Minimally invasive management of the third ventricle glioma in a patient without hydrocephalus: neurofiberscopic biopsy followed by gamma knife radiosurgery.

There is usually concern that ventricular enlargement is necessary for safe neuroendoscopic procedures. However, newly developed models of neurofiberscopes with a small outer diameter can be effectively used even in patients without ventriculomegaly. We present the case of a successful neurofiberscopic biopsy of a third ventricle anaplastic astrocytoma in a previously shunted patient without hydrocephalus. Subsequent gamma knife radiosurgery led to complete disappearance of the tumor. It seems that presence of collapsed ventricles, and even symptoms consistent with the slit ventricle syndrome, should not be considered as contraindications for neurofiberscopic surgery when brain compliance is sufficiently preserved. The latter should be considered as the key point of safe endoscopic manipulations. The combination of the neuroendoscopy and stereotactic radiosurgery provides wide possibilities for minimally invasive management of selected intracranial tumors.

Coronary flow reserve after coronary intervention in similar in patients with preserved viability in previous myocardial infarction and in those with angina pectoris.

The relationship between coronary flow reserve (CFR) and viability in the infarcted myocardium has not been fully clarified. We measured coronary blood flow velocity immediately after coronary intervention (with percutaneous transluminal coronary angioplasty [PTCA] or stenting) in 38 patients with previous myocardial infarction and preserved viability and 48 with angina pectoris. CFR was calculated and was similar between the two patient groups. No differences in the incidence of post-intervention CFR > 2.0 were detected; there were no differences in post-intervention CFR between patients with preserved myocardial viability and those with angina pectoris who underwent PTCA. Coronary stenting reduced the percentage diameter stenosis in both groups compared with PTCA and slightly increased the post-intervention CFR. No differences were, however, detected in post-intervention CFR between patients with preserved myocardial viability and those with angina pectoris who underwent additional stenting. These results reveal that in patients with preserved myocardial viability, post-intervention CFR was restored to values similar to those in patients with angina pectoris.

Flexible endoscope-assisted endonasal transsphenoidal surgery for pituitary tumors.

We have performed rigid endoscope-assisted endonasal transsphenoidal microsurgeries for pituitary tumors in 230 patients. Recently, we further introduced the use of a flexible endoscope to inspect the tumor bed and suprasellar structures more extensively. We report our experience with the flexible endoscope in endonasal transsphenoidal surgery for pituitary tumors. The endoscopes were used to complement the microscope in visualization. The flexible endoscopes were used in 34 recent cases with suprasellar and/or lateral tumor extension. During or after removal of the main tumor bulk, the flexible endoscope together with a rigid endoscope was used to inspect the tumor cavity, especially at the blind spot of the microscope. Despite limited resolving power, in all the 34 cases the flexible endoscope was a highly efficient tool permitting extensive visualization of almost the whole surgical area, even in narrow surgical fields and spaces not visible with an operating microscope or a rigid endoscope, and allowing continuous change of viewing angle. The residual tumor situated laterally or in the suprasellar areas that could not be reached and was impossible to remove by a rigid endoscope could be dissected and extirpated under a flexible endoscope using grasping forceps in 5 patients with pituitary adenoma and all the craniopharyngioma cases. The flexible endoscope may be more efficient in the lateral and suprasellar areas than the rigid endoscope in compensating for the narrow surgical field in endonasal pituitary surgery, despite its limited resolving power. Surgeons should make the best use of the advantages of each instrument.

Ectopic clival craniopharyngioma.

Ectopic craniopharyngioma is a rare entity. The authors present a very rare case of an ectopic clival craniopharyngioma completely separate from the sella turcica.A 44-year old woman presented with abducens palsy. A MR imaging study and a CT scan revealed a cystic clival lesion separate from the sella turcica. Surgical resection was performed successfully with flexible endoscope-assisted procedure using an endonasal transsphenoidal approach. No evidence of involvement of the sellar region was found according to radiological, intra-operative, and clinical findings.A review of the literature revealed no other such cases. The discussion includes the formation of craniopharyngioma from the ectopic Rathke's pouch remnants and the surgical approach for clival lesions. We believe that our approach provides good results with minimal invasiveness for some clival lesions.

Intraventricular hemorrhage in neonates: endoscopic findings and treatment by the use of our newly developed Yamadori-type 8 ventriculoscope.

Profound intraventricular hemorrhage (IVH) has devastating effects on neonates, leading to significant neurodevelopmental morbidity. We have developed a flexible fiberoptic ventriculoscope (Yamadori-type 8), which has a conspicuously high resolving power and is equipped with a bipolar coagulator and a working channel for irrigation. Four neonates with IVH were examined and treated for the first time using the flexible ventriculoscope. The patients had grade III or IV IVH on computed tomography scans and received endoscopic operations three to four weeks after birth. In patients with IVH, fragments of old hematomas were observed as brown masses because of the presence of hemosiderin, a characteristic endoscopic finding. We have found, for the first time, IVH due to rupture of the varices of septal veins, which could be cauterized endoscopically. Hydrocephalus was relieved by irrigation, third ventriculostomy, coagulation of the choroid plexus, and adequate placement of ventriculoperitoneal shunting was performed endoscopically. The flexible ventriculofiberscope could be a useful modality for early treatment of IVH in neonates because of the minimal invasiveness. The pathogenesis of IVH should be reviewed to include septal vein varices as a possible cause of IVH.

Endoscopic treatment of hydrocephalus in children: a controlled study using newly developed Yamadori-type ventriculoscopes.

Although cerebrospinal fluid (CSF) shunting is the most common neurosurgical treatment for hydrocephalus, the long-term results have still been unsatisfactory because of a wide variety of shunt complications. We have recently developed flexible ventriculoscopes (Yamadori-type) which have excellent image quality, maneuverability, and capabilities for endoscopic operation. Here we report the efficacy of the new treatment in 88 children with hydrocephalus who initially underwent either ventriculoscopic operation or shunting surgery. The primary outcome measures were the rate of shunt independency and/or shunt complications with a follow-up of 2 years in each group. We performed endoscopic third ventriculostomy in cases of aqueductal stenosis, cyst fenestration, and choroid plexus coagulation in limited cases of communicating hydrocephalus. Overall, thirty-three (75%) of the 44 children initially treated endoscopically did not require ventriculoperitoneal (VP) shunts. The endoscopic procedures were repeated in the remaining 11 children (25%) mostly less than 1-year-old who ultimately required endoscope-guided VP shunting. Even in such patients, there was virtually no need for shunt revisions and no major complications such as slit-like ventricle, meningitis, and intraventricular hemorrhage. These results were statistically highly significant (p < 0.0001) compared to a control group of 44 patients treated initially by VP shunting. Our data demonstrate that therapeutic ventriculoscopy is safe and clinically effective as the first-line treatment of hydrocephalus in children.

Application of flexible neuroendoscopes to intracerebroventricular arachnoid cysts in children: use of videoscopes.

Videoscopes used in other parts of the human body are potential tools for neuroendoscopy as long as they are slim enough, because they provide exceptionally high resolution images. We describe the application of flexible videoscopes and neuroendoscopes developed in Japan to intraventricular arachnoid cysts in children. Thirty-eight children with middle fossa arachnoid cysts were treated either by conventional cystoperitoneal shunting operations (n = 28) or by neuroendoscopes (n = 10). Neuroendoscopic operations such as cyst fenestration were highly useful, eliminating the need for open surgery for cyst excision/fenestration or cystoperitoneal shunting operations in all of the patients during a mean follow-up period of 17.7 months. Statistically highly significant reductions were observed in the major complications (p < 0.0001 by chi(2)-test) because shunting operations were inevitably accompanied by shunt malfunction, infection, or dependence. Compared to the traditional neuroendoscopes, our slim videoscopes provided outstanding image quality, allowing for more comprehensive examination and treatment while minimizing operative trauma.

A patient whose cerebral aneurysm ruptured soon after an operation to remove a maxillary cyst.

A hypertensive woman complained of a headache soon after an operation to remove a maxillary cyst. A computed tomogram showed evidence of subarachnoid haemorrhage and on angiogram an aneurysm of an anterior cerebral artery. The aneurysm was treated by clipping and the patient recovered.

Pineoblastoma showing unusual ventricular extension in a young adult--case report.

A 19-year-old male presented with a 4-week history of headache. Neurological examination showed bilateral papilledema. Computed tomography revealed a pineal region mass with remarkable obstructive hydrocephalus. Magnetic resonance imaging showed a pineal region tumor continuously invading through the tectum into the cerebral aqueduct and the fourth ventricle with the preservation of the adjacent structures. The tumor appeared an iso- to hypointense mass on T1-weighted images, a heterogeneous iso- to hyperintense mass on T2-weighted images, and a heterogeneously enhanced mass after administration of contrast medium. Histological examination after endoscopic biopsy confirmed that the tumor was a pineoblastoma. Radiotherapy was given to the whole brain and the spinal cord, and magnetic resonance imaging showed complete remission of the tumor. Pineoblastomas are highly malignant tumors with seeding potential through the neighboring ventricle or along the meninges, and this type of tumor becomes larger with local extension. We found no previous reports of the continuous extension into the fourth ventricle. The present case showed ventricular extension with minimal mass effect to adjacent structures, and did not disturb ventricular configuration. According to the unusual finding of ventricular extension, this rare case of pineoblastoma requires adjuvant chemotherapy.

[A case of primary cerebral neuroblastoma surviving for eight years].

We report a case of a patient with primary cerebral neuroblastoma who has survived for 8 years. A 10-year-old boy was admitted to our hospital because of headache and nausea. CT scan on admission revealed a large cystic tumor on the right frontal lobe. Subtotal tumor resection was carried out. A second operation was performed for the residual tumors which were removed meticulously with confirmation of the absence of tumor cells on each frozen section. After tumor removal, YAG laser was applied at each local area. Histological diagnosis disclosed primary cerebral neuroblastoma. Because of postsurgical meningitis and parent's refusal, neither chemotherapy nor radiation therapy was performed. There have been no findings of the tumor recurrence during the last eight years, and now the patient is enjoying high school life to the full, without any neurological deficits. In reviewing the literature, outcomes of neuroblastoma cases are very poor. Our case seems to be one of the rare long-survival cases.

[A case of renal pelvic cancer with high serum level of CA 19-9].

A case of left renal pelvic cancer with a high level of serum CA19-9 is reported. Radiological examination showed a left renal pelvic cancer with lymph node metastasis, but did not reveal any tumors producing CA19-9 in any other organs. Chemotherapy was performed in addition to left total nephroureterectomy. The serum level of CA19-9 decreased to the normal range within three weeks after the operation. Immunohistochemical examination demonstrated that CA19-9 might have been produced from the tumor cells themselves in this case.

[Treatment and diagnosis of middle fossa arachnoid cyst: ventriculofiberscopy and cine-MRI].

The treatment of intracranial arachnoid cysts in controversial regarding its surgical indication and operative procedures. Conventional surgical approaches such as fenestration, membranectomy, and shunting operation are invasive. Also CT cisternography and/or RI cisternography are invasive, when it has been performed to evaluate the possible CSF communications between the arachnoid cyst and subarachnoid space. Between July 1994 and February 1997, 10 patients with intracranial middle fossa arachnoid cysts were treated with a newly developed ventriculofiberscope which is characterized by splendid mechanical flexibility and high resolution. The cine-MRI, which is a non-invasive diagnostic tool, is used to evaluate the CSF circulation around the cyst fenestration. The patients' ages ranged from 4 months to 10 years, with a mean of 4.46 years. The cyst locations were left middle fossa (9), and right (1). Eight patients presented with macrocrania, 4 with developmental delay, three with seizure, two with headache, and one with subdural hematoma. The patients were preoperatively evaluated by means of MRI and cine-MR images. In all patients ventriculofiberscopic procedures including cyst fenestration, membranous dissection, cyst puncture and shrivelling were successfully performed. Postoperative MR and cine-MR studies have shown reduction of the cyst size and appropriate CSF circulation. Neuroendoscopic procedures seem to be the choice for children with arachnoid cysts and the ventriculofiberscope proved to be very useful not only for cyst fenestration but also for cyst dissection. In addition, the non-invasive cine-MR studies are useful for long follow-up at OPD.

[14C-oxalate autoradiographic studies on distribution of oxalate and calcium oxalate crystal fixation in rat kidney].

To elucidate the intrarenal distribution of oxalate and to reveal the first site of calcium oxalate crystal fixation along the nephron, we carried out 14C-oxalate renal microautoradiography by the thaw mount method 30, 60 and 90 min after intravenous administration of 14C-oxalate, in normal rats and in hyperoxaluric rats fed a vitamin B6-deficient diet for 4 and 9 weeks. In normal rats, radioactivity was observed in the entire kidney area at 30 min after the injection and at 90 min there was radioactivity only in the papilla, where radioactivity appeared in the parenchyma, mamely the epithelial cells of collecting ducts and the surrounding interstitial tissue. In hyperoxaluric rats, microautoradiograms showed the spotted deposits of 14C-oxalate in both renal papilla and medulla. In 600 x magnification of the autoradiograms, most of the deposits were detected in the epithelial cells of collecting ducts and the surrounding interstitial tissue. These deposits were identified by a polarizing microscope and X-ray microanalysis as crystal deposits of calcium oxalate. These results indicated that oxalate remained for an extended period of time in the epithelial cells of collecting ducts and in the surrounding interstitial tissue in renal papilla, and the calcium oxalate crystals fixed to the same tissue was the first step in the development of calcium oxalate stones.

[The management of slit-like ventricle with the Medos programmable Hakim valve and the ventriculofiberscope].

A slit-like ventricle is one of the serious complications which can occur after a shunting operation. Low pressure valve systems are usually applied for hydrocephalus during infancy. As a result the shape of the ventricle often becomes slit-like after the operation. Many shunt dependent children with slit-like ventricles have to undergo shunt revisions repeatedly. From April 1995 to February 1997 the authors used the Medos programmable Hakim valve system for 20 hydrocephalic children with slit-like ventricles who had been suffering from multiple shunt problems. The patients ages at the operation were between 3-16 Male:Female was 12:8. Follow up periods were 10-20 months. In 12 of 20 patients the shunt revisions were performed at the time of shunt dysfunction and the valve pressure levels were able to be set at the highest levels without the appearance of any symptoms. In this group the size of all the ventricles had become slightly enlarged. In the other 8 patients the operations were performed for fear of other troubles arising if shunt revisions were neglected. In this group the valve pressure levels were set with reference to the intraoperative ICP. It took a relatively long period to elevate the valve levels. Shunt dysfunction due to obstruction of the ventricular catheter was seen in one case but the symptom was not so severe and the catheter which had firmly adhered to the choroid plexus was removed endoscopically. In 2 cases of this series the shunt systems were successfully eliminated. The authors report the method and efficacy of their series using the Medos programmable Hakim valve system and a newly developed ventriculofiberscope for the slit-like ventricle of children.

Role of the transition zone for elevating serum prostate-specific antigen in benign prostatic hyperplasia.

BACKGROUND: Patients with benign prostatic hyperplasia (BPH) have a wide range of concentrations of PSA. However, it is not known what factors influence the concentration of serum PSA other than the prostate volume. BPH is composed of an enlarged transition zone (TZ) and other zones (nonTZ). The TZ is thought to play a more important role than the nonTZ in determining the concentration of serum PSA in BPH patients. METHODS: We investigated the individual glandular zone volume, the amount of PSA produced by each zone and the PSA density in each zone in 23 patients with histologically-confirmed BPH. The PSA density in the TZ was calculated by dividing the difference between the serum PSA before and after surgical resection by the specimen weight. We examined the influence of these parameters on the concentration of serum PSA in BPH patients. RESULTS: The serum PSA concentration correlated with the amount of PSA produced by the TZ (r=0.90, P< 0.0 1), but not the nonTZ (r=0.25, P=0.29). The concentration of serum PSA also showed a significant correlation with the TZ volume (r=0.67, P< 0.01) and the PSA density in the TZ (r=0.51, P< 0.05), but not with the PSA density in the nonTZ (r=-0.06, P=0.81). Also, age was inversely correlated with the PSA density in the TZ (r=-0.69, P< 0.01). CONCLUSION: The hypertrophic prostate cell volume (TZ volume) and activity (PSA density in the TZ) significantly correlated with the concentration of serum PSA in BPH patients, and the TZ cell activity decreased inversely with age in these BPH patients.

Development of flexible ventriculoscope (Yamadori-type VII) and its application to experimental animals.

We developed a new ventriculoscope (Yamadori-type VII), a 2.1 mm calibrated fiberscope with a monopolar coagulator, that can be inserted from the cisterna cerebellomedullaris into the third cerebral ventricle of experimental animals, like dogs. With the improved performance of the neuroendoscope compared to its prototype, Yamadori III, it was possible to inspect clearly and to produce electrocoagulative lesions accurately on any part of the intraventricular structures with minimal injury to nearby vital brain areas.

[Treatment of hydrocephalus without shunt placement: third ventriculostomy].

Hydrocephalus is usually treated by placing an extracranial CSF shunt. Endoscopic third ventriculostomy, however, has been revived recently as a less invasive method for treatment. We intended to avoid shunting or to eliminate the previously placed shunt with this procedure. The authors review their experiences on third ventriculostomy employing a flexible neuroendoscope under video monitoring in 14 cases of pediatric hydrocephalus. The result was that we succeeded in 11 cases (79%) by third ventriculostomy alone; we avoided shunting in 8 cases and eliminated a previously placed shunt in 3 cases. Clinical summary is shown on Table 1, and illustrative cases are presented with the figures and legend. The patients' group consisted of 8 males and 6 females. Their age ranged from 1 month to 17 years (average age, 6 yr) old. Background diseases of hydrocephalus were brain tumor in 6 cases, Chiari type I malformation in 3, intraventricular hemorrhage in 3, neonatal meningitis in 1 and arachnoid cyst in 1 case. In the remaining 3 cases, however, we failed to avoid the necessity of placing shunt because of indirect reasons (recurrence of tumor, infection after another operation, subdural fluid collection). There was no major complication in relation to third ventriculostomy, except for a moderate elevation of temperature of several days' duration following the procedure. Indication and outcome of this operation is also discussed. Endoscopic third ventriculostomy is an efficacious procedure for the treatment of hydrocephalus in selected patients.

[Autoradiographic studies of oxalate distribution in rat kidney].

BACKGROUND: We performed macro and micro-autoradiographic studies using 14C-oxalate in normal and hyperoxaluric rats in order to elucidate intrarenal distribution of oxalate and to determine where calcium oxalate crystal can be adhere in the kidney. METHODS: Macro and micro-autoradiographic studies of the kidney in normal rats were carried out at intervals of 15, 30 and 90 min after intravenous administration of 14C-oxalate (37 MBq/kg BW). Hyperoxaluria was induced by vitamin B6 deficient diet. The procedure of macro and micro autoradiography is the same as that in normal rat. RESULTS: In normal rats, macroautoradiogram showed that the radioactivity of 14C-oxalate exists in the whole kidney, and microautoradiogram identified this radioactivity mainly in the extraluminal space of renal tubules at 15 min. Macro and micro-autoradiograms taken 90 min after the injection showed practically no radioactivity of 14C-oxalate in the cortex or the medulla, but it was located in the extraluminal space of the papilla. In hyperoxaluric rats, macroautoradiogram showed some spotty accumulations of 14C-oxalate in the inner medulla and papilla. Microautoradiogram revealed that these accumulations are mainly seen in the extraluminal space. CONCLUSION: These results indicate that in normal rats the injected 14C-oxalate remains in the renal papilla, especially in the extraluminal space, when nearly all oxalate was excreted by urine, and in hyperoxaluric rats 14C-oxalate exists there as calcium oxalate crystal or microlith.