is rare, and to date, not many relevant studies have been published worldwide. In particular, a nail penetrating intracranially, just near the superior sagittal sinus (SSS), is extremely rare. We treated the case of a large nail that penetrated the middle of the head and strategized its removal. CASE DESCRIPTION: A 70-year-old man had experienced headache lasting a day. Computed tomography of the brain revealed a nail penetrating the middle of his head; in particular, the tip of the nail had penetrated the right ventricle, causing a slight subarachnoid hemorrhage. Angiography showed that the nail was very close to the SSS and that the venous flow was normal. However, there was a risk of the nail penetrating through the SSS or injuring other arteries, and we removed the nail directly from the intracranial view to stop bleeding from the SSS or other vessels. Fortunately, there was no bleeding, and we washed the hole created by the nail penetration and concluded the surgery. CONCLUSIONS: Our technique is useful and safe for removing large nails penetrating the head.

[Two Case Reports of Paroxysmal Sympathetic Hyperactivity Following Craniotomy for Cerebral Hemorrhages].

Paroxysmal sympathetic hyperactivity(PSH)is a clinical condition characterized by abnormal paroxysmal surges in sympathetic nervous system activity. PSH is well known to happen after severe head injury and hypoxic encephalopathy. There are reports of cases of PSH developing after stroke, but PSH is not well recognized in the stroke field in Japan. Case 1 is a 79-year-old woman who became unconscious and suffered a large left mixed-type hemorrhage. Emergency craniotomy was performed. Two months postoperatively, she developed a high fever, tachycardia, tachypnea, and decerebrate posture. After taking clonazepam, her symptoms improved, and she was transferred to another hospital. Case 2 is a 67-year-old man with right hemiplegia, a history of thrombectomy for left M1, occlusion and left carotid artery stenting for asymptomatic left severe carotid artery stenosis performed one year previously. Five hours after right corotid artery stenting, he became restless and hemiplegic on his left side. His computed tomography showed extensive cerebral hemorrhage in the right hemisphere necessitating emergency craniotomy. About a month after surgery, he had a high fever, tachypnea, tachycardia, and decerebrate posture. Taking gabapentin improved his symptoms. Prolonged PSH may be a factor greatly impairing activities of daily living in stroke patients. It is important to diagnose and treat PSH early.

Spindle cell/sclerosing rhabdomyosarcoma with intracranial invasion without destroying the bone of the skull base: a case report and literature review.

Spindle cell/sclerosing rhabdomyosarcoma (ssRMS) is a new subtype of rhabdomyosarcoma included in the World Health Organization soft tissue and bone tumor classification in 2013. Despite the increasing number of reported cases of ssRMS, the imaging characteristics of ssRMS are not established. Herein, we present the case of an elderly Japanese woman with ssRMS of the masticator space with intracranial invasion without destruction of the adjacent bone. Attention should be paid to the presence of intracranial infiltration that may indicate a worse prognosis. Tumor growth without bone destruction could be a key finding to differentiate ssRMSs from conventional subtypes of rhabdomyosarcoma.

Intraoperative visualization of cerebral oxygenation using hyperspectral image data: a two-dimensional mapping method.

PURPOSE: Superficial temporal artery (STA)-middle cerebral artery (MCA) bypass is an important technique for cerebrovascular reconstruction. Intraoperative hemodynamic imaging is needed to perform cerebrovascular reconstruction safely and effectively. Optical intrinsic signal (OIS) imaging is commonly used for assessing cerebral hemodynamics in experimental studies, because it can provide high-resolution mapping images. However, OIS is not used clinically due to algorithm, instrumentation and spectral resolution limitations. We tested the feasibility of a hyperspectral camera (HSC) for assessment of cortical hemodynamics with spectral imaging of the cerebral cortex in rats and in vivo humans. METHODS: A hyperspectral camera (HSC) was tested in a rat model of cerebral ischemia (middle cerebral artery occlusion) and during human revascularization surgery (STA-MCA anastomosis). Changes in cortical oxygen saturation were derived from spectral imaging data (400-800 nm) collected by exposing the cortex to Xenon light. Reflected light was sampled using the HSC. The system was then tested intraoperatively during superficial temporal artery to middle cerebral artery anastomosis procedures. Comparison with single-photon emission computed tomography (SPECT) imaging data was done. RESULTS: During middle cerebral artery occlusion in rats, the HSC technique showed a significant decrease in cortical oxygen saturation in the ischemic hemisphere. In clinical cases, the cortical oxygen saturation was increased after STA-MCA anastomosis, which agreed with the SPECT imaging data. CONCLUSION: Continuous collection of imaging spectroscopic data is feasible and may provide reliable quantification of the hemodynamic responses in the brain. The HSC system may be useful for monitoring intraoperative changes in cortical surface hemodynamics during revascularization procedures in humans.

Image-guided placement of the Bonebridge™ without surgical navigation equipment.

PURPOSE:    Most of the current Bonebridge surgeries undergo preoperative simulation planning in a computer. However, surgeons usually use the landmarks on the bone surface to determine the location where to implant the device, using the simulation image in the computer only as a reference (conventional method). We developed an image-guided method for precisely replicating simulation surgery upon performing Bonebridge implantation. METHODS:    Based on our previous development of the surface template-assisted marker positioning (STAMP) method for performing image-guided otologic surgery, we fabricated templates that fit only at the designated location on the patient's temporal bone surface. The Bonebridge STAMP (BB-STAMP) plate shows the exact location where to start drilling. The BB-STAMP was also combined with a perforator-guiding sleeve, so that the location, direction and depth of the cylindrical well could be precisely replicated as simulated. We also created a STAMP plate for confirmation that fits only after sufficient drilling at the correct location is finished. To evaluate the proposed methods, we performed simulation surgery on four cadaveric temporal bones and their 12 replicas (three each for four bones). The time used and the degree of mismatch between the simulated location and the drilled location were compared. RESULTS:    A feasibility study was successfully conducted using the proposed BB-STAMP methods and the conventional method. The amount of time required for the procedure did not differ significantly between the surgical methods, although using the BB-STAMP and perforator guide was always quicker. The degree of mismatch between the simulation and resected models had tendency to be smaller when the surgery was guided by the BB-STAMP with or without a perforator guide, although the difference was not statistically significant. CONCLUSIONS:    The proposed BB-STAMP is a promising method for replicating exactly what is performed during simulation without using a surgical navigation system.

Long-term hearing outcome after retrosigmoid removal of vestibular schwannoma.

Although many investigators have reported the hearing function in the immediate postoperative period in patients with vestibular schwannoma (VS), little is known about the long-term outcomes of the postoperative hearing. The aim of this study was to analyze the long-term hearing outcomes at a mean follow-up of 5 years in patients with unilateral VS treated via the retrosigmoid approach. Twenty-four patients with immediate postoperative serviceable hearing who underwent repeated audiogram or phone interview were included in this study. During the mean follow-up period (68.8 ± 30.2 months, range 14-123 months), serviceable hearing was preserved in 20 out of the 24 patients (83%). Pure tone average (PTA) was reevaluated within 6 months in seven patients. In the two patients whose PTA deteriorated ≥ 5 dB in 6 months after surgery, their PTA worsened ≥ 15 dB compared to the immediate postoperative PTA. In the remaining five patients whose PTA deteriorated < 5 dB in 6 months after surgery, PTA was maintained within a 15-dB deterioration at the final follow-up (p = 0.04, Fisher's exact test). According to Kaplan-Meier survival plots, the 5-year or 7-year preservation rate of serviceable hearing was 86.2% or 71.8%, respectively. Further study will be needed to clarify the mechanism underlying the long-term decline of serviceable hearing; however, the deterioration of PTA in the early postoperative period may help to predict the long-term outcomes of hearing.

Intra-arterial injection of indocyanine green in cerebral arteriovenous malformation surgery.

Surgical microscope-integrated intraoperative angiography with intra-venous injection of indocyanine green (ICG) has been widely used during bypass or aneurysm surgery. Instead of intra-venous injection of ICG, we describe a case of intraoperative video angiography with intra-arterial injection of ICG in cerebral arteriovenous malformation (AVM) surgery. During the surgery, we injected ICG through a catheter placed in the internal carotid artery in each step. The technique was feasible and useful to distinguish feeders from normal arteries and to observe changes in flow dynamics. Intra-arterial injection of ICG had better phase contrast than intra-venous injection of ICG and better spatial resolution than digital subtraction angiography. Therefore, this technique can be helpful in cerebral AVM surgery.

Facial nerve schwannoma arising from the cerebellopontine angle.

A 74-year-old female suffered hearing disturbance in the right ear persisting for several years, followed by sudden onset of right facial nerve palsy. Her symptoms gradually worsened and neuroradiological imaging revealed a 4-cm cerebellopontine angle (CPA) tumor. Intraoperatively, the tumor was found to originate from the facial nerve. Total removal of the tumor was achieved, followed by a split hypoglossal-facial nerve anastomosis. Facial nerve schwannomas are rare and extremely difficult to preoperatively distinguish from vestibular schwannomas, especially if arising from the CPA and the internal auditory canal. However, preoperative diagnosis of facial nerve schwannomas is important because functional preservation of the facial nerve is more challenging than for vestibular schwannomas. Facial nerve palsy is one of the most unique symptoms in patients with facial nerve schwannomas, but is rare with vestibular schwannomas. Facial nerve schwannomas should be included in the differential diagnosis of CPA tumors with atypical clinical manifestations, and patients should be informed before surgery of the possibility of facial nerve dysfunction and the consequent need for facial nerve graft or reconstruction.

New detachable occlusion balloon unit for transrectal natural orifice translumenal endoscopic surgery.

INTRODUCTION: Transrectal natural orifice translumenal endoscopic surgery (NOTES) requires a good endoluminal view and adequate intrarectal bacterial clearance in the working area. We developed a new occlusion balloon unit with an easily detachable inflation device, which allows the surgeon a clear working area distal to the balloon. MATERIAL AND METHODS: The effectiveness of the sealing balloon and the extent of macroscopic and histopathological injury to the bowel wall at the site of balloon placement were examined in 12 pigs. RESULTS: The mean time to place and inflate the balloon unit was 12.0 ± 3.5 min, effective air-tightness lasted for 21.0 ± 12.0 min. There was no leakage of dye (methylene blue) past the balloon when pressure was maintained >6.70 ± 0.08 kPa (6.62-6.78 kPa). After gut irrigation, good visibility was maintained in the working area for six hours, and adequate bacterial clearance was maintained for three hours. There were no macroscopic signs of intestinal wall damage at the site of balloon placement. Histopathological examination showed only patchy mucosal damage and submucosal thrombus at the site of balloon placement. CONCLUSION: This newly-developed occlusion balloon unit helps to establish good visibility and adequate bacterial clearance for endoluminal surgical procedures.

Ultra-minimally invasive local immune cell therapy and regenerative therapy by multi-piercing surgery for abdominal solid tumor: therapeutic simulation by natural orifice translumenal endoscopic surgery-assisted needlescopic surgery using 3-mm diameter robots.

BACKGROUND/PURPOSE: We have invented multi-piercing surgery (MPS) which could potentially solve the triangular formation loss and device clashing which occur in single-port surgery (SPS), as well as restricted visual field, organ damage by needle-type instruments, and impaired removal of a resected organ from the body which occur in needlescopic surgery (NS). MPS is natural orifice translumenal endoscopic surgery (NOTES)-assisted NS. We used 3-mm diameter robots as needle-type instruments for MPS to examine the possibility of local immune cell therapy and regenerative therapy using stem cells for pancreatic cancer. METHODS: In MPS using two robots, the therapeutic cell suspension was injected into a target region of pancreas in two pigs. Both retention of a capsule of liquid cell suspension and invasive level were evaluated. RESULTS: Triangular formation could be ensured. The use of small-diameter robots allowed (1) the surgical separation of the pancreas and the retroperitoneum, and (2) the formation of the capsule containing the immune cell and stem cell suspension. The endoscope for NOTES provided a clear visual field and also assisted the removal of a resected organ from the body. The visual field of the endoscope could be oriented well by using an electromagnetic navigation system. CONCLUSIONS: MPS using small-diameter robots could potentially solve the issues inherent in SPS and NS and could allow minimally invasive local immune cell and stem cell therapy.

[A case of parental artery occlusion for a non-ruptured giant thrombosed aneurysm at the right vertebral artery using a goose neck snare to hold a guiding catheter].

The stabilization of a guiding catheter is one of the important factors for achieving successful endovascular treatments. However, obtaining sufficient stabilization is sometimes difficult due to the tortuousity of the approach route. A goose neck snare is useful not only for the retrieval of intravascular foreign bodies but also for holding a guiding catheter. This report presents a case of parental artery occlusion for a non-ruptured giant thrombosed aneurysm occurring in the right vertebral artery using a goose neck snare to hold a guiding catheter.

The 'triangle' rubber dam interposition technique: preservation of the arteries around an aneurysm.

The authors describe an intraoperative technique in which a triangular rubber dam is inserted between the aneurysm and the perforating arteries. In this way, we can avoid obstruction of perforating arteries on application of a clip. This technique is especially useful for deep-seated aneurysms, such as basilar bifurcation aneurysms.

[A Japanese hospital reports long-term survival for 10 years after carotid endarterectomy].

BACKGROUND: Several reports in Western countries have demonstrated the net benefit and an acceptable long-term survival of carotid endarterectomy (CEA) for severe carotid stenosis. However, long-term follow-up after CEA for carotid stenosis is not well-documented in Japan. The aim of this study was to determine long-term outcomes of CEA in our hospital. METHODS: 38 consecutive patients underwent 42 CEAs at the Kyushu Medical Center between May, 1994 and December, 1998. Survival follow-up was conducted in December 2008 and the incidence of late stroke was investigated in all surviving patients. RESULTS: A total of 37 CEAs in 30 patients (83.3%) were registered. There were 28 males and 2 females, 25 symptomatic and 5 years asymptomatic, mean ages 68+/-7 years. Survival rate after CEA was 80.0% after 5 and 53.3% after 10-years, respectively. The 10 year survival ratio free from cerebral infarction was 36.7%. CONCLUSIONS: For the patients in this study, CEA is associated with an acceptable long-term survival as well as a satisfactory benefical effect in stroke prevention.

[Usefulness of surgical loupes and headlights for the neurosurgical field].

Surgical loupes and headlights are mainly used in the cardiovascular field. Neurosurgeons use a loupe and a headlight less commonly especially in Japan. In our institute, all six neurosurgeons have their own loupes and two headlights. Both an operator and an assistant use loupes and headlights in every operation. Loupes and headlights are useful also in the neurosurgical field since they give us a clearer and wider surgical field than the macroscopic view and make it possible to move the surgical field quicker than using a microscope.