Gamma Knife Surgery for Residual or Recurrent Craniopharyngioma After Surgical Resection: A Multi-institutional Retrospective Study in Japan.

Objective The optimal treatment for a craniopharyngioma has been controversial. Complete resection is ideal, but it has been difficult to obtain total resection in many cases because of intimate proximity to critical structures such as the optic pathway, hypothalamus, and pituitary gland. A growing number of studies have demonstrated the utility of radiosurgery in controlling residual or recurrent craniopharyngioma. However, most of them are small series. The aim of this multi-institutional study was to clarify the efficacy and safety of Gamma Knife (Elekta, Stockholm, Sweden) surgery for patients with a craniopharyngioma. Methods This was a multi-institutional retrospective study by 16 medical centers of the Japan Leksell Gamma Knife Society. Data on patients with craniopharyngiomas treated with Gamma Knife Surgery (GKS) between 1991 and 2013 were obtained from individual institutional review board-approved databases at each center. A total of 242 patients with craniopharyngioma were included in this study. The mean age of the patients was 41 (range, 3 to 86) years. The median follow-up time was 61.4 months (range, 3 to 180 months). The mean radiosurgery target volume was 3.1 ml (range, 0.03-22.3 ml), and the mean marginal dose was 11.4 Gy (range, 8-20.4 Gy). Results Two-hundred twenty patients were alive at the time of the last follow-up visit. The three-, five-, and 10-year overall survival rates after GKS were 95.4%, 92.5%, and 82.0%, respectively. The three-, five-, and 10-year progression-free survival rates after GKS were 73.1%, 62.2%, and 42.6% respectively. The rate of radiation-induced complications was 6.2%. Conclusion GKS is effective for controlling the tumor growth of craniopharyngiomas with an acceptable complication rate.

Risk Factors for Hemorrhagic and Cardioembolic Complications of Intracerebral Hemorrhage Associated with Anticoagulants.

BACKGROUND: Patients with intracerebral hemorrhage taking anticoagulants are increasingly common in Japan due to the aging population. The clinical benefit of restarting anticoagulants is established, but the optimal timing of resumption is controversial. Risk factors for hemorrhagic and cardioembolic events in the acute phase are also unknown. This study investigated hemorrhagic and cardioembolic events and risk factors in intracerebral hemorrhage patients taking anticoagulants. METHODS: The clinical data of 65 consecutive intracerebral hemorrhage patients taking anticoagulants were retrospectively reviewed. Hemorrhagic and cardioembolic complications and risk factors were analyzed. RESULTS: Lobar hemorrhage was the most frequent (21 of 65 cases, 32.3%). At discharge, 31 patients (47.7%) showed severe disability or had died. Eight (18.6%) of 43 patients who restarted anticoagulants after initial treatment developed hemorrhagic events, including recurrent intracerebral hemorrhage in 3. HAS-BLED score was 2-3 in these 3 patients. Six (15.8%) of 38 patients who took anticoagulants for cardiogenic factors suffered cardioembolism. Systemic inflammatory response syndrome was significantly more common in the cardioembolic group (66.7%) compared with the noncardioembolic group (21.9%, P < .05). CHA2DS2-VASc score was paradoxically high in the noncardioembolic group (3 versus 5, P < .05). CONCLUSION: HAS-BLED score and CHA2DS2-VASc score were not useful for risk assessment for hemorrhagic events, recurrent intracerebral hemorrhage, and cardioembolism in the acute phase. Inflammatory response might be important in the occurrence of cardioembolic events.

De Novo Arteriovenous Malformation after Aneurysm Clipping.

We report a 73-year-old woman with de novo arteriovenous malformations (AVMs) that developed in the ipsilateral parietal lobe after craniotomy and aneurysm clipping. While intracerebral AVMs are considered to be congenital lesions, there have been several reported cases of acquired AVM arising after ischemic or traumatic episodes. We summarize previously reported cases of such acquired 'de novo' AVMs with a discussion of some pathophysiological responses or factors suggested to promote their development.

Characteristics of subcortical infarction due to distal MCA penetrating artery occlusion.

OBJECTIVE: Isolated deep subcortical infarcts develop as a result of occlusion of the penetrating arteries from the internal carotid artery (ICA) and the proximal (M1) and distal middle cerebral artery (MCA). However, the clinical and neuroimaging characteristics of infarcts due to the occlusion of the distal MCA penetrating artery are unclear. METHODS: Consecutive patients with ischemic stroke or transient ischemic attack with magnetic resonance imaging (MRI) performed within 2days of onset were studied retrospectively. Using coronal MRI data, isolated deep subcortical infarcts were classified into two groups: 1) proximal group, described as being longer than they are wide, which were expected to be related to the occlusion of the ICA or M1 penetrating artery; and 2) distal group, described as oblong, which were expected to be associated with the occlusion of penetrating arteries from the distal MCA (M2/M3/M4). RESULTS: A total of 653 consecutive acute ischemic stroke patients (proximal group, 50 [7.7%]; distal group, 14 [2.1%]) were enrolled. Baseline clinical characteristics were not different between the 2 groups. Modified Rankin Scale scores were lower in the distal group than in the proximal group 3months after stroke onset (1.43±0.36 vs. 2.26±1.35, p=0.023). We measured the lengths of the infarcts in the X and Y directions using axial MRI. The X/Y ratio was larger in the distal group than in the proximal group (1.3±0.6 vs. 0.7±0.2, p<0.01), which indicated that distal MCA penetrating artery infarcts appear more oblong on axial MRI. CONCLUSIONS: One cause for deep subcortical infarction is the occlusion of the distal MCA penetrating arteries, which occurs in 22% of patients with deep subcortical infarctions. These patients had better clinical outcomes than those with ICA and M1 penetrating artery infarctions. Distal MCA penetrating artery infarctions appear oblong on axial MRI.

Gamma Knife surgery for patients with jugular foramen schwannomas: a multiinstitutional retrospective study in Japan.

OBJECTIVE This study aimed to explore the efficacy and safety of stereotactic radiosurgery in patients with jugular foramen schwannomas (JFSs). METHODS This study was a multiinstitutional retrospective analysis of 117 patients with JFSs who were treated with Gamma Knife surgery (GKS) at 18 medical centers of the Japan Leksell Gamma Knife Society. The median age of the patients was 53 years. Fifty-six patients underwent GKS as their initial treatment, while 61 patients had previously undergone resection. At the time of GKS, 46 patients (39%) had hoarseness, 45 (38%) had hearing disturbances, and 43 (36%) had swallowing disturbances. Eighty-five tumors (73%) were solid, and 32 (27%) had cystic components. The median tumor volume was 4.9 cm3, and the median prescription dose administered to the tumor margin was 12 Gy. Five patients were treated with fractionated GKS and maximum and marginal doses of 42 and 21 Gy, respectively, using a 3-fraction schedule. RESULTS The median follow-up period was 52 months. The last follow-up images showed partial remission in 62 patients (53%), stable tumors in 42 patients (36%), and tumor progression in 13 patients (11%). The actuarial 3- and 5-year progression-free survival (PFS) rates were 91% and 89%, respectively. The multivariate analysis showed that pre-GKS brainstem edema and dumbbell-shaped tumors significantly affected PFS. During the follow-up period, 20 patients (17%) developed some degree of symptomatic deterioration. This condition was transient in 12 (10%) of these patients and persistent in 8 patients (7%). The cause of the persistent deterioration was tumor progression in 4 patients (3%) and adverse radiation effects in 4 patients (3%), including 2 patients with hearing deterioration, 1 patient with swallowing disturbance, and 1 patient with hearing deterioration and hypoglossal nerve palsy. However, the preexisting hoarseness and swallowing disturbances improved in 66% and 63% of the patients, respectively. CONCLUSIONS GKS resulted in good tumor control in patients with either primary or residual JFSs. Although some patients experienced some degree of symptomatic deterioration after treatment, persistent adverse radiation effects were seen in only 3% of the entire series at the last follow-up. Lower cranial nerve deficits were extremely rare adverse radiation effects, and preexisting hoarseness and swallowing disturbances improved in two-thirds of patients. These results indicated that GKS was a safe and reasonable alternative to surgical resection in selected patients with JFSs.

Two Cases of Trigeminal Neuralgia Caused by the Trigeminocerebellar Artery.

The trigeminocerebellar artery (TCA) is a unique branch of the basilar artery. We treated two cases of trigeminal neuralgia caused by the TCA. A 72-year-old woman had severe typical trigeminal neuralgia for ∼ 3 years. Thin-slice T2-weighted magnetic resonance imaging revealed an offending TCA. During microvascular decompression (MVD), we found that the TCA was compressing the medial aspect of the trigeminal nerve. We therefore transposed the TCA loop medially and anteriorly away from the nerve and inserted shredded Teflon between the TCA and the trigeminal nerve. Postoperatively, this patient's trigeminal neuralgia resolved, and she remained pain free at her 24-month follow-up. An 80-year-old man had trigeminal neuralgia. Magnetic resonance cisternography revealed that the course of the offending artery was the same as that of the TCA, originating from the superior cerebellar artery. During the MVD, we performed the same procedure as in case 1. Postoperatively, this patient's trigeminal neuralgia resolved, and he remained pain free at his 24-month follow-up. Because the TCA has a unique anatomical course, its decompression may sometimes be difficult.

Gamma Knife surgery for patients with facial nerve schwannomas: a multiinstitutional retrospective study in Japan.

OBJECTIVE: The aim of this study was to explore the efficacy and safety of stereotactic radiosurgery for patients with facial nerve schwannomas (FNSs). METHODS: This study was a multiinstitutional retrospective analysis of 42 patients with FNSs treated with Gamma Knife surgery (GKS) at 1 of 10 medical centers of the Japan Leksell Gamma Knife Society (JLGK1301). The median age of the patients was 50 years. Twenty-nine patients underwent GKS as the initial treatment, and 13 patients had previously undergone surgery. At the time of the GKS, 33 (79%) patients had some degree of facial palsy, and 21 (50%) did not retain serviceable hearing. Thirty-five (83%) tumors were solid, and 7 (17%) had cystic components. The median tumor volume was 2.5 cm(3), and the median prescription dose to the tumor margin was 12 Gy. RESULTS: The median follow-up period was 48 months. The last follow-up images showed partial remission in 23 patients and stable tumors in 19 patients. Only 1 patient experienced tumor progression at 60 months, but repeat GKS led to tumor shrinkage. The actuarial 3- and 5-year progression-free survival rates were 100% and 92%, respectively. During the follow-up period, 8 patients presented with newly developed or worsened preexisting facial palsy. The condition was transient in 3 of these patients. At the last clinical follow-up, facial nerve function improved in 8 (19%) patients, remained stable in 29 (69%), and worsened in 5 (12%; House-Brackmann Grade III in 4 patients, Grade IV in 1 patient). With respect to hearing function, 18 (90%) of 20 evaluated patients with a pure tone average of ≤ 50 dB before treatment retained serviceable hearing. CONCLUSIONS: GKS is a safe and effective treatment option for patients with either primary or residual FNSs. All patients, including 1 patient who required repeat GKS, achieved good tumor control at the last follow-up. The incidence of newly developed or worsened preexisting facial palsy was 12% at the last clinical follow-up. In addition, the risk of hearing deterioration as an adverse effect of radiation was low. These results suggest that GKS is a safe alternative to resection.

Correlation between the Occlusion Site and Clinical Outcome after Acute Ischemic Stroke.

OBJECTIVE: The significance of early mild clinical improvement after intravenous tissue plasminogen activator (IVtPA) treatment is unclear. Therefore, we examined whether the timing of clinical improvement after IVtPA predicted the clinical outcome at 3 months. METHODS: Consecutive patients with acute cerebral infarction in the anterior circulation who received IVtPA treatment within 3 hours of the onset of symptoms were enrolled in the study. Patients were classified according to the timing of clinical improvement [early responder (ER), National Institutes of Health Stroke Scale (NIHSS) score improved ≥4 points or who had a score of 0 within 2 hours after IVtPA; late responder (LR), a similar improvement between 2 and 24 hours; and non-responder (NR)] and according to the arterial occlusion site (P group, internal carotid artery and proximal middle cerebral artery M1 region; and D group, distal M1 and M2). RESULTS: Ninety-three patients [median age, 74 (67-79) years; 54 men (58%); median NIHSS score, 11 (7-16)] were enrolled in the study. The P group consisted of 48 (52%) patients and the D group consisted of 45 (48%) patients. Thirty-eight patients (41%) were classified as ERs, 20 (22%) as LRs, and 35 (38%) as NRs. On a multivariate regression analysis, the P group [odds ratio (OR), 3.24; 95% confidence interval (CI), 1.08-10.45; p=0.036] and NR (OR, 4.04; 95% CI, 1.29-14.27; p=0.016) were independent predictors of a poor outcome. ER (47%, p=0.01) and LR (45%, p=0.01) patients showed fewer poor outcomes than NR (77%) patients, but the rate did not differ significantly between the ER and LR patients. CONCLUSION: Early mild clinical recovery did not predict a good outcome. The occlusion site was a stronger predictor of clinical improvement after IVtPA administration.

Prediction of cerebrovascular reserve capacity by computed tomography perfusion using 320-row computed tomography.

BACKGROUND: Acetazolamide loading has been the "gold standard" for evaluating cerebrovascular reserve capacity (CVRC). However, life-threatening side effects of acetazolamide have recently been reported. The aim of the study was to identify alternative methods for evaluating CVRC. METHODS: We reviewed 6 patients who underwent both computed tomography perfusion (CTP) imaging and xenon CT (XeCT) imaging with and without acetazolamide loading during the same periods. The data were obtained as volume data using 320-row CT and applied to the automated region of interest-determining software and converted to standardized images. Correlations between CVRC and CTP parameters were analyzed by Pearson correlation coefficient analysis, and simple regression was used to assess the relationship between the data. When statistically significant, correlation between CVRC and any CTP data is identified, and cutoff points for CVRC 30% and 10% were calculated with receiver operating characteristic curves. RESULTS: Of 4 CTP parameters evaluated, statistically significant correlations were observed between time to peak (TTP) by CTP and CVRC (P < .0001, r = -.7228) calculated from XeCT. The regression line using CVRC as outcome variable (y) and using TTP as predictor variable (x) was y = -9.062x + 140.1. The cutoff value for the TTP for CVRC less than 10% was 12.56 seconds (sensitivity of 86% and specificity of 85%) and that for CVRC less than 30% was 9.34 seconds (sensitivity of 77% and specificity of 96%). CONCLUSIONS: TTP calculated from CTP data correlated well with the CVRC calculated from XeCT data. These results suggest that TTP calculated from CTP could be used to estimate CVRC in patients with occlusive cardiovascular disease.

Comparison of cerebral blood flow data obtained by computed tomography (CT) perfusion with that obtained by xenon CT using 320-row CT.

Cerebral blood flow (CBF) data obtained by computed tomography perfusion (CTP) imaging have been shown to be qualitative data rather than quantitative, in contrast with data obtained by other imaging methods, such as xenon CT (XeCT) imaging. Thus, interpatient comparisons of CBF values themselves obtained by CTP may be inaccurate. In this study, we have compared CBF ratios as well as CBF values obtained from CTP-CBF data to those obtained from XeCT-CBF data for the same patients to determine CTP-CBF parameters that can be used for interpatient comparisons. The data used in the present study were obtained as volume data using 320-row CT. The volume data were applied to an automated region of interest-determining software (3DSRT, version 3.5.2 ) and converted to 59 slices of 2 mm interval standardized images. In the present study, we reviewed 10 patients with occlusive cerebrovascular diseases (CVDs) undergoing both CTP and XeCT in the same period. Our study shows that ratios of CBF measurements, such as hemodynamic stress distribution (perforator-to-cortical flow ratio of middle cerebral artery [MCA] region) or the left/right ratio for the region of the MCA, calculated using CTP data have been shown to correlate well with the same ratios calculated using XeCT data. These results suggest that such CBF ratios could be useful for generating interpatient comparisons of CTP-CBF data obtained by 320-row CT among patients with occlusive CVD.

Usefulness of Preoperative Surgical Simulation with Three-Dimensional Fusion Images for Resection of Cerebral Cavernous Malformations Near Broca's Area.

Treating subcortical brain lesions in or near eloquent areas is challenging not only because lesions must be resected while preserving brain tissue involved in essential functions, but also because lesions often cannot be easily identified from the surface of the brain. Here, we report 2 cases of cerebral cavernous malformations near Broca's area. In both cases, lesions were surgically removed by utilizing three-dimensional fusion images created using preoperative magnetic resonance imaging and computed tomography data. Excisions were completed without any worsening of speech function, and the use of presurgical simulations was found to be useful in the design and execution of the actual operations. The technique described in this report serves as a useful tool in simulating surgical strategies by using brain gyri and sulci as surgical landmarks. Furthermore, in contrast to other intraoperative techniques, this method can aid in shortening the duration of surgery and can help limit damage to eloquent areas of the brain.

Neurenteric cysts found on the outer membrane of a subdural haematoma.

We report on a patient initially diagnosed with a chronic subdural haematoma that was resistant to treatment. After the second burr hole craniostomy within a half month failed to resolve the subdural haematoma (SDH), we performed a craniotomy to identify the point of bleeding. Macroscopic evaluation showed that most of the outer membrane of the SDH was transparent; however, further examination revealed the presence of multiple white regions. Pathologic examination showed that the white regions were fluid filled and surrounded by columnar ciliated epithelial cells. These lesions were pathologically diagnosed as neurenteric cysts. To our knowledge, this is the first report on a patient with neurenteric cysts found on the outer membrane of a CSDH. We agree that a craniotomy is a treatment of last resort for recurrent CSDHs; however, sometimes this procedure can be very useful for identifying underlying causes of obstinate SDHs as well as for their treatment.

Speech-induced modulation of interhemispheric inhibition.

This study aimed to determine the effects of speech and mastication on interhemispheric inhibition between the right and left primary motor areas (M1s) by using transcranial magnetic stimulation (TMS). Motor-evoked potentials (MEPs) were recorded from the first dorsal interossei (FDIs) of each hand of 10 healthy right-handed subjects under 3 conditions: at rest (control), during mastication (non-verbal oral movement), and during speech (reading aloud). Test TMS was delivered following conditioning TMS of the contralateral M1 at various interstimulus intervals. Under all conditions, the MEPs in the left FDIs were significantly inhibited after conditioning of the left M1 (i.e. inhibition of the right M1 by TMS of the left hemisphere). In contrast, the left M1 was significantly inhibited by the right hemisphere only during the control and mastication tasks, but not speech task. These results suggest that speech may facilitate the activity of the dominant M1 via functional connectivity between the speech area and the left M1, or may modify the balance of interhemispheric interactions, by suppressing inhibition of the dominant hemisphere by the non-dominant hemisphere. Our findings show a novel aspect of interhemispheric dominance and may improve therapeutic strategies for recovery from stroke.

Neuroendoscope-assisted removal of an organized chronic subdural hematoma in a patient on bevacizumab therapy--case report.

A 78-year-old Japanese man with a history of colon cancer was referred to our department of neurosurgery for the management of asymptomatic left chronic subdural hematoma (CSDH). He was receiving bevacizumab therapy for colon cancer, and the size of the CSDH increased or decreased depending on bevacizumab administration. Simple drainage was performed because of the risk of a critical increase in the size of CSDH during bevacizumab therapy, but since the CSDH was organized and firm, the drainage was insufficient. Therefore, neuroendoscope-assisted craniotomy was performed, and the organized CSDH was almost completely removed. The present case indicates the possible involvement of bevacizumab in the occurrence of CSDH and the efficacy of the neuroendoscopic approach in the surgical treatment of organized CSDH.

Assessment of cognitive function before and after surgery for posterior cranial fossa lesions using computerized and conventional tests.

Cognitive function has not been well studied after neurosurgery for posterior fossa lesions despite its potential importance in determining surgical indications and approaches. The present study evaluated changes in cognitive functions after posterior fossa surgery to detect any differences between the middle cranial fossa and lateral suboccipital approaches in 50 patients with posterior fossa lesions such as tumors and vascular diseases. Twenty-five patients underwent surgery via the middle fossa and 25 via the lateral suboccipital approaches. Computerized test battery (CogState) and conventional neuropsychological tests (serial seven-word learning test and mini-mental state examination) were examined before, 1 month after, and 3 months after surgery. All scores of the neuropsychological tests remained within normal limits after surgery. However, the scores of one computerized test battery and serial seven-word learning tests decreased significantly 1 month after surgery and recovered within 3 months, indicating temporary deterioration of short-term memory in the middle fossa group. The computerized tests detected significantly larger numbers of patients with worsened results than the conventional tests. The middle fossa approach and operation time showed correlations with the postoperative neuropsychological declines. The computerized tests could be performed easily and were beneficial for detecting subtle changes of the cognitive function after surgery. Cognitive function, especially short-term memory, may decline temporarily with the middle fossa approach and long operation time.

Spontaneous regression after standard transsphenoidal surgery in a huge pituitary adenoma with epidural extension.

A 59-year-old female presented with a huge non-functioning pituitary adenoma which mainly extended from the intrasellar region to the epidural space of the anterior cranial base, manifesting as a 2-year history of disturbance of the visual field. Transsphenoidal surgery was performed to decompress the optic pathway as the first step of a two-staged operation. Postoperative magnetic resonance images unexpectedly showed spontaneous regression of the major portion of the epidural tumor which had not been manipulated during the first operation. The reason for the spontaneous regression remains unclear.

Central tumor necrosis of a large meningioma following acute anemia caused by hysterectomy.

A 55-year-old woman, with a one-year history of headache, gait disturbance, and slight aphasia, was transferred to our hospital after head injury. Magnetic resonance (MR) imaging and computed tomography revealed a large meningioma with peripheral edema. However, priority was given to previously planned gynecological surgery for uterine cancer. She developed severe anemia after the surgery, followed by consciousness disturbance. MR imaging revealed spontaneous tumor necrosis. The meningioma was totally removed. Her consciousness improved, and she was discharged with no neurological deficit. Patients with large meningioma may suffer deterioration of symptoms due to central tumor necrosis triggered by acute anemia.