A case of pituitary adenoma with infiltration into the sphenoid sinus accompanied by melanocyte proliferation.

A 71-year-old woman presenting with headache and nausea was admitted to hospital. Magnetic resonance imaging revealed a tumorous lesion that surrounded the sella turcica and infiltrated the sphenoid sinus with bone destruction. The tumor was removed by nasal endoscopy. The histology was consistent with pituitary adenoma; immunohistochemistry indicated silent corticotroph adenoma with melanocyte proliferation. The possibility that melanocytes were incorporated into the tumor mass in the sphenoid sinus and underwent proliferation was evaluated by investigating the mechanisms of melanocyte proliferation associated with basic fibroblast growth factor (bFGF) and α melanocyte-stimulating hormone (αMSH). In the normal tissue, the pars intermedia and adrenocorticotropic hormone (ACTH)-producing cells were positive for αMSH. None of the control adenoma tissues were positive for bFGF or αMSH by immunostaining. In the present case, bFGF-positive cells and αMSHpositive cells were observed, suggesting that both may have been involved in melanocyte proliferation. The expression of bFGF has been linked to aggressive disease. Pituitary adenoma with melanocyte proliferation has not been previously reported. Careful follow-up is deemed necessary in the future.

Functional Prognosis Following Temporal Bone Chondroblastoma Resection: A Systematic Review and Case Illustration.

BACKGROUND: Chondroblastomas are rare tumors that account for <1% of all bone tumors, and 5.7% of them occur in the skull. The aim of this study was to investigate factors related to their functional prognosis by conducting a systematic review, including our own case. METHODS: A systematic review was conducted of case reports that clearly stated postoperative symptoms in temporal chondroblastomas. Tumor localization was limited to cases of the temporal bone. Cases not described in English were excluded. RESULTS: We obtained 30 articles comprising 44 cases and included our own case for a total of 45 cases. Postoperative asymptomatic cases accounted for 53.3% (24/45), and symptomatic cases accounted for 46.7% (21/45). Complications were observed in 31.1% (14/45) of cases. The main complications were facial palsy (9 cases), occlusal disorders (4 cases), and hearing loss (4 cases). The occurrence of facial palsy as a complication was considered likely. Tumor size was confirmed in 36 cases. Cases with postoperative complications were more likely to involve tumors ≥5 cm in size (77.8%, 7/9) compared with cases without complications (40.7%, 11/27). There was a significant association between rate of postoperative complications and tumor size (P = 0.061). CONCLUSIONS: As temporal chondroblastoma poses a risk of residual postoperative symptoms when the tumor grows, aggressive surgical treatment should be considered even in asymptomatic or small tumors.

Endoscopic-assisted Duraplasty with Collagen Matrix for Growing Skull Fracture: A Case Report.

Growing skull fracture (GSF) is a rare complication of pediatric head injury. Early diagnosis and immediate surgical intervention are required for the prevention of irreversible brain damage. Surgical management involves water-tight closure of the dural defect and commonly uses autologous materials because of tissue compatibility; however, a large skin flap and craniotomy are necessary to harvest the autologous materials and repair the dural defect. We describe a successful case of endoscopic-assisted duraplasty using collagen matrix in a female infant suffering from early phase GSF. A 4-month-old female infant presented with a GSF. We surgically treated her because the fracture width progressively expanded 6 days post-injury. A zigzag skin incision was made, and the extent of the skull fracture and dural laceration was observed using an endoscope. Utilizing the collagen matrix, duraplasty was performed to completely seal the dural defect. Subsequently, cranioplasty was performed and the opposite sides of the fracture margins were drawn and bonded by nylon suture. Postoperatively, the patient did not develop any complication or experience recurrence. This is the first report of duraplasty using collagen matrix in GSF, and the collagen matrix can be used as a dural substitute. This novel technique was safe and a less invasive surgical approach for treating patients with GSF.

Optimal surgical indications of endoscopic surgery for traumatic acute subdural hematoma in elderly patients based on a single-institution experience.

Recently, treatment of acute subdural hematoma (ASDH) by minimally invasive surgery with endoscopy has been successfully demonstrated. However, few case series are available on this procedure for ASDH, and the surgical indication has not been established. We retrospectively analyzed the data of patients (n = 26) aged 65 years or older who underwent endoscopic surgery (ES) for ASDH at our institution between January 2011 and March 2019. We then evaluated the surgical outcomes and procedure-related complications in patients who underwent ES. The mean hematoma reduction rate was over 90%. Percentage of favorable outcomes at discharge was 69.2% in ES-treated patients. The presence of a skull fracture, subarachnoid hemorrhage, midline shift/subdural hematoma thickness ratio > 1.0, and early surgery were associated with postoperative IPHs in patients who underwent ES or conventional surgery for ASDH. The present study revealed that ES for elderly patients with ASDH is likely to be an efficient and safe procedure when patients are selected appropriately. However, ES is not recommended in patients with significant IPHs on initial CT scan. Additionally, ES should be carefully considered in cases with the factors, where IPHs may progress following surgery.

A Case of Salivary Duct Carcinoma Intracranial Invasion due to Perineural Invasion Through the Facial Nerve.

BACKGROUND: Salivary duct carcinoma (SDC) is a rare parotid tumor that often develops as a rapidly growing mass with a poor prognosis. It has a high rate of distant metastases, sometimes with infiltration along nerves. We describe a case of SDC that originated outside the cranium and extended into the cranium along the path of the facial nerve. CASE DESCRIPTION: A 74-year-old man underwent magnetic resonance imaging at a local hospital, which revealed a tumor in the left internal acoustic canal; the patient was referred to our department. A left facial schwannoma was suspected, and magnetic resonance imaging was performed again 6 months later. Rapid tumor growth was confirmed, and the tumor was resected. The tumor displayed atypical epithelial cells with comedo necrosis and cribriform structure and was diagnosed as SDC. All residual intracranial tumors were removed using the middle fossa approach. The tumor, which was considered to be a primary tumor, was found near the stylomastoid foramen, and it was removed with the parotid gland. Five months after the initial surgery, metastasis to the trigeminal nerve was observed, and this was removed using a retrosigmoid approach, followed by radiation therapy. CONCLUSIONS: All 4 surgical specimens of this case were presented, and the path of tumor progression was examined in detail. Although the primary lesion was small, intracranial invasion along the facial nerve occurred. SDC should be considered as a tumor that can extend into the cranium, even with a small primary lesion.

Surgical management of adverse events associated with deep brain stimulation: A single-center experience.

OBJECTIVES: Deep brain stimulation is widely used to treat movement disorders and selected neuropsychiatric disorders. Despite the fact, the surgical methods vary among centers. In this study, we aimed to evaluate our own surgical complications and how we performed surgical troubleshooting. METHODS: A retrospective chart review was performed to evaluate the clinical data of patients who underwent deep brain stimulation surgery and deep brain stimulation-related procedures at our center between October 2014 and September 2019. We reviewed surgical complications and how surgical troubleshooting was performed, regardless of where the patient underwent the initial surgery. RESULTS: A total of 92 deep brain stimulation lead implantation and 43 implantable pulse generator replacement procedures were performed. Among the 92 lead implantation procedures, there were two intracranial lead replacement surgeries and one deep brain stimulation lead implantation into the globus pallidus to add to existing deep brain stimulation leads in the bilateral subthalamic nuclei. Wound revision for superficial infection of the implantable pulse generator site was performed in four patients. There was neither intracerebral hemorrhage nor severe hardware infection in our series of procedures. An adaptor (extension cable) replacement was performed due to lead fracture resulting from a head trauma in two cases. CONCLUSION: We report our experience of surgical management of adverse events associated with deep brain stimulation therapy with clinical vignettes. Deep brain stimulation surgery is a safe and effective procedure when performed by a trained neurosurgeon. It is important for clinicians to be aware that there are troubles that are potentially manageable with optimal surgical treatment.

Midline Glioma in Adults: Clinicopathological, Genetic, and Epigenetic Analysis.

The histone H3K27M-mutant diffuse midline glioma is often seen in children and has a very poor prognosis regardless of its histological grade. Although it can occur in adults, few studies on adult cases have been reported. We examined adult midline glioma cases for their histological grade, presence of H3K27M mutation, and expression of related factors-enhancer of zeste homolog 2 (EZH2), H3K27me3, p16, and methylthioadenosine phosphorylase. These tumor characteristics were also evaluated for their prognostic value in adult midline glioma. High histological grade, H3K27M-mutant, high EZH2 expression, and high H3K27me3 expression was detected in 12/23 (53%), 11/23 (48%), 9/23 (39%), and 12/23 (52%) cases, respectively. Histological grade and prognosis were significantly correlated (P <0.01). The high expression of EZH2 and the low expression of H3K27me3 correlated with histological malignancy (P = 0.019 and 0.009) and prognosis (P = 0.048 and 0.047). To broaden the scope of our analysis, a review of cases reported in the literature (2014-2019) was performed. In the 171 cases, H3K27M-mutant showed poor prognosis in the young adult group (P = 0.001), whereas H3K27 status had no effect on prognosis in the older age group (P = 0.141). Histological grade was correlated with prognosis in both young adults and older groups (P <0.001, P = 0.003, respectively). We demonstrate differences in prognostic factors for diffuse gliomas in the midline region for children and adults. Importantly, the H3K27M mutation significantly influences prognosis in children, but not necessarily in adults. Contrarily, histological grading and immunostaining are important prognostic tools in adults.

[COMBINING MODALITY THERAPY WITH SURGERY CAN PROVIDE LONG-TERM SURVIVAL WITH IMPROVED QUALITY OF LIFE FOR PATIENTS WHO HAVE PROSTATE CANCER WITH INTRACRANIAL DURAL METASTASIS: A CASE REPORT].

A 61-year-old man visited our hospital with a headache and left visual field defect. A head MRI showed an intracranial dural tumor with cerebral compression, which was suspected to be metastatic. Analysis of the tumor markers revealed an increase in prostate-specific antigen (PSA) levels (172.8 ng/mL), and therefore prostate cancer was suspected as the primary tumor. Histological diagnosis of a prostatic tissue sample using a transrectal needle biopsy gave a prostate carcinoma with Gleason score of 5+4=9. Additional imaging examinations revealed metastatic lesions in the intra-pelvic lymph node and bones. These data indicated to us that curative surgery was unlikely to be successful, but finally we decided to perform a craniotomy for tumor resection for the intracranial dural tumor to remove his neurological symptoms. After surgery, his headache and visual field defect improved. The pathological finding was intracranial dural metastasis from prostate cancer and the clinical stage was diagnosed as T3bN1M1c in the UICC criteria (ver. 8). Endocrine therapy with degarelix and bicalutamide was started for the primary and residual metastatic prostate cancers. After one year of initial treatment, bicalutamide was changed to enzalutamide because of a tendency towards increased plasma PSA levels. The patient has survived for two and a half years after surgery with no new metastatic tumors or intracranial tumors. Our experience indicates that combined modality therapy with surgery can provide long-term survival with no cranial nerve disorders for patients who have prostate cancer with intracranial dural metastasis.

Impact of Spot Sign Etiology in Supratentorial Intracerebral Hemorrhage on Outcomes of Endoscopic Surgery.

BACKGROUND: The spot sign (SS) in spontaneous intracerebral hemorrhage has been reported to be a predictive factor of poor outcome; however, how SS is related with the clinical outcome remains unclear. We aimed to investigate how etiology associated with SS affects the clinical outcome of endoscopic surgery. METHODS: We retrospectively analyzed data from 104 patients (43 women and 61 men, mean age: 64.2 ± 11.0 years) who underwent endoscopic surgery for supratentorial intracerebral hemorrhage. The outcome variables analyzed were in-hospital mortality and modified Rankin scale score at 90 days from onset. RESULTS: The prevalence of intraventricular hemorrhage and the mean initial modified Graeb score were greater in SS-positive than in SS-negative patients (100% vs. 47.7%, P < 0.001, and 14.4 ± 5.4 vs. 10.6 ± 6.0, P = 0.03, respectively). Postoperative rebleeding occurred more frequently in SS-positive than -negative patients (25.0% vs. 6.8%, P = 0.045). The in-hospital mortality rate was 7.7% and was not significantly different between the groups (18.8% vs. 5.7%, P = 0.09). There was a significant unfavorable shift in modified Rankin scale scores at 90 days among SS-positive patients compared with SS-negative patients in an analysis with ordinal logistic regression (adjusted common odds ratio, 4.38; 95% confidence interval 0.06-0.79, P = 0.02). CONCLUSIONS: Intraventricular hemorrhage and postoperative rebleeding were considered to be associated with the poor outcome in patients with SS. The SS on computed tomography angiography may be valuable in predicting rebleeding and clinical outcome after surgery.

Feasibility and Safety of Endoscopic Procedure in Burr-Hole Surgery for Chronic Subdural Hematoma in Patients of Very Advanced Age.

OBJECTIVE: The usefulness of endoscopic procedures for chronic subdural hematoma (CSDH) has been described, but the indications in patients of very advanced age have not been analyzed. The aim of this study was to evaluate the feasibility, safety, and usefulness of introduction of an endoscopic procedure for such patients. METHODS: We retrospectively analyzed the data of 540 CSDHs treated by burr-hole surgery with endoscopic examination. The safety of the endoscopic procedure was assessed according to postoperative complications, morbidity, and mortality. The outcome was evaluated by statistical comparison among 4 different age-groups, and the recurrence rate and risk factors for recurrence was investigated in patients of very advanced age. RESULTS: Postoperative complications occurred in 7 cases (1.5%). The 6-month morbidity and mortality were 13.5% and 4.5%. No complications, morbidity, or mortality associated with the additional endoscopic procedure occurred even in patients of very advanced age. The endoscopic features of trabecular structures and residual septa separating the cavity were also risk factors for recurrence in patients of very advanced age. Releasing of the septa showed the possibility of decreasing the risk of recurrence to 6.6% in patients aged ≥85 years as well as in younger patients. There were some inevitable problems such as prolongation of the surgical time and inadequate endoscopic surgical skill. CONCLUSIONS: An endoscopic procedure for CSDH can be safely indicated and useful even in patients aged ≥85 years. However, clinicians should carefully select the patients based on clinical information associated with risk factors for recurrence.

Analysis of Endoscopic Findings in the Chronic Subdural Hematoma Cavity: Bleeding Factors in Chronic Subdural Hematoma Natural History and as Predictors of Recurrence.

OBJECTIVE: Possible factors associated with bleeding from endoscopy-detected chronic subdural hematomas (CSDHs) have rarely been analyzed. We therefore evaluated intraoperative endoscopic findings to elucidate the clinical course and assess predictors of CSDH recurrence. METHODS: Altogether, 540 CSDHs were reviewed in this retrospective study. Six possible signs of bleeding were detected in the cavity: spotty bleeding on the outer membrane, hematoma clots, cerebral parenchymal suspension, stretched cortical vessels, intraluminal trabecular structures, and septa separating the cavity. We evaluated the association of each with the radiologic findings, endoscopic features, and interval from trauma to surgery and then assessed the correlation between each endoscopic feature and CSDH recurrence. RESULTS: Spotty bleeding, cerebral parenchymal suspension, and stretched cortical vessels occurred during every period. Hematoma clots exhibited a 2-peak pattern with significant resurgence during the chronic phase. Trabecular structures significantly increased 61 days after the trauma, reaching 71.2% of patients on day 91. Septa were found in the cavity in only 12.5% during the initial 30 days but subsequently increased significantly to 37.3%. At 2 months, an exacerbation stage was inferred. The multivariable analysis revealed that trabecular structures and residual septa were significant independent risk factors for recurrence. We opened most septa intraoperatively. Their recurrence rate was 7.5%, which is lower than has been previously reported. CONCLUSIONS: Evaluation of the changes in the endoscopic findings and their association with recurrence was useful for clarifying the mechanism of CSDH enlargement, the risk of recurrence, and the potential for endoscopic surgery.

Clinicopathological and genetic characteristics associated with brain metastases from lung adenocarcinoma and utility as prognostic factors.

Brain metastases (BM) are common in patients with lung adenocarcinoma, and represent a significant cause of morbidity in the disease. A more comprehensive understanding of the clinicopathological characteristics that serve as prognostic factors for survival in patients with BM from lung adenocarcinoma may aid in informing treatment strategies for this patient population. In the present study, clinicopathological factors, including EGFR mutation status, were evaluated in 59 patients who were diagnosed with BM from lung adenocarcinoma, and underwent BM resection between January 1985 and December 2014 at Fukuoka University Hospital. The most frequent subtype of BM from lung adenocarcinoma was solid adenocarcinoma (57.6%), followed by papillary adenocarcinoma (22.0%) and acinar adenocarcinoma (18.6%). A total of 14 patients (23.7%) exhibited EGFR mutations, which were significantly associated with female sex (9/14, 64.3%), non-smoker status (8/14, 57.1%), BM in the frontal lobes (9/14, 64.3%) and papillary adenocarcinoma (5/14, 35.7%). Statistical analysis revealed a significant association between non-smoker status and BM in the frontal lobes, and more favorable disease prognosis. The results of the present study suggest that histological and genetic analysis of tissue from BM provides information useful for managing treatment of patients with resectable BM arising from lung adenocarcinoma.

Potential of Hybrid Assistive Limb Treatment for Ataxic Gait Due to Cerebellar Disorders Including Hemorrhage, Infarction, and Tumor.

Cerebellar hemorrhage (CH) is a severe life-threatening disorder, and surgical treatment is often required in an emergency situation. Even in cases in which the surgical procedure is successful, functional recovery is likely to be delayed because of cerebellar symptoms such as ataxia and gait disturbance. Here, we briefly review the efficacy of hybrid assistive limb (HAL) treatment in neurosurgical practice and propose a new comprehensive treatment strategy for CH to facilitate early neurological recovery. We have experienced cases of ataxic gait due to various etiologies, treated with rehabilitation using the HAL, and our data showed that HAL treatment potentially improves ataxic gait and balance problems. HAL treatment seems to be an effective and promising treatment modality for selected cases. Future studies should evaluate gait appearance and balance, in addition to walking speed, to assess improvement in cerebellar symptoms.

Endoscopic surgery via a combined frontal and suboccipital approach for cerebellar hemorrhage.

BACKGROUND: Spontaneous cerebellar hemorrhages (CHs), which frequently require surgical intervention, are life-threatening and can be complicated by intraventricular hemorrhages (IVHs) and obstructive hydrocephalus. Commonly, endoscopic surgery is performed to remove CHs via a suboccipital approach (SA) alone. At our institution, when patients exhibited supratentorial IVH-associated hydrocephalus, we used a combined frontal and suboccipital approach (CA) to evacuate both CHs and supratentorial IVHs. The present study retrospectively evaluated the effectiveness and safety of this CA, as no prior studies examining this approach currently exist. METHODS: Twenty-six patients with spontaneous CH were surgically treated at our hospital from April 2009 to March 2016. Twenty-two patients who could independently perform activities of daily living before the onset underwent endoscopic surgery to evacuate the CHs; among these, 13 patients underwent the SA alone, while nine underwent the CA. We assessed and compared the patients' baseline characteristics, surgical results, and prognosis at 1 month after the intervention between the SA and CA groups. RESULTS: Patients who underwent the CA had significantly poorer consciousness before the surgery owing to IVH extension and obstructive hydrocephalus. However, the surgical results and prognosis at 1 month were not significantly different between the two approaches. The CH-associated IVHs were successfully removed with the CA and resulted in shorter external ventricular drainage (EVD) placement durations. CONCLUSION: Endoscopic surgery performed via the CA appeared to neutralize the deteriorating effects of CH-associated IVHs. Surgical strategies employing the CA may have the potential to improve the prognosis of patients with CH.

Intraoperative Active Bleeding in Endoscopic Surgery for Spontaneous Intracerebral Hemorrhage is Predicted by the Spot Sign.

BACKGROUND: Endoscopic evacuation of hematoma (EEH) has recently been applied to treat patients with spontaneous intracerebral hemorrhage (sICH). Intraoperative active bleeding (IAB), which is occasionally observed in EEH, might lead to greater blood loss, further brain damage, and more postoperative recurrent hemorrhage. However, no definite predictor of IAB has been established. Because the spot sign is associated with other hemorrhagic complications, we aimed to evaluate whether it predicts IAB. METHODS: We retrospectively assessed the incidence and risk factors of IAB, including the spot sign, in 127 sICH patients who underwent EEH within 6 hours after computed tomography angiography at our institution between June 2009 and December 2017. RESULTS: The study included 53 women and 74 men with an average age of 66.7 ± 11.8 years. IAB occurred in 40 (31.5%) of the 127 patients, and it was more frequent in patients with the spot sign than in patients without it (14/24 [58.3%] vs. 26/103 [25.2%]; P = 0.003). Multivariable regression analyses suggested that the spot sign was an independent predictor of IAB (odds ratio [OR], 3.02; 95% confidence interval [CI], 1.10-8.30; P = 0.03). In addition, earlier surgery gradually increased the risk of IAB, and surgery within 4 hours of onset was an independent risk factor (OR, 4.34; 95% CI, 1.12-16.9; P = 0.03, referring to postonset 8 hours or more). CONCLUSIONS: The spot sign and early surgery were independent predictors of IAB in EEH for sICH. In patients with sICH and spot sign, complete treatment of IAB by electrocoagulation might be important for minimizing surgical complications.

Spot sign as a predictor of rebleeding after endoscopic surgery for intracerebral hemorrhage.

OBJECTIVEIn patients with spontaneous intracerebral hemorrhage (sICH), postoperative recurrent hemorrhage (PRH) is one of the most severe complications after endoscopic evacuation of hematoma (EEH). However, no predictors of this complication have been identified. In the present study, the authors retrospectively investigated whether PRH can be preoperatively predicted by the presence of the spot sign on CT scans.METHODSIn total, 143 patients with sICH were treated by EEH between June 2009 and March 2017, and 127 patients who underwent preoperative CT angiography were included in this study. Significant correlations of PRH with the patients' baseline, clinical, and radiographic characteristics, including the spot sign, were evaluated using multivariable logistic regression models.RESULTSThe incidence of and risk factors for PRH were assessed in 127 patients with available data. PRH occurred in 9 (7.1%) patients. Five (21.7%) cases of PRH were observed among 23 patients with the spot sign, whereas only 4 (3.8%) cases of PRH occurred among 104 patients without the spot sign. The spot sign was the only independent predictor of PRH (OR 5.81, 95% CI 1.26-26.88; p = 0.02). The following factors were not independently associated with PRH: age, hypertension, poor consciousness, antihemostatic factors (thrombocytopenia, coagulopathy, and use of antithrombotic drugs), the location and size of the sICH, other radiographic findings (black hole sign and blend sign), surgical duration and procedures, and early surgery.CONCLUSIONSThe spot sign is likely to be a strong predictor of PRH after EEH among patients with sICH. Complete and careful control of bleeding in the operative field should be ensured when surgically treating such patients. New surgical strategies and procedures might be needed to improve these patients' outcomes.

Cerebral and spinal cavernomas associated with Klippel-Trenaunay syndrome: case report and literature review.

Klippel-Trenaunay-Weber syndrome (KTWS) involves a triad of conditions, including cutaneous hemangiomas, venous varicosities, and osseous and soft-tissue hypertrophy of the affected limb. We describe a rare case of multiple cavernomas in the central nervous system in a patient with KTWS. A-64-year-old man with KTWS and a previous brain hemorrhage presented with sudden onset of gait and vesicorectal disturbance. The magnetic resonance imaging scan showed a cavernoma associated with hemorrhage in his lumbosacral spinal cord. Moreover, numerous cavernomas were identified in his brain. He was treated conservatively with no adverse events. Gait disturbance improved, but vesicorectal disturbance did not improve.

Patients' characteristics and outcomes depending on complete or incomplete unilateral spatial neglect.

Unilateral spatial neglect (USN) is known to depress the activities of daily living. The purpose of this study was to clarify that categorizing the type of USN using line cancelation and line bisection tests is important when evaluating patients with acute intracerebral hemorrhage (ICH). In this study, patients with ICH were prospectively evaluated for the presence of USN using line cancelation and line bisection tests. They were classified into an incomplete USN group (iUSN = abnormal results in either test) or a complete USN group (cUSN = abnormal findings in both tests). We compared the initial severity of ICH and the outcomes of USN in the two groups. We were able to assess 16 patients, among whom 10 showed USN. Seven were then categorized as having iUSN and three as having cUSN. The median hematoma volume was larger in the cUSN group than in the iUSN group. The USN symptoms of patients in the iUSN group disappeared during the chronic phase, whereas the symptoms of patients in the cUSN group continued. The type of USN was associated with the initial severity of ICH and the persistence of USN.

Hybrid Assistive Limb (HAL) Rehabilitation in Patients with Acute Hemorrhagic Stroke.

The efficacy of hybrid assistive limb (HAL) rehabilitation in the acute phase of stroke remains unclear. The purpose of this study was to evaluate the outcomes of patients with acute intracranial hemorrhage (ICH) who were treated with or without HAL rehabilitation. Among 270 patients with acute ICH from 2009 to 2014, 91 patients with supratentorial ICH were included in this retrospective study. Of these, 14 patients (HAL group) received HAL rehabilitation at approximately 1 week after ICH occurrence, while the remaining 77 patients received usual rehabilitation without HAL (N-HAL group). We obtained various patient data from the hospitals where the patients were moved to for further rehabilitation. Statistical comparisons were performed for the characteristics of the ICH patients, and outcomes between the HAL and N-HAL groups. There were no differences in outcomes between the HAL and N-HAL groups. However, patients with right ICH in the HAL group exhibited a significant association with a functional independence measure (FIM) score of ≥ 110 compared with patients in the N-HAL group (HAL group: 81.8%, N-HAL group: 43.9%, P = 0.04). In patients with right ICH, HAL rehabilitation was associated with improved outcomes as evaluated by the FIM score. Thus, HAL rehabilitation may improve outcomes of acute ICH in appropriately selected patients.

Management of Trigeminal Neuralgia Caused by an Intraneural Spiral Trigeminocerebellar Artery: A Case Report.

The trigeminocerebellar artery (TCA) is a branch of the basilar artery that may have an intraneural course and may cause trigeminal neuralgia. We report a case of trigeminal neuralgia with right vertebral artery aneurysm caused by an intraneural TCA that compressed the trigeminal nerve in multiple places. We performed proximal trapping for the fusiform aneurysm with extra-intracranial bypass to preserve flow of the posterior inferior cerebellar artery, followed by microvascular decompression that successfully changed the course of the TCA. This procedure provided relief from the neuralgia without direct bisection of the trigeminal nerve that may cause severe nerve injury. Reshaping of the course of the artery can achieve good pain relief.