Subclavian Artery Stenting Under Cerebral Protection by Balloon-Guiding Catheter Inflation Inside the Aortic Arch at the Left Subclavian Artery Origin.

BACKGROUND: We describe a simple and novel technique for cerebral protection during left subclavian artery (SA) stenting by inflation of a balloon-guiding catheter inside the aortic arch at the SA origin. METHODS: A total of 12 patients with left SA stenosis underwent SA stenting with inflation of a balloon-guiding catheter inside the aortic arch at the left SA origin between January 2020 and December 2020. The SA stenting procedures under proximal protection were retrospectively reviewed to assess ischemic complications, hyperintense spots on diffusion-weighted imaging (DWI), and flow direction of left vertebral artery (VA) during balloon-guiding catheter inflation using ultrasonography (US). RESULTS: The success rate of the SA stenting procedure was 100% with no symptomatic ischemic complications. None of the 12 patients showed small hyperintense spots in DWI. In all patients, the left VA on US during balloon inflation showed retrograde blood flow. CONCLUSIONS: The left VA on US had retrograde blood flow during inflation of the balloon-guiding catheter inside the aortic arch at the SA origin. Therefore, the proximal balloon protection inside the aortic arch at the SA origin is a simple and maybe a safe technique for cerebral protection during SA stenting.

In-hospital mortality and poor outcome after surgical clipping and endovascular coiling for aneurysmal subarachnoid hemorrhage using nationwide databases: a systematic review and meta-analysis.

There has never been evidence for aneurysmal subarachnoid hemorrhage (aSAH) by endovascular coiling compared to surgical clipping with all grade. The present study and meta-analysis aimed to clarify the in-hospital mortality and poor outcome in the nationwide databases of patients with all grade aSAH between them. The outcome of modified Rankin scale (mRS) at discharge was investigated according to the comprehensive nationwide database in Japan. The propensity score-matched analysis was conducted among patients with aSAH in this database registered between 2010 and 2015. Meta-analysis of studies was conducted based on the nationwide databases published from 2007 to 2018. According to this propensity score-matched analysis, no significant association for poor outcome of mRS > 2 was shown between surgical clipping and endovascular coiling (47.7% vs 48.3%, p = 0.48). However, significantly lower in-hospital mortality was revealed after surgical clipping than endovascular coiling (7.1% vs 12.2%, p < 0.001). Meta-analysis of propensity score-matched analysis in the nationwide database showed no significant association for poor outcome at discharge between them (odds ratio [OR], 1.08; 95% confidence interval [CI], 0.93 to 1.26; p = 0.31). Meta-analysis of propensity score-matched analysis for in-hospital mortality was lower after surgical clipping than after endovascular coiling, however, without significant difference (OR, 0.74; 95% CI, 0.52 to 1.04; p = 0.08). Further prospective randomized controlled study with all grade aSAH should be necessary to validate the in-hospital mortality and poor outcome.

Analysis of outcome at discharge after aneurysmal subarachnoid hemorrhage in Japan according to the Japanese stroke databank.

The outcomes at discharge for ruptured cerebral aneurysms after subarachnoid hemorrhage (SAH) were investigated using data from the Japanese stroke databank. Among 101,165 patients with acute stroke registered between 2000 and 2013, 4693 patients had SAH caused by ruptured saccular aneurysm. Of these, 3593 patients (1140 men and 2453 women; mean age 61.3 ± 13.7 years) were treated by surgical clipping (SC) and/or endovascular coiling (EC). The outcomes of modified Rankin scale (mRS) at discharge were compared between the SC and EC groups. There were 2666 cases in the SC group, 881 cases in the EC group, and 46 cases in the SC and EC group. The rates of poor outcome of mRS > 2 were 33.0 and 45.5% in the SC and EC groups (p < 0.05), respectively. Cases were selected using two types of criteria compatible with both treatments. Under the first compatible criteria, the rates of poor outcome of mRS > 2 were 18.9 and 24.8% in the SC and EC groups (p < 0.05), respectively. Under the second compatible criteria, the rates of poor outcome of mRS > 2 were 16.0 and 14.8% in the SC and EC groups (p = 0.22), respectively. No significant differences were found in clinical characteristics or outcomes between the two groups. Multivariate analysis of aneurysmal SAH revealed no significant risk for poor outcome associated with the treatment method. The present study was not a randomized controlled study, but no significant differences in mRS at discharge were found between SC and EC in the Japanese stroke databank.

Effect of actual age on outcome at discharge in patients by surgical clipping and endovascular coiling for ruptured cerebral aneurysm in Japan.

The Japanese population features the highest rate of elderly individuals worldwide. However, the difference of actual age indication for surgical clipping (SC) and endovascular coiling (EC) has never reported. We clarified the effect of actual age on poor outcome at discharge in patients by each treatment for ruptured cerebral aneurysm according to the Japanese Stroke Data Bank. A total of 3593 patients with ruptured saccular cerebral aneurysm were treated by SC and/or EC between 2000 and 2013. The effect of actual age on poor outcome (modified Rankin scale [mRS] score > 2) at discharge was evaluated by the cutoff age using receiver operating characteristic analysis for each treatment. There were 2666 cases in the SC group and 881 cases in the EC group. The cutoff age for poor outcome was 3 to 9 years older for EC than for SC. The gap of cutoff age between two treatments was 3 years shorter in mild subarachnoid hemorrhage than severe cases. The gap of cutoff age between two treatments was 7 years in elderly patients over 65 years old. The cutoff age was 78 years old for both SC and EC in elderly female patients. In conclusion, the cutoff age for poor mRS score > 2 was 3 to 9 years older for EC than for SC. Actual age was one of the indications for elderly patients to achieve the optimum outcome; however, the treatment indication should be carefully considered based on the condition in each country.

Multivariate risk factor analysis and literature review of postoperative deterioration in Karnofsky Performance Scale score in elderly patients with skull base meningioma.

OBJECTIVE Elderly patients are particularly at risk for severe morbidity following surgery. Among the various risk factors, age and skull base location of meningioma are known to be poor prognostic factors in meningioma surgery. The authors conducted this study to analyze significant preoperative risk factors in elderly patients with skull base meningioma. METHODS A total of 265 elderly patients (≥ 65 years old) with meningioma were surgically treated at the authors' institute and affiliated hospitals between 2000 and 2016, and these cases were reviewed. Among them, 57 patients with skull base meningioma were evaluated. Among the various risk factors, the authors analyzed age, sex, Karnofsky Performance Scale (KPS) score, American Society of Anesthesiologists score, and tumor size, location, and pathology. Body mass index (BMI) and serum albumin were investigated as the frailty factors. The authors also reviewed 11 surgical studies of elderly patients ≥ 60 years old with meningioma. RESULTS The mean age was 72.4 ± 5.7 years, and 42 patients were female (73.6%). The mean size of meningioma was 36.6 ± 14.8 mm at the maximum diameter, and the mean follow-up period was 31.1 ± 31.5 months. (The continuous variables are expressed as the mean ± SD.) Histopathological investigation revealed a higher incidence (71.9%) of WHO Grade I. The rates of deterioration after surgery, at 3 months, and at 1 year were 33.3%, 37.3%, and 39.1%, respectively. Univariate analysis revealed location, preoperative KPS score, BMI level 2, and serum albumin level (p = 0.010, 0.017, 0.0012, and 0.0019, respectively) to be poor prognostic factors. Multivariate analysis revealed that location (p = 0.038) and BMI (p = 0.035) were risk factors for KPS score deterioration immediately after surgery. According to the 11 papers reviewed, the median rate (25th-75th percentile) of skull base-related location was 43.5% (39.6-47.75); for asymptomatic status the mean was 24%; and for mortality at 3 months and 1 year the medians were 6.3% (0.7-7.1) and 8% (4.8-9.4), respectively. CONCLUSION Careful preoperative assessment based on the frailty concept was essential for better outcome in elderly patients with skull base meningioma. The BMI is appropriate as a quantitative factor for measure of frailty, particularly in elderly individuals with skull base meningioma. Further prospective randomized controlled trials are necessary to validate frailty as a preoperative risk factor. Not only patient selection but also surgical timing was an important factor.

Bioinformatic Exploration of Circulating microRNAs Related to Functional Outcomes in Patients With Acute Ischemic Stroke: An Exploratory Prospective Study.

Background Although epigenetic modifications have been expected to play an important role in neuroplasticity for stroke recovery, the role of dynamic microRNA (miRNA) regulation related to functional outcomes after ischemic stroke remains unclear. Therefore, the current study performed a comprehensive miRNA expression analysis in serum to identify specifically altered circulating miRNAs associated with different grades of functional outcomes in patients with acute ischemic stroke (AIS). Methods Twelve patients with AIS in the middle cerebral artery region were included in this study. Peripheral blood samples were collected from patients one or two days after hospitalization. Total RNA, including small RNAs, was extracted from 400 µL of serum, and comprehensive miRNA expression analysis was performed to identify specifically altered circulating miRNAs associated with different grades of functional outcomes. Functional outcomes were evaluated three months after stroke onset using the modified Rankin Scale (mRS), classified as favorable (mRS score of 0 or 1) or unfavorable (mRS score of 2 to 5). Differentially expressed miRNAs were analyzed using the DESeq2 package. Target genes of the miRNAs were explored using miRTargetLink 2.0. Results Acute miRNA expression dynamics were characterized by differences in the patients' functional outcomes following ischemic stroke. The favorable outcome group exhibited significantly downregulated miRNAs, including hsa-miR-218-1, hsa-miR-218-2, hsa-miR-320e, hsa-miR-320d-1, hsa-miR-320d-2, hsa-miR-326, and hsa-miR-4429. In addition, 15 miRNAs, including hsa-miR-223, hsa-miR-18a, hsa-miR-411, and hsa-miR-128-1, were significantly upregulated in the favorable outcome group compared to the unfavorable outcome group. Interesting and strong validated networks between miRNAs and their target genes were identified. Conclusion This study identified specifically altered circulating miRNAs in serum associated with varying grades of functional outcomes in AIS patients and explored miRNA-target gene networks that might contribute to these outcomes. Although further studies are needed, this study highlights their potential role as biomarkers for predicting functional outcomes in patients with AIS.

Flow alteration surgery using a radial artery graft for recurrent ruptured vertebral artery dissecting aneurysm after stent-assisted coil embolization: A case report.

BACKGROUND: Ruptured vertebral artery dissecting aneurysm (VADA) is often treated surgically with coil embolization and sometimes recurs. We herein report a case of recurrent ruptured VADA after stent-assisted coil embolization (SAC) that was successfully treated with flow alteration surgery using a radial artery (RA) graft. CASE DESCRIPTION: A 67-year-old woman presented with headache and coma. Enhanced CT revealed subarachnoid hemorrhage due to right VADA. Since the left VA was hypoplastic, the aneurysm was treated with SAC. However, follow-up angiography revealed recurrence of the aneurysm. Additional embolization was not considered due to the small size of the recurrent lesion and the presence of a stent; therefore, flow alteration surgery was performed using a RA graft. There were no neurological deficits after surgery or recurrence. CONCLUSION: Flow alteration surgery using a RA graft is useful for recurrent VADA after SAC.

[Abducens palsy due to unruptured aneurysms of the internal carotid artery in a patient with systemic lupus erythematosus].

We report a rare case of unruptured aneurysms in systemic lupus erythematosus (SLE). A 28-year-old female who had suffered from SLE for 5 years was admitted to our hospital because she noticed diplopia three weeks before. She presented with left abducens palsy on admission. CT scans revealed intracranial multiple calcified lesions. MRA and the cerebral angiography showed multiple saccular aneurysms from the cavernous segment to the petrous segment of the left internal carotid artery (ICA). These findings suggested that left abducens palsy was related to cranial nerve compression due to the aneurysm at the cavernous segment of the left ICA. As balloon occlusion test for 15 minutes of the left ICA with 99mTc-HMPAO SPECT was tolerable, the patient underwent the endovascular trapping of multiple aneurysms from the cavernous segment to the petrous segment of the left ICA with detachable coils. Postoperative course was uneventful and left abducens palsy fully recovered. She was discharged with no neurological deficits. This is the first report presenting left abducens palsy due to unruptured aneurysms in SLE. We summarized the previous reports of cerebral aneurysms in SLE.

[Superficial temporal artery-middle cerebral artery anastomosis in a patient of temporal arteritis with internal carotid artery occlusion: a case report].

Temporal arteritis is a rare systemic autoimmune disease and the arteritic process in this case of temporal arteritis involved large and medium-size arteries. Temporal arteritis with internal carotid artery (ICA) occlusion is very rare. We report a case of temporal arteritis with ICA occlusion following superficial temporal artery (STA) -middle cerebral artery (MCA) anastomosis, together with steroid therapy. A 73-year-old female presented with a headache, visual disturbance of left side, and suppression of activity. Left STA was inflammatory and overswelling. Magnetic resonance angiography (MRA) and angiography revealed occlusion of the left internal carotid artery (ICA) at the cervical portion and lowering of vascular reserve on PAO SPECT. Diagnosis as temporal arteritis was conclusive due to the clinical presentation, laboratory studies, and left temporal artery biopsy, so steroid pulse therapy was initiated. Inflammation of left STA disappeared after steroid therapy, but left ICA occlusion on angiography and lowering of vascular reserve on SPECT remained for 3 months afterwards. Because of this, STA-MCA anastomosis was performed. There were no complications after the operation and the donor artery has been patent for two years. Temporal arteritis with ICA occlusion that requires extracranial-intracranial bypass (EC-IC bypass) is very rare. STA-MCA anastomosis with steroid therapy is effective for the prevention of cerebral infarction.

[A case of multiple dural arteriovenous fistulas treated by multiple modalities].

The authors report a rare case of multiple intracranial dural arteriovenous fistulas (DAVF) at separate sinuses. A 70-year-old man was introduced to our hospital complaining of visual disturbance due to bilateral choked disk, headache, and tinnitus. Initial angiography showed DAVFs involving the superior sagittal sinus and bilateral transverse-sigmoid sinuses, and the occlusion of the right jugular vein. The patient developed progressive impairment of visual activity and had high intracranial pressure (ICP) caused by venous hypertension. No cerebral alteration was seen on magnetic resonance imaging. To decrease the high ICP, surgical sinus isolation of the superior sagittal sinus was performed. After the surgery, transvenous embolization was performed to the right transverse-sigmoid sinus DAVF. Headache and tinnitus improved after these treatments, but visual activities rapidly declined and he experienced blindness in just a few months. Gamma knife radiosurgery was performed to the residual DAVFs. We discussed the etiology and treatment of the multiple DAVF, and reviewed past literatures.

Early Transplantation of Human Cranial Bone-derived Mesenchymal Stem Cells Enhances Functional Recovery in Ischemic Stroke Model Rats.

We analyzed the cell characteristics, neuroprotective, and transplantation effects of human cranial bone-derived mesenchymal stem cells (hcMSCs) in ischemic stroke model rats compared with human iliac bone-derived mesenchymal stem cells (hiMSCs). The expressions of brain-derived neurotrophic factor (BDNF) and vascular endothelial growth factor (VEGF ) as neurotrophic factors were analyzed in both MSCs. hiMSCs or hcMSCs were intravenously administered into ischemic stroke model rats at 3 or 24 h after middle cerebral artery occlusion (MCAO) and neurological function was evaluated. The survival rate of neuroblastoma × glioma hybrid cells (NG108-15) after 3 or 24 h oxidative or inflammatory stress and the neuroprotective effects of hiMSCs or hcMSCs-conditioned medium (CM) on 3 or 24 h oxidative or inflammatory stress-exposed NG108-15 cells were analyzed. The expressions of BDNF and VEGF were higher in hcMSCs than in hiMSCs. hcMSCs transplantation at 3 h after MCAO resulted in significant functional recovery compared with that in the hiMSCs or control group. The survival rate of stress-exposed NG108-15 was lower after 24 h stress than after 3 h stress. The survival rates of NG108-15 cells cultured with hcMSCs-CM after 3 h oxidative or inflammatory stress were significantly higher than in the control group. Our results suggest that hcMSCs transplantation in the early stage of ischemic stroke suppresses the damage of residual nerve cells and leads to functional recovery through the strong expressions of neurotrophic factors. This is the first report demonstrating a functional recovery effect after ischemic stroke following hcMSCs transplantation.

[Multiple penetrating head injury by 8 nails: a case report].

A case report of penetrating head injury due to 8 nails and a review of multiple penetrating head injury by nails were described. The patient who was a 48-year-old man with a history of for psychiatric care was transferred to our emergency room on May 2007. He had shot his head with 8 nails using a nail-gun in a suicide attempt. His family called an ambulance. His conscious level was 1 on the Japan Coma Scale and 15 on the Glasgow Coma Scale with monoplegia of the right lower extremity and hypoesthesia of the right extremities. X-ray films of his head revealed 8 nails penetrating his cranium. The CT scan showed thin hematoma on the right convexity. Angiography didn't demonstrate any evidence of vascular injury. Under general anesthesia, all nails were removed after craniotomy. His post-operative course was good and he was discharged home with minimal deficits. Penetrating head injury with nail-gun use is sometimes seen, but cases with multiple nails are rare. Operative strategies were discussed in the review. It also suggested the need for the care of mental or background problems.

Navigation of a 6-French guiding sheath into the common carotid artery using a tri-axial catheter system in transbrachial carotid artery stenting.

BACKGROUND AND PURPOSE: Placement of a large-bore guiding sheath or catheter into the common carotid artery (CCA) is crucial in transbrachial carotid artery stenting (CAS). Herein, we describe technical tips for the navigation of a 6-French guiding sheath into the CCA using a tri-axial catheter system in transbrachial CAS. MATERIALS AND METHODS: A total of 27 patients underwent transbrachial CAS. For the right side, a 6-French straight guiding sheath was navigated directly into the CCA using a tri-axial catheter system, with a 4-French Simmons catheter placed through a 6-French straight guiding catheter. For the left side, a 6-French Simmons guiding sheath was navigated into the CCA using a tri-axial catheter system, with a 4-French Simmons catheter placed through a 6-French Simmons guiding catheter. After the placement of a 6-French guiding sheath into the CCA, CAS was performed under distal filter or balloon protection. RESULTS: Fifteen patients had a right carotid stenosis and 12 patients had a left carotid stenosis. The 6-French guiding sheath was safely placed with ease and provided adequate stabilization for CAS. All procedures were successfully performed without any complications. CONCLUSION: The use of a tri-axial catheter system for the navigation of a 6-French guiding sheath into the CCA appears safe and efficient, allowing transbrachial CAS, with 6-French guiding sheath stabilization, to be performed without any complication.

Preservation of Memory Despite Unresected Contralateral Hippocampal Volume Loss After Resection of Hippocampal Sclerosis in Seizure-Free Patients.

OBJECTIVE: To determine postoperative long-term changes of hippocampal volume (HV) correlating with cognitive functions in patients who underwent surgery for hippocampal sclerosis with postoperative freedom from seizures. METHODS: We studied 1.5T magnetic resonance imaging before and after surgery in 24 patients (mean ± SD age, 36.9 ± 11.0 years) with hippocampal sclerosis. We performed serial magnetic resonance imaging at 6 months to 1 year, 1-2 years, 2-3 years, and 3-5 years postoperatively. We compared HVs of 24 patients with HVs of 14 age-matched control subjects. We analyzed correlations between consecutive HVs and seizure duration and age at surgery. We compared consecutive changes in HVs between dominant and nondominant hemispheres with concurrent cognitive functions. RESULTS: Preoperative HVs of unresected contralateral hippocampus were significantly smaller than HVs of control subjects (P < 0.01). Unresected contralateral HV changes compared with preoperative HVs were -3.6% ± 6.9%, -2.3% ± 8.5%, -3.6% ± 10.2% (P < 0.05), and -5.0% ± 9.5% (P < 0.05) at consecutive postoperative periods. Largest change in HVs at 3-5 years was significantly correlated with older age at surgery (P < 0.05). Unresected contralateral dominant 14 HVs remained consistently smaller than nondominant 10 HVs up to 5 years with statistical significance (P < 0.05). Verbal memory was preserved in 14 patients with unresected contralateral smaller dominant hippocampus. CONCLUSIONS: In seizure-free patients after hippocampal sclerosis resection , unresected contralateral HV significantly declined with older age at surgery. Visual memory was preserved regardless of side and volume loss. Despite significantly reduced HVs, verbal memory was preserved with the unresected contralateral dominant hippocampus. Earlier surgical intervention may have lower potential risk for memory decline secondary to postoperative HV loss.

Cauda Equina Occupation Ratio as a New Imaging Parameter for the Evaluation of Spinal Dural Arteriovenous Fistulae.

BACKGROUND: Because spinal dural arteriovenous fistulae (SDAVF) are rare and their clinical presentation is nonspecific, they are often overlooked during diagnostic evaluations. Typical magnetic resonance imaging (MRI) findings are intramedullary T2-weighted signal hyperintensity and perimedullary flow voids. There are few reports on the characteristic signs of the cauda equina. We assessed the significance of a new imaging parameter, the cauda equina occupation ratio (CEOR), for the evaluation of SDAVF. METHODS: We retrospectively analyzed the clinical charts and radiological findings of 20 SDAVF patients treated at our institutions. We evaluated sagittal T2-weighted MRI scans and assessed the CEOR, the occupation ratio of the cauda equina compared to the sagittal diameter of the corresponding lumbar spinal canal. The controls were 21 age- and sex-matched subjects. RESULTS: Of the 20 SDAVF, 10 were at the thoracic and 10 at the lumbar spine. There was no significant difference between the preoperative CEOR and the spinal level of the fistulae or the neurological signs. On preoperative MRI scans, the mean CEOR was 56.0 ± 7.8; postoperatively, it was 37.1 ± 7.4 (P = 0.000). The preoperative CEOR was significantly larger in SDAVF patients than in the controls (P = 0.000); postoperatively, it was smaller than in the controls (P = 0.14). CONCLUSIONS: The preoperative CEOR was larger in patients with SDAVF than in the controls. It normalized after successful occlusion of the fistula. Our findings indicate that the CEOR is a useful parameter for the pre- and postoperative evaluation of SDAVF.

Applicability of Carotid Artery Stenting for Patients 80 Years or Older: A Single-Center Experience.

BACKGROUND: A meta-analysis found that for internal carotid artery stenosis procedures in elderly patients, the risk of perioperative stroke is significantly greater for carotid artery stenting (CAS) than for carotid endarterectomy. We retrospectively examined characteristics and perioperative results of CAS for patients 80 years and older at a single medical center. METHODS: A total of 97 patients with internal carotid artery stenosis underwent CAS using the dual-protection (simultaneous flow reversal and distal filter) and blood-aspiration method. We divided patients into 2 groups, octogenarian and non-octogenarian. We evaluated patient background, captured visible debris, in-stent protrusion, major adverse events (i.e., major stroke and death), and hyperintense spots on diffusion-weighted images after CAS. RESULTS: The success rate of the CAS procedure was 100% with no major adverse events within 30 days. We found vulnerable plaque in 50% (15/30 patients) and 26.9% (18/67 patients) of octogenarian and non-octogenarian groups, respectively (P = 0.047). Diffusion-weighted images revealed small hyperintense spots in 20% (6/30 patients) and 18.0% (12/67 patients) of the octogenarian and non-octogenarian groups, respectively (P = 0.785). Visible debris was observed in 43.3% (13/30 patients) and 22.4% (15/67 patients) of the octogenarian and non-octogenarian groups, respectively (P = 0.004). CONCLUSIONS: The plaque of carotid stenosis in octogenarians is often vulnerable, but using a dual protection and blood aspiration method, we safely performed CAS in octogenarian patients.

Epidemiology and Overview of the Clinical Spectrum of Degenerative Cervical Myelopathy.

Degenerative cervical spondylosis (DCM) is an umbrella term used to describe myelopathy caused by various degenerative changes in the cervical spine. This article outlines the spectrum of DCM and reviews the epidemiology of each factor composing DCM. The uniform term of DCM is expected to elucidate the epidemiology of myelopathy caused by degenerative changes of the cervical spine."

Intraoperative Neurophysiologic Monitoring for Degenerative Cervical Myelopathy.

Multimodal intraoperative neurophysiologic monitoring is a reliable tool for detecting intraoperative spine injury and is recommended during surgery for degenerative cervical myopathy (DCM). Somatosensory evoked potential (SEP) can be used to monitor spine and peripheral nerve injury during positioning in surgery for DCM. Compensation technique for transcranial evoked muscle action potentials (tcMEPs) should be adopted in intraoperative monitoring during surgery for DCM. Free-running electromyography is a useful real-time monitoring add-on modality in addition to SEP and tcMEP.

Isolated Tuberculoma Mimicking Foramen Magnum Meningioma in the Absence of Primary Tuberculosis: A Case Report.

Central nervous system tuberculosis is a devastating complication of systemic tuberculosis. Intradural extramedullary (IDEM) tuberculoma at the foramen magnum is rare, and mimics en plaque meningioma. We report the case of a 53-year-old woman who presented with dysesthesia of the tongue and lower cranial nerve (CN) palsy, with onset 4 months prior to admission. The neurologic examination revealed left upper-limb weakness and hypoesthesia on the sole and dorsum of the left foot. Other physical examinations revealed no features of tubercular infection. Laboratory investigations likewise showed no signs of infection or inflammation. Magnetic resonance imaging of the brain showed an IDEM mass originating from the left intradural surface at the foramen magnum extending to the C2 segment and compressing the brainstem and upper cervical cord. The mass was isointense/hypointense on T1- and T2-weighted images and homogeneously-enhanced on postcontrast images. The lesion also exhibited the dural-tail sign and was preoperatively diagnosed as en plaque meningioma. The patient underwent surgery via the left transcondylar fossa approach with partial laminectomy of the atlas. Intraoperatively, the mass exhibited a dural origin and encased the vertebral artery and lower CNs, with strong adhesions. While the histopathological study of the mass was strongly suggestive of tuberculoma with multifocal granulomas, caseous necrosis, and Langerhans giant cells, extensive diagnostic studies failed to detect Mycobacterium tuberculosis itself. Although the patient had recurrence with multisystem involvement, she responded well to antitubercular treatment. IDEM tuberculoma of the foramen magnum may present as en plaque meningioma. Histopathology is required for a definitive diagnosis. Prompt surgical resection and decompression with adequate antitubercular treatment yield better neurological outcomes.

Usefulness of Preoperative Simulation in Skull Base Approach: A Case Report.

Skull base approach is a neurosurgical challenge requiring dexterity of the operating surgeon for good postoperative outcome. In addition to the experience of the operating surgeon, adequate preoperative information of the tumor is necessary to ensure better outcome. In clinoid meningioma, it is sometimes difficult to determine its relationship with the surrounding structure and the feeding artery. Previously, preoperative simulation has been utilized to determine the intracranial course of the compressed nerves in relation to the petroclival meningioma. We report a case of clinoid meningioma where preoperative fusion of three dimensional computed tomography angiography (3D-CTA) and 3T-fast imaging employing steady-state acquisition (FIESTA) images was useful in determining the exact location of the feeding artery to devascularize the tumor and aid in surgery. Preoperative simulation with three-dimensional digital subtraction angiography (3D-DSA) and 3T-FIESTA fusion images can be a useful adjunct tool to supplement surgery and to train neurosurgical trainees.