Fatal Fungal Aneurysm Rupture Due to Aspergillosis after Craniopharyngioma Removal via Endoscopic Endonasal Surgery: Case Report and Comparison with Seven Reported Patients.

There has been a noted increase in the incidence of intracranial aspergillosis; this is often attributed to the wider use of antibiotics, corticosteroids, and immunosuppressants. Fungal cerebral aneurysms due to aspergillosis after neurosurgery remain extremely rare; in fact, only seven cases have been reported in the literature. In this study, we present a patient with an Aspergillus aneurysm that elicited subarachnoid hemorrhage after endoscopic endonasal surgery (EES) for craniopharyngioma. A 70-year-old woman with recurrent craniopharyngioma and steroid treatment underwent uneventful EES. On the 5th postoperative day, she suffered subarachnoid hemorrhage. As per her computed tomography angiography findings, an aneurysm was detected on the left internal carotid artery (ICA). Subsequent digital subtraction angiography showed occlusion of the ICA and an irregularly shaped wall. The diagnosis was pseudoaneurysm. We then performed craniotomy to place a left high-flow bypass and to trap the pseudoaneurysm. Despite continuous intensive care, she died on the 25th postoperative day of a huge, left cerebral infarct. The final diagnosis was made at autopsy; it revealed destruction of the ICA and Aspergillus invasion of the vessel wall, confirming the presence of a true fungal aneurysm. Perioperatively, patients with potential immunosuppression must be carefully managed. Advanced age is a risk factor. As surgery via the paranasal sinuses raises the risk for aspergillosis, fungal infection must be ruled out in patients whose postoperative course is deemed concerning.

Hanging foot switch for bipolar forceps: a device for surgeons operating in the standing position: technical note.

For surgeons operating in the standing position, the manipulation of foot switches involves shifting of the weight to the pivoting leg and the possible loss of contact between the switch and the foot. We solved this problem by changing the position of the switch that operates bipolar forceps. Our novel device is made of aluminum plates. The base plate features a foot strap and a height-adjustable overhang over the switch-operating foot. A commercially-available disc type foot switch is attached to the underside of the overhang in upside-down position, so the switch is operable with the toe. To turn on the switch, the toe is flexed dorsally to push the switch pedal, so the action is limited to the part distal to the metatarsophalangeal joints. Our switch was used in more than 100 consecutive microsurgeries performed by surgeons operating in the standing position. The switch manipulation required no shifting of the weight and was easier and quicker than manipulation of conventionally-placed switches. The surgeons were able to change the foot position freely with the modified switch, thereby avoiding loss of contact with the switch. The modified switch placement reduced physical fatigue in the lower extremities, annoyance related to the manipulation of conventionally-placed switches, and increased the comfort of surgeons operating in the standing position.

Reactive oxygen species are involved in gibberellin/abscisic acid signaling in barley aleurone cells.

Reactive oxygen species (ROS) act as signal molecules for a variety of processes in plants. However, many questions about the roles of ROS in plants remain to be clarified. Here, we report the role of ROS in gibberellin (GA) and abscisic acid (ABA) signaling in barley (Hordeum vulgare) aleurone cells. The production of hydrogen peroxide (H2O2), a type of ROS, was induced by GA in aleurone cells but suppressed by ABA. Furthermore, exogenous H2O2 appeared to promote the induction of α-amylases by GA. In contrast, antioxidants suppressed the induction of α-amylases. Therefore, H2O2 seems to function in GA and ABA signaling, and in regulation of α-amylase production, in aleurone cells. To identify the target of H2O2 in GA and ABA signaling, we analyzed the interrelationships between H2O2 and DELLA proteins Slender1 (SLN1), GA-regulated Myb transcription factor (GAmyb), and ABA-responsive protein kinase (PKABA) and their roles in GA and ABA signaling in aleurone cells. In the presence of GA, exogenous H2O2 had little effect on the degradation of SLN1, the primary transcriptional repressor mediating GA signaling, but it promoted the production of the mRNA encoding GAMyb, which acts downstream of SLN1 and involves induction of α-amylase mRNA. Additionally, H2O2 suppressed the production of PKABA mRNA, which is induced by ABA:PKABA represses the production of GAMyb mRNA. From these observations, we concluded that H2O2 released the repression of GAMyb mRNA by PKABA and consequently promoted the production of α-amylase mRNA, thus suggesting that the H2O2 generated by GA in aleurone cells is a signal molecule that antagonizes ABA signaling.

Modified wound dissection preserving the greater occipital nerve in foramen magnum decompression: a technique to reduce postoperative pain.

Patients undergoing foramen magnum decompression for Chiari malformation may experience severe postoperative pain in the area innervated by the greater occipital nerve (GON). We developed a modified dissection to lessen this pain. A midline skin incision was extended 2 cm in a cephalad direction to the inion and the skin was minimally retracted. After exposing the occipital bone, the semispinalis capitis and the trapezius muscles were detached subperiosteally in a caudal-to-cephalad direction. Consequently, the muscles and skin containing the GON were retracted in a single layer. We retrospectively compared the intensity of postoperative pain recorded on the visual analogue scale (VAS) by patients who underwent decompression using our (group A, n = 5) and the conventional layer-by-layer dissection technique (group B, n = 5). The VAS scores were not different on the day of surgery, but subsequently they fell faster in group A. Group A patients received a mild analgesic for a short period. Group B patients required a stronger analgesic for prolonged periods. Postoperative GON numbness/tenderness was observed only in group B. With respect to most evaluation criteria, the difference between the two groups was significant. Our anatomically rational dissection that protects the GON results in less postoperative pain.

[Dural scoring: an assistance technique for primary dural closure at craniotomy].

OBJECTIVE: At craniotomy the dura shrinks due to the drying effect of illumination and air exposure, rendering primary closure of this tissue difficult. We have developed a new technique, "dural scoring", that facilitates primary dural closure. PATIENTS AND METHODS: We used this technique in adults who underwent craniotomy when we encountered difficulties with primary dural closure of openings less than 5 mm in width. We placed scores along the edge of the opening on the surface of the dura (periosteal dura), taking care not to perforate the deep layer (meningeal dura). The dura relieved of tension expanded enough to be closed with sutures. RESULTS: This technique was successful in achieving primary dural closure in 53 patients who primarily underwent small supratentorial craniotomies. There were no procedure-related complications, e. g. cerebrospinal fluid leakages. CONCLUSIONS: Dural scoring is simple, requires no special instrumentation, and facilitates primary dural closure.

Anchoring of methylmethacrylate filler to the calvarium--technical note.

Implanted methylmethacrylate may be unexpectedly displaced due to poor adherence to the bone. We developed a simple technique to fix the material plugging the burr holes for use primarily in cosmetically important areas. At the closure of craniotomy, 2-3 small drill holes are made at the rim of the craniotomy burr hole. To address cranial defects in the pterional region, small holes are placed on the bone surface around the key burr hole. The holes extend into the diploic layer and have no parallel relationship. After fixation of the bone flap, a methylmethacrylate filler mixture is manually plugged into the burr hole and pushed into the small holes, thereby forming horns for secure fixation. None among over 100 patients developed an objectionable bulge attributable to displacement of the filler. Our technique requires no special instruments or materials and decreases the risk of cosmetic problems.

Inclined foot switches for surgical microscopes: a comfortable design for seated surgeons: technical note.

During microneurosurgical procedures, surgeons sitting on a stool may experience muscular fatigue in the lower half of the body due to repeat manipulation of foot switches controlling the surgical microscope. The mechanisms contributing to this fatigue were examined and a method developed for fatigue reduction. The switch panel harboring the pedals was originally designed to be placed horizontally, but was inclined toward the surgeon with a sandbag placed under the panel. The modified panel was used in consecutive surgeries by 3 surgeons. Surface electromyographs of the bilateral gastrocnemius and gluteus maximus muscles were obtained during simulated activation of the switches on horizontal and inclined panels using the left foot. Inclined panels facilitated stepping on the pedals, required less muscle power, and lessened fatigue and hip pain. Electromyographs obtained during stepping on the switches on the horizontal panel showed contraction of the left gluteus maximus, and the right gastrocnemius and gluteus maximus, muscles that do not directly contribute to stepping, in addition to contraction of the left gastrocnemius, a main muscle in the stepping motion, i.e. flexion of the ankle. Electromyographs obtained during stepping on the switches on the inclined panel showed muscle contraction was limited to the left gastrocnemius with lower frequency and amplitude motor unit potentials compared to those elicited during use of the horizontal panel. Our simple modification facilitates operating microscope manipulation and reduces surgeon fatigue.

Repositioning of Cranial Bone Flaps Cut with a Diamond-Coated Threadwire Saw: 5-Year Experience with Cosmetic Cranioplasty without Fixation Devices.

Artificial fixation systems for cranial bone flaps have problems related to their materials and designs. We developed an alternative technique for supratentorial craniotomy that employs a diamond-coated threadwire saw (diamond T-saw), originally developed for spinal surgery, and reduces the bone gap for fitted bone flap fixation. The study subjects were 77 adults undergoing elective supratentorial craniotomy. After placing a burr hole at each corner of the craniotomy, we performed osteotomy between adjacent burr holes to approximately one-third of the length of the osteotomy with a craniotome; this leaves a bony bridge at each corner. The diamond T-saw was introduced between adjacent burr holes through the epidural space and a bridge was cut with reciprocating strokes. On closure, the bridge firmly supports the flap and only sutures are needed for fixation. Successful bone flap fixation was obtained in all followed-up cases. There were no technique-related complications such as dural laceration, flap displacement, or resorption. Our method is ideal for bone cuts in cosmetic cranioplasty; it is easy, safe, and inexpensive and avoids the need for flap fixation with artificial devices.

Prognostic significance of nuclear DJ-1 expression in astrocytoma.

The present study was conducted to determine whether any correlation exists between the expression of DJ-1 and WHO grading of the tumor or patient prognosis, and to analyze the function of this oncogene in astrocytomas. Twenty-nine formalin-fixed and paraffin-embedded glioblastomas (grade IV), 21 anaplastic astorocytomas (grade III), and 14 diffuse astrocytomas (grade II) were immunohistochemically studied to identify the expression of DJ-1 protein. The expression of DJ-1 was detected both in the nucleus and cytoplasm of tumor cells; however, such expression varied from case to case. While there was no difference in the cytoplasmic expression of DJ-1 among astrocytomas, its nuclear expression was inversely correlated with the WHO grading of astrocytomas. Moreover, the overall survival of patients with maintained (group 1) or mixed (groups 2 and 3) was significantly longer than those with decreased (group 3) expression (p=0.0063). The present study demonstrated that the survival of patients with astrocytomas was correlated with the nuclear DJ-1 status of the tumor. We herein demonstrated for the first time that the DJ-1 molecule might therefore play an important role as a tumor suppressor in astrocytomas.

Dietary pectin up-regulates monocaboxylate transporter 1 in the rat gastrointestinal tract.

This work was undertaken to study the effect of pectin feeding on the expression level, cellular localization and functional activity of monocarboxylate transporter 1 (MCT1) in the gastrointestinal tract of rats. The results indicated that MCT1 protein level was significantly increased along the entire length of the gastrointestinal tract of pectin-fed rats in comparison with control animals. Immunohistochemical analysis revealed an increase in MCT1 in the stratified squamous epithelia of the forestomach as well as in the basolateral membranes of the cells lining the gastric pit of the glandular stomach of pectin-fed rats when compared with control animals. The parietal cells, which showed barely any or no detectable MCT1 in the control group, exhibited a strong intensity of MCT1 on the basolateral membranes in pectin-fed rats. In the small intestine of pectin-fed rats, strong immunopositivity for MCT1 was detected in the brush border and basolateral membranes of the absorptive enterocytes lining the entire villi, while in control rats, weak reactivity was detected on the brush border membrane in a few absorptive enterocytes in the villus tip. In the large intestine of control animals, MCT1 was detected on the basolateral membranes of the epithelia lining the caecum and colon. This staining intensity was markedly increased in pectin-fed rats, along with the appearance of strong reactivity for MCT1 on the apical membranes of the surface and crypt epithelia of caecum and colon. Our results also showed that MCT1 co-localizes with its chaperone, basigin (CD147), in the rat gastrointestinal tract, and that the pectin feeding increased the expression of CD147. In vivo functional studies revealed an enhanced acetate absorption in the colon of pectin-fed in comparison with control animals. We conclude that MCT1 is up-regulated along the gastrointestinal tract of pectin-fed rats, which might represent an adaptive response to the increased availability of its substrates.

Symptomatic Rathke's cleft cyst with cavernous sinus syndrome.

An 88-year-old man presented with Rathke's cleft cyst (RCC) manifesting as complete cavernous sinus syndrome. He had no headache, endocrinological symptom, or blood abnormality. Neuroimaging revealed a cystic intrasellar lesion with lateral extension. The patient underwent surgery by a transsphenoidal approach. Histological examination revealed squamous and cuboidal epithelium. The diagnosis was RCC. RCC is rarely symptomatic, but enlargement and compression of the surrounding structures usually causes headache, visual field defects, or symptoms of pituitary dysfunction. The present case shows that RCC may manifest as complete cavernous sinus syndrome.

Histological examination of false positive tissue resection using 5-aminolevulinic acid-induced fluorescence guidance.

Intraoperative 5-aminolevulinic acid (5-ALA)-induced fluorescence guidance for resection of malignant brain tumors was correlated with histological examination to investigate false positive findings in 42 patients with malignant glioma and six patients with metastatic brain tumor. Patients received a single 1 g oral dose of 5-ALA 2 hours before surgery. The tumor site was illuminated with a laser with a peak wavelength of 405 +/- 1 nm and output of 40 mW. Samples with strong fluorescence were obtained from the tumor bulk and samples with weak fluorescence from the tumor cavity. Fluorescence was observed in 36 of the 42 malignant gliomas and four of the six metastatic brain tumors. No tumor cells were found in fluorescent samples from six of the 36 malignant gliomas and all four metastatic brain tumors. Five of the six malignant gliomas were recurrent cases. Fluorescence was found in areas of peritumoral edema or inflammatory cell and reactive astrocyte infiltration. Intraoperative 5-ALA-induced fluorescence guidance is useful for the resection of initial malignant glioma since false positive results are rare, but only non-eloquent weak positive areas should be resected. In contrast, all weak positive areas of recurrent malignant gliomas must be resected. Weak positive areas of the peritumoral edema surrounding metastatic brain tumors should be removed carefully as false positive results are common.

Histological features of intracranial germinomas not disappearing immediately after radiotherapy.

The histological features of germinomas were investigated to differentiate tumors which completely disappear immediately after irradiation and those that persist. Eighteen previously untreated patients underwent germinoma biopsy and irradiation or combined irradiation and chemotherapy. Four tumors were located only in the pineal gland, eight in the suprasellar region, two in multiple locations, one in the basal ganglia, and three in other regions. Histologically, the germinomas could be divided into type A found in 13 cases which consisted mainly of large neoplastic cells and small lymphocytes, the so-called two-cell pattern, and type B found in five cases which consisted predominantly of fibrous tissue and granulomatous reaction containing occasional neoplastic cells. Follow-up computed tomography or magnetic resonance imaging showed the enhanced mass lesion disappeared in all cases of type A germinomas within 1 month after treatment, but persisted in all cases of type B germinomas for at least 1 month. Type B tumors required up to 12 months to show complete radiographic resolution. Persistent germinomas consisted predominantly of fibrous tissue and granulomatous reaction containing occasional neoplastic cells.

Expression of autocrine motility factor mRNA is a poor prognostic factor in high-grade astrocytoma.

It has been reported that tumor infiltration is correlated with the expression of autocrine motility factor (AMF) and its receptor 78 kDa glycoprotein (gp78). The purpose of the present study was to detect AMF and gp78 mRNA expression levels and their localization in high-grade astrocytomas (glioblastoma and anaplastic astrocytoma) and to determine whether AMF and gp78 are important prognostic factors. A total of 32 formalin-fixed and paraffin-embedded glioblastomas and 23 formalin-fixed and paraffin-embedded anaplastic astrocytomas was used. The expressions of AMF and gp78 mRNA were detected using the highly sensitive in situ hybridization method. The expression of AMF mRNA was detected in 27 of 32 glioblastomas (84.4%) and 11 of 23 anaplastic astrocytomas (47.8%). The positivity of AMF mRNA was significantly higher in glioblastomas than in anaplastic astrocytomas (P = 0.0094), but gp78 mRNA was detected in most cases and no statistical significance was observed. The overall survival of patients with AMF expression was significantly shorter than patients without AMF expression (P = 0.0175). In anaplastic astrocytomas, the overall survival of patients with AMF expression was also significantly shorter than in patients without AMF expression (P = 0.0058). This study demonstrated that AMF is a poor prognostic factor in high-grade astrocytomas.

Pathological and clinical features of cystic and noncystic glioblastomas.

The aim of this study is to review the different histological and clinical characteristics of glioblastoma multiforme (GBM) with and without cysts (cystic and noncystic GBM, respectively). Thirty-seven GBM were collected; these were tumors for which more than 80% of the volume was surgically resected, including a portion of the peripheral parenchyma of the brain. Based on preoperative magnetic resonance (MR) imaging studies, tumors were tentatively classified as cystic GBM if more than 50% of their volume appeared to be liquid; otherwise, they were considered to be noncystic GBM. Tumor volumes were estimated from contrast-enhanced T1-weighted MR images. Edema was deduced from the maximum width of contrast-enhanced edges. Peritumoral pathological analysis showed distinct margins, indicating little or no infiltration of tumor cells into white matter. Five cases were classified as cystic and 32 were noncystic GBMs. There was a statistically significant difference in age (Mann-Whitney U test; P < 0.05) between the patients with cystic tumors (median, 44 years; range, 26-59 years) and those with noncystic tumors (median, 54 years; range, 26-81 years). Four of the cystic tumors and eight of the noncystic tumors were more than 5 cm in maximum diameter. Cystic GBMs had a well-defined tumor interface and less than 2-cm-thick peritumoral edema compared to the noncystic GBMs (Fisher's exact test; P < 0.05). For patients with cystic GBMs, median survival time after surgery was 19.8 months and the 2-year survival rate was 50%. Patients with noncystic GBMs had a median survival time of 12.8 months and a 2-year survival rate of only 17%. Median time to tumor recurrence was 13.3 months for patients harboring cystic GBMs and 8.5 months for those with noncystic GBMs (log-rank test; P < 0.05). Thus, the prognosis for cystic GBM was significantly better than that for noncystic GBM, possibly because cystic GBMs showed comparatively little infiltration of the peritumoral brain parenchyma.

Pathological features of intracranial germinomas with reference to fibrous tissue and granulomatous change.

Intracranial germinomas are accompanied occasionally by a significant granulomatous change and abundant fibrous tissue, and this has made their pathological diagnosis difficult. However, the incidence of the granulomatous reaction and the presence of fibrous tissue together with their clinical characteristics in intracranial germinomas have not been fully investigated. Twenty-four germinomas, none of which had received preoperative treatment, were clinicopathologically examined. The location of the tumor was the pineal region (5 cases), the suprasellar region (13 cases), multiple lesions (2 cases), the basal ganglia region (1 case), and other regions (3 cases). Histologically, the germinomas could be divided into two types: (1) type A (18 cases) consisted mainly of large neoplastic cells and small lymphocytes, showing a two-cell pattern; (2) type B (6 cases) consisted predominantly of fibroinflammatory tissues containing occasional neoplastic cells (5/6 cases) and, rarely, neoplastic cells (1/6 cases). Perioperatively, two-cell-pattern germinomas (type A) were characterized as soft tumors and fibroinflammatory germinomas (type B) as hard tumors. Thus, the fibroinflammatory type B accounted for 25% of the intracranial germinomas. Although there were no topographical and clinical differences between the two types, we conclude that immunohistological studies to detect neoplastic germ cells are warranted in cases of small stereotactic biopsies of hard type B tumors.

Pineal parenchymal tumor with marked retinoblastic differentiation: case report.

A 53-year-old woman was found to have a tumor in the pineal region. Histologically, Homer-Wright rosettes were sporadically distributed in a diffuse proliferation of round tumor cells that were immunoreactive for synaptophysin and chromogranin. A few perivascular pseudorosettes were also present, and the perivascular tumor cells were immunoreactive for glial fibrillary acidic protein and vimentin. By electron microscopy, well-developed junctions and pronounced interdigitation of abutting plasma membranes were noted in many tumor cells, as well as abundant intracytoplasmic microtubules. These findings indicated that the tumor was a pineal parenchymal tumor accompanied by an extraordinary epithelial-like differentiation, suggesting retinoblastic photoreceptor cell differentiation.

Collaborative validation study of the in vivo micronucleus test using mouse colonic epithelial cells.

The in vivo micronucleus test using mouse colonic epithelial cells was evaluated as the 11th collaborative study organized by the Collaborative Study Group on the micronucleus test (CSGMT) with three model chemicals that were known to induce chromosome damage in mouse colonic cells. Five laboratories participated in this validation study. All three model chemicals, i.e. 1,2-dimethylhydrazine dihydrochloride (1,2-DMH), N-methyl-N-nitrosourea (MNU), and mitomycin C (MMC), induced micronucleated colonic epithelial cells in a 4-day exposure protocol in all participating laboratories. We confirmed that the present single cell suspension method could be used to detect the model chemicals as micronucleus inducers in mouse colonic epithelial cells. Advantages of this method are that experiments are easy to perform and that intact cells can be analyzed. The present study suggested that the colon micronucleus assay proposed here is useful for mechanistic studies of colon carcinogenesis.