[Formation of a Subcutaneous Amputation Neuroma after Incomplete Endoscopic Carpal Tunnel Release Resulting in Complex Regional Pain Syndrome:A Case Report].

This 64-year-old woman had undergone endoscopic carpal tunnel release(ECTR)for right carpal tunnel syndrome 16 months earlier. Thereafter, she reported persistent dysesthesia in the thumb and index finger, developed burning pain in the middle and ring finger, paleness, coldness, and edema of the hand, a decreased range in hand motion, and a painful subcutaneous nodule just distal to the portal in the forearm. Based on physical, radiological, and electrophysiological studies, the diagnosis was incomplete carpal tunnel release associated with complex regional pain syndrome(CRPS). At open revision surgery, the carpal tunnel was released completely and the nodule was removed. Symptoms other than hypesthesia in the middle and ring fingers improved. Pathologically, the nodule was an amputation neuroma. Her CRPS was attributed to ECTR complications; i.e., persistence of median nerve compression and the formation of an amputation neuroma in the palmar cutaneous branch of the ulnar nerve at the portal. Surgeons must be aware that ECTR, a less invasive technique, may result in serious complications including CRPS.

Safe Stereotactic Biopsy for Basal Ganglia Lesions: Avoiding Injury to the Basal Perforating Arteries.

BACKGROUND: One of the most serious complications of stereotactic biopsy is postoperative symptomatic hemorrhage due to injury to the basal perforating arteries such as the lenticulostriate arteries neighboring the basal ganglia lesions. OBJECTIVES: A new target-planning method was proposed to reduce hemorrhagic complications by avoiding injury to the perforating arteries. METHODS: Three-dimensional 3-T time-of-flight (3D 3-T TOF) imaging was applied to delineate the basal perforating arteries such as the lenticulostriate arteries. The incidence of postoperative hemorrhage in basal ganglia cases was compared between a new method using 3D 3-T TOF and a conventional target-planning method based on contrast-enhanced T1-weighted magnetic resonance images obtained by 1.5-T scanning. RESULTS: 3D 3-T TOF imaging could delineate the basal perforating arteries sufficiently in target planning. No postoperative hemorrhage occurred with the new method (n = 10), while 6 postoperative hemorrhages occurred with the conventional method (n = 14). The new method significantly reduced the occurrence of postoperative hemorrhages (p = 0.017). CONCLUSIONS: 3D 3-T TOF MR imaging with contrast medium administration provides useful information about the perforating arteries and allows safe stereotactic biopsy of basal ganglia lesions.

Tumor microenvironment after biodegradable BCNU wafer implantation: special consideration of immune system.

Biomaterials to treat cancers hold therapeutic potential; however, their translation to bedside treatment requires further study. The carmustine (1,3-bis (2-chloroethyl)-1-nitrosourea; BCNU) wafer, a biodegradable polymer, currently is the only drug that is able to be placed at the surgical site to treat malignant tumors. However, how this wafer affects the surrounding tumor microenvironment is not well understood to date. We retrospectively reviewed all patients with glioblastoma treated with and without BCNU wafers who underwent repeat resection at tumor recurrence. We investigated radiological imaging; the interval between the two surgeries; and immunohistochemistry of CD3, CD4, CD8, CD20, CD68, FOXP3, and PD1. We implanted BCNU wafers in 41 newly diagnosed glioblastoma patients after approval of the wafer in Japan. Of them, 14 underwent surgery at recurrence and tissue was obtained from around the wafers. The interval between the first and second surgeries ranged from 63 to 421 days. The wafer could be observed on magnetic resonance imaging at up to 226 days, whereas intraoperatively the biodegraded material of the wafer could be found at up to 421 days after the initial surgery. Immunohistochemical analysis demonstrated that CD8+ and CD68+ cells were significantly increased, but FOXP3+ cells did not increase, after wafer implantation compared to tissue from cases without wafer implantation. MRI data and immune cells, as well as interval between surgeries and immune cells, demonstrated positive correlation. These results helped us to understand the bioactivity of bioengineered materials and to establish a new approach for immunotherapy.

Total Resection of Brainstem Extension of Tentorial Schwannoma Using an Occipital Transtentorial Approach.

BACKGROUND: Approximately 60 cases of schwannoma unrelated to the cranial nerve have been reported, and only 12 arose from the tentorium. We present a case of tentorial schwannoma extending into the pons and midbrain without cranial nerve involvement, which was almost totally resected with an occipital transtentorial approach. CASE DESCRIPTION: A 37-year-old man was admitted to our institution with memory disturbance beginning 2 years ago and gait disturbance from 1 year ago. Magnetic resonance imaging on admission revealed a heterogeneously enhanced 33 × 33 × 35 mm tumor in the pons and midbrain, and a dural tail sign connecting the lesion to the tentorial edge. Gross total resection of the tumor was performed with an occipital transtentorial approach. The trochlear nerve was identified and preserved, and the tumor did not involve this cranial nerve. The tumor was firmly attached to the edge of tentorium, and extended into the pons with sharp tumor border. Postoperative recovery was good, and brain magnetic resonance imaging performed 2 months after the surgical procedure revealed gross total removal of the lesion without signs of recurrence, but a slightly enhanced lesion in the right edge of the tentorium. CONCLUSIONS: The occipital transtentorial approach provides a direct approach to tentorial schwannoma, resulting in total resection even if the tumor extends into the pons and midbrain.

Chronic Phase Intracranial Hemorrhage Caused by Ruptured Pseudoaneurysm Induced by Carmustine Wafer Implantation for Insulo-opercular Anaplastic Astrocytoma: A Case Report.

Carmustine wafers improve the survival of patients with high-grade gliomas, but several adverse events have been reported. A 42-year-old man with left Insulo-opercular anaplastic astrocytoma developed a massive intra-cavital hematoma with subarachnoid hemorrhage caused by ruptured pseudoaneurysm of the left middle cerebral artery (MCA) adjacent to the site of carmustine wafers implanted 6 months previously. Intraoperative finding demonstrated a dissection of the insular portion of the MCA, and pathological examination identified the resected pseudoaneurysm. This case demonstrates that carmustine wafers can cause changes in local vessels. Therefore, implantation of carmustine wafers near to important vessels passing close to the resection cavity should be considered with great caution.