Endoscopic Evacuation of Putaminal Hemorrhage Using the Trans-Middle Temporal Gyrus Approach: Technical Notes and Case Presentations.

BACKGROUND: The development of minimally invasive endoscopic neurosurgery has enabled widespread application of endoscopic surgery via the ipsilateral transfrontal approach for putaminal hematoma evacuation. However, this approach is unsuitable for putaminal hematomas that extend into the temporal lobe. We adopted the endoscopic trans-middle temporal gyrus approach, instead of the conventional surgical approach, for the management of these complicated cases and determined its safety and feasibility. METHODS: Twenty patients with putaminal hemorrhage underwent surgical treatment at the Shinshu University Hospital between January 2016 and May 2021. Of these, two patients with left putaminal hemorrhage that extended into the temporal lobe underwent surgical treatment using the endoscopic trans-middle temporal gyrus approach. The procedure entailed the use of a thinner transparent sheath to reduce the technique's invasiveness, a navigation system to determine the location of the middle temporal gyrus and the sheath's trajectory, and an endoscope with a 4K camera for higher image quality and utility. The sylvian fissure was compressed superiorly using our novel "port retraction technique" (i.e., by tilting the transparent sheath superiorly) to avoid damage to the middle cerebral artery and Wernicke's area. RESULTS: The endoscopic trans-middle temporal gyrus approach allowed sufficient hematoma evacuation and hemostasis under endoscopic observation without any surgical complexities or complications. The postoperative course was uneventful in both patients. CONCLUSION: The endoscopic trans-middle temporal gyrus approach for putaminal hematoma evacuation helps avoid damage to normal brain tissue, which could result from the wide range of motion of the conventional technique, particularly when the hemorrhage extends to the temporal lobe.

The efficacy of a visiting surgical service versus that of a hospital-based surgical service in providing endoscopic endonasal surgery to remove nonfunctioning pituitary adenomas in rural communities.

PURPOSE: To satisfy the increasing demand for endoscopic endonasal approach (EEA) to treat pituitary tumors, especially in rural areas, the "mobile EEA" system, a visiting surgical service, has been established We report this unique system for maintaining community healthcare and evaluate the surgical results of mobile EEA. METHODS: A retrospectively acquired database of 225 consecutive cases of EEA at Shinshu University Hospital (i.e., "home EEA") and its affiliated hospitals (i.e., "away EEA") between May 2018 and May 2022 was reviewed. A total of 105 consecutive patients who fulfilled the criterion of a diagnosis of new-onset nonfunctioning pituitary adenoma (PA) were included. Clinical characteristics and postoperative clinical outcomes were statistically compared between the home EEA and away EEA groups to assess the presence of a home advantage and/or an away disadvantage. RESULTS: Patients were stratified into two cohorts: patients treated at our hospital (home EEA: n = 41 [39.0%]) and those treated in the visiting surgical service at an affiliated hospital (away EEA: n = 64 [61.0%]). Postoperative clinical outcomes, such as the extent of tumor resection (p = 0.39), operation time (p = 0.80), visual function (p = 0.54), and occurrence of surgical complications (p = 0.53), were comparable between the groups. There were no visiting surgical service-related adverse events or accidents caused by physicians' driving to away hospitals. CONCLUSION: Pituitary surgeries performed via the mobile EEA system for nonfunctioning PAs may help maintain local community healthcare. Furthermore, this system can also contribute to the efficient training of surgeons by the same experienced pituitary surgeon using the same protocol.

Frontal Encephalocele Plus Epilepsy: A Case Report and Review of the Literature.

An encephalocele is a pathological brain herniation caused by osseous dural defects. Encephaloceles are known to be regions of epileptogenic foci. We describe the case of a 44-year-old woman with refractory epilepsy associated with a frontal skull base encephalocele. Epilepsy surgery for encephalocele resection was performed; however, the epilepsy was refractory. A second epilepsy surgery for frontal lobectomy using intraoperative electroencephalography was required to achieve adequate seizure control. Previous reports have shown that only encephalocele resection can result in good seizure control, and refractory epilepsy due to frontal lobe encephalocele has rarely been reported. To the best of our knowledge, this is the first report of frontal encephalocele plus epilepsy in which good seizure control using only encephalocele resection was difficult to achieve. Herein, we describe the possible mechanisms of encephalocele plus epilepsy and the surgical strategy for refractory epilepsy with encephalocele, including a literature review.

A preliminary study of the diagnostic efficacy and safety of the novel boring biopsy for brain lesions.

Existing methods for biopsy of intraparenchymal brain lesions, including stereotactic biopsy and open block biopsy, have advantages and disadvantages. We propose a novel biopsy method, called "boring biopsy," which aims to overcome the drawbacks of each conventional method. This method is less invasive and allows obtaining continuous specimens of sufficient volume. We aimed to assess the feasibility and efficacy of using boring biopsy for intraparenchymal brain lesions. We included 26 consecutive patients who underwent boring biopsy for intraparenchymal lesions. Columnar continuous specimens from the surface of the normal brain tissue to the tumor margin and the center of the lesion were obtained using the boring biopsy method. We used a catheter introducer with original modifications to create a cylindrical biopsy tool for surgery. Columnar continuous specimens were successfully obtained. Histopathological diagnosis was based on cellular changes and differentiation from normal tissues to the core of the lesion and established in all cases. No permanent deficits, major adverse outcomes, or deaths were observed. This novel technique may improve diagnostic accuracy and reduce invasiveness associated with brain biopsy. This method may become the next standard procedure, particularly in some cases where histological evaluation is paramount, and conventional biopsy methods are not suitable.

Intraoperative Image-Guided Surgery for Gliomas in the Smart Cyber Operating Theater (SCOT): A Preliminary Clinical Application.

BACKGROUND: Various devices exist for glioma image-guided surgery to improve tumor resection. These devices work as stand-alone units, making the flow of operative information complicated and disjointed. A novel networked operating room, the Smart Cyber Operating Theater (SCOT), has been developed, integrating stand-alone medical devices using the OPeLiNK communication interface. We report and evaluate the impact of SCOT for glioma surgery and our initial experiences. METHODS: Patients with gliomas who underwent tumor resection in SCOT between July 2018 and June 2021 were retrospectively reviewed. Various types of intraoperative information were integrated, managed, and shared with the surgical strategy desk using OPeLiNK. Patients' demographics, tumor characteristics, treatment details, and outcomes were obtained. The impact of the SCOT system was evaluated. RESULTS: Twenty-seven patients, with a mean age of 48.6 years (range, 13-88 years), met the inclusion criteria. We successfully completed all the surgical procedures using SCOT. The mean operation time was 420.6 minutes (range, 225-667 minutes).Gross total resection was accomplished in 13 patients (48.1%), subtotal resection in 4 (14.8%), and partial resection in 10 (37.0%). The main surgeon in the operating room and other neurosurgeons at the strategy desk shared and discussed the information in real time during the procedures. CONCLUSIONS: The use of SCOT was shown to be safe and feasible in glioma surgery. This study suggests that SCOT may improve surgical outcomes and educational impact by sharing information in real time with the strategy desk.

An autopsy case of widespread brain dissemination of glioblastoma unnoticed by magnetic resonance imaging after treatment with bevacizumab.

BACKGROUND: Although glioblastoma has been shown to be able to disseminate widely in the intracranially after treatment with bevacizumab without any significant radiological findings, reports on such cases with subsequent autopsy findings are lacking. CASE DESCRIPTION: A 36-year-old man presented with a general seizure and a mass of the right frontal lobe, which was diagnosed as diffuse astrocytoma (WHO Grade II). The patient underwent a total of four surgeries from 2005 to 2017. He showed tumor recurrence, progression, and malignant transformation to glioblastoma (GBM) (WHO Grade IV) despite repeated tumor resections, radiotherapy, and chemotherapies with temozolomide and carmustine wafers. Bevacizumab (10 mg/kg body weight) was started following the fourth surgery. After bevacizumab administration, the patient's clinical condition improved to a Karnofsky performance status (KPS) score of 50-60, and he was stable for several months before finally deteriorating and passing away. Although sequential magnetic resonance imaging (MRI) showed shrinkage of the lesion and a reduction of edema, an autopsy showed widespread tumor invasion that was not revealed on MRI. Neoplastic foci were identified extensively in the cerebral cortex, basal ganglia, pituitary gland, cerebellum, and brainstem, imposing as gliomatosis cerebri. CONCLUSION: Imaging follow-up of malignant gliomas needs to be interpreted with caution as marked improvement in radiological response after bevacizumab treatment may not be indicating tumor regression. Despite the notable lack of evidence to increase overall survival in GBM patients with bevacizumab, the increase in progression-free survival and the observed relief of symptoms due to a decrease in edema should be considered relevant for patient management.

Expression of L-type amino acid transporter 1 in various skin lesions.

L-type amino acid transporter 1 (LAT1) is a Na(+)-independent neutral amino acid transporter that has an essential role in cell proliferation. Although the involvement of LAT1 in human carcinogenesis has been investigated by immunohistochemistry in various organs, LAT1 expression in skin has not been reported yet. Therefore, in the present study, immunohistochemistry for LAT1 was performed in 15 keratoacanthoma (KA), 10 seborrheic keratosis, 16 Bowen's disease, 11 basal cell carcinoma (BCC), and 9 squamous cell carcinoma (SCC) cases as well as 61 normal epidermis as control. It was demonstrated that LAT1 expression limited to the basal layer was occasionally observed in normal epidermis while its expression was significantly decreased in the epithelium of seborrheic keratosis and Bowen's disease (P<0.05). By contrast, a significantly higher rate of LAT1 expression was observed in the epithelium of KA, BCC, and SCC than in normal epidermis (P<0.05). Although LAT1 expression was limited to the basal layer or rim of the nests in KA, LAT1 expression was also observed in the center of the nests in BCC and SCC (P<0.001). Thus, LAT1 is differentially expressed in various skin lesions and may be an especially useful marker to distinguish KA from SCC.

Divergent expression of L-type amino acid transporter 1 during uterine cervical carcinogenesis.

L-type amino acid transporter 1 (LAT1) is a Na⁺-independent neutral amino acid transporter that has an essential role in cell proliferation. Although LAT1 expression is observed in various tumor cell lines and immunohistochemical expression of LAT1 has been investigated in carcinomas of various organs, LAT1 expression in uterine cervical neoplasm has not been reported. Therefore, in the present study, we immunohistochemically analyzed LAT1 expression along with the well-known markers of cervical carcinogenesis Ki-67 and p16 in normal uterine cervical mucosa (49 specimens) as well as cervical intraepithelial neoplasia (17 mild or moderate dysplasias and 19 severe dysplasias or carcinomas in situ) and invasive carcinomas (17 squamous cell carcinomas and 9 adenocarcinomas). LAT1 expression was limited to the basal layer of normal squamous epithelium, and it was significantly decreased in cervical intraepithelial neoplasia (P < .001), generally paralleled by increased expression of Ki-67 and p16. Interestingly, in invasive squamous cell carcinoma, LAT1 expression again increased especially at the invasive fronts (P < .001), whereas Ki-67 and p16 expressions were almost unchanged relative to noninvasive neoplasia. Although virtually no LAT1 expression was demonstrated in normal uterine cervical glands, LAT1 expression was observed in some adenocarcinomas (P < .001). The present study suggests that LAT1 expression decreases because of human papillomavirus infection as reflected by p16 overexpression in cervical intraepithelial neoplasia, whereas LAT1 expression in invasive carcinoma is associated with acquired malignant potential.