Postoperative Intratumoral or Peritumoral Hematomas After Vestibular Schwannoma Resection.

BACKGROUND: Surgical removal of a vestibular schwannoma is a complex and challenging procedure, which may be complicated by development of postoperative hematomas, particularly after incomplete resection of the tumor. OBJECTIVE: To investigate the occurrence of postoperative intra- or peritumoral hematomas after surgery for a vestibular schwannoma. METHODS: This retrospective study evaluated 49 patients (age range 17-78 years) with a vestibular schwannoma, who were treated surgically via the lateral suboccipital approach between 2011 and 2016. The tumors ranged in size from 0 mm (in a case of an intracanalicular lesion) to 56 mm. In 30 cases (61%), total or near-total resection was accomplished, and in 19 cases (39%), subtotal or partial resection was done. On the basis of their bleeding tendency during tumor removal, the patients were divided into a "less-bleeding" (38 cases; 78%) and a "more-bleeding" (11 cases; 22%) subgroups. RESULTS: A maximal vestibular schwannoma diameter >30 mm, patient age >60 years, and more bleeding during tumor removal were significantly associated with incomplete (subtotal or partial) resection. In six cases (12%), serial computed tomography after surgery demonstrated a postoperative hematoma, which was caused by insufficient irrigation of the surgical field (in two cases) or resulted from peritumoral hemorrhage (in two cases), intratumoral hemorrhage (in one case), or both intra- and peritumoral hemorrhage (in one case). The latter patient required urgent reoperation. In all cases, postoperative hematomas occurred after incomplete (subtotal or partial) resection of a vestibular schwannoma, and their development was significantly associated with more bleeding during tumor removal. CONCLUSION: For avoidance of postoperative hematomas, careful hemostasis is required after completion of vestibular schwannoma removal, especially in cases with incomplete resection and an excessive bleeding tendency of the tumor tissue.

Petroclival tension pneumocephalus: an unrivalled life threatening complication linked to molecular-targeted therapy.

A 73-year-old man with a petroclival tumor (metastatic renal cell carcinoma) presented with a progressive consciousness disturbance attributed to tension pneumocephalus during molecular-targeted therapy following low-dose fractionated radiotherapy for a petroclival tumor. The skull base defect was successfully reconstructed vi an endoscopic endonasal approach.

Pitfalls of skull base reconstruction in endoscopic endonasal approach.

Various skull base reconstruction techniques have been developed in endoscopic endonasal approach (EEA) for skull base lesions to prevent postoperative cerebrospinal fluid (CSF) leakage. This study was performed to evaluate the efficacy and pitfalls of our method of skull base reconstruction after EEA. A total of 123 patients who underwent EEA (127 surgeries) between October 2014 and May 2017 were reviewed. Our algorithm for skull base reconstruction in EEA was categorized based on intraoperative CSF leakage graded as follows: grade 0 was excluded from this study; grade 1, dural suturing with abdominal fat graft or packing of gelatin sponge into the cavity; grade 2, method for grade 1 with addition of mucosal flap or nasoseptal flap (NSF); and grade 3, duraplasty in fascia patchwork closure with NSF. Bony reconstruction was not mandatory, and there was no postoperative bed rest or initial lumbar drainage (LD) insertion in any of the cases. Postoperative CSF leakage after EEA was mostly prevented (96.3%) by our algorithm without postoperative initial LD or bed rest. On the other hand, reconstruction surgery was required for postoperative CSF leakage in two cases-one with prior multitranssphenoidal surgery and radiotherapy and another patient with poor compliance due to communication difficulties. Both of the latter patients were obese. Greater care with regard to postoperative CSF leakage is required in patients with prior EEA with radiotherapy and obesity. In such high-risk patients, initial LD or bed rest may be required to prevent postoperative CSF leakage. It is also important to restrict activities that result in increased intracranial pressure.

STA-ACA bypass using the ipsilateral free STA graft as an interposition graft and A3-A3 anastomosis for treatment of bilateral ACA steno-occlusive ischemia.

BACKGROUND: Anterior cerebral artery (ACA)-related ischemia is a rare entity in patients with atherosclerosis. Some surgical treatments are reported to date. METHOD: We present the modification of intracranial-intracranial and intracranial-extracranial bypasses for symptomatic bilateral ACA steno-occlusive disease. The A3-A3 bypass followed by the superficial temporal artery-ACA bypass using the ipsilateral free superficial temporal artery graft is useful without harvesting of the radial artery. CONCLUSION: Bilateral ACA steno-occlusive induced ischemia can be treated with tailored bypass procedures.

Clipping Surgery for Paraclinoid Carotid Aneurysm.

BACKGROUND: Paraclinoid carotid aneurysm is widely treated with coil embolization. However, all paraclinoid carotid aneurysms cannot be obliterated by the endovascular approach. METHODS: Our direct surgical procedure was presented. The clinical data of surgically treated paraclinoid carotid aneurysms were retrospectively reviewed. RESULTS: One hundred ninety paraclinoid carotid aneurysms in 181 patients were directly obliterated at the Shinshu University Hospital and its affiliated hospitals between 1991 and 2013. CONCLUSIONS: Direct surgical repair of the paraclinoid carotid aneurysm is still useful, even in the era of endovascular treatment.

Unique double recurrence of cerebral arteriovenous malformation.

Surgically treated patients with arteriovenous malformations (AVMs) are considered cured when the postoperative angiogram proves complete resection. However, despite no residual nidus or early draining vein on postoperative angiogram, rare instances of AVM recurrence have been reported in adults. In this paper, the authors present a case of a 24-year-old woman with asymptomatic double recurrence of her cerebral AVM after angiographically proven complete resection. To the authors' knowledge, this patient represents the first case with double de novo asymptomatic recurrence of Spetzler-Martin grade I AVM. Also, she represents the first case with unique AVM criteria in each recurrence.

Transradial Mechanical Thrombectomy Using a Radial-specific Neurointerventional Guiding Sheath for Anterior Circulation Large-Vessel Occlusions: Preliminary Experience and Literature Review.

BACKGROUND: Transradial mechanical thrombectomy (MT) is increasingly used because it is associated with a low incidence of vascular access site complications. However, transradial carotid cannulation can be technically challenging to perform in patients with an unfavorable supra-aortic takeoff. In this study, the feasibility and safety of a new transradial MT system with a radial-specific neurointerventional guiding sheath-6F Simmons guiding sheath was evaluated-in patients with anterior circulation large-vessel occlusions. Additionally, a literature review was performed. METHODS: We retrospectively analyzed data from our institutional database about consecutive patients who underwent transradial MT for anterior circulation large-vessel occlusion. After the 6F Simmons guiding sheath was engaged into the target common carotid artery, a triaxial system (Simmons guiding sheath/aspiration catheter/microcatheter), was established. MT using the continuous aspiration prior to intracranial vascular embolectomy technique was performed. Then, procedural success rate, successful revascularization, and procedure-related complications were assessed. RESULTS: A total of 13 patients who had transradial MT were included in the analysis. All 13 patients underwent successful thrombectomy without catheter kinking or system instability, and 12 of them achieved successful revascularization (modified Thrombolysis in Cerebral Infarction score of ≥2b). No complications occurred. CONCLUSIONS: To the best of our knowledge, this is the first case series on transradial MT using a radial-specific neurointerventional system for anterior circulation large-vessel occlusions. This method may increase the success rate of transradial MT. Based on our initial experience, transradial MT, using this system, was feasible and safe for anterior circulation large-vessel occlusions.

Treatment Strategy for Giant Invasive Macroprolactinoma with Spontaneous Cerebrospinal Fluid Rhinorrhea: A Case Report and Literature Review.

BACKGROUND: Spontaneous cerebrospinal fluid (CSF) rhinorrhea associated with untreated prolactinomas is rare, which is in contrast to medical treatment-induced CSF rhinorrhea. Previous studies have suggested that cessation of drug administration should be the first line of treatment for prolactinoma with medically induced CSF rhinorrhea. On the other hand, there is no standard treatment strategy for prolactinoma with the development of spontaneous CSF rhinorrhea, because of its complicated pathology. Here, we report a case of giant invasive macroprolactinoma with spontaneous CSF rhinorrhea, and discuss the treatment strategy for this complicated condition with a review of the relevant literature. CASE DESCRIPTION: A previously healthy 39-year-old man presented with 1-year history of intermittent clear fluid nasal discharge with headache and vomiting. Magnetic resonance imaging showed a large parasellar mass with destruction of the skull base. This tumor was diagnosed as prolactinoma with hypopituitarism based on the results of hormone examinations. Tumor resection with skull base reconstruction in the endoscopic endonasal approach was performed because CSF rhinorrhea was aggravated by bromocriptine loading test and administration of dopamine agonist. Life-threatening bacterial meningitis occurred after surgery, which was cured with antibiotics along with resolution the CSF rhinorrhea. CONCLUSIONS: Careful consideration is necessary before applying standard first-line protocols with dopamine agonist administration in patients with prolactinoma, especially in cases with spontaneous CSF rhinorrhea. An appropriate treatment strategy should be planned according to the individual case, including factors such age, sex, pituitary function, tumor mass size, prolactin concentration, and condition of CSF leakage.

Cyst fenestration and Ommaya reservoir placement in endoscopic transcortical transventricular approach for recurrent suprasellar cystic craniopharyngioma without ventriculomegaly.

The efficacy of the endoscopic transcortical transventricular approach (ETTA) for craniopharyngioma in the third ventricle with hydrocephalus has been reported focusing on its reduced invasiveness. On the other hand, suprasellar craniopharyngioma without ventriculomegaly is generally surgically managed by craniotomy or the endoscopic endonasal approach (EEA). Here, we report an elderly patient who received cyst fenestration and Ommaya reservoir placement in ETTA for recurrent suprasellar cystic craniopharyngioma without ventriculomegaly. The ETTA as a less invasive procedure is feasible in patients not only with intraventricular craniopharyngioma but also with suprasellar craniopharyngioma without hydrocephalus provided a navigational system is applied and the surgeon has ample experience with transcranial endoscopic procedures.

Resection and imbrication of symptomatic sacral Tarlov cysts: A case report and review of the literature.

BACKGROUND: Symptomatic Tarlov cysts are extremely rare, and there is no consensus regarding their optimal surgical management. Here, we encountered a patient with a symptomatic sacral Tarlov cyst and reviewed the appropriate literature. CASE DESCRIPTION: A 40-year-old male presented with right lower extremity pain and hypoesthesia in the right S2 dermatome. The lumbosacral MR demonstrated a right S2 Tarlov cyst compressing the S2-S3 perineural sheaths. After the patient underwent microscopic cystectomy with obliteration of the subarachnoid connection to the cyst, the patient's symptoms resolved. Here, we reviewed our operative approach, and others proposed in the literature for the surgical management of these lesions. CONCLUSIONS: Here, we present a 40-year-old male who was symptomatic from a right S2 Tarlov cyst compressing the S2-S3 perineural sheaths and successfully underwent microscopic cystectomy with obliteration of the subarachnoid connection. Additionally, the appropriate Tarlov cyst literature was reviewed.

Gliosarcoma in the Cerebellopontine Angle with Rapid Tumor Growth and Intratumoral Hemorrhage.

BACKGROUND: Gliosarcoma is a relatively rare and bimorphous brain tumor, predominantly located in the brain lobe. Here, we report a rare case of gliosarcoma presenting radiologically in the cerebellopontine angle (CPA) region. CASE DESCRIPTION: The patient was a 71-year-old woman with progressive tinnitus. A series of image examinations showed a rapidly growing CPA tumor, which enlarged from nonexistent to 4 cm in diameter with extension to the internal auditory canal in a short period of 6 months. The patient was operated on in emergency because of intratumoral hemorrhage and rapidly deteriorating neurologic symptoms. Under the diagnosis of gliosarcoma confirmed by pathologic examination, chemotherapy and radiotherapy were conducted after partial resection. The patient recovered uneventfully and the residual tumor disappeared nearly completely on the image taken 6 months later. CONCLUSIONS: Although rare, gliosarcoma should be considered in the differential diagnosis of CPA tumors, especially if it is associated with rapid tumor growth or intratumoral hemorrhage.