Malignant Meningioma Mimicking Chronic Subdural Hematoma.

BACKGROUND: Chronic subdural hematoma (CSDH) is the most common disease encountered in neurosurgery. Diagnoses of CSDH are usually made on the basis of computed tomography (CT) images. In this report, we discuss the case of a patient with meningioma whose findings instead suggested CSDH. CASE DESCRIPTION: A 91-year-old woman complained of dizziness. Brain CT imaging revealed a low-density subdural space, following which we diagnosed her with CSDH. On the same day, we performed burr hole surgery. However, when opening the burr hole and cutting the dura, a light yellowish tumor was observed under the dura. After the operation, her condition deteriorated and she died 2 days later. After 10 days, pathologic examination of the tumor specimen led to a diagnosis of atypical meningioma. CONCLUSIONS: In almost all cases, CSDH can be diagnosed using CT images only. However, our patient's true diagnosis was meningioma, rather than CSDH. We rouse attention not to take it for CSDH with a CT image easily.

Flexible Endoscopic Aspiration for Intraventricular Casting Hematoma.

BACKGROUND: Conventionally, patients suffering a massive intraventricular hemorrhage have undergone external ventricular drainage. However, long-term or repeated drainage increases the risk of complications due to infections or shunt dependency. Neuroendoscopic surgery may offer some advantages over more conventional procedures. METHODS: Thirteen patients suffering intraventricular hematoma associated with intracerebral hemorrhage, treated in our hospital between April 2011 and March 2014, were reviewed retrospectively. Casting hematomas in the ventricles were manually aspirated using a flexible endoscope. The timing of the operation, period of post-endoscopic ventricular drainage, additional internal shunt surgery, 3-month post-surgical outcome, and critical complications were evaluated. RESULTS: Two patients (treated during our earliest use of endoscope) who underwent surgery on the 7th and 16th day post-onset required subsequent cerebrospinal shunt surgery. In contrast, of the 11 patients who underwent endoscopic surgery on the day of onset, only 1 patient required an additional, third ventriculostomy due to a secondary obstruction of the aqueduct by adhesive fibrous membranes. After 3 months, all six patients with mRS scores of 2-3 satisfied all the following criteria: initial Glasgow Coma Scale scores higher than 8, flexible endoscopic surgeries performed on the day of onset, and period of ventricular drainage of less than 4 days. CONCLUSIONS: Early surgical intervention using a flexible endoscope and short period of post-surgical drainage can be highly effective for patients suffering from casting intraventricular hematomas associated with intracerebral hemorrhage. The advantages of this treatment may be a less invasive procedure, ICP control in the acute phase, breaking away from ventricular drainage in the early stage, and prevention of hydrocephalus or intracranial infectious complications in the long term.

A novel three-dimensional and high-definition flexible scope.

PURPOSE: Recent high-tech innovations in digital surgical technology have led to advances in three-dimensional (3D) and high-definition (HD) operating scopes. We introduce a novel 3D-HD flexible surgical scope called "3D-Eye-Flex" and evaluate its utility as an alternative to the operating microscope. METHODS: The 3D-Eye-Flex has a 15 mm long 3D-HD scope-head with a 15 mm outer diameter, a focus distance of 18-100 mm and 80° angle of view. Attached to a 615-mm-long flexible bellows, 3D-Eye-Flex can be easily fixed to the operating table. Microsurgical dissection of wet brain tissue and drilling a skull base model were performed under the scope while using the 3D-HD video monitor. RESULTS: This scope system provided excellent illumination and image quality during the procedures. A large depth of field with stereoscopic vision had a greater advantage over using an operating microscope. 3D-Eye-Flex was easy to manipulate and provided an abundance of space above the operative field. Surgeons felt comfortable while working and could easily shift the position of the scope. CONCLUSION: This novel 3D-HD flexible scope is an effective alternative to the operating microscope as a new surgeon's eye and will be suitable for digital image-based surgery with further refinement.

Nonsurgical treatment of chronic subdural hematoma with tranexamic acid.

OBJECT: Chronic subdural hematoma (CSDH) is a common condition after head trauma. It can often be successfully treated surgically by inserting a bur hole and draining the liquefied hematoma. However, to the best of the authors' knowledge, for nonemergency cases not requiring surgery, no reports have indicated the best approach for preventing hematoma enlargement or resolving it completely. The authors hypothesized that hyperfibrinolysis plays a major role in liquefaction of the hematoma. Therefore, they evaluated the ability of an antifibrinolytic drug, tranexamic acid, to completely resolve CSDH compared with bur hole surgery alone. METHODS: From 2007 to 2011, a total of 21 patients with CSDH seen consecutively at Kuki General Hospital, Japan, were given 750 mg of tranexamic acid orally every day. Patients were identified by a retrospective records review, which collected data on the volume of the hematoma (based on radiographic measurements) and any complications. Follow-up for each patient consisted of CT or MRI every 21 days from diagnosis to resolution of the CSDH. RESULTS: Of the 21 patients, 3 with early stages of CSDH were treated by bur hole surgery before receiving medical therapy. The median duration of clinical and radiographic follow-up was 58 days (range 28-137 days). Before tranexamic acid therapy was initiated, the median hematoma volume for the 21 patients was 58.5 ml (range 7.5-223.2 ml); for the 18 patients who had not undergone surgery, the median hematoma volume was 55.6 ml (range 7.5-140.5 ml). After therapy, the median volume for all 21 patients was 3.7 ml (range 0-22.1 ml). No hematomas recurred or progressed. CONCLUSIONS: Chronic subdural hematoma can be treated with tranexamic acid without concomitant surgery. Tranexamic acid might simultaneously inhibit the fibrinolytic and inflammatory (kinin-kallikrein) systems, which might consequently resolve CSDH. This medical therapy could prevent the early stages of CSDH that can occur after head trauma and the recurrence of CSDH after surgery.

Introduction of the videoscope in neurosurgery.

OBJECTIVE: This article demonstrates that a newly developed videoscope for use in neurosurgery is effective for patients with lesions in their ventricles, cisterns, and intraparenchyma. METHODS: Neuroendoscopy was performed on 13 patients using a videoscope system with narrow-band imaging technology. RESULTS: The results showed that the new videoscope was far superior to conventional fiberscopes in terms of visual quality and ease of manipulation. Observation of subependymal blood vessels, which had been difficult with fiberscopes, was possible with the videoscope. Furthermore, the videoscope was capable of producing enhanced images of capillary blood vessels under the ependymal layer space if used in conjunction with narrow-band imaging technology. CONCLUSION: This videoscope will be effective in avoiding capillary vessel injuries during neuroendoscopic procedures. It will also contribute to the future development of neuroendoscopy.

Results of a long-term follow-up after neuroendoscopic biopsy procedure and third ventriculostomy in patients with intracranial germinomas.

OBJECT: The authors report the results of long-term follow-ups in 12 patients with intracranial germinomas who underwent neuroendoscopic procedures before chemotherapy and radiotherapy, and discuss the usefulness and safety of these procedures. METHODS: Between January 1996 and December 2005 at Kyushu University Hospital, 12 patients with intracranial germinomas underwent neuroendoscopic biopsy procedures involving a flexible fiberscope. Eight patients simultaneously underwent endoscopic third ventriculostomy (ETV) for existing obstructive hydrocephalus. All patients received chemotherapy and radiotherapy postoperatively, according to the regimen promulgated by the Japanese Pediatric Brain Tumor Study Group. The patients were followed for an average of 78.6 months (range 15-134 months), and a retrospective study was conducted. RESULTS: Germinomas were histologically verified in all patients. No postoperative deaths or permanent morbidity was related to the neuroendoscopic procedures. No other cerebrospinal fluid diversion, such as that achieved with a ventriculoperitoneal shunt, was needed for the management of hydrocephalus. A complete response to postoperative chemotherapy and radiotherapy was achieved in all cases. Only one patient had a recurrent lesion in the spinal cord 6 years after the initial treatment; however, this patient had undergone only the neuroendoscopic biopsy procedure without ETV. CONCLUSIONS: Neuroendoscopic procedures can permit a precise histological diagnosis of intracranial germinomas and are safe and effective in the management of hydrocephalus associated with these tumors. The risk of tumor dissemination due to the neuroendoscopic procedures appears to be minimal when the appropriate chemotherapy and radiotherapy are provided postoperatively.