Proposed imaging assessment score for aneurysmal subarachnoid hemorrhage correlated with prognosis: Shinshu Aneurysmal subarachnoid hemorrhage score.

BACKGROUND: Aneurysmal subarachnoid hemorrhage (aSAH) imaging has been shown to correlate with prognosis. However, no numerical index of bleeding severity has been established. This study aimed to propose a new simple scoring system for computed tomography imaging of aSAH and to confirm its effectiveness in retrospective and prospective studies. METHODS: We devised an image evaluation system as an objective index. This system was established by scoring six items, with a maximum total of 19 points. Using this score, named the Shinshu Aneurysmal Subarachnoid Hemorrhage Score (S-score), we performed a retrospective study of 210 patients with aSAH at a single institution to confirm its efficacy. Age and World Federation of Neurosurgical Societies grades were adopted as other verification items, and the modified Rankin Scale was used for prognostic evaluation. A multicenter prospective study was then conducted to examine the function of the score by examining 214 patients with aSAH. RESULTS: In the retrospective study, the threshold of the S-score between good and poor prognoses was 9/19 points. The area under the curve by receiver operating characteristic analysis of the S-score was 0.819, suggesting efficacy, with an odds ratio (OR) of 1.291 (1.077-1.547). In the prospective study, the judgment capability of the S-score was evaluated with a sensitivity of 0.674, specificity of 0.881, positive predictive value of 0.789, negative predictive value of 0.804, false-positive ratio of 0.119, false-negative ratio of 0.325, positive likelihood ratio of 6.072, and negative likelihood ratio of 1.369. S-score showed a significant difference in prognosis. The OR was 1.183 (1.009-1.388). CONCLUSIONS: The scoring system could contribute to patient prognosis assessment. S-score and its prognostic formulas may serve as an objective source of information in the development of clinical medicine.

The Importance of Intratumoral Venous Drainage Preservation in Two-Stage Surgery of Large Hypervascular Choroid Plexus Papilloma: A Case Report.

Two-stage surgery may be necessary when total tumor removal cannot be accomplished in the first surgery; however, the extent and condition in which the remaining tumor should be before the next surgery have not yet been established. There is a risk of postoperative hemorrhage in the residual tumor, especially in hypervascular tumors. We report a case of hypervascular choroid plexus papilloma (CPP) in a 22-year-old male patient where the preservation of intratumoral venous drainage was considered important to avoid hemorrhagic complications during a two-stage surgery. In the first surgery, it was difficult to control the bleeding from the debulked tumor, and the surgery was terminated due to severe blood loss. Large draining veins running in the tumor were preserved as it was suspected that these were important drainage routes of the bloodstream of the tumor. The preserved draining red veins changed to normal venous color in the second surgery performed after one week. The residual tumor was not vascularized during the second surgery and underwent gross total resection with less blood loss. The patient was discharged without sequelae. There was no recurrence of the tumor and no neurological deficit during the three-year follow-up. To prevent postoperative hemorrhage associated with a residual tumor, it may be important to preserve venous drainage of the tumor in hypervascular tumor resection.

＜Editors' Choice＞ Surgical removal of an intracranially migrated acupuncture needle: a case report and literature review.

Acupuncture is a popular alternative therapy worldwide and is generally safe. However, serious acupuncture-related complications can occur. Intracranial complications caused by a migrated acupuncture needle are extremely rare. Herein we report a surgical case of intracranial acupuncture needle migration and discuss the key technical aspects of the procedure. We additionally performed a review of the relevant literature. A 55-year-old woman presented with migration of a broken acupuncture needle via the posterior cervical skin. Computed tomography (CT) showed that the needle migrated intra- and extradurally via the atlanto-occipital junction. CT angiography revealed that the needle tail was located adjacent to the right distal horizontal loop of the vertebral artery. Meanwhile, the needle tip was positioned in the premedullary cistern adjacent to the medulla oblongata via the right lateral medullary cistern. Emergent surgical removal was conducted. Intradural exploration was required as the needle was not found in the epidural space. The needle penetrated the adventitia of the right intradural vertebral artery. We failed to pull out the needle toward the epidural space. After the needle was completely pulled into the intradural space, it was successfully removed without bleeding complication. Postoperative CT showed no evidence of residual needle fragment. The patient was discharged home without any sequelae. To the best of our knowledge, this is the first case of penetrating vertebral artery injury caused by radiologically confirmed acupuncture needle migration. An intracranially migrated needle should be removed urgently to prevent further migration causing brainstem, cranial nerve, and vessel injuries. The surgical strategy should be selected according to needle location and direction.

The Efficacy of Intraoperative Passive Language Mapping for Glioma Surgery: A Case Report.

Background: Recently, electrocorticographic (ECoG) studies have emphasized the importance of gamma band-based functional mapping in the presurgical localization of the eloquent cortex. Passive functional mapping using ECoG signals provides a reliable method for identifying receptive language areas without many of the risks and limitations associated with electrical cortical stimulation. We report a surgical case of left temporal malignant glioma with intraoperative passive language mapping. Case Description: A 78-year-old woman was diagnosed with left temporal glioma with inspection of her language difficulty. MRI showed a left temporal tumor measuring 74.6 × 50.0 × 51.5 mm in size. Real-time CortiQ-based mapping using high-gamma activity by word-listening and story-listening tasks was performed. Significant listening task-evoked high gamma activities were detected in 5 channels in the superior temporal gyrus and one channel in the middle temporal gyrus. The tumor was grossly removed except for the region corresponding to listening task-evoked high gamma activities. Postoperatively, the patient's symptoms of language comprehension difficulty improved, and no new neurological deficits were observed. Conclusion: Intraoperative passive language mapping was successfully performed, and the patient's language function was well-preserved. Intraoperative passive language mapping, which is applicable in a short time and under general anesthesia, can be an important tool for detecting language areas.

Supratentorial Intraparenchymal Neurenteric Cyst Treated by Neuroendoscopic Fenestration: A Case Report and Review of Literature.

Neurenteric cysts (NCs) are rare benign congenital neoplasms in the central nervous system that originate from endodermal elements. NCs are more commonly located in the spine than in the brain. Although almost all intracranial NCs are found in the posterior fossa, some have reported supratentorial NCs. The complete excision of the cyst wall is suggested as a curative treatment; however, endoscopic treatment is less discussed. We present a supratentorial intraparenchymal NC in the frontal lobe treated by neuroendoscopic fenestration and review the literature regarding supratentorial NCs. A 43-year-old woman presenting with right hemiparesis and gait disturbance who was found to have a huge cystic lesion with calcification in her left frontal lobe underwent endoscopic fenestration to the ipsilateral lateral ventricle and biopsy. The histopathological diagnosis was consistent with NC. Postoperatively, her right hemiparesis and gait disturbance disappeared. Postoperative MRI showed shrinkage of the cyst. She was discharged without neurological deficits and no recurrence was seen 1 year after surgery. To the best of our knowledge, there have been no reports of a supratentorial intraparenchymal NC treated by neuroendoscopic fenestration. Minimally invasive treatments, such as neuroendoscopic cyst fenestration, can be considered depending on the location of the cyst.

Symmetric dumbbell ganglioneuromas of bilateral C2 and C3 roots with intradural extension associated with von Recklinghausen's disease: case report.

BACKGROUND: Ganglioneuromas are rare benign tumors arising most commonly from the sympathetic nervous system. They occasionally grow in a dumbbell fashion extending into the spinal canal extradurally. However, ganglioneuromas of the cervical spine with intradural extension or multiple locations or in association with von Recklinghausen's disease are rare. CASE DESCRIPTION: A 35-year-old man with von Recklinghausen's disease presented with tetraparesis and respiratory dysfunction. Preoperative neuroimaging revealed an intradural mass extending from the foramen magnum to the C4 vertebral level, as well as bilateral extravertebral extension connecting it with bilateral paraspinal lesions in a dumbbell fashion. Four intradural tumors associated with the bilateral C2 and C3 nerves and located ventrally were removed, leaving the intraforaminal and extradural portion intact. The procedure resulted in postoperative symptomatic improvement. Second, extravertebral tumors of the left neck, which were not related to the cervical sympathetic nerve, were removed. The pathologic diagnosis of the tumors of both the intradural space and cervical neck was ganglioneuroma. CONCLUSION: We present an extremely rare case in an adult with von Recklinghausen's disease who had bilateral, symmetric and multiple dumbbell ganglioneuromas with intradural extension, and also multiple bilateral ganglioneuromas at the neck. The intradural ganglioneuromas were suspected to have originated from the posterior root ganglions of the bilateral C2 and C3 nerves and to have extended ventrally to the spinal cord involving not only sensory but also motor rootlets; the ganglioneuroma of the neck was suspected to have originated from the cervical nerve itself.

Re-occlusion of the superior sagittal sinus after surgical recanalisation.

A 24-year-old woman was struck on the head by a hammer. Because of early signs and symptoms of intercranial hypertension, she underwent surgery for elevation of the depressed fragments which was compressing the superior sagittal sinus (SSS). After operation, the intracranial pressure (ICP) once decreased, but it gradually increased again. After hypothermia and barbiturate therapy, she recovered fully except for partial visual field defect due to brain contusion. A carotid angiogram 28 days after injury revealed complete occlusion of the whole SSS with good collateral circulation. After brain edema had subsided, a follow-up angiogram revealed normal blood flow through the SSS. Elevation of depressed bony fragments is required for a case presenting with early signs and symptoms of intracranial hypertension due to sinus compression. In a case with severe destruction of the SSS, one needs to know that re-occlusion of the dural sinus may occur after surgical recanalisation.

Surgical experience with resection en bloc of intramedullary astrocytomas and ependymomas in the cervical and cervicothoracic region.

We performed 8 operations on 7 patients with benign intramedullary astrocytomas and ependymomas in the cervical and cervicothoracic region. All patients initially underwent gross total tumor resection en bloc. One patient with an astrocytoma showed tumor recurrence postoperatively, and underwent a second operation resulting in subtotal removal. The follow-up after the initial surgery ranged from 2.7 to 19.7 years (mean 8.5 years). Symptomatic improvement was observed in 6 patients after the initial operation. Two patients showed postoperative neurological deterioration, one with an ependymoma and the other after the second operation. No operative complications or deaths, nor postoperative respiratory dysfunction occurred. Benign intramedullary astrocytomas and ependymomas of the cervical and cervicothoracic spinal cord can be treated by radical resection en bloc with a low morbidity and recurrence, as well as acceptable outcomes. We describe here the surgical technique for en bloc tumor removal.