Middle meningeal artery embolization before craniotomy for infected organizing chronic subdural hematoma: A case report and review of the literature.

Background: Organizing chronic subdural hematoma (OSDH) is intractable and its radical treatment remains controversial. Middle meningeal artery embolization has emerged as an adjunctive treatment to craniotomy for OSDH. Case Description: The patient is an 86-year-old man. He had been taking warfarin for atrial fibrillation and was referred to the department for the treatment of bilateral chronic subdural hematoma (CSDH), which was found on head computed tomography after a fall. Bilateral burr hole drainages were performed, but his hematomas were organized, so the hematomas could not be drained sufficiently. The patient was discharged from the hospital without any neurological symptoms. Two months later, the patient presented with persistent fever and headache and had recurrent bilateral CSDHs. The hematoma on the right side was larger. Based on the initial intraoperative findings, OSDH was suspected, and craniotomy was performed on the right hematoma. Propionibacterium acnes were detected in the hematoma culture, and antimicrobial therapy was started postoperatively. Since the right hematoma recurred on the 7th postoperative day, bilateral middle meningeal artery (MMA) embolization with 20% n-butyl-2-cyanoacrylate was performed, followed by craniotomy for the left hematoma and drainage for the right recurrent hematoma. Antimicrobials were administered for 2 weeks after the last operations. Six months after the operations, both bilateral hematomas had almost disappeared. Conclusion: Craniotomy is effective for the treatment of infected OSDH, and MMA embolization is useful to reduce the risk of bleeding complications in the perioperative period, and may also reduce the recurrence of CSDH.

Thrombosis of the draining vein causes intracranial haemorrhage in the natural history of brain arteriovenous malformation: case report.

Rupture of arteriovenous malformations (AVM) may be caused by venous outflow restriction, but there is no radiographic evidence of this. We report a case showing only a venous thrombus preceding intracranial haemorrhage from AVM. This is the first evidence that venous thrombus results in AVM rupture in its natural history.

Posterior cerebral artery giant aneurysm associated with bilateral internal carotid artery occlusion in a Klippel-Trenaunay syndrome patient: a case report.

We experienced an extremely rare case of a giant P1-P2 partially thrombosed aneurysm associated with bilateral ICA occlusion in a Klippel-Trenaunay syndrome patient. In our experience, direct surgical clipping via a pterional approach is generally favored for aneurysms located in the junction of the P1-P2 segments, even if they are giant.

Incidental ethmoidal dural arteriovenous fistula coexisting with a pituitary adenoma exacerbating post-transsphenoidal epistaxis.

A 64 year-old man with pituitary adenoma developed massive epistaxis after an uneventful endoscopic transsphenoidal surgery. Angiography showed extravasation from the sphenopalatine artery, to which embolisation was performed. An incidentally coexisting ethmoidal dural arteriovenous fistula supplied by the ophthalmic artery aberrantly originated from the middle meningeal artery caused increased haemorrhage.

Contiguous Metastasis of Pulmonary Adenocarcinoma to Meningioma.

BACKGROUND: Metastasis from one tumor into another is known as tumor-to-tumor metastasis. We report a case of a contiguous occurrence of meningioma and brain cancer metastasis. PATIENT: A 91-year-old woman presented with a sudden onset of weakness in her right limbs and gait disturbance. Fourteen years previously, she had a tumor that was suspected to be a meningioma in the left frontal convexity with no change for several years. One year earlier to presentation she was diagnosed with lung carcinoma in the left lower lobe. RESULTS: Magnetic resonance images revealed enlargement of the tumor with perifocal edema. Histologic examination showed a meningioma with contiguous metastatic poorly differentiated adenocarcinoma, as well as a clearly defined border between the two components. The clinical origin of the metastasis was presumed to be from the left lower lobe of the lung. CONCLUSION: Although our case does not strictly fulfill the definition of tumor-to-tumor metastasis, we suggest a contiguous occurrence develops by the same mechanism and may be a subtype of this process. Although previous reports suggested the loss of epithelial cadherin (E-cadherin) expression in the recipient tumor as the cause of contiguous metastasis, E-cadherin expression was positive in our case and did not seem to be involved in the localization of the metastasis.

Neuroendoscopic hematoma removal with a small craniotomy for acute subdural hematoma.

The present study evaluated the safety and effectiveness of neuroendoscopic hematoma removal with a small craniotomy for the treatment of acute subdural hematoma (ASDH). Five patients (4 men and 1 woman) with ASDH underwent neuroendoscopic surgery with a small-size craniotomy between October 2016 and June 2018. The mean age was 87.4 years (range, 82-94). The eligibility criteria were as follows: 1) the presence of symptoms; 2) no moderate or massive brain contusion or edema; and 3) inability to use a large craniotomy because of poor general condition or absence of an anesthesiologist. After performing the small craniotomy, a 4-mm rigid endoscope was inserted and the hematoma was evacuated. Endoscopic surgery was performed under general or local anesthesia. The bleeding origin was a cortical artery in 2 cases, a bridging vein in 2 cases, and unknown in 1 case. The hematoma was completely removed without re-bleeding and the procedure was lifesaving in all cases. Three patients were discharged with independent gait following rehabilitation whereas 2 patients died due to causes unrelated to ASDH. Despite some surgical limitations, neuroendoscopic hematoma evacuation of ASDH is a safe and effective method that minimizes operative complications in some cases. Small craniotomy was sufficient for inserting and maneuvering ordinal neurosurgical instruments. This technique should be considered carefully before surgery in cases of ASDH.

Autologous bone dust technique for one burr hole surgery to prevent severe skin depression.

OBJECTIVE: One burr hole surgery is a common treatment modality for initial chronic subdural hematoma and stereotactic hematoma surgery, but severe skin depression is often a postoperative complication. We report the autologous bone dust technique, which uses autogenous bone dust generated during burr hole creation to prevent cosmetic deformity. PATIENTS AND METHODS: The autologous bone dust technique was performed for 51 sides on which burr hole surgery was conducted mainly for chronic subdural hematoma and stereotactic hematoma removal. As much bone dust as possible was collected during the burr hole creation and preserved until closure and the burr hole was plugged with the autologous bone dust. The skin depression after surgery was classified as "no or mild" or "severe" by palpating the postoperative scar. The postoperative osteogenesis was evaluated with a bone window or three-dimensional bone computed tomography (CT). RESULTS: The rate of no or mild skin depression was 86.3%. Osteogenesis in the bone window or on three-dimensional bone CT was observed in 88.6% of the cases with no or mild skin depression, whereas no osteogenesis was found in 11.4%. The rate of no or mild skin depression in patients aged greater than 82 years old (74.1%) was significantly lower than that in those aged less than 82 years old (100%). CONCLUSIONS: The autologous bone dust technique is effective in preventing skin depression after one burr hole surgery without using artificial materials.

Surgical Treatment for Primary Brainstem Hemorrhage to Improve Postoperative Functional Outcomes.

BACKGROUND: It remains controversial whether primary brainstem hemorrhage (PBH) should be managed conservatively or treated promptly by surgical evacuation of the hematoma. In the present study, we discuss 5 cases of PBH that were treated surgically and the ability of surgical management to improve postoperative functional outcomes. METHODS: The 4 patients with pontine and medullary hemorrhage underwent surgery via the lateral or midline suboccipital and trans-rhomboid fossa approach in the half-sitting position. The patient with a midbrain hemorrhage underwent surgery via the subtemporal approach in the supine lateral position. We analyzed the postoperative functional outcomes 1 week after surgery and the modified Rankin scale scores 6 months after discharge. RESULTS: Three patients with disturbance of consciousness experienced improvement in their level of consciousness. Four patients with hemiparesis improved in motor function. Oculomotor nerve function improved in 2 of 3 cases. Facial nerve function improved in 2 of 2 cases. Spontaneous respiration improved in 1 patient. The postoperative modified Rankin scale scores improved in all 5 cases. CONCLUSIONS: Because of the good results with these 5 patients with PBH, this surgical strategy could be encouraged with exclusion criteria for early initiation of rehabilitation strategies. We hope to increase our number of patients to accumulate further evidence.

Improvement of Respiratory Depression in a Patient with Primary Medullary Hemorrhage Following Removal of Hematoma in the Half-sitting Position.

Primary medullary hemorrhage is a rare event that may result in ataxic respiration. Although it remains controversial whether primary medullary hemorrhage should be managed conservatively or surgically, recent advancements in neuroimaging and microsurgical techniques have shown promise for improving outcomes and prognosis following surgery. The present report discusses the case of a 70-year-old woman admitted to our institution due to sudden-onset nausea and vomiting. The patient underwent surgical removal of a right medullary hematoma for the treatment of daytime respiratory depression and nocturnal apnea while in the half-sitting position. Following surgery, her spontaneous respiration improved, and she was discharged with independent gait. Despite the risk of venous air embolism, accumulating evidence suggests that the half-sitting position is suitable for brainstem surgery because gravity-assisted blood and irrigation drainage from the surgical field allows for cleaner dissection and reduces the need for bipolar coagulation.

Significant antitumor response of disseminated glioblastoma to bevacizumab resulting in long-term clinical remission in a patient with encephalocraniocutaneous lipomatosis: A case report.

The prognosis of recurrent and disseminated glioblastoma is very poor. Bevacizumab is an effective established therapy for recurrent glioblastoma following treatment with radiotherapy plus temozolomide. However, the efficacy of bevacizumab is limited to prolonging progression-free survival, without significant prolongation of the overall survival. We herein report a case of glioblastoma in a 32-year-old female patient with encephalocraniocutaneous lipomatosis (ECCL) that had disseminated following surgical resection and subsequent treatment with temozolomide and radiation therapy. The disseminated tumors disappeared completely after five courses of bevacizumab therapy. Surprisingly, the patient has remained in clinical remission for >2.5 years after dissemination by continuing this therapy. To the best of our knowledge, this is the first case of long-time clinical remission following glioblastoma dissemination and treatment with bevacizumab. In the present case, bevacizumab exerted an atypically strong antitumor effect against disseminated glioblastoma after multidisciplinary treatments had already been applied. Moreover, this is the first report of ECCL associated with a malignant brain tumor.