Time-of-flight magnetic resonance angiography for detection of postoperative recurrence in patients with chronic subdural hematoma.

PURPOSE: Chronic subdural hematoma (CSDH) is associated with postoperative recurrence. Although various factors are involved in postoperative recurrence of CSDH, blood flow, especially in the middle meningeal artery (MMA), is considered to play an important role. We investigated whether the degree of signal intensity (SI) of the MMA on time-of-flight magnetic resonance angiography (TOF MRA) and various clinical factors are involved in recurrence of CSDH. METHODS: The maximum SI of both MMAs was measured on TOF MRA images within 1 month before or after the initial surgery. RESULTS: In total, 185 patients (20 with and 165 without recurrence of CSDH) were included in the analysis. The SI ratio and dementia were significant predictors of recurrence of CSDH (SI ratio: odds ratio [95% confidence interval (CI)] = 1.71 [1.32, 2.22], p < 0.0001; dementia: odds ratio [95% CI] = 7.41 [1.83, 30.1], p = 0.005). The estimated regression coefficients in the final model were 6.14 for the SI ratio and 1.28 for dementia. The risk score was derived according to these regression coefficients as follows: score = 5 × SI ratio + 1 (dementia: yes). With a score of 5, the predicted probability of recurrence was 2% [95% CI 0.7, 5.7], whereas with scores of 8 and 10, the probability was 43.3% [27.0, 61.1] and 89.5% [65.7, 97.5], respectively, which increased the risk of recurrence. CONCLUSION: Patients with an increased SI ratio of the affected MMA on TOF MRA who underwent surgery for CSDH were significantly more likely to experience recurrence.

Early rebleeding of a foramen magnum dural arteriovenous fistula: A case report and review of the literature.

Foramen magnum dural arteriovenous fistula (FM-DAVF) is a subset of craniocervical junction arteriovenous fistulas. We report a rare case of FM-DAVF with early rebleeding and review the literature. A 50-year-old man experienced 3 episodes of intracranial bleeding from a vessel malformation in the acute stage. We identified an FM-DAVF, supplied by multiple feeding arteries (eg, left ascending pharyngeal artery) that drained into the straight sinus and left superior petrosal sinus. The draining vein had venous varices. We performed transarterial feeder embolization and surgical disconnection of the DAVF. Early rebleeding of FM-DAVF is rare. High-risk patients require risk assessment and appropriate treatment as soon as possible in the acute stage.

An analysis of the demographic history of the risk allele R4810K in RNF213 of moyamoya disease.

BACKGROUND: Ring finger protein 213 (RNF213) is a susceptibility gene of moyamoya disease (MMD). A previous case-control study and a family analysis demonstrated a strong association of the East Asian-specific variant, R4810K (rs112735431), with MMD. Our aim is to uncover evolutionary history of R4810K in East Asian populations. METHODS: The RNF213 locus of 24 MMD patients in Japan were sequenced using targeted-capture sequencing. Based on the sequence data, we conducted population genetic analysis and estimated the age of R4810K using coalescent simulation. RESULTS: The diversity of the RNF213 gene was higher in Africans than non-Africans, which can be explained by bottleneck effect of the out-of-Africa migration. Coalescent simulation showed that the risk variant was born in East Asia 14,500-5100 years ago and came to the Japanese archipelago afterward, probably in the period when the known migration based on archaeological evidences occurred. CONCLUSIONS: Although clinical data show that the symptoms varies, all sequences harboring the risk allele are almost identical with a small number of exceptions, suggesting the MMD phenotypes are unaffected by the variants of this gene and rather would be more affected by environmental factors.

Prospective, Multicenter Clinical Study of Microvascular Decompression for Hemifacial Spasm.

BACKGROUND: Microvascular decompression (MVD) is the most effective procedure for hemifacial spasm (HFS). MVD results from nonspecialized or low-volume institutes are not always reliable. Most studies on MVD for HFS are retrospective and single centered; to the best of our knowledge, no prospective, multicenter studies exist. OBJECTIVE: To evaluate short- and long-term outcomes and complications in patients who underwent MVD for HFS in specialized Japanese institutions, in this multicenter, prospective, cohort study. METHODS: Included patients had undergone MVD for HFS in study centers between April 2012 and March 2015. Patients' postoperative grade of involuntary movements and complications were recorded postoperatively at 7 d (short-term) and at 1 (mid-term) and 3 (long-term) yr. RESULTS: A total of 486 patients (150 men, 336 women; mean age 53.9 yr with 181 patients over 60 yr) were enrolled during the study period. Neuromonitoring was used in 96.3% of the cases. The complete cure rate of symptom relief, mortality rate, and complication rate at short-term follow-up were 70.6%, 0%, and 15%, respectively. The long-term follow-up was completed by 463 patients (95.3%); the complete cure rate of symptom relief and complication rate were 87.1% and 3.0%, respectively. CONCLUSION: Our study revealed that under expert guidance and intraoperative neuromonitoring, the long-term curative effect rate of MVD for HFS is high, while complications are uncommon and usually transient. Our results indicate that MVD is an effective and safe treatment for patients with HFS, including elderly patients.

Parent Artery Occlusion for Treatment of a Traumatic Pericallosal Artery Aneurysm: Case Report and Review of the Literature.

BACKGROUND: Traumatic intracranial aneurysms are rare complications after head trauma. This report describes the case of a patient with a traumatic pericallosal aneurysm. CASE DESCRIPTION: A 73-year-old man developed headache and lower limb paresis, and emergency computed tomography scan revealed a hematoma in the corpus callosum. We performed coil embolization for a pericallosal aneurysm, but follow-up angiography showed recurrence of the aneurysm 6 days after the surgery. We diagnosed this as a traumatic aneurysm and subsequently performed parent artery occlusion without any complications. CONCLUSIONS: We performed parent artery occlusion for a traumatic aneurysm of the pericallosal artery without complications. Pericallosal aneurysms are rare, but we must consider them when encountering a delayed hematoma around the corpus callosum.

A new targeted capture method using bacterial artificial chromosome (BAC) libraries as baits for sequencing relatively large genes.

To analyze a specific genome region using next-generation sequencing technologies, the enrichment of DNA libraries with targeted capture methods has been standardized. For enrichment of mitochondrial genome, a previous study developed an original targeted capture method that use baits constructed from long-range polymerase chain reaction (PCR) amplicons, common laboratory reagents, and equipment. In this study, a new targeted capture method is presented, that of bacterial artificial chromosome (BAC) double capture (BDC), modifying the previous method, but using BAC libraries as baits for sequencing a relatively large gene. We applied the BDC approach for the 214 kb autosomal region, ring finger protein 213, which is the susceptibility gene of moyamoya disease (MMD). To evaluate the reliability of BDC, cost and data quality were compared with those of a commercial kit. While the ratio of duplicate reads was higher, the cost was less than that of the commercial kit. The data quality was sufficiently the same as that of the kit. Thus, BDC can be an easy, low-cost, and useful method for analyzing individual genome regions with substantial length.

[A Case of Moyamoya Disease with Postoperative Cerebral Hyperperfusion Syndrome Followed by Cerebral Infarction due to Watershed Shift].

The concept of "watershed shift"(WS)has been proposed as a cause of the ischemic complications following a superficial temporal artery-middle cerebral artery(STA-MCA)bypass operation performed for the management of moyamoya disease. Previous reports have observed that only 1.2-5.7% of the patients who underwent a bypass operation for the management of moyamoya disease developed cerebral infarction secondary to the WS phenomenon. To date, the WS phenomenon has not been objectively proven on imaging studies. We describe a 39-year-old woman who presented with right facial palsy and aphasia. Magnetic resonance imaging revealed cerebral infarction in the left frontal lobe secondary to moyamoya disease. Three days after undergoing the left STA-MCA bypass procedure, she showed deterioration in aphasia secondary to the occurrence of cerebral hyperperfusion syndrome(CHPS). Diffusion-weighted imaging(DWI)performed on postoperative day(POD)1 and 5 showed no area of high signal intensity. DWI performed on POD 8 showed an area of high signal intensity in the deep white matter of the left parietal lobe outside the range of the craniotomy. Postoperative fusion images of computed tomography angiography and DWI performed on POD 8 showed that the blood flow through the MCA from the bypass graft and that through the posterior cerebral artery crossed each other at the surface of the subcortical infarction. In the present case, the WS could be directly confirmed on imaging studies, and the cerebral infarction may have occurred secondary to WS concomitant with CHPS. Clinicians need to be aware of the WS phenomenon even after performing a direct bypass to treat adults with moyamoya disease.

[A Case of Cardiac Arrest Caused by Coronary Spasm Related to Induction of General Anesthesia before Carotid Endarterectomy].

Coronary vasospasm(CV)can cause severe arrhythmia and myocardial infarction(MI). Intraoperative CV is not limited to cardiac surgery alone. We report the case of a patient who experienced cardiac arrest after the induction of general anesthesia, but did not demonstrate any abnormalities on preoperative examination. The patient was a 60-year-old man with no history of ischemic heart disease, with NASCET 80% asymptomatic left internal carotid stenosis(ICS). We decided to perform carotid endarterectomy(CEA). Preoperative stress myocardial scintigraphy did not reveal decreased local uptake. General anesthesia was rapidly induced with propofol and remifentanil, and maintained with sevoflurane. Shortly before the start of CEA, systolic blood pressure dropped to 80 mmHg. Electrocardiography indicated decreased ST, followed by an increase, after which complete atrioventricular block occurred. Cardiopulmonary resuscitation was initiated immediately as the patient's pulse was not palpable;heart beat resumed quickly. CEA was canceled. CV was suspected by the test of nitrate administration to coronary artery performed afterwards. A temporary pacemaker was inserted and carotid artery stenting was performed under local anesthesia. Hence, no pacemaker was used intraoperatively and no abnormality was observed on electrocardiography. In the present case, CV in the coronary artery caused complete atrioventricular block, leading to cardiac arrest after inducing general anesthesia. For ICS treatment performed under general anesthesia, care must be taken regarding the possibility of the occurrence of CV.

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.

Moist-condition Training for Cerebrovascular Anastomosis: A Practical Step after Mastering Basic Manipulations.

As cerebrovascular anastomosis is performed in moist conditions that may impede precise manipulations, surgeons must undergo extensive preoperative training. We developed a simple moist-condition training method. It involves placing a free-floating inner platform hosting an artery from a chicken wing in an outer container filled with tap water to just below the specimen. Trainees performed anastomosis under magnification. Training sessions mimicked difficulties encountered during operations such as poor visibility of the lumen and problems handling the sutures. A retrospective comparison of 100 wet- and 100 dry-condition training sessions for end-to-side anastomoses with 8 stitches showed that under moist condition the time required for the entire procedure was significantly longer (17.8 ± 2.1 vs. 15.3 ± 2.1 min, p < 0.01) and the incidence of wrong stitching was greater (0.38 vs. 0%, p = 0.04). In 8 cases after introducing moist-condition training, the time required in superficial temporal artery to middle cerebral artery bypass surgery was significantly shorter than 8 cases before introducing the training (32.3 ± 5.6 min vs. 48.3 ± 15.9 min, p = 0.01). Incidence of wrong stitches was less in cases after introducing moist-condition training (2.7 vs. 7.4%, p = 0.10). Those indicate that moist-condition training is a useful and practical step and a bridge between training for basic manipulations under dry conditions and actual surgery.

Clinicopathological features of human brainstem gliomas.

We describe the clinicopathological features of 25 brainstem gliomas (BSGs). Twenty BSGs located in the pons and were all in children. Four BSGs located in the medulla oblongata were in 2 children and 2 adults. One (in a child) was located in the midbrain. Radiological findings on MR images were low-intensity on T1 weighted images and high-intensity on T2 weighted images. Mean survival when pontine glioma was treated by radiotherapy and/or use of temozolomide was 14 months, although 4 patients (3 cervicomedullary types and one focal type arising from midbrain) are alive. Follow up was from 5 months to 6 years. Histopathological features of 10 cases of the diffuse type were: 4 grade II astrocytomas, 4 grade III astrocytomas, and 2 glioblastomas. MIB-1 index was from 0.8 to 38 %. P53 was positive for 80 % of 15 tumors and there were no negative results. MGMT was positive in 60 % of 15 tumors and negative in 12.4 %. IDH1 was negative in 61.6 %. There was no positive result for IDH1 in this study. Thus, our histopathological results were indicative of high p53 immunoreactivity and no IDH1 immunoreactivity related to secondary malignant change.

Tailored flow alteration treatment for intracranial internal carotid artery aneurysms: strategy beyond parent artery occlusion with bypass. Case report.

A 58-year-old woman with multiple right internal carotid artery (ICA) aneurysms detected incidentally was referred to us. Three-dimensional computed tomography (CT) angiography revealed a broad-necked paraclinoid aneurysm and an aneurysm on the C(1) segment. Aneurysm clipping with preservation of the anterior choroidal artery and posterior communicating artery was not possible because these vessels could not be adequately identified. Intraoperative digital subtraction angiography during obliteration of the cervical portion of the ICA confirmed retrograde flow from the extracranial-intracranial (EC-IC) bypass to the right ophthalmic artery and stagnation of flow in the aneurysms. The cervical portion of the ICA was ligated. Postoperative three-dimensional CT angiography confirmed complete occlusion of both aneurysms and absence of ischemic lesions involving branches of the ICA. Reversal of the blood flow in the ICA via the EC-IC bypass primarily into the ophthalmic artery as the flow outlet by obliterating the cervical portion of the ICA was successful. To prevent ischemia in the territory fed by the perforating arteries of the ICA, tailored flow alteration treatment may be superior to simple parent artery occlusion of the ICA with/without bypass. The pattern of flow alteration should be deliberately based on individual anatomic variations, especially the preservation of flow outlets.

Contrast stasis in large and giant internal carotid artery aneurysms as a good prognostic factor for endovascular coil embolization: retrospective study.

OBJECTIVE: Before treatment for large and giant aneurysms, we need some of the predictors to prognose a good result. In this retrospective study, we attempted to determine criteria such as angiographic signs to identify good candidates for effective endovascular surgery. METHODS: This study involved 45 patients with large or giant aneurysms treated by endovascular embolization. For angiographic study, we delivered a bolus injection of contrast medium. All aneurysms were confirmed angiographically and the morphology was defined in detail before endovascular embolization. We divided the patients into two groups based on angiographic findings. Group A (n=16) manifested stasis of the contrast medium in the aneurysm on venous phase. Group B (n=29) exhibited other findings. We retrospectively evaluated the relationship between stasis of the contrast medium in the aneurysm and results of endovascular embolization. RESULTS AND DISCUSSION: There was no significant difference between the two groups with respect to the size of the aneurysm. However, the neck/dome ratio (P=0·04) and size of the neck (P=0·003) were significantly different between groups A and B. The morphological outcome was better in group A than group B (P=0·03). We demonstrate that contrast stasis is a good predictor of outcome in patients with large or giant aneurysms to consider the endovascular embolization. Hemodynamic studies on large patient populations may reveal other factors predictive of a good treatment outcome.

Effectiveness of interferon-beta therapy for recurrent glioblastoma: a case report.

AIMS AND BACKGROUND: Glioblastoma has a poor prognosis, with few therapeutic options if it recurs. We report a case in which we were able to inhibit the growth of a recurrent glioblastoma by weekly single-dose administration of interferon-beta. CASE REPORT: A patient with recurrent glioblastoma after radiation and chemotherapy was treated with nimustine and interferon-beta. After 2 cycles of nimustine, the patient's leukocyte, neutrophil, and platelet counts showed grade 4 toxicity according to the National Cancer Institute's Common Toxicity Criteria. The patient was treated with a weekly single dose of interferon-beta at 6 x 10(6) IU. The tumor showed no remarkable changes after 18 months, and the patient's Karnofsky performance status remained at 50%. CONCLUSIONS: The administration of interferon-beta produced long-term control in one case of glioblastoma and may be an effective therapy.

Fluorescence diagnosis of tumor cells in hemangioblastoma cysts with 5-aminolevulinic acid.

Peritumoral hemangioblastoma cysts are usually composed of fibrous tissue without tumor cells. The authors describe the first case in which fluorescence with 5-aminolevulinic acid (5-ALA) was used to diagnose a hemangioblastoma tumor in a peritumoral cyst wall. A 27-year-old woman with a homogeneous, enhanced nodular lesion in the right hemisphere of the cerebellum underwent surgical treatment. After the nodular lesion was removed, the cyst region was observed with the aid of a semiconductor laser with a peak wavelength of 405 +/- 1 nm, which was powered using a fiberoptic cable. The cyst region was visualized with strong fluorescence, which disappeared after tissue removal. The fluorescent cyst consisted of tumor cells. The authors conclude that fluorescence diagnosis performed using 5-ALA can inform the choice of removing hemangioblastoma cysts.

Brachial plexopathy due to massive swelling of the neck associated with craniotomy in the park bench position.

BACKGROUND: During prolonged neurosurgical procedures, anesthetized patients are at risk for position-related complications. We report a rare combination of neck swelling and brachial plexopathy as operative position-related complications. CASE DESCRIPTION: This 56-year-old woman was placed in the left park bench position for removal of a tentorial meningioma in the right posterior fossa. At 2 hours after the 10-hour procedure, her left neck began to swell with progression during the next 10 hours to involve the face on the same side and the face and neck on the opposite side. Computed tomography showed swelling of the muscles and deep soft tissue primarily on the left. No brain edema was observed. She was conservatively treated with orotracheal intubation, placed in the head-up position, and received anticoagulants. Her swelling subsided by the 20th postoperative day; however, she manifested weakness in the proximal muscles of the left upper extremity. Magnetic resonance imaging revealed swelling of the brachial plexus on the left; electrophysiologic studies were compatible with damage to the upper trunk of the brachial plexus. She was discharged 2 months after surgery with improved weakness. CONCLUSION: Possible pathologic mechanisms are kinking of the jugular vein due to extremely flexed neck position during surgery and associated delayed swelling of the neck and brachial plexus. The cerebral venous return may have been maintained by anastomosis between the internal jugular and the vertebral venous system. To prevent such complications, we must take great care of the anesthetized patients when placed in the forced neck position.

Symptomatic Rathke's cleft cyst with cavernous sinus syndrome.

An 88-year-old man presented with Rathke's cleft cyst (RCC) manifesting as complete cavernous sinus syndrome. He had no headache, endocrinological symptom, or blood abnormality. Neuroimaging revealed a cystic intrasellar lesion with lateral extension. The patient underwent surgery by a transsphenoidal approach. Histological examination revealed squamous and cuboidal epithelium. The diagnosis was RCC. RCC is rarely symptomatic, but enlargement and compression of the surrounding structures usually causes headache, visual field defects, or symptoms of pituitary dysfunction. The present case shows that RCC may manifest as complete cavernous sinus syndrome.

Neuroendoscopic appearance of an intraventricular cavernous angioma blocking the foramen of monro - case report.

A 47-year-old woman presented with unilateral ventricular enlargement detected by magnetic resonance imaging during a medical checkup. Neuroendoscopic exploration identified a multilocular lesion in which dark red fluid formed a niveau near the right side of the foramen of Monro. The diagnosis was intraventricular cavernous angioma. Restricted flow of cerebrospinal fluid at the foramen of Monro was observed. Xanthochromia, which seemed to be due to previous bleeding, was observed at the fornix. When the neuroendoscope touched the angioma, the wall collapsed and bled. Endoscopic removal of the angioma was abandoned, and craniotomy and resection of the angioma were performed. No new neurological anomalies were observed after surgery. Preoperative diagnosis of intraventricular cavernous angioma is difficult based on neuroimaging. Neuroendoscopy is effective for diagnosis and the decision-making process regarding treatment.

Usefulness of transcervical approach for surgical treatment of hypoglossal schwannoma with paraspinal extension: case report.

BACKGROUND: Usefulness of transcervical approach to hypoglossal schwannoma with paraspinal extension is described herein. CASE DESCRIPTION: A 54-year-old woman presented with gradually worsening left hypoglossal nerve palsy. The findings were of a tumor lying in the left hypoglossal canal and paraspinal region and were consistent with hypoglossal schwannoma. Subtotal intracapsular removal of the tumor was performed via transcervical approach. The symptoms improved, and no additional symptoms were noted. CONCLUSION: The transcervical approach and intracapsular removal of the tumor under electrophysiological monitoring provided for successful minimally invasive surgery in this case of hypoglossal schwannoma.