Indocyanine green fluorescence visualizes landmark arteries for endoscopic sinus and skull base surgery.

OBJECTIVE: Landmark arteries during endoscopic sinus surgery are currently identified on the basis of anatomy, CT imaging and navigation, and Doppler flowmetry. However, the advantage of intraoperative fluorescence imaging during endoscopic sinus surgery has not been demonstrated. This study aimed to investigate whether Indocyanine Green (ICG) is useful for visualizing landmark arteries during endoscopic sinus and skull base surgery. METHODS: Eight patients who underwent endoscopic sinus and pituitary surgeries and consented to study participation were included. After planned procedures were performed as usual, landmark arteries were examined by ICG endoscope. Recorded video and preoperative CT images were analyzed for identification of five landmark arteries: anterior ethmoidal artery (AEA), posterior ethmoidal artery (PEA), internal carotid artery (ICA), sphenopalatine artery (SPA), and postnasal artery (PNA). Identification of arteries was evaluated three grades: identifiable, locatable, unrecognizable. RESULTS: Eight patients and eleven sides were evaluated. The ICG dose was 2.5 mg/body and a single shot was sufficient for evaluation. 100 % of AEA was identified (9/9 sides), 86 % of PNA (6/7 sides), 56 % of ICA (5/9 sides), and 25 % of PEA and SPA (2/8 sides). CONCLUSION: ICG could visualize landmark arteries, even thin arteries like AEA, during endoscopic sinus and skull base surgeries. Visualization was affected by thickness of bone or soft tissue above arteries, blood clots, sensitivity setting, and angle and distance of near-infrared light irradiation. ICG visualization of landmark arteries may help avoid vascular injuries during endoscopic sinus and skull base surgeries, particularly of AEA, PNA and ICA.

[Diagnostic efficacy and pitfalls of a 64-raw multislice computed tomography scan for mild head injuries in children].

The aim of this study is to analyze the usefulness of 64-raw multislice computed tomography (CT) scans and bone images of three-dimensional CT (3D-CT) scans for evaluation of mild head injuries in children. Thirteen children (9 boys and 4 girls, less than or equal to 15 years old) with mild head injury were included in the study. Head CT scans obtained within 24 hours after injury. All children had no episodes of loss of consciousness, amnesia, epilepsy, vomiting, and no neurological abnormality on arrival at hospital. We detected 9 positive findings on CT scans, which looked like fracture lines at the frontal bone in 7 cases. The bone images of CT axial views revealed a true fracture in one case in which a skull X-ray could not demonstrate a fracture line, but, other positive findings turned out to be a diploic vein surrounded by a thin bone cortex. All false positive findings were detected in the patients under the age of 6. By the 3D-reconstructive CT scan, it is easier to detect not only the intracranial lesions but also the cranial fracture. But, the diploic vein is apt to be misdiagnosed as the fracture line, especially in patients under the age of 6.

High expression of L-type amino acid transporter 1 in infiltrating glioma cells.

L-type amino acid transporter 1 (LAT1), a neutral amino acid transport agent, is essential for the transport of large neutral amino acids. LAT1 also corresponds to tumor-associated gene-1 (TA1), an oncofetal antigen that is expressed primarily in fetal tissues and cancer cells such as glioma cells. We have investigated the expression of the transporter in the human primary glioma tissue from 68 patients. Among these patients, we could see the border zone between tumors and normal bain tissues in 10 patients. By WHO criteria, two of the specimens were diagnosed as grade 2, three as grade 3, and five as grade 4 [glioblastoma multiforme (GBM)]. In 9 of 10 cases, we could identify the infiltrating glioma cells associated with stronger immunoreactivity for LAT1. These tumor cells aggregated around the neurons in the border zone and were often found in the perivascular space. In one GBM case, the tumors seemed to develop expansively and separated from the normal brain with a border of arachnoid membrane. The expression of LAT1 was always higher in infiltrating glioma cells than in cells located in the center of the tumor. These findings suggest that LAT1 is one of the molecular targets for glioma therapy.

[A case of bleeding dural arteriovenous fistula of the transverse-sigmoid sinus with pure leptomeningeal drainage, varix: case report].

We reported a case of bleeding from the varix of a transverse-sigmoid sinus dural arteriovenous fistula with pure leptomeningeal drainage. A 55-year-old man presented with visual disturbance. neurological examination revealed left homonymous hemianopsia. CT scans demonstrated a subcortical hemorrhage in the right occipital lobe. Right external carotid angiograms showed a dural arteriovenous fistula of the transverse-sigmoid sinus fed by middle meningeal arteries and the occipital artery. The draining vein was the cortical vein with a varix. Transverse and sigmoid sinuses were patent. We concluded that the cause of the subcortical hemorrhage was a varix of the dural arteriovenous fistula. Initially, we embolized the dural arteriovenous fistula using a transarterial approach with GDC. Additionally, we interrupted the draining vein of the dural arteriovenous malformation. Angiographic cure was obtained and the postoperative course was uneventful. We discussed the clinical features, and the management of this case.

[The improvement in regional cerebral blood flow in the anterior cranial fossa which was affected by a dural arteriovenous fistula: case report].

We report a case of dural arteriovenous fistula of the anterior cranial fossa with venous ischemia. A 55-year-old man presented with headache and visual disturbance. Neurological examination showed no abnormality. MR images demonstrated flow void at the right anterior cranial fossa. Right internal carotid angiograms showed a dural arteriovenous fistula of the anterior cranial fossa, fed by the anterior ethmoidal artery. The draining vein was the leptomeningeal vein draining into the basal vein, the straight sinus, and the left transverse sinus. 123I-IMP SPECT revealed a low perfusion area in the left occipital region. We interrupted the draining vein at the anterior cranial fossa. Angiographic cure was obtained and venous circulation was improved. 123I-IMP SPECT revealed improvement in the low perfusion area in the left occipital region. The postoperative course was uneventful. We discuss the clinical features, the hemodynamic findings and the management of this case.

[Postoperative subdural empyema due to Propionibacterium acnes].

Propionibacterium acnes are gram-positive pleomorphic rods that grow under an anaerobic condition. They are the most frequent inhabitants of sebaceous glands of skin, hair follicles, mouth, upper respiratory tract, and as a frequent contaminant in laboratory cultures. Propionibacterium acnes is an underestimated but significant cause of postneurosurgical infection, especially in the presence of foreign bodies such as shunt systems. We present a rare case with a postoperative subdural empyema in which the only pathogen isolated was Propionibacterium acnes. In our case, the clinical course was atypically rapid. The most effective antibiotic therapy for Propionibacterium acnes infections has not been established. However, high dose penicillin in combination with surgical drainage and removal of foreign bodies is recommended as the treatment of choice.