Anatomy of the Frontal Sinus Drainage Pathway Evaluated in 247 Cadavers to Prevent Cerebrospinal Fluid Leakage After Frontobasal Craniotomy.

BACKGROUND AND OBJECTIVES: The frontal sinus (FS) drainage pathway (FSDP) may be a conduit for cerebrospinal fluid leakage after frontobasal craniotomy. In this cadaveric study, we aimed to evaluate the anatomy of the FSDP. METHODS: The FSs and FSDPs of 247 cadavers were investigated. We counted the number of FSs and FSDPs in each half-head, verified the presence of a narrowing section in each FSDP, and evaluated the depth, shape, and size of each narrowing FSDP section. RESULTS: We investigated 494 sides and 472 FSDPs of 247 cadavers. FSs were unilaterally undeveloped in 13 of 247 cadavers (5.3%) and bilaterally in 8 (3.2%). FSs were unilaterally duplicated in 7 of 247 cadavers (2.8%), and no FSs were bilaterally duplicated or triplicated. No FSs had 2 or more FSDPs, and all 472 investigated FSDPs were invariably narrowed at various depths. The narrowing FSDP sections were elliptical (78.6%), circular (18.1%), triangular (1.8%), or crescent-shaped (1.4%) and of varying thickness and orientation. Although FSDPs were asymmetric in 92.2% of cadavers and narrowing FSDP sections were located deep (8.9 ± 4.4 mm from the anterior skull base), the narrowing FSDP sections were typically small (area: 5.9 ± 3.3 mm 2 ) or thin (short diameter: 2.1 ± 0.7 mm). CONCLUSION: Each FS had only one FSDP, all FSDPs were invariably narrowed at various depths, and the narrowing FSDP sections were sufficiently small or thin to allow local closure, facilitating prevention of cerebrospinal fluid leakage after frontobasal craniotomy.

Effect of newly developed scissors-attached micro-forceps on the recipient clamp time and occurrence of anastomotic site infarction after bypass surgery for moyamoya disease.

Introduction: This study aimed to examine the effect of newly developed scissors-attached micro-forceps in superficial temporal artery-to-middle cerebral artery (STA-MCA) anastomosis for moyamoya disease (MMD). Materials and methods: Of 179 consecutive STA-MCA anastomoses on 95 hemispheres of 71 MMD patients at the University of Fukui Hospital between 2009 and 2023, 49 anastomoses on 26 hemispheres of 21 patients were enrolled in this retrospective cohort clinical trial intraoperative indocyanine green video-angiography did not demonstrate bypass patency in three anastomoses in two patients who were excluded. Twenty-one anastomosis in 19 hemispheres of 16 patients were performed using the conventional micro-forceps (conventional group, CG), and 25 anastomoses in 22 hemispheres of 19 patients were performed using scissors-attached micro-forceps (scissors group, SG). A small infarction near the anastomotic site detected using postoperative diffusion-weighted imaging was defined as anastomotic site infarction (ASI). Factors affecting the occurrence of ASI were examined by univariate, logistic regression, and receiver operating curve (ROC) analysis. Results: There were no significant differences in clinical parameters such as age, sex, number of sacrificed branches, number of sacrificed large branches, and number of sutures between the CG and SG. However, the clamp time and occurrence of ASI were significantly lower in the SG than in the CG. Logistic regression analysis revealed that the clamp time was the only significant factor predicting the occurrence of ASI. A receiver operating curve analysis also revealed that the clamp time significantly predicted the occurrence of ASI (area under the curve, 0.875; cutoff value, 33.2 min). Conclusion: The newly developed scissors-attached micro-forceps could significantly reduce the clamp time and occurrence of ASI in STA-MCA anastomosis for MMD.

Prediction of Occurrence of Cerebral Infarction After Successful Mechanical Thrombectomy for Ischemic Stroke in the Anterior Circulation by Arterial Spin Labeling.

PURPOSE: The overall goal of our study is to create modified Alberta Stroke Program Early Computed Tomography Score (ASPECTS) determined by the findings on arterial spin labeling imaging (ASL) to predict the prognosis of patients with acute ischemic stroke after successful mechanical thrombectomy (MT). Prior to that, we examined predictive factors including the value of cerebral blood flow (CBF) measured by ASL for occurrence of cerebral infarction at the region of interest (ROI) used in the ASPECTS after successful MT. METHODS: Of the 92 consecutive patients with acute ischemic stroke treated with MT at our institution between April 2013 and April 2021, a total of 26 patients who arrived within 8 h after stroke onset and underwent MT resulting in a thrombolysis in cerebral infarction score of 2B or 3 were analyzed. Magnetic resonance imaging, including diffusion-weighted imaging (DWI) and ASL, was performed on arrival and the day after MT. The asymmetry index (AI) of CBF by ASL (ASL-CBF) before MT was calculated for 11 regions of interest using the DWI-Alberta Stroke Program Early CT Score. RESULTS: Occurrence of infarction after successful MT for ischemic stroke in the anterior circulation can be expected when the formula 0.3211â€¯× history of atrial fibrillation +0.0096â€¯× the AI of ASL-CBF before MT (%) +0.0012â€¯× the time from onset to reperfusion (min) yields a value below 1.0 or when the AI of ASL-CBF before MT is below 61.5%. CONCLUSION: The AI of ASL-CBF before MT or a combination of a history of atrial fibrillation, the AI of ASL-CBF before MT, and the time from onset to reperfusion can be used to predict the occurrence of infarction in patients arriving within 8 h after stroke onset in which reperfusion with MT was successful.

Factors affecting reasonable duration of continuous electrocardiographic monitoring to detect atrial fibrillation in acute ischemic stroke.

BACKGROUND: To examine the reasonable duration of continuous electrocardiographic monitoring (CEM) to detect AF at acute ischemic stroke. MATERIALS AND METHOD: 811 consecutive patients admitted to Tsuruga Municipal Hospital by acute ischemic stroke between April 2013 and December 2021 were enrolled in this study. Excluding 78 patients, 733 patients were analyzed by cluster analysis with SurvCART algorithm, followed by Kaplan-Meier analysis. RESULTS: The analysis provided step graphs for 8 subgroups. The duration of CEM to achieve the sensitivity of 0.8, 0.9, and 0.95 in each could be calculated. The duration of CEM to achieve the sensitivity of 0.8 are 18 days in female patients with heart failure (HF) (subgroup 1), 24 days in male patients with HF (subgroup 2), 22 days in patients without HF with arterial occlusion and pulse rate (PR) more than 91 (subgroup 3), 24 days in patients without HF with occlusion with PR less than 91 (subgroup 4), 18 days in patients without HF without occlusion with lacuna (subgroup 5), 26 days in patients without HF, occlusion, and lacuna, with arterial stenosis (subgroup 6), 15 days in patients without HF, occlusion, lacuna, and stenosis with BMI more than 21%(subgroup 7), and 44 days in patients without HF, occlusion, lacuna, stenosis and with BMI less than 21% (subgroup 8). CONCLUSIONS: Duration of CEM with the sensitivity of 0.8, 0.9, and 0.95 could be determined by presence of HF, female sex, arterial occlusion, PR more than 91/minute, presence of lacuna, presence of stenosis, and BMI more than 21%. (250).

[Monitoring of the Floor of the 4th Ventricle for Brainstem Surgery].

The brainstem is densely aggregated with important cranial nerve nuclei and nerve tracts. Surgery in this area is, therefore, risky. Not only anatomical knowledge but also electrophysiological monitoring is essential for brainstem surgery. The facial colliculus, obex, striae medullares, and medial sulcus are important visual anatomical landmarks at the floor of the 4th ventricle. As cranial nerve nuclei and nerve tracts deviate by lesion, it is important to have a firm image of the cranial nerve nuclei and nerve tracts before making an incision in the brainstem. The entry zone into the brainstem is selected where the parenchyma is the thinnest due to the lesions. The suprafacial or infrafacial triangle is often used as an incision site for the floor of the 4th ventricle. In this article, we introduce the electromyographic method of observing the external rectus muscle; orbicularis oculi muscle; orbicularis oris muscle; and tongue; and two cases in which monitoring was used(the pons and medulla cavernoma cases). By examining surgical indications in this way it may be possible to improve the safety of such operations.

Cross-tissue correlations of genome-wide DNA methylation in Japanese live human brain and blood, saliva, and buccal epithelial tissues.

Neuroepigenetics considers genetic sequences and the interplay with environmental influences to elucidate vulnerability risk for various neurological and psychiatric disorders. However, evaluating DNA methylation of brain tissue is challenging owing to the issue of tissue specificity. Consequently, peripheral surrogate tissues were used, resulting in limited progress compared with other epigenetic studies, such as cancer research. Therefore, we developed databases to establish correlations between the brain and peripheral tissues in the same individuals. Four tissues, resected brain tissue, blood, saliva, and buccal mucosa (buccal), were collected from 19 patients (aged 13-73 years) who underwent neurosurgery. Moreover, their genome-wide DNA methylation was assessed using the Infinium HumanMethylationEPIC BeadChip arrays to determine the cross-tissue correlation of each combination. These correlation analyses were conducted with all methylation sites and with variable CpGs, and with when these were adjusted for cellular proportions. For the averaged data for each CpG across individuals, the saliva-brain correlation (r = 0.90) was higher than that for blood-brain (r = 0.87) and buccal-brain (r = 0.88) comparisons. Among individual CpGs, blood had the highest proportion of CpGs correlated to the brain at nominally significant levels (19.0%), followed by saliva (14.4%) and buccal (9.8%). These results were similar to the previous IMAGE-CpG results; however, cross-database correlations of the correlation coefficients revealed a relatively low (brain vs. blood: r = 0.27, saliva: r = 0.18, and buccal: r = 0.24). To the best of our knowledge, this is the fifth study in the literature initiating the development of databases for correlations between the brain and peripheral tissues in the same individuals. We present the first database developed from an Asian population, specifically Japanese samples (AMAZE-CpG), which would contribute to interpreting individual epigenetic study results from various Asian populations.

Assessment of Arterial Transit Time and Cerebrovascular Reactivity in Moyamoya Disease by Simultaneous PET/MRI.

We investigated the relationship between MRI-arterial spin labeling (ASL) parameters and PET-cerebral blood flow (CBF)/cerebrovascular reactivity (CVR) simultaneously obtained by PET/MRI in Moyamoya disease. Twelve patients underwent 15O-water PET/MRI with the acetazolamide (ACZ) challenge test. PET-CBF and PET-CVR were measured using 15O-water PET. Pseudo-continuous ASL obtained the robust arterial transit time (ATT) and ASL-CBF estimation. ASL parameters were compared with PET-CBF and PET-CVR. Before ACZ loading, absolute and relative ASL-CBF were significantly correlated with absolute and relative PET-CBF (r = 0.44, p < 0.0001, and r = 0.55, p < 0.0001, respectively). After ACZ loading, absolute and relative ASL-CBF were significantly correlated with absolute and relative PET-CBF (r = 0.56, p < 0.001, and r = 0.75, p < 0.0001, respectively), and ΔASL-CBF was significantly correlated with ΔPET-CBF (r = 0.65, p < 0.0001). Baseline ASL-ATT had strong negative correlations with ΔPET-CBF and PET-CVR (r = -0.72, p < 0.0001, and r = -0.66, p < 0.0001, respectively). Baseline ASL-ATT of MCA territories with CVR <30% (1546 ± 79 ms) was significantly higher than that with CVR > 30% (898 ± 197 ms). ASL-ATT ratio of MCA territories with CVR < 30% (94.0 ± 10.5%) was significantly higher than that with CVR > 30% (81.4 ± 11.3%). ATT correction using multiple postlabeling delays increased the accuracy of ASL-CBF quantitation. Baseline ASL-ATT is a hemodynamic parameter and may represent an efficient alternative to PET-CVR.

The Utility of Arterial Transit Time Measurement for Evaluating the Hemodynamic Perfusion State of Patients with Chronic Cerebrovascular Stenosis or Occlusive Disease: Correlative Study between MR Imaging and 15O-labeled H2O Positron Emission Tomography.

PURPOSE: To verify whether arterial transit time (ATT) mapping can correct arterial spin labeling-cerebral blood flow (ASL-CBF) values and to verify whether ATT is a parameter that correlates with positron emission tomography (PET)-oxygen extraction fraction (OEF) and PET-mean transit time (MTT). METHODS: Eleven patients with unilateral major cerebral artery stenosis or occlusion underwent MRI and PET in the chronic or asymptomatic phase. ASL-MRI acquisitions were conducted with each of two post-label delay (PLD) settings (0.7s and 2.0s) using a pseudo-continuous ASL pulse sequence and 3D-spin echo spiral readout with vascular crusher gradient. ATT maps were obtained using a low-resolution pre-scan approach with five PLD settings. Using the ASL perfusion images and ATT mapping, ATT-corrected ASL-CBF images were obtained. Four kinds of ASL-CBF methods (PLD 0.7s with or without ATT correction and PLD 2.0s with or without ATT correction) were compared to PET-CBF, using vascular territory ROIs. ATT and OEF were compared for all ROIs, unaffected side ROIs, and affected side ROIs, respectively. ATT and MTT were compared by the ratio of the affected side to the unaffected side. Transit time-based ROIs were used for the comparison with ATT. RESULTS: Comparing ASL-CBF and PET-CBF, the correlation was higher with ATT correction than without correction, and for a PLD of 2.0s compared with 0.7s. The best correlation was for PLD of 2.0s with ATT correction (R2 = 0.547). ROIs on the affected side showed a low but significant correlation between ATT and PET-OEF (R2 = 0.141). There was a low correlation between the ATT ratio and the MTT ratio (R2 = 0.133). CONCLUSION: Low-resolution ATT correction may increase the accuracy of ASL-CBF measurements in patients with unilateral major cerebral artery stenosis or occlusion. In addition, ATT itself might have a potential role in detecting compromised hemodynamic state.

Factors affecting global neurocognitive status and frontal executive functions in the early stage after surgical clipping of unruptured anterior circulation aneurysms with respect to keyhole clipping and conventional clipping.

PURPOSE: This study investigated the most significant factor for the preservation of the global neurocognitive status and frontal executive functions in the surgical clipping of unruptured anterior circulation aneurysms, specifically in keyhole and conventional clipping procedures. METHODS: The prospective study that was performed to examine the effects of aneurysm surgery on the patient's global neurocognitive status and frontal executive functions started on April 2016. After exclusion posterior circulation aneurysms, anterior communicating aneurysms treated by interhemispheric approach, giant aneurysms, and paraclinoid aneurysms, 23 patients who were enrolled before May 2017 were treated by conventional clipping, and 18 patients who were enrolled after June 2017 were treated by keyhole clipping. Two patients were excluded from each group due to missing data. Finally, 21 and 16 patients in each group were analyzed, respectively. Three-tesla magnetic resonance imaging was performed before and after surgery to detect the presence of perioperative cerebral infarctions and brain edema. The Mini-Mental State Examination, Frontal Assessment Battery, and Self-Rating Depression Scale scores were obtained before and 1 month after surgery. RESULTS: Logistic regression analyses indicated that anterior communicating and internal carotid artery aneurysms were the most significant factors for poor outcomes and that keyhole clipping for these two types of aneurysm was the most significant factor for the preservation of patient global neurocognitive status. Keyhole clipping was also the most significant factor for the preservation of frontal executive functions in patients. CONCLUSIONS: Keyhole clipping may be more favorable than conventional clipping for the preservation of the global neurocognitive status and frontal executive functions. Moreover, it may be the most effective factor for preservation of global neurocognitive status when it is indicated for anterior communicating or internal carotid artery aneurysms.

Functional Outcomes of Microsurgical Resection for Cavernous Malformations of the Brainstem.

Long-term functional outcomes of microsurgical resection for cavernous malformations of the brainstem (CMB) have been largely unknown. Favorable outcomes after CMB surgery might be related to the achievement of complete resection and mRS at 1 month after the surgery. Preoperative sensory, cerebellar, trigeminal nerve, and lower cranial nerve symptoms tended to improve after surgery.We evaluated 25 consecutive patients with CMB surgically treated at our center between 2006 and 2021. The subjects included 11 men and 14 women, with ages ranging from 13 to 61 years (mean ± SD = 37 ± 12 years). Modified Rankin Scale (mRS) scores and neurological symptoms of the patients were evaluated before surgery, 1 month after surgery, and at the final follow-up at the outpatient clinic. The mean number of previous hemorrhages was 7 ± 1.0 and the mean lesion size was 21 ± 8 mm. The mRS scores on admission and at the final follow-up were 2.9 points and 1.7 points, respectively. The mRS scores at the final follow-up were significantly improved compared to those on admission. There was no statistical difference between the preoperative mRS and mRS at 1 month after the operation. Multivariable analysis indicated that mRS scores at 1 month after surgery were the most significant predictive factors for favorable outcomes. Complete resection was achieved in 24 of 33 operations. Incomplete resection was significantly related to the frequency of subsequent recurrent hemorrhage and high mRS scores at the final follow-up. Preoperative sensory, cerebellar, trigeminal nerve, and lower cranial nerve symptoms improved significantly after surgery.

[Optic Neuropathy Secondary to Compression by the Internal Carotid Artery Concomitant with an Inflammatory Granuloma:A Case Report].

A 77-year-old man presented with a 6-month history of progressive right optic neuropathy secondary to compression by the ipsilateral internal carotid artery(ICA). We performed anterior clinoidectomy and optic canal unroofing. Subsequently, we wrapped the ICA with a polytetrafluoroethylene tape, pulled the vessel laterally, and sutured the tape to the dura mater at the anterior skull base for optimal decompression. An inflammatory mass lesion was observed around the ICA, which led to further compression of the optic nerve. Histopathological examination of the resected specimen showed an inflammatory granuloma. The patient's visual field deficit showed partial improvement postoperatively. Transposition using a tape might be an effective surgical alternative for compressive optic neuropathy.

Quantitative Analysis of the Far-Lateral, Supra-Articular Transcondylar Transtubercular Approach Using Cadaveric Computed Tomography and Magnetic Resonance Imaging.

BACKGROUND: Removing the jugular tubercle (JT) is regarded as an important step in the far-lateral approach; however, few cadaveric studies have objectively evaluated it. OBJECTIVE: To quantitatively analyze the effect of JT removal in the far-lateral approach, using cadaveric computed tomography (CT) and magnetic resonance (MR) imaging. METHODS: The far-lateral, supra-articular transcondylar transtubercular approach was employed on 23 sides of 13 formalin-fixed cadaveric heads. CT bone images were obtained before and after JT removal, and MR images were obtained before dissection and were merged with the CT bone images. The angles of attack used to approach the ventral region of the medulla, the distances between the medulla and the bony structure, and the volume of the paramedullary space were measured at the level of the JT on axial CT-MR fusion images. The values obtained after JT removal were compared with those obtained before JT removal. RESULTS: All evaluated values were significantly increased after JT removal, including the angle of attack at the level of the JT (29.8 ± 7.4° vs 58.2 ± 15.5°, P < .001), the distance between the olive and the JT (6.4 ± 2.0 mm vs 9.5 ± 5.0 mm, P = .01), and the volume of the space around the medulla (0.28 ± 0.04 cm3 vs 0.47 ± 0.09 cm3, P < .001). CONCLUSION: The paramedullary surgical working space widened by JT removal was quantitatively demonstrated in the cadaveric CT and MR imaging study. The measurement methods in this study can be applied to clinical cases and other skull base cadaveric studies.

No significant difference found in PET/MRI CBF values reconstructed with CT-atlas-based and ZTE MR attenuation correction.

BACKGROUND: Accurate attenuation correction (AC) is one of the most important issues to be addressed in quantitative brain PET/MRI imaging. Atlas-based MRI AC (AB-MRAC), one of the representative MRAC methods, has been used to estimate the skull attenuation in brain scans. The zero echo time (ZTE) pulse sequence is also expected to provide a better MRAC estimation in brain PET scans. The difference in quantitative measurements of cerebral blood flow (CBF) using H215O-PET/MRI was compared between the two MRAC methods, AB and ZTE. METHOD: Twelve patients with cerebrovascular disease (4 males, 43.2 ± 11.7 years) underwent H215O-PET/MRI studies with a 3-min PET scan and MRI scans including the ZTE sequence. Eleven of them were also studied under the conditions of baseline and 10 min after acetazolamide administration, and 2 of them were followed up after several months interval. A total of 25 PET images were reconstructed as dynamic data using 2 sets of reconstruction parameters to obtain the image-derived input function (IDIF), the time-activity curves of the major cerebral artery extracted from images, and CBF images. The CBF images from AB- and ZTE-MRAC were then compared for global and regional differences. RESULTS: The mean differences of IDIF curves at each point obtained from AB- and ZTE-MRAC dynamic data were less than 5%, and the differences in time-activity curves were very small. The means of CBF from AB- and ZTE-MRAC reconstructions calculated using each IDIF showed differences of less than 5% for all cortical regions. CBF images from AB-MRAC tended to show greater values in the parietal region and smaller values in the skull base region. CONCLUSION: The CBF images from AB- and ZTE-MRAC reconstruction showed no significant differences in regional values, although the parietal region tended to show greater values in AB-MRAC reconstruction. Quantitative values in the skull base region were very close, and almost the same IDIFs were obtained.

Deflation of a Rathke cleft cyst triggered rupture of a superior hypophyseal artery aneurysm: a case report.

A 57-year-old woman was diagnosed as a Rathke cleft cyst (RCC). Endoscopic transsphenoidal surgery (TSS) was performed uneventfully. She developed subarachnoid haemorrhage on postoperative day 3. The vessels adhered the cyst had been pulled into the pituitary fossa, causing an aneurysm.

Noninvasive method for measurement of cerebral blood flow using O-15 water PET/MRI with ASL correlation.

PURPOSE: A noninvasive image derived input function (IDIF) method was applied to estimate arterial input function from brain H215O-PET/MRI images for the measurement of cerebral blood flow (CBF) because of difficulty in arterial blood sampling during PET/MRI scans. To evaluate accuracy and reproducibility of radioactivity in the internal carotid arteries (ICA) for the IDIF method, a new phantom using a skull bone was applied in the cross-calibration process between the scanner and a gamma-well counter. METHODS: Eleven healthy volunteers (9 males, 43.9 ±â€¯10.9y) underwent PET/MRI studies with a 3-min H215O-PET and several MRI scans including arterial spin labeling (ASL) perfusion MRI. PET images were reconstructed as dynamic data using two sets of reconstruction parameters, which were determined by basic assessment of radioactivity concentration reproducibility in the tubes of the phantom. The IDIF method extracted the time-activity curves of the ICA from several image slices in the PET data. CBF images were calculated using the autoradiographic (ARG) method and a one-tissue compartment model (1-TCM). RESULTS: The global means of CBF from the ARG, 1-TCM, and ASL-MRI were 44.8 ±â€¯4.3, 47.9 ±â€¯5.9 and 57.9 ±â€¯8.6 (mL/min/100 g), respectively. CBF from ASL-MRI was significantly greater compared with CBF from H215O-PET (P < 0.001). However, these CBF values were significantly correlated with each other in the scatter plots (P < 0.05). CONCLUSIONS: Noninvasive measurement of CBF using H215O-PET/MRI and IDIF with the cross-calibration method with a skull phantom experiment provided reasonable quantitative values. The IDIF method allowed reliable estimation of arterial radioactivity concentration, which is useful for clinical application. The ASL-MRI perfusion image from the simultaneous acquisition tended to overestimate CBF.

[Vestibular Schwannoma Surgery with Continuous Intraoperative Monitoring of Evoked Facial Nerve Electromyograms].

Preservation of facial nerve function is crucial during vestibular schwannoma surgery. Here, we report the utility of continuous intraoperative monitoring of evoked facial nerve electromyograms(EMGs)for preservation of facial nerve function during vestibular schwannoma surgery. A 64-year-old man presented with left ear hearing disturbance. CT and MRI revealed a tumor mass(4cm)with cyst formation in the left cerebellopontine angle. Microsurgical removal was performed with continuous intraoperative monitoring of evoked facial nerve EMGs. An electrode with Ag wire and absorbable gelatin sponge, which we developed, was used for continuous monitoring. It could be placed and fixed more easily on the root exit zone of the facial nerve than the previously reported electrodes and provide reliable information during surgery. The tumor mass could be removed safely without inducing facial nerve palsy. Continuous intraoperative monitoring of evoked facial nerve EMGs with this newly developed electrode could facilitate successful schwannoma surgery.

Pathological examination of cerebral amyloid angiopathy in patients who underwent removal of lobar hemorrhages.

Cerebral amyloid angiopathy (CAA) is a degenerative disorder characterized by amyloid-ß (Aß) deposition in the brain microvessels. CAA is also known to contribute not only to cortical microbleeds but also lobar hemorrhages. This retrospective study examined CAA pathologically in patients who underwent direct surgeries for lobar hemorrhage. Thirty-three patients with lobar hemorrhage underwent open surgery with biopsy from 2007 to 2016 in our hospital. Cortical tissues over hematomas obtained surgically were pathologically examined using hematoxylin, eosin stain, and anti-Aß antibody to diagnose CAA. We also investigated the advanced degree of CAA and clinical features of each patient with lobar hemorrhage. In the 33 patients, 4 yielded specimens that were insufficient to evaluate CAA pathologically. Twenty-four of the remaining 29 patients (82.8%) were pathologically diagnosed with CAA. The majority of CAA-positive patients had moderate or severe CAA based on a grading scale to estimate the advanced degree of CAA. About half of the CAA-positive patients had hypertension, and four took anticoagulant or antiplatelet agents. In five patients who were not pathologically diagnosed with CAA, one had severe liver function disorder, three had uncontrollable hypertension, and one had no obvious risk factor. Our pathological findings suggest that severe CAA with vasculopathic change markedly contributes to lobar hemorrhage. The coexistence of severe CAA and risk factors such as hypertension, anticoagulants or antiplatelets may readily induce lobar hemorrhage.

Spinal endoscopy combined with selective CT myelography for dural closure of the spinal dural defect with superficial siderosis: technical note.

The authors describe a new procedure to detect the tiny dural hole in patients with superficial siderosis (SS) and CSF leakage using a coronary angioscope system for spinal endoscopy and selective CT myelography using a spinal drainage tube. Under fluoroscopy, surgeons inserted the coronary angioscope into the spinal subarachnoid space, similar to the procedure of spinal drainage, and slowly advanced it to the cervical spine. The angioscope clearly showed the small dural hole and injured arachnoid membrane. One week later, the spinal drainage tube was inserted, and the tip of the drainage tube was located just below the level of the dural defect found by the spinal endoscopic examination. This selective CT myelography clarifies the location of the dural defect. During surgery, the small dural hole could be easily located, and it was securely sutured. It is sometimes difficult to detect the actual location of the small dural hole even with thin-slice MRI or dynamic CT myelography in patients with SS. The use of a coronary angioscope for the spinal endoscopy combined with selective CT myelography may provide an effective examination to assess dural closure of the spinal dural defect with SS in cases without obvious dural defects on conventional imaging.

Evaluation of the Use of Calcium Phosphate Cement for Aesthetic Neurosurgical Cranial Reconstruction.

OBJECTIVE: The objective of this article is to evaluate whether newly developed calcium phosphate cement (CPC), mounted around the titanium plates, is useful for aesthetic cranial reconstruction by using 2 methods. METHODS: The morphologic changes of CPC were observed in videos of 6 patients who had undergone cranial reconstruction with CPC during the first surgery and required second surgery. The facial aesthetic outcomes of 74 consecutive patients, more than 12 months after frontotemporal or bifrontal craniotomy and reconstruction with or without CPC, were evaluated. RESULTS: Observations of CPC changes were available 1 day, 2 weeks, 2 months, 5 months, 10 months, and 26 months after the first surgeries. CPC, applied superficially on the cranial surface, had not set sufficiently. CPCs, mounted thickly around the titanium plates and forming hydroxyapatite, were residual during the latter period. Comparison between the aesthetic reconstruction group (with CPC) and the simple reconstruction group (without CPC) showed that the objective bump detected by the investigator, and the subjective bump noticed by the patients themselves, were significantly more frequent in the simple reconstruction group. Comparison between the patients without an objective bump and the patients with an objective bump during the follow-up period showed that the proportion of patients after aesthetic cranial reconstruction with CPC was significantly higher in patients without an objective bump. Patients' characteristics, craniotomy procedure, use of a vascularized pericranial flap, and craniotomy-associated complications did not influence the objective bump significantly. CONCLUSIONS: Use of CPC was expected to bring better aesthetic outcomes after neurosurgical cranial reconstructions.

Mitogen-activated protein kinase in gliosis and pilocytic astrocytoma.

Pilocytic astrocytoma (PA), featuring activation of the mitogen-activated protein kinase (MAPK) pathway, is the most common tumor of the pediatric central nervous system. However, it remains unknown whether MAPK activation is present in the reactive gliosis of non-neoplastic lesions. Therefore, we investigated the expression of MAPK in reactive gliosis associated with cavernous angiomas. Immunohistochemical expression and the extent of BRAF, ERK, p38, and JNK were investigated in 10 patients with gliosis surrounding cavernous angiomas (GS group) and 10 patients with PA (PA group). Evaluation of these parameters was scored as 0, none; 1, scarce; 2, moderate; 3, global. In the GS group, histopathologic features of PA (piloid cells, Rosenthal fibers, microcysts with eosinophilic granular bodies) were identified. Expression of ERK, and p38 was shown in all patients in the GS and PA group. Expression of BRAF was identified in 5 patients (50%) in the GS group and in 8 (80%) in the PA group. The mean score of BRAF expression in the PA group was significantly higher than that in the GS group (p = 0.019). Reactive gliosis may resemble PA in histological findings and MAPK activation. Therefore, PA could be indistinguishable from reactive gliosis with classic histopathologic and/or immunohistochemical methods.
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