Lateral Suboccipital Infrafloccular Approach with Extensive Arachnoid Dissection for Vertebral Artery-Associated Hemifacial Spasm: Two-Dimensional Operative Video.

Hemifacial spasm (HFS) is generally caused by compression of the root exit zone (REZ) of the facial nerve by the anterior and posterior inferior cerebellar arteries and occasionally the vertebral artery (VA). Owing to its large caliber and high stiffness, microvascular decompression (MVD) for VA-associated HFS is considered more difficult, and the result is worse than for HFS not associated with the VA.1,2 Therefore, a safer, more reliable MVD is required for VA-associated HFS. In Video 1, we demonstrate our MVD technique in a 57-year-old woman who presented with left HFS owing to facial nerve compression by a dolichoectatic VA. A lateral suboccipital infrafloccular approach with extensive arachnoid dissection was performed. Arachnoid dissection was started from the cisterna magna and continued from the caudal to the rostral direction. This extensive arachnoid dissection provided access to the facial nerve REZ through the infrafloccular route with gentle retraction of the flocculus in the caudorostral direction, while avoiding strong retraction of cranial nerve VIII and the cerebellum. In addition, we were able avoid damaging the neurovascular structures in the operative field. This is mandatory to make the operative field bloodless and facilitate identifying the relationship between the facial nerve REZ and the offending vessels. MVD of the facial nerve REZ was achieved. The patient's postoperative course was uneventful, and her HFS resolved postoperatively. Patient consent was obtained to perform the surgery and to publish the surgical video.

A Case of Posterior Communicating Artery Aneurysm Accompanied with Infundibular Dilatation Mimicking a Double-Hump Aneurysm.

Posterior communicating artery (PComA) aneurysms are common cerebral aneurysms. In cases of PComA aneurysms accompanied by anatomical variations of PComA, such as hypoplasia, hyperplasia, or infundibular dilatation, it is challenging to completely determine the relationship between the parent artery, daughter arteries, and the aneurysmal neck preoperatively. We present a case of a ruptured PComA aneurysm originating from the PComA, accompanied by infundibular dilatation, which was preoperatively diagnosed as a double-hump PComA aneurysm with hypoplastic or absent PComA, based on computed tomography (CT) angiography images. This case emphasized that CT angiography does not always visualize the entire vasculature. A more meticulous dissection of the retrocarotid space should be performed to confirm the relationship between the parent artery, daughter arteries, and aneurysmal neck, especially when digital subtraction angiography is omitted, and clipping is planned for double-hump PComA aneurysms, wherein the PComA is not clearly depicted on preoperative CT angiography.

Microsurgical Resection of Tuberculum Sellae Meningioma through Pterional Approach with Extradural Optic Canal Unroofing.

Tuberculum sellae meningiomas pose significant challenges because they are surrounded by crucial neurovascular structures, such as the optic and oculomotor nerves, pituitary stalk, internal carotid artery and its branches, and the anterior cerebral arteries. Even if small, such meningiomas frequently extend to the optic canal that is considered a poor prognostic factor for vision. In this video clip, we illustrate the case of a 60-year-old female who had an approximately 3-cm tuberculum sellae meningioma with optic canal involvement. She underwent surgical resection of the tumor through a pterional approach. After extradural optic canal unroofing, detaching, devascularizing, and debulking the tumor, careful dissection of the meningioma from the surrounding tissues was performed. Next, the tumor extensions into both of the optic canals were removed. Finally, coagulation and resection of the tumor origin on the dura of the tuberculum sellae following Simpson's grade-I resection were performed. Histopathology revealed that the tumor was a World Health Organization (WHO) grade-I meningioma. The patient had an uneventful postoperative course and her visual acuity was preserved, with no visual field defect on postoperative visual examination. In this video, the basic surgical techniques in performing extradural optic canal unroofing, preserving the arachnoid plane, and stay in collect layer, which is the essential technique for dissecting meningiomas and for preserving neurovascular structures, are demonstrated. The link to the video can be found at: https://youtu.be/vD54Iji0C4Q .

Discrepancy in the Ki67 labeling index of brain and orbital metastatic lesions from gastrointestinal neuroendocrine tumors: A case report.

Proliferative activity examined by Ki67 labeling index (LI) plays pivotal role for managing gastrointestinal neuroendocrine tumor (GI-NET). Few reports indicated the intra-patient heterogeneity of Ki67-LI among metastatic tumor sites. We report a case of brain and orbital metastases from GI-NET that showed discrepancy of the Ki67-LI. A 71 year-old woman who was diagnosed as GI-NET with liver and bone metastases and performed medical therapy, had headache, right exophthalmos, and pain of right eye and was referred to our department. Magnetic resonance image revealed that tumors in the left occipital region and right orbit. We diagnosed as metastatic brain and orbital tumors from GI-NET. Surgical removal of both symptomatic lesions was performed and the diagnosis was pathologically confirmed. Immunohistochemical studies revealed the discrepancy of the Ki67-LI of the lesions (brain tumor: 8% versus orbital tumor: 22%). Sampling of multiple metastatic sites may prevent underestimate tumor proliferative activity.

Carotid ultrasonography predicts collateral development following combined direct and indirect revascularization surgery in adult ischemic Moyamoya disease.

OBJECTIVE: The relationship between carotid ultrasonographic parameters and postoperative collateral development in adult ischemic moyamoya disease (MMD) patients who received combined direct and indirect revascularization surgery remains unclear. Herein, we investigated the postoperative changes in carotid ultrasonographic parameters in patients with adult ischemic MMD. METHODS: We studied 28 adult ischemic MMD patients (31 hemispheres) who underwent combined revascularization surgery. Patients underwent preoperative and postoperative (within 14 days and 3, 12, and 24 months after surgery) magnetic resonance imaging and carotid ultrasonography. We defined the hemisphere in which all signal intensities of the superficial temporal, middle meningeal, and deep temporal arteries were increased compared with that before surgery on magnetic resonance angiography as well-developed collateral establishment. RESULTS: Patients with good collateral establishment on MRA at 2-year after surgery had a lower external carotid artery (ECA) pulsatility index (PI) (P = 0.0413) and ECA/internal carotid artery (ICA) pulsatility index (PI) ratio (P = 0.0427) at 3-month post-operation. At 3-month post-operation, a cut-off ECA PI of 1.416 (sensitivity 40.0 %, specificity 92.3 %, area under the curve 0.7282, likelihood ratio 5.20, P = 0.0404) and ECA/ICA PI ratio of 0.8768 (sensitivity 50.0 %, specificity 92.31 %, area under the curve 0.7308, likelihood ratio 6.50, P = 0.0415) provided reliable values for good prediction of collateral development at 2 years after revascularization. CONCLUSION: ECA/ICA PI ratio and ECA PI at 3-month after surgery can be one of the indicators for predicting future well-developed neovascularization on MRA and better outcome in patients with adult ischemic MMD who received combined direct and indirect revascularization surgery.

Discrepancy in the Ki67 labeling index of brain and orbital metastatic lesions from gastrointestinal neuroendocrine tumors: A case report.

Proliferative activity examined by Ki67 labeling index (LI) plays pivotal role for managing gastrointestinal neuroendocrine tumor (GI-NET). Few reports indicated the intra-patient heterogeneity of Ki67-LI among metastatic tumor sites. We report a case of brain and orbital metastases from GI-NET that showed discrepancy of the Ki67-LI. A 71 year-old woman who was diagnosed as GI-NET with liver and bone metastases and performed medical therapy, had headache, right exophthalmos, and pain of right eye and was referred to our department. Magnetic resonance image revealed that tumors in the left occipital region and right orbit. We diagnosed as metastatic brain and orbital tumors from GI-NET. Surgical removal of both symptomatic lesions was performed and the diagnosis was pathologically confirmed. Immunohistochemical studies revealed the discrepancy of the Ki67-LI of the lesions (brain tumor: 8% versus orbital tumor: 22%). Sampling of multiple metastatic sites may prevent underestimate tumor proliferative activity.

Impact of antithrombotic therapy on surgical treatment in patients with chronic subdural hematoma.

OBJECTIVE: The effects of antithrombotic therapy on chronic subdural hematoma (CSDH) are controversial. Herein, we investigated the association of antithrombotic therapy with surgical complications and outcomes in patients with CSDH. METHODS: We retrospectively analyzed 323 consecutive patients with CSDH who underwent single burr-hole craniostomy. RESULTS: One hundred and eight patients (33%) underwent preoperative antithrombotic therapy. Hemorrhagic and thromboembolic complications were detected in 6 and 8 patients, respectively, which peaked at 3 and 4.5 days after CSDH surgery, respectively. CSDH recurrence was detected in 62 cases, and reoperation was required in 16 cases. Discontinuance of antiplatelet therapy for >2 weeks was significantly associated with thromboembolic complications (43%; p = 0.005). Postoperative use of multiple antithrombotic agents was significantly associated with CSDH recurrence (40%; p = 0.03). Further, earlier recurrence within 2 weeks was significantly associated with the following reoperation (62%; p = 0.006). CONCLUSIONS: To reduce morbidity and minimize the risk of CSDH reoperation, the optimal timing for resumption of antithrombotic agents is approximately 3 days after CSDH surgery. Postoperative use of multiple antithrombotic agents can increase CSDH recurrence, while earlier recurrence may be a predictor for the following reoperation.