Angiographic Evaluation of the Feeding Artery in Skull Base Meningioma.

To identify the characteristics of feeding arteries in skull base meningioma including location and prevalence, we evaluated the distributions and types of feeding arteries in skull base meningioma by cerebral angiography and assessed relationships to tumor attachment. We enrolled patients with skull base meningioma who underwent MRI and cerebral digital subtraction angiography (DSA), from September 2015 to October 2022. Subjects comprised 115 patients (32 males, 83 females; mean age, 52.7) with 117 meningiomas, showing tumor attachments around the "cavernous sinus to the upper part of the clivus" (Area 1), "lower part of the clivus to foramen magnum" (Area 2), and "tentorium around the petrous bone" (Area 3). Frequent arteries, such as the dorsal meningeal artery (DMA), the ascending pharyngeal artery (APA), the tentorial artery (TA), and the petrosal branch (PB) of the middle meningeal artery (MMA) were analyzed in terms of their associations with tumor attachment to Areas 1-3. Meningiomas with the DMA as a feeding artery correlated with tumor attachment to Area 1 (p < 0.001). Meningiomas with the APA correlated with tumor attachment to Area 2 (p < 0.001). Meningiomas with the TA correlated with tumor attachment to Area 3 (p < 0.001). The PB correlated with Area 3 (p < 0.05). Our study founded that visualization of these arteries correlated well with specific areas. These arteries were also the main feeders in each type of skull base meningioma.

Intraparenchymal and Subarachnoid Hemorrhage in Stereotactic Electroencephalography Caused by Indirect Adjacent Arterial Injury: Illustrative Case.

The complication rate of stereotactic electroencephalography (SEEG) is generally low, but various types of postoperative hemorrhage have been reported. We presented an unusual hemorrhagic complication after SEEG placement. A 20-year-old man presented with suspected frontal lobe epilepsy. We implanted 11 SEEG electrodes in the bilateral frontal lobes and the left insula. Computed tomography after implantation showed intraparenchymal hemorrhage in the left temporal lobe and insula and subarachnoid hemorrhage in the left Sylvian cistern. Later, the point of vessel injury was revealed from the identification of a pseudoaneurysm, but this location was not along the planned or actual electrode trajectory. The cause of hemorrhage was suggested to be indirect injury from stretching of the arachnoid trabeculae by the puncture needle.

Case report and review of the literature of primary central nervous system lymphoma of the fourth ventricle.

Background: Primary central nervous system lymphoma of the fourth ventricle is very rare. We present a case of primary central nervous system lymphoma originating from the fourth ventricle and review cases reported in the literature. Case Description: A 54-year-old man with no previous medical history presented with headache and nausea. Magnetic resonance imaging showed a homogeneously enhancing tumor in the fourth ventricle and obstructive hydrocephalus. We performed biopsy of the tumor, which was diagnosed pathologically as diffuse large B-cell lymphoma. Although the tumor disappeared after 5 cycles of R-MPV regimen, the patient required repeated ventricular drainage and finally received a ventriculoperitoneal shunt. Complete response was achieved after 2 cycles of high-dose cytarabine chemotherapy with an autologous peripheral blood stem cell transplant. There was no sign of recurrence at 20 months after biopsy. Conclusion: Morbidity arising due to radical resection/radiotherapy of resistant primary central nervous system lymphoma originating from the fourth ventricle could be prevented by ventriculoperitoneal shunting with chemotherapy and autologous blood stem cell transplantation.

Deep Learning-based Angiogram Generation Model for Cerebral Angiography without Misregistration Artifacts.

Background Digital subtraction angiography (DSA) generates an image by subtracting a mask image from a dynamic angiogram. However, patient movement-caused misregistration artifacts can result in unclear DSA images that interrupt procedures. Purpose To train and to validate a deep learning (DL)-based model to produce DSA-like cerebral angiograms directly from dynamic angiograms and then quantitatively and visually evaluate these angiograms for clinical usefulness. Materials and Methods A retrospective model development and validation study was conducted on dynamic and DSA image pairs consecutively collected from January 2019 through April 2019. Angiograms showing misregistration were first separated per patient by two radiologists and sorted into the misregistration test data set. Nonmisregistration angiograms were divided into development and external test data sets at a ratio of 8:1 per patient. The development data set was divided into training and validation data sets at ratio of 3:1 per patient. The DL model was created by using the training data set, tuned with the validation data set, and then evaluated quantitatively with the external test data set and visually with the misregistration test data set. Quantitative evaluations used the peak signal-to-noise ratio (PSNR) and the structural similarity (SSIM) with mixed liner models. Visual evaluation was conducted by using a numerical rating scale. Results The training, validation, nonmisregistration test, and misregistration test data sets included 10 751, 2784, 1346, and 711 paired images collected from 40 patients (mean age, 62 years ± 11 [standard deviation]; 33 women). In the quantitative evaluation, DL-generated angiograms showed a mean PSNR value of 40.2 dB ± 4.05 and a mean SSIM value of 0.97 ± 0.02, indicating high coincidence with the paired DSA images. In the visual evaluation, the median ratings of the DL-generated angiograms were similar to or better than those of the original DSA images for all 24 sequences. Conclusion The deep learning-based model provided clinically useful cerebral angiograms free from clinically significant artifacts directly from dynamic angiograms. Published under a CC BY 4.0 license. Supplemental material is available for this article.

Combination of p53 and Ki67 as a Promising Predictor of Postoperative Recurrence of Meningioma.

BACKGROUND: Meningioma is a common intracranial tumor originating from arachnoid cap cells. Meningiomas are generally benign tumors curable by one-time resection. However, some meningiomas regrow and invade into the dura mater, and thus frequently require additional treatment. A useful marker to predict the regrowth of meningioma is desired. This study aimed to clarify the significance of p53 and Ki67 for postoperative recurrence of meningioma. MATERIALS AND METHODS: The expression of p53 and Ki67 in 215 intracranial or intraspinal meningiomas was investigated by immunohistochemistry. RESULTS: Of the 215 meningiomas, 35 cases (16.3%) were p53-positive and 49 cases (22.8%) were Ki67-positive. Multivariate analysis revealed Ki67 and p53 status as being significantly correlated with recurrence. Positivity for either Ki67- or p53 was significantly associated with poor recurrence-free survival. CONCLUSION: Combined p53 and Ki67 status might represent a useful independent predictive marker for recurrence of meningioma.

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.

Spheno-Orbital Meningioma: Surgical Outcomes and Management of Recurrence.

OBJECTIVE: Spheno-orbital meningioma (SOM) is a rare intracranial tumor that arises at the sphenoid wing, extends into the orbit, and is associated with hyperostosis of the sphenoid bone. These tumors often invade important neurovascular structures around the orbital apex, superior orbital fissure, and cavernous sinus. Aggressive tumor removal could achieve acceptable control; however, residual tumor can regrow. In this article, our surgical management and long-term outcomes are described. METHODS: Retrospectively, 12 patients with SOM who were treated surgically over a 21-year period were included. The clinical features and long-term tumor control were evaluated. RESULTS: Participants comprised 12 patients (5 men and 7 women). Mean follow-up was 74.4 months (range, 10-262 months). Ten patients (83%) were identified as World Health Organization grade 1 (WHO-I), and 2 patients (17%) were identified as WHO grade 2 (WHO-II). We encountered 4 recurrences, 2 of which needed additional surgeries. One patient with WHO-I (10%) experienced recurrence 10 years after the initial surgery and required a second surgery. Two patients with WHO-I (20%) showed slight regrowth of residual tumor around the superior orbital fissure; nevertheless, additive therapy was not recommended. Despite radical tumor resection, including eyeball and adjunctive radiotherapy for 1 patient with WHO-II, tumor recurrence in the posterior fossa was documented 19 years after the initial aggressive surgery. CONCLUSIONS: SOM follows a relatively benign clinical course given the invasive radiologic findings. Abnormal bone resection is paramount to prevent early-stage recurrence. Although intradural residual tumor might regrow, additional surgery could achieve reasonable long-term tumor control with better outcome.

Usefulness of the anterior transpetrosal approach for pontine cavernous malformations.

Surgical resection of pontine cavernous malformation remains a particularly formidable challenge. We report the surgical outcome of eight cases with pontine cavernous malformations operated using the anterior transpetrosal approach. All cases presented with neurological deficits caused by hemorrhage before surgery. Gross-total removal was achieved in all cases without any postoperative complication such as worsening of facial nerve palsy, ocular movement disorder, or hemiplegia. A small incision of the pons with multidirectional dissection is the most important factor for minimizing postoperative neurological deficits, so resection of a pontine cavernous malformation via this approach can be an alternative better option. The video can be found here: https://youtu.be/2Q2CUhBbo28.

Efficacy of arachnoid plasty with collagen sheets and fibrin glue: An in vitro experiment and a case review.

BACKGROUND: Postoperative subdural fluid collection sometimes occurs after clipping of cerebral aneurysms. Arachnoid plasty is used to prevent such postoperative complications; however, the optimal materials for arachnoid plasty remain unclear. In this study, we aimed to clarify the optimal materials for arachnoid plasty and report our experience of arachnoid plasty after clipping of unruptured aneurysms. METHODS: In an in vitro experiment, adhesive strengths of three materials permitted for use in the intradural space, such as collagen sheets, gelatin sponge, and oxidized cellulose sheets, were measured by assessing their water pressure resistance. Then, 80 consecutive cases surgically treated unruptured cerebral aneurysms were retrospectively reviewed to examine the occurrence rate of postoperative subdural fluid collection. RESULTS: The collagen sheet exhibited the greatest adhesive strength, so we used collagen sheets for the arachnoid plasty procedures. In all of these cases, arachnoid plasty was performed with fibrin glue-soaked collagen sheets. No postoperative subdural fluid collection, inflammation, or allergic reactions occurred in any case. CONCLUSIONS: The present study suggests that collagen sheet might be one of the optimal materials for arachnoid plasty. This technique is simple and may be effective to prevent subdural fluid collection after clipping.

Microsurgical interintimal dissection in carotid endarterectomy.

BACKGROUND: Safe and complete surgical excision of carotid plaque in carotid endarterectomy (CEA) is essential for preventing postoperative embolic stroke and restenosis. We considered the dissection plane for the plaque according to pathological findings of carotid atherosclerosis. We report our experiences with inner-intimal dissection in CEA. METHODS: To obtain complete resection of the plaque with a smooth distal edge and bloodless surface by minimal exposure of the media, the thickened intima was sliced under high-magnification microscopy. The excised specimens were examined pathologically. RESULTS: Sixty-three CEAs were performed for 61 patients with carotid stenosis. Complete resection without tacking suture was obtained in all procedures. No mortality was encountered. Minor stroke was recorded in 1 procedure (1.6%). No early restenosis was recorded during follow-up (range, 1-35 months; mean, 15.6 months). Pathological examination revealed interintimal excision of the lesion in each case. CONCLUSION: Microsurgical interintimal dissection could accomplish good surgical outcome, including absence of significant early restenosis.

Analysis of venous drainage from sylvian veins in clinoidal meningiomas.

OBJECTIVE: To categorize clinoidal meningiomas according to their venous drainage patterns, and use each category as a guideline to establish an appropriate surgical strategy. METHODS: We performed a retrospective analysis of 22 consecutive surgically treated patients with clinoidal meningioma who underwent preoperative digital subtraction angiography to examine the characteristics of the venous drainage system. These patients were categorized into: 1) cortical type in which the sylvian vein did not drain medially but drained to cortical veins, 2) sphenobasal type in which the sylvian vein drained into the pterygoid plexus, or 3) cavernous type in which the sylvian vein drained into the cavernous sinus directly through the sphenoparietal sinus. We tailored the surgical strategy to preserve these draining veins. RESULTS: Preoperative angiographic evaluation demonstrated 14 patients (63.6%) with cortical type, 6 patients (27.3%) with sphenobasal type, and 2 patients (9.1%) with the cavernous type. In most cases, no restriction from the venous structure was observed because the sylvian vein belonged to the cortical type. However, in the case of the sphenobasal or sphenoparietal type, the surgical strategy seemed to be tailored to preserve the venous drainage system. CONCLUSIONS: The surgical risk from venous complication in the treatment of clinoidal meningiomas appears to be low; however, there are likely to be patients that require a tailored surgical approach to avoid venous complications. Detailed preoperative assessment of anatomic structure and consideration of the optimal surgical strategy are critical to improve treatment outcomes.

Tentorial schwannoma mimicking meningioma.

A 58-year-old woman presented with a rare tentorial schwannoma manifesting as a chief complaint of headache. Magnetic resonance imaging showed an infratentorial extra-axial mass lesion with both cystic and solid components and dural tail sign. The tumor was easily separated from the surrounding structures, and the origin was apparently the tentorial branch of the trigeminal nerve. Tentorial schwannoma should be considered in the differential diagnosis of mixed cystic and solid mass lesions associated with the tentorium around the ambient cistern.

Middle skull base approach with posterolateral mobilization of the geniculate ganglion to access the clival regions.

BACKGROUND: Clival lesions remain one of the most challenging intracranial tumors to treat surgically. Many skull base approaches have been described to improve resection and to decrease patient morbidity. OBJECTIVE: To describe a middle skull base approach with posterolateral mobilization of the geniculate ganglion of the facial nerve to access the clival regions. METHODS: Three patients with petroclival chordoma and 1 patient with petroclival meningioma underwent surgical resection of lesions with our new procedure. Surgical techniques consisted of temporal craniotomy and exposure of the facial nerve from the tympanic segment to the labyrinthine segment, keeping the fundus of the internal auditory canal intact. The geniculate ganglion was mobilized posterolaterally, followed by drilling of the cochlea and exposure of the Dorello canal. RESULTS: Four lesions were successfully removed with complete preservation of facial nerve function. CONCLUSION: This approach is a modification of the Goel procedure in which the facial nerve from the tympanic segment to the cisternal segment was totally mobilized. Our procedure carries less risk to the facial nerve function than the Goel procedure and provides sufficiently wide exposure of clival lesions.

Pathological findings of fusiform dilation of the internal carotid artery following radical dissection of a craniopharyngioma.

Fusiform dilation of the internal carotid artery (FDICA) after radical resection of a suprasellar craniopharyngioma has been reported. To the authors' knowledge, however, fatal conditions associated with FDICA have not been reported and pathological findings have not been obtained. The authors performed biopsy sampling of the wall of an FDICA for histopathological evaluation and found hyperplastic adventitia. This pathological result strongly supports conclusions from previous reports that FDICA has a low risk of rupture.

Microroll retractor for surgical resection of brainstem cavernomas.

BACKGROUND: Safe and complete surgical resection of brainstem cavernoma is difficult without injury surrounding normal structures because the lesions are deep and intra-axial. In this article, the authors describe the "microroll retractor" technique for brainstem cavernoma surgery. METHODS: The microroll retractor is made of expanded polytetrafluoroethylene sheet. The sheet is cut in several sizes of square piece and transformed into a tubular shape. We insert this roll retractor via minimal brain incision and keep surgical corridor without usual spatulas during lesionectomy. RESULTS: This technique was adopted for 7 patients with brainstem cavernomas. In all patients, we achieved total excision; improvement was recorded in 6 patients, and no change was recorded in 1 patient. CONCLUSIONS: The microroll retractor is extremely simple but provides enough surgical corridors for safe total resection of brainstem cavernomas.

The role of radical microsurgical resection in multimodal treatment for skull base meningioma.

OBJECT: Because resection followed by timely stereotactic radiosurgery (SRS) is becoming a standard strategy for skull base meningiomas, the role of initial surgical tumor reduction in this combined treatment should be clarified. METHODS: This study examined 161 patients with benign skull base meningiomas surgically treated at Osaka City University between January 1985 and December 2005. The mean follow-up period was 95.3 months. Patients were categorized into 3 groups based on the operative period and into 4 groups based on tumor location. Maximal resection was performed as first therapy throughout all periods. In the early period (1985-1994), in the absence of SRS, total excision of the tumor was intentionally performed for surgical cure of the disease. In the mid and late periods (1995-2000 and 2001-2005), small parts of the tumor invading critical neurovascular structures were left untouched to obtain good functional results. Residual tumors with high proliferation potential (Ki 67 index > 4%) or with progressive tendencies were treated with SRS. The extent of initial tumor resection, recurrence rate, Karnofsky Performance Scale score, and complication rate were investigated in each group. RESULTS: The mean tumor equivalent diameter of residual tumors was 3.67 mm in the no-recurrence group and 11.7 mm in the recurrence group. The mean tumor resection rate (TRR) was 98.5% in the no-recurrence group and 90.1% in the recurrence group. A significant relationship was seen between postoperative tumor size, TRR, and recurrence rate (p < 0.001), but the recurrence rate showed no significant relationship with any other factors such as operative period (p = 0.48), tumor location (p = 0.76), or preoperative tumor size (p = 0.067). The mean TRR was maintained throughout all operative periods, but the complication rate was lowest and postoperative Karnofsky Performance Scale score was best in the late period (p < 0.001 each). Late-period results were as follows: mean TRR, 97.9%; mortality rate, 0%; and severe morbidity rate, 0%. Stereotactic radiosurgery procedures were added in 27 cases (16.8%) across all periods. Throughout all follow-up periods, 158 tumors were satisfactorily controlled by maximal possible excision alone or in combination with adequate SRS. CONCLUSIONS: The combination of maximal possible resection and additional SRS improves functional outcomes in patients with skull base meningioma. A TRR greater than 97% in volume can be achieved with satisfactory functional preservation and will lead to excellent tumor control in combined treatment of skull base meningioma.

Primary epidural peripheral primitive neuroectodermal tumor of the thoracic spine.

A 25-year-old male patient presented with an extremely rare primary spinal peripheral primitive neuroectodermal tumor (pPNET) manifesting as acutely progressive paraparesis and back pain. Neuroimaging and intraoperative examination showed that the tumor was confined to the epidural space of the thoracic spine. The patient was treated successfully by gross total resection of the tumor followed by chemotherapy and local radiotherapy. The present case illustrates the unexpected occurrence and important differential diagnosis of primary epidural pPNET of the thoracic spine in young patients presenting with progressive paraparesis and back pain.

Primary squamous cell carcinoma of the frontal sinus treated with en bloc resection: case report.

A 66-year-old man presented with an extremely rare primary frontal sinus squamous cell carcinoma who was successfully treated by the extreme radical extended frontobasal approach. The tumor was resected en bloc with a clear margin and the large defect of the frontal region was reconstructed using a rectus abdominis myocutaneous flap. The tumor was well controlled without adjuvant therapy, and no recurrence or metastasis had occurred 2 years after the operation. Frontal sinus malignancy can be resected by the extreme radical extended frontobasal approach. The rectus abdominis myocutaneous flap is useful for the large defect of the skin and frontal base.

[Enlarged perivascular spaces associated with hydrocephalus: a case report].

We report a case of enlarged perivascular spaces (EPVS) in the mesencephalothalamic region associated with hydrocephalus. EPVS are extensions of the subarachnoid space that accompany penetrating arteries and may cause mass effects. A 56-year-old woman with EPVS-associated hydrocephalus underwent third ventriculostomy and biopsy. We compared pre-and postoperative images by magnetoencephalography (MEG) and tractography, and evaluated the effects of EPVS. These images were useful to determine the patient' s condition.

New pull-through technique using the superficial temporal artery for transbrachial carotid artery stenting.

Carotid artery stenting (CAS) is an effective and less invasive alternative to carotid endarterectomy for internal carotid artery (ICA) stenosis, but the guiding catheter is often technically difficult to introduce into the common carotid artery (CCA) in patients with concomitant atherosclerotic disease in the peripheral vessels or aorta. A new pull-through technique between the superficial temporal artery (STA) and the brachial artery was used to deliver the guiding catheter into the CCA safely and steadily. An 83-year-old male presented with repeated transient left hemiparesis caused by severe stenosis of the origin of the right ICA. He also had severe systemic atherosclerotic disease with occlusion of the bilateral femoral arteries. The innominate artery branched at an acute angle from the aorta. Therefore, catheterization of the right CCA seemed to be impossible using a conventional approach. The guidewire introduced from the right STA was lassoed by a loop snare wire and pulled out of the left brachial artery, forming the pull-through system. The guiding catheter could be introduced into the CCA from the left brachial artery over this guidewire. Subsequently, successful stent placement was performed under the distal protection. This new technique may facilitate safe and stable CAS even in patients with a severely tortuous access route due to concomitant atherosclerotic disease.