Culture-based bacterial evaluation of the appendix lumen and antibiotic susceptibility of acute appendicitis in Japan: A single-center retrospective analysis.

The question of whether to perform an appendectomy or conservative treatment for acute appendicitis can differ depending on the facility or surgeon, but antibiotic treatment is administered regardless of whether an appendectomy or conservative treatment is selected. We investigated the contemporary bacteriology for acute appendicitis and evaluated the antibiotic sensitivity of the bacteria that are currently associated with appendicitis. We retrospectively analyzed the bacterial culture results and antibiotic susceptibility of 141 patients who underwent appendicitis surgery, including the identification and antimicrobial susceptibility of the cultured bacteria within the excised appendices. Bacterial cultures were positive in 131 cases (92.9%). The most commonly isolated bacteria were Escherichia coli (90 isolates, 66.7%), followed by Enterococcus species (n = 19, 14.5%), Pseudomonas aeruginosa (n = 18, 13.7%), Streptococcus species (n = 15, 11.5%), and Klebsiella species (n = 8, 6.1%). Eight strains (8.8%) of E coli were extended-spectrum ß-lactamase producers, and ten strains (11.1%) were fluoroquinolone-resistant. Tazobactam/piperacillin and meropenem inhibited the growth of 100% of the major identified bacteria. The patients with appendicoliths had a significantly higher bacterial culture rate. Enterococcus species were frequently isolated from the patients with complicated appendicitis. For the antibiotic treatment of appendicitis, it is essential to understand the patient's microbiological profile and antibiotic susceptibilities. Research from Asian countries such as Japan can enhance our knowledge of regional antibiotic resistance patterns and inform effective treatment strategies.

Application and Advantages of the Trans-Unco-Discal (TUD) Approach for Cervical Spondylotic Myelopathy and Radiculopathy: Classification and Modification of Surgical Technique Based on the Location of Spinal Cord and/or Nerve Root Compression.

Purpose: We assess the application and advantages of modifying the trans-unco-discal (TUD) approach which we underwent for cervical myelo-radiculopathy. We present the surgical techniques of the modified TUD approach. Materials and Methods: The material was 180 cases where anterior cervical decompression (ACD) was performed by the modified TUD approach. We classified the material into four groups based on the location of the nerve root and/or spinal cord compression: I, compression of the root at intervertebral foramen (IVF); II, compression of the posterior margin of the vertebral body; III, compression of the IVF and posterior margin of the vertebral body; IV, compression of the bilateral IVF and posterior margin of the vertebral body. We applied the modified TUD approach to these four types. We present the surgical procedures and techniques for the modified TUD approach. The Japanese orthopedic association (JOA) score and neuroradiological alignment were examined. Results: The improvement rate of the JOA score was 78.4% at 6 months post-surgery and 77.5% in the most recent examinations. By the modified TUD approach, compressive lesions of the spinal cord and/or nerve roots were removed, and good alignment was acquired and sustained. Conclusions: ACD by the modified TUD approach safely achieved appropriate decompression for the spinal cord and/or nerve roots, and the patients had a high improvement rate and good alignment. Complications were less common than with other surgical procedures. If the TUD approach and endoscopic approaches can be combined, their application to new area is anticipated.

The Symptomatic Calcification and Ossification of the Ligamentum Flavum in the Spine: Our Experience and Review of the Literature.

INTRODUCTION: We report our experience regarding the clinical features and pathological findings of the calcification of the ligamentum flavum (CLF) and ossification of the ligamentum flavum (OLF) in the spine. In addition, we reviewed the previous studies on CLF and OLF to enhance the understanding of these conditions. MATERIALS AND METHODS: We compared the clinical, radiological, and histopathological features of CLF and OLF. RESULTS: In CLF, a computed tomography (CT) scan showed egg-shaped or speck-like calcification in the ligamentum flavum. Magnetic resonance (MR) imaging demonstrated spinal cord compression due to a thickened ligamentum flavum, which appeared as a low-intensity mass. Pathological findings demonstrated fused islands of calcification resembling sand-like calcification. In OLF, CT showed beak-like ossification extending into the intervertebral foramen. MR imaging demonstrated spinal cord compression by a low-intensity mass. Pathological findings revealed laminar ossification of LF with chondrocytes near the calcification and laminar hyaline cartilage. CONCLUSIONS: CLF and OLF appear to be distinct entities based on their clinical, neuroradiological, histopathological, and pathogenetic features. We suggest that the causes of CLF include both metabolic and dystrophic factors, while the pathogenesis of OLF is characterized by enchondral ossification induced by a genetic cascade triggered by shearing/tension stress.

[Attainment of the Lessinvasive Neurospinal Surgery: Full Endoscopic Spinal Surgery].

Full endoscopic spinal surgery(FESS)is the the least invasive surgery among the current spinal surgeries. FESS approach can be used to perform discectomy, decompression for stenosis, posterolateral fusion, etc. with little destruction of the spinal structure and posterior supporting elements, under local or general anesthesia. A major difference from conventional spinal surgeries is "underwater surgery," in which surgery is performed under continuous saline irrigation. In addition, for neurosurgeons, there is a steep learning curve to becoming proficient in using a small diameter endoscope for full-endoscopic surgery as well as performing treatment with the surgical field completely. We would like to explain the indication and surgical procedure of the transforaminal approach, then introduce decompression by FESS at the cervical spine level as well as full endoscopic lateral lumbar interbody fusion(ELIF).

Burr hole drainage without irrigation for chronic subdural hematoma.

BACKGROUND: Chronic subdural hematoma (CSDH) is one of the most common neurosurgical conditions, with different strategies for treatment. Most recent trials favor the use of drainage to reduce the recurrence rate. However, few reports have discussed the efficacy of burr hole drainage without irrigation for treating CSDH. This study aimed to examine the efficacy of burr hole drainage without irrigation in a series of 385 symptomatic CSDH lesions. METHODS: This retrospective study included a series of 385 symptomatic CSDH lesions in 309 patients, who underwent burr hole drainage without irrigation, between September 2009 and August 2017 at the Department of Neurosurgery, Yao Tokushukai General Hospital, Japan. The risk of recurrence was evaluated based on the patients' age, sex, preoperative magnetic resonance imaging (MRI) findings, preoperative anticoagulants, hematoma drainage rate, and bilaterality. RESULTS: Of the 385 lesions, 41 cases (16 with inadequate follow-up periods and 25 with contraindications for MRI) were excluded from the analysis. The overall recurrence rate in the index study was 4.9% (17/344 lesions). The effects of the preoperative hematoma volume and nonhyperintensity on T1-weighted imaging on the recurrence rate were significant. CONCLUSION: Our findings indicated that burr hole drainage without irrigation is a good surgical modality in patients with CSDH, and preoperative MRI findings can evaluate the risk of recurrence.

Intracavernous Hemangiopericytoma: Case Report and Review of the Literature.

Intracavernous hemangiopericytoma/solitary fibrous tumor is an extremely rare tumor, with only seven cases reported. We present a case of intracavernous hemangiopericytoma/solitary fibrous tumor and review all cases reported in the literature. A 67-year-old man experienced numbness over the left half of the face. Magnetic resonance imaging revealed a left intracavernous tumor extending into Meckel's cave and the posterior fossa. We performed gamma knife surgery (GKS) which a prescribed dose to the tumor of 12 Gy, but tumor recurred 43 months after GKS. We performed partial tumor resection via a subtemporal interdural approach. The pathological diagnosis was hemangiopericytoma. Postoperatively, we performed second GKS with a prescribed dose of 15 Gy. Diplopia and ptosis improved markedly and the tumor initially reduced in size, but tumor regrowth was seen again 29 months after second GKS. Third GKS was performed with a prescribed dose of 15 Gy. Recurrence was not seen at 18 months after third GKS, but was identified about 2 years after third GKS. We performed fourth GKS with a prescribed dose to the residual tumor of 16 Gy. We report a rare case of intracavernous hemangiopericytoma originating in the cavernous sinus, but distinguishing between hemangiopericytoma and schwannoma is difficult for round, intracavernous tumors showing homogeneous enhancement without flow voids. GKS might be one of the options for residual and recurrent intracavernous hemangiopericytomas.

Pylorus-preserving pancreatoduodenectomy for pancreatic head cancer after surgery for esophageal cancer with gastric tube reconstruction in a long-term survivor: A case report.

INTRODUCTION: To maintain the blood circulation of the gastric tube in pylorus-preserving pancreatoduodenectomy (PPPD) for periampullary cancer after esophagectomy for esophageal cancer, it is necessary to preserve the gastroduodenal artery and its branch, the right gastroepiploic artery, which are usually resected for more convenient, complete, and effective lymph node dissection. Here we report the case of a patient with a postoperative survival period of more than 5 years. PRESENTATION OF CASE: A 79-year-old man, who underwent subtotal esophagectomy and gastric tube reconstruction 11 years ago, was diagnosed with pancreatic head cancer during routine examination 5 years after the esophageal surgery. After placement of a coronary artery stent for an arterial branch stenosis incidentally found during preoperative screening electrocardiogram, he underwent pancreatic surgery. As the tumor did not extend to the anterior surface of the pancreas and as there were no swollen lymph nodes in the area, the gastroduodenal artery, the gastroepiploic artery and vein could be preserved. Elective PPPD was conducted without incident, and good preoperative gastric tube circulation was maintained postoperatively. Reconstruction was performed according to the modified Child procedure with duct-to-mucosa stentless pancreaticojejunostomy. The postoperative course was uneventful and though it took the patient a long time to overcome the physical decline, he remains alive with no recurrent disease over 5 years post-operation. CONCLUSION: Although PPPD may be performed after esophagectomy with gastric tube reconstruction, it is still unclear how the risk of recurrence is affected. Therefore, the indications of this procedure should always be carefully considered.

Cervical lift-up laminoplasty with titanium basket plates after resection of intradural tumor.

BACKGROUND: Performing cervical laminoplasty after wide laminectomy may be technically demanding. The unique technique of cervical lift-up laminoplasty using titanium basket plates was applied for the reconstruction of cervical laminae after wide laminectomy for the resection of intradural tumors. MATERIALS AND METHODS: This technical study included 14 cases that could be followed periodically for at least 6 months after surgery. Participants were 8 male and 6 female, with a mean age of 41.6 years (range, 13-71 years). Tumors were intramedullary in 11 cases and extramedullary in 3 cases. After resection of intradural tumors, custom-designed titanium baskets were fitted to expand the spinal canal. Combining baskets of different sizes are also possible for each side at one level. A mixture of hydroxyapatite granules and collagen was packed into the basket. The reconstructed posterior laminae were secured using titanium mini plates. The fascia of the paravertebral muscles was sutured to the spino-ligamentous complex to further stabilize the posterior elements of the cervical spine. RESULTS: No wounds or implant problems requiring revision surgery were recognized. Imaging analysis demonstrated no significant change in C2-C7 angle cervical range of motion between before and after surgery, suggesting sequential spinal stability at the base of the laminae. CONCLUSIONS: This technical note suggests that cervical lift-up laminoplasty with titanium basket plates appears practical and useful as a procedure to reconstruct cervical laminae after wide laminectomy.

Influence of prevertebral soft tissue swelling on dysphagia after anterior cervical discectomy and fusion using a rectangular titanium stand-alone cage.

BACKGROUND: Postoperative oropharyngeal complications such as dysphagia after anterior cervical spine surgery are some of the least discussed surgery-related complications. The purpose of this retrospective study is to investigate the incidence and possible risk factors for 30-day postoperative dysphagia after anterior cervical discectomy and fusion (ACDF). MATERIALS AND METHODS: This study included 152 consecutive patients who underwent 1- or 2-level ACDF using a rectangular titanium stand-alone cage in our institutes. Surgery-related dysphagia early after surgery was analyzed based on hospital charts. Radiological evaluation of prevertebral soft tissue swelling (PSTS) was performed by comparing plain lateral radiographs of the cervical spine before surgery with those after surgery. The percentage of PSTS (%PSTS) was defined by retropharyngeal soft tissue diameter divided by vertebral diameter. Positive %PSTS was determined when %PSTS exceeded its mean + 2 standard deviations. RESULTS: Twelve patients (7.9%) demonstrated prolonged symptoms of dysphagia within 30-day postoperatively. All patients eventually demonstrated satisfactory or acceptable recovery late after surgery, except one case of hypoglossal nerve palsy. %PSTS was significantly highest early after surgery and returned to presurgical levels within 30 days after surgery. Statistical analysis suggested that the positive %PSTS at C3 or C4 level early after surgery was significantly associated with the occurrence of postoperative dysphagia. CONCLUSIONS: Although the possible reasons for postoperative dysphagia may not only be multifactorial but also be highly surgeon-dependent, such a complication is still underestimated and needs to be carefully resolved. %PSTS appeared to be easy and reliable index to judge the possible risk of postoperative dysphagia.

Efficacy of Self-Expandable Metallic Stent Inserted for Refractory Hemorrhage of Duodenal Cancer.

Because of advances in the technology of gastrointestinal endoscopy and improvements in the quality of stents, it has become routine to place a stent as palliative therapy for malignant gastrointestinal obstruction. On the other hand, stent placement for malignant gastrointestinal hemorrhage has scarcely been reported, although it may be performed for hemorrhage of the esophageal varicose vein. We recently experienced a patient with refractory hemorrhage from an unresectable duodenal cancer who underwent placement of a self-expandable metallic stent (SEMS) and thereafter had no recurrence of the hemorrhage. A 46-year-old man underwent laparotomy to radically resect a cancer in the third portion of the duodenum, which invaded widely to the superior mesenteric vein and its branches and was considered unresectable. After stomach-partitioning gastrojejunostomy was performed, chemotherapy was initiated according to the regimen of chemotherapy of far advanced gastric cancer. One year and 4 months after induction of chemotherapy, gastrointestinal hemorrhage occurred. Upper gastrointestinal endoscopy revealed the hemorrhage oozing from the duodenal cancer, and endoscopic hemostasis, such as injection of hypertonic saline epinephrine and argon plasma coagulation, was unsuccessful. Twenty days after emergence of the hemorrhage, an endoscopic covered SEMS was placed with confirmation by fluoroscopy. Immediately after placement of the stent, the tarry stool stopped and the anemia ceased to progress. The recurrence of the hemorrhage has not been confirmed without migration of the stent. SEMS is an effective hemostatic procedure for malignant refractory hemorrhage.

A minimum 2-year comparative study of autologous cancellous bone grafting versus beta-tricalcium phosphate in anterior cervical discectomy and fusion using a rectangular titanium stand-alone cage.

Although titanium stand-alone cages are commonly used in anterior cervical discectomy and fusion (ACDF), there are several concerns such as cage subsidence after surgery. The efficacy of ß-tricalcium phosphate (ß-TCP) granules as a packing material in 1- or 2-level ACDF using a rectangular titanium stand-alone cage is not fully understood. The purpose of this study is to investigate the validity of rectangular titanium stand-alone cages in 1- and 2-level ACDF with ß-TCP. This retrospective study included 55 consecutive patients who underwent ACDF with autologous iliac cancellous bone grafting and 45 consecutive patients with ß-TCP grafting. All patients completed at least 2-year postoperative follow-up. Univariate and multivariate analyses were performed to examine the associations between study variables and nonunion after surgery. Significant neurological recovery after surgery was obtained in both groups. Cage subsidence was noted in 14 of 72 cages (19.4 %) in the autograft group and 12 of 64 cages (18.8 %) in the ß-TCP group. A total of 66 cages (91.7 %) in the autograft group showed osseous or partial union, and 58 cages (90.6 %) in the ß-TCP group showed osseous or partial union by 2 years after surgery. There were no significant differences in cage subsidence and the bony fusion rate between the two groups. Multivariate analysis using a logistic regression model showed that fusion level at C6/7, 2-level fusion, and cage subsidence of grades 2-3 were significantly associated with nonunion at 2 years after surgery. Although an acceptable surgical outcome with negligible complication appears to justify the use of rectangular titanium stand-alone cages in 1- and 2-level ACDF with ß-TCP, cage subsidence after surgery needs to be avoided to achieve acceptable bony fusion at the fused segments. Fusion level at C6/7 or 2-level fusion may be another risk factor of nonunion.

Posterolateral approach for spinal intradural meningioma with ventral attachment.

BACKGROUND: Spinal meningioma with ventral attachment is a challenging pathology. Several technical modifications have been proposed to secure safe and precise resection of these tumors. MATERIALS AND METHODS: This retrospective study focused on the precise and safe surgery of spinal meningiomas with strictly ventral attachment of cervical or thoracic spine. The surgical technique included a lateral oblique position for the patient, laminectomy with unilateral medial facetectomy on the tumor side, and spinal cord rotation with the dentate ligament. The neurological status of patients was assessed using the modified McCormick functional schema (mMFS) and sensory pain scale (SPS) before and at least 3 months after surgery. Patients were followed-up for a mean of 23.7 months. Tumor removal was graded using the Simpson grade for removal of meningiomas, and the extent of excision was confirmed using early postoperative magnetic resonance imaging. RESULTS: Simpson grade 1 or 2 resections were achieved in all cases. No major surgery-related complications were encountered, postoperatively. The mean mMFS score before surgery was 3.1, improving significantly to 1.7 after surgery (P < 0.05). The mean SPS score before surgery was 2.4, improving significantly to 1.6 after surgery (P < 0.05). CONCLUSIONS: This surgical technique offers a posterolateral surgical corridor to the ventral canal of both cervical and thoracic spine. The present preliminary analysis suggests that functional outcomes were satisfactory with minimal surgery-related complications, although considerable surgical experience is needed to achieve a high level of surgical confidence.

An FDG-PET/CT-positive lesion mimicking local recurrence of colon cancer 5 years after radical colectomy.

BACKGROUND: Radical resection of colorectal cancer yields satisfactory results. Even if the cancer recurs, long-term survival is expected through further surgical resection of the recurrent disease. For early detection of recurrent lesions, we routinely perform periodic blood tests and imaging studies, in which 18F-fluorodeoxyglucose-glucose positron emission tomography (FDG-PET) plays an important role, for lesion differentiation. We encountered a case of a benign lesion, which had been clinically diagnosed as recurrence of resected colon cancer by FDG-PET/computed tomography (CT). CASE REPORT: A 69-year-old woman underwent radical resection of stage II sigmoid colon cancer. Five years after the operation, local recurrence was suspected on the basis of follow-up CT examination findings. Since the standardized uptake value (SUV) on FDG-PET/CT was 13.3, we diagnosed the lesion as a postoperative local recurrence and performed surgical resection of the lesion. The lesion was conclusively diagnosed as benign fatty tissue, including a fibrovascular component, by histopathological examination. CONCLUSIONS: FDG-PET is a very useful technique for differentiating benign from malignant disease. In colorectal cancer, FDG-PET not only enables the differentiation of malignancy in the primary tumor, but also the confirmation of metastasis and postoperative recurrence. However, even if the SUV is high, as in the presented case, the lesion may eventually be diagnosed as benign. Therefore, further advances in the PET technique are expected along with the development of more useful modalities.

An analysis of epileptic negative myoclonus by magnetoencephalography.

PURPOSE: To clarify the neurophysiologic mechanism of epileptic negative myoclonus (ENM), we analyzed the magnetoencephalography (MEG) of a patient with ENM. METHODS: The 52-year-old right-handed male had frequent ENM in the right upper limb during awake and monthly seizures with sudden tonic stiffening of the right forearm during sleep. MRI demonstrated a focal cortical dysplasia in the cortex of the posterior portion of the left superior frontal sulcus. Whole-head type MEG, electroencephalography and electromyography were simultaneously recorded during ENM. Single equivalent currents dipoles (ECDs) were calculated for each spike component followed by silent period (SP) in the right deltoid muscle. These MEG spike components were averaged with respect to their peaks, and single ECD was also calculated for the averaged spike component. Furthermore, we analyzed the MEG with the silent-period-locked-averaging (SPLA) method. Twenty MEG signal data were averaged with respect to the onset of SP. Twenty epochs in each of five separate periods of recording were repeatedly averaged. ECDs were calculated for spike components observed in each averaged epoch. RESULTS: ECDs of each spike followed by SP were clustered near the cortex of the left central sulcus. In MEG spike averaging and SPLA method, ECDs at the peak of spike components were located near the right shoulder division of the primary sensorimotor cortex reproducibly. ECDs on the ascending phase before the peak were located lateral to the above ECD location in MEG spike averaging method. CONCLUSIONS: ENM was produced by an inhibitory action on the primary sensorimotor cortex corresponding to the body segment in which ENM occurs.

Technical procedures causing biliary complications after hepaticojejunostomy in pancreaticoduodenectomy.

BACKGROUND: Although pancreaticoduodenectomy has been established as a standard operation for pancreatobiliary diseases, postoperative biliary complications still exist and impair patient quality of life. METHODS: We enrolled 67 patients who underwent pancreaticoduodenectomy. Patients were divided into 2 chronological groups representing different surgical procedures: group A (G-A) included patients treated between 2003 and 2006 and group B (G-B) included patients treated later. We compared surgical procedures and postoperative biliary complications between the groups. RESULTS: The number of stitches at hepaticojejunostomy was 33.2 ± 8.4 in G-A and 14.0 ± 2.3 in G-B. A biliary drainage stent was placed in 31 of 32 cases in G-A and in none of the 35 cases in G-B. For each surgical procedure, there was a significant difference between the groups. Bile leakage occurred in 9.4% of G-A patients and 2.9% of G-B patients. The serum alkaline phosphatase level was significantly higher in G-A than in G-B. Moreover, the number of patients hospitalized for cholangitis was significantly greater in G-A than in G-B. CONCLUSION: Among procedure-related factors pertaining to hepaticojejunostomy in pancreaticoduodenectomy, the number of anastomotic stitches and the placement of a biliary drainage stent were confirmed to affect the development of an anastomotic stricture.

Long-term survival after sequential chemotherapy and surgery for advanced gastric cancer.

INTRODUCTION: We experienced a case with long relapse-free survival after successful treatment of chemotherapy and surgery to advanced gastric cancer. PRESENTATION OF CASE: A 56-year-old man was examined because of rapid weight loss and was diagnosed as having far-advanced gastric cancer with portal vein tumor thrombus (PVTT) and liver, lymph node and peritoneal metastases. Immediately after beginning chemotherapy, gastric obstruction due to gastric cancer was discovered. Therefore gastrojejunostomy, a bypass operation, was performed, and this was followed by the first course chemotherapy with S-1 and cisplatin. After 4 courses of this regimen were completed, PVTT and the peritoneal metastasis could no longer be confirmed, and new lesion had not appeared; therefore, the patient underwent a radical operation with distal gastrectomy, lymph node dissection and partial hepatectomy. After the operation, he received second-line chemotherapy with S-1 and paclitaxel for 1 year. He has been in good health without any signs of recurrence for 3 years and 8 months after the radical operation. DISCUSSION AND CONCLUSION: Although complete recovery from far-advanced gastric cancer is rarely expected, this case demonstrates that long-term survival is achievable with carefully considered treatment plans.

[Spontaneous cerebrospinal fluid rhinorrhea associated with long-standing overt ventriculomegaly in adults (LOVA)].

OBJECTIVE: Spontaneous cerebrospinal fluid rhinorrhea associated with aqueductal stenosis is rare. CSF diversion is reported to be a failure in the majority of cases. The combination of the repair of the skull base and CSF diversion is reported to be successful. We describe a case successfully treated by intradural repair with ventricular drainage followed by endoscopic third ventriculostomy. CLINICAL PRESENTATION: A 28-year-old woman presented with rhinorrhea, and occasional attacks of headache, vomiting, and unconsciousness for two years. She had been diagnosed as arrested hydrocephalus for 10 years. Magnetic resonance imaging revealed triventriculomegaly with ballooning of the floor of the third ventricle, tonsilar herniation, right anterior horn herniation into the cribriform plate, and bilateral temporal lobe herniation into the temporal base. INTERVENTION: A ventricular drain was inserted followed by dissection of the herniated brain and repair of the enlarged cribriform foramen with periosteal flap. Make sure that the bacterial culture negative, endoscopic third ventriculostomy has been performed. There is no recurrence of hydrocephalus and rhinorrhea for two years. CONCLUSION: Direct communication between the lateral ventricle and the nasal/paranasal sinus is a rare complication of aqueductal stenosis and LOVA. Surgical repair of the skull base followed by cerebrospinal fluid diversion with endoscopic third ventriculostomy was a safe and reliable method.

[Transsphenoidal surgery for pituitary tumors from microsurgery to the endoscopic surgery: single surgeon's experience].

We reviewed results of the surgical outcome of pituitary tumors treated via the transsphenoidal approach between January, 1994 and January, 2010 at our institution. This data included 100 patients (124 procedures) treated through the sublabial transsphenoidal approach and 45 patients (54 procedures) treated through the endoscopic endonasal (bilateral nostrils) transsphenoidal approach performed by a single surgeon. The extent of tumor removal was significantly improved with endoscopic surgery; adjuvant gamma knife radiosurgery was needed for 65% of patients undergoing microsurgery vs. 30% for patients who had endoscopic surgery (p<0.0001). Patients who underwent endoscopic surgery had less intraoperative blood loss (mean volume: 100 mL for microsurgery patients vs. 30 mL for endoscopic surgery patients, p<0.0001), less pain, and less need for postoperative hormone replacement therapy (19% for microsurgery patients vs. 6% for endoscopic surgery patients; p<0.05). CSF leakage and meningitis were experienced in one microsurgery patient (1%) and one endoscopic surgery patient (2.2%). Endoscopic surgery is a reasonable alternative to microsurgery and our experience supports the concept that an otolaryngologist/neurosurgeon team skilled in endoscopic techniques and pituitary surgery can safely make the transition from microsurgery to endoscopic surgery.

Protection of anastomotic pathways to the vertebral artery during stenting of external carotid artery stenosis.

A 61-year-old man presented with a severe external carotid artery (ECA) stenosis with concomitant ipsilateral internal carotid artery (ICA) occlusion manifesting as amaurosis fugax. The left ophthalmic artery was supplied from the left ECA. The left intracranial ICA was supplied by the collateral flow from the contralateral ICA and ipsilateral ECA through the ophthalmic artery. The left vertebral artery also participated in the latter collateral pathway through the left occipital artery and ascending pharyngeal artery. Percutaneous revascularization of the ECA was performed using a nitinol self-expanding stent. To prevent embolic complications through the ophthalmic or vertebral arteries, distal protection was performed using a balloon. During a 22-month follow-up period, the patient was completely free from any ocular or neurological symptoms. The present case of severe ECA stenosis with ipsilateral ICA occlusion showed that percutaneous balloon angioplasty with stenting is feasible and effective. This intervention requires cautious evaluation of the anastomotic pathways connecting the ECA to the cerebral circulation to avoid embolic complications.

[Formed visual hallucination after excision of the right temporo parietal cystic meningioma--a case report].

We report the case of a 64-year-old woman with cystic meningioma; this patients was otherwise healthy and experienced formed visual hallucinations after excision of the tumor. She experienced diplopia associated with metamorphopsia, which had persisted for 5 years only when she laid down and turned on her left side. After the excision of the convexity meningioma located in the right temporoparietal lobe, she experienced several types of formed visual hallucinations such as closet-like pictures, flowers sketched on stones, falling maple-like leaves, and moving or wriggling dwarves. She was alert and her visual field was normal; further, she did not experience delirium or seizures. She experienced these hallucinations only when she closed her eyes; these hallucinations persisted for 3 days after the operation. The patient illustrated her observations with beautiful sketches, and the mechanism of visual hallucinations was studied.