Metastasis infiltrating tumor to meningioma: a case report.

BACKGROUND: There have been many reports of tumor-to-tumor metastasis, in which cancer metastasizes directly into meningiomas. However, metastasis infiltrating tumors in which cancer metastasizes around meningiomas are rare. Therefore, we report a case of metastasis originating from lung cancer that infiltrated meningioma. CASE PRESENTATION: A 79-year-old Japanese woman underwent head magnetic resonance imaging for brain metastasis screening before lung cancer surgery. At that time, asymptomatic meningioma of the left frontal region was accidentally found. Magnetic resonance imaging 6 months later revealed a lesion suspected to be a metastatic brain tumor close to the meningioma. Brain tumor resection was performed, and histopathological diagnosis was meningioma and metastatic brain tumor. Metastatic cancer had invaded the meningioma at the boundary between the brain tumor and metastasis. CONCLUSIONS: A sudden change in imaging findings on routine examination of meningiomas in patients with lung carcinoma may indicate a metastatic brain tumor. The form of cancer metastasis to meningioma is not limited to tumor-to-tumor metastasis, but also includes metastasis infiltrating tumors near the meningioma.

Local and systemic factors associated with quantitative stiffness of carotid plaque.

PURPOSE: Plaque stiffness in carotid artery stenosis is a clinically important factor involved in the development of stroke and surgical complications. The purpose of this study was to clarify which local and systemic factors are associated with the quantitatively measured stiffness of plaque. METHODS: The subjects were 104 consecutive patients who underwent carotid endarterectomy at our institution. To measure quantitative stiffness of plaque, we used an industrial hard meter in the operating room within 1 h after removal of plaque. Local factors related to carotid plaque hardness were evaluated, including maximum intima-media thickness (max IMT), degree of stenosis using the European Carotid Surgery Trial (ECST), presence of ulceration or calcification, and echo brightness on preoperative carotid ultrasound. The degree of stenosis was also evaluated using the North American Symptomatic Carotid Endarterectomy Trial method in digital subtraction angiography. Age, sex, and presence or absence of hypertension, diabetes, and dyslipidemia (low-density lipoprotein cholesterol and triglyceride [TG] levels) served as systemic factors and were compared with the quantitative stiffness of carotid plaque. RESULTS: In multivariate analysis, ECST stenosis degree, calcification, and IMT max as local factors affected plaque stiffness. As a systemic factor, plaque stiffness was statistically significantly negatively correlated with TG values in multivariate analysis (p < 0.05). CONCLUSION: The quantitative stiffness of the plaque was negatively correlated with TG levels as a systemic factor in addition to local factors. This might suggest that reducing high TG levels is associated with plaque stabilization.

Differentiation between Anterior and Posterior Roots Using Compound Muscle Action Potential in Intradural Extramedullary Spinal Tumor Surgery.

This study aims to determine the cutoff values for the compound muscle action potential (CMAP) stimulus in anatomically identified anterior (motor nerve) and posterior roots (sensory nerve) during cervical intradural extramedullary tumor surgery. The connection between CMAP data from nerve roots and postoperative neurological symptoms in thoracolumbar tumors was compared with data from cervical lesions. The participants of the study included 22 patients with intradural extramedullary spinal tumors (116 nerve roots). The lowest stimulation intensity to the nerve root at which muscle contraction occurs was defined as the minimal activation intensity (MAI) in the CMAP. In cervical tumors, the MAI was measured after differentiating between the anterior and posterior roots based on the anatomical placement of the dentate ligament and nerve roots. The MAIs for 20 anterior roots in eight cervical tumors were between 0.1 and 0.3 mA, whereas those for 19 posterior roots were between 0.4 and 2.0 mA. The cutoff was <0.4 mA for both the anterior and posterior roots, and sensitivity and specificity were both 100%. In thoracolumbar tumors, the nerve root was severed in 12 of 14 cases. All MAIs were determined to be at the dorsal roots as their scores were higher than the cutoff and did not indicate motor deficits. The MAIs of the anatomically identified anterior and posterior root CMAPs were found to have a cutoff value of <0.4 mA in the cervical lesions. Similar MAI cutoffs were also applicable to thoracolumbar lesions. Thus, CMAP may be useful in detecting anterior and posterior roots in spinal tumor surgery.

Academic Activities of Female Neurosurgeons in All Branch Meetings of the Japan Neurosurgical Society.

This study aims to evaluate the academic activities of female neurosurgeons at all branch meetings of the Japan Neurosurgical Society and identify related issues they encountered. The programs of all seven branch meetings of the Japan Neurosurgical Society (Hokkaido, Tohoku, Kanto, Chubu, Kinki, Chugoku/Shikoku, and Kyushu) were used to determine the number of presentations and chairpersons by sex. The covered period was from January 2008 to December 2020, which was available for viewing during the survey. Of note, only the Kinki branch used data from January 2008 to December 2019. The Neurologia Medico-chirurgica (NMC), the journal of the Japan Neurosurgical Society, was also reviewed to identify publication achievements during the same period. In all seven branches, the percentage of presentations given by female physicians increased from 7.9% in 2008 to 9.6% in 2020 (p < 0.05).Conversely, the percentage of female chairpersons in all branch meetings did not change over time and it was significantly lower (1.1%) than that of female presenters (7.9%) for all branch meetings combined in over 13 years (p < 0.01). In the NMC, the number of articles with female physicians as first authors did not increase or decrease over the years. We conclude that efforts to smoothly promote female neurosurgeons as chairpersons and increase the number of female first authors are necessary to facilitate their academic activities.

Diagnosis and treatment of vertebral artery injuries due to blunt trauma: A case series.

Blunt traumatic vertebral artery injuries are rare, but they cause rapid secondary strokes with worsening prognoses. We report four blunt traumatic vertebral artery injury cases that were diagnosed before developing stroke and successfully treated with coil embolization. All four patients were male, aged between 45 and 71 years (mean 57 years). The injuries were caused by road accidents in 2 cases and falls in 2 cases. The GCS at initial examination was 15, except for one case of hypoxic encephalopathy associated with pulmonary contusion (11 points). The vertebral arteries were completely occluded (Denver grade IV). Before treatment, only one patient had a mild right cerebellar hemispheric stroke, but three patients were asymptomatic. All patients underwent coil embolization (2 on 0 days, 1 on 7 days, and 1 on 17 days), and the postoperative course was uneventful. The neuroradiological imaging studies should be performed as early as possible in vertebral artery injuries due to blunt neck trauma. Moreover, endovascular coil embolization is a safe, effective treatment for blunt traumatic vertebral artery injuries.

Intraperitoneal hemorrhage due to segmental arterial mediolysis associated with cerebral vasospasm after subarachnoid hemorrhage.

A man in his 50s with no significant past medical history developed subarachnoid hemorrhage due to ruptured left middle cerebral artery aneurysm. On the ninth hospital day, he had a ruptured visceral aneurysm with segmental arterial mediolysis, and we successfully treated with transarterial embolization using metallic coils.

A Case of Lateral Ventricular Subependymoma with Intratumoral Hemorrhage via Neuroendoscopic Surgery.

Subependymoma (SE) is a rare, usually asymptomatic, brain tumor predominantly affecting older adults and occurring in the fourth and lateral ventricles. We report a rare case of SE with intratumoral hemorrhage that could be removed by neuroendoscopy. The 81-year-old patient had been followed as an outpatient for 10 years due to an intraventricular tumor. It did not grow over the patient's lengthy follow-up. The patient was transferred to our hospital after he fainted near his home; at the time of admission, he had mild consciousness disturbance, and his Glasgow Coma Scale score was 10 points (E3V3M4). Computed tomography showed intratumoral hemorrhage and slight ventricular enlargement. Magnetic resonance (MR) imaging showed a 4 cm-sized tumor in the anterior horn of the right lateral ventricle. The lesion appeared as a mixed-intensity solid tumor and showed irregular enhancement with gadolinium. The patient underwent neuroendoscopic tumor resection on the 30th day of the patient's hospital stay. A histopathological examination revealed small tumor cells with round nuclei scattered in the glial fibrillary background. Immunostaining was positive for glial fibrillary acidic protein; these findings are consistent with an SE diagnosis. The patient in this study had hypertension and used anticoagulants, risk factors for intratumoral hemorrhage. For intraventricular tumors with bleeding-particularly in older or more physically frail patients-minimally invasive neuroendoscopic surgery should be considered an option for tumor resection.

The diagnostic value of 123I-IMP SPECT in ocular adnexal lymphoma.

BACKGROUND: N-isopropyl- (123I) p-iodoamphetamine (123I-IMP) is specifically accumulated in primary central nervous system lymphoma (PCNSL) during single-photon emission tomography (SPECT) and contributes to its diagnostic imaging. However, whether 123I-IMP is accumulated in ocular adnexal lymphoma (OAL), one of the malignant intraorbital tumors, remains unclear. This study aimed to evaluate the diagnostic value of 123I-IMP SPECT in OAL. METHODS: Between August 2005 and June 2020, 26 patients with intraorbital tumors underwent neurosurgery at the tertiary care center. Of these, 15 patients who underwent 123I-IMPSPECT before surgery were retrospectively examined. The region of interest was set in the cerebellum ipsilateral to the intraorbital tumor on 123I-IMP SPECT, and the tumor-to-cerebellum ratio (T/C ratio) was calculated using the following formula: T/C ratio = [accumulation of tumor (count/pixel)]/[accumulation of ipsilateral normal cerebellar hemisphere (count/pixel)]. RESULTS: Six patients were included in the OAL group, who were pathologically diagnosed with extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma), diffuse large B-cell lymphoma (DLBCL), and plasmacytoma. The T/C ratio in the OAL group was statistically higher than that in the non-OAL group (p < 0.01). The optimal cutoff values for both groups were between 0.76 and < 0.93. The sensitivity and specificity were 1.00, respectively. CONCLUSIONS: 123I-IMP SPECT is useful as one of the examinations in the differential diagnoses of OAL, because it showed a significantly higher accumulation in OAL group than in non-OAL group.

Repeated intracranial empyema following cranioplasty in a patient with atopic dermatitis: a case report.

BACKGROUND: Atopic dermatitis is a chronic inflammatory skin disease associated with pruritus. Skin affected by atopic dermatitis not only shows a high percentage of Staphylococcus aureus colonization, but corneal barrier dysfunction is also known to occur. It is considered a risk factor for bacterial infections in various areas of the body. However, the relationship between atopic dermatitis and bacterial infection following neurological surgery has not yet been reported. Here, we present a case of atopic dermatitis in which the surgical site became infected twice and finally resolved only after the atopic dermatitis was treated. CASE PRESENTATION: A 50-year-old Japanese woman with atopic dermatitis underwent cerebral aneurysm clipping to prevent impending rupture. Postoperatively, she developed repeated epidural empyema following titanium cranioplasty. As a result of atopic dermatitis treatment with oral antiallergy medicines and external heparinoids, postoperative infection was suppressed by using an absorbable plastic plate for cranioplasty. The patient's postoperative course was uneventful for 16 months. CONCLUSIONS: Atopic dermatitis is likely to cause surgical-site infection in neurosurgical procedures, and the use of a metal implant could promote the development of surgical-site infection in patients with dermatitis.

Comparison of quantitative measurements of central nervous system tumour consistency and the associated preoperative imaging findings.

Purpose: Central nervous system (CNS) tumour consistency is one of the factors determining the difficulty of surgery for such lesions. We measured the consistency of surgically excised CNS tumour specimens using a hardness meter. The purpose of this study was to identify imaging parameters that reflect tumour consistency by comparing preoperative imaging findings with CNS tumour consistency measurements. Material and methods: Of 175 consecutive patients with CNS tumours who underwent surgery at our hospital between October 2012 and October 2018, 127 were included in this study (those whose specimens were difficult to measure were excluded). CNS tumour consistency was measured immediately after surgical excision using a hardness meter and compared with preoperative T1-weighted, T2-weighted (T2WI), fluid attenuated inversion recovery (FLAIR), diffusion-weighted imaging, gadolinium-enhanced magnetic resonance imaging, plain computed tomography (CT), and contrast-enhanced CT findings. Tumour consistency was also subjectively classified by the surgeon into soft, hard, or very hard. Results: The intracranial meningiomas were harder than the metastatic tumours and gliomas (p = 0.03 and p = 0.03, respectively). Among the intracranial meningiomas, the tumours that exhibited high intensity on T2WI were softer than those that displayed isointensity or low intensity (p < 0.001 and p < 0.001, respectively), and the isointense tumours were softer than the low intensity tumours (p = 0.02). Among the metastatic tumours, the tumours that exhibited high intensity on T2WI were softer than those that displayed isointensity or low intensity (p < 0.001 and p < 0.001, respectively). Among the intracranial meningiomas and metastatic tumours, significant correlations were detected between the T2WI findings and subjective tumour consistency according to the surgeon or quantitative tumour consistency (p = 0.01 and p = 0.03, respectively). Conclusions: The preoperative T2WI findings of intracranial meningiomas and metastatic tumours were significantly correlated with quantitatively measured tumour consistency and subjectively evaluated tumour consistency. Therefore, we concluded that T2WI findings are useful for preoperatively predicting the consistency of such tumours.

[A Case of Male Breast Cancer with Brain Metastasis 24 Years after a Mastectomy].

Male breast cancer accounts for less than 1.0% of all breast cancer cases, and its brain metastasis is very rare. We encountered a male patient in whom brain metastasis occurred more than 20 years after the development of breast cancer. The patient was a 78-year-old male who underwent surgery for right breast cancer 24 years ago. Nausea and anorexia had appeared 2 months earlier, and the patient was referred to our department because a brain tumor was suspected on MRI. A 4×4-cm tumorous lesion was observed in the right temporal lobe, and it was heterogeneously enhanced with gadolinium. Suspecting a metastatic brain tumor, tumor resection with craniotomy was performed. Through pathological examination, the patient was diagnosed with brain metastasis of the breast cancer. Whole-brain irradiation was additionally performed. The patient recovered smoothly without neurological deficit and was discharged. No intracranial recurrence was noted on follow-up imaging, but the general condition aggravated, and the patient died after 13 months. Breast cancer in males may metastasize to the brain after a prolonged period in rare cases, for which follow-up examinations by imaging may be necessary.

Kikuchi-Fujimoto disease (histiocytic necrotizing lymphadenitis) with atypical encephalitis and painful testitis: a case report.

BACKGROUND: Kikuchi-Fujimoto disease is a self-limited clinicopathologic entity that is increasingly recognized worldwide. Kikuchi-Fujimoto disease is characterized by cervical lymphadenopathy occurring in young adults. Neurologic involvement is rare, and testitis directly caused by Kikuchi-Fujimoto disease has not yet been reported. CASE PRESENTATION: A 19-year-old man was brought to our clinic with complaints of fever, headache, fatigue, and left lower quadrant pain that had persisted for 3 weeks. On physical examination, painful cervical lymphadenopathies were observed. Meningitis was suspected based on a cerebrospinal fluid examination, and left-sided orchitis was diagnosed based on findings from magnetic resonance imaging and ultrasonography. However, neither antibiotics nor antiviral drugs were effective in treating the patient's symptoms. On the 20th day of hospitalization, the patient experienced a loss of consciousness, and brain T2-weighted magnetic resonance imaging showed asymmetrical, high-signal intensities in both basal nuclei and the left temporal lobe. Encephalitis was suspected, and the patient was treated with intravenous prednisolone pulse therapy (1 g/day) for 3 days and intravenous immunoglobulin therapy for 5 days. A left cervical lymph node biopsy showed apoptotic necrosis in paracortical and cortical areas with an abundance of macrophages and large lymphoid cells, which had irregular nuclei suggestive of Kikuchi-Fujimoto disease; the pathological findings from a brain biopsy were the same as those of the cervical lymph node biopsy. The encephalitis and cervical lymphadenopathies followed a benign course, as did the testitis. CONCLUSIONS: This is the first report of Kikuchi-Fujimoto disease involving painful testitis and pathologically proven asymmetrical brain regions. Kikuchi-Fujimoto disease should be included in the differential diagnosis when a patient presents with encephalitis, testitis, and fever of unknown origin.

A neurosurgical simulation of skull base tumors using a 3D printed rapid prototyping model containing mesh structures.

BACKGROUND: Deep regions are not visible in three-dimensional (3D) printed rapid prototyping (RP) models prepared from opaque materials, which is not the case with translucent images. The objectives of this study were to develop an RP model in which a skull base tumor was simulated using mesh, and to investigate its usefulness for surgical simulations by evaluating the visibility of its deep regions. METHODS: A 3D printer that employs binder jetting and is mainly used to prepare plaster models was used. RP models containing a solid tumor, no tumor, and a mesh tumor were prepared based on computed tomography, magnetic resonance imaging, and angiographic data for four cases of petroclival tumor. Twelve neurosurgeons graded the three types of RP model into the following four categories: 'clearly visible,' 'visible,' 'difficult to see,' and 'invisible,' based on the visibility of the internal carotid artery, basilar artery, and brain stem through a craniotomy performed via the combined transpetrosal approach. In addition, the 3D positional relationships between these structures and the tumor were assessed. RESULTS: The internal carotid artery, basilar artery, and brain stem and the positional relationships of these structures with the tumor were significantly more visible in the RP models with mesh tumors than in the RP models with solid or no tumors. CONCLUSIONS: The deep regions of PR models containing mesh skull base tumors were easy to visualize. This 3D printing-based method might be applicable to various surgical simulations.