Endoscopic Endonasal Transsphenoidal Surgery for Intrasellar Mixed Germ Cell Tumors.

A mixed germ cell tumor (MGCT) in the neurohypophysis is very rare, with only a few reported cases1-4 but none with surgical videos. In this report, the endoscopic endonasal transsphenoidal approach for MGCT in the neurohypophysis is presented (Video 1). A 12-year-old girl with ocular pain, fatigue, and nausea presented with gradual onset of quadrant hemianopsia and left oculomotor palsy. Magnetic resonance imaging showed an enhanced mass in the sella turcica with multiple components involving the pituitary gland and stalk. Her endocrinological examination showed decreased levels of pituitary hormones and simultaneously elevated serum levels of alpha-fetoprotein and beta-human chorionic gonadotropin. After pituitary hormone replacement, endoscopic endonasal transsphenoidal surgery was planned. The tumor was strongly adherent to the surrounding structures, and gross total resection was achieved. The histological diagnosis was MGCT with a teratoma component. Postoperatively, her vision and oculomotor palsy improved swiftly, and adjuvant chemotherapy and radiotherapy were administered. In this case, 3-dimensional computer graphics were created from the preoperative computed tomography and magnetic resonance imaging studies. Preoperative simulation with the 3-dimensional computer graphic images and intraoperative verification with indocyanine green images facilitated our understanding of the surrounding anatomy, including the tumor components, pituitary gland, and internal carotid arteries.5 After removal of the tumor, multilayer fascial closure was performed for skull base reconstruction.6 MGCT in the neurohypophysis can be strongly adherent to the surrounding structures, requiring careful dissection and resection under endoscopy. At the last follow-up (8 months after surgery), the tumor was successfully controlled, and the patient had no neurological symptoms with pituitary hormone replacement therapy.

Efficacy of a Novel Augmented Reality Navigation System Using 3D Computer Graphic Modeling in Endoscopic Transsphenoidal Surgery for Sellar and Parasellar Tumors.

In endoscopic transsphenoidal skull base surgery, knowledge of tumor location on imaging and the anatomic structures is required simultaneously. However, it is often difficult to accurately reconstruct the endoscopic vision of the surgical field from the pre-surgical radiographic images because the lesion remarkably displaces the geography of normal anatomic structures. We created a precise three-dimensional computer graphic model from preoperative radiographic data that was then superimposed on a visual image of the actual surgical field and displayed on a video monitor during endoscopic transsphenoidal surgery. We evaluated the efficacy of this augmented reality (AR) navigation system in 15 consecutive patients with sellar and parasellar tumors. The average score overall was 4.7 [95% confidence interval: 4.58-4.82], which indicates that the AR navigation system was as useful as or more useful than conventional navigation in certain patients. In two patients, AR navigation was assessed as less useful than conventional navigation because perception of the depth of the lesion was more difficult. The developed system was more useful than conventional navigation for facilitating an immediate three-dimensional understanding of the lesion and surrounding structures.

Congenital malformations of the external and middle ear accompanied by temporal bone anomaly in a calf.

A 7-month-old female Holstein calf presented with bilateral microtia and absent external acoustic meatus. The real-time polymerase chain reaction test was negative for bovine viral diarrhea virus and bovine leukemia virus. The calf's dam had a normal reproductive history. Computed tomography confirmed bilateral atresia of external auditory canals, aplasia of tympanic cavities and the ossicular chain, and temporomandibular joint abnormality. Necropsy revealed a severe malformation of the temporal bone. In the tympanic region, the external acoustic pore, tympanic bulla, and muscular process were absent bilaterally. The bilateral inner ear structure was normal. Based on these findings, we diagnosed the present case as congenital malformations of the external and middle ear accompanied by temporal bone anomaly.

[Non-anastomotic Pseudoaneurysm of a Prosthetic Graft with Sternal Erosion after Total Aortic Arch Replacement].

An 82-year-old man underwent total aortic arch replacement with a 24 mm Triplex four-branched graft for aortic arch aneurysm. After two years, he was diagnosed with pseudoaneurysms due to bleeding from a non-anastomotic site of the branch graft to the left common carotid artery and minor leakage from a distal anastomotic site of the main graft. A self-expandable Fluency covered stent and cTAG thoracic endograft were used for the aneurysm. After four years, he was referred to our hospital with a complaint of pulsatile swelling of the anterior chest wall. Contrast enhanced computed tomography (CT) revealed a pseudoaneurysm arising from a non-anastomotic site of the branch graft to the left common carotid artery, which extended into the anterior chest wall and the skin through the sternum. He underwent emergency endovascular repair using a Niti-S ComVi covered stent. The postoperative course was uneventful. Postoperative CT showed shrinkage of the pseudoaneurysm. The patient was discharged and required no reintervention during the follow-up.

Coil Embolization of VA-PICA Aneurysm Presenting with Hemifacial Spasm with Assistance of Abnormal Muscle Response Monitoring.

Objective: We report a rare case of symptomatic vertebral and posterior inferior cerebellar arteries (VA-PICA) aneurysm-caused ipsilateral hemifacial spasm (HFS) for which coil embolization of the aneurysm with the assistance of abnormal muscle response (AMR) monitoring was effective. Case Presentation: A 62-year-old woman presented with left HFS. Magnetic resonance imaging showed a saccular aneurysm of the left VA-PICA which compressed the seventh cranial nerve at its root exit zone (REZ). Stent-assisted coil embolization resulted in intraoperative disappearance of AMR in the intraoperative electrophysiological study and HFS was relieved temporally. One month after endovascular surgery, HFS slightly occurred again with the re-appearance of the AMR, although there was no recurrence of aneurysm. Thereafter, the frequency of her HFS markedly decreased to once per several days 1 year after the coiling. Conclusion: Although complete disappearance of symptoms was not obtained, it was suggested that coil embolization is one of the therapeutic options for HFS which is caused by aneurysmal compression of REZ and intraoperative AMR is useful for identification of responsible lesions and determination of therapeutic effects.

Bypass Surgeries in the Treatment of Cerebral Aneurysms.

BACKGROUND: During surgery for cerebral aneurysm, revascularization techniques are occasionally needed to (1) treat an aneurysm (trapping or flow alteration); (2) preserve blood flow during temporary parent artery occlusion (insurance); and (3) repair accidentally injured vessels (troubleshooting). Herein we present our surgical case experiences. METHODS: Revascularization modalities were employed in 33 (7.6 %) of 452 cases of surgically treated aneurysms. The aneurysm locations and associated required bypass procedures were: (1) 7 middle cerebral artery (MCA) aneurysms with 7 superficial temporal artery (STA)-MCA bypass procedures; (2) 10 internal carotid artery (ICA) aneurysms with 9 high-flow and 1 STA-MCA procedures; (3) 10 vertebro-basilar artery aneurysms with 2 high-flow, 6 occipital artery (OA)-posterior ICA, and 1 STA-superior cerebellar artery (SCA) procedures; (4) 1 posterior cerebral artery (PCA) aneurysm with OA-PCA bypass; and (5) 5 anterior cerebral artery aneurysms with 4 A3-A3 and 1 A3-STA-A3 procedure. Curative bypasses for aneurysmal treatment, temporary bypasses, and troubleshooting procedures were performed in 25, 3, and 5 cases, respectively. RESULTS: Among the 26 aneurysms treated via curative bypass, 16 aneurysms that were trapped or clipped using revascularization techniques had better outcomes (no aneurysmal rupture and 1 perforator infarction), whereas among the 10 aneurysms that could not be trapped or clipped and were thereby treated via flow alteration (e.g., bypass plus proximal artery clipping), 2 developed symptomatic infarction and 2 exhibited aneurysmal rupture after partial thrombosis. Patients whose bypass procedures were used for temporary parent artery occlusion (insurance) or troubleshooting had no complications. CONCLUSION: Complex aneurysm clipping or trapping using bypass techniques yielded good results. In particular, perforator vessel ischemia still requires resolution. Flow alteration techniques leading to aneurismal thrombosis carried the risks of ischemic and hemorrhagic complications when applied to intracranial aneurysms. Bypasses for temporary use or troubleshooting were quite effective.

Heparin-induced thrombocytopenia associated with polycythemia vera during the treatment of acute coronary syndrome.

Here, we report a case of heparin-induced thrombocytopenia (HIT) associated with polycythemia vera (PV) during the treatment of acute coronary syndrome. An 84-year-old woman with pre-existing PV had an acute myocardial infarction and developed HIT after using heparin. An additional myocardial infarction was caused by HIT, and caused marked damage to her cardiac function. However, she was successfully treated with argatroban infusion and intensive care. In this case, we suspected HIT at an extremely early stage, when the decline in platelet count remained at 16%, which might have prevented further thrombosis. Subsequently, the nadir in the platelet count remained at 32%, which resulted in "intermediate possibility of HIT" according to the 4Ts score; thus, further detailed serological examination may be required for accurate diagnosis of HIT. .

Radiation-induced meningiomas in multiple regions, showing rapid recurrence and a high MIB 1 labeling index: a case report and review of the literature.

Combined chemotherapy and prophylactic cranial irradiation has improved the prognosis of children with acute leukemia. However cranial irradiation carries a latent risk of the induction of secondary intracranial tumors. We encountered a patient who developed multiple intracranial radiation-induced meningiomas (RIMs) 25 years after prophylactic cranial irradiation for the treatment of acute leukemia in childhood. The patient had 3 intracranial lesions, 1 of which showed rapid growth within 6 months; another of the tumors also enlarged within a short period. All of the tumors were surgically treated, and immunohistochemistry indicated a high MIB-1 labeling index in each of the multiple lesions. In the literature, the MIB-1 labeling indices of 27 tumors from 21 patients were examined. Among them, 12 recurrent tumors showed higher MIB-1 labeling indices compared to the MIB-1 labeling indices of the non-recurrent tumors. Overall, 11 of the patients with RIM had multiple lesions and 8 cases developed recurrence (72.7%). RIM cases with multiple lesions had higher MIB-1 labeling indices compared to the MIB-1 labeling indices of cases with single lesions. Collectively, these data showed that the MIB-1 labeling index is as important for predicting RIM recurrences, as it is for predicting sporadic meningioma (SM) recurrences. RIMs should be treated more aggressively than SMs because of their greater malignant potential.

Skull base osteosarcoma presenting with cerebrospinal fluid leakage after CyberKnife® treatment: a case report.

INTRODUCTION: CyberKnife® radiation is an effective treatment for unresectable skull base tumors because it can deliver a highly conformational dose distribution to the complex shapes of tumor extensions. There have been few reports of severe complications with this treatment. This is the first published case report to our knowledge of cerebrospinal fluid leakage induced by CyberKnife® radiotherapy. CASE PRESENTATION: A skull base tumor was identified on magnetic resonance imaging in a 78-year-old Asian woman with a headache in her forehead. An endoscopic transnasal tumor resection was performed; however, the tumor, invading into the cavernous sinuses and optic canal, was not completely removed. During the subtotal resection of the tumor, no cerebrospinal fluid leakage was observed. Osteosarcoma was histologically diagnosed, and CyberKnife® radiation was performed to the residual tumor considering the aggressive feature of the tumor with a molecular immunology Borstel-1 index of 15%. Five months after the treatment, magnetic resonance imaging showed definite tumor shrinkage, and the patient had been living her daily life without any troubles. After another month, the patient was transferred to our clinic because of coma with high fever, and computed tomography demonstrated severe pneumocephalus. Rhinorrhea was definitely identified on admission; therefore, emergency repair of the cerebrospinal fluid leakage was performed using an endoscope. Dural defects at the bottom of the sella turcica were identified under careful endoscopic observation and fat tissue was patched to the dural defects. Follow-up computed tomography proved complete disappearance of air from the cisterns 2 weeks after the surgery, and the patient was discharged from our hospital without any neurological deficits. CONCLUSION: CyberKnife® radiation is one of the effective treatments for skull base tumors; however, the risk of cerebrospinal fluid leakage should be considered when tumor invasion to the dura mater is suspected. Emergency surgical treatment is required when cerebrospinal fluid leakage is induced by the radiotherapy because the leakage is not expected to be healed by palliative treatments.

A simple and consistent technique for ventricular catheter insertion using a tripod.

OBJECTIVE: For long-term preservation of ventriculo-peritoneal (VP) shunt function, it is essential to place the ventricular catheter tip above the foramen of Monro. But the free-hand technique for ventricular catheter passage is not consistent. METHODS: Supposing that a convex of skull matches to a sphere, in which the foramen of Monro is the center, a perpendicular direction from the surface of the sphere to inside always directs toward the center. The authors identified the range of skull where corresponded to the sphere by magnetic resonance imaging assessment and utilized tripod to achieve exactly perpendicular insertion of ventricular catheter. And an optimal length of catheter insertion was investigated by navigation system. RESULTS: The anterior-posterior range of the spherical portion was from coronal suture to 20mm anterior, and the lateral range of it was between 15 and 35mm lateral from sagittal suture. The optimal catheter length for insertion was between 55 and 58mm from the brain surface. Ideal placement of a ventricular catheter tip was achieved in more than 90% of cases (31/34) with this technique. CONCLUSION: Tripod-guided ventricular catheter insertion is a simple and reliable method for VP shunt at any angle of head-rotation.

Personal exposure level and environmental ethylene oxide gas concentration in sterilization facilities of hospitals in Japan.

Personal and environmental (stationary) ethylene oxide (EO) gas concentrations in gas sterilization facilities were measured at six workplaces in five hospitals. An ethylene oxide gas monitor (3M #3551) was used for both personal and stationary samplings. A gas detector tube was also used for instantaneous sampling. In most workplaces, the personal exposure levels of EO were below the detection limit of the gas monitor. Most of the time-weighted average (TWA) concentrations by the stationary sampling were below the threshold limit value of EO (TLV-TWA = 1 ppm), but in one workplace, more than 4 ppm of EO were detected in front of the sterilizer in a clean room during a 24-hour measurement, although all the personal exposure levels were below the detection limit. Method of aeration after the sterilization was very important for reducing the EO exposure. The EO gas concentrations in two workplaces where sufficient aeration was carried out were below the detection limit in all the stationary samples. In one workplace where insufficient aeration was performed, EO was detected from 16 of 17 stationary samples, and more than 90-200 ppm of EO was determined by the gas detector tube near the worker's face at the moment when the door of the sterilizer was opened and the sterilized materials were removed.