A Case of Bilateral Papilledema With Improved Clinical Symptoms by Venous Stenting for Superior Sagittal Sinus Stenosis.

Superior sagittal sinus (SSS) obstruction causes intracranial hypertension, often requiring surgical stenting. Consensus on treating brain venous sinus stenosis, another cause, is lacking. This study reports a case of SSS stenosis and intracranial hypertension treated with venous stenting, improving bilateral papilledema. A 51-year-old with a headache and visual disturbance had papilledema and visual field loss. MR venography showed SSS stenosis, leading to a neurosurgery referral. Lumbar puncture confirmed intracranial hypertension (>35 cmH2O), prompting venous stenting. Post-procedure, papilledema, headache, and visual field loss improved. Venous stenting could be effective for SSS stenosis with clinically proven or recurrent pressure differences. Further cases are needed for standardization.

Surgical Strategy in Modification of the Transpetrosal Approach to Avoid Postoperative Venous Complications: A Report of 74 Consecutive Cases.

BACKGROUND: The transpetrosal approach is a complex skull base procedure with a high risk of complications, particularly caused by injury of the venous system. It is in part related to variability of blood outflow pathways and their distinctive patterns in each individual patient. OBJECTIVE: To evaluate outcomes and complications after skull base surgery with use of the petrosal approach modifications, which selection was based on the detailed preoperative assessment of venous drainage patterns. METHODS: Overall, 74 patients, who underwent surgery via the transpetrosal approach at our institution between 2000 and 2017, were included in this study. In all cases, the venous drainage pattern was assessed preoperatively and categorized according to the predominant blood outflow pathway into four types as previously suggested by Hacker: (1) sphenoparietal sinus (SpPrt), (2) sphenobasal vein (SpB), (3) sphenopetrosal sinus (SpPS), and (4) cortical. The blood outflow through the bridging petrosal vein and the vein of Labbé was also taken into consideration. In patients with SpPrt- and a cortical-type venous drainage, the transpetrosal approach was used in a standard way. In patients with SpB-type venous drainage, limited extradural anterior petrosectomy was combined with intradural anterior petrosectomy after dural opening, superior petrosal sinus transection, tentorial cutting, Meckel's cave opening, and trigeminal nerve mobilization. In patients with SpPS-type venous drainage, after standard petrosectomy, dural opening, and tentorial cutting, SpPS ligation was done followed by 2-week interval before staged definitive tumor resection. RESULTS: Gross total, near-total, and subtotal resection of the lesion (meningioma, 48 cases; retrochiasmatic craniopharyngioma, 11 cases; brain stem cavernoma, 7 cases; other tumors, 8 cases) was achieved in 30 (40.5%), 24 (32.4%), and 20 (27.0%) patients, respectively. Postoperative complications that were possibly related to venous compromise were noted in 18 patients (24.3%), but neither one was major. Of these 18 patients, 9 were symptomatic, but all symptoms-aphasia (4 cases), seizures (2 cases), and confusion (3 cases)-fully resolved after conservative treatment. Overall, 13 patients, including 4 symptomatic, had signal changes on T2-weighted brain MRI, which were permanent only in 3 cases (all asymptomatic). CONCLUSION: Our suggested surgical strategy can be applied to any type of the venous drainage pattern. Preoperative evaluation and intraoperative preservation of the blood outflow pathways are crucial means for safe and effective application of the transpetrosal approach.

Visualization of Resected Area in Endonasal Endoscopic Approach versus Transcranial Approach for Skull Base Meningiomas by Voxel-Based-Lesion Mapping.

BACKGROUND: We aimed to evaluate the resected area of endonasal endoscopic approach (EEA) and transcranial approach (TCA) for skull base meningiomas (SBMs) using voxel-based-lesion mapping and visualized the appropriate tumor location in each approach. METHODS: We retrospectively examined 182 patients with SBMs who underwent tumor resection in our hospital between 2014 and 2019. Pre- and post-operative SBMs were manually delineated on MRI to create the voxels-of-interest (VOIpre and VOIpost) and were registered onto the normalized brain (normalized VOIpre and normalized VOIpost). The resected map was created by subtracting normalized VOIpost from the normalized VOIpre divided by the number of cases. The resected maps of TCA and EEA were compared by subtracting them. RESULTS: Twenty patients underwent EEA and 135 patients underwent TCA. The tumor resected map demonstrated that the resected area of EEA frequently accumulated on the central skull base, while that of TCA accumulated near the central skull base. The border of both approaches matched the circle that connects neural foramens at the skull base. CONCLUSIONS: The resected area of SBMs by EEA and TCA was well visualized by voxel-based-lesion mapping. The circle connecting the neural foramens was the border of EEA and TCA.

Maximum 11C-methionine PET uptake as a prognostic imaging biomarker for newly diagnosed and untreated astrocytic glioma.

This study aimed whether the uptake of amino tracer positron emission tomography (PET) can be used as an additional imaging biomarker to estimate the prognosis of glioma. Participants comprised 56 adult patients with newly diagnosed and untreated World Health Organization (WHO) grade II-IV astrocytic glioma who underwent surgical excision and were evaluated by 11C-methionine PET prior to the surgical excision at Osaka City University Hospital from July 2011 to March 2018. Clinical and imaging studies were retrospectively reviewed based on medical records at our institution. Preoperative Karnofsky Performance Status (KPS) only influenced progression-free survival (hazard ratio [HR] 0.20; 95% confidence interval [CI] 0.10-0.41, p < 0.0001), whereas histology (anaplastic astrocytoma: HR 5.30, 95% CI 1.23-22.8, p = 0.025; glioblastoma: HR 11.52, 95% CI 2.27-58.47, p = 0.0032), preoperative KPS ≥ 80 (HR 0.23, 95% CI 0.09-0.62, p = 0.004), maximum lesion-to-contralateral normal brain tissue (LN max) ≥ 4.03 (HR 0.24, 95% CI 0.08-0.71, p = 0.01), and isocitrate dehydrogenase (IDH) status (HR 14.06, 95% CI 1.81-109.2, p = 0.011) were factors influencing overall survival (OS) in multivariate Cox regression. OS was shorter in patients with LN max ≥ 4.03 (29.3 months) than in patients with LN max < 4.03 (not reached; p = 0.03). OS differed significantly between patients with IDH mutant/LN max < 4.03 and patients with IDH mutant/LN max ≥ 4.03. LN max using 11C-methionine PET may be used in prognostic markers for newly identified and untreated WHO grade II-IV astrocytic glioma.

Minimal anterior and posterior combined transpetrosal approach for large petroclival meningiomas.

OBJECTIVE: Petroclival meningiomas (PCMs) remain difficult to remove, and radical tumor resection continues to pose a relatively high risk of neurological morbidity in patients with these lesions because of the proximity of the tumor to neurovascular structures. The anterior and posterior combined (APC) transpetrosal approach allows resection of a large petroclival lesion with minimal retraction of the temporal lobe. However, this approach is thought to be complex and time-consuming. The authors simplified this approach by minimizing the petrosectomy and used this method for large PCMs. This retrospective study describes the surgical technique and surgical outcomes of large PCMs. METHODS: Between 2014 and 2019, 23 patients (19 women and 4 men) with benign (WHO grade I) PCMs were treated using the minimal APC (MAPC) transpetrosal approach. The mean age at surgery was 54.0 years (range 37-74 years). The mean tumor diameter was 40.3 mm (range 30-74 mm). The surgical technique consisted of a temporo-suboccipital craniotomy and minimal drilling of the petrous ridge. After opening Meckel's cave and removing the lesion at the prepontine cistern, drilling of the petrous apex with superior mobilization of the trigeminal nerve was performed through the subdural space for further tumor resection around the petrous apex. Finally, the tumor was removed as much as possible. RESULTS: The mean preoperative and postoperative tumor volumes were 26.8 and 1.3 cm3, respectively. The mean extent of resection was 95.4% (range 62%-100%). Postoperative impairments included facial numbness in 7 patients, trochlear nerve palsy in 3 patients, mild oculomotor nerve palsy in 2 patients, and transient abducens nerve palsy in 1 patient. Preoperative Karnofsky Performance Status was improved in 13 patients, remained stable in 9 patients, and deteriorated in 1 patient. CONCLUSIONS: The MAPC transpetrosal approach provides sufficiently wide exposure of petroclival lesions. Maximal resection via the MAPC transpetrosal approach is a suitable surgical option for the treatment of large PCMs.

Diagnostic Performance of [11C]Methionine Positron Emission Tomography in Newly Diagnosed and Untreated Glioma Based on the Revised World Health Organization 2016 Classification.

BACKGROUND: The relationship between uptake of amino acid tracer with positron emission tomography (PET) and glioma subtypes/gene status is still unclear. OBJECTIVE: To assess the relationship between uptake of [11C]methionine using PET and pathology, IDH (isocitrate dehydrogenase) mutation, 1p/19q codeletion, and TERT (telomerase reverse transcriptase) promoter status in gliomas. METHODS: The participants were 68 patients with newly diagnosed and untreated glioma who underwent surgical excision and preoperative [11C]methionine PET examination at Osaka City University Hospital between July 2011 and March 2018. Clinical and imaging studies were reviewed retrospectively based on the medical records at our institution. RESULTS: The mean lesion/contralateral normal brain tissue (L/N) ratio of diffuse astrocytomas was significantly lower than that of anaplastic astrocytomas (P = 0.00155), glioblastoma (P < 0.001), and oligodendrogliomas (P = 0.0157). The mean L/N ratio of IDH mutant gliomas was significantly lower than that of IDH wild-type gliomas (median 1.75 vs. 2.61; P = 0.00162). A mean L/N ratio of 2.05 provided the best sensitivity and specificity for distinguishing between IDH mutant and IDH wild-type gliomas (69.2% and 76.2%, respectively). The mean L/N ratio of TERT promoter mutant gliomas was significantly higher than that of TERT promoter wild-type gliomas (P = 0.0147). Multiple regression analysis showed that pathologic diagnosis was the only influential factor on L/N ratio. CONCLUSIONS: Distinguishing glioma subtypes based on the revised 2016 World Health Organization classification of the central nervous system tumors on the basis of [11C]methionine PET alone seems to be difficult. However, [11C]methionine PET might be useful for predicting the IDH mutation status in newly diagnosed and untreated gliomas noninvasively before tumor resection.

Combination of p53 and Ki67 as a Promising Predictor of Postoperative Recurrence of Meningioma.

BACKGROUND: Meningioma is a common intracranial tumor originating from arachnoid cap cells. Meningiomas are generally benign tumors curable by one-time resection. However, some meningiomas regrow and invade into the dura mater, and thus frequently require additional treatment. A useful marker to predict the regrowth of meningioma is desired. This study aimed to clarify the significance of p53 and Ki67 for postoperative recurrence of meningioma. MATERIALS AND METHODS: The expression of p53 and Ki67 in 215 intracranial or intraspinal meningiomas was investigated by immunohistochemistry. RESULTS: Of the 215 meningiomas, 35 cases (16.3%) were p53-positive and 49 cases (22.8%) were Ki67-positive. Multivariate analysis revealed Ki67 and p53 status as being significantly correlated with recurrence. Positivity for either Ki67- or p53 was significantly associated with poor recurrence-free survival. CONCLUSION: Combined p53 and Ki67 status might represent a useful independent predictive marker for recurrence of meningioma.

Changes in cognitive function after resection of lesions in the anterior part of the lateral ventricle via an interhemispheric transcallosal approach.

Anterior callosotomy to about 20 mm has been considered relatively safe empirically. The present study aimed to compare cognitive function before and after resection of tumors in the anterior part of the lateral ventricle. We analyzed 6 patients with intraventricular tumors located in the anterior horn or body of the lateral ventricle who underwent surgical excision via interhemispheric transcallosal approach at Osaka City University Hospital between March 2015 and August 2018. And clinical and imaging studies, neuropsychological function using MMSE, WAIS-III and WMS-R and surgical complications were retrospectively reviewed based on the medical records at our institution. As a result, 4 patients achieved gross total resection of the tumor and 2 patients achieved subtotal resection. 4 patients showed hydrocephalus, which disappeared in each case within 6 months after tumor resection. Mean length of callosotomy was 16.9 mm (range, 15.5-26.1 mm). One patient showed postoperative transient deficits including aphasia, microphonia, ballism in all extremities and hemiplegia, and another patient experienced subjective difficulty when talking. These symptoms disappeared within 3 months after tumor resection. Scores from the MMSE and WAIS-III showed no significant postoperative deterioration. Performance intelligence quotient (P = 0.04), full intelligence quotient (P = 0.04) and perceptual organization (P = 0.03) of WAIS-III were significantly improved after surgery compared with preoperatively. In conclusion, anterior corpus callosotomy of about 20 mm for intraventricular tumor in the anterior horn or body of the lateral ventricle might have little effect on cognitive function in the chronic phase, although the influence of hydrocephalus cannot be ignored.

Skull Base Dural Repair Using Autologous Fat as a Dural Substitute: An Efficient Technique.

BACKGROUND: Dural repair during skull base approaches remains challenging, especially in the presence of significant defects. The autologous fat has become an alternative to various substitute materials being used previously. We report here our experience and technique for the repair of notable skull base dural defects using autologous fat as a dural substitute. METHODS: Over a period of 5 years, 71 consecutive patients operated on for skull base pathologies with an important intraoperative dural defect repaired using autologous fat tissue as replacement material were reviewed. The graft, withdrawn from the abdomen or thigh, was flattened and applied to the defect. The clinical findings and outcomes were assessed. RESULTS: Main pathologies included schwannomas (45%) and meningiomas (35.21%), with no side predilection. Surgical approaches such as transcondylar fossa, suboccipital, and frontotemporal approaches were used. Dural defects were mainly located in the posterior (73.2%) and middle cranial fossae (25.4%). No harvesting site-related complication occurred. In 7 cases, transitory subcutaneous fluid collection spontaneously resorbing after 8 days to 2 months was observed. No external cerebrospinal fluid leakage, infection, or other complication was noted during the following period. CONCLUSIONS: Dural repair can be effectively and durably achieved using autologous fat graft as a dural substitute during skull base approaches, even in cases of extended defects. The observed characteristics of the fat graft along with the achieved outcome make it an ideal dural substitute.

Spheno-Orbital Meningioma: Surgical Outcomes and Management of Recurrence.

OBJECTIVE: Spheno-orbital meningioma (SOM) is a rare intracranial tumor that arises at the sphenoid wing, extends into the orbit, and is associated with hyperostosis of the sphenoid bone. These tumors often invade important neurovascular structures around the orbital apex, superior orbital fissure, and cavernous sinus. Aggressive tumor removal could achieve acceptable control; however, residual tumor can regrow. In this article, our surgical management and long-term outcomes are described. METHODS: Retrospectively, 12 patients with SOM who were treated surgically over a 21-year period were included. The clinical features and long-term tumor control were evaluated. RESULTS: Participants comprised 12 patients (5 men and 7 women). Mean follow-up was 74.4 months (range, 10-262 months). Ten patients (83%) were identified as World Health Organization grade 1 (WHO-I), and 2 patients (17%) were identified as WHO grade 2 (WHO-II). We encountered 4 recurrences, 2 of which needed additional surgeries. One patient with WHO-I (10%) experienced recurrence 10 years after the initial surgery and required a second surgery. Two patients with WHO-I (20%) showed slight regrowth of residual tumor around the superior orbital fissure; nevertheless, additive therapy was not recommended. Despite radical tumor resection, including eyeball and adjunctive radiotherapy for 1 patient with WHO-II, tumor recurrence in the posterior fossa was documented 19 years after the initial aggressive surgery. CONCLUSIONS: SOM follows a relatively benign clinical course given the invasive radiologic findings. Abnormal bone resection is paramount to prevent early-stage recurrence. Although intradural residual tumor might regrow, additional surgery could achieve reasonable long-term tumor control with better outcome.

Sympathetic Plexus Schwannoma of Carotid Canal: 2 Cases with Surgical Technique and Review of Literature.

Carotid sympathetic plexus schwannomas are rare, and only 3 cases have been reported to the best of our knowledge. We report the fourth and fifth cases and define its origin on the basis of the exact division of the plexus from which the tumor arises. The surgical approach and technique in each variety and the postoperative outcome are also described. The relationship of partial Horner syndrome with the sympathetic plexus schwannoma of the internal carotid artery is discussed in detail.

Surgical management of solitary nerve sheath tumors originating around the epiconus or conus medullaris: a retrospective case analysis based on neurological function.

The objective of this retrospective case analysis was to evaluate the surgical impact on neurological functional recovery in cases of solitary spinal nerve sheath tumors (NSTs) originating around the epiconus, conus medullaris, or cauda equina and not associated with neurofibromatosis. This 10-year surgical study included 30 cases of spinal NSTs originating around the spine level of T12-L1 (epiconus-to-conus medullaris: Epi-CM group), and 15 cases of spinal NSTs originating below the spine level of L2 (cauda equina: CE group). A minimally invasive posterior unilateral approach was applied in 22 of 30 subjects in the Epi-CM group and in 14 of 15 subjects in the CE group. Total removal of the tumor was achieved in all cases except in two cases of subpial growth and foraminal extension in the Epi-CM group at the initial surgery. Functional assessment revealed satisfactory or acceptable neurological recovery in both groups. Twelve of 30 patients (40%) in the Epi-CM group demonstrated significant motor weakness of the ipsilateral leg, predominantly manifested as drop foot before surgery, and only 4 of 12 patients demonstrated complete recovery. Ten of 30 patients (33%) in the Epi-CM group demonstrated a significant disturbance of urination before surgery, and only 6 of 10 demonstrated complete recovery. No patients in the CE group demonstrated unsatisfactory recovery of leg motor weakness or urinary disturbance. The present study suggests that surgeons should be aware that spinal NSTs originating around the epiconus or conus medullaris may result in delayed or inadequate functional recovery, even after successful surgical resection of tumors.