[Two Cases of Difficult-to-Treat Acute Epidural Hematoma and a Review of Decompressive Craniectomy with Hematoma Evacuation].

INTRODUCTION: Decompressive craniectomy(DC)with craniotomy for acute epidural hematoma(AEDH)removal is controversial. Here, we summarized two difficult AEDH cases where DC was performed. CASE 1:A 26-year-old man sustained a head injury in a bicycle accident, with a Japan Coma Scale(JCS)score of 200, right pupil mydriasis, and a left decerebrate posture on admission. Computed tomography(CT)revealed right AEDH with a midline shift. Craniotomy was performed without DC. Postoperatively, his consciousness level and anisocoria improved(JCS score, 30). Furthermore, no cerebral infarction was observed on CT at 9 h after surgery;however, at 48 h after surgery, a cerebral infarction with a mild midline shift was evident in the right hemisphere. His consciousness level deteriorated(JCS score, 100), and we initiated glyceol infusion. Worsening of the midline shift was apparent on CT 100 h after surgery;thus, DC was immediately performed. CASE 2:A 15-year-old boy was injured in a fall. On admission, his JCS score was 10. Immediately afterward, he showed neurological deterioration(JCS score, 200), right pupil mydriasis, and a left decorticate posture. CT revealed right AEDH with a midline shift;thus, craniotomy was performed with DC. On hospitalization day 10, he had orthostatic headache and a JCS score of 1. CT revealed paradoxical midline shift to the opposite side of craniotomy, and syndrome of the trephined was considered. He was placed in the Trendelenburg position until cranioplasty was performed on hospitalization day 18. CONCLUSION: Patients with AEDH presenting severe consciousness issues should undergo hematoma removal. Although DC is controversial, surgeons should administer intensive and prompt treatment according to the circumstance and should consider DC for appropriate AEDH cases.

[Neuroendoscopic surgery for intra- and para-ventricular tumors:impacts on biopsy and hydrocephalus treatment].

In this report, the authors retrospectively review and discuss their results for neuroendoscopic surgery for intra- and para-ventricular tumors. This study included 28 patients who were admitted to our hospital for intra- or para-ventricular tumors between January 2005 and March 2013. There were 17 males and 11 females, and their age varied widely from 1 to 75 years. Using a neuroendoscopic technique, tumor biopsy was attempted in all 28 patients. Biopsy was possible in 25 patients(89.3%)but not in the other 3(10.7%)because of hypervascularity or tumor bleeding. Of these 25 patients, pathological diagnosis was possible in 23(92%), but not in other 2(8%)because of incomplete sampling. In 18 of 28 patients, various forms of hydrocephalus were observed. Neuroendoscopic procedures were quite useful to improve cerebrospinal fluid dynamics in 13 of these patients, including endoscopic third ventriculostomy(ETV)in 9(except for 1 patient with ETV failure), septostomy with ventriculoperitoneal shunting(VPS)in 3, and cystostomy in 1. Simple VPS was performed in the other 4 patients. These results suggest that neuroendoscopic surgery is valuable as a minimally invasive procedure for pathological diagnosis and hydrocephalus treatments in patients with intra- and para-ventricular tumors. Further development of neuroendoscopic equipment is warranted to accurately diagnose tumors with hypervascularity and subependymal tumors.

Effect of carotid endarterectomy on cognitive function in patients with asymptomatic carotid artery stenosis.

BACKGROUND: This study was conducted to determine if patients with asymptomatic carotid artery stenosis show cognitive function decline, and if they experience any changes in cognitive function after carotid endarterectomy (CEA). METHOD: Cognitive function was examined in 15 patients (12 males and three females, 70.0 ± 6.5 years) with asymptomatic carotid artery stenosis before and 3 months after CEA. Cognitive function was assessed with the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), two subtests of the Wechsler Adult Intelligence Scale-Revised (WAIS-R 2 subtests), and the Japanese version of National Adult Reading Test (JART). The patients' average scores were compared with the normal average by one-sample t-tests, and the before and after scores were compared with paired t-tests. Changes in each patient were calculated from difference before and after CEA using 95 % confidence intervals. RESULTS: Before surgery, patients showed significant cognitive decline in RBANS total scale and immediate memory, language, and attention. At 3 months after CEA, the total scale and the immediate memory were not significantly different from the normal average. The average total scale score, the immediate memory and attention, and the WAIS-R 2 subtests scores were increased after treatment. Changes in each patient were calculated from the scores before and after CEA. At 3 months after CEA, the rate of increase in RBANS scores were 60.0 % of the patients for immediate memory, 26.7 % for visuospatial/constructional, 33.3 % for language and attention, 26.7 % for delayed memory, 47.7 % for total scale and 26.7 % for WAIS-R 2 subtests. Thus, so-called asymptomatic patients exhibit mild cognitive impairment before surgery, but after CEA, patients recover normal memory abilities. CONCLUSIONS: Our findings of mild cognitive dysfunction in asymptomatic patients suggest that they might be symptomatic after all.

Prognostic factors in elderly patients with supratentorial malignant gliomas.

The prognostic factors were retrospectively analyzed in 30 patients aged 70 years or over with supratentorial malignant gliomas treated by surgery in our hospital. The histological diagnosis was confirmed as grade 3 in 13 patients and grade 4 in 17. Seventeen patients received adjuvant radiation therapy. Only 10 patients underwent chemotherapy. Survival time was analyzed with the Kaplan-Meier method. Prognostic factors were obtained from the Cox proportional hazards model. Univariate analysis showed preoperative Karnofsky performance status (KPS) score of 70 or greater and radiation therapy were significantly associated with longer survival. However, multivariate analysis revealed that preoperative KPS score of 70 or greater was the only independent prognostic factor and radiation therapy lost its significance due to selection bias. Neurological deterioration and medical complications occurred in six and seven patients, respectively. Performance status rather than histological grade is the key prognostic factor in elderly patients with supratentorial malignant gliomas. Patients with good preoperative KPS score should be aggressively treated with extensive resection and radiotherapy.

Intraosseous cavernous hemangioma of the frontal bone.

A 32-year-old man presented with a primary intraosseous cavernous hemangioma manifesting as a small painless swelling of the right forehead. Radiography revealed a radiolucent osteolytic lesion in the right frontal region. Bone window computed tomography demonstrated a 1.5 cm mass between the outer and inner tables just lateral to the right frontal sinus. The outer and inner tables were thin and partially defective, but without bone fracture. Magnetic resonance imaging revealed a small mass lesion with bone erosion of the posterior table of the frontal bone. Preoperative examination yielded no final diagnosis. En bloc resection was performed. The histological diagnosis was primary intraosseous cavernous hemangioma. Total resection is recommended for definitive diagnosis of intraosseous tumor.

Transparent endoscopic sheath and rigid-rod endoscope used in endoscopic third ventriculostomy for hydrocephalus in the presence of deformed ventricular anatomy.

OBJECT: Endoscopic third ventriculostomy (ETV) has been widely performed for the treatment of noncommunicating hydrocephalus. In cases of hydrocephalus in conjunction with deformed and complex ventricular anatomy, it is preferable to use a rigid-rod endoscope for ETV, because the excellent visibility provided by this instrument yields a smooth and correct orientation in the ventricle. The authors report on ETV procedures in which they used a transparent endoscopic sheath that has a common channel in which a rigid-rod endoscope and an instrument can be inserted. METHODS: In 15 cases of noncommunicating hydrocephalus, a transparent endoscopic sheath and a rigid endoscope were used for ETV. In 11 of the 15 patients, the diameter of the foramen of Monro and the width of the third ventricle were greater than 5 mm, and thus a transparent endoscopic sheath and a rigid endoscope could be smoothly introduced through the foramen of Monro and an ETV successfully performed. Four patients had congenital or acquired narrowing of the foramen of Monro and an anatomically deformed ventricular system. In three of the patients, opening of the narrowed foramen and an ETV were successfully performed using the transparent endoscopic sheath under direct visualization through the rigid-rod endoscope. CONCLUSIONS: A transparent endoscopic sheath increases safety by offering a corridor to the third ventricle. It also provides excellent visibility without troublesome bleeding from tissues surrounding the foramen of Monro during endoscopic procedures in which a rigid endoscope is used.

Comparative efficacy of acyclovir and vidarabine on the replication of varicella-zoster virus.

Acyclovir and less frequently, vidarabine are (or have been) used in the treatment of varicella-zoster virus (VZV) infection and are administered either intravenously (vidarabine) or orally (acyclovir, up to five times per day). The pharmacological bases of the administration interval were modeled in vitro in this study. Incubation of VZV-infected cultures with acyclovir or vidarabine for 24, 48, 72 and 96h showed similar duration-dependent anti-viral activities as assessed by a plaque-reduction assay. Treatment with vidarabine for only 8h/day for 4 days (intermittent treatment) showed anti-VZV activity equivalent to that of continuous treatment for 4 days in terms of the inhibitory dose that reduced plaque formation by 50% (IC(50)). In contrast, intermittent treatment with acyclovir exhibited a 7.9 times higher IC(50) value than that of continuous treatment. The mode of inhibition of expression of most of viral protein was similar in both drugs, but the degree of inhibition was different for each protein. Thus, vidarabine with a limited period of treatment showed anti-VZV activity comparable to continuous treatment with acyclovir, indicating the longer duration of anti-viral activity of vidarabine.

Multiple aneurysms arising from the origin of a duplication of the middle cerebral artery.

Duplication of the middle cerebral artery is an anomalous vessel arising from the internal carotid artery. There have only been 14 reports of aneurysms arising from the origin of a duplication of the middle cerebral artery and 5 of these patients had multiple aneurysms. Aneurysms at this site have a high rupture rate compared to aneurysms in other locations and aggressive management is indicated.

Multiple epidermoid cysts located in the pineal and extracranial regions treated by neuroendoscopy.

A 22-year-old woman presented with a rare case of multiple epidermoid cysts located in the pineal and extracranial regions. Magnetic resonance (MR) imaging showed a lesion in the pineal region as hypointense on the T(1)-weighted image and hyperintense on the T(2)-weighted image, without enhancement. Neuroendoscopic treatment was performed under a diagnosis of pineal cyst. However, the cyst wall was too thick to perforate, although third ventriculostomy was performed. Diffusion-weighted MR imaging demonstrated the lesions in the pineal and extracranial regions as marked hyperintensity. The diagnosis was epidermoid cyst. Subsequently, neuroendoscopic treatment of the pineal epidermoid cyst was performed. Careful preoperative diagnosis of epidermoid cysts based on diffusion-weighted MR imaging is required.

[Selection of surgical approach for quadrigeminal cistern arachnoid cyst].

Preoperative magnetic resonance imaging of 4 cases of quadrigeminal cistern arachnoid cyst were retrospectively reviewed and patterns of extension to surrounding cisterns from the quadrigeminal cistern were examined. Relationship between patterns of extension to surrounding cisterns and selected surgical approach were evaluated. In 2 cases, the cyst extended anteriorly and compressed the quadrigeminal plate. These two cases had hydrocephalus due to aqueductal stenosis. The anteroirly extending cyst was treated with endoscopic ventriculocystocisternostomy via the lateral and third ventricles. In one case, the cyst extended superiorly to the velum interpositum cistern, and was treated with endoscopic ventriculocystocisternostomy via the lateral ventricle. In one case, the cyst extended laterally to the ambient cistern and compressed the posterior horn of the lateral ventricle. This case had loculated hydrocephalus of the inferior horn. The laterally extending cyst was treated with resection of the wall of the arachnoid cyst via an infratentorial supracerebellar approach assisted by endoscope. All cysts were successfully treated. Injury of the foramen of Monro occurred during a procedure using a flexible endoscope in a case with an anterior extending cyst. Exact analysis of the preoperative imaging and selection of appropriate surgical approach are key factors for successful treatment of a quadrigeminal cistern arachnoid cyst.

Therapeutic basis of vidarabine on adenovirus-induced haemorrhagic cystitis.

When adenovirus causes haemorrhagic cystitis in immunocompromised patients, vidarabine is used for its treatment because therapeutic choice is limited. Although vidarabine has been reported to be effective for these patients, its therapeutic basis has not yet been established. Vidarabine dose-dependently inhibited viral replication as assessed by a yield reduction assay. Viral protein synthesis was dose-dependently inhibited by vidarabine but not at all by acyclovir, and the degree of inhibition by vidarabine was different for each of the viral proteins, ranging from 0-40% of the untreated control. These results indicated the specificity and mechanism of action of vidarabine against adenovirus. The concentration of vidarabine and its metabolite in the bladder is suggested to exhibit effective anti-adenoviral activity in suppressing the replication of adenovirus. Thus, our results support vidarabine therapy as a possible candidate for adenovirus-induced haemorrhagic cystitis in immunocompromised patients.

Reversal of cognitive dysfunction by total removal of a large lateral ventricle meningioma: a case report with neuropsychological assessments.

Although cognitive impairment is one of the major symptoms of ventricular tumors, few studies have reported the details of cognitive impairment before and after their surgical removal. The expected effects on cognitive function should also be considered when choosing a surgical approach. We report the case of a large lateral ventricle meningioma in which cognitive impairment was detected on detailed neuropsychological examinations. The tumor was totally removed through the right superior temporal gyrus. Postoperative neuropsychological assessment revealed the reversal of cognitive impairment. As cognitive impairment is complex and easily overlooked, it is important to precisely assess neuropsychological function in patients with large brain tumors.

Unilateral anterior interhemispheric approach for anterior communicating artery aneurysms with horizontal head position--technical note.

The horizontal head position was adopted in the unilateral anterior interhemispheric approach to treat an anterior communicating artery (ACoA) aneurysm. The patient was placed in the supine position. The patient's head was rotated to the right to orient the midline horizontally, and tilted 45 degrees superiorly. After bicoronal skin incision and bifrontal craniotomy, the dura on the right side (downside) was opened. Dissection of the right interhemispheric fissure allowed gravity to retract the right (downside) hemisphere, which fell away from the falx, while the falx supported the upside hemisphere. The present approach was used in three patients with ACoA aneurysm between January 2009 and April 2010. The aneurysms were adequately clipped with this approach. No complication related to the approach occurred. No patients exhibited anosmia after surgery. This approach is useful for ACoA aneurysms.

Middle cranial fossa arachnoid cyst presenting with subdural effusion and endoscopic detection of tear of the cyst--case report.

A 15-year-old boy presented with a case of middle cranial fossa arachnoid cyst associated with subdural effusion and manifesting as headache and vomiting after minor head injury. Computed tomography disclosed a cystic lesion in the left middle cranial fossa and ipsilateral subdural effusion. Fundoscopic examination revealed papilledema. A small tear of the cyst wall was confirmed endoscopically. Fenestration of the cyst was performed under the operating microscope. Postoperative course was uneventful. The tear in the outer wall of an arachnoid cyst may suggest the mechanism of occurrence of subdural effusion associated with middle cranial fossa arachnoid cyst.

Neuropsychological changes after endoscopic third ventriculostomy for long-standing overt ventriculomegaly in adults. Case report.

A 39-year-old woman presented with long-standing overt ventriculomegaly in adults (LOVA) manifesting as gradually worsening headache. Past history included treatment for myeloschisis at birth. Intelligence quotient (IQ) was 115 and preoperative psychological assessment using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) showed normal scores in all domains. However, scores for constructional ability were slightly low. Computed tomography revealed severe ventriculomegaly involving the lateral and third ventricles, and magnetic resonance imaging showed aqueductal stenosis. Endoscopic third ventriculostomy was performed under a diagnosis of LOVA. Postoperatively, the headache resolved and the RBANS showed improvements in memory and constructional ability. Detailed evaluation of cognitive function provides a good indicator in the treatment of hydrocephalus with normal IQ.

Preparation of a simple and efficient laboratory model for training in neuroendoscopic procedures.

OBJECTS: Because the lateral ventricles of cadaver heads are often collapsed, they can be difficult to cannulate endoscopically. We present a novel method for preparing a cadaveric model for endoscopic intraventricular procedures. MATERIALS AND METHODS: A burr hole was placed in the midpupillary line anterior to the coronal suture. A triangular wedge of frontal scalp, skull, and dura with its base 6 cm superior to the orbitomeatal line and 6 cm posterior to the forehead was cut and removed. A wedge of the underlying brain was similarly cut along the edge of the bone window. After removal of the brain block, the anterior horn of the lateral ventricle was exposed. The endoscope sheath was inserted through the burr hole into the anterior horn in the brain block, following its return to its original location with the skull and scalp. CONCLUSION: This model is easily prepared and optimizes training in endoscopic ventricular surgery.

Pilomyxoid astrocytoma in a patient presenting with fatal hemorrhage. Case report.

The authors report on a rare case of pilomyxoid astrocytoma in a patient presenting with fatal hemorrhage. This 5-year-old boy presented to the outpatient clinic with headache and vomiting. Computed tomography and magnetic resonance imaging studies revealed a mass lesion with partial hemorrhage in the suprasellar region extending into the third ventricle. Partial resection via a transcallosal approach was performed. Because the pathological diagnosis was pilomyxoid astrocytoma, chemotherapy was administered. However, 4 months after the first operation, during chemotherapy, the boy presented with massive intratumoral and intraventricular hemorrhage with hydrocephalus. Although emergent external ventricular drainage was performed, the patient died. In this report, the authors review the literature and discuss the clinical features and treatment of pilomyxoid astrocytoma.

A rare case of shunt malfunction attributable to blockage of a Codman-Hakim programmable shunt valve.

BACKGROUND: We report a rare case of shunt malfunction resulting from blockage of a Codman-Hakim programmable shunt valve by fibrinoid-like tissues. HISTORY: The patient had undergone shunt system placement for hydrocephalus after hemorrhagic infarction at the age of 8 months; a Codman-Hakim programmable shunt valve was used at that time. LATER COURSE: Two years after shunt placement, the boy suffered from irritability and poor activity when the aforementioned shunt malfunction arose following valve blockage by fibrinoid-like tissues. He underwent shunt revision and was subsequently free of symptoms.

Herpes simplex virus-induced, death receptor-dependent apoptosis and regression of transplanted human cancers.

Inoculation of a live attenuated herpes simplex virus (HSV) vector, betaH1, into human U87MG glioblastoma cells transplanted into athymic nude mice induced complete regression of tumors. The infected cells underwent histochemically confirmed apoptosis without lymphocyte infiltration after expressing CD30, CD30 ligand (CD30L), tumor necrosis factor (TNF)-alpha, TNF receptor 1 (TNF-R1), FAS, and FAS ligand (FAS-L) with activation of caspases 3 and 8. Induction of the transcripts of these receptors and ligands in inoculated tumors was confirmed by quantitative RT-PCR. To examine the specificity of apoptosis in the transplanted tumor, we inoculated betaH1 into transplanted human lung, breast, gastric, and colon cancer tumors, and similar tumor regression with apoptosis was observed in all tumors. We analyzed the roles of expression of CD30, CD30L, TNF-alpha, TNF-R1, FAS, and FAS-L in the tumors, and found that HSV-induced apoptosis was suppressed by the respective antibodies. These findings indicate that the CD30/CD30L, TNF-alpha/TNF-R1, and FAS/FAS-L interactions resulted in apoptosis and tumor regression in immunocompromised mice. In addition to the death receptor-dependent apoptosis induced by HSV, the expressed ligands and receptors might enhance the susceptibility of tumor cells to cell-mediated cyto-toxicity and augment the activation of tumor-killing lymphocytes in immunocompetent models.