Academic Activities of Female Neurosurgeons in All Branch Meetings of the Japan Neurosurgical Society.

This study aims to evaluate the academic activities of female neurosurgeons at all branch meetings of the Japan Neurosurgical Society and identify related issues they encountered. The programs of all seven branch meetings of the Japan Neurosurgical Society (Hokkaido, Tohoku, Kanto, Chubu, Kinki, Chugoku/Shikoku, and Kyushu) were used to determine the number of presentations and chairpersons by sex. The covered period was from January 2008 to December 2020, which was available for viewing during the survey. Of note, only the Kinki branch used data from January 2008 to December 2019. The Neurologia Medico-chirurgica (NMC), the journal of the Japan Neurosurgical Society, was also reviewed to identify publication achievements during the same period. In all seven branches, the percentage of presentations given by female physicians increased from 7.9% in 2008 to 9.6% in 2020 (p < 0.05).Conversely, the percentage of female chairpersons in all branch meetings did not change over time and it was significantly lower (1.1%) than that of female presenters (7.9%) for all branch meetings combined in over 13 years (p < 0.01). In the NMC, the number of articles with female physicians as first authors did not increase or decrease over the years. We conclude that efforts to smoothly promote female neurosurgeons as chairpersons and increase the number of female first authors are necessary to facilitate their academic activities.

[Sedation for Magnetic Resonance Imaging in Pediatric Patients: Complications and Future Measures].

The use of sedation to examine children is common in hospitals. MRI examinations require sedation when applied to pediatric patients, because of the high magnetic field and noisy environment, but complications such as respiratory failure and cardiac arrest have occurred in Japan. Unfortunately, there is no risk-free sedation. In order to perform sedation safely, it is necessary to understand the Recommendation on pediatric sedation for MRI examinations, which was published in 2020. Restrictions on oral intake prior to the exam and the 2-4-6 rules must be adhered to in order to avoid vomiting, and patients must be monitored every 5 minutes during the exam. In addition, non-sedative MRI with the use of videos and preparation tools should be performed more often.

Elimination of the check-valve mechanism of the sacral Tarlov cyst using a rotation flap technique in a pediatric patient: technical note.

OBJECTIVE: Symptomatic Tarlov cysts in children are not sufficiently reported and treatment methods for Tarlov cysts are still controversial. The goal of this manuscript is to introduce a new variation of the surgical technique. METHODS: We performed surgery to eliminate the one-way check valve mechanism of the Tarlov cyst in a 7-year-old female who presented with urinary and fecal incontinence. A relatively large S3 nerve root cyst showed a one-way check valve on computed tomography myelography. The inlet of the check valve was enlarged with rotation flap reconstruction. RESULTS: Two months after surgery, the patient had established normal sphincter control. MRI performed two years later showed that the treated cyst was collapsing, and no recurrence occurred. CONCLUSIONS: Rotation flap enlargement of the check valve inlet is a safe and efficacious option for the treatment of pediatric patients with sacral Tarlov cysts.

A case of pediatric moyamoya disease with severe cerebral vasospasm and delayed cerebral infarction following an intraventricular hemorrhage.

Reports on patients with moyamoya disease presenting cerebral ischemic complications after the onset of intraventricular hemorrhage (IVH) and/or intracerebral hemorrhage (ICH) are limited. Herein, we report a case of a 7-year-old girl with moyamoya disease with severe cerebral vasospasm and delayed cerebral infarction following an IVH. Although the case is rare, the potential for vasospasm-induced cerebral infarction should be carefully considered and thus, intensive treatment should be immediately initiated.

Prenatal clinical manifestations in individuals with COL4A1/2 variants.

BACKGROUND: Variants in the type IV collagen gene (COL4A1/2) cause early-onset cerebrovascular diseases. Most individuals are diagnosed postnatally, and the prenatal features of individuals with COL4A1/2 variants remain unclear. METHODS: We examined COL4A1/2 in 218 individuals with suspected COL4A1/2-related brain defects. Among those arising from COL4A1/2 variants, we focused on individuals showing prenatal abnormal ultrasound findings and validated their prenatal and postnatal clinical features in detail. RESULTS: Pathogenic COL4A1/2 variants were detected in 56 individuals (n=56/218, 25.7%) showing porencephaly (n=29), schizencephaly (n=12) and others (n=15). Thirty-four variants occurred de novo (n=34/56, 60.7%). Foetal information was available in 47 of 56 individuals, 32 of whom (n=32/47, 68.1%) had one or more foetal abnormalities. The median gestational age at the detection of initial prenatal abnormal features was 31 weeks of gestation. Only 14 individuals had specific prenatal findings that were strongly suggestive of features associated with COL4A1/2 variants. Foetal ventriculomegaly was the most common initial feature (n=20/32, 62.5%). Posterior fossa abnormalities, including Dandy-Walker malformation, were observed prenatally in four individuals. Regarding extrabrain features, foetal growth restriction was present in 16 individuals, including eight individuals with comorbid ventriculomegaly. CONCLUSIONS: Prenatal observation of ventriculomegaly with comorbid foetal growth restriction should prompt a thorough ultrasound examination and COL4A1/2 gene testing should be considered when pathogenic variants are strongly suspected.

A Questionnaire to Assess the Challenges Faced by Women Who Quit Working as Full-Time Neurosurgeons.

OBJECTIVE: To analyze why women quit full-time employment as neurosurgeons and to discuss the conditions required for their reinstatement. METHODS: We asked 94 core hospitals providing training programs in the board certification system adopted by the Japan Neurosurgical Society to indicate the total number and present status of women in their department and to send our anonymous questionnaire to women who had formerly worked as full-time neurosurgeons. The questionnaire consisted of closed and open questions on their reasons for quitting as full-time neurosurgeons. RESULTS: Among 427 women evaluated, 72 (17%) had quit full-time employment as neurosurgeons. Twenty-one women who had quit 3-21 years after starting their neurosurgery careers responded to the questionnaire, including 17 board-certified neurosurgeons, 11 individuals with master's degrees, and 16 mothers. Their main reasons for quitting full-time work were difficulty in balancing their neurosurgical career and motherhood (52%) and the physical burden (38%). At the time of quitting, only 2 units (5%) had a career counseling system for women. Two thirds of participants might resume full-time work as neurosurgeons in the future. Their support system during pregnancy and the child-raising period, and understanding of male bosses and colleagues were identified as the key themes. CONCLUSIONS: The Japan Neurosurgical Society could facilitate supportive environments for women in neurosurgery by enhancing adequate childcare services, changing the work style of full-time neurosurgeons to incorporate diverse working styles, shorter working hours, understanding of their bosses and colleagues, and a career counseling system.

Incidence and risk factors of neonatal hypoglycemia after ritodrine therapy in premature labor: a retrospective cohort study.

BACKGROUND: Ritodrine hydrochloride (RD), a ß2-adrenergic agonist, is widely used as a tocolytic medication to suppress premature labor, but can cause neonatal hypoglycemia, a potentially severe side effect. We examined the incidence and risk factors of neonatal hypoglycemia following maternal intravenous administration of RD. METHODS: This was a retrospective study of neonates, who had birth weight of ≥2000 g and were delivered at 36 weeks gestation or later in Kanazawa University Hospital from August 2013 to July 2016. We defined neonatal hypoglycemia as blood glucose level < 50 mg/dL. Neonates who were delivered without maternal intravenous RD or who were delivered 8 days or more after stopping maternal RD or who received oral RD were defined as the RD non-administration group, while those delivered within 7 days after stopping maternal RD were defined as the RD intravenous administration group. We examined the incidence and risk factors of RD-induced neonatal hypoglycemia by comparing these two groups. RESULTS: We enrolled 603 neonates in this study; 504 (83.6%) showed no neonatal hypoglycemia, while 99 (16.4%) exhibited neonatal hypoglycemia. The incidence of neonatal hypoglycemia was significantly higher (61.7%; 58/94) in the RD intravenous administration group than in the RD non-administration group (8.1%; 41/509) (p < 0.001). Binomial logistic regression analysis in the RD intravenous administration group showed that maternal age over 35 years (AOR: 3.385; 95% CI, 1.082-10.588, p = 0.036) and the interval to delivery from stopping intravenous administration of RD (AOR: 0.974; 95% CI, 0.953-0.996, p = 0.020) were independent factors associated with neonatal hypoglycemia. The cut-off value of the interval to predict the incidence of neonatal hypoglycemia was about 6 h (sensitivity 82.8%, specificity 63.9%). CONCLUSIONS: The incidence of neonatal hypoglycemia was significantly increased by maternal intravenous administration of RD. We newly identified maternal age (over 35 years) and the interval to delivery from stopping intravenous administration of RD (within 6 h) as independent risk factors for neonatal hypoglycemia following maternal intravenous administration of RD. In cases with these risk factors, careful blood glucose monitoring is recommended for early detection and treatment of neonatal hypoglycemia.

Status epilepticus induced by treatment with dopamine agonist therapy for giant prolactinoma: a case report.

BACKGROUND: Dopamine agonists are the standard first-line medical therapy for prolactinoma. We report a rare case of giant prolactinoma with a first epileptic seizure due to rapid reduction of the tumor as a complication of dopamine agonist therapy. CASE PRESENTATION: A 27-year-old Japanese man presented to our institution with a history of visual disturbance for 1 year and general fatigue for 3 months. Magnetic resonance imaging showed a tumor that arose from the pituitary and extended to the bilateral anterior skull base, the clivus, and the cavernous sinus, with compression of the optic chiasm and the bilateral frontal and temporal lobes. On the basis of the patient's serum concentration of prolactin, we diagnosed a prolactinoma and started dopamine agonist therapy with cabergoline. The patient had a general seizure immediately after starting dopamine agonist therapy and required general anesthetic treatment following the rapid reduction of the tumor. We speculated that the rapid reduction of the tumor resulted in the retraction of the surrounding brain structure, and the epileptic seizure was then induced by dopamine agonist therapy. CONCLUSIONS: We report a rare case of giant prolactinoma with a first epileptic seizure immediately after the initiation of dopamine agonist therapy. Clinicians need to be aware that the rapid reduction of a giant prolactinoma by dopamine agonist therapy may cause an epileptic seizure.

Extensive spinal epidural immature teratoma in an infant: case report.

Here, the authors present an extremely rare case of an extensive spinal epidural teratoma (SET) in an infant and provide a review of the cases in the literature. In this report, the authors focused on the clinical manifestation and management of extensive SET. A 64-day-old girl presented with severe dyspnea and paraparesis caused by a large thoracic mass. Imaging studies revealed that the mass originated from the epidural space of the thoracic spine and extended from C7 to L1. The tumor extended bilaterally through the intervertebral foramina and formed a large posterior mediastinal mass. The tumor was partially resected via laminotomy after an emergency thoracotomy. The remnant grade I immature teratoma grew rapidly. After a re-laminotomy and bilateral thoracotomy, the residual tumor stopped growing. However, the patient's paraparesis improved very little, and her scoliosis progressed gradually. Therefore, SET should be included in the differential diagnosis when an infant patient with paraparesis of the lower extremities is encountered. Timely diagnosis, aggressive treatment, and close monitoring are of critical importance to successful recovery in such patients.

Possible involvement of pericytes in intraplaque hemorrhage of carotid artery stenosis.

OBJECTIVEIntraplaque hemorrhage (IPH) is most often caused by the rupture of neovessels; however, the factors of intraplaque neovessel vulnerability remain unclear. In this study, the authors focused on pericytes and aimed to investigate the relationship between IPH and pericytes.METHODSThe authors retrospectively analyzed the medical records of all patients with carotid artery stenoses who had undergone carotid endarterectomy at their hospitals between August 2008 and March 2016. Patients with carotid plaques that could be evaluated histopathologically were eligible for study inclusion. Intraplaque hemorrhage was analyzed using glycophorin A staining, and patients were divided into the following 2 groups based on the extent of granular staining: high IPH (positive staining area > 10%) and low IPH (positive staining area ≤ 10%). In addition, intraplaque neovessels were immunohistochemically evaluated using antibodies to CD34 as an endothelial cell marker or antibodies to NG2 and CD146 as pericyte markers. The relationship between IPH and pathology for intraplaque neovessels was investigated.RESULTSSeventy of 126 consecutive carotid stenoses were excluded due to the lack of a specimen for histopathological evaluation; therefore, 53 patients with 56 carotid artery stenoses were eligible for study inclusion. Among the 56 stenoses, 37 lesions had high IPH and 19 had low IPH. The number of CD34-positive neovessels was equivalent between the two groups. However, the densities of NG2- and CD146-positive neovessels were significantly lower in the high IPH group than in the low IPH group (5.7 ± 0.5 vs. 17.1 ± 2.4, p < 0.0001; 6.6 ± 0.8 vs. 18.4 ± 2.5, p < 0.0001, respectively).CONCLUSIONSPlaques with high IPH are associated with fewer pericytes in the intraplaque neovessels. This finding may help in the development of novel therapeutic strategies targeting pericytes.

Curved Planar Reformation for the Evaluation of Hydromyelia in Patients With Scoliosis Associated With Spinal Dysraphism.

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: Scoliosis and hydromyelia have frequently been observed in patients with spinal dysraphism. We investigated the applicability of curved planar reformation (CPR) for evaluating hydromyelia in patients with scoliosis associated with spinal dysraphism. SUMMARY OF BACKGROUND DATA: It is quite difficult to evaluate scoliosis and hydromyelia in patients with spinal dysraphism. METHODS: We identified 11 patients with scoliosis and a Cobb angle of >20° among 107 spinal dysraphism patients. In addition to routine T1- and T2-weighted axial and sagittal MRI, we obtained three-dimensional constructive interference in steady-state magnetic resonance imaging (MRI) as sagittal cross-section volume images. The spinal cord and hydromyelia were rendered into a single-plane, two-dimensional image using the straightened CPR technique. In cases of scoliosis with hydromyelia, the sagittal length and maximal diameters of hydromyelia and the spinal cord were measured by three examiners. Measurement errors among examiners were evaluated using standard deviation (SD) and coefficient of variation (CV). RESULTS: Each series of image sets provided a straightened CPR image that clearly delineated the entire length of the linearized spinal cord in a single plane. The straightened CPR image also demonstrated the accurate lengths and estimated volume of hydromyelia. Given that three of the 11 patients underwent serial MRI during this period, we were able to accurately compare volume changes. In the sagittal length of the hydromyelia, SD and CV were smaller with the straightened CPR technique than with the conventional T2 WI sagittal section in all cases, showing a statistically significant difference between both techniques (SD: P = 0.014, CV: P = 0.013). Even in the measurements, the difference in CV between both techniques was close to statistical significance. CONCLUSION: The straightened CPR technique is useful for accurately identifying volume changes in hydromyelia, even in patients with severe scoliosis. LEVEL OF EVIDENCE: 1.

Dural arteriovenous fistula manifesting as pontine hemorrhage at the craniocervical junction.

Craniocervical junction (CCJ) dural arteriovenous fistula (DAVF) manifesting as intracerebral hemorrhage is extremely rare. We report the first case of CCJ-DAVF manifesting as pontine hemorrhage. A 69-year-old male presented with a pontine hemorrhage manifesting as a sudden onset of right hemiparesis and dysarthria. Digital subtraction angiography revealed a CCJ-DAVF fed by the meningeal branches of the right vertebral artery. The patient underwent surgical ligation of the cerebral draining veins to prevent re-bleeding. The postoperative course was uneventful. The patient had no neurological deficit after 1 month rehabilitation.

[A Rare Case of Cerebellar Hemangioblastoma Causing Taste Disorder].

Taste(gustation)is one of the five senses, and comprises the types: sweet, bitter, salty, sour, and umami. Taste disorders, such as dysgeusia and parageusia, are classified into 2 types: those with peripheral origin and those with central origin. The peripheral origin-type taste disorder is caused by zinc deficiency, mouth dryness, a side effect of radiotherapy or complication of systemic diseases such as, diabetes, hepatopathy, and nephropathy. The central origin-type taste disorder is reported to be caused due to demyelinating disease, pontine hemorrhage, pontine infarction, and thalamic infarction; it is very rarely caused by a brain tumor. We surgically treated a 69-year-old man with cerebellar hemangioblastoma who had developed taste disorder. The tumor compressed the solitary nucleus, which includes the taste tract in the central nervous system. On removal of the tumor, the taste disorder gradually improved.

Brain metastasis from primary peritoneal carcinoma: Case report and literature review.

Here, we describe a patient with primary peritoneal carcinoma (PPC) who developed a late, solitary brain metastasis. It is a case of a 68-year-old female presented with a 1-month history of progressive gait disturbance who had undergone a surgical resection of PPC five years prior, followed by adjuvant chemotherapy. An MRI revealed a 4.6cm mass lesion in her right cerebellum. The patient underwent total removal of the tumour. The histopathology was consistent with a brain metastasis due to PPC. This condition is a rare malignancy of peritoneum, and only six cases of brain metastasis have been reported in PPC patients to date. Due to the prolongation of survival resulting from advanced chemotherapy for PPC, more patients will live long enough to develop brain metastases.

Working Conditions and Lifestyle of Female Surgeons Affiliated to the Japan Neurosurgical Society: Findings of Individual and Institutional Surveys.

To investigate the working conditions of female neurosurgeons in Japan, two surveys were conducted by The Japan Neurosurgical Society: one involving female neurosurgeons themselves and the other involving the chiefs of neurosurgical departments. The responses were received from 224 (43.8%) female neurosurgeons and 496 (61.2%) departmental chiefs. About half (50.2%) of the female neurosurgeons were married and 39.2% had children (average number of children, 1.27). Their work was full-time in 80.6% of cases; on average, they worked 51.9 h per week, had night duty 2.8 times per month, and had 5.7 days off per month. Many of them stated that they were satisfied with their job status, but about half of them reported difficulty in maintaining a correct work-life balance. Among the institutions surveyed, 29% had female neurosurgeons. The survey of departmental chiefs revealed that the proxies for maternity leave were not available at most institutions, and that there was only limited availability of night child care (41%) or sick child care (39%); female neurosurgeons did not appear to be well-informed of these support systems. These findings suggest that apart from systematic approaches already in place, female neurosurgeons would prefer to have more understanding from their peers and chiefs.

Gliosarcomas arising from the pineal gland region: uncommon localization and rare tumors.

Gliosarcomas are a variant of glioblastomas and present a biphasic pattern, with coexisting glial and mesenchymal components. In this study, two unusual cases are presented. Case 1 is a 52-year-old woman with a headache and memory disturbance for a month. Case 2 is an 18-year-old man with a headache lasting two weeks. In both cases, an MRI revealed enhancing T1-low to iso, T2-iso to high intensity lesions in the pineal gland region. Histologically, in case 1, the tumor showed spindle cell proliferation with disorganized fascicles and cellular pleomorphism. Tumor cells variously exhibited oncocytic transformation. Immunohistochemically, most of the spindle tumor cells were positive for myoglobin and desmin. Some of the tumor cells were positive for GFAP and S-100 protein. On the other hand, all tumor cells were positive for CD133, Musashi1, and SOX-2 which are the markers of neural stem cells. In case 2, the tumor showed monotonous proliferation of short spindle cells with disorganized fascicles and cellular atypism. The morphological distinction between glial and mesenchymal components was not apparent. Immunohistochemically, most of the spindle tumor cells were positive for desmin. Glial tumor cells that were dispersed within the sarcoma as single cells were positive for GFAP. In addition, all tumor cells were positive for CD133, Musashi1 and SOX-2. Based on these microscopic appearances, and immunohistochemical findings, these cases were diagnosed as gliosarcomas arising from the pineal gland region. These results also indicated that pluripotential cancer stem cells differentiated into glial and muscle cell lines at the time of tumor growth. In a survey of previous publications on gliosarcoma arising from the pineal gland, these cases are the second and third reports found in English scientific writings.

Reduction cranioplasty for macrocephaly caused by giant occipital cystic lesion.

Reduction cranioplasty for macrocephaly improves patients' quality of life both functionally and aesthetically. However, it is indicated for only a small number of patients because of the risks of complications. Thus, it is rarely performed, and not many reports have been published. In Dandy-Walker syndrome, there is often a posterior fossa cyst continuous with the fourth ventricle. We report here a case of scaphocephalic macrocephaly because of such a cystic lesion. The patient underwent a single-stage surgery with plication of the cyst wall and posterior reduction cranioplasty. This procedure achieved good results.

Risk factors for the occurrence of spina bifida (a case-control study) and the prevalence rate of spina bifida in Japan.

BACKGROUND: The Japanese government recommended in 2000 that women planning pregnancy should take 400 µg of folic acid daily to decrease the risk of having an infant with spina bifida. We aimed to identify risk factors for the occurrence of spina bifida and to evaluate how the prevalence rate has altered over the past 3 decades. METHODS: Subjects comprised 360 women who gave birth to spina bifida-affected offspring and 2333 women who gave birth to offspring without spina bifida between 2001 and 2012. A self-administered questionnaire was used to collect data, which were analyzed by multiple logistic regression models. The prevalence rate of spina bifida was obtained through data provided by international and domestic organizations. RESULTS: Four variables were significantly associated with the increased risk of having newborns afflicted with spina bifida: not taking folic acid supplements (odds ratios [OR], 2.50; 95% confidence interval [CI], 1.72-3.64), presence of spina bifida patients within third-degree relatives (OR, 4.26; 95% CI, 1.12-16.19), taking anti-epileptic drugs without folic acid (OR, 20·20; 95% CI, 2.06-198.17), and low birth weight in the newborns ≤ 2500 g (OR, 4.21; 95% CI, 3.18-5.59). The prevalence rate of spina bifida has remained 5 to 6 per 10,000 total births and has not shown any decreasing trend over the past 11 years. CONCLUSION: Four risk factors were identified among Japanese women. Because recommendations and information have not decreased the occurrence of spina bifida, the Japanese government should implement mandatory food fortification.

[A case of medullomyoblastoma].

Medullomyoblastoma is a rare histologic variant of medulloblastoma. We report a case of medullomyoblastoma occurring in the cerebellar vermis. A 12-year-old girl presented with a 3-month history of headache, nausea, vomiting and unsteadiness of gait. Magnetic resonance imaging (MRI) revealed a mass lesion in the cerebellar vermis. A suboccipital craniectomy was perfomed to remove a tumor. Immunohistochemical studies confirmed the presence of both a primitive neuroectodermal component and rhabdomyoblastic differentiation, consistent with the diagnosis of medullomyoblastoma.